Sunday, October 02, 2011

Intersubjectivity in Therapeutic Communication

My interest and studies in Heinz Kohut's Self Psychology have taken me into an offshoot of his own work with empathy - intersubjectivity theory. There are a small handful of well-known authors in this area of modern relational psychoanalytic practice (Robert Stolorow, Donna Orange, Daniel Stern, Stephen Mitchell, George Atwood, Jessica Benjamin, Bernard Brandchaft, and Beatrice Beebe, among others).

When I wrote off modern psychoanalytic work as a recontextualized version of Freud over the past few years on this blog, I apparently had no idea what the hell I was talking about (sorry about that!).

This whole relational and intersubjective realm of study was thriving and I had not been exposed to it. Certainly there is still a large contingent of neo-Freudian psychoanalysts who still use much of the familiar Freudian terminology, and they are still the mainstream in some sense, but the intersubjectivists are having a tremendous influence not just in psychoanalysis, but in other psychotherapeutic approaches as well.

This newer field of relational psychoanalysis is more aptly viewed, to me, as neo-Kohutian in that it builds from Kohut's essential rejection of Freudian drive theory and his replacement of it with Self Psychology, placing the Self as the central motivation in human development.

The following is a very brief overview of intersubjectivity theory (written by Daniel Stern) from the American Psychoanalytic Publishing Textbook of Psychoanalysis (2005, p. 77).
BROADLY SPEAKING, intersubjectivity concerns the ability to share in another’s lived experience. More specifically, Dunn provides a convenient summary definition of intersubjectivity in psychoanalysis as “the dynamic interplay between the analyst’s and the patient’s subjective experience in the clinical situation” (Dunn 1995, p. 723). The issue of intersubjectivity entered the psychoanalytic discourse through the doors of transference (Freud 1905 [1901]/1953, 1912a/1958) and countertransference (Freud 1912b/1958), with     large influence from Ferenczi (Aron and Harris 1993). But alongside these specific contributions, intersubjectivity has permeated psychoanalysis since its beginning as a hidden basic assumption. After all, persons would never even bother to talk to others about their personal subjective experiences if they did not assume that the others could share or see the mental landscape they were describing. In this sense, intersubjectivity has been almost like the oxygen we breath but never see or think of.

In the last decades, however, intersubjectivity not only has been made visible but is assuming a foreground position in the theories and practice of psychoanalysis. It has emerged as one of the major underpinnings of several new schools in psychoanalysis: the broad category of intersubjectivist schools (Aron 1991; Atwood and Stolorow 1984; Beebe and Lachman 2002; Benjamin 1988, 1995; Ehrenberg 1982, 1992; Greenberg 1988; Hoffman 1991; Jacobs 1991; Knoblauch 2000; Modell 1993; Ogden 1994; Renik 1993; Spezzano 1995; Stolorow et al. 1987, 1992, 1994), the interactional school (Boesky 1990; Chused 1991; Chused and Raphling 1992), the relational schools (Bollas 1987; Greenberg and Mitchell 1983; Mitchell 1988, 1993, 1997, 2000), and schools based on aspects of self psychology (Goldberg 1988, 1994; Kohut 1959, 1977; Wolf 1988). All have highlighted some of the basic intersubjectivist assumptions that set these approaches apart from classical Freudian psychoanalysis, at least theoretically (see Aron 1991; Dunn 1995; Mitchell 2000 for critical reviews).
I need to add a note of caution here. Stern contends that, "In the extreme, there is no objective reality that stands outside the intersubjective matrix of a session" (p. 78). Other authors disagree with this statement, notably Stolorow, who argues that objective reality is not knowable or accessible through using the introspective/empathic stance of intersubjective psychoanaltsis ("Clarifying the intersubjective perspective: A reply to George Frank," 1998), which is qualitatively different than saying it does not exist.

Anyway, Stern also offers the following working definition of intersubjectivity.
Intersubjectivity is the capacity to share, know, understand, empathize with, feel, participate in, resonate with, and enter into the lived subjective experience of another. It is a form of nonmagical mindreading via interpreting overt behaviors such as posture, tone of voice, speech rhythm, and facial expression, as well as verbal content. Such a capacity is, of course, a crucial aspect of the work of psychoanalysis, which assumes that the analyst can come to share, know, and feel what is in the mind of a patient, in the sense of what the patient is experiencing. And the analysand expects (hopes and fears) that the analyst can and will do this.

We first turn to a more complete definition of intersubjectivity, in which we can distinguish its various forms and other related terms, especially as they are used in psychoanalysis.

How is intersubjectivity different from empathy or sympathy? For all practical purposes, psychoanalysis has used the term empathy in the place of intersubjectivity. (Actually, the original meaning of sympathy comes closer to the current sense of intersubjectivity.) The problem with comparing empathy and intersubjectivity is that empathy, as used in the context of psychoanalysis, has come to have so many meanings (Lichtenberg et al. 1984). Reed (1984) noted that the concept of empathy in psychoanalysis not only has multiple meanings but also has several antithetical usages. The active use (grasping meanings, understanding, interpreting) and the passive use (resonating, loosing the self in the other, illumination) are two examples. There is a tension in usages of the term between those in which empathy appears to be basically rational and those in which it is ultimately mysterious, having a completely intuitive basis. In a similar vein, there is a tension between empathy as a process belonging essentially to art (where it had its origin in aesthetics) and one belonging to science (a dichotomy long evident in psychoanalysis). In the totality of its usages, there is also confusion as to whether empathy refers more, or even exclusively, to emotional experience or feelings than to explicit, verbal, propositional content. Furthermore, empathy has been antithetically viewed as penetration (phallic and masculine) or as creation (nurturing and feminine). There is also the confusion about the nature and scope of empathy. Is it a tool, instrument, clinical mechanism, a way of listening, a condition of humanness, or a basic principle of therapeutic technique? Where are its limits? Or, in a similar vein, is empathy periodic, only being activated from time to time, or a continuous process? Is it empathy only when it evokes a response or action toward the person empathized with? Or can it be silent and motionless? This summary does not exhaust all the meanings and uses of the concept of empathy, but it gives an idea of the complexity and weight of the intellectual and historical baggage that the concept carries in psychoanalysis.

In short, empathy has become the term in psychoanalysis that has been used to encompass the many facets of the concept of intersubjectivity. For this reason I will not try to explore where the definitions of empathy and intersubjectivity overlap or diverge. It would be useless. Instead, I plan to take the term and concept of intersubjectivity and establish it as the fundamental human process that empathy borrows from in creating its multiple meanings.

This isolating of intersubjectivity (both the term and the concept) from empathy is justified on several grounds. First, as discussed in the next section, we are beginning to have a solid, unified, scientific, and developmental basis for understanding intersubjectivity. Other disciplines (philosophy, development psychology, consciousness studies, academic psychology, neuroscience) are all actively studying intersubjectivity, and the term intersubjectivity has become the coinage of the larger realm. If psychoanalysis would use it too, we could better note where psychoanalysis, because of its particular nature, may need other terms to distinguish concepts clearly from the base concept of intersubjectivity. It would also clarify and systematize the multiple meanings sought after in psychoanalysis.

Is consciousness required for intersubjectivity? In philosophy, intersubjectivity refers only to mental material that is conscious (this can include material that was preconscious or unconscious just before). This restriction is necessary because intersubjectivity addresses the subjectivity of the other, and subjectivity concerns only what is now being experienced on the mental stage of consciousness. Indeed, as noted at the opening of this chapter, Dunn (1995) defines intersubjectivity in the psychoanalytic situation as the interplay of two subjectivities. For other psychoanalysts, on the contrary, intersubjectivity also includes mental material that is unconscious or simply out of awareness. The knowable mental stage of the other has been extended, and one can know what is happening in the wings as well as on the stage of consciousness. To push it even further, Heller and colleagues (2001) suggest that a therapist can know another’s mind implicitly and nonconsciously through their nonverbal behaviors—that is, without consciously knowing that he or she knows. It is clear that intersubjectivity requires an awareness of subjective states but not necessarily a reflective consciousness of these states.

Is intersubjectivity symmetric in the analytic setting (symmetry or asymmetry; one-way or two-way intersubjectivity)? If the analyst understands or feels what is going on in the mind of the patient but the patient does not know that (or if the patient understands or feels the analyst’s experience but the analyst does not know that), we have a situation of one-way, asymmetric intersubjectivity. Neither knows that the other knows. This is the situation that prevails in psychoanalysis much of the time. In two-way intersubjectivity, both analyst and patient are viewing a similar mental landscape together and they know it and mutually validate each other’s knowledge. It permits them to sense or to say, “I know that you know that I know,” or, “I feel that you feel that I feel.” This also happens during sessions but is a rarer, more circumscribed event. The two-way experience often results during interpretive activities, especially immediately after an interpretation has been made and the impact is being absorbed by the patient.

Many psychoanalysts (Stolerow et al. 1992) focus mainly on the one-way intersubjectivity of the analyst’s knowing the patient’s subjective experience; this focus is congruent with an emphasis on the transference. Others (e.g., Benjamin 1995; Jacobs 1991) focus more on the one-way intersubjectivity going in the other direction; here the emphasis is more on the countertransference. Still others (Boston Process of Change Study Group 2003a, 2003b; Stern et al. 2002) talk in terms of a roughly symmetrical field, or at least one whose direction fluctuates frequently.

Is intersubjectivity about understanding or about feeling? Some analysts focus on the understanding of what is going on in another’s mind—understanding in the sense of knowing, describing, and even explaining. Others (e.g., Kohut 1977) focus on the empathic immersion, the participation in the other’s experience. Intersubjectivity includes both. This distinction can also be seen through the lens of verbal versus nonverbal sources of intersubjectivity. While talking has a very special place in psychoanalysis, it is always accompanied by gestures, changes in body tonus, shifts in posture, and changes in tone of voice and other paralinguistic features such as spacing of silences and rhythm. These nonverbal features are the other source for intersubjectivity, along with the content of speech. Without the nonverbal it would be hard to achieve the empathic, participatory, and resonating aspects of intersubjectivity. One would only be left with a kind of pared down, neutral “understanding” of the other’s subjective experience. One reason this distinction is drawn is that in many cases the analyst is consciously aware of the content of speech while processing the nonverbal aspects out of awareness. With an intersubjectivist perspective, a more conscious processing by the analyst of the nonverbal is necessary. A second reason for distinguishing between verbal and nonverbal sources is that the purely verbal source for intersubjectivity operates in a different time frame and by way of a different process than the nonverbal sources (Stern 2003).

Can intersubjectivity be imaginary? In projective identification the patient, for example, imagines that he or she feels or knows what is in the therapist’s mind, but in fact these mental contents belong to the patient and were projected onto the other’s mind. If that were all, it would be a false or imagined intersubjectivity. However, the projection is not made of whole cloth; it is usually built around a piece of truth about the analyst, however small. In addition, it is frequently noted that a countertransference may begin to emerge in the analyst that complements the transference of the patient. Even if the truth is small, we end up with a complex mixture of “true” and imagined intersubjectivity. Intersubjectivity comprises a large set of phenomena. It seems unnecessary at this point to restrict its usage with too tight a definition, especially in clinical matters. Nonetheless, the distinctions noted above should be kept in mind in order to think and communicate more clearly. (Stern, p. 78-80)
For those who are interested in this theory, several of the books (actually most) in the I recommend box from Amazon (on the sidebar) are explications of this model and how to use it in psychotherapy.

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