INTRODUCTION TOTHE PRACTICE OFPSYCHOANALYTICPSYCHOTHERAPY
THE PROCESSOF PSYCHIC CHANGE
Our models of the mind inform how we practice psychotherapy. As ourunderstanding of unconscious processes has become more sophisticated,it has shed new light on how psychic change might occur and howpsychoanalytic therapy can assist this process. In this chapter, we willexamine the nature of unconscious perception and the workings of memoryas a springboard for addressing the question of therapeutic action inpsychoanalytic therapy.
THE EVIDENCE FOR UNCONSCIOUS PROCESSING
Consciousness is considered as a distinctive feature of human beings.However, the influence of unknown factors on the human mind haslong been recognised. It was certainly not Freud’s original discoverythat human conscious behaviour was driven by forces that were notimmediately accessible to us. Before the notion of a dynamic unconsciouswas formulated by Freud, Gods or destiny were convenient repositoriesfor unknown – and often destructive – forces that exerted an impact onbehaviour and were experienced as alien to the individual.Freud’s early theories described a rational, conscious mind separatedby a barrier from a non-rational part of the mind pictured as hedonistic,self-seeking and destructive. The Freudian unconscious consisted ofunsatisfied instinctual wishes understood to be representations of instinctualdrives. He posited an intermediary zone called the preconscious,involving not conscious processes but ones capable of becoming so. Thismodel was subsequently further refined into the structural model withthe three agencies of the mind, the id, the ego and the superego (seeChapter 1). It soon became apparent that not only was the id unconsciousbut that many of the functions ascribed to the ego and the superego werealso unconscious.
Since Freud, the evidence for unconscious mentation has steadily accumulated.Studying unconscious processes has never been as exciting orpromising as it is today because of a gradual rapprochement betweenpsychoanalysis and neuroscience. Factors operating outside of consciousawareness are now recognised in many cognitive psychological theories.Unconscious activities are understood to constitute far more of mentationthan consciousness could ever hope to explain. Findings from cognitivepsychology and neuroscience have repeatedly demonstrated that a significantproportion of our behaviour and emotional reactions is controlled byautonomous, unconscious structures, bypassing consciousness altogether(Damasio, 1999; Pally, 2000). Psychoanalysis and cognitive psychologynowadays also converge on the recognition that meaning systems includeboth conscious and unconscious aspects of experience.
The most compelling evidence for the unconscious has emerged fromstudies of perception. What we perceive is the end result of a very complexneurophysiological process. To perceive an object, the brain processesall of the object’s individual environmental features and compares it withpatterns stored inmemory. When amatch for the current pattern is found,perception occurs.1 Our perceptual system has evolved in response to theneed to perceive not only accurately but also speedily. The brain has thusdeveloped a split perceptual system (LeDoux, 1995). The slower perceptualsystem involves the cortex and can thus include conscious awareness. Thissystem allows formore detailed information to be gathered,which in turn,helps us to inhibit responses and initiate alternative behaviours. The othersystem‘‘fast tracks’’ perception bypassing the cortex. This systemdoes notinvolve any conscious awareness. The problem with the ‘‘fast-track’’ systemis that itdoes not allow for amore fine-grained appraisal ofwhatwe areperceiving. However, many situations in our day-to-day lives rely on justsuch a system. This means that when we fast track perceptions, past experiencesalways influence the current perceptions and hencemay contributeto patterns of behaviour or feelings that closely resemble past experiences.Some of themost interesting examples of unconscious processing are to befound in the neurological literature. Damasio (1999), for example, describesface-agnosic patients who can no longer consciously recognise people’sfaces but yet can detect familiar faces non-consciously. In experimentalsituations where these patients are shown pictures of faces, they are allunrecognisable to them whether they are familiar ones (e.g. friends orfamily) or unfamiliar ones. Yet, on presentation of every familiar face, adistinct skin conductance response is generated, while on presentationof unknown faces no such reaction is observed. This suggests that eventhough the patient is consciously unaware of any level of recognition, thephysiological reaction tells a different story: the magnitude of the skinconductance response is greater for the closest relatives. It would thusappear that our brain is capable of producing a specific response thatbetrays past knowledge of a particular stimulus and that it can do thisbypassing consciousness totally.
Learning too often occurs without consciousness. So, much of our socalled‘‘knowledge’’ is not acquired in a conscious, purposeful way. Forexample, knowledge acquired through conditioning remains outside ourconsciousness and is expressed only indirectly. The retrieval of sensorymotor skills (e.g. how to drive or ride a bike) without consciousness ofthe knowledge expressed in the movement is perhaps the most commoneveryday example of how our behaviour does not require the mediationof consciousness. This is referred to, within cognitive science, as implicitprocessing. This type of processing is applied to mental activity that isrepetitive and automatic and provides speedy categorisation and decisionmaking, operating outside the realm of focal attention and verbalisedexperience (Kihlstrom, 1987). Indeed, it is precisely becausewe can rely onsuch implicit processing, and we are therefore not dependent all the timeon a conscious survey of our behaviour, that we are freed up in terms ofattention and time. The device of consciousness can thus be deployed tomanage the environmental challenges not predicted in the ‘‘basic designof our organism’’ (Damasio, 1999).
Such isnowthe evidential basis for unconscious perception and processingthat no therapeutic approach can dispute the existence of an unconscious,at least in the descriptive sense. However, even though there is evidencefor unconscious processing, that is, for learning and perception that occurswithout conscious awareness, the notion of a dynamic unconscious ismoreproblematic. In Freud’s original formulations, the dynamic unconsciouswas depicted as a constant source of motivation that makes things happen.In this sense, what is stored in the unconscious was said not only to beinaccessible but Freud also suggested that its contents were the resultof repression. Repression was a means of protecting consciousness fromideas and feelings that were threatening and hence the source of anxiety.At first, Freud, along with Breuer, suggested that repression operated onmemories of traumatic events excluding them from consciousness. Later,he suggested that repression operated primarily on infantile drives andwishes, rather than on memories of actual events.
The concept of repression raises an interesting question because it is onlywhen an experience can be known and represented that it can it be hidden.To be able to maintain a specific idea at an unconscious level,wemust firsthave a stable ability to specify an experience. Developmental psychologyhas shown that the ability to represent our experiences in a stable andmeaningful fashion only develops over time. This suggests that from acognitive point of view, repression is not a defence that can operate fromthe very beginning of life. Freud too understood repression as a mode ofdefence against unwanted impulses that develops over time:
Psychoanalytic observation of the transference neuroses. . . leads usto conclude that repression is not a defensive mechanism which ispresent from the very beginning, and that it cannot arise until a sharpcleavage has occurred between conscious and unconscious mentalactivity (Freud, 1915a).
On the basis of the current evidence, the notion of repression as a fullyunconscious process, or as one directed primarily at infantile wishes,finds little empirical support. Although we can still speak of a dynamicunconscious and of repression as a defensive process, this requires aredefinition of the concepts in keeping with what we now know about theworkings of memory.We shall now turn our attention to this.
PSYCHOANALYTIC PERSPECTIVES ON MEMORY
The question ofmemory, ofwhatwe can, cannot or do notwant to rememberis of central concern to psychoanalytic practitioners and researchers. Inhis early formulations on the nature of hysteria, Freud understood the hysteric’sproblem as one of ‘‘suffering from reminiscences’’ (Breuer & Freud,1895: 7). Freud and Breuer (1895) suggested that the source of the hystericalpatient’s psychic pain was the inability to forget traumatic events that hadoccurred in childhood but which could not be consciously remembered.The goal of therapywas therefore to bring back to the surface the repressedtraumatic events. Although Freud changed his ideas about hysteria later,this early link between disturbances of memory and psychopathology canstill be traced in the implicit thinking of some psychoanalytic practitionerswho view the excavation of the past as a necessary goal of psychotherapy.As our knowledge of memory has become increasingly more sophisticated,the classical psychoanalytic view of memory and hence of thenature of therapeutic action has been challenged.
A feature of memory that is of special relevance to clinical practice isthat memory is by definition always reconstructed and, importantly,influenced by motivation. Memory is influenced as much by presentcontext, mood, beliefs and attitudes, as it is by past events (Brenneis,1999).Memories are not direct replicas of the facts per se. On the contrary,memory undergoes a complex process of reconstruction during retrieval.This means that memory of some autobiographical events may be reconstructedin ways that differ from the original event ormay never be recalledat all. The view that memory is continually being constructed rather thanretrieved from storage in original pristine form is consistent with currentthinking in cognitive psychology and neurobiology. However, it wouldbe mistaken to infer from this that early memories are mostly inaccurate:research suggests that there is in fact substantial accuracy in early memories(Brewin et al., 1993) even though the more fine-grained details ofan experience, even if vividly recalled and reported by the patient, areunlikely to be entirely accurate.
We are now all too aware of the heated debates about so-called falsememories. The interest, and indeed controversy, about the reliability andaccessibility of early memories gainedmomentum over ten years agowhenthemedia drew attention to a groundswell of reconstruction of incestuoussexual abuse within the context of psychotherapy. Dreams, puzzling bodysensations, specific transference and countertransference patterns and dissociativeepisodes were taken by many therapists as evidence that theirpatients had repressed a traumatic experience. This conclusion was predicatedon the assumption that analytic data can reconstruct and validateconsciously inaccessible historical events. In other words, it reflected abelief that analytic data was ‘‘good enough’’. Any of the symptoms listedabove,which have been taken as evidence of repressed trauma, may occurin conjunctionwith trauma, and often do, but they do not occur exclusivelywith trauma. The danger lies in inferring the nature of unrememberedevents solely from the contents of any of these repetitive phenomena.Suggesting that memory is reconstructed does not mean that psychoanalyticreconstructions are necessarily false or that recovered memoriesare invariably, or mostly, false. It does mean, however, that we mustapproach notions of ‘‘truth’’ based on reconstructions within the contextof psychotherapy with some caution. All that we can assert with anycertainty is that what our patients believe to be true has important consequencesfor how they feel and act in the world. Our role as therapistsis neither that of an advocate or a jury: we are facilitators of the patient’sattempts to understand his internal world and how this impacts on hisexternal relationships and day-to-day functioning. I am not advocatingdisbelieving what patients say. Patients who have experienced a traumaneed to have their traumatic experiences validated. However, all we canvalidate is their emotional experience of an event and their individualnarrative about it. Importantly, we often have to bear the anxiety of notknowingwhat may have happened so thatwe can help our patients to bearit too. When our patients have no conscious recollection of any traumabut we, as therapists, infer trauma from their symptomatic presentation,we need to caution against an overeagerness to fill in the unbearable gapsin understanding with the knowing certainty of formulations that may,or may not, be correct. There exists in us and in our patients, as Brenneissuggests, ‘‘. . . a balder desire to locate an original event that unlocks themysteries of present experience’’ (1999: 188). This desire can mislead us attimes because, as Kris wisely reminds us:
. . . we are [not], except in rare instances, able to find the events of theafternoon on the staircase where the seduction happened. (1956: 73).
Research on human memory helps us to understand the need for cautionin these matters. It suggests that there are different kinds of memorysystems and hence different types of memories. Certain sets of memoriesare consistently reactivated moment by moment. These memories concernthe facts of our physical, mental and demographic identity. They orientus in the world. Conventionally, this is variously referred to as declarativeor explicit2 or autobiographical memory. Declarative memory – the term Iwill use from now on – is the underlying organisation that allows us toconsciously recall facts and events. It refers to the conscious memory forpeople, objects and places. It involves symbolic or imaginistic knowledgethat allows facts and experiences to be called into conscious awareness inthe absence of the things they stand for. This kind of memory includessemantic memory for general and personal facts and knowledge and episodicmemory for specific events.
There are also contents of memory that remain submerged for long periodsof time, some never to be retrieved. Many aspects of our behaviour relyon us remembering ‘‘how to do things’’, and we can do this withoutconsciously remembering the details of how to carry out a particularbehaviour. This kind of memory is conventionally variously referredto as procedural or implicit or non-declarative memory. It includes primedmemory (e.g. for words, sounds or shapes), which facilitates the subsequentidentification or recognition of them from reduced cues or fragments,emotional memory and procedural memory, that is, memory for skills, habitsand routines.
2‘‘Explicit’’ and ‘‘implicit’’ refer, respectively, to whether conscious recollection is involvedor not in the expression of memory. Long-term memory may be both explicit and implicit.Both involve the permanent storage of information: one type is retrievable (i.e. explicitmemories), the other most probably is not (i.e. implicit memories).
Emotional memory is the conditioned learning of emotional responses to asituation and is mediated by the amygdala. There is a difference betweenemotional memory, that is, a conditioned emotional reaction formed inresponse to a particular event, and declarative memory of an emotionalsituation, that is, the recall of events felt to be of emotional significance.Classically conditioned emotional responses (e.g. classically conditionedexpectations, preferences, desires) constitute the affective colouring of ourlives. They orient us unconsciously to aspects of our environment andto particular types of relationships. Often, there is no conscious memoryconnected with this learning. LeDoux (1994) suggests that a focal pointfor cognition – the hippocampus – can be involved in the activation ofemotions before cognitive processes take place.His research indicates thatemotions can bypass the cortex via alternative pathways leading from thethalamus to the amygdala. This makes it possible for emotionally chargedschemas to be repeated without the mediation of consciousness.Like emotionalmemory, procedural memory is unconscious and is evident inperformance rather than in conscious recall. This type of memory refers tothe acquisition of skills, maps and rule-governed adaptive responses thatare manifest in behaviour but remain otherwise unconscious. It includesroutinised patterns or ways of being with others. For example, we mayhave a coordinated procedural system for ‘‘how to ask for help’’. In turn,these procedures shape, organise and influence a person’s unconsciousselection of particular interpersonal environments.Moreover, emotionallycharged events are particularly prone to repetitionwhen events of a similarnature are anticipated.
Neuropsychology has demonstrated complete independence of the declarativeand procedural memory systems. Declarative memory is located inthe hippocampus and the temporal lobes. Procedural memory is locatedin sub-cortical structures such as the basal ganglia and the cerebellum.The declarative and procedural memory systems are relatively independentof each other. Studies of amnesic patients provide evidence for thepotential dissociability of the two forms of knowledge contained withinthese memory systems: amnesic patients, for example, demonstrate evidenceof prior learning of words, as shown in a word-recognition task,but display no conscious recollection of whether they had ever seen theword before. This suggests that procedural knowledge was acquired inthe absence of any conscious recall of the learning experience. This findingsuggests that a change in procedural forms of learning may thus comeabout through different mechanisms than a change in conscious, declarativeforms of knowledge. As we shall see later in this chapter, this hasimportant implications for psychotherapy.
In normal adult development, both declarative and procedural memorysystems overlap and are used together. Constant repetition, for example,can transform a declarative memory into a procedural one. Likewise,repeated avoidance of particular thoughts or feelings may result in theassociated behaviour becoming automated, thus resulting in a so-called‘‘repression’’. Procedural memory influences experience and behaviourwithout representing the past in symbolic form; it is rarely translated intolanguage. Whilstwe can say that proceduralmemories operate completelyoutside of conscious awareness (i.e. they are unconscious), they are notrepressed memories or otherwise dynamically unconscious. This meansthat they cannot be directly translated into conscious memory and theninto words: they can only be known indirectly by inference.
In the very early years of childhood, declarative memory is impairedbecause of the immaturity of the prefrontal cortex and hippocampus,whereas the basal ganglia and amygdala are well developed at birth.During the first two to three years, the child relies primarily on herprocedural memory system. Both in humans and in animals, declarativememory develops later. In other words, a child learns how to do thingsbefore she is able to recall an actual event in her past. Research suggeststhat it is highly unlikely that we can remember events predating our thirdor fourth year of life. This means that there may be procedural memoriesfor infantile experiences in the absence of declarative memories. Indeed,amongst many analytic therapists there is a shared assumption that preverbalexperiences are expressed indirectly and can only be graspedthrough the skilled use of the countertransference.
Declarative memories emerge around three years in line with the increasingmaturity of the relevant brain systems. This finding suggests that theinfantile amnesia Freud spoke of may have less to do with the repressionof memory during the resolution of the Oedipus complex, as he suggested;rather, it may reflect the slow development of the declarative memorysystem. Lack of verbal access to early experiences may therefore have littleto do with repression as an unconscious defence process. On the contrary,it probably results from the fact that these early experiences are encodedin a pre-verbal form and are expressed indirectly, for example, throughsomatic symptoms. In this sense, it is both true to say that we do notforget and that we cannot remember very early events, thereby explainingtheir continued hold over us in the absence of conscious recollection ofthe formative experiences in our early childhood.
The very early events that may exert a profound influence on the developmentof the psyche are most probably encoded in procedural memory.Procedural memory stores a lot of knowledge, but the experiences out ofwhich such knowledge is born are seldomretrievable. In proceduralmemory,we thus find a biological example of one component of unconsciousmental life: the procedural unconscious. This is an unconscious system thatis not the result of repression in the dynamic sense (i.e. it is not concernedwith drives and conflicts), but it is nevertheless inaccessible toconsciousness. By contrast, the world of the psychoanalytic unconscious,in its dynamic sense, has its rootsmost probably in the neural systems thatsupport declarativememory. Repression can occur here, but it is a processthat can only act on events that are experienced at a developmental stagewhen encoding into declarative memory is possible.
Taken as a whole, our current understanding of perception and memorypoints to a fundamental fact, namely, as Gedo put it, ‘‘What is mostmeaningful in life is not necessarily encoded in words’’ (1986: 206). This, as weshall see in the next section, has important implications for how we mightunderstand the process of change in psychoanalytic therapy.
THERAPEUTIC ACTION IN PSYCHOANALYTIC THERAPY
Given that so many therapeutic approaches successfully promote psychologicalchange, it is clear that psychoanalytic treatment is not unique inthis respect. Yet, the attention psychoanalysis has assiduously devotedto the therapeutic process sheds helpful light on those factors that mightcontribute to psychic change.
All schools of psychoanalysis subscribe to the view that clarifying andresolving the patient’s idiosyncratic ways of perceiving the world andother people in light of internal reality will help him to perceive theexternal world more clearly. Broadly speaking, the origins of psychic painare understood to be not simply the result of an external event(s) that wastraumatic but also of the way the event itself is subjectively interpretedand organised around a set of unconscious meanings. Notwithstandinga broad agreement over these questions, there is lesser consensus overhow psychic change occurs through psychotherapy and the techniquesthat drive change. The lack of agreement partly reflects a dearth ofempirical research on these matters. This opens the way for hyperbolicclaims to be made about a variety of techniques that purportedly leadto change.
There are several versions of the process of psychic change. Each versionemphasises different, though sometimes overlapping aspects of the therapeuticprocess and of the techniques believed to facilitate change. Letus briefly review the most dominant accounts. I shall, however, focus inparticular on the account that I find the most persuasive and consistentwith the available research.
The Excavation of the Past
The archaeological metaphor originatesfrom Freud’s topographical model.Compelling in its simplicity, and revolutionary in its time, this versionsuggests that change results from remembering past events that have beenrepressed and from exploring their meaning and impact on the patient.Change is said to occur through the lifting of repression, the recovery ofmemory and the ensuing insight. This is themodel most lay people identifyas characteristically psychoanalytic.
Not inconsistent with this version is the emphasis placed by Freud’s laterstructural model on the importance of helping the patient to build astronger ego that is better able to withstand the pressures of the id and thesuperego. Therapy is said to assist the latter by engaging the patient’s egoin an alliance with the therapist to combat, as it were, the other sourcesof pressure. In particular, the relationship with the therapist is thoughtto allow for the internalisation of a more benign superego. Rememberingthe past and making connections with the present behaviour neverthelessremains a key aspect of the therapeutic work.
The central function accorded in this account to the recovery of memoryleads to a view of the therapist’s role as that of reconstructing the pastthrough the patient’s associations. Reconstructive interpretations thatmake genetic links back to the patient’s early experience and lead toinsight are considered to be important agents of change.
Working Through in the Transference
TheKleinian version of change focuses on the working through of paranoidanxieties and the associated defences to allow the patient to reach thedepressive position. Change is linked to the development of the capacityto mourn the separateness from the object and to bear the guilt and concernfor the state of the object as a result of the phantasised, and real, attacks onit. As the depressive position is established, feelings of guilt and concerncontribute to a wish to repair the perceived damage to the objects. Thecapacity to constructively manage depressive anxieties without resortingto paranoid modes of functioning leads, in turn, to a strengthening ofthe ego.
One of the main goals of treatment is to achieve greater integration ofsplit-off aspects of the self rather than on insight. This task is said tobe largely assisted in therapy by the detailed exploration of transferencephenomena so as to help the patient to understand how he managesintolerable psychic states. The interpretation of transference is believedto facilitate a change in the patient’s relationships to his internal objects,paving theway for a more realistic appraisal of the significant others in hislife. This allows for a greater discrimination between the internal and theexternal world. Kleinians therefore suggest that change results not from aconscious exploration of the past but from a modification of underlyinganxieties and defences as they arise in the therapeutic relationship and areworked through in the transference.
In this view of change, understanding (i.e. insight) and the relationshipwith a therapist who lends meaning to the patient’s communicationsthrough an analysis of the jointly evolving interaction are inseparable.The transference relationship is held to be a key to the change processbecause of its focus on affect – itself regarded as an agent of psychicchange – and because the Kleinians subscribe to the view that the hereand-now relationship is an enactment of the past, that is, it is thought tobe isomorphic with the infantile past. By interpreting the transference, thetherapist is said to be interpreting concurrently the past and the present(Malcolm, 1988). Given this, reconstruction of the past is not regarded asthe most significant aspect of the technique; rather, it is the enactmentin the present and its interpretation that is the effective agent of psychicchange. Linking present patterns to the past is nevertheless acknowledgedto offer the patient ‘‘a sense of continuity in his life’’(Malcolm, 1986: 73).
The Healing Power of the Narrative
Language allows us to begin to form an autobiographical history thatover time develops into the narrative of our life. This is the story that thepatient presents to the therapist, a story that is likely to evolve duringthe therapeutic process. Currently, there is a trend towards understandingtherapeutic action in terms of the integration of accounts from thepatient’s past, leading to the achievement of narrative coherence. In thisversion, it is the stories we tell that make the difference. Narrative truthis considered to be just as ‘‘real’’ as historical truth. Spence (1982), forexample, has suggested that people seek help when they feel confusedby their life stories or when they are felt to be somehow incomplete,painful or chaotic. Psychotherapy helps patients by providing them withan opportunity to create or rewrite a narrative about their lives, throughthe relationship with the therapist, which brings greater cohesion. Therefore,within this model, reconstruction of the past retains an importanttherapeutic function.
The Corrective Emotional Experience
All therapies aim to establish a relationship between the therapist andthe patient, which allows for a safe exploration of the patient’s mind.The majority of psychoanalytic therapists converge on the assumptionthat change occurs through the relationship with the therapist.How this relationship exerts its therapeutic effects and thus facilitateschange remains nevertheless a hotly debated question. For example, isit because the therapist becomes a transference object thereby allowingthe patient to examine patterns of relating in the here and now (asmany contemporary therapists suggest), or do people get better throughinvolvement with an emotionally responsive therapist who providesa new interpersonal experience that disconfirms negative expectationsof others?
Those who subscribe to the idea of therapy as a corrective experience suggestthat the therapeutic encounter offers an opportunity for a new objectrelationship that becomes internalised and disconfirms more pathogenicassumptions about the self and the other. Put simply, the therapist becomesthe ‘‘good’’ object that the patient never had. This position suggests thatbenefits accrue from a relationship with a new object along with the internalisationof new perspectives and ways of responding. In this respect,it is important to make a distinction between the patient’s use of hisexperience with the therapist as a new object that leads to a revisionof internalised object relationships, and in this sense ‘‘corrects’’ the oldmodels, and the more common usage of the term corrective emotional experienceto denote the therapist’s deliberate attempts to act in specific waysto provide the patient with a new experience instead of interpreting thepatient’s internalised object relationships as they manifest themselves inthe transference. Under the influence of infant developmental research,therapeutic changes are sometimes understood as a kind of new developmentanalogous to the emotional development of infancy, but otherclinicians argue that change takes place alongside rather than replacingfaulty development whereby we become more tolerant of the aspects ofthe self and of early phantasies.
Until comparatively recently, the notion of a corrective emotional experiencewas perhaps all too readily dismissed. As we shall see below, somecontemporary thinking on the change process converges on the notionthat the patient’s experiencewith a new objectwho responds qualitativelydifferently towards the patient may indeed be contributing to change atthe procedural level, bypassing language.
Present Change: Making Implicit Models of Relationships Explicit
Led by research, and originating primarily within the ContemporaryFreudian tradition (Sandler & Sandler, 1984, 1997), lies an account ofthe process of change that brings together coherently several of thestrands mentioned above. As we have seen, contemporary models of themind have developed out of an appreciation that much of our relationalexperience is represented in an implicit, procedural or enactive form thatis unconscious in the descriptive sense though not necessarily dynamicallyunconscious.
This version of psychic change suggests that we all have formativeearly interpersonal experiences that contribute to the development ofdynamic templates or, if you like, schemata of self–other relationships.These templates are encoded in the implicit procedural memory system.This system stores a non-conscious knowledge of how to do things andhow to relate to others. Sandler and Sandler (1997) see mother–infantinteractions as the contexts for the earliest formulations of self and objectrepresentations and as providing the basic unit of self-representation.The Sandlers refer to this as the past unconscious. Its contents are notdirectly accessible. Nevertheless, it stores procedures for relationshipsthat may well be stamped into the developing frontal limbic circuitry inthe brain and provides strategies for affect regulation, thus influencingthe processing of socio-affective information throughout the lifespan(Schore, 1994).
The so-called present unconscious, on the other hand, refers to our hereand-now unconscious strivings and responses. If there is any kind ofrepression or censorship, it is said to occur here. Although the contents ofthe present unconscious may become conscious, they are still frequentlysubject to censorship before being allowed entry into consciousness.The lifting of repression in the present unconscious gives us accessto autobiographical memories; it does not give us access to the pastunconsciouswith its procedural memories. The distinction between a pastand present unconscious highlights that our behaviour in the presentfunctions according to templates that were set down very early on in ourlives while simultaneously acknowledging that the actual experiences thatcontributed to these templates are, for the most part, irretrievable.Procedural models for being with others are organised, to begin with,according to the developmental level of understanding available atthe time when they are taking shape. Children internalise their experienceswith significant others. Internalisation, in this sense, occurs ata pre-symbolic level, predating the capacity to evoke images or verbalrepresentations of the object. The primary form of representation is not ofwords or images but of enactive relational procedures governing ‘‘how tobe with others’’ (Stern et al., 1998). Depending on the environment, andthe experiences the individual is presented with, the procedures may ormay not become reorganised over time with the aid of more sophisticatedlevels of understanding. They may be, for example, less integrated withother procedures ormore likely to involve fearful or hostile interpretationsof others’ behaviour that are not open to revision. Moreover, models ofself–other relationships reflect networks of unconscious expectations orunconscious phantasies:
Themodels are not replicas of actual experience but they are undoubtedlydefensively distorted by wishes and fantasies current at the timeof the experience (Fonagy, 1999b: 217).
The internalmodels of relationships that are stored as procedures and thatorganise our behaviour are retained in parts of the brain that are separatefrom the storage of autobiographical memories. This suggests that themodels of how-to-be-with-others that are re-enacted in the transferencebecome autonomous and that the events that may have originally contributedto their elaboration need not be recalled in order for therapeuticchange to occur.
In any therapeutic encounter, several models of self–other relationshipswill be activated and the patient may produce stories about experiencesrelevant to the model that is activated (Fonagy, 1999b). In this version oftherapeutic action, therapy thus aims to bring to awareness possiblemeaningsof the patterns of current relationships. In turn, therapeutic change issaid to result from the elaboration and re-evaluation of current models thatare implicitly encoded as procedures, leading to a change in the proceduresthat the patient uses in his relationships. In this respect, the excavation ofthe past as memories is not considered to be the route to change.
MUTATIVE EXCHANGES
It will no doubt be clear by now that I lean towards the type of model putforward by the Sandlers. The idea that change occurs at the procedurallevel has been further refined by those theoreticians and clinicians influencedby both psychodynamic and developmental ideas who underscorethe importance of the co-construction of new contexts by the meeting oftwo subjectivities (Beebe & Lachmann, 1988, 1994; Sameroff, 1983; Sternet al., 1998). Like the Sandlers and Fonagy, these practitioners also proposethat psychic change occurs partly at a procedural level. Their contributionbuilds on these ideas and specifies more explicitly the implications fortechnique, namely, that verbal interpretations by the therapist may havebecome overvalued tools overshadowing the importance of the quality andthe nature of the interactions between therapist and patient that bypasslanguage itself. The underlying assumption in these accounts is that bothpatient and therapist contribute to the regulation of their exchanges, evenif their respective contributions cannot be regarded as equal. From thisperspective, regulation is an emergent property of the dyadic system aswell as a property of the individual. Within this context, there is room fora variety of interventions, other than transference interpretations, whichmay have mutative potential.
The research that has inspired these perspectives originates from thefield of developmental psychology. A notable contribution from this fieldhas been the description of interaction as a continuous, mutually determinedprocess, constructed moment to moment by both partners in themother–infant dyad. Approaching the question of the patient–therapistrelationship from the standpoint of infant research, Lachmann & Beebe(1996) propose three organising principles of interactive regulation,namely, ongoing regulation (i.e. a pattern of repeated interactions), disruptionand repair (i.e. a sequence broken out of an overall pattern)and heightened affective moments (i.e. a salient dramatic moment). Theysuggest that the three principles serve as metaphors for what transpiresbetween patient and therapist. Moreover they believe that:
At every moment in a therapeutic dyad there is the potential toorganise expectations of mutuality, intimacy, trust, repair of disruptions,and hope, as well as to disconfirm rigid, archaic expectations(Lachmann & Beebe, 1996: 21).
In the therapeutic situation, ongoing regulations range from postural andfacial exchanges to greetings and parting rituals. The way in which theseare regulated promotes, according to Lachmann & Beebe (1996), newexpectations and constitutes a mode of therapeutic action. In other words,they are suggesting that the qualitative nature of the interactions betweenpatient and therapist, even if not verbally articulated, are neverthelesspotentially mutative. Their work underscores a view of psychoanalyticinteraction consisting of non-verbal communication signals that closelyresemble the exchanges between mother and baby.
I would like to draw attention, in particular, to Lachmann & Beebe’s(1996) notion of ‘‘heightened affective moments’’. Pine (1981) originallydescribed particular interactions between mother and baby, which werecharacterised by a heightened affective exchange, either of a positiveor of a negative nature. This might denote, respectively, for example,the experience of united cooing by both mother and baby or momentsof intense arousal in the absence of gratification. Pine suggests that suchevents are psychically organising, that is, they allow the infant to categoriseand expect similar experiences and so facilitate cognitive and emotionalorganisation. Beebe & Lachmann (1994) propose that heightened affectivemoments are psychically organising because they trigger a potentiallypowerful state3 transformation that contributes to the inner regulation. Ifthe regulation is experienced positively as, for example, when the motherand baby are engaged in facial mirroring interactions in which each facecrescendos higher and higher, subsequent experiences of resonance, orof ‘‘being on the same wavelength’’ with another person, are organisedaround such a heightened moment. The notion of heightened affectivemoments is by no means new, and most therapists would agree thatsuch exchanges are essential in developing an emotionally meaningfulrelationship with their patients.
Stern et al. (1998) elaborate some of the above ideas. In their paper, theygrapple with the notions of the ‘‘real’’ relationship and ‘‘authenticity’’.They observe that what we often remember as patients of our therapeuticexperiences are ‘‘moments of authentic person-to-person connection’’withthe therapist:
When we speak of an ‘authentic’ meeting, we mean communicationsthat reveal a personal aspect of the self that has been evoked inan affective response to another. In turn, it reveals to the other apersonal signature, so as to create a new dyadic state specific to thetwo participants (1998: 917).
They refer to these particular exchanges as ‘‘moments of meeting’’. These‘‘moments’’, in a general sense, are interpersonal events that provideopportunities for new interpersonal experiences (Lachmann & Beebe,1996). Stern et al. (1998) propose that they rearrange ‘‘implicit relationalknowing’’ for both patient and therapist. This rests on an important distinctiondrawn by the authors between ‘‘declarative knowledge’’, whichthey hypothesise is acquired through verbal interpretations and ‘‘implicitrelational knowing’’, which is acquired through the experience of actualinteractions between patient and therapist. They suggest that moments ofmeeting contribute to the creation of a new intersubjective environmentthat directly impinges on the domain of ‘‘implicit relational knowing’’,thereby altering it. Such interventions are therefore believed to be mutative.They bring about change through ‘‘alterations in ways of beingwith’’,which facilitate a recontextualisation of past experience in the present,3‘‘State’’ is used here to denote the arousal and activity level, facial and vocal affect andcognition (Lachmann & Beebe, 1996).
. . . such that the person operates from within a different mentallandscape, resulting in new behaviours and experiences in the presentand future (Stern et al., 1998: 918).
In contrast to the suggestion that it is primarily the interpretation oftransference that allows for an elaboration of the object relationships dominatingthe patient’s internal world, Stern and colleagues underscore theimportance of moments of interaction between patient and therapist thatrepresent the achievement of a new set of implicit memories that facilitateprogression to a new level of interaction in the therapeutic relationship.The therapist’s task is to facilitate the deconstruction of established butunsatisfying ways of ‘‘being with’’ while simultaneously moving towardsnew experiences. Moments of reorganisation involve new kinds of intersubjectivemeeting that occur in a new opening in the interpersonal space,allowing both participants to become agents towards one another in a newway. In the course of their exchanges, patient and therapist find themselvesbeingwith each other in a differentway that reflects an emergent propertyof their unique and complex system of intersubjective relatedness.The clinically relevant implication of the position outlined by Sternet al. (1998) is that psychic change may not rely on the patient becomingaware of what has happened. In other words, this account of therapeuticaction suggests that insight may not be necessary to facilitate psychicchange. Rather, the opportunity that therapy provides for qualitativelydifferent types of interactions promotes an increase in procedural strategiesfor action, which are reflected in the ways in which one personinteractswith another. The therapeutic relationship is conceptualised hereas a source of information that is implicitly communicated (Lyons-Ruth,1999), that is, it bypasses language. Elsewhere, I have described theuse of humorous exchanges between patient and therapist as providingan opportunity for relating differently (Lemma, 2000). If we approach thetherapeutic interaction in this manner, prosodic elements of language suchas rhythm and tonality emerge as influential features of the interaction, atleast as much as, if not more than, the actual words exchanged betweenthe therapist and the patient. It thus encourages us to pay attention to theaffective components of language.
As we develop, the increasing integration and articulation of new enactiveprocedures for ‘‘being-with-others’’ destabilise existing enactive organisationsand act as the engine for change. The relationship with thetherapist provides opportunities for new experiences, which challengeexisting enactive procedures.Attachment research has shown that enactiveprocedures become more articulated and integrated through participationin coherent and collaborative forms of subjective interaction. Thedevelopment of coherent internal working models of relationships is tiedto the experience of participation in coherent forms of parent–child dialogue.Such dialogue is characterised by the quality of the caregiver’sopenness to the state of mind of the child. In such interactions, the child’saffective or motive states are recognised and elaborated so that the childis helped in regulating her affective experience. The parent provides‘‘scaffolding’’ (Lyons-Ruth, 1999) to the child’s emotional experience.To illustrate the idea of emotional scaffolding, let us take the example of achild who has just tipped over a pot of paint over the drawing she has beenworking on for some time.When this happens, the child bursts into tears.In one version, the mother rushes over and comforts the child telling her:‘‘Sometimes these things happen and it’s really upsetting.Do you thinkweshould try again?’’ The mother here acknowledges the child’s emotionalexperience, invites the child to re-engage in her drawing thereby alsoimplicitly suggesting that nothing too catastrophic has happened, but alsoleaves it open for her to decide not to pursue it. In otherwords, she respectsthe child’s experience, but also conveys that the child’s internal state offrustration and disappointment can be overcome. In another version, themother rushes over and says: ‘‘Look what you’ve done. I’m going to haveto clean this up now. You’re a ‘bad’ girl. Go to your room.’’ In this scenario,the mother, who for all sorts of reasons may be very stressed, reveals thather mind is so full of her own preoccupations that she reacts to the eventin an accusatory way, depriving the child of an opportunity to process theexperience emotionally. Importantly, she makes a crucial attribution: sheconveys to the child that this has happened because she is ‘‘bad’’. Thislatter exchange is neither collaborative nor coherent.
In the account of change that I favour, we can trace echoes of the notionof a corrective emotional experience. Here the patient is seen to benefitfrom the experience of a new object/therapist4 who has the capacity tomentalise and whose way of relating implicitly attributes significanceto the patient’s emotional experience and acknowledges the patient’sseparateness from the therapist’s own mind. This version of psychicchange provides a more fine-tuned account of how the new experiencewith the therapist can lead to change by altering implicit procedures. Itproposes that non-declarative processes (i.e. procedurally unconscious)underlie much of the non-interpretable changes in psychoanalysis. Inother words, as Lyons-Ruth put it:
4I am not advocating that the therapist should actively behave in ways that, for example,aim to ‘‘correct’’ early parental failures. The therapist’s role is to understand the impact suchdeficits may have had on the patient and, in so doing implicitly provides the patient with a‘‘new’’ experience.
. . . the medium is the message; that is, the organisation of meaningis implicit in the organisation of the enactive relational dialogue anddoes not require reflective thoughts or verbalisation to be, in somesense, known (1999: 578).5
This perspective challenges psychotherapy’s traditional emphasis on thespoken word as the mediator of psychic change. Rather, it proposes thattranslating, or if you like ‘‘interpreting’’, enactive knowledge into wordsmay be an overvalued therapeutic tool:
If representation of how to do things with others integrates semanticand affective meaning with behavioural and interactive procedures,then a particular implicit relational procedure may be accessedthrough multiple routes and representational change may be setin motion by changes in affective experience, cognitive understandingor interactive encounters, without necessarily assigning privilegedstatus to a particular dimension such as interpretations (Lyons-Ruth,1999: 601).
In a post-modern zeitgeist that has so emphasised the relativity of thestories we tell about our lives, psychotherapies of different persuasionshave increasingly viewed the therapeutic process as one that provides theconditions of safety that allow the patient to narrate and rewrite his life.This may well be one of the functions of therapy and it may contribute toits eventual outcome. However, as Frosh so aptly captures:
Many stories can be told about something not because they are allequivalent, but because of the intrinsic insufficiency of language. Thereal is too slippery, it stands outside of the symbolic system (1997a: 98).What is so unique and privileged about the therapeutic encounter is thatit provides an interpersonal context for the narrative process. It maytherefore be that change takes place in the interpersonal space betweentherapist and patient and thatwhat is experiencedmay not be verbalisable,but may yet be mutative.
CONCLUSIONS
Ask any psychoanalytic therapist whether understanding the past isimportant if we are to help the patient and most would agree that it is.Our childhood years are considered to be the most formative period ofour lives. However, the question of how the past influences the presenthad, until comparatively recently, remained unclear, adding confusion tothe question of therapeutic action.
WhenFreud first started to practice psychoanalysis, he believed in the therapeuticimportance of discharging affect and bringing latent instinctualwishes to consciousness so as to overcome resistances to their acceptance.Retrieving early memories that had been repressed was seen to be thelegitimate goal of psychotherapy. To this end, reconstructive interpretationslinking the present to the past were themainstay of analytic practice.A minority of Freudians continue to model themselves on a more classicalapproach conceiving of change as an essentially intrapsychic process thatreliesonthe retrievalofmemories andonthe reconstruction of early events.However, if, as some of the contemporary models reviewed here suggest,change rests on the elaboration and refinement of implicit procedures forbeing with others in a range of emotionally charged situations, then makingthe unconscious conscious does not do justice to the process of changein psychotherapy. Indeed, nowadays many therapists – irrespective oftheoretical group – devote their analytic efforts to an exploration of thehere-and-now transference relationship and the understanding of thepatient’s internal reality. The frequency of references to the past varies,but reconstructive interpretations no longer hold the centre stage affordedto such interventions by the early Freudians.
Contemporary Freudians influenced by developmental perspectives alsoview change as occurring in the here and now. Accordingly, their interventionsare often indistinguishable from those of the Kleinians, the objectrelationists and the intersubjectivists. If there is a difference, it is probablythat the Freudians are more inclined to refer to the past than theothers. Although Freudians and Kleinians approach the patient’s communicationsdifferently in terms of the extent to which they focus on theinterpretation of transference versus reconstructive interpretations, theynevertheless share in common the belief that the present is isomorphicwith the past. This sets them apart from the British Independents whoadopt a developmental view, thereby understanding the here-and-nowsituation as a highly modified derivative that is transformed throughexperience at different developmental stages.
All contemporary accounts of change broadly converge on the importanceof the relationship between patient and therapist although, as we haveseen, this is conceptualised in different ways. We do not yet knowwhich version is the most valid. We need research to help us understandwhat function(s) the therapist performs that facilitates psychic change. Ifwe model our understanding of therapeutic interaction on the functionperformed early on by the good enough parent who helps the child todevelop a capacity to mentalise, that is, to think about her own and otherpeople’s behaviour in terms of mental states, then we can hypothesisethat psychic change occurs through finding a new object in the therapistwho deciphers the patient’s communications and lends meaning to them,ascribing intentions and desires to him. This introduces the patient to anew experience of being with another who can think about his mentalstates without distorting them. Being able to pull together into a narrativesometimes inchoate experiences can feel very relieving most probablybecause creating a narrative is a part of creating meaning and because it isjointly created with another person who shows an interest in the contentsof the patient’s mind, lending meaning to his experiences. This may beone of the functions of psychoanalytic work. As Fonagy suggests:
Psychoanalysis is more than the creation of a narrative, it is the activeconstruction of a new way of experiencing self with other (Fonagy,1999b: 218).
Whilst this new experience will depend in part on the therapist’s verbalinterpretations of the patient’s experience in the transference, it is alsolikely that the way in which therapist and patient interact will conveya great deal of information implicitly. Change is thus likely to also reston the quality of such implicit communications, leading to change at theprocedural level.
The current interest in the ‘‘something more than interpretation’’ (Sternet al., 1998) may pave the way for research into other features of thetherapeutic process that contribute to change. Much will be gained in ourunderstanding of how psychotherapy works if we become more awareof the functions of the relationship between patient and therapist in itsbroadest sense:
Change can only take place if an interpersonal process betweenpatient and therapist is created, establishing a climate of seeing thingsdifferently, of recognising what we can do and what we cannot do, ofunderstanding what is ours and what is not (Bateman, 2000: 153).
The interpretations that we make are more than words leading to insight.At its best, an interpretation is a reciprocal mode of interaction that initself provides an opportunity for the patient to experience a different wayof relating. As we approach the delicate task of helping our patients tochange, we do well to remind ourselves to focus less on the content of theverbal exchanges we have with them and more on the qualitative processunderpinning these exchanges.
FURTHER READING
Sandler, J. & Dreher, A. (1996) What do Psychoanalysts Want? The Problem of Aims inPsychoanalytic Psychotherapy. London: Karnac Books.Sinason, V. (Ed.) Memory in Dispute. London: Karnac Books.
NOTE
1Pattern matching is of interest because as Pally (2000) highlights, it provides some explanationfor the clinical observation that patients often repeat certain experiences. It suggeststhat rather than repeating a particular experience, it may be more accurate to say that wefall into repetitive behavioural patterns because we tend to interpret situations with a biastowards what has occurred in the past (Pally, 2000).
2 ‘‘Explicit’’ and ‘‘implicit’’ refer, respectively, to whether conscious recollection is involvedor not in the expression of memory. Long-term memory may be both explicit and implicit.Both involve the permanent storage of information: one type is retrievable (i.e. explicitmemories), the other most probably is not (i.e. implicit memories).
3 ‘‘State’’ is used here to denote the arousal and activity level, facial and vocal affect and
cognition (Lachmann & Beebe, 1996).
4 I am not advocating that the therapist should actively behave in ways that, for example,aim to ‘‘correct’’ early parental failures. The therapist’s role is to understand the impact suchdeficits may have had on the patient and, in so doing implicitly provides the patient with a‘‘new’’ experience.
5 This is very reminiscent of Bollas’ (1997) evocative notion of the ‘‘unthought known’’.
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