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Theodore J. JACOBS, M.D.
Several months ago, I attended a meeting in which my friend and colleague, Dr. James McLaughlin was speaking. At one point in his talk, which was about enactments, he surprised me by stating that the term, enactment, was coined by Ted Jacobs in 1986.
I had no idea that this was true. I had always thought that the word, enactment, was in general use and that I had simply borrowed it to describe certain behaviors of my patients, and of my own, because I preferred it to the term "acting out" which always seemed to me to have pejorative connotations.
Since that time, the term, enactment, has been so widely employed in America that it is impossible to pick up an analytic journal without encountering an article that focuses on one or another aspect of that phenomenon. Overused and utilized in different ways by different authors, the concept has begun to lose clarity and, not infrequently, it is difficult to know just what a colleague means when he or she speaks of an enactment.
Regarding behavior of any kind as an expression of an individual's psychology, certain authors (Renik, 1993b, McLaughlin, 1992) maintain that any action taking place in analysis, including speech, is an enactment. While theoretically this is true, so broad a view of enactments, I believe, renders the term equivalent to the word, action, and essentially robs it of any specific meaning.
Other colleagues (Chused, 1991), while limiting the idea of enactment to behavioral manifestations of conflict in patient and analyst maintain that enactments always involve actions taking place on both sides of the fence and should be regarded as joint creations of the two participants.
My own view is somewhat different. While I agree that most often enactments are the product of two psychologies interacting to create the clinical phenomenon, I believe that there are times when an enactment represents a manifestation of one individual's psychology that is played out vis-à-vis the other participant. While the latter may be--and usually is--drawn into the conflict, in these situations it would not, I think, be correct to see the enactment as invariably the product of both patient and analyst.
What I tried to convey, in fact, when in 1986 I first wrote about enactments was the idea that these are behaviors on the part of patient, analyst, or both, that arise as a response to conflicts and fantasies aroused in each by the ongoing therapeutic work. While linked to the interplay of transference and countertransference, these behaviors are also connected, via memory, to associated thoughts, fantasies and experiences of childhood or adolescence. Thus, for me, the idea of enactment contained within it the notion of reenactment, the reliving of bits and pieces of our psychological past.
In this paper, I will describe two instances of countertransference enactments which grew out of, and were closely linked to, blocks and impasses which developed in treatment. My behavior in these cases developed in response to behavior on the part of the patients that could also be characterized as enactments, as they represented a living out of aspects of their own histories. These examples illustrate the fact that most often enactments involve actions on both sides of the couch; actions that contain communications of the greatest importance.
Some years ago, in the early days of the women's movement, when most male analysts wore their chauvinism like a comfortable old cardigan, a girl of 18, a militant young feminist, came to see me. That she did so for target practice among other complex reasons, soon became evident, for from the moment Ms. N stepped foot in my office, she unleashed a blistering attack on Freud and his testosterone-heavy theories, on analysis as male propaganda, and on me as one of its sexist practitioners. Finally, leaning forward in her chair and looking for all the world like a bull about to charge, she hurled a challenge at me.
"I'm into consciousness-raising," she announced. "What are you into?" Taken aback, I did not know what to say. For several seconds I stared at her blankly. Then a response popped into mind.
"Unconsciousness-raising," I replied.
That exchange pretty much summed up the situation between Ms. N and myself. From the outset a major disagreement divided us. For Ms. N, the pain and suffering that she experienced and the unhappiness in her life for which she sought relief stemmed from a single source; society's discriminating attitude towards women. I, on the other hand, was interested in promoting the idea that in addition to this harsh reality, the inner world of fantasies and beliefs that Ms. N developed as a consequence of her unique psychological experiences played a role in her troubles.
It was a standoff, and, as the result of this non-meeting of the minds, for some months progress in the analysis could be measured by the thimble full. In time, however, things began to change. Largely, I think, because we came to understand one another, Ms. N and I finally reached an accommodation. I learned to listen to and appreciate her realities, external as well as psychological, and to convey that appreciation to her, and she, grudgingly, allowed that the particular way in which she put things together in her mind might have influenced her thinking about herself and others.
We still had our troubles, though, and one difficulty centered around the tedium which I sometimes experienced during Ms. N's sessions. Although her capacity for self-reflection gradually improved, Ms. N was given to much externalization. It was not rare for her to focus on the shortcomings of others and to complain at length about the way that she was treated by friends and family. Leaving no detail to the imagination, she would cite every fault, foible and blemish of the miscreants who had used her badly. A particular target of hers was her father, a vain, bigoted, and devious man who fancied himself a scholar and a gentleman and who sought, through lies and rationalizations, to induce others to believe in this deluded self-image.
While the material relating to Ms. N's father and other family members was assuredly important, after a while it became so familiar, the same complaints and stories so oft repeated, that I found myself experiencing fatigue in sessions. Recognizing that strong emotions must be lurking behind this reaction of mine, I undertook what self-reflection I could and came into touch with the feelings of anger and annoyance that Ms. N's clearly defense behavior was evoking in me. While useful in providing some insight into what was transpiring beneath the analytic surface, this approach had little effect on my responses to Ms. N.
I felt a clear sense of relief, then, when, in the second year of treatment, some new and rather dramatic material made its appearance in Ms. N's sessions. This material had to do with the strong possibility that my patient, as a young child, had been sexually fondled by a male teenage cousin who occasionally baby-sat for her. Although, generally speaking, I am wary of the idea that such experiences are the key to neuroses, I was interested in exploring the sequelae of this episode. I thought that the fantasies it had evoked and the transformations in memory it had undergone over the years might help account for Ms. N's persistent and irrational anxiety over physical contact with the boys whom she dated; a symptom for which I did not, at that point, have an entirely satisfactory explanation.
Keenly interested in this newly emerging material and eager to hear more about it, I was frustrated and disappointed when, soon after making a transient appearance in Ms. N's associations, it disappeared from view. It was as if the repressive forces that had originally overtaken it had, once again, driven it underground. And although I worked as actively as I could with the defenses that I thought were keeping the relevant affects and memories out of conscious awareness, they remained undercover.
Instead of speaking of the material that was new and possibly of great significance in her development, Ms. N returned to the old complaints, wrapping herself in them as though they were a suit of used clothing.
Once again I found it difficult to keep attuned to her; once again I experienced tedium.
During one early morning hour following a night in which I had had little sleep, I was particularly restless. As often happens when I am tired, I moved about more than usual in my chair. I twisted, fidgeted, I shifted positions, all no doubt in an effort to stay alert. Finally, as Ms. N was droning on about one of her tight-fisted relatives, I found myself reaching for the notebook that I keep at my side to record an occasional dream, an intriguing sequence of associations, or other material that I may wish to review. There was nothing in what Ms. N was saying, however, that I wished to record. Nonetheless, I had reached for the book and fingered its binding. Then I opened it to the section reserved for Ms. N and glanced at an old note that I had written. All this I did as a distraction. I was bored and tired and I wanted some stimulation, some relief from the feelings of dullness and uneasiness that I was experiencing. And in the process of thumbing through the notebook and glancing at the previous note, I had tuned my patient out and had missed a few sentences of what she was saying. I had managed to blank them out.
Although my movements were carried out quietly, they were not so quiet that Ms. N did not hear them. At first she said nothing and simply carried on with her dissection of the penny-pinching relative. There was something different in her voice, however. She was speaking in a routinized way, like an actor reciting his lines while thinking of an unpaid rent bill.
Then, suddenly, Ms. N was silent. For several minutes she did not speak.
"Something's happened," I said. "Something seems to be blocking you."
"I didn't think that you were interested in what I was saying," Ms. N replied. "I thought that you were distracted. I heard noises."
"And what did you make of what you heard?"
"I don't know. There were odd sounds, like you were stroking something or fingering something. Then it sounded as though you were opening a book and turning pages."
As Ms. N spoke, I recalled something that she had told me sometime before; that as he read her a goodnight story, her cousin's fingers would begin to play over the pages of the book. Then, slowly, he would reach out, touch her thigh, and move his hand toward her genital area.
"I thought that you had no interest in what I was saying," Ms. N went on, "that I was totally boring and that you had picked up a book and were leafing through it. Either that or you were just playing with it to amuse yourself."
"'Stroking it,' you said before."
"Yes, that, too. I heard rubbing noises. Maybe that's the way shrinks get off in sessions when they are bored. They rub their books instead of their dicks. That's their perversion."
Then Ms. N fell silent again. When she resumed speaking, her voice contained a note of resignation.
"Okay. I get it. You think I thought that you were like my cousin, George; ready to make a move, ready to reach for my crotch. I wasn't aware of that, but maybe I did. Actually, I wouldn't put it past any shrink. Most of them end up screwing their patients one way or another. You guys are a pious lot, but sneaky. Patients get abused in therapy all the time."
Ms. N went on to speak at some length of her distrust of therapists, especially males, and of her suspicion that I might turn out to be as devious as most men who, one way or another, use women. Then towards the end of the session, she spoke once more of the nighttime scene with her cousin, repeating what she had told me and recalling for the first time that she had a crush on him and felt very excited in his presence. Then she added that there was probably something to the fact that she had come to believe that all men, basically, were like George; charming and exciting, but not to be trusted. And rising from the couch she added a final note.
"It's true," she said, "that lying down scares me. I don't see you and I don't know what you are about. When you start moving around I get jittery. I don't know what might happen next. In that sense, I've probably gotten you and George all mixed up in my mind. But what bugs me, what really makes me crazy, is when I begin to think that you are like my father. Not only that I imagine that you are like him, but that you really are like him."
After that session, Ms. N's distrust of me increased. Her resistances hardened and silences dominated the sessions. When she did speak, what she said was mostly reportage; dispatches consisting largely of descriptions of other people and accounts of events at school. She had gone into hiding and the reason for this was clear. In some part of her, Ms. N knew that I had deceived her with a piece of psychoanalytic slight of hand. Out of boredom, anger, and a wish to escape from those feelings, I had turned away from Ms. N and tuned her out. I had not been doing my job, the job she was paying me to do, and for which I had signed on. And, seeking distraction from inner tensions, I had been caught out. Ms. N sensed what was happening. Rather than acknowledging the truth of her perceptions, however, and thereby experiencing the feelings of shame and guilt that would accompany such an acknowledgment, I had led Ms. N down another path. And for reasons of her own which Had much to do with her fear of a threatening confrontation, she went along with me.
It so happens that the path on which I set her needed to be explored and both of us knew it. And that exploration had its own value, for significant memories concerning a traumatic and influential childhood experience were, in fact, triggered by my behavior in making covert noises. Her associations led to the emergence of some new and important material related to that experience, and one might even argue that, unconsciously, I was enacting the role of the cousin in an effort to stimulate the re-emergence of the repressed material. But as important as these factors were, it is also true that both patient and analyst made use of them to avoid confronting what, for each, was a more anxiety-provoking issue. By moving rapidly to the past, we entered into a collusion in which the apparent analytic investigation of an important childhood experience was used in the service of this mutual avoidance. Utilizing a particular kind of body English, I had turned Ms. N away from the truth. In doing so, I had, in fact, become what she feared most that I would be; an untrustworthy person. Ms. N's remarks at the end of the hour summed up the situation succinctly. As a consequence of the deception that I had initiated, I had become not only the father in the transference, but a man who, in actuality, had behaved like Ms. N's father. And until I could return to this incident, replay it with my patient, and help her understand what had truly happened, she could not trust me.
Some colleagues have asked me how I did this. This question seems to me to reflect the discomfort that many of us feel at the idea of an analyst revealing anything of himself to patients. No doubt there is much to be said for learning as much as we can about ourselves as we work, for keeping what we learn to ourselves, and using that knowledge in the service of understanding our patients. It goes without saying, too, that we need to explore our patients' fantasies without burdening them with our own problems, our own realities. But there are times when not to acknowledge a mistake or not to confront the fact that, in order to avoid hard issues, a collusion between patient and analyst has taken place and that, as a result, the treatment has been turned in a particular direction, is, I believe, a serious error. It compounds the mistake initially made and puts the patient in a destructive bind; a bind, incidentally, that often cannot be resolved solely through exploration of the patient's fantasies. Sensing that we do not want her to see the truths, he has to deny what, in fact, some part of her knows. Such a situation cannot foster growth. It can only lead to concealment, deception and distrust.
When, in a subsequent session, I detected a reference to the incident in question in Ms. N's associations, I drew her attention to her ongoing concern with it and sought to continue exploration of her thoughts and imaginations about what had happened. This yielded little, however, nor did interpretations of her anxiety about speaking frankly about the episode. Recognizing the untenable position in which Ms. N had been put--she had, in reality, been gaslighted--and realizing that meaningful work in analysis could not take place under these circumstances, I felt it important to address the issue more directly. I therefore asked Ms. N if she had any awareness of the fact that her perceptions had been accurate and that she had correctly identified the sounds she heard as my thumbing through a notebook. She replied that she had, but had quickly dismissed that idea. I then confirmed the truth of her observations and said that I had become distracted and that my mind had wandered. I also told her that I had been embarrassed by this lapse, had not been comfortable acknowledging it, and so had focused her attention on another possible connection--a safely distant one--with the noises I had made in the hour.
Ms. N replied that she had sensed that this was true but that she could not confront me with my evasion. She was too afraid of the consequences. Once the air was cleared in this way, we could do what we should have been doing all along; exploring more fully the covert communications taking place between us that led on the one hand to my experiencing boredom and fatigue during Ms. N's hours, and, on the other, to her need to present herself in a way that contributed to the evocation of such reactions. Later on we had a chance to explore other relevant issues; Ms. N's reaction to my evasion, her own need to evade the truth and not confront me with her perceptions, and the response she had to my finally acknowledging what had happened. Each of these reactions was important as they contained views of me, initially as weak and vulnerable, then as more hardy and able to face harsh realities, that were meaningfully connected with long-standing self and object representations. Of particular importance in this regard was Ms. N's shifting perception of her father, a talented and effective, but thoroughly devious, businessman with whom she was unconsciously identified.
On her part, then, this enactment constituted a re-employment of an important mode of defense; the unconscious denial of an accurate perception whose conscious recognition would have led to the mobilization of rage and to consequent inner turmoil based on the fear that to reveal her feelings would result in the loss of a person that she both loved and needed. It was this conflict, involving me at the moment, but related in the past both to her father and her beloved cousin, George, that Ms. N handled through a familiar enactment, one whose interpretation proved to be a very significant experience in her analysis.
On my side, my enactment also served defensive purposes. It spared my self-esteem for I was deeply ashamed of my behavior and helped stave off the intense self-criticism that was on the verge of being released. Thus, it served as a rationalized effort to avoid a narcissistic injury, a maneuver not unknown to analysts as well as their patients.
But there was also a less conscious determinant of my behavior, a factor that I became aware of only later, when, at home, I reflected on what had happened. As an adolescent, I had experienced seductive behavior on the part of a female relative. Typically, this woman would act in a provocative, teasing way towards me, and then if I showed any interest or began to respond to her, she would suddenly shut off this behavior, talk of something else, and act as though nothing had happened. After a while, I began to respond in kind. When she would try to engage me, I would ignore her, pretending to listen, but, in fact, tuning her out.
It was this old response, I believe, that was activated in my work with Ms. N and that I enacted in the session that I've mentioned. Clearly, I was more frustrated with, and annoyed by, her behavior than I knew, a reaction that, in part, was linked to a piece of my own history. But I realized also that, in fact, Ms. N had, unconsciously been teasing me by dangling intriguing, sexual material in front of me and then withdrawing it. It turned out that she had often acted this way with boyfriends and with her father, a pattern of behavior that represented an identification with his own teasing behavior. This insight opened up channels of memory, and Ms. N recalled a number of incidents in which she attempted to turn the tables on others, teasing and mocking playmates and siblings as she had been teased and mocked by her father.
It is of interest, too, that in picking up a notebook and making the noises that I did, I was, in effect, recreating the scene involving her cousin, George. This was an unconscious act on my part, one that, I believe, was partly motivated by my wish to evoke further material concerning the childhood situation. This material, as I noted, had gone underground and my action contained within it an expression of some impatience and irritation at this turn of events. Whether on a deeper level I also identified with George and was covertly enacting some sexual feelings towards Ms. N, I cannot say with certainty. While I was not conscious of such feelings, both my behavior in the hour and my history with my relative made me want to reexamine this possibility.
This is one of the great values of enactments. Not infrequently they offer us a means of exploring aspects of our psychology that otherwise would not be accessible to us.
The second case that I would like to tell you about involved a young man in his mid-twenties who was floundering rather badly in life. A highly intelligent and artistically gifted person, this man lived a charmed life until the age of 17, popular and successful in school, he was generally regarded by all who knew him as the most promising student in his class. Then when he was a senior in high school, disaster struck. At that time, F's father developed a progressive neurological disease that, within months, left him severely impaired. Over this brief span of time he changed from a powerful figure, strong willed, ambitious and imperious, to a helpless invalid who, unable to care for himself, had to be placed in a nursing home. F was devastated by this tragedy and shortly after his father died, which occurred when he was 19, his own progress seemed to stop. Having difficulty concentrating on his work and confused about what course of study to pursue, F dropped out of college after the first year and for two years thereafter traveled aimlessly. When he returned to school, he remained an indifferent student who barely earned enough credits to graduate. Thereafter F held a number of jobs, most of which he lost because of poor attendance, and at the age of 27, he had not yet embarked on a career path.
F's social life, too, was unsatisfactory. Although he had a few old friends, most of these had married or moved away, and F found himself quite isolated. His closest companion was his mother from whom he had great difficulty separating and who, after her husband's death, turned to F as a replacement spouse. At that time, mother and son leaned on one another for comfort and companionship and, a decade later, they remained emotionally entwined. The intermittent efforts that F made to distance himself from his mother and to have a girlfriend of his own came to nothing. Although he was an attractive man and women were interested in him, sooner or later he--or his mother--would find fault with any woman who seemed to be a potential mate. At that point, the young woman would be dropped and the relationship of mother and son resumed as before.
There was no doubt in my mind that analysis was the treatment of choice for F. It seemed quite clear that his father's deterioration and death had had a profound effect on his development, leading not only to its arrest, but to a complex regression, involving ego as well as affects, from which the boy had never fully emerged.
F's central conflicts, I thought, centered on his unconscious ambivalence towards his father. Aware only of feelings of admiration and love for this parent, F had effectively repressed and driven underground all other emotions. There was evidence, however, that F had long been envious of his father's power and prestige and that, secretly, he resented the latter's efforts to map out and plan his son's life. It became clear, too, that the tragedy that had befallen his father had left F with irrational feelings of responsibility and guilt along with the conviction that now he had no right to any ambition for himself. Any effort on his part to excel, to win recognition, and, especially, to attempt to assume his father's role in the world of business, would, he believed, bring on some terrible disaster.
Although well entrenched and of considerable severity, F's problems seemed amenable to analysis. In fact, given the strength of his anxiety and the degree of regression that had taken place over the years, it seemed doubtful to me that any other treatment method could effectively reach him.
F readily accepted this suggestion for analysis and was eager to begin. Although he knew very little about analysis, he seemed intuitively to sense that the best--and perhaps only--chance that he had to resolve his debilitating conflicts lay in an in-depth approach.
It was, then, with considerable hope, as well as much anxiety, that F and I embarked on analysis and, for a time, all went well. F turned out to be not only an articulate and imaginative patient, but a psychologically astute one. Dreams and memories were accessible and, after some initial hesitation, he began to touch on certain transference feelings, feelings that appeared to be growing in intensity with each passing day.
Then, after about 18 months of treatment, progress stopped. Instead of filling the hours with spontaneous and free-flowing associations as he had done before, F now focused on a single topic; his relationship with S, a new woman in his life. Returning to descriptions of this relationship hour after hour, day after day, F seemed to be able to think of nothing else. His sessions became, in essence, dispatches from the field, detailed accounts of the latest developments in his ongoing efforts to court this young woman.
Initially, I thought that it was anxiety that was responsible for F's obsessive preoccupation with S. He felt strongly about her and had begun to think about marriage, a prospect that both attracted and terrified him. And, as could be expected, his mother disapproved of S. a situation that caused my patient to be torn between the two women.
It was true, then, that anxiety contributed much to the clinical picture that had developed. But after some months, when progress in the analysis all but ground to a halt, it was clear that a good deal more than anxiety was involved in the change that had taken place. In fact, it became apparent that F's single-minded focus was serving as a powerful resistance, a resistance so tenacious, in fact, that it nearly capsized the treatment.
What had provoked this increased defensiveness, however, was not at all clear. Outside of his relationship with S, there was nothing in F's life that was an obvious source of anxiety and nothing--or almost nothing--in the material provided a clue to the underlying reason for the upsurge of resistance that now colored the analytic field. In fact, there was a clue that I missed. On several occasions, F's associations contained indirect allusion to my clothing and general appearance, but for reasons that became clear later, I did not follow upon these hints. I became convinced, however, that as important as it was, F's relationship with S could not fully explain the change that had taken place in treatment. I strongly suspected that F was responding to something that had happened between us; to some change, real or imagined, in our relationship; a change that had caused him to pull back, to run for cover, and to hide behind the convenient screen provided by his involvement with S.
For some time, however, this idea remained just that, a speculation for which I was hard pressed to find any supporting evidence. It took enactments on the part of both patient and analyst to clarify the situation and to supply that evidence. These enactments, in fact, constituted unconscious communications of the greatest importance, conveying messages that, for each of us, could not be otherwise transmitted.
On my side, my enactment involved a rather unusual--and embarrassing--error; one that involved the clothing that I wore to a session.
At that time, I was seeing F early in the morning in my office at home. It was winter then and when I rose it was dark outside. Not wanting to awaken my wife, I made a practice of dressing in dim light, a feat that most days I could accomplish without too much difficulty.
One morning, however, feeling particularly tired, I stayed in bed too long and had to dress hastily. In doing so, I inadvertently took from my closet the jacket from one gray suit and the pants from another, similar in color, but quite differently patterned.
When I greeted F in the waiting room, he looked at me in what I thought was a quizzical way but said nothing about my unusual appearance. That he took it in and was troubled by it became clear later. In fact, in reviewing my notes for that hour, I discovered that his associations contained a number of references to what he had perceived. In that session, F made comments about an eccentric analyst friend of his mother's, an individual who wore an earring, went around town in a cape, and liked to shock his colleagues with the bizarre outfits that he wore. While his mother was amused by her friend's behavior, F himself was not. In fact, he wondered just how sick this individual actually was.
Unaware of my mistake and how I appeared to F, I did not know what to make of these comments. The session ended, I recall, with my feeling confused and frustrated by my inability to understand the meaning of these clearly displaced negative feelings about me. Moreover, I was puzzled by an incident that occurred at the very end of the hour. Rising from the couch, F did not proceed directly to the door as usual, but turned and quickly, almost furtively, looked back at me. Then before I could speak, he was gone.
Feeling ill at ease and confused by the session, I went into the house for a cup of coffee. There my discomfort rapidly turned into acute embarrassment. Entering the kitchen, I encountered my wife who greeted me first with an expression of incredulity, then one of mirth. Finally in a futile attempt to stifle a laugh, she covered her moth with a hand. Then, pointing out my mistake as gently as she could, she suggested that unless I was planning to conduct experiments in subliminal perception all morning, it would probably be a good idea before the next patient arrived to change my suit jacket to one that matched my trousers.
When, sometime later, I had recovered sufficient composure to think about my error, I attempted a bit of self-analysis in an effort to grasp its meaning both for myself and for F's treatment. My first thoughts went to how foolish I must have looked, and how disorganized. Then the image of a character in a Samuel Becket play came to mind. This figure, aptly named Krapp, is a confused, disheveled, and demented individual on the verge of senility. Reflecting on these associations to an old man suffering from organic brain disease, I realized that they pointed to certain aspects of my behavior that I had not wanted to acknowledge; to a change in myself, in fact, to which I had been quite blind. And this change, this alteration, I recognized, was related not only to the error that I had made, but to much that had been happening in F's treatment.
Some months earlier, my father had suffered a stroke that had left him partially paralyzed and suffering from some cognitive and expressive defects. His judgment, too, was affected, as was his ability to perceive himself and others accurately. As a consequence of his disability, he often made mistakes. He misread and misunderstood written material, was quite forgetful, and became careless about his appearance. A man who, all his life, took pains to be well-groomed and smartly dressed, now he seemed indifferent to the way that he looked. Often unkempt, he would walk around the house in an ill-fitting bathrobe or in clothes seemingly chosen at random from a dresser drawer.
In the months after my father's illness struck, I, too, began to make a number of mistakes. I miscalculated some bills, forgot to hand out others, lost my appointment book, and neglected to inform some patients about times when I would be out of the office. F had noted this forgetfulness and it worried him, but he had said nothing to me about it. Immediately, however, he linked my behavior to that of his father in the initial phase of the latter's illness. F wondered if something terrible was also happening to me and if I, too, was showing early signs of organicity. The thought of this possibility so frightened F, though, that he could not confront it. Instead, he tried simply to banish the idea from consciousness by not thinking or talking about it. While this effort at suppression helped keep F's anxiety in check, it led to an unconscious holding back. Whereas, before, F was eager to be involved with me as a new father, now he withdrew and was careful to maintain a safe distance.
It was, then, F's fear that I, like his father, was secretly ill, would become increasingly disabled, and would ultimately abandon him that lay behind the change that had taken place in the analysis. Wounded by the sudden and unexpected loss of his father, F was taking no chances with a second father. Propelled by the need to keep a safe distance from me, he deliberately threw himself into an intense relationship with S. Now it was she, not me, who absorbed his interest and commanded his full attention. Preoccupied with S, he had neither the time nor energy to dwell either on my mental condition or on the anxiety that it generated in him.
It was in this setting, with F already suspicious that something untoward was happening to me, that, early one morning, he encountered his analyst looking for all the world like a Samuel Becket character. The quick, but penetrating look that he gave me at the end of that session conveyed F's anxiety and his concern. Not grasping the significance of his behavior--it was highly unusual for F to turn back to look at me before leaving--I let it pass and did not bring the matter up in the following session. Thus is was necessary for F, about a week later, to repeat this piece of nonverbal behavior in order to get his message through.
For my part, I had been quite unaware of the fact that the errors that I had been making constituted an identification with my father's symptoms. Nor had I been aware of the impact that this identification--and my own symptomatic behavior--had been having on my work with F. Like my patient, I rationalized the errors I had been making by attributing them to factors safely removed from the true source; to fatigue, overwork, preoccupation with a presentation that I was giving, concern about my children, and the like.
I concealed the truth from myself because to be aware of how deeply I had been affected by my father's condition and the very real prospect of his death, would have been to open up a storehouse of old, painful feelings that I did not wish to confront. Instead I acted out many of them through behavior that condensed and expressed the entangled network of love, yearning, hurt, anger, and guilt that was mobilized by the stroke that had left my father a sick and crippled man.
As part of my need to keep at bay feelings that I was not prepared to deal with, I had managed to forget a piece of F's history: that, initially, his father's symptoms were not unlike those that followed my father's stroke. I knew well, of course, the story of F's father's illness and was convinced that for him to move forward in life it was important for him to gain greater understanding of his complex reactions to it. For a period of time I worked actively with him around this issue. In fact, by dealing with F's fear and avoidance of his rivalrous and competitive feelings towards me in the transference, it was possible to help him get in touch with earlier conflicts involving similar feelings towards his father.
My father's sudden illness, and my reaction to it, had the effect of disrupting this work. As I mentioned, F retreated in the face of what he perceived as signs of disability in his analyst. Since I did not understand and therefore could not interpret, the underlying fantasies that led to this withdrawal, progress in the analysis essentially came to a halt. Indirectly, however, through associations that contained references to ill, disturbed, or otherwise nonfunctioning physicians, teachers, or other authority figures, F expressed the anxious concerns that, consciously, he had managed to keep at bay.
For reasons of my own, I did not pick up these messages. To do so would have been to confront my own behavior, to explore its meaning, and to come in touch with the conflictual issues concerning my father, parallel to those F was struggling with, that I, too, wished to avoid.
In fact, I realized later that my behavior in not dealing earlier with F's persistent focus on S as a resistance was motivated in part by defensive needs of my own. Although I was not conscious of it at the time, I must have sensed that to engage F's resistance and to pursue the question of his deep and troubling ambivalence towards his own father would, inevitably, stir conflicts in myself that I was not ready to face.
It is perhaps significant that the early morning error that I made, one so flagrant that neither F nor I could overlook or avoid dealing with it (as we had managed to avoid dealing with my previous, more easily dismissed mistakes), came at a time when my father's condition had improved. He had regained some movement in the paralyzed limbs and had shown improvement in his cognitive functioning. Encouraged by these gains, and relieve by the diminished threat of sudden death that accompanied them, I no longer felt as anxious and as assailed by conflict as I had before. As a consequence, I believe, I could afford emotionally to begin to examine my feelings about my father and his illness, a change in myself that allowed me to re-engage F in the exploration of his reactions to the loss of his father.
Thus, the mistake that I made in wearing a mismatched outfit and looking for all the world like someone suffering from dementia, functioned, I believe, in two ways. First, it acted as a communication to myself. An error that I could not overlook, it was one that caused me to pause and reflect, not only on this mistake, but on the many mistakes that I had been making for several months. And utilizing as much introspection and self scrutiny as I could manage, I began to understand how, out of feelings of guilt, remorse, and yearnings for closeness, I had not only been living out an identification with my disabled father, but, in the process, had been affecting F's treatment. Unconscious communication of this kind; that is, messages sent to oneself via slips, errors and enactments of various kinds constitute an important, although often overlooked, aspect of the analyst's psychology as it operates in the clinical setting.
My mistake also acted, I believe, as a communication to F. A blatant error, it made obvious behavior of mine that in less dramatic form had been taking place for some time; behavior that F had perceived but had tried to keep out of mind. This mistake he could not ignore and when, finally, he was able to confront his reactions to it, he came in touch with warded-off feelings of anxiety, guilt, triumph and remorse; feelings that had also arisen in response to his father's illness. Unable as a youngster to understand and to integrate these complex and frightening emotions, F had reacted to them with retreat and withdrawal.
In making the mistake that I did, I not only enacted conflicts of my own concerning my father, but by creating a situation that involved F's coming face-to-face with a man whose peculiar behavior was like that of his impaired father, in essence, I forced him to confront the central issue that he was avoiding. It was this issue that, in fact, was at the heart of his resistance and that was blocking progress, not only in the analysis but in his life as well. It was, I believe, this unconscious motive; a wish on my part to compel F--and myself--to deal with the source of the stalemate that had developed, that contributed to my error.
For F, however, it was not easy to face a problem that he had skirted for so long, and for some time he continued his pattern of avoidance. In the sessions following the mismatched suit incident, F said nothing about it. While, as I've mentioned, reference to it clearly showed up in the analytic material, F could not broach the subject directly. When, on several occasions I brought up my error, he could acknowledge only that he sensed that there was something different about me in that session. Remembering the quizzical but penetrating look that F had given me a few days before, I was on the alert for communication of that kind, ones that might provide access to the underlying anxiety concerning my condition that F was warding off.
Such a nonverbal message was delivered about a week later as I entered the waiting room. F was, as usual, sitting on a straight-backed chair, magazine in hand. As I approached, he raised his head, fixed me with the same intense, piercing look as before, and then quickly lowered his eyes. Then he rose and, looking past me, strode into the office. This behavior was a distinct departure from his accustomed manner. Usually F would greet me with a nod or a smile, making eye contact as he did so. Observing this change, I waited to see whether in the session F would comment on it.
He did not. Instead he launched into a detailed account of his latest encounter with S. When there was a pause in his narrative, I took advantage of the momentary silence to draw F's attention to what had just happened in the waiting room. I observed that in recent sessions, he had looked at me in what seemed to be an intense but furtive way. Adding that his associations contained many references to ill or impaired physicians, teachers and the like, I asked F if he could say anything about what he was experiencing at that moment.
For some time he did not respond. He remained silent, almost motionless, for several minutes. Then he spoke. "Is there something wrong with you," he asked finally, "or do you always buy your clothes at a Salvation Army store?" Then, unburdening himself, F launched into an account of what, in recent months, he had observed about me; not only that I had appeared for a session dressed like a clown in jacket and trousers from two different suits, but that for some time now my outfits had been chosen with all the taste and discernment of a rapidly advancing Alzheimer's case. This, he acknowledged, had terrified him, but he had tried to put his fear out of mind. And what he could not forget he rationalized. Most likely I was not demented, he thought--at least not yet--but eccentric; one of those peculiar analysts, like some of his mother's friends, whose unpressed suits and soup-stained ties were taken to be evidence of an Einsteinian-like brilliance.
Spurred by what had been happening between us and emboldened by his being able, finally, to speak about his fear, F went on in the ensuing months of treatment to come in touch with the pain, the fear, and the guilt that he had experienced during his father's illness. And he was able both to understand, and, in large measure, to work through, the psychological residues left by this traumatic experience; residual feelings that, linked with long-repressed childhood conflicts over rivalry with, and hostility towards his father, had caused him to retreat from life.
On my side, too, there was some working through to do. It was necessary for me, as it was for my patient, to confront certain long-standing issues involving my relationship with my father; issues that, in fact, were not so different from the ones that F had to face. Both of us, then, patient and analyst, had to deal with fathers; the fathers of memory, the fathers we created, and our actual fathers, whose dynamic and often difficult personalities had an enduring impact on our lives. For each of us these long-standing conflicts, mostly repressed and kept at bay, were activated by the catastrophic illnesses that struck both men; illnesses which revived not only profoundly ambivalent feelings in their sons, but anxiety that had to be warded off. The result was that both patient and analyst had to struggle with issues that, outside of awareness, affected not only their lives, but the treatment as well.
This example highlights the role of nonverbal behavior as a prime vehicle for unconscious communication in analytic work. Not infrequently, messages conveyed unobtrusively, almost inperceptively, through posture, gesture, facial expression or tone of voice provide keys in both patient and analyst, to what is not otherwise expressible.
Speaking of the importance of the nonverbal sphere as a pathway for the reliving and reenacting of crucial aspects of the forgotten past, James McLaughlin (1992) describes effective analytic experiences as a "prolonged enactment or actualization in which nonverbal behaviors have an essential role." In his own work, he says, he tries "to fashion a dramatic unity out of the words of patient and analyst, along with their large and small actions, that portray the themes of the past and present. Through transference these come alive in the mind of the patient and analyst and are enacted between the pair in the analytic moment, they then blend in the music of the affective experience of both parties to authenticate the whole." And summing up his views of the centrality of nonverbal communication as a prime conveyor of unconscious mental life, McLaughlin reminds us "that we constantly provide stamp and signature for what we are and for what we feel through our posture, gestures, facial expressions, voice qualities and the rest. That to a varying extent, we are forever signers, as well as speakers, because we spent so many years in rapt mimetic-absorption of our world, before we had words to supplement these alternative ways of knowing and telling. And that we do not lose or relinquish these ways because there are times when words are better" (p.159-160).
In my work with F, it took an exchange of nonverbal behaviors; enactments on both sides of the couch, to alert patient and analyst to what was transpiring, both within ourselves and in our interaction. The unconscious messages conveyed in this form, then, played a crucial role in treatment. They not only provided clues to the source of the impasse that had developed, but opened a pathway to the exploration of the unconscious conflicts in each of us that, interacting, were responsible for this stalemate. And it was this exploration, initiated and made possible by unconscious communications in the form of enactments, that allowed the treatment to move forward and for healing to take place in patient and analyst.
What I have wished to illustrate in these examples then, is the way that we analysts, as well as our patients, frequently enter into enactments whose unconscious purpose is to avoid issues that cause us pain, embarrassment or anxiety. Also often enacted--and concealed--within our well-accepted analytic techniques are subtle expressions of envy, rivalry and aggression towards our patients. Hidden, too, in our interpretations, although well rationalized, may be our need to maintain our position of authority and superiority. Equally important are the unrecognized sexual feelings that, at times, are stimulated in sessions and may be subtly enacted along with the feelings of love and dependency that we commonly experience in the course of our work. We are somewhat better, in fact, at recognizing and confronting negative feelings that positive ones. The vast majority of papers on countertransference deal with conflicts over aggression. Very few touch on the vicissitudes of loving and sexuality in an analytic treatment.
Other potential sources of tension and anxiety in the analyst, too, may be embedded within our quite proper interventions. Often overlooked in this way are our attitudes towards money and its importance to us; the effect on us of growing older; the impact of our personal losses and disappointments on our approach to patients; and the role that our status in our institutes and in the profession plays in affecting our sense of ourselves and the way we function in the clinical situation.
It is our petty faults, too, that we have trouble recognizing and integrating into our clinical work; the moments of meanness, of spiteful retaliation, of boastfulness, of greed, of inattention, of self-justification, and of small-minded competitiveness with colleagues that we live out on occasion with our patients. Often we shut out recognition of these traits in ourselves and effectively manage not to be aware of them. And when we are unable to do that, we find ways to ignore them, to set them aside, and to avoid the hard task of confronting the impact that they are having on our work. Instead we focus on the patient's material. We are good at that. When we have a need to avoid a sensitive matter we can pick up themes and trends in what patients say that are relevant to their conflicts, interpret them accurately and with insight, and to all appearances do a useful piece of analysis. What we are doing in those situations, however, is not only useful (which on its own terms it clearly is) we are also creating what might be called an analytic screen; that is, engaging in a particular kind of enactment; one in which we use our analytic skills and insights to avoid confronting an uncomfortable truth; that our personal shortcomings, whether they take the form of a lapse of attention, an unnecessarily critical comment, a failure to recognize the truth of a patient's perception, or a momentary need to upstage him, exert a powerful influence on all that occurs at any given time in the treatment situation.
In short, it is our natural and normal self-esteem needs operating as an ever-present force in analysis, as they do in life, that along with our need to protect against pain, constitute ongoing sources of difficulty for the analyst. Unrecognized or not confronted, they can subtly, but effectively undermine his or her best efforts.
In closing, I would like to quote a poem that no doubt is familiar to many of you. It is called The Dormouse and the Doctor and was written by that great English author, A.A. Milne. It describes what often happens when, for reasons that have much to do with narcissistic issues, we fail to hear what is being communicated to us, covertly enact needs of our own, and rationalize our behavior with the conviction that, as trained analysts, we surely know just what theories and approaches will heal the troubled spirits of our patients.
There once was a Dormouse who lived in a bed A Doctor came hurrying round, and he said : The Dormouse lay there, and he gazed at the view The Doctor came back and, to show what he They took out their spades and they dug up the The Dormouse looked out, and he said with a sigh : The Doctor came round and examined his chest, The Dormouse turned over to shut out the sight The Doctor said, "Tut! It's another attack!" The Dormouse lay there with his paws to his eyes, The Doctor next morning was rubbing his The Dormouse lay happy, his eyes were so And that is the reason (Aunt Emily said)*
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References
Chused, J. (1991). The evocative power of enactments. J. Amer. Psychoanal. Assoc. 39:615-638. Jacobs, T. (1991). On countertransference enactments. In The Use of the Self : Counter-transference and Communication in the Analytic Situation. Madison, CT: International Universities Press.
McLaughlin, J. (1992). Nonverbal behavior in the analytic situation : The search for meaning in nonverbal cues. In S.Kramer & S. Akhtar (Eds.), When the Body Speaks : Psychological Meanings in Kinetic Cues. Northvale, NJ : J. Aronson. Milne, A.A. (1924). The doctor and the dormouse. In When We Were Very Young.New York : Dutton, 1961. Renik, O. (1993b). Analytic interactions. Conceptualizing technique in light of the analyst's irreducible subjectivity. Psychoanal. Q. 562:553-571.
© Les Etats Généraux de la Psychanalyse - 2001 -
