4 The Unitary Sequence for Processing Interactional Communications An Introduction
We have outlined a sequence consisting of three phases: Reception, Internal Processing, and Communication. In the first phase, the therapist receives the patient’s interactional communications and is thereby acted upon and influenced by the patient; the second phase encompasses the therapist’s internal experience and analysis of what has been communicated through the interaction by the patient; and the final phase entails the therapist “giving back” to the patient through the interaction what has been internally processed. (Page 88)
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if a therapist has a clearer understanding of what he is experiencing and how that might be useful rather than disruptive, he is in a much better position to implement whatever technique he happens to favor. The same is true regardless of his position on countertransference disclosure. The schema offers a framework that facilitates the therapist’s understanding of his internal reactions and helps lay the groundwork for the ultimate technical application of the emotional knowledge of the patient that has been achieved. (Page 90)
the therapist’s degree of conscious awareness of his internal state at any point in the processing sequence depends largely on his capacity to tolerate the image of self that is aroused by the interactional communication from the patient.Optimally, the therapist is a willing recipient of the introjective identifications that are induced by the patient’s interactional pressure. However, therapists differ in their willingness to tolerate potentially uncomfortable self-states, depending on the particular dynamic involved and the intensity with which it is transmitted. The therapist, for example, who is being portrayed relentlessly by his patient as withholding, incompetent, intentionally depriving, and greedy is truly on the “hot seat.” Although there certainly are occasions when a therapist must impose limits on a patient’s actions, it is the ability to tolerate and become aware of the powerful feelings stirred up by such forceful interactional communications that largely determines a therapist’s progress within the sequence of phases described in the following chapters. (Page 90)
Borrowing from the developmental literature, we have delineated two general patterns of empathic disruption—arrest and regression—which may occur at any subphase level in the Reception and Internal Processing phases. (Page 91)
5 The Reception Phase
Subphase 1. Mental Set
The term mental set refers to the therapist’s mental activity immediately before and during the session with a particular patient. The therapist aspires to a state of mind characterized by the absence of preoccupation with outside matters and allowing for optimal attention to the interactional presence of the patient. What is called for here is not a deliberate effort to concentrate, but rather what Freud (1912) referred to as “evenly suspended attention,” in which the therapist does not direct his “notice to anything in particular.” (Page 94)
The same point has been made with respect to “free association,” in that a patient’s “utterances” are never entirely devoid of censorship, conscious or unconscious. Similarly, a therapist can never be said to be entirely neutral in his presentation to the patient, though he may exercise restraint so as to allow the patient maximum opportunity to construe what he believes the analyst’s position to be. (Page 94)
Everyone familiar with psychological testing understands the effortful concentration required to perform well on the Arithmetic subtest. This mental facility is quite different from the free-flowing, spontaneous attention necessary to perform well on Digit Span, a subtest calling for the subject to repeat an increasingly long series of numbers orally presented by the examiner. The latter state of mind represents the optimal listening stance during the first stage of the empathic process, when the therapist is seeking heightened receptivity to an empathic trial identification. (Page 95)
Sandler was suggesting that Freud’s evenly suspended attention should be directed not only to the patient but also to the therapist’s own material emanating from within. But in addition Sandler elaborated Freud’s recommendation still further by advocating what he called “free-floating responsiveness” in the therapist. He proposed that a therapist’s experience with a particular patient most often represents a compromise between his own tendencies or propensities and the role-relationship the patient is unconsciously seeking to establish. Thus, by focusing free-floating attention not only on thoughts, feelings, and associations coming from within, but also on his own overt behavior, the analyst may learn something very important about the patient in light of the roles the patient may unconsciously be seeking to orchestrate. Within the limits established by the treatment situation, free-floating responsiveness in actions—such as the use of humor or the particular way the patient is greeted—can thus be a potentially useful source of empathic insight. (Page 95)
it is always useful to maintain an interactional focus and to consider possible ways in which the patient may have stimulated the therapist’s response. Even if the contribution of the patient is felt to be slight, this awareness may nevertheless prove to be very useful to the therapist, both in overcoming the disruption and in learning something about himself and the patient. (Page 97)
The combination of factors—characterological tendency to selfdoubt, fear of disappointing a respected colleague, defensive skepticism from the patient—so riddled the therapist’s capacity for free-floating attention and responsiveness that the empathic process was subtly but abruptly short-circuited even before the interactional pressure from the patient could be developed more fully. (Page 98)
Subphase 2. Interactional Pressure
Within the limits of his or her tolerance, it is the therapist’s task to allow the patient the freedom to develop the communication through the verbal and nonverbal channels of the therapeutic interaction. In so doing, the therapist is required to sustain an openness to being influenced emotionally by the patient in order to be receptive to the induction of a projective identification. (Page 100)
Disruptions at this juncture of the empathic process typically fall into one of two opposite categories. At one extreme, the therapist assumes an overly rigid or controlling posture, thereby consciously or unconsciously shutting off or clamping down on the interactional transmission of a patient’s projective identification in its incipient stage before the identification has really taken hold within the therapist. (Page 100)
Consequently, the therapist conveys to the patient, with varying degrees of explicitness, that the therapist is experiencing discomfort and is not open to the continued reception of the particular communication which is being developed in the interaction. (Page 101)
Such a communication from the therapist directly conveyed to the patient that he was not willing to tolerate further interactional pressure aimed at communicating hopelessness, anger, and retaliatory impulses. In this instance, the therapist missed an opportunity to learn that the patient was unconsciously trying to communicate her own uncomfortable experience of feeling abandoned and unwanted by attempting to make the therapist feel the same way. (Page 102)
At the other extreme from the therapist who shuts off interactional pressure before the transient identification takes place is the therapist who disrupts the empathic process by adopting an “anything goes,” laissez-faire posture. If the former class of disruption generates identifications that may be described as “undercooked,” the latter scenario is associated with therapist identificatory experiences that are dramatically “overcooked.” (Page 102)
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When, for example, a therapist allows a patient to scream at him for long periods of time, Kernberg argues, the patient is being provided with a destructive opportunity for gratification of aggressive instinctual drives. He suggests (pp. 185–190) various “modifications in technique” to provide necessary structure both outside the treatment and in the session itself (e.g., prohibition against destroying objects in the office). These modifications are essential for a predominantly interpretive treatment to occur. (Page 103)
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Interactional pressure often takes place behaviorally around the ground rules and structural arrangements (cancellation policy, phone calls, timeliness of appointments and payment schedule) of the treatment. (Page 103)
Although the empathic process may not entirely fall apart until the next subphase or even later, in retrospect it can often be seen that the seeds of disruption were sown when the therapist, either by a laissez-faire passivity or by active collusion, permitted the patient’s interactional pressure to exceed useful limits. (Page 104)
the therapist’s primary efforts were to address the patient’s interactional pressure in order to render the experience manageable for both parties so that useful psychoanalytic work could occur. The alternative would have been either to clamp down too early and reject the patient before the projective identification could be transmitted, or simply to allow the abusive behavior to continue unchecked.
Subphase 3. Identification-Signal Affect (Page 105)
Under optimal conditions in the empathic sequence, the therapist, having allowed the interactional pressure to unfold within workable limits, has an identificatory experience characterized by particular self-experiences and their associated affective states. The therapist can be thought of as having introjected a communication that exerts a modifying influence on his experience of self in the interaction. His affective reaction to the particular self-experience elicited by the immediate interaction optimally is a “signal affect” (Schafer, 1959; Zetzel, 1965; Olinick, 1969; Beres and Arlow, 1974). His tasks at this subphase level are to continue his receptivity, again within tolerable and reasonable limits, to the modification of his self-experience and to become aware of this shift in experience by recognizing the signal affects emanating from within that alert him to the possibility that an identification has been made. The nature and intensity of the interactional communication being processed vis-à-vis the therapist’s capacity to tolerate the transitory modification of his self-experience largely determine the degree of awareness in the therapist of the identificatory experience. (Page 105)
Although a projective identification transmitted by the patient has taken hold within, the therapist cannot move forward in the Internal Processing phase without becoming more aware that this critical event has in fact taken place. (Page 106)
Unaware of the affective signals (anger, exhaustion, and powerlessness) that accompanied the reception of the patient’s projective identification, the therapist devised a plan for dealing with the patient that would “adequately address her needs.” He recommended that she consult a psychiatrist for antianxiety medication. The patient followed the recommendation and received medication, only to terminate treatment shortly therafter. Unable to tolerate a conscious awareness of himself as angry with the patient and exhausted and powerless in his efforts to help her, the therapist had blocked from consciousness the affective signals that he might otherwise have utilized to alert himself to the fact that he had received a projective identification. As a result, he could not apply his self-experience to increase his understanding of the patient and guide his interpretations. (Page 107)
The Reception phase comprises three subphases: Reception, Interactional Pressure, and Identification-Signal Affect. In this opening phase of the empathic process, the therapist must first be able to clear his mind of outside preoccupations in order to attend adequately to the interactional presence of the patient; second, he must sustain a receptivity to verbal and nonverbal interactional pressure from the patient, within reasonable and tolerable limits, so that the patient has the opportunity to transmit projective identifications. Last, the therapist optimally recognizes his emotional response to the patient, not as a surface “reality,” but as a signal affect, containing potentially valuable underlying meanings, which can alert the therapist to the fact that an identificatory experience has in fact occurred. (Page 108)
La composición de la primera fase de comunicación afectiva en psicoterapia.
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