Patients incapable of higher-order (symbolic) thinking can often not tolerate evidence of the analyst's separate existence, particularly when that "otherness" becomes evident in the process of the analyst's reflecting upon and interpreting how the patient experiences or represents the analyst. The patient's intolerance of the analyst's efforts to think (reflect upon and interpret) renders the usual psychoanalytic maneuvers employed to stimulate reflective thought ineffective with such patients. Such patients have to learn to tolerate multiple perspectives before they can allow the analyst, or themselves, to think in the other's presence. The author presents two clinical vignettes that illustrate how the analyst's efforts to think about the patient were experienced by the patient as both intolerably distancing and as rejecting of an aspect of the patient's subjective reality. Working psychoanalytically with such patients requires the analyst to forego the use of narrow interpretations that elucidate unconscious meanings and motives in favor of alternate technical maneuvers capable of facilitating the development of symbolic thinking and reflective thought (insightfulness). These maneuvers include a demonstration of the analyst's willingness and ability to withstand (rather than "interpret away") how he is being psychically represented by the patient, without becoming destroyed by, or lost within, the patient's characterization of him. Beside modeling a tolerance of alternate perspectives of one's self, other non-interpretive maneuvers that help facilitate the development of self-reflective thought include: stimulating the patient's curiosity about the workings of his own mind by identifying incompletely understood behaviors or reactions worthy of greater psychological understanding, and insinuating doubt about the adequacy of the patient's explanations of such phenomena.
This paper illustrates the breadth and depth of the spectrum of perversion and perversity as currently represented in the psychoanalytic literature, raises questions about recent tendencies to include a host of diverse-seeming phenomena under the same conceptual umbrella, and strives to demonstrate what these phenomena have in common that justifies lumping them together under the same rubric. One end of this spectrum is represented by the employment of simple fetishes introduced into a sexual scene in order to promote sexual arousal. Moving along the continuum, one encounters increasing complex behavioral patterns including the enactment of scripts that actualize one's perverse fantasies, including the assumption of complementary roles (e.g. sadomasochism) that equally serve the needs, and represent the desires, of both parties involved. A unique clinical entity, 'perverse modes of relatedness,' lies on the extreme end of the spectrum, representing the reification of the relationship as it becomes little more than a vehicle to take possession and control one's object for the gratification of one's sole needs and desires. What each of these phenomena share in common is both the insertion of a thing or condition - ranging from a simple fetishistic object to an elaborate style of relating that reduces the other into pawn played upon the pervert's chessboard, between the two 'relating' objects as well as a less than honest relationship with reality.
Psychic trauma results when the ego is overwhelmed by intolerable affect. Some childhood experiences are directly traumatic, requiring no intervening interpretive process to render them traumatic. Troublesome affect that falls short of being truly traumatic, in the strict sense of the term, may nevertheless exert a psychopathogenic effect on the child's psychic development. Whether a child is troubled by an experience depends on what that experience meant to the child. Accordingly, the psychopathogenic effects of childhood experience are a function of the child's general level of cognitive sophistication and specific ability to appreciate the subtle nuances of social interactions. If a child's cognitive capabilities are not up to the task of providing the necessary explanations for a given social interaction, the child is left to fall back on fantasy to fill in the gaps. The field of "social cognition" proves particularly helpful in understanding what a child is capable of gleaning from an experience. Research in this area helps psychoanalysts understand how experience becomes constructed and reconstructed in the form of memories. Social cognition also helps psychoanalysts understand when and how a lived experience ends up being psychopathogenic or, alternatively, ceases any longer to exert an ongoing psychopathogenic effect on an individual's psyche. A review of social cognition research leads to a reconsideration of such psychoanalytic concepts as repression, dissociation, reconstruction, and resistance. It also directs attention to the concept of developmental (as opposed to psychoanalytic) reconstruction and deconstruction.
Empathy is often a poorly understood concept. While some feel its value to psychoanalysis cannot be overstated, others feel it has been overemphasized as has the value of properly managing empathic failures that arise during an analysis. This paper will attempt to (1) demonstrate how patients sometimes resist empathy and erect barriers to being understood; (2) illustrate how empathy may sometimes be unachievable due to the difficulties encountered when one tries to empathize with the various aspects of another's experience that are in conflict with one another; and (3) propose that analysts may need to go beyond the common definition of empathy in order to help patients question and discard certain cherished beliefs they hold about themselves.
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