The transference and the zone of proximal development

Mentalization, insightfulness, and therapeutic action: The importance of mental organization

Continuing debates over the relative importance of the role of interpretation leading to insight versus the relationship with the analyst as contributing to structural change are based on traditional definitions of insight as gaining knowledge of unconscious content. This definition inevitably privileges verbal interpretation as self-knowledge becomes equated with understanding the contents of the mind. It is suggested that a way out of this debate is to redefine insight as a process, one that is called insightfulness. This term builds on concepts such as mentalization, or theory of mind, and suggests that patients present with difficulties being able to fully mentalize. Awareness of repudiated content will usually accompany the attainment of insightfulness. But the point of insightfulness is to regain access to inhibited or repudiated mentalization, not to specific content, per se. Emphasizing the process of insightfulness integrates the importance of the relationship with the analyst with the facilitation of insightfulness. A variety of interventions help patients gain the capacity to reflect upon and become aware of the intricate workings of their minds, of which verbal interpretation is only one. For example, often it seems less important to focus on a particular conflict than to show interest in our patients' minds. Furthermore, analysands develop insightfulness by becoming interested in and observing our minds in action. Because the mind originates in bodily experience, mental functioning will always fluctuate between action modes of experiencing and expressing and verbal, symbolic modes. The analyst's role becomes making the patient aware of regressions to action modes, understanding the reasons for doing so, and subordinating this tendency to the verbal, symbolic mode. All mental functions work better and facilitate greater self-regulation when they work in abstract, symbolic ways. Psychopathology can be understood as failing to develop or losing the symbolic level of organization, either in circumscribed areas or more ubiquitously. And mutative action occurs through helping our patients attain or regain the symbolic level in regard to all mental functions. Such work is best accomplished in the transference. The concept of transference of defense is expanded to all mental structure, so that transference is seen as the interpersonalization of mental structure. That is, patients transfer their mental structure, including their various levels of mentalizing, into the analytic interaction. The analyst observes all levels of the patient's mental functioning and intervenes to raise them to a symbolic one. At times, this will require action interpretations, allowing oneself to be pulled into an enactment with the patient that is then reprocessed at a verbal, symbolic level. Such actions are not corrective emotional experiences but are interpretations and confrontations of the patient's transferred mental organization at a level affectively and cognitively consistent with the level of communication. Nonetheless, the goal becomes raising the communication to a symbolic level as being able to reflect symbolically on all aspects of one's mind with a minimum of restriction is the greatest guarantee of mental health.

On an Evolving Theory of Attachment

This paper adds a new dimension to the evolution of attachment and of representation formation in the toddler stage. During rapprochement, under appropriate conditions, symbolic activity begins to take prominence over sensorimotor activity to guide and regulate affective experience. We propose that as the toddler comes to increasingly reorganize early sensorimotor experiences under the influence of language, the mother plays a new and vital role in helping the toddler achieve new and higher levels of organization. The intensity of the toddler's proximity seeking-behavior, as described by Bowlby, takes on a new element in light of the toddler's need for mother as an essential interlocutor who helps him or her to verbally articulate and organize experience. The toddler's need to seek proximity with mother particularly pro- found during the rapprochement phase, serves not only to safe-guard the toddler's physical well-being but to ensure the survival of the child's developing mind. Moreover the mother's failure to respond appropriately during this time to this emerging need for her as a verbal interpreter of experience may result in disruption of the toddler's burgeoning ability to make appropriate use of verbally mediated representations of the world, self and others. This paper discusses the rapprochement stage in light of this new developmental perspective.

Zone of proximal development (ZPD) as an ability to play in psychotherapy: a theory-building case study of very brief therapy

OBJECTIVES

This theory-building case study examined the zone of proximal development (ZPD) in psychotherapy within the assimilation model. Theoretically, the ZPD is the segment of the continuum of therapeutic development within which assimilation of problematic experiences can take place. Work within a problem's current ZPD may be manifested as a Winnicottian ability to play, that is, an ability to adopt a flexible reflexive stance to the presenting problem and be involved in joint examination of possible alternatives. Play may be recognized in the client's receptivity to and creative use of the therapist's formulations of the presenting problems.

DESIGN AND METHODS

A case was selected from a comparative clinical trial of two very brief psychotherapies for mild to moderate depression, the Two-Plus-One Project (Barkham, Shapiro, Hardy, & Rees, 1999, J. Consult. Clin. Psychol., 67, 201). Martha, a woman in her late forties, received two sessions of psychodynamic-interpersonal therapy 1 week apart and a follow-up ('plus one') session approximately 3 months later. Dialogical sequence analysis was used to analyse the transcripts of the three sessions.

RESULTS

The analysis revealed Martha's problematic action pattern, which remained unchanged throughout the three sessions. Her ability to use and elaborate the therapist's formulations depended on the referential object that the therapist addressed; in particular, she seemed unable to play with the therapist's formulations of her more problematic experiences.

CONCLUSIONS

The case helped elucidate how the ZPD is content dependent. Winnicott's conception of playing emphasizes the quality of client response as an indicator of this content sensitivity. Differing breadths of major problems' ZPD, manifested as differing abilities to play with therapists' formulations may explain why some clients improve in psychotherapy while some do not.

PRACTITIONER POINTS

Accessing very problematic content may be very difficult even though the client's ability to mentalize other material appears ordinary. Mildly depressed clients who have developed powerful care-taking coping strategies may not respond to very brief therapeutic interventions. A client's minimal acknowledgements may mislead the therapist into supplementing the client's failing self-reflection rather than addressing the issue that provokes this failure.

Repairing links: building attachments in the preschool classroom

A psychoanalytic model of preschool consultation is presented, born of the conviction that psychoanalysis has powerful tools with which to tackle some of our most difficult and entrenched community problems. Since trauma is known to impact our ability to think reflectively and symbolically (Fonagy, Moran, and Target 1993), the clinical methods of psychoanalysis-drawing on the ideas of container/contained, the capacity to hold alternate points of view, and the capacity to reflect empathically (here with teachers in the face of their at times harsh and insensitive treatment of students)-are crucial to success in work with cumulatively traumatized staff (Khan 1963). The strongest resistances to consultation arise from an anti-attachment system developed as a result of cumulative trauma and operating at multiple levels in the preschool. Consultation services are organized around an understanding of this anti-attachment system. At various levels of the system, including staff, parents, and children, consultants work to facilitate secure relationships in the preschool setting. These relationships foster recognition of children's emotional complexities and build cooperative links between staff and parents, in an atmosphere that otherwise might often push adults into fearful, self-protective states that interfere with their contact with children's states of mind.

The contribution of the analyst's actions to mutative action: a developmental perspective

The concept of action has evolved since Freud's initial attempts to adticdress the topic. It is no longer viewed as just serving a defensive function. Instead it is increasingly seen as a mode of experiencing and n, communicating, one that is less developmentally advanced than the verbal one usually emphasized in psychoanalysis. Research from many fields documents the view that experiencing, thinking, and communicating originate in bodily action. Hence psychoanalysts have learned to use the patient's actions to broaden their understanding of the patient and to deepen the analytic process. But they have been slower to apply this understanding to their own actions. This paper uses an extended clinical vignette of an action intervention by the analyst to demonstrate its importance in maintaining and deepening an analytic process. It then suggests a theoretical and clinical rationale that such action interventions are a common and necessary aspect of most analyses. Finally it raises the question of whether such interventions can be regarded as interpretations offered at the developmental level being used by the patient to communicate at particular moments in analysis. Can they be viewed as the initial interpretation in the process of interpretation?

History of the unconscious in Soviet Russia: from its origins to the fall of the Soviet Union

Russia accepted the notion of the unconscious and psychoanalysis before many Western countries. The first Russian Psychoanalytic Society was established in 1911. After World War I and the Russian Revolution, for a short happy period, the following psychoanalysts were active: Sabina Spielrein, Tatiana Rosenthal, Moshe Wulff, Nikolai Osipov and Ivan Ermakov. Scholars associated with Soviet ideas participated too, including Aleksandr Luria, Michail Rejsner and Pavel Blonskij. Lev Vygotskij himself dealt with the unconscious. A second psychoanalytical society was set up in Kazan. Unfortunately, at the end of the 1920s, repression dissolved the psychoanalytic movement. Even the word 'psychoanalysis' was banned for decades. Nonetheless, interest in the unconscious, as distinct from psychoanalytic theory, survived in the work of the Georgian leader D. Uznadze. His followers organized the 1979 International Symposium on the Unconscious, in Tbilisi, Georgia, which marked the breaking of an ideological barrier. Since then, many medical, psychological, philosophical and sociological scholars have taken an interest in the unconscious, a subject both feared, for its ideological implications, and desired. Since the 1980s, psychoanalytic ideas have been published in the scientific press and have spread in society. The fall of the USSR in 1991 liberalized the scientific and institutional development of psychoanalysis.

Non-conscious prediction and a role for consciousness in correcting prediction errors

As a result of the evolutionary pressure for survival, the brain relies on a number of non-conscious predictive neural mechanisms which allow for rapid, efficient behavioral responses to the environment. These predictive mechanisms enable the brain to recognize objects by sampling just a few sensory inputs, to anticipate what events are likely to occur and to prepare a response before events actually occur. Consciousness appears to play a role in the detection and correction of prediction errors. The author, a psychotherapist and psychoanalyst, proposes that this monitoring or oversight function of consciousness can be used to understand how conscious awareness facilitates change in the psychotherapeutic treatment of patients who repeat maladaptive patterns of behavior.

Analytic preparation: the creation of an analytic climate with patients not yet in analysis

The art and science of beginning an analysis has a life of its own and can be considered in many ways quite apart from its later stages. An incremental path forward is smoothed for patients who are not yet prepared to analyze, and builds eventually into something readily recognizable as an analysis. The term analytic preparation refers to this set of processes. Early on, the analyst is concerned less with facilitating an early replica of an idealized analysis than with facilitating the mutual adaptation of patient and analyst as they begin to negotiate a "thought community." Since analytic preparation is not an entity, it does not neatly overlap in real time with the opening phase as usually described, does not have a discrete beginning or end, and does not abruptly shift mid-stream into analysis proper. Some relations between analytic preparation, analytic interaction, and the interpretation of transference are examined.

Patient-therapist attachment in the treatment of borderline personality disorder

The authors report preliminary findings from a longitudinal study on the impact of attachment state of mind and reflective function on therapeutic process and outcome with borderline patients in Transference-Focused Psychotherapy (TFP). TFP is a manualized, psychoanalytically oriented treatment based on an object relations model of understanding patients with severe personality disorders. The attachment theory constructs of internal working models of attachment and mentalization or reflective function provide an important means of both conceptualizing borderline disorders and assessing therapeutic process and change. In the Personality Disorders Institute at New York Presbyterian Hospital-Weill Medical College of Cornell University, the authors have been using the Adult Attachment Interview (AAI) to assess changes in state of mind with respect to attachment and reflective function over the course of 1 year in borderline patients in TFP treatment. As part of the authors' investigations of the impact of patients' attachment status on the therapeutic process, they have adapted the AAI to evaluate states of mind with respect to attachment within the therapeutic relationship through an interview called the Patient-Therapist Adult Attachment Interview (PT-AAI). The AAI is given at 4 months and 1 year, and the PT-AAI is given to patients after 1 year of TFP, and both interviews are scored for attachment classification and reflective function. The authors present preliminary findings on change in both attachment classification and reflective function ratings at 4 months and 1 year for a subsample of 10 patients and therapists. They also present two cases that illustrate how the quality of mentalization or reflective function in the therapeutic dyad may be seen as a bidirectional process in that therapists' and patients' levels of reflective function are mutually and reciprocally influential. In one case, the patient's and therapist's reflective function mirrored each other directly and remained at a low or rudimentary level for the treatment year. Such a pattern of direct imitation does not necessarily promote intrapsychic change. In the second case, the patient moved from a rejecting or bizarre stance toward mentalization on the AAI to some rudimentary consideration of mental states after 1 year of treatment with a therapist who showed a full and nuanced awareness of mental states, but who adjusted his level of mentalization to that of the patient. These findings suggest that optimally the therapist ought to be one step ahead of the patient in the capacity for mentalization.

A new model for conceptualizing insightfulness in the psychoanalysis of young children

Traditional definitions of insight fail to take into account the cognitive and developmental limitations of young analysands, who lack the capacity to mentalize. It is suggested that insightfulness be redefined as promoting mentalization in young children. Gaining this key psychological function furthers the internal integration and self-regulation necessary to regain developmental momentum. The central importance of promoting such development in child psychoanalysis suggests that the facilitation of a mechanism for self-understanding, not the interpretation of content, is essential. Insightfulness is facilitated by employing a range of interventions beyond the interpretation of resistance and content, rendering meaningless the distinction between interpretive and relational aspects of the analyst's role.

A note on transference and alliance: I. Transference--variations on a theme

Conceptual and pragmatic difficulties are encountered in relating and differentiating transference from alliance. Transference and alliance, along with the real relationship, are component elements of the analytic relationship, and are mutually involved in intermingling and interaction at all points of the analytic process. Variants of transference are discussed with an eye to distinguishing their differentiation from and relationship to alliance components and functions. Forms of transference differentiated are classical transferences (libidinal and aggressive), transference neuroses, transference psychoses, narcissistic transferences, selfobject transferences, transitional relatedness, transferences as psychic reality, and relational or intersubjective transferences. Transference mechanisms--specifically displacement, projection, and projective identification--and their role in transference development are discussed. Differences in the concept of transference conceived classically as opposed to relationally or intersubjectively are explored. Therapeutic advantages and limits of these differentiations are considered.

A note on transference and alliance: II. Patterns of interaction

Conceptual and pragmatic difficulties are encountered in relating and differentiating transference from alliance. Transference and alliance, along with the real relationship, are component elements of the analytic relationship, and are mutually involved in intermingling and interaction at all points of the analytic process. Variants of transference, as discussed in a companion article (Meissner, 2001), are differentiated from and related to alliance components and functions. Transference and alliance can interact in oppositional terms, each undermining or obfuscating the other; an emphasis on alliance may subvert transference and, conversely, transference may act as one of the major sources of misalliance. They may also sustain and reinforce each other; alliance often serves as a vehicle for providing a safe context for emergence of difficult transference derivatives, and benign and mild forms of positive or idealizing transference can offer reinforcement to the analytic relationship, and in some degree, to the alliance. Some forms of transference, especially selfobject transferences, may enjoy significant overlap with alliance functions. Therapeutic implications and limits of these differentiations are considered.

A conjoint phase of treatment involving a severely disturbed adolescent boy and his father

A phase of father-son conjoint treatment during psychoanalytic psychotherapy of the son is described. The son, who met descriptive criteria for schizophrenia, felt most alive when planning revenge on his father; the father frantically dwelled on the son to the exclusion of virtually everything but work. The conjoint therapy complemented the son's individual therapy and led to a stable, hence analyzable transference. The outcome was generally positive in a case whose prognosis at the outset had appeared dismal. Questions concerning therapeutic change and clinical technique are raised. The author suggests that others in similar clinical circumstances might consider a phase of conjoint treatment.

Neutrality, abstinence, and the therapeutic alliance

Concepts of neutrality and abstinence are discussed in terms of the variant opinions about them, pro and con, with particular reference to efforts to dispense with them based on the unavoidable role of the analyst's personal influence and subjectivity in the analytic process. Stereotypes of both neutrality and abstinence are examined, and the therapeutic alliance established as the most appropriate context within which to articulate the essential and constructive role of effective analytic neutrality and abstinence. The alliance is not possible without the persistent exercise of both neutrality and abstinence; conversely, other components of the alliance are intended to facilitate and preserve neutrality and abstinence on the part of both analyst and analysand. These elements are essential factors in effective analytic practice.

Integrating some mind and brain views of transference: the phenomena

Because understanding the underpinnings of transferential learning allows the analyst to more effectively exploit transference in the clinical situation, as well as to advance psychoanalytic theory, the functions and mechanisms of transference phenomena in learning are subjected to an interdisciplinary analysis. Through transference the brain creates hierarchical databases that make emotional sense of the world, especially the world of human relationships. Transference plays a role in defense and resistance clinically; less explored but equally important is the adaptive potential of transference and its effect on an individual's readiness for structural change through the activation of working memory. Most investigators within psychoanalysis have not considered the importance of similarity judgments and memory priming, especially as these help to explain why transference and its proper handling are effective in treatment. Yet there are complex relationships among transference, similarity judgment, and memory priming that tie together psychoanalysis, cognitive psychology, and neurophysiology. Evidence increasingly suggests a relationship between transference and the transfer of knowledge between various content domains (databases) of mind and brain, which is essential to cognitive and emotional learning. There are indications as well that transference decisively facilitates learning readiness ("windows") in general by means of two of its components: free association and spontaneous (self-initiated) activity. The important question of which mind/brain mechanisms motivate transference is not yet understood comprehensively. However, Vygotsky's work on the zone of proximal development (ZPD), M.Stern's teleonomic theory, schema theory, and neural network theory offer further insights into what motivates transference.