Ellen Blumenthal dissertation by ICSW

Institute for Clinical Social Work

The Psychotherapistâ&#x20AC;&#x2122;s Use of Associations to Cultural Experience

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Ellen R. Blumenthal Chicago, Illinois December 18, 2015

Abstract

This research inquiry employed a psychoanalytic case study methodology to explore the ways in which the psychoanalytic listener utilizes her associations to cultural experience in the service of increased understanding of her patient’s non conscious process. Its question was founded on the premise that cultural objects are a fundamental and essential component of one’s internal and external life, and that they hold the potential to function as condensed imagery much as in dream-work, and hold the capacity to elucidate a textured set of affective elements. Five seasoned psychodynamically oriented psychotherapists participated in three 90-minute in-depth interviews with this question as their focus. Data analysis was structured by first formulating five case studies elucidating categories of meaning that emerged in each participant’s narrative. This was followed by a cross case analysis in which common themes as well as idiographic motifs were culled with the intention of making meaning of the research question across participants’ narratives. The study’s findings elucidated in granular detail the nature of the psychoanalytic listener’s engagement with herself and her client in their dyadic enterprise. Findings include the fundamental notion that cultural experience has the capacity to function as a vehicle for unconscious communication, conveying affective resonance and relational data. In this way cultural objects provide a vehicle through which the clinician is able to both receive and offer essential conscious and non conscious communications within the therapeutic dyad.

iii

For Jeff

And the painting, above his head, was the still point where it all hinged: dreams and signs, past and future, luck and fate. There wasnâ&#x20AC;&#x2122;t a single meaning. There were many meanings. It was a riddle expanding out and out and out. ~Donna Tart, The Goldfinch

Acknowledgments

I am grateful to my teachers for nurturing my growth as a clinician and as a thinker. Jennifer Tolleson, my dissertation chairperson, mirrored my excitement for this inquiry, and nourished it with her incisive intellect, wise and measured guidance, generous support and enthusiasm, which matched my own. She further welcomed and encouraged my voice in the formulation of my questions, my thinking, and my writing, maintaining a steadying, compassionate connection throughout this project. Woody Faigen provided me with his wealth of knowledge of and passion for this subject, was generously patient with my questions and unceasing curiosity, and additionally offered his wry wit to temper my intensity. Amy Eldridge wisely guided me to a topic that would enrich my clinical learning and thinking in untold ways. My readers, Freddi Friedman and Barbara Berger, sensitive consultants and inspirational teachers, balanced expectations of academic excellence with psychological mindedness, nurturing my clinical learning. My cohort listened openly and contributed creatively, as we formulated our dissertation thinking. Michael Hoffman lent a thoughtful ear to my musings, reflecting delight and interest in my endeavor. ERB

Table of Contents

Page Abstract………………………………………………………….........…………………iii Acknowledgments……………………………………………………...…….........……vi Chapter I. Introduction………………………............……………………………………1 II. Literature Review…………………………………….........…………..……10 Introduction Freud’s Cultural Milieu Cultural Objects “Non Conscious” The Nature of Psychoanalytic Listening: Free Association; Duality; the “Freudian Pair” Countertransference: States of Subjectivity within the Therapist, the Ways in Which It Is Aroused in the Work, How It Can Be Used to Inform the Work The Therapist’s Use of Associations to Cultural Objects in Her Work Analyzing The Process of Attending to Oneself as One Listens to One’s Patient

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Table of Contents—Continued

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III. Methodology…………………………………………………………………..........73 Type of Study and Design Scope of Study Data Collection and Instruments Data Analysis Statement on Protecting the Rights of Human Subjects Limitations of the Research Plan

IV. Findings……………………………………………………………..............86 Case Study Introduction Case Study Sample Clinician 1 Clinician 2 Clinician 3 Clinician 4 Clinician 5

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Table of Contents—Continued

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V. Discussion.......................................................................................................348 Cross Case Analysis: Theoretical Summary Clinical Implications Research Implications Conclusion

Appendices A. Recruitment Flyer…………………………………............………………418 B. Informed Consent Process..........................................................................420 C. Consent Form……………………………………………………...............422 D. Consent Form Addendum………………………….............……………..426 References……………………………………………………….……………..428

Chapter I

Introduction

This phenomenological study sets out to explore the nature and experience of therapeutic listening, through a study of the literature on this subject and through the medium of descriptions gleaned from interviews with five study participants. Specifically it investigates the elements inherent in the practice of therapeutic listening within a small population of seasoned psychotherapists who self-identify as comfortable with reverie, and believe that their engagement with the arts serves to enrich their practice. This inquiry is driven by an interest in how this circumscribed population draws upon their free associations to the aesthetic in the course of listening to their patients’ overt and non conscious 1 process. My central objective is to analyze and delineate the mechanics of psychotherapeutic listening refracted through this specific lens, and to elucidate the ways in which these components of attunement to one’s own process provide the therapist with generative data about the patient’s non conscious material in the service of one’s search

By non conscious processes this researcher is referencing psychic phenomena which exist outside of conscious awareness. This conceptualization includes but is not limited to Freud’s (1912b) definition of the dynamic unconscious. It includes memories whose origins precede language acquisition: pre-verbal mental contact, procedural memory, which are distinguished in the literature from memories that have been repressed. Bollas (1987) calls this phenomenon “the unthought known” (p. 246). This definition is developed more fully in section IV.

for in-depth understanding of the psychic realities of one’s patient. My research design employed a case study methodology. My interest takes as its focus the nature of this delineated aspect of therapeutic listening, specifically as it is reflective of the ways in which the therapist is in attunement with herself, 2 that is, her subjectivity, as she listens. The study reflects a curiosity about the concentrated, essential themes evoked from the clinician’s repertoire of aesthetic engagement with literature, film, music, drama and the visual arts insofar as they are called up in the process of her “evenly hovering attention.” 3 This research is interested in exploring the ways in which these elements have the capacity to function as an object, or “third thing” 4 within the dyadic environment, offering clues about the non conscious communication within the treatment milieu. This investigation has its roots in psychoanalytic theory insofar as Freud’s theories are rooted in the context of the rich literary cultural climate in which he lived. Graham Frankland (2000), in his book Freud’s Literary Culture, suggests, “Freud’s intimate acquaintance with classical literature is fundamental not only to his make-up as a writer, but to his very sense of his own identity” (p. 2). Freud’s immersion in the arts and sciences held the single greatest influence on the development of Freud’s psychoanalytic theories. Frankland believes Freud drew upon his propensity for and love of literature in order to understand the human psyche. Freud’s papers and theoretical musings are replete with allusions to the classical humanist tradition in which he was steeped. Similarly, Joseph Campbell (2008) suggests that the self-same myths that drew Freud have a 2

Participants were comprised of members of both genders, three men and two women. For the sake of simplicity, the feminine pronouns “she” and “her” will be employed whenever speaking in a generic sense of participants in singular format. 3 (Freud, 1912, p. 111) 4 (Ogden, 1994)

universality because they mirror the existential struggles that make us human. Accepting these notions as intellectual givens, and contextually significant, it makes sense to me that a subset of psychoanalytic practitioners draws upon a rich tradition of aesthetic imagery as they listen to their patients within the therapeutic space. Thomas Ogden, Jacob Arlow, Adam Phillips, Paul Orenstein, Neville Symington, Christopher Bollas, Stephen Mitchell, Philip Bromberg, Jessica Benjamin, and others write about this phenomenon as it plays a primary role in the way they consider therapeutic engagement. This study aims at an inquiry about the ways in which this phenomenon plays a significant role in the therapeutic practice of psychoanalytically oriented practitioners, both as it resides within their thought processes, and informs their therapeutic practice. The importance of the therapist accessing her associations in the service of the work has a comprehensive presence in the literature. This research project set out to utilize the lens of association to cultural objects, offering a unique, personally meaningful perspective into the ways non conscious material can be attended to in order to shed light on the inter-psychic world of oneâ&#x20AC;&#x2122;s clients, and the inter-subjective world of the therapeutic dyad. It was my intention to engage with psychodynamic psychotherapists to elicit descriptions of the ways in which they both conceptualize and draw upon this phenomenon in the service of their work. It is my hope that this exploration will contribute valuable portrayals that have the capacity to encourage and sustain an ongoing conversation within the psychodynamically oriented social work community regarding the practice of attuning to oneself, in this specific manner, in the service of attuning to oneâ&#x20AC;&#x2122;s client.

In my engagement with a review of the literature on subjects of free association, evenly hovering attention, and reverie, it became apparent that the nature of my inquiry is of interest to an increasing minority and limited population of psychotherapeutic practitioners. In addition, the subject of attention to one’s associative process within therapeutic dyadic engagement is controversial at best. Lothane (2006) describes the psychoanalytic community as divided between “poets and pragmatists” (p. 711), flushing out this polarity as imagination, image and metaphor versus logic and literalness. One could further elucidate this dichotomy by conceptualizing the epistemological polarity of a scientific/objectivist agenda which prioritizes evidence based, time limited psychotherapy in opposition to a hermeneutic and social constructivist orientation. It is the latter which privileges the unfolding of the therapeutic dyad over time with attention to the phenomena of non conscious associations and unconscious communication. In his article, Lothane goes on to say that attention to the unconscious has historically been controversial, noting that the therapeutic stance of “evenly hovering attention” and reverie is often not adhered to, but rather it is construed as “misguided, dangerous and fostering mystification” (p. 715) by many psychoanalytic practitioners. Yet, he insists, the poles of this dichotomy need not be mutually exclusive in one’s practice or one’s theoretical underpinnings: “A good method requires the conjoining of all the available approaches” (p. 711). It is both because the subject of this research topic has grown out of favor due to a series of competing priorities and value systems, and because it is reflective of my own passionate, personal predilection that I chose to pursue this avenue of inquiry. It is my

hope that my process of inquiry will contribute to a rich clinical process tradition insofar as: 1.

It draws upon the early underpinnings of psychoanalytic theory in Freudâ&#x20AC;&#x2122;s historical and cultural milieu.

It sustains a focus on a discussion of non conscious phenomena which are alive within the dyadic space.

It invites practitioners to attend to their associations in the service of the work; it evolves from an integral place of personal engagement and passion, providing a nourishing marriage of self and academic pursuit;

It holds the possibility of enriching the field as it takes as one of its goals the valuing of the therapistâ&#x20AC;&#x2122;s associative process and the ways in which it holds the capacity to enrich the therapeutic endeavor, providing a potential window into the psychology of the patient to whom she listens.

This dissertation describes an investigation into the research problem which inquires into the therapistâ&#x20AC;&#x2122;s use of cultural objects in her work. This inquiry grows out of a unique confluence of my interests, insofar as my life is enriched by my aesthetic sensibility. I am deeply curious about the extent to which this kind of listening is common practice among psychodynamically oriented clinicians, both out of an intellectual interest and a personal quest to establish an abiding home in the professional clinical community. The study has relevance for the field insofar as Freud sculpted his prescriptions for psychodynamic listening out of his own rich culturally contextual associations, and the cultural traditions continue to inspire, inform, and fuel the work of other significant present-day psychodynamic thinkers.

Specific objectives to be achieved included an engagement with psychoanalytically oriented practitioners in order to gain insight into the following phenomena: 1. The non conscious process that unfolds within the psychoanalytic work, with attention to the ways in which association to cultural objects lends insight into the non conscious. 2. That which is privileged as one listens to oneself listening to the other 3. The impact of the cultural milieu in which a therapist is embedded on the texture of her listening. 4. The ways in which the therapist’s associations to cultural objects functions as a way to make meaning of the patient’s narrative.

5. The ways in which this characterological manner of listening contributes authenticity to the dyadic process in the service of moving the work forward. This inquiry also seeks to examine the therapeutic listening process, and establish some criteria in realms of both common and idiographic practice, with attention to what Lipson (2006) terms unique “characterological feature[s]” (p. 875) of one’s listening habits. In this way, this inquiry sets out to create a broad, but by no means all encompassing, catalog of the unique ways in which contemporary psychodynamically oriented clinicians attune to their associations and those of their patients in the service of enhancing the therapeutic enterprise. When I was 7 years old, I sat beside my father, nestled in close, on a contemporary sofa with a blue softbound book, containing the Hebrew alphabet, between

us. There he began to teach me the sounds the letters made to initiate my literacy in this holy tongue, precious to him and to those who preceded him. This book of letters became a location for us of meaningful relational connection, and although I am certain it was not the first, it is what I remember. In similar fashion, friendships in adolescence were mediated through writings by Saint Exupéry and Heschel; Paul Simon, Leonard Cohen and D.H. Lawrence, among others. Ideas and the music of language carried relational nuance that reverberated in our deep seeking for meaning with the intensity unique to our developmental place. In university, the booming, erratically rhythmic and atonal voice of a beloved humanities and poetry professor vibrated within me and the university classroom like a cello’s resonant vibrato, in ways that were both deeply personal and simultaneously communally experienced, as we shot one another glances during lectures and recitations, and imitated and echoed his voice and thinking as we sat together over dinner, and meandered through the campus. To this day, 40 years later, when this intimate group of friends gathers, we almost religiously recite Shakespeare and Yeats in Allen Grossman’s voice. It would be fair to say that over the course of my lifetime, my experience of the arts has functioned as a place of significant relational interface and intense emotional resonance. The most significant member of this peer group from high school and college grew to be my partner and husband of 30 years, until his precipitous death at 52. With him the arts continued to be a conduit of the deepest kind of connection and meaning making. As a family we read together, recited with one another, and gravitated to storytellers as a way of sharing in deeply meaningful ongoing ways, each with one’s own characterologic pull towards certain genres.

As a middle school teacher of the Hebrew Bible, in mid-life, I believed that the text functioned as a vehicle of meaning making between and among us, and the questions it raised for us were the ones we would wrestle to the ground together. Embarking on my own psychotherapy in the wake of my husband’s death, it was not unusual for my therapist to pull a book of poetry down from his shelf to read to me, or to sing a song that came to him as we worked with one another. A particular thin work of poetry functioned as a transitional object for me in our early work, as I carried it with me everywhere and slept with it beside my bed. Similarly, I would enter the therapeutic space bearing tomes and texts. On one occasion, I suggested that we might study a Biblical text in a session, and together we investigated the Biblical character of Hannah whose deep sorrow and subsequent taking hold of her life in the face of seemingly misattuned others, coupled with a distant deity, began to serve as an archetype for me in life changing ways. On another, I arrived bearing an excerpt from Dante 5 outlining the companioned journey into hell taken by Virgil and Dante. As a young clinician following my college years, I was critically aware of the ways in which my poetry education had attuned my ear to the metaphoric layer of communication, aware of the bridge between my humanities education and my newfound profession. Resuming life as a psychodynamically oriented clinician in mid-life, following the tragic upending of my life course, early on I began to experience associations to snippets of films stored away over 30 years, a day camp song not consciously visited in half a century, a show tune gone unsung since adolescence. These internal experiences ignited a curiosity about the phenomenon of the therapist’s listening 5

“O my dear guide,” I said,/ “Who has restored my confidence seven times over,/And drawn me out of peril—/stay at my side.” (8.92-94)/. . . “You know the things I leave unsaid” (19.35). (Robert Pinsky, The Inferno of Dante).

to herself and her associations to cultural objects in her work, as I found myself seeking other clinicians for whom this phenomenon occurs, and grew increasingly interested in what these associations might yield in terms of the work with oneâ&#x20AC;&#x2122;s clients. It was against this backdrop, with the predilections delineated above, that I embarked on this study, with humility, curiosity, and powerful personal relational meaning that both grounded and held me as I engaged in this inquiry. My uniquely personal story shaped the way I entered the data in significant ways. First, each interview was approached with a presumption that the two of us would be engaged with one another in a deeply satisfying way around the subject of my inquiry. As I reflect back on sitting down to conduct a screening interview, I am aware of an evocative longing for and expectation regarding the potential for deep and meaningful connection around a profoundly personal set of passions. This, in some measure, can be attributed to my affinity for intimate, rich conversation. In equal part it can be explained by the fact that this project reflected an authentic, integral extension of self, characterized by a genuine enthusiasm for, pleasure in, intellectual curiosity regarding, and emotional engagement with the dynamism of the psychodynamic process, and the personally enriching aspects of cultural arts. An immersion in the aesthetic nourishes, soothes and enriches me, and has historically functioned as an emotional life preserver. I believe this contributes in large measure to my investigation of this phenomenon for my doctoral work.

Chapter II

Literature Review

This literature review explores definitions of psychoanalytic listening, and takes as a fundamental assumption that psychodynamic work is based on the idea that non conscious mental life exists. It further assumes that one of the goals of the psychotherapeutic endeavor is to bring into awareness that which is at present being kept out of one’s accessible knowledge, with the express intention of facilitating the patient’s fuller capacity to live her life in more meaningful ways, characterized by increased authenticity, vitality and creativity both in relation to one’s sense of self and within one’s relational matrix. In addition, my perusal of the literature has gained resonance in attending to the ways in which psychodynamic clinicians analyze the process of listening as they attune to their own internal processes and those of their patients, and build a bridge of communication between the two within the interpersonal space they co-inhabit. To this end, the following concepts have been examined: 1.

A consideration of the literary and aesthetic milieu which gave rise to the underpinnings of Freud’s psychoanalytic model, since it serves as a significant component of the rationale for this research’s privileging association to cultural objects.

A definition and exploration of the term “cultural object,” with the aim of both elucidating the enterprise of this inquiry and tracing the trajectory of

this concept as it provides a window into the role cultural objects may play in housing non conscious material, and providing insight into the nature of the inter-subjective process when this vehicle is employed. 3.

An exploration of the term “non conscious” as it is first introduced by Freud (1912b) in his work on the dynamic unconscious, and adhered to by those who followed; and as understood by Bollas (1987) as “the unthought known” (p. 246) and the conserved object (p. 246), by Stern (1983) as the idea of “unformulated experience,” and conceptualized by infant researchers as “implicit relational knowing” (Stern 1998, p. 903).

An examination of the nature of therapeutic listening as it entails: •

Free association and evenly hovering attention as separate entities, and as they comprise the duality of the therapeutic work, what Bollas (2002) terms “the Freudian Pair.”

•

The multi-faceted aspects of the therapist’s subjectivity as it interfaces with her therapeutic work, including concepts of “reverie” (Bion 1962a, Ogden, 1997), and uses of imagination (Ogden, Bollas).

•

An exploration of countertransference as it was defined in the years following 1950, insofar as it relates to the therapist’s use of her own subjectivity, and the ways in which her self inquiry is engaged in the service of connecting with the patient’s unconscious processes, thereby informing the work.

•

An exploration of the process in which associations to cultural objects are used by psychodynamically informed clinicians who are immersed in a late Twentieth and early Twenty-First century cultural context, in order to lend insight into the therapeutic work, with attention to the ways these cultural objects function as condensed images likened to what Bollas (1995) calls “dreamwork” ( p. 11) within the therapist’s associative idiom.

•

An investigation into the ways in which seasoned clinicians parse the process of attending to oneself as one listens to one’s patient.

These concepts have been explored in order to achieve a deeper understanding of each one as it stands alone within its theoretical framework; and to investigate the ways in which they are utilized by the skilled clinician in a schematic way within a thoughtfully developed theoretical model.

Freud’s Cultural Milieu Freud, situated as he was within a rich, humanistic, cultural environment writes from a place reflective of his cultural milieu in a manner reflective of the impact this immersion in culture had on his thinking. His crafting of theory from a place of immersion in the aesthetic serves as a paradigm for this study’s focus on the clinician’s associations to cultural objects and the ways they inform her work. Graham Frankland (2000), in his book Freud’s Literary Culture, suggests that “Freud’s intimate acquaintance with classical literature is fundamental not only to his make-up as a writer,

but to his very sense of his own identity . . . .” (p. 2), and held the single greatest influence on the development of Freud’s psychoanalytic theories. Frankland believes Freud drew upon his self-defining immersion in and love of literature in order to understand the human psyche. Freud’s papers and theoretical musings are replete with allusions to the classical humanist tradition in which he was steeped. The ways in which Freud’s cultural immersion becomes apparent is in his writings, rather than in the details of his technique. While it is clear from his writings that he made use of cultural objects as he associated freely to them and drew upon them as a generative act, they did not often find their way directly into the actual interpretations he offered to his patients. 6 For example, in his recounting of his work with Dora, Freud (1905) makes reference to Dora’s dream in which she finds herself in a museum where she stays for several hours viewing the Sistine Madonna (p. 96). Freud interprets the meaning of the Madonna, but the painting does not function as a cultural object in his reverie. It does however seem important for the work that he and his patient share cultural objects as images, which carry meanings beyond themselves, and offer fodder for rich and elucidating dream interpretation. From Freud’s writings it is evident that he would attend to various cultural allusions evoked in him, and use them because these cultural objects were part of what made up his mental life, providing him with creative associative material to draw upon. 7 In Freud’s recording of his work with Dora regarding her dream in which she sits for hours viewing the Madonna painting, he does not go into great detail about the role of the painting. Yet in several footnotes (pp. 100, 104), he makes a connection between Dora’s preoccupation with the painting and what 6 7

S. Faigen, personal communication, August 23, 2013 S. Faigen, personal communication, January 17, 2014

Freud understands to be significant libidinal relationships tied up with the Madonna image (pp. 96, 162, 166). Adam Phillips (2001) places the development of psychoanalysis within its cultural context, fin de siècle Vienna, noting that it is “entirely of a piece with its culture” (p. xii). He offers examples of psychoanalysts turning to literature when they are lost, referencing Klein citing Wordsworth, Keats and George Eliot. He notes that Freud envied the poet who had easier access to the soul, to the unspoken, to the “most profound truths.” Freud writes enviously of “the poet’s apparent easy access to profound psychological truth” (p. 3). After quoting Goethe, Freud wrote, “One may well sigh when one realizes that it is nevertheless given to a few to draw the most profound insights, without any real effort, from the maelstrom of their own feelings, while we others have to grope our way restlessly to such insights through agonizing insecurity” (Phillips, citing Freud, p. 3). According to Phillips, Freud wrote to Fliess about the inspiration he found in Sophocles and Shakespeare. He also explains that for Freud, patient content resembled literature as is reflected in his case studies. In his letter to Fliess, edited by Masson (1985), dated May 31, 1897, Freud writes, The mechanism of fiction is the same as that of hysterical fantasies. For his Werther Goethe combined something he had experienced, his love for Lotte Kästener, and something he had heard, the fate of young Jerusalem, who died committing suicide. … So Shakespeare was right in juxtaposing fiction and madness (fine frenzy). (p. 251) Masson notes that the quote “fine frenzy” appears in the original in English and is a citation from A Midsummer Night’s Dream, Act V, scene i (p. 252):

The poet’s eye, in fine frenzy rolling, Doth glance from heaven to Earth, from Earth to heaven. And as imagination bodies forth The forms of things unknown, the poet’s pen Turns them to shapes and gives to airy nothing A local habitation and a name. According to Phillips (2001), Freud was inspired by the poet Schiller who wrote, “The mechanisms of the world are held together by ‘hunger and love,’” which informed Freud’s idea of the two basic instincts: self preservation and sex (p. 3). He points out that privileging the poetic happens across psychotherapeutic schools of thought: Freud, Jung Lacan, Winnicott, Bion, Meltzer, Milner, Segal and others . . . (p. 4), and suggests human beings seek out poetry as well as psychoanalysis in order to access “better words” (p. 5) to talk about their struggles. Inspired by Freud’s (1908) “Creative Writers and Daydreaming,” Phillips suggests that the goal of psychoanalysis is to make the patient “the good-enough poet of his own life” (p. 9), telling his reader that Freud believed the creative writer to be an ego ideal: “the best possible version of what it is to be a person” (p. 9). Berman (1985), citing Lehrman (1940) suggests that Trilling (1953) took the following quote from a conversation Freud had in 1928 with Professor Beck, the Prussian Minister of Art, Science and Education (p. 304, n, 40): When, on the occasion of the celebration of his seventieth birthday, Freud was greeted as the ‘discoverer of the unconscious,’ he corrected the speaker and disclaimed the title. ‘The poets and philosophers before me discovered the

unconscious,’ he said. ‘What I discovered was the scientific method by which the unconscious can be studied.’ (p. 32) Phillips (2001) writes, “It was left to Freud to discover how, in a scientific age, we still feel and think in figurative formations, and to create, what psychoanalysis is, a science of tropes, of metaphor and its variants, synecdoche and metonymy” (p. 10). According to Phillips, literature supplies psychoanalysis with “keywords in its evolving sense of itself” (p. xiii). My research seeks to investigate this phenomenon as it continues to be true for a subset of psychodynamically oriented clinicians today. It takes as an aim the exploration of the ways in which therapists elicit the language and imagery inherent in cultural objects to promote their therapeutic work. Inherent in this discourse are the ways in which human beings draw upon their internal creative resources for the elucidation and expression of psychic life, and how this phenomenon is mined within the psychoanalytic enterprise in the service of meaning-making, particularly in the realms of accessing that which has been purposely left out of awareness (the dynamic unconscious), self definition, the access of core values, as well as acts of connecting with an intimate emotional resonance, what Bollas (1987) calls “aesthetic moments” (p. 16). In his article, “The Theme of the Three Caskets,” Freud (1913) summons literary examples in which groupings of three feature prominently, seeking a common thread in underlying themes associated with each object. In this article, Freud is both demonstrating the ways in which his psychic life is anchored in a far reaching set of cultural objects, as well as illustrating the ways in which he mines them as a resource for elucidating an understanding of the human psyche. While he lays out for his reader a panoply of myths, fairytales and literary examples that take as their subject a life-defining

choice which a character must make from among three, he carries us to a place of recognition of the forward thrust of the human spirit to choose love in order to forestall death’s acerbic sting. He does this masterfully, highlighting his profound literary roots and his wide-reaching access to the nature of the human spirit. One avenue Freud draws upon to bring us to this understanding is the notion of the “overpowering effect” (p. 300, original emphasis) Shakespeare’s King Lear has on its audiences in order to help him elicit the play’s core message as something beyond that of life lessons. His attention to “overpowering effect,” begun in the context of what seems on the surface to be a literary analysis, initiates a therapeutic methodology insofar as Freud reminds us that a memory, experience, or association which carries affective resonance is the ticket in to what matters, providing significant opportunities for meaning-making and the discovery of repressed material, both relational and intra-psychic. In this spirit, Joseph Campbell (2008) suggests that the self-same myths that drew Freud, have a universality because they mirror the existential struggles that make us human. Accepting these notions as intellectual givens, and contextually significant, it seems both intellectually and psychologically congruent that a subset of psychoanalytic practitioners draws upon the layered meanings provided by the rich tradition of aesthetic imagery, what I am calling “cultural objects,” as they listen to their patients within the therapeutic space. A century after Freud, psychoanalysts for whom literature and the arts provide access to their own humanity and enterprise of meaning-making, draw upon cultural objects to elucidate their thinking both about work with individual patients, and in an effort to communicate what informs their work in the service of making this accessible to

others. Bollas (1995a) cites Melville ‘s (2000) description of Ishmael in Moby Dick in order to expound his notion of personal idiom in his work with clients. Ogden (1999) analyzes a Robert Frost poem as an offering up of the minute and intricate aspects of a single analytic session. Symington (1996) shares the ways in which a summer reading of Middlemarch lent him insight the ways in which “a person’s self-esteem is more rooted in his ability to love another than in the sense that he is loved” (p.18). Paul Ornstein (1993) analyzes the protagonist in Dostoevsky’s Notes from Underground as a way of sharing the ways this literary work, not only buttresses our own [work on chronic rage], but actually fills in many of the details not yet fully articulated in our literature. These “notes” present a remarkably vivid, pertinent microscopic study of the personality structure and experiences of those who suffer from chronic rage. (p. 144) In the process, Ornstein also teaches about the process of drawing upon such associations in the service of enhancing the therapeutic endeavor. Faigen shared a clinical vignette in which he associated to Kafka’s short story, “The Judgment” between sessions in connection with a client’s narrative. He noted that his association could be refracted through many lenses: It could be understood as a defensive measure by the therapist to distance a bit from the patient’s pain; it functions as a way into the work as it forges an intimacy and point of contact through the sharing of a cultural object and the communication, “I thought of you while reading . . . ”; it is also a way of locating the patient as well as oneself within a larger world that is understandable, as if to say, “We

are not oddities because of our pain . . . , but rather linked with a larger universe of meanings.” 8

Cultural Objects For the purposes of this research endeavor, which takes as its focus the therapist’s associations to cultural objects, the term “cultural objects” will be used to reference phenomena imbued with aesthetic and cultural significance, inclusive of, but not limited to works of literature: poetry, fiction, drama, mythology; the visual arts: painting, sculpture and architecture; music of all genres with and without lyrics; film and television; images and artifacts associated with religious practice. This definition is drawn from the work of Winnicott (1967) in his discussion of “The Location of Cultural Experience,” and from Bollas (1987) in his discussion of the transformational object as an aesthetic experience. These cultural objects, when considered within the scope of contemporary object relations thinkers like Bollas and Ogden, have the capacity to carry personal, mnemic meanings that may be creatively explored for their therapeutic value as they arise within the therapeutic dyad, either within the psyche of patient or therapist, or in the inter-subjective space which they co-inhabit. A cultural object, in and of itself, does not carry significance. Rather, it is the manner in which we reference it, the resonant meanings which it carries that imbues it with value for this enterprise, as it functions as a “derivative of the unconscious when utilized by the therapist to better understand one’s patient.” Attention to the therapist’s

8S. Faigen, personal communication, October 9, 2013

associations to cultural objects is one way to talk about unconscious association. 9 The cultural object provides an opportunity for mental contents to come into awareness, enabling the therapist and patient to invite this new understanding into the conversation of their dyadic therapeutic work. The cultural object, along with other ideas and images, arises within the dyadic work, prompted by therapeutic engagement, 10 thereby providing an opportunity to engage with affective and ideational material previously out of one’s awareness. Like other associations, images and sounds, cultural objects are evocative, carrying meanings that are unclear and which dredge up archived knowledge and experience by using our perceptual apparatus. They are embedded in iconic, echoic memory and in some ways dovetail with dream work. 11 In this way, Bollas (1987) writes of “the conserved object” (pp. 241-246), defining a core aspect of therapeutic work to entail “the creation of new objects” (p. 241) through interpretation and “via evocation, in which self and object representations (as images, ideas, or affects) emerge where they have not existed before” (p. 241). He goes on to write about, Those experiences . . . that were simply beyond comprehension . . . I think that all children store the quality of an experience that is beyond comprehension, and hold on to it in the form of the self-in-relation-to-object state, because events beyond comprehension are disturbing and yet seem life defining. I have described this process as the conservative process, and I have defined the event as an

S. Faigen, personal communication, January 17, 2014 S. Faigen, personal communication, October 9, 2013 11 J. Tolleson, personal communication, November 1, 2013). 10

internal object: a conservative object because the child’s and then the adult’s aim is to preserve the experience unchanged. (p. 246) Bollas believes a goal of treatment is, over time, to help the conserved object move from mood to memory (p. 102), to “push forward an internal experience so that it can be thought” (p. 246). In this way cultural objects have the capacity to serve as conserved objects as they house emotionally and relationally resonant images, ideas, or affects. They carry these kinds of meanings. They come upon us uninvited, evoked, and hold the potential to help us understand the ways in which both therapist and client experience self and other. In addition, they have the capacity to function as condensed images, much as in dream work. As this study investigates the role of the cultural object in the clinician’s imagination, a review of psychoanalytic theory’s use of the term “object” proved elucidating. While Freud (1917), in his article “Mourning and Melancholia,” writes of “object-choice” as “an attachment of the libido to a particular person” (p. 249), the independent object relations theorists, beginning with Fairbairn, invested the term “object” with a different meaning. For Fairbairn and those who followed him, the individual was understood to be object seeking, with the goal of satisfying relational yearnings, what Winnicott (1967) called “a forward yearning for ‘total experience’” (p. 370). He believed that the child’s pleasure seeking was not the goal, but rather a means to the attainment of that which would satisfy: connectedness within the context of relationship, and the holding of this relationship as mental contents within the psyche. This provides a template for one’s sense of self and other, both possible and real in the

sense of that which is yearned for in order to achieve satisfaction. In defining object relations, Horner (1991) writes, The word “object” refers to the mental image of the primary caretaker that is constructed by the mind of the very young child . . . The unique quality of an individual’s inner world of self and object derives from his or her early experience vis-à-vis the primary caretaker, usually the mother. What is at first interpersonal becomes structured as enduring organizations of the mind—that is, it becomes intrapsychic—and then what has become intrapsychic once again is expressed in the interpersonal situation. The internal object relations function as a kind of template that determines one’s feelings, beliefs, expectations, fears, wishes, and emotions with respect to important interpersonal relationships. (pp. 7-8, original emphasis) Fairbairn (1940a), like Winnicott after him, locates the symbolic meaning of a cultural object at the intersection between environment and the “inner world of wish fulfillment” (p. 96), and suggests that this phenomenon is the source of a cultural object’s aesthetic worth. He writes, “aesthetic experience is a specific emotional reaction occurring in the beholder when he discovers an object which functions for him symbolically as a means of satisfying his total unconscious emotional needs (pp. 96-97, original emphasis). In addition, Fairbairn believes that the fact that the work of art has psychological significance is what defines it. In the process of the artist’s signifying an object to be worthy of the creative act, there is the experience of intense emotion, which Fairbairn (1940b) believes is what allows the creator to attribute the notion of essential beauty to the work (p. 170). He believes that the artist’s choice of an object to represent is

founded on the fact that “the object happens to possess features which enable it to represent for the artist fulfillment of his emotional needs” (p. 172), and that these emotional needs are “predominantly unconscious” (p. 173). His final contribution offers that an essential element contributing to the aesthetic object’s characterization as beautiful, consists in “a certain ‘perfection’ or completeness in the object” (p. 179). It is this perfection that provides the impression of “the integrity of the object” (p.180, original emphasis). He writes that in order for a work of art to be ‘beautiful’, it must “satisfy[y] the particular conditions demanded by [the beholder’s] need for restitution” (p.180), by producing a sense of completion as well as an emotional catharsis. Fairbairn’s contribution has resonance for this study insofar as he delineates the nature of a cultural object as satisfying an emotional need in its creator, and thereby functioning as a container for emotional resonance, symbolic significance and meanings. In this way, his ideas converse with Bollas’ (1987) conceptualization of the “the conserved object” (p. 246): One’s associations to aesthetic phenomena carry a multiplicity of meanings and dream-like connections across time, space and relational experience, both that which is housed internally and that which is enacted between oneself and another in real time. This study takes as its focus the ways in which the therapist’s associations to cultural objects inform therapeutic action, and is enriched by Fairbairn’s understanding of cultural experience. Winnicott (1967), reflecting Fairbairn’s influence, sets out to fill a gap in Freud’s psychoanalytic paradigm by offering a model to attend to the location of cultural experience within the human psyche. Winnicott extends his thoughts on transitional phenomena, projection and introjection, as well as play, to take cultural experience into

account. He writes of the “use of objects” (p. 369) to include the category of cultural objects as he considers the ways in which mental representations in the form of objects occupy one’s psychic reality. Defining play as the transitional space between internal and external reality, he believes that an exploration of play as an aspect of life-in-transitionalspace provides access to understanding and locating cultural experience within the mind. He reminds his reader that the transitional object, “the first not-me possession” (p.369), is the child’s first symbol and first play experience: It symbolizes the union between caregiver and infant, becoming developmentally possible once the infant is able to let in an awareness of maternal separateness, and has the capacity to experience the caregiver as a representational object. In effect, the transitional object functions as a symbol of the bond between these two autonomous persons. This developmental capacity is predicated upon the assumption that the caregiver’s presence is ongoing in the infant’s life, even as it proposes that manageable separations facilitate the infant’s capacity to draw upon the transitional object’s properties. An essential component of Winnicott’s conceptualization of the connection between transitional phenomena and cultural experience consists in his idea that it is within the experience of separation that the experience of union can be experienced (p. 369). Rather than assuming an orgiastic, libidinally satisfied resonance, Winnicott, drawing upon Milner’s work, considers play as “a non-climactic experience” (p. 370) within the context of healthy living. Believing that play happens in this transitional space, Winnicott contends that “the place where cultural experience is located is in the potential space between the individual and the environment” (p. 371, original emphasis), a parallel to the space between infant and maternal figure: “It is these cultural experiences that provide the continuity in the human race which transcends personal

existence” (p. 370), and nourish one’s vitality. Winnicott argues that it is important for psychoanalysis to acknowledge “this third area, that of cultural experience which is a derivative of play” (p. 372). Employing Winnicottian language, this study is interested in the psychotherapist’s capacity to play. Within the context of this study this is defined as her association to cultural objects, her attention to what it is that this play may yield in terms of her therapeutic action, and the ways in which she uses these associations in the work. Bollas (1987), understood by some to be a contemporary object relations theorist, suggests that the mother functions as a transformative object for the infant in the preverbal period. Bollas believes that the experience of desire for the individual across the lifespan is a longing to re-create this early, affectively intense and meaningful care-giving experience in the form of other transformational objects, in this way conveying emanations from both the maternal object and the transitional phenomena. He suggests that the human experience of these “uncanny aesthetic moment[s],” whether encoded with positive or negative resonance, hold the capacity to fill an emptiness, as they facilitate the individual’s ability to experience an intense moment of “fusion with the aesthetic,” (p. 16) an outgrowth of the experience of the maternal transformational presence. On the subject of relating to a cultural object, Bollas writes, on the occasion of an aesthetic moment . . . the individual feels a deep subjective rapport with an object (a painting, a poem, an aria or symphony, or a natural landscape) and experiences an uncanny fusion with the object, an event that reevokes an ego state that prevailed during early psychic life. [These experiences] evoke a psychosomatic sense of fusion that is the subject’s recollection of the

transformational object. [The adult] nominates such objects as sacred” (pp. 1617). The object carries a power and intensity, because it is identified in the adult’s unconscious with a “powerful metamorphosis of being.” (p. 17) In this way, the “aesthetic moment” is a re-experiencing, i.e. a re-enacted memory of an early experience of fusion with a gratifying-and-or-frustrating (p. 29) transformative object.

“Non Conscious” “A felt meaning can contain very many meanings and can be further and further elaborated.” 12 The term “non conscious” is investigated in depth in the service of this research inquiry. This literature review provided essential information in the service of understanding the material evoked by and housed within an association to a cultural object. Bollas (1987) speaks to this point when he elucidates aesthetic experience in the context of the transformational object. He writes, In the aesthetic moment the subject briefly re-experiences, through ego fusion with the aesthetic object, a sense of the subjective attitude towards the transformational object, although such experiences are re-enacted memories, not recreations. (p. 17) For the purposes of this dissertation, the term “non conscious” will be used to describe psychic phenomena that exist outside of conscious awareness. This understanding includes, but is not limited to, Freud’s (1912b) definition of the dynamic unconscious. It includes a category of psychic phenomena whose definition is influenced 12

D.B. Stern, 1983, p 91

by Donnel Stern’s (1983) concept of “unformulated experience;” Bollas’ (1987) idea of “the unthought known” (p. 246); and the BCPSG’s (2005, 2008; D. N. Stern et al., 1998) term ‘implicit relational knowing’” (p. 59). Other terms assigned to this category of mental contents include “pre-verbal”, “nonverbal”, “pre-representational,” as well as “pre-symbolic” in the work of Beebe and Lachmann (1994), as well as others. My discussion of “non conscious,” in a descriptive sense, encompasses that which is repressed in the Freudian understanding of the dynamic unconscious, as well as what he (1915) alludes to as “the wider compass . . . of the unconscious” (p. 166) and that which is housed in preconscious thought. Freud’s understanding of the dynamic unconscious consisted of mental contents he deemed “repressed.” He (1912) writes, The term unconscious, which was used in the purely descriptive sense before, now comes to imply something more. It designates not only latent ideas in general, but especially ideas with a certain dynamic character, ideas keeping apart from consciousness in spite of their intensity and activity. (p. 262, original emphasis) Freud (1915) writes, The essence of the process of repression lies, not in putting an end to, in annihilating, the idea which represents an instinct, but in preventing it from becoming conscious. When this happens we say of the idea that it is in a state of being “unconscious.” (p. 166) It is significant to note, however that he writes with an awareness of aspects of the unconscious that do not fall into the category of repression. He stresses, “. . . let us state at the very outset that the repressed does not cover everything that is unconscious. The

unconscious has the wider compass: the repressed is a part of the unconscious” (p. 166). This is what infant researchers who include Daniel Stern, Beebe and Lachmann, and others speak of as the “preverbal unconscious,” contending that psychic phenomena which fall into this category of the “preverbal unconscious” have the capacity to provide a window into one’s character. Procedural memory also falls in this category and provides useful opportunities to lend resonance to their stance. Freud understood unconscious psychic material to gain expression within the “preconscious” through derivatives which he believed to be disguised unconscious ideas which take the forms of psychical symptoms, parapraxes, idiosyncratic language usage, obsessions, and dream content. Freud (1912) writes, As for latent conceptions, if we have any reason to suppose that they exist in the mind—as we had in the case of memory—let them be denoted by the term “unconscious.” Thus an unconscious conception is one of which we are not aware, but the existence of which we are nevertheless ready to admit on account of other proofs or signs. (p. 260) He believed the work of psychoanalysis took place on the border between that which is preconscious and the psychical material, which is unconscious, proposing that the therapeutic work to be engaged in consists of ushering that which is unconscious into consciousness. He (1916) speaks of this as “consciousness run[ning] to meet [the unconscious]. . . .” (p. 42), that which Ogden (2001) calls the “impulse toward symbolic expression” (p. 7). For Freud, unconscious ideas exist out of awareness, existing as repressed. Primary process is primarily not about ideas, but most often about images, which carry ideational content through the act of condensation. In his wide-reaching

work on dreams, Freud offers his conceptualization about the ways in which ideas are expressed via images in dream-work, bringing ideas residing in the unconscious into consciousness. He (1912) writes, During the night this train of [preconscious] thoughts succeeds in finding connections with one of the unconscious tendencies present ever since his childhood in the mind of the dreamer, but ordinarily repressed and excluded from his conscious life. By the borrowed force of this unconscious help, the thoughts, the residue of the day's work . . . become active again, and emerge into consciousness in the shape of the dream. (p. 265, original emphasis) This takes place as a result of a concept, with verbally potential meaning, “dreamworked” in such a way as to disguise the ideational material in the form of images. Freud (1916) writes, We experience [dreams] predominantly in visual images; feelings may be present too, and thoughts interwoven in it as well; the other senses may also experience something, but nonetheless it is predominantly a question of images. Part of the difficulty of giving an account of dreams is due to our having to translate these images into words. “I could draw it,” a dreamer often says to us, “but how to say it.” (p. 90, original emphasis) My interest lies in the ways in which non conscious echoes, which can be housed within cultural objects, carry concepts, ideas, memory and affective reminiscence into the therapist’s reverie in much the same way that thoughts are “dream-worked” into imagery as described by Freud.

Donnel Stern (1983), influenced by Sullivan (1940), James (1890), and Bergson (1903) departed from Freud’s conceptualization of dynamic repression. They believe that non conscious, non verbal material also abides outside of conscious awareness, but not as a result of repression. Stern offers the concept of “unformulated experience,” to describe these categories of experience outside of awareness, defining it as, content without shape, "a beginning of insight, still unformulated, a kind of manyeyed cloud . . . a humble and trembling inchoation, yet invaluable, tending toward an intelligible content to be grasped” (Maritain, 1953, p. 99). In William James's (1890) metaphor, each of us "sculpts" conscious experience from a block of the unformulated, which might have been carved in any number of different ways. Meaning becomes creation, not discovery. "Insight into an unconscious wish," says Fingarette (1963), "is like noticing a well-formed 'ship' in the cloud instead of a poorly formed 'rabbit.' On the other hand, insight is not like discovering an animal which has been hiding in the bushes." (p. 72) Whereas Freud’s model held that mental contents which are subject to distortion, reside in the unconscious as a result of defenses against drives, Stern contributes to the field by identifying an additional aspect of unconscious life, that which is unformulated. He emphasizes and privileges the concept of non conscious and unformulated over Freud’s idea of repression as the source of unconscious thinking. He understands these mental contents as “meanings waiting to be put into words” (p. 73), and thereby entering the preconscious arena. For Freud these “unthought” thoughts emerge without the primary process material, “tamed,” whereas Stern writes, “In order to enter consciousness, an unformulated thought must become "more itself" (p. 73). He is making

an important differentiation between that which repression and defensive structures house out of out awareness, and that which he calls “familiar chaos”(p. 74) which, Stern believes, could not have been distorted or placed out of awareness due to its inherent lack of clarity and differentiation. In this way, the patient in psychotherapy creates meaning, rather than uncovering it. Sullivan (1940, p. 185) writes, One has information about one’s experience only to the extent that one has tended to communicate it to another or thought about it in the manner of communicative speech. Much of that which is ordinarily said to be repressed, is merely unformulated. [as cited in Stern, 1983, p.75] Embracing Sullivan’s influence he writes, “Unlike repression, . . . which . . . is a rejection from awareness, material affected by the process Sullivan describes . . . was never banished from consciousness—because it has never ‘been there’” (p. 75). Stern writes, A felt meaning can contain very many meanings and can be further and further elaborated. Thus, the felt meaning is not the same in kind as the precise symbolized explicit meaning. The reason the difference in kind is so important is because if we ignore it we assume that explicit meanings are (or were) already in the implicit felt meaning. We are led to make the felt, implicit meaning a kind of dark place in which countless explicit meanings are hidden. We then wrongly assume that these meanings are "implicit" and felt only in the sense that they are "hidden." I must emphasize that the "implicit" or "felt" datum of experiencing is a sensing of body life. As such it may have countless organized aspects, but this

does not mean that they are conceptually formed, explicit, and hidden. Rather, we complete and form them when we explicate. (p. 92) The contribution of Stern and others shifts the understanding of significant emerging experience of increased awareness of both thoughts and memory that abides within the individual in unformed states, and which takes shape over time in the context of successful psychodynamic work. One way for the implicit to take shape is through the act of articulation of feeling states previously outside of awareness. Stern’s shift in emphasis has implications for therapeutic action as the psychotherapist is no longer working to uncover that which is hidden, but rather translating aspects of the therapeutic relationship to elucidate unformulated non conscious non verbal relational data. Bollas (1987), in similar fashion, writes of “the unthought known” (p. 246). His ideas carry both a Winnicottian tone and anticipate Daniel Stern’s thinking in terms of explaining the ways in which we house feeling states within relational memory. Bollas writes that the “unthought known,” is a form of knowledge that has not yet been dreamed or imagined because it is not yet mentally realized. In part, it corresponds to the primary repressed unconscious, particularly when we take into account that the unconscious ego is itself a memory of ontogenesis. This would be the experience of the inherited disposition (ego idiom at the beginning of life) meeting up with the maternal process through which ego dispositions, feelings and ultimately structure are mutually negotiated between mother and child. A form of knowledge that has not yet been mentally realized, it has not become known via dreams or phantasy, and

yet it may permeate a person’s being, and is articulated through assumptions about the nature of being and relating. (p. 246) He goes on to write about experience which abides outside of our understanding: I think that all children store the quality of an experience that is beyond comprehension, and hold on to it in the form of the self-in-relation-to-object state, because events beyond comprehension are disturbing and yet seem life defining. I have described this process as the conservative process, and I have defined the event as an internal object: a conservative object because the child’s and then the adult’s aim is to preserve the experience unchanged. (p. 246) Stern, Sandler, Nahum, Harrison, Lyons-Ruth, Morgan, Bruschweilerstern, and Tronick (1998) provide texture and specificity to Stern’s (1983) concept of “unformulated experience” and Bollas’ (1987) conceptualization of “the unthought known.” Grounding their thinking on their investigation of infant-mother relational choreography, they introduce the concept of “implicit relational knowing.” They offer their thinking to enhance the prior psychoanalytic model that values interpretation as the sole mutative tool, counseling an attunement to and investigation of relational choreography as another form of therapeutic action. They write that this kind of knowing consists of “inter-subjective moments occurring between patient and analyst” (p. 903) which provides for the construction of new patterns of relational knowing. They posit that the patient’s procedural knowledge of relationships may be reorganized within the context of the therapeutic relationship, calling this interactional phenomenon “now moments;” or “moments of meeting” (p. 903). They distinguish this kind of therapeutic action from self psychology and other relational theories’ therapeutic interventions. Stern

et al. (1998) propose that much of what is observed to be lasting therapeutic effect results from such changes in this “inter-subjective relational domain” (p. 903), privileging a “psychological act” as opposed to “a psychological word;” change in “psychological structures,” and the “mutative relationship with the therapist” (p. 903). The authors elucidate their concept of implicit relational knowing, by suggesting it may take the form of anticipations, expectations and interactive forms, stressing that it is recording “in a non-symbolic form” beginning in the first year of life. Their work draws upon Bowlby’s (1973) concept of “internal working models” of attachment. Like Stern (1993) before them, they push back against Freud’s conceptualization of dynamic repression. In contrast, they believe that this kind of interactional knowledge is “often not symbolically represented but . . . not necessarily dynamically unconscious in the sense of being defensively excluded from awareness” (p. 906). In this way, Stern et al. (1998) theorize that implicit relational knowing is carried by non conscious imagistic affective states. Insofar as this kind of knowing abides within the treatment space and has the capacity to convey a resonance, it has relevance for this research study as a cultural object may function as a vehicle, which carries the data of implicit relational knowing. Altman (2002) discusses the conceptual overlap between cognitive psychology’s language of “implicit communication” and Freud’s (1912), Bollas’ (2001), and others’ conceptualization of “unconscious communication,” which he describes as “communication that travels directly from unconscious to unconscious without the mediation of consciousness at all” (p. 499). He teaches that the field of infancy research provides this link. Like others, Altman locates “action patterns, . . . facial expression, posture and movement patterns, and the prosodic and rhythmic levels of vocalization” (p.

499) within the category of implicit communication, also understood to be non conscious. Inherent in Altman’s article, in the context of his identification of the profound contribution of infant research, is an inquiry into the nature of therapeutic action. In other words, he wonders if the experience of non conscious connectedness can be inherently therapeutic, or if the explicit mediation of this experience via verbalization is requisite for increased awareness, shifts in interactional patterns, and an expanded capacity for vitality in one’s life. He draws his answer from Loewald (1988) and Ogden by establishing a model that consists of both elements, and reflects what occurs between therapist and patient within the therapeutic dyad: For Loewald, what is key are links between primary and secondary process, between the conscious and unconscious levels of the mind. Verbalization remains crucial here, but verbalization that is not cut off from the primary process level. Another way of thinking about a kind of unity between patient and analyst is provided by Ogden (1994), who, in speaking of the “analytic third,” portrays patient and analyst as subsumed, on one level, by a larger entity constituted by their unconscious interaction. (p. 505) In similar fashion, Stern (1998) proposes that the mutative element of the “welltimed interpretation” may in part be due to its characterization as one kind of “moment of meeting.” That is to say, the relational component figures prominently into the transformative impact of a useful insight, offered in a timely way, thereby pointing to the power of the “psychological act” in addition to the “psychological word”(p. 904). Altman expands his thinking in his clarification of the contents of what he calls the “preverbal,” but nonetheless symbolically processed, nodding to the infant researchers who provide

evidence of young children’s capacity for symbolically encoded meaning-making prior to the acquisition of verbal expression. Altman locates components of future intersubjective communication within the realms of “protocommunicative behaviors . . . that [draw] on affect and linguistic categories” (p. 506), which include relational patterns, as well as implicit communication and knowing. 13 Schwaber (1998) writes of the phenomenon of “state,” which she understands to be “in its essence, a continuing underlying presence” (p. 667). She conceptualizes “state” along the lines of Sander (1995), who writes of “a ‘whole-ness in the living system’ . . . constructed in continuing process by the ‘complexity of unending interactions, transactions, and exchanges’” (cited in Schwaber, p. 668), and suggests that as it is made up of “basic, primal, psyche and soma . . . it can be verbalized, and it can be analyzed” (p. 668). As Schwaber considers “state” in terms of the numerous nuanced nonverbal subjective and interactional data accrued as we attend to dyadic engagement, she stresses that, “in its subtle manifestation, often at first outside awareness, it offers another ‘royal road’ to the unconscious—rather, to what had been unconscious” (p. 669). Her work, along with that of others who attend to the nonverbal aspects of human communication and interaction has ramifications for this study insofar as one’s associations to cultural objects may invite data about the nature of one’s patient’s (or one’s own “state”) into consciousness. The idea of cultural objects provides one way of discussing the nature of the 13

Fosshage (2011) is interested in the ways in which therapeutic action and therapeutic change can be understood by considering the interaction between what he calls “implicit” and “explicit” systems as they relate to the processing of affective and cognitive material. In contrast to Altman (2002) and Stern et al (1998), he believes both implicit and explicit information is encoded in the mind via images and verbal symbolic forms, rather than previously thought that implicit memory is encoded only in non-symbolic ways

psychotherapist’s mind at work insofar as it pertains to unconscious communication. 14 This research study takes as its focus the ways in which the therapist listens to herself and her patient through the lens of her associations to cultural objects. The ways in which cultural objects function as what Bollas (1987) calls “conserved objects” (p. 246), as well as Bollas’ (1992) idea of the “condensation of many ideas” (p. 48) have the capacity to serve as a window into Freud’s (1916) belief that the material of dreams interweave thoughts and feelings together with imagery; Stern’s (1983) conception of unformulated experience and “sensing of body life” (p. 91); as well as Stern et al.’s (1998) concept of “implicit relational knowing,” elicited within the relational milieu.

The Nature of Psychoanalytic Listening: Free Association, Duality, and the “Freudian Pair” Across the literature explored there is a common thread attending to the duality of the listening process: The therapist attends to both the patient’s process and her own. This phenomenon pertains to this research inquiry as it attends to the ways in which the clinician attunes to her internal musings as she listens to her patient. This occurs as a layered kind of listening insofar as the therapist is attuned to both manifest and latent content, both secondary process and primary process thinking, both verbal and nonverbal evocations. Another commonly invoked tenet is that of the therapist’s unique, idiosyncratic, characterological listening capacities and the ways these both receive and privilege the information gleaned on multiple levels and across a variety of modalities of communication.

Faigen, personal communication, February 7, 2014

Beginning with Freud, there is a caution proffered to avoid getting lost in the content of the patient’s material. There is instruction to attune to unconscious messages within the narrative and between the participants, and a prescription to adopt a position of “not knowing,” as counseled by Bion (1967), Symington (1996), and others. Many, beginning with Freud, encourage the exploration of nonverbal, non conscious primary process thought as it is encoded in dreams, images, and other nonverbal vehicles including body sensations, vocal rhythm and tonality, idiosyncratic language usage, imagery carried by metaphor, visual and auditory mental objects, as well as interactional choreography and rhythm, and feeling states. Within the literature, attention to this kind of associative information is encouraged in reference to both members of the dyad as they experience and investigate their own and their inter-connected unconscious processes. The nature of the process engaged in by the therapist, as she moves from listening to her own spontaneous thought emanations in connection to her patient to the outward engagement with the other in the service of the therapeutic work is a primary aspect of this literature review. Bollas (2002) encourages the therapist to “dream-work the patient’s material” (pp. 19-20), echoing Freud’s notion of condensation in The Interpretation of Dreams. Faigen (1996) discusses the essential nature of the therapist’s attunement to “his own subjective states as the source of psychological information about the patient” (p. 3), offering the patient what Symington (1990) calls, “the personal centre of another” (p. 102). He counsels focusing attention on the ways in which the therapist’s spontaneous, free, shared associations impact to move the work forward. Jessica Benjamin (1998) writes about the importance of the patient gaining an awareness of “the implacable reality of the Other” (p. 39). Of the articles read and culled from for the purposes of this

literature review, Freud (1912, 1913); Lothane (2006); Balter, Lothane and Spencer, (1980), Symington (1996), Ogden (1986, 1994, 1997a. 1997b, 1997c, 1999, 2001) and Bollas (1983, 1987, 1992, 1995, 1999, 2000, 2001, more dates, 2002) elucidate the issues of psychotherapeutic listening most fully. Adams (1995), Lipson (2006), Bion (1962, 1967), Schwaber (1983), and Faigen (1996, 1998) raise issues and introduce conceptual notions that converse with the essential ideas fostered by the others. Of primary interest to this researcher is the delineation of the components of the therapist’s internal processes while sitting with a patient. Writers beginning with Freud, across theoretical frameworks, pinpoint the ways in which the therapeutic process of speaking and attending as a duality in the service of attending to the dynamic that occurs between the subjects to be an essential component of therapeutic work. Freud (1912a) describes therapeutic listening, asserting that he developed this methodology because it is “suited to my individuality” (p. 111). He writes, The technique, however, is a very simple one. As we shall see, it rejects the use of any special expedient (even that of taking notes). It consists simply in not directing one's notice to anything in particular and in maintaining the same ‘evenly-suspended attention’ . . . in the face of all that one hears. In this way we spare ourselves a strain on our attention, which could not in any case be kept up for several hours daily, and we avoid a danger which is inseparable from the exercise of deliberate attention. (pp. 111-112) In a footnote (p. 111), Strachey notes that the concept of “evenly-suspended attention” was first coined by Freud, a bit differently, in his case history of Little Hans (1909b), and occurs again in “Two Encyclopaedia Articles” (1923a). Freud cautions his reader that if

one focuses on what is of interest in particular to the clinician, it biases the clinician to only hear what she already knows. He explains that what one hears will not attain meaning until much later in the treatment (p. 112). Freud suggests the therapist “give himself over completely to his ‘unconscious memory’ . . . . ‘He should simply listen, and not bother about whether he is keeping anything in mind’” (p. 112). In this way, both patient and therapist have opened themselves to a free association, what Stern (1995) calls “being-with” (as cited in Stern, 1998, p. 905) in an attempt to access a connection between unconscious processes. Freud suggests that the unconscious “interplay of forces in [the therapist]” (p. 115) will enable the treatment to proceed well, and cautions that having an agenda interferes with the work. Articulating his goal for the therapeutic process, he states, The most successful cases are those in which one proceeds as it were, without any purpose in view, allows oneself to be taken by surprise by any new turn in them, and always meets them with an open mind, free from any presuppositions. (p. 114) Offering his articulate prescription, he writes, “To put it in a formula: He must turn his own unconscious like a receptive organ towards the transmitting unconscious of the patient” (pp. 114-115). Freud’s article continues with other articulations of his methodology and underpinning beliefs, which include his idea that the process of engaging in this journey together yields unmeasured advantage (p. 117). He continues by articulating the essential requirement that the therapist be intimately knowledgeable of her own unconscious processes by virtue of her own analysis (p. 117). He further underlines the importance of

not contaminating treatment by interjecting one’s own conflicts and life details into the therapy. He also warns the therapist not to give the patient assignments in the form of how to focus her attention in anyway (p. 119). He cautions, like others who come later, that when the clinician holds an agenda for the therapeutic work, it interferes with the endeavor. In reference to Freud’s (1912a) prescriptions, Altman (2002) suggests, Although the term “implicit communication” did not arise from psychoanalysis per se, the idea also might well apply to what analysts refer to as unconscious communication, or communication that travels directly from unconscious to unconscious without the mediation of consciousness at all. Freud (1912) . . . noted early on that communication could occur, unconscious to unconscious, between patient and analyst. (p. 499) In this way, Altman is linking Freud’s foundational recommendations to a more contemporary understanding of unconscious communication within the dyad. Freud (1913), in the context of recommendations of technique, discusses the significance of the process of his unconscious thought as he attunes to the patient’s material and the value of free association, along with other key foundational concepts. In this last regard, Freud shares the now paradigmatic instructions he would offer patients beginning treatment regarding the enterprise of free associating: “Act as though, for instance, you were a traveller sitting next to the window of a railway carriage and describing to someone inside the carriage the changing views which you see outside” (p. 135). Balter et al. (1980), writing from an ego psychological perspective, and hearkening back to an important presentation by Isakower (1963b) at the New York

Psychoanalytic Society, invoke the term “analyzing instrument” to describe what is employed by “the analyst in rapport with the patient” (p. 475). Quoting Isakower, they define the analyzing instrument as “a composite consisting of two complementary halves . . . Both halves function together as one unit in continuous communication” (p. 490). In this way, they write about what Bollas (2002) later terms “the Freudian Pair.” The authors set out to operationalize the analyzing instrument. Utilizing Kris’s (1950) formulation of the work of the patient in this process, they contribute to the field by broadening it to also describe the parallel work of the analyst. They outline the issues as essential for this work to unfold well: primary process thinking, the importance of images as opposed to words, a prescription to overcome inhibitions and a need for reality-testing, the achievement of a fluid dream-like state, and the employment of language. Aspects of the patient’s thought processes are understood less for communication, which they see as a secondary process function, but rather to privilege an interface with one’s emotional experience (p. 481). Symington (1996) is interested in the process of psychoanalytic listening and partnering insofar as “proto-feelings” can be transformed into “feelings.” He grounds his thinking on Freud’s (1923a) foundational concept of “evenly hovering attention” (p. 239), suggesting that Freud’s intention was for one to hone “the mental conditions necessary for the imagination to operate to its maximum capacity” (p. 44). Symington expands Freud’s notion by calling for the access of one’s imagination, which he believes must be nurtured by the psychotherapist, thereby creating a “mental culture” whose salient component is that of a “mental space”(p. 44). Prescribing the cultivation of one’s imagination as a requisite companion to one’s theoretical orientation, he writes:

The contemplation of the natural landscape and of works of art, listening to music, and the enjoyment of poetry are all food for the soul and for the imagination . . . The work of the imagination requires great mental effort— usually it is much easier to rush off and clutch at a passing theory . . . When we do this, we give up on that struggle to stay in emotional contact with our patients. (p. 45) By this I believe he means that the therapist metabolizes amorphous feeling states that she experiences as she sits with her patient within the context of an unconsciously connected dyadic relationship. He is very interested in the ways in which the therapist’s imagination is the vehicle through which this transformation occurs. He writes, “The imagination takes up this raw material and transforms it into patterned imagery so that a feeling comes into being. The feeling comes into being through the imaginative processes in the mind” (p. 39). In this way, Symington is instructing the therapist to listen and work the material by sifting it through her own internal world. He believes that a careful attunement to one’s own internal processes is a key component to the process of listening to one’s patient, advocating that we need to listen well to ourselves in order to listen to our patient. Wishing to guide us to open up our imaginative capacities far beyond the parameters of theoretical orientation, naming this a “relax[ing] into an inner attitude of free association” (p. 40) on the part of the therapist, Symington believes the therapist “also needs to have available a whole range of images arising from his own present and past life, stretching right back to his childhood, in order to meet the stimuli, sensations and sensuous modalities that come to him when he is sitting with a patient” (p. 40). In

this way he advocates our access to imaginative processes in the service of generatively and meaningfully “meeting” that which the patient brings to the work. Bollas (1995a) writes of the act of therapeutic listening, likening it to dream-work and the ways in which the clinician attends to his patient, as the “unconscious attendant” (p. 13), describing the act of listening as an act of “unconsciously re-signifying” the patient’s communication by “transforming his material into [his] own . . . according to [his] own unconscious processes” (p. 25). Bollas (1999) expands on this notion of dreamwork as he writes about the primitive nature of a dream: an economical condensation of images which carry a multiplicity of communications (p. 182), theorizing that the therapeutic act is to translate this pre-representational imagery into language: The work of association . . . moves the self from the pre-verbal to the verbal. . . . The associative process also sets the self into subsequent deep internal imaginings, that is, back into the visual-sensorial-affective orders. . . . Emerging from such reveries into speech the analysand renews language with unconscious depth.” (p. 183) A useful aspect to Bollas’ (1995) “dream-work” analogy is the way he elucidates the process of therapeutic listening as it echoes this process of dream-work. Some of the significant similarities he designates include the ways in which time is fluid and chronology is unimportant; the ways in which contradictions which dwell side by side are mined for meaning, and do not disturb as they may in ordinary life; the ways in which realities are distorted: People from varied times and places in one’s life interact with one another in ways that yield information but whose absurd nature is not a distraction within this context (p. 13). Similarly, the analytic process, according to Bollas, has a “time

warp” (p. 13) quality for both analyst and patient. He identifies this as the intermingling of the conscious and unconscious; the dynamism of contradictions; the condensation of events and individuals; as well as “recurrently confused, wandering in the strange country of even suspension” (p. 13, original emphasis). Bollas (1995b) strongly emphasizes and cautions that this kind of connection between therapist and patient “is like learning a new language and may take years” (p. 31), humbling the practitioner by inserting the factor of time into the relational equation. Speaking of patient and therapist as “the analytic couple” (pp. 30-31), he describes a process in which the analyst’s “unconscious sensibility” (p. 31) is impacted by the patient’s unconscious material, deepening the therapeutic connection as it unfolds. He names this phenomenon “relational knowing” (p. 32). Like Symington, he delineates the ways in which the highly subjective internal processes of the therapist dovetail with those of the patient. He emphasizes that the ways in which the therapist prioritizes this material, deciding what leads to follow and which overlapping threads to unfurl, significantly impact the treatment process. He also seems to be suggesting that the very practice of experiencing one another in this way has healing capacities, when he writes, “The sense is the thing. Not the particular contents it reveals” (p. 38). Bollas (1995b) elicits Bion’s writings about “O” to further develop his idea, highlighting the emotional experience that develops within this therapeutic dyad (p. 39). He writes, If we assume that such a separate sense exists, just how does it work? Working with a patient, an analyst comes to develop an inner constellation of preconscious ideas, feelings, visual images, sonic metaphors, somatic dispositions, and bodyego acuities, a kind of psychosomatic organization that forms his matrix for

unconscious communication with his patient. This separate intuitive sense is a network of the many different planes of reference that constitute subjectivity. (p. 39) Bollas (2002) understands Freud’s contribution to have “highly privileged” (p. 7) the therapeutic environment in which a patient brings “the monologic nature of solitary inner speech to the dialogic structure of a two-person relation. Calling this a partnership” (p. 7), he defines the psychoanalytic enterprise as supply[ing] a relationship that allows the analysand to hear from his or her unconscious life” (p. 10). Bollas (1987) believes that this dialogic act—“being-with” (p. 32) another as one opens out one’s unconscious thought processes has what Bollas (2002) describes as the capacity to “expand the unconscious mind” (p. 67). As Bollas conceptualizes the act of psychoanalytic listening, he underscores the highly idiosyncratic and characterologic nature in which the therapist condenses material received from the patient into his own associative images. He believing that this process holds the capacity to connect in valuable ways with the patient’s thought processes (pp. 17-18). The condensation that Bollas writes about is of great interest to this researcher insofar as it can both contain and be held within images such as cultural objects. The therapist’s condensation of the patient’s associative material is a key component to understanding the nonverbal images, many of which have cultural resonance, that are evoked in the process of psychoanalytic listening. Like Balter et al. (1980), he parses the analytic process, defining the analyst’s act as “pattern recognition” (p. 18): the therapist’s act of understanding the patient’s set of realities alongside the therapist’s own “unconscious contents or emotional states of mind” (pp. 17-18). He draws the analogy between this dyadic process and that of early infant-mother

communication. Bollas believes that this “is easy to do because we are open to such unconscious mutual influence when relaxed in the presence of an other” (p. 19). He draws the analogy to two friends talking freely. The process, according to Bollas, looks like this: The patient communicates through “free talking,” the analyst functions as “a medium for thought,” both partners utilize “a part of the ego” that has the capacity to engage in “the work of unconscious reception” (pp. 17-18). He stresses that the nature of this attentional immersion is a matter of attention to “form versus content” (p. 18), emphasizing the analyst’s ability to attune to the patient’s essential communication: “the patient’s unconscious logic” (p. 18). Again, this is a description of engagement and listening characterized by interactive relational “moves” that are fueled by an exquisitely honed attunement to internal processes within the respective members of and between the members of this dyad. Like Bollas, Ogden (1997) notes that finely attuned therapeutic listening is a process that unfolds over time, stressing the nature of a process. Overall it feels that Ogden is promoting a therapeutic stance characterized by “moving toward” and not “arriving at” (p. 570). Deepening insight may not tie up neatly at the end of a session, but spans a series of sessions. Like Bollas (2002), he understands this therapeutic phenomenon to occur contextually within the dyad, as a co-creation (p. 569). Like Bollas, Ogden parses the listening process in a useful way: attuning to what it feels like to be with his patient, the tenor of his own voice over the course of the treatment hour, intense feelings that interfere with offering a usable interpretation, affective shifts in the session. In addition he identifies the symbolic forms this reverie takes, including images and feelings, emotional power, and emotional context (p. 187). Like Bollas, he is

interested in the process of moving from dream-work to symbolic, language-based communications. Ogden’s (1997) notion of “reverie”—the capacity to let one’s mind wander— grows out of his 1986 ideas about imagination as the “capacity to play with an idea,” as well as feelings, symbols and thoughts, the act of creating a space “in which meanings exist, where one things stands for another in a way that can be thought about and understood” (p. 241). He offers reverie to his readers as a core component of the work, identifying it as his “emotional compass” (p. 570). Using language very carefully, he describes this process as both highly subjective and inter-subjective. It is the intersubjective arena that he designates “the inter-subjective analytic third” (p. 569). Ogden (1994) defines the analytic third as “a product of a unique dialectic generated by (between) the separate subjectivities of analyst and analysand within the analytic setting” (p. 4). This is the art of the work of listening both to oneself [introspection] and to one’s patient, with the express goal of “further[ing] the analytic process” (p. 568). He writes that [Reveries] are things made out of lives and the world that the lives inhabit … [they are about] people: people working, thinking about things, falling in love, taking naps . . . [about] the habit of the world, its strange ordinariness, its ordinary strangeness . . . ” (Randall Jarrell [1955, p. 68] speaking about Frost's poetry). They are our ruminations, daydreams, fantasies, bodily sensations, fleeting perceptions, images emerging from states of half-sleep (Frayn, 1987), tunes (Boyer, 1992) and phrases (Flannery, 1979) that run through our minds, and so on. (p. 568)

Ogden (1994) spends some time writing about why this way of being with one’s self and one’s patient exists on the margins of psychoanalytic practice: It is highly personal, demanding of the therapist to both access and then reveal deeply subjective internal musings. He further notes that attending to one’s reverie is construed by some as “mystical,” and therefore inscrutable, and unattainable. Additionally, the use of one’s reverie as an essential analytic tool has been understood by its detractors to reflect a narcissistic preoccupation with one’s internal self. And yet, he argues like Bollas and Symington, that one’s attunement to oneself in the unconscious connectedness with one’s patient has the capacity to inform one’s work in elemental ways, noting its unique, idiosyncratic and non-generalizable nature (p. 572) which he illustrates with several elucidating case examples.

Countertransference: States of Subjectivity within the Therapist, the Ways in Which It Is Aroused in the Work, How It Can Be Used to Inform the Work Authors who write about a therapist’s associative process and the ways it can be understood within the work, consider this phenomenon as a source of countertransferential data, among other understandings. For this reason, a review of the literature regarding countertransference occupies a place in this literature review. Jacobs (1999) provides an historical overview of the phenomenon of countertransference vis-à-vis its significance within the analytic process, understanding it contemporarily in the broader context of “issues of inter-subjectivity, enactments, self-analysis” (p. 575). Jacobs (1999) cites Freud’s (1910) early observation,

“We have noticed,” he wrote, “that no psychoanalyst goes farther than his own complexes and resistances permit, and we consequently require that he shall begin his activity with a self-analysis and continually carry it deeper while he is making his own observations on his patients . . .” (pp. 141-142) [cited in Jacobs, page 576] He teaches that in an ongoing way, psychotherapeutic thinking understands “Freud's recognition of the enduring nature of countertransference and of the fact that it exists as an ever-present force in analytic work” (p. 576). While Freud did caution that one’s countertransference can function as interference, Jacobs also believes that Freud’s thinking provides a foundation stone for the notion that counter-transference also functions “as a pathway to understanding the unconscious of the patient [thereby] . . . play[ing] an indispensable role in treatment” (p. 576). Here he cites Freud’s (1912) article in which an essential recommendation to physicians embarking on psychoanalytic practice is to be cognizant of the ways in which the unconscious of the patient and that of the analyst intersect. He advises that in order to be aware of this phenomenon, one must attune both to oneself and one’s patient. Bollas (2002) names this dyadic engagement “The Freudian Pair” (p. 56). Countertransference as a window into the subjectivity of the therapist has resonance vis-à-vis my research study insofar as it may include within its scope the therapist’s associations to cultural objects and what this kind of internal musing may yield for the work. While Freud primarily situated himself on the cautionary side of countertransference discussions, Jacobs understands Ferenczi (1919) to have introduced the idea that countertransference is both unavoidable and a useful tool to gaining insight

into one’s patient (cited in Jacobs, p. 577). In addition, Ferenczi believed that a therapist’s intentionality to curb her countertransference interferes with the essential element of free association as one listens. In this way, Jacobs instructs that Ferenczi’s ideas are embraced by social constructivists and intersubjectivists. He communicates “an appreciation of the role of meta-communications in analysis and of the interplay between the minds of patient and analyst” (p. 578). Heimann (1950) echoes Ferenczi when she writes, The analyst's emotional response to his patient within the analytic situation represents one of the most important tools for his work. The analyst's countertransference is an instrument of research into the patient's unconscious and there is general agreement about its unique character. But my impression is that it has not been sufficiently stressed that it is a relationship between two persons. (p. 81, original emphasis) Heimann shifts the definition of countertransference when she characterizes it as “all the feelings which the analyst experiences towards his patient” (p. 81). She writes, I would suggest that the analyst along with this freely working attention needs a freely roused emotional sensibility so as to follow the patient's emotional movements and unconscious phantasies. Our basic assumption is that the analyst's unconscious understands that of his patient. This rapport on the deep level comes to the surface in the form of feelings which the analyst notices in response to his patient, in his “counter-transference.” This is the most dynamic way in which his patient's voice reaches him. In the comparison of feelings roused in himself with his patient's associations and behaviour, the analyst possesses a most valuable

means of checking whether he has understood or failed to understand his patient. (p. 82) Racker (1957) builds on his 1954 paper in which he agrees with Heimann and emphasizes that, Countertransference reactions of great intensity, even pathological ones, should also serve as tools. Countertransference is the expression of the analyst's identification with the internal objects of the analysand, as well as with his id and ego, and may be used as such. Countertransference reactions have specific characteristics (specific contents, anxieties, and mechanisms) from which we may draw conclusions about the specific character of the psychological happenings in the patient. (p. 305) In his 1957 paper, he sets out to elucidate countertransference issues in order to better know what material to interpret and when to initiate these interpretations (p. 306). Expanding a definition of countertransference, and setting it in analogous relationship to Freudâ&#x20AC;&#x2122;s understanding of transference, Racker (1957) writes, In the analyst there are the countertransference predisposition and the present real, and especially analytic, experiences; and the countertransference is the resultant. It is precisely this fusion of present and past, the continuous and intimate connection of reality and fantasy, of external and internal, conscious and unconscious, that demands a concept embracing the totality of the analyst's psychological response, and renders it advisable, at the same time, to keep for this totality of response the accustomed term 'countertransference.â&#x20AC;&#x2122; (p. 310)

One can see that the phenomenon of countertransference reactions as defined by Racker has the potential to be housed within the condensed imagistic form of cultural objects as countertransference reactions are characterized by a dream-like quality of transcending time and space, reality and fantasy, much the way cultural objects are characterized by this capacity. Racker further develops his thinking in paradigm-shifting ways as he explicates and defines both “concordant” and “complementary” countertranferential reactions. His nuanced dichotomy adds to the countertransference discussion within the scope of his introduction of the concept of “concordant” identification. This set of feelings elicited within the therapist, is understood as “this part of you is I” as well as “this part of me is you” (p. 312). In this way a “union or identity” (p. 312) takes form within the therapist, and facilitates an empathic stance. His understanding of complementary countertransference has its roots in a more traditional definition in which the therapist identifies aspects of her patient with archaic objects of her own and responds to her patient in light of these unconscious connections. Racker (1957) broadens an understanding of countertransference reactions to include “the totality of the analyst's psychological response to the patient” (p. 313). Jacobs (1999) delineates a controversy in the analytic community regarding how one uses one’s experience of countertransference. Practitioners who include Deutsch (1926) and Arlow (1993) believe that the associations offered by one’s patient give rise to internal experiences on the part of the analyst. As a result, the analyst’s intuition can be derived from the ways in which she processes this inner material. Arlow builds on the conception, which advocated both unconscious experience and intellectual processing,

when he states that this data is processed in the service of the formulation of interpretations. Abiding in the other camp, Jacobs (1993) and others’ conviction lies with the notion that the therapist’s subjective response to her patient’s material inevitably is enacted prior to a conscious acknowledgement of said experience, making it challenging for one’s subjective response to undergo an intellectual, formulated process to be shared out with one’s patient. Bollas (1983), in his article about the therapist’s experience of countertransference, writes of the ways in which the therapist enters into, and thereby experiences, the patient’s “environmental idiom” (p. 4). By “welcom[ing] news from within himself” (p. 3) the therapist accesses avenues to his patient’s essence. Often “disturbed patients . . . in very distressed states of mind . . . need to place their distress into the analyst” (p. 2). Here he is advocating a different kind of listening, as one “allows the patient to affect [oneself].” In another article, Bollas (1999) discusses Freudian dream listening and Kleinian listening through projective identification. In his discussion of Bion, Bollas (1999) writes, “The analyst was a container to the patient’s introduction of mental contents, as if the patient were posing a question: ‘How do you live with these contents and what will you do to find them survivable?’”(p. 190). In this way, Bollas (1983) analyzes the ways in which the therapist “function[s] as a transformational object” (p. 30), first by naming the feeling states engendered within himself in the context of the countertransference reaction, and then in an attempt to understand them and finally, utilizing them in the service of interpretation. Like some of the other aspects of therapeutic listening articulated by Symington, Bollas and Ogden, this too requires one’s

exquisite capacity to attune to one’s internal processes in order to listen well to the patient.

The Therapist’s Use of Associations to Cultural Objects in Her Work Within the context of this literature review, a perusal of literature in which psychodynamically oriented psychotherapists have written about the presence of cultural objects within their reverie occupies a key place. I set out to discover how thoughtful psychoanalytic teachers and writers consider this phenomenon within their work, as a prelude to engaging with participants for this study. The author St. Aubyn (2012) writes, “Once you’ve finished a novel, what happened in it is of little importance and soon forgotten. What matters are the possibilities and ideas that the novel’s imaginary plot communicates to us and infuses us with” (p. 1). Dewey (1934) writes that what “the artist selected, simplified, clarified, abridged and condensed . . . the beholder [goes through] according to his interest. In both, an act of abstraction, that is of extraction of what is significant, takes place” (p. 56). In this way, cultural objects are comprised of meanings that endure beyond our immediate experiencing of them. Bollas (1987), strongly influenced by Winnicott’s (1967) conceptualization of the way in which cultural experience functions as a transitional phenomenon, situated in the dyadic intermediate and connecting space, describes the aesthetic moment, as a caesura in time when the subject feels held in symmetry and solitude by the spirit of the object. “What would characterize experience as aesthetic rather than

either cognitive or moral,” writes Murray Krieger 15, “would be its self sufficiency, its capacity to trap us within itself, to keep us from moving beyond it to further knowledge or to practical effort.” Whether this moment occurs in a Christian’s conversion experience, a poet’s reverie with his landscape, a listener’s rapture in a symphony, or a reader’s spell with his poem, such experiences crystallize time into a space where subject and object appear to achieve an intimate rendezvous (p. 31) . . . .a generative illusion of fitting with an object. A form of déjà vu, it is an existential memory: a non-representational recollection conveyed through a sense of the uncanny. Such moments feel familiar, sacred, reverential, but are fundamentally outside cognitive coherence. They are registered through an experience in being, rather than mind, because they express that part of us where the experience of rapport with the other was the essence of life before words existed . . . The aesthetic moment constitutes part of the unthought known. The aesthetic experience is an existential recollection of the time when communicating took place primarily through this illusion of deep rapport of subject and object. Being-with, as a form of dialogue, enabled the baby’s adequate processing of his existence prior to his ability to process it through thought. (p. 32) The ways in which cultural objects infuse the therapist’s reverie with meanings that carry into the work is evidenced in the literature in a multiplicity of elucidating examples. Symington (1996) describes in detail a profound interaction he experienced in the reading of George Eliot’s Middlemarch. He writes of what he understands to be an 15

Krieger was an American literary critic who engaged in studying the nature of the language of imaginative literature. He believed that poetic language is uniquely available to unfold vision and meaning, well beyond that of diurnal language.

unconsciously motivated choice of this novel at a time when he was struggling in his treatment of a girl whose personal narrative evidenced a disconnect between her experience of severe emotional deprivation as a child and her tenacious adherence to a “rapture about her home” (p. 17). The insistent puzzle gnawing at him—“I knew . . . that it was denial, but what purpose did the denial serve?” (p. 18)—accompanied him, along with the novel, on a summer holiday. Symington suggests that the confluence of his work with this patient, and his choice of a novel to take on vacation was inspired by an “emotional signal” that increased his professional knowledge and insight into his patient’s paradoxical emotional stance, but also “allowed my soul to grow” (p. 20). In this way, the company of Eliot’s “delicate sensibility, range of understanding, and combination of vast knowledge with emotional sympathy” (p. 18), invited Symington to both cognitively consider the professional conundrum he took with him on vacation, but maintain an unconscious empathic resonance with this patient as he began to experience, through Eliot’s protagonist, that one’s “self-esteem is rooted in his capacity to love rather than in the knowledge that he is loved himself. Fairbairn said that narcissism results from a turning away from the love object in abject disappointment. One might say, therefore, that Lydgate was fighting a desperate battle against being engulfed by a fateful narcissism” (p. 18). While Symington’s example does not take place within the consultation room in a real time engagement with his patient, I offer this example from the literature as it elucidates Freud’s (cited in Trilling 1953) notion that the poets knew what it took him years to prove. It is a fine example of the internal processes of a thoughtful psychotherapist for whom cultural objects convey meaning. And Symington’s immersion

in the cultural object’s emotional and meaning-making resonances held the capacity to move his work forward in significant ways. Further, in introducing this vignette, Symington offers that the book had been a recommendation from a beloved friend “whose enthusiasm for Eliot had touched me somewhere” (p. 18). His affective, relationally meaningful connection to the novel, is suggestive of both Bollas’ (1987) and Winnicott’s (1967) understanding of the cultural object as a transitional phenomenon occupying the space between self and other. In this narrative, the passage from Middlemarch functions as a transitional phenomenon for both the dyadic pairing of Symington with his friend, and Symington with his patient. While Ogden (1997b) stresses that he is writing about the act of listening to three poems by Robert Frost “for the sheer pleasure of reading and writing about poetry” (p. 619), in the process he instructs regarding the nature of the activity of listening that takes place between two participants, reader and poet, weaving the connection between the experience of analytic listening and the experience of listening to poetry in subtle, implicit ways. Ogden (1997c, 1999) attends to and develops these same themes in two additional articles. He maintains that the overlap in the music of the language, and the ways in which the communicative act, as opposed to the words conveyed, comprises the experience’s essence. In addition he highlights some idiosyncratic aspects of language that have the capacity to convey meanings that can be mined in our therapeutic work, including unusual word choice, surprising syntax, silence interspersed with speech, as well as “run-on” phrasings in contradistinction to staccato rhythmic communication. In his analysis of these three poems, Ogden attributes significance to these aspects of

communication suggesting some ways in which the aesthetic carries meanings that may be drawn upon consciously and unconsciously in the analytic work. Many psychotherapeutic thinkers, like Freud before them, draw upon both their humanistic and personal cultural environments to elucidate the human psyche. Mitchell (1988) elicits imagery of Penelope’s loom in Homer’s The Odyssey to provide textured meanings for his idea about psychopathology in the analytic process. He describes Penelope’s action, She weaves during the daylight hours and, after the household has gone to sleep, unravels her work by torchlight. She spends years at her endless project, whose seeming futility belies its effective and poignant role in preserving her dedication and holding together her subjective world. (p. 272) Drawing upon this image he writes, “Psychopathology is an unconscious commitment to stasis, to embeddedness in and deep loyalty to the familiar” (p. 273). Enhancing his thinking for his audience, he posits, One might regard the relational matrix within which each of us lives as a tapestry woven on Penelope’s loom, . . . whose design is rich with interacting figures. Some represent images and metaphors around which one’s self is experienced; some represent images and phantoms of others, whom one endlessly pursues, or escapes, in a complex choreography of movements, gestures, and arrangements woven together form fragments of experience and the case of characters in one’s early interpersonal world. Like Penelope, each of us weaves and unravels, constructing our relational world to maintain the same dramatic tensions, . . . the same longings, suspense, revenge, surprises and struggles. (pp. 272-273)

Mitchell’s offering of Penelope’s loom as a conserved object housing a layered set of meanings has the power to communicate; to “dream-work” his idea in a manner which enhances one’s understanding and capacity to make meaning of his notion of the universal human propensity to maintain a loyalty to one’s conflictual attachments, as well as one’s tenacious identification with archaic objects. Mitchell’s hearkening to Homer is possible because of what Freud, Campbell (2008) and others comprehend about cultural objects’ mirroring of the existential struggles that make us human. Bromberg (1984), in similar fashion, hearkens to Castenada’s development of the sorcerer-teacher interface in his novels to elucidate the phenomenon of magical thinking in schizoid patients. He also draws upon Henry James’ (1875) novel Roderick Hudson to coin a phrase that encapsulates a key concept in his writing about the schizoid patient’s process of dwelling within himself, and the therapeutic task of helping this type of individual attain an “absorbing errand” (p. 443) in order to venture outside of himself into relationship. Like Mitchell’s conceptualization of Penelope’s loom, Bollas’ idea of one’s personal idiom, Bromberg’s configuration of the absorbing errand is an example of a condensed, textured image that conveys meanings the psychotherapist can draw upon to enrich her work. Ornstein (1993) draws upon Dostoevski’s Notes for Underground in order to elucidate some theoretical and clinical considerations of aggression and rage. Understanding the first person narrative to convey significant aspects of a patient’s free association, he insightfully intuits and uncovers a deeper understanding of the unnamed protagonist’s anguish which is characterized by humiliation, degradation, coupled with preoccupations around physical ailments and revenge fantasies for an injurious but

dramatically distorted grievance. Ornstein’s gift as a reader, psychoanalyst and teacher lies in his ability to understand that while, We would undoubtedly judge [this man’s obsessive musings] from the outside as self-defeating . . . Dostoyevsky illuminates [them] from the inside as desperate attempts to regain lost self-regard. All these reactions are embedded in the context of a pervasive sense of superiority and self-importance, which exists side by side with a sense of utter worthlessness and unbearable shame. (p. 143) Ornstein experiences the unnamed speaker’s first person narrative as “compulsively honest, often monotonously repetitious, yet courageous and cogent selfrevelations a particular urgency and dramatic intensity” (pp. 143-144). In this way he draws upon a condensed image to elucidate a complex and textured panoply of psychic phenomena, drawing connections to Kohut’s (1972) conceptualization of narcissistic rage (p. 144). Altman (2002), in his exposition on unconscious communication, offers a case illustration in which he and his patient experience parallel and spontaneous free associations to the same Country Western singer. This experience is characterized by an almost uncanny, mystical telepathy between them, which he likens to examples offered in the literature by Bass (2001), Mayer (1996), and Mitchell (2000) (as cited in Altman, 2002, p. 504). Again citing Loewald, Altman writes of a “primal density” or unity that underlies interpersonal interaction. On a secondary process level there is a distinction between self and other, so that one needs to explain how communication occurs across the divide. On a primary process level, one that Loewald felt coexists with secondary process differentiation, there is no

differentiation. The primal unity of self and other persists, so that patient and analyst are each part of a larger whole. From this point of view, one need not wonder how communication occurs from one person to another any more than one needs to wonder, or seek an explanation for, how I know what I am thinking. (p. 504) In Altman’s (2002) example he attunes to a “beautiful, mournful poignant” (p. 509) melody wafting into his office alongside his patient’s narrative of listening to a new Emmy Lou Harris album that had evoked an unprecedented deep sadness and longing for his father. Moved by his sense of impending sadness as he listened to the melody and then his patient, Altman experienced an emotional resonance with his patient, disclosed his own affinity for this singer, and joined his patient in free associating to the lyrics from the song that had particularly moved his patient to tears. In this vignette, what Bollas (1992) identifies as “an intense condensation of many ideas thought simultaneously”(p. 48) lies within the images evoked in the Country Western song. Freud (1912) understands this phenomenon as primary process material encoded within an image, most clearly delineated for him in dream work. Altman terms this “a mutually dreamed image” (p. 510), which carries meanings of significance in the analyst’s interpretation, It was fitting that Mr. P's route of access to his feeling for his father went via a woman's feeling for the man, as if Mr. P needed his mother to mediate his feeling for his father, although this was not going to happen. Further, I thought about how Mr. P and I had connected in a parallel, extremely powerful way, also mediated by a woman we both loved, [Emmy Lou Harris]. . . . We had located some shared emotional space in which, simultaneously, Mr. P. could find his father and we

could find each other. . . . The country music singer seemed the perfect symbol for our shared area of emotional responsiveness, for his mother, perhaps for my mother. She emerged between us like a mutually dreamed image. Verbal symbols were mere vehicles for this more profound dreaming. One might say that whatever passed between us, or whatever it was that subsumed us, existed in symbolized, but not verbalized, form. (p. 510) Lipson (2006), motivated by his own characterological manner of “thinking in music” (p. 859), explores the way associations to the cultural object of music, which he terms “auditory images” (p. 860), evoke and convey affective meanings, likening it to Ogden’s (1997) understanding of reverie (p. 861). Citing Reik’s (1953) article “The Haunting Melody”, Lipson describes “numerous examples of uncovering hidden meanings by analyzing the associations to melodies that occurred spontaneously in his mind and in the minds of his patients (p. 860). He offers an example, and concludes that attention to the associations that accompanied the music ultimately permitted an expanded view of my patient's struggle (p. 862). I was holding a pencil in my right hand so that it protruded from my partially closed fist, and with the fingers of my left hand, I was “playing” on the pencil as if it were the fingerboard of a violin. The music was the opening of the Brahms clarinet quintet, and I was playing both violin parts simultaneously, . . . As I observed what was happening, my immediate thought was that this was the favorite work of the wife of a close friend, a woman to whom I was attracted. Before my associations wandered further, it occurred to me that my male patient was expressing derivatives of oedipal conflicts and incestuous desires. My brief

associations expressed both the triangular relationship and the idea of “not something I would do.” My understanding of the patient was a spontaneous event rather than a reasoned conclusion. (p. 861) He continues by exploring the questions that arise from such an associative experience, Does playing both violin parts represent analyst and patient, or other pairs? What would one make of the fingers playing on the protruding pencil? Unfortunately, the only associations available at that time were those reported, and they were interrupted as the connection with the patient became clear, thus ending the reverie. My current view is that analytic listening activated certain issues of mine to a degree that they temporarily interfered with understanding. These issues gained an outlet through the described musical experience, which served as a compromise of resistance and expression. (pp. 861-862) In concert with Bollas’ idea of the “conserved object”, Lipson addresses the depth and breadth of what may be condensed into musical expression (p. 862). Lipson compares this internal musical process to dream-work, I find it helpful to approach these issues as we do dreams and dreaming. In my view, Freud's (1900) consideration of dreams as “a sort of substitute for thoughtprocesses, full of meaning and emotion” (p. 640, italics in original) is equally applicable to the experience of internally heard music . . . One can use a melody or composition to express a collection of affects—i.e., feelings plus cognitive

content—in a parsimonious way by means of condensation. Thus, the music may well express more than can easily be put into words. (p. 865) Understanding music as an imagistic vehicle carrying affective meanings more readily available than words, perhaps hearkening to a non conscious location of affective memory, appears as his article builds. He draws an analogy between visual imagery and the auditory, citing Gardener (1983): “In describing his frequent experience of visual images, . . . [he] states, ‘Each pulls things together and informs me more quickly than if my ideas and feelings had to be or could be put into words’” (p. 71). Nodding to remarks by Mozart and Mendelsohn about the ways in which their thoughts and feelings find expression through music to the exclusion of verbal language Lipson (2006) concludes, Music, for many, is a more suitable vehicle than words for the expression of unconscious content, filled as it is with fantastic imaginings and dominated by the primary process. In other words, musical sounds can be used to represent one's inner life, just as words and visual images do. (p. 875) Echoing Lipson, Lothane (2006) enhances one’s understanding of the role music can play in the therapeutic milieu when he writes, There is an analogy between listening to music and attuning to psychological meanings. In all languages the ear is literally the anatomical organ of hearing and figuratively the soul’s instrument of discernment and understanding. (p. 714) Like Penelope’s loom, the narrative of the underground man, and the poetry of Robert Frost, the music of Emmy Lou Harris functions as a cultural object held in one’s imagination, carrying “dreams and signs, past and future . . . ” characterized by many meanings . . . Expanding out and out and out” (Tartt, 2013, p. 755), that hold implications

for therapeutic action, what Lipson (2006) defines as “the potential of using internally generated auditory imagery to understand transference-counter-transference interactions” (p. 876).

Analyzing the Process of Attending to Oneself as One Listens to One’s Patient Lothane (2006), Symington (1996), Renik (1993), Hoffman (1991), Arlow (1979), Faigen (1996, 1998), Bollas (2002) and Lipson (2006) attend to the factors contributing to the therapist’s associative process within the therapeutic setting. When these clinicians’ explorations of the subjective associative process are placed in conversation with one another, they engage in an inquiry as to whether this associative act is one of leaving the therapeutic milieu in a defensive fashion, or accessing what lies between the partners within the therapeutic dyad. They also treat of what is to be gained or lost in this process. In addition, among others, Arlow (1979), Bollas (1987), and Lothane (2006) break down the process of listening to one’s self and one’s patient into its unfolding components, in some cases characterized by a progressive nature, proceeding step by step. An investigation of this kind in which the process of listening to one’s own associations, in particular those referring to cultural objects, as one attends to one’s patient’s internal musings, is an essential focus of this research study. Arlow (1979), in his article on interpretation, traces the inner workings of the therapist as she experiences the patient’s free association material and moves toward interpretation. Arlow suggests that there are two overarching facets to this process, the aesthetic and the cognitive. He does not believe that they are necessarily linear, suggesting that they may occur

simultaneously. He then proceeds to elucidate the activities of the analyst’s unconscious as it works along the lines Freud (1912) formulated, breaking this process down into four components. Initially the therapeutic listening is characterized as “passive-receptive” (p. 201). Secondarily, the therapist transitions to a more observational and interpretive stance as she attunes to her own internal processes. Arlow introduces a variety of associations to cultural objects that may become operative for the attuned therapist at this stage, including music, jokes, personal narrative, poetry, and film, as well as literature. His third listening stage notes the provision for the analyst of initial insight that unfolds as the therapist uses her free associations for important communication about the patient’s material. Fourth, the therapeutic internal work reaches a place he calls “intuition” (p. 201) when she is able to organize this body of associations—belonging both to patient and therapist—into a pattern that yields meaning. For Arlow, empathy also functions as an important component of this process as it combines the therapist’s internal experience of identification with her patient. Arlow’s approach examines the attuned therapist’s internal listening as it is activated by the patient’s material, and is founded on a trust in the wellhoned, exquisitely trained attunement to one’s own internal, unconscious processes in the presence of the patient’s unfolding of unconscious (as well as non conscious and conscious) material through her free association. In effect, Arlow is delineating the ways in which the analyst’s unconscious associations to cultural objects have the capacity to provide meaning making opportunities—in both intra-psychic and inter-subjective realms-- in the service of therapeutic action. In his discussion of self-analytic work and countertransference, Bollas (1987) analyzes the process of attuning to one’s inner workings, breaking it down to its distinct

components. He believes that embracing countertransference theory enables the therapist to “talk more frankly about what is taking place in his mind during his work” (p. 254). Bollas presents several elements that comprise this process. He enumerates the process as, (a) the therapist’s attending to the ways in which she is experienced as significant objects from the patient’s life, with a focus on “thoughts or moods determined by the analysand” (p. 255); and, (b) the patient gaining an awareness that the therapist’s “own inner experiencing” and “consider[ation of] his own inner life, which is being accessed in order to more deeply understand the patient’s inner life” (p. 255). In this way the therapist’s associative act functions as a relational bond insofar as the patient gains awareness that both members of the dyad are engaged in self-analytic work, and that as a validation that his inner life is a significant subject for the therapist’s internal reflections. Finally, Bollas sees the benefit in this process culminating in the patient’s understanding that while We may be separated by necessary professional tasks . . . we both share the selfanalytic function: we undergo experiences and contemplate them as subject and object. When the analysand understands that some of his own self-analytic efforts parallel our psychic activity, I believe the patient feels more profoundly supported by us. He knows us then . . . [as] someone who like himself struggles to know and may often find the struggle painful and unpleasant. (p. 255) Lothane (2006) elucidates mechanics of listening, synthesizing a variety of listening approaches including those of Freud, Isakower, Reik and Gill. Founding his conceptualization of the work that transpires within psychoanalysis, Lothane (1984) coins the phrase “reciprocal free association.” In this way he stresses the therapist’s attunement

to herself in concert with her listening to her patient. In addition he attempts to synthesize the opposing camps that value listening to content, dreams and images on the one hand, and those who stress the privileging of resistance and transference on the other. He founds his mechanics of listening on the overlapping three aspects of analytic activity delineated by Isakower and Reik: 1. The initial act of experiencing. 2. The subsequent act of self-observation, leading to a potential interpretation. 3. The therapeutic decision for an actual, spoken communication to the analysand. (p. 715) He makes the point that while he is analyzing the process, in the language of those he cites, the lines are not tightly drawn. Lothane expands on each element. For him the “act of experiencing” is characterized by the therapist interweaving her own associative material with what has been heard and felt. The conscious and preconscious interweave to yield a new understanding of the patient’s material. The second element, that of self-observation, consists of three sets of awareness: (a) reflecting back on what one has experienced; (b) striving for insights regarding the cause and effect relationship between one’s associations; and (c) further engaging with one’s experience of what has transpired within oneself in the presence of one’s patient’s internal process, within an intellectual framework. Lothane further develops his notion of “experiencing.” Hearkening to Freud (1900/1953), he writes, In this light we can understand Freud's formulation of the method of free association as giving rise to a condition marked by an altered state of

consciousness: “[…] a psychical state which in its distribution of psychical energy (that is, mobile attention), bears some analogy to a state before falling asleep— and no doubt to hypnosis […] As we fall asleep, ‘unbidden [ungewollte] thoughts’ emerge […] which—and here the situation differs from falling asleep— retain the character of ideas”(Freud, 1900/1953, p. 102). Freud stressed the sleeplike quality of the altered state of consciousness which is instrumental in weakening repression and facilitating the emergence of pictorial forms of thought, or images. (p. 716, original emphasis) He draws upon Reik’s (1949) thinking when he notes that, “The analyst must oscillate in the same rhythm with his patient within the realm between fantasy and reality, sometimes approaching one, sometimes the other” (Lothane, p. 717, quoting Reik, pp. 109-116). He also cites Reik’s (1949) belief that the analyst’s attention moves fluidly between his own musings and those of his patient: [The third ear can] hear voices from within the self that are otherwise not audible because they are drowned out by the noise of our conscious thought processes […]. What is to be emphasized is that such associations, such vague but nonetheless indicative sensations as those which accompanied the hearing of a patient's report, are instrumental in reaching the most important analytic insights. (Lothane, p. 718, citing Reik, pp. 125-126, 131, 314). He tells his reader that Reik understood “the totality of the analyst's shared experience, his silent monologue as evoked by the patient's words, the response . . .” (p. 718), Reik (1949) defines this as,

the reaction of the analyst to the communications, words, gestures, pauses and so forth of the analyzed person. I call the sum total of this reaction, which includes all kinds of impressions, response. . . . It includes the awareness of inner voices. (p. 269) Lothane continues, In the dream atmosphere of the psychoanalytic situation both participants are particularly receptive to figurative speech, symbolization, metaphors, clang associations, punning, that is, psychological processes close to dream work, wit, and poetry. (p. 718) Lothane cites Reik, An essential element in analytic comprehension is understanding things, filling gaps, smoothing out distortion; in short, tracing the way back to the repressed core of communications. . . . In the process of reproduction the analyst must use the same technique of the patient, must apply the same mechanism of condensation, displacement, and omission, because by no other means has he any prospect of under-standing the secret meaning of unconscious processes (p. 253, cited in Lothane. (p. 718) The third component of experiencing consists of a time of internal processing on the part of the therapist. Here Lothane borrows a phrase from Arlow (1969): the therapist “thinks along, dreams along” with his patient, giving herself an opportunity to incubate on the patient’s material, what Reik (1949) describes as the unconscious interval to allow perception to mature” (pp. 208, 210). In this third element of experiencing, Lothane writes of “emergence” (p.718),

Thoughts suddenly emerge in forms which are common in this dream atmosphere and less common in the full waking state: visual, acoustic, and other images and memories, to be beheld with free-floating attention in the ongoing activity of introspection. (p. 718) The ways in which the therapistâ&#x20AC;&#x2122;s free associative material expresses itself as the conserved images of cultural objectsâ&#x20AC;&#x201D;visual, acoustic and literary, among others-- is the focus of this dissertation work. Reviewing the literature that attends to this phenomenon was undertaken in anticipation that the interview process, which would engage the participants for this inquiry in a discussion of this phenomenon, would yield textured examples from their seasoned clinical practices. Further, the ways in which Reik (1949), Arlow (1979), Bollas (1997), and Lothane (2006) have broken down their subjective experience of the therapeutic process serves as a paradigm for the kind of data I was hoping to elicit in my inquiry.

Chapter III

Methodology Type of Study and Design This study is qualitative in nature, employing a psychoanalytic case study methodology (Tolleson, 1996), and applying psychoanalytic theory as its conceptual frame. It sets out to investigate the phenomenon of how the psychoanalytically oriented psychotherapist utilizes her associations to the imagistic echoes from cultural arts in the service of furthering the therapeutic action, specifically as it has the capacity to facilitate increased understanding of the patientâ&#x20AC;&#x2122;s non conscious processes. Open-ended interviews were conducted with five psychodynamically oriented psychotherapists over three ninety minute sessions, initiated by a 30 minute screening interview and followed by an hour long feedback session. Feedback conversations took place after each participant read her respective case study document. Data gleaned from this interview process was analyzed utilizing a psychoanalytic interpretive frame, as Tolleson (1996) describes, Specifically, the researcher analyzed the raw data for various categories of meaning, based on the words and behaviors of subjects, which appeared to offer compelling insights. . . . These meaning categories were comprised of both the subject's stated, or manifest, psychological experiences as well as the researcher's

own inferences of latent meaning as derived from her overall experience of the subject and her own clinical and theoretical knowledge. (p. 99) This study method was adopted, taking into consideration Yin’s (2014) assertion that case study research has the capacity to “produce its own findings” (p. 215), most likely taking a rich form in its descriptive mode. Further, Hoffman (2009) makes a case for this methodology as he expresses a deep concern that a scientific approach would subjugate the humanity and freedom of both patient and therapist. In concert with this chosen methodology, he argues in favor of the valuation of the uniqueness and uncategorizable nature of each patient and patient-therapist dyad. In light of his respect for the singularity contributed by each human subject, he cogently promotes the case study as a tool to elucidate current psychodynamic practice, privileging mystery and ambiguity, as opposed to prescriptive practice ordinances. The aim of this study was the exploration of the role of association to cultural objects within the psychotherapist’s reverie, an area of study marginalized within the field at the present time. It was my hope that by rekindling a discussion of the ways in which the psychotherapist’s reverie holds the capacity to inform dyadic work, it might make inroads into contemporary professional discourse. Consistent with Tolleson (1996) and Hoffman (2009), the psychoanalytic case study method adopted for this research privileges a phenomenological approach to the data. My inquiry focused on the lived experience of its participants, and sought to explore the meanings that participants attribute to their clinical experiences. Valuing the contribution of participants’ interview material was founded on the belief that the participants were experts in the area to be researched and that their insights, thoughts, experiences, priorities, ways of working, and feelings could elucidate the phenomenon

being explored. In addition, participants demonstrated a willingness to engage in an endeavor of co-constructing meaning vis-à-vis the phenomenon under investigation.

Scope of Study Favoring depth over breadth (Tolleson, 1996), my study set out to encompass narrative interviews drawn from an in-depth engagement with five participants who were selected through an intentional, purposive screening along the lines of Cresswell’s (2009) conceptualization: “The idea behind qualitative research is to purposefully select participants . . . that will best help the researcher understand the problem and the research question” (p. 178). Cresswell (2013) writes, “The inquirer selects individuals . . . for study because they can purposefully inform an understanding of the research problem and central phenomenon in the study” (p. 156). Specifying sampling methodology for phenomenological studies, he writes, “It is essential that all participants have experience of the phenomenon being studied. Criterion sampling works well when all individuals studied represent people who have experienced the phenomenon. This research was predicated on the notion that the psychotherapist participants whom I would interview were deeply immersed in the humanistic cultural tradition, valuing the arts as both a window into the human condition, and a way to enhance the meaning- making of one’s life in ongoing ways, such that allusions to cultural objects was a fluid, natural and unique aspect to the participants’ manner of living a meaningful lives. The following criteria were operative in my selection process: Participants needed to be in practice 15 or more years, following the completion of a degree program. Participants self-identified as self-reflective, with a capacity to be articulate about their

work, as well as a willingness to participate in this study commensurate with the requisite commitment of as much as four 60 to 90 minute interviews. Participants self-identified as psychodynamic in orientation, embracing an â&#x20AC;&#x153;analytic attitudeâ&#x20AC;? as defined by Hoffman (2009, p. 1047), and Gorman (2002, p. 58). Participants identified an ability to be reflective about their internal processes, and an awareness that they listen to themselves as they attend to their patients. Participants confirmed a comfort with the use of reverie to further therapeutic dyadic work. Additionally, they identified a capacity and tolerance for countertransference reactions. Further, these clinicians self-identified as assuming a humanistic stance vis-Ă -vis the confluence of human struggle as depicted in the arts and as experienced within the therapeutic dyad. Each one described a life enhanced by an ongoing engagement with cultural objects such as literature, film, music, drama and the visual arts, noting that these cultural objects are readily available to their imaginations, and each had a willingness to utilize their free associations to literature, film, visual art and music in their work. Finally, these participants were willing to disguise case material shared within the interview process. The screening process consisted of the development of a recruitment flyer (see Appendix C), which was sent via email to colleagues and teachers. Each of the five participants was referred by one of my Institute for Clinical Social Work Long Term Treatment Case or Case Study consultants. In one instance, a recommended participant had been affiliated with the Institute, but was at present assuming an emeritus status. In this case, IRB approval was sought and received, and an addendum to the consent form was developed to meet IRB requirements (see Appendix C). Recommending clinicians put potential participants in touch with me via email and phone, and I proceeded to

engage in an interview screening by phone to establish participantsâ&#x20AC;&#x2122; appropriateness for my study, using the criteria delineated in my dissertation proposal, which appear above. Following this process, time was established with each participant to engage in the three ninety minute interviews, which took place in the participantsâ&#x20AC;&#x2122; offices. Interviews were recorded using a recording application on my computer. Files related to the interview process were password protected. These password-protected files will be kept for 5 years and then deleted, in accordance with IRB regulations. I listened to and transcribed each interview. This process provided me with a deep, arduous opportunity to engage in an initial review of the data. And, while not anticipated, it kept the material alive within my imagination between interviews in a manner that fueled the interview process in meaningful ways. Additionally, it facilitated my process of conceptualizing new lines of inquiry as I moved through the interview process with each successive interviewee. Following the interview process and my conceptualization of Case Study and Categories of Meaning documents, I contacted each participant again by email requesting that they review their respective documents and meet with me for a 45 minute to one hour member checking and feedback interview. This process had been contracted for at the outset of the interview process. Each member received her respective Case Study Document following each oneâ&#x20AC;&#x2122;s assent to dedicate the time to this process. Participants were asked to review the document for adequate disguising of their identity and that of the case material, as well as for thoughts and reactions to the conceptualization of the data gathering interview process we had engaged in together. In all cases, participants provided additional thoughts as well as some corrections to the Case Study and

Categories of Meaning documents. These interviews took place at participants’ convenience, either in person or by phone. Feedback was integrated into revised documents at my discretion, with particular attention to disguising the identities of both participants and their case material, and correcting for errors.

Data Collection Methods and Instruments I engaged with participants in three ninety-minute interviews. These interviews took place in each participant’s therapeutic space, which proved significant for this study, which takes as its focus the clinicians’ engagement with cultural objects, as each participant demonstrated a powerful, deeply meaningful connection to the physical space they inhabit in unanticipated ways. Similarly, this proved valuable as it provided me with a palpable sense of the environment in which clinical vignettes unfolded, often proving significant as they were occasionally connected up with feelings elicited by cultural objects that abide within the clinician’s therapeutic space, for either client or clinician. Additionally, meeting in person enabled me to attend to both verbal and nonverbal communication, voice intonation, body language and facial expressions, and contributed to a rich connection between us. The first interview began with a scripted reading of the document formatted for the dissertation proposal (Appendix B), an invitation to ask any initial questions, and the participant’s review and signing of the consent form, or forms in the case of one participant. I consciously opened the interview process with a set of questions to elicit participants’ fuller sense of self, beyond the scope of her psychotherapeutic practice, as this had implications for my study which takes as its focus the clinician’s attention to her

associations to cultural objects within the therapeutic interview. I also hoped that initiating engagement in this way would set the tone of inviting personal disclosures, and that this would be a comfortable way to begin to establish a dialogic rapport between us. What followed was a request for objective details of the clinician’s practice: number of hours engaged in psychotherapeutic work, number of clients, times per week that individuals are seen, as well as the kinds of concerns individuals bring to the work, and the wider parameters of each clinician’s job description, educational background and theoretical predilections. In an organic and flowing manner I then segued to an open-ended dialogic engagement, querying participants about examples of the phenomenon I was investigating in each one’s unique psychodynamic practice. I assumed an open, listening stance, coupled with a questioning curious sensibility. I attempted to leave room for quiet contemplation as I paced my open-ended questions, at times electing to sit in silence, and at others slowing down a participant’s narrative. I worked to both follow the train of thought initiated by participants in a manner consistent with psychotherapeutic listening and free association. Additionally, however, I strived to bring participants back to the phenomenon which we were exploring together, when the narrative wandered a bit far afield. Between interviews, I listened to the recorded interview process multiple times, recording field notes and follow up questions. During this process, I attended to themes and patterns in the participant’s narrative, lines of questioning that received short shrift for one reason or another that I wished to pursue further, nonverbal elements of the interview process in terms of voice intonation in particular, as I was transcribing for

emphatic statements, softer-voiced reflections, and contemplative or resistant periods of silence. In addition I attended to relational and sequencing phenomena that unfolded within the interview, for example moments when we worked with painful material, hit an impasse, or a participant voiced a sense of inadequacy in the process. Like other aspects of the interview process, this had parallels with an “analytic attitude” (Hoffman, 2009) characteristic of therapeutic engagement. Each subsequent interview was initiated with a question for the participant about thoughts that arose between interviews. At times there was only a week between sessions, and in other instances more time elapsed. While the process of transcription, keeping field notes, reviewing the data and formulating further lines of questioning kept the data alive within my imagination, this proved to be out of sync with participants’ experience of the process. I named this phenomenon as I grew aware of it, which seemed to set participants at ease with their sense that we were in some ways beginning anew to establish a rapport and rhythm, and also seemed to further a sense of the value I was actively ascribing to their multifaceted contributions. Additionally the easy availability to me of material offered in earlier sessions provided participants with a sense of being attended to and known in ways most participants identified as meaningful, and had parallels with the therapeutic dyadic experience.

Data Analysis Using Tolleson’s (1996) psychoanalytic case study methodology, I examined data through a thorough and systematic analysis, founding my analysis on the ways in which participants make sense of the phenomenon of their associations to cultural objects and

experience within their psychodynamic practice, and the ways in which I made sense of their communications. I carefully took into account the intersubjective nature of the interview endeavor, with the intent of gleaning meaning from both narrative content communicating thoughts, feelings and associations, as well as nonverbal communications, which facilitated meaning-making. Transcripts were reviewed multiple times and coded for categories of meaning (Tolleson, 1996). These categories of meaning were grouped along idiographic and nomothetic lines, including both verbal and nonverbal communication, as recorded in routinely recorded field notes. The plan for data analysis included a) individual narrative analysis following a case study methodology as articulated by Runyan (1984) and Tolleson (1996), as well as an extensive cross-case analysis as delineated by Tolleson (1996), Yin (2014) and others. The case study aspect of data analysis consisted of significant verbatim excerpts from the interview transcriptions, ranging from four to sixty quotations. Importance of participants’ voices in the analysis, was viewed through the lens provided by Tolleson (1996) who writes, “The material derived from each subject … [will be] initially examined as an entity in and of itself: idiomatic, distinctive, and informative in its own right” (p. 115). Runyan (1984) understands the case study method to provide an in-depth description of experience. He writes, citing Kanzer and Glenn (1980, p. 43), “The case studies of Freud are ‘rare works of art and a record of the human mind in one of its most unparalleled works of scientific discovery’” (p. 121). In explicating the case study approach, Runyan explains, If one’s purpose is to describe the experience of a single person, to develop interpretation or explanations of that experience, or to develop courses of action

and to make decisions appropriate for this particular individual, then the case study method is an extremely useful one. (p. 125) He defines this method as “a systematic presentation of information about the life of a single unit” (p. 127). Writing of case study research in psychology, Yin (2014), citing Bromley (1986, p. 1) notes that its goal is to “derive an up close or otherwise indepth understanding of a single or small number of ‘cases’” (p. 209). Reid, et al. (p. 205) stress that the case study model, through the lens of interpretive phenomenological analysis, “…prioritizes the participants’ world view at the core of the account” (p. 22). Delineating characteristics of case study research within the field of psychology, Yin (2014) states •

It is an in-depth inquiry.

•

It studies conditions over time, even if there is only a brief interlude between episodes studied, for example, three interviews spaced over a period of three weeks. “Case studies rarely serve as literal snapshots—as if everything occurred at the same exact moment” (p. 214).

•

The research considers contextual circumstances: Data about the individual in her living context is an essential aspect of data collection. The blurring of boundaries between individual and context is a strength of case study research (p. 214) and may lend richer understanding of a case.

In the case of this research endeavor, the ways in which a psychotherapist situates herself within her cultural milieu has significant implications for what is learned. Yin (2014) believes that case study research has the capacity to “produce its own findings” (p. 215), most likely taking a rich form in its descriptive mode. In light of a respect for the

uniqueness contributed by each human subject, Hoffman (2009) cogently promotes the case study as a tool to elucidate current psychodynamic practice, affirming living with mystery and ambiguity, as opposed to prescriptive practice ordinances. Additionally, data was analyzed employing a cross-case analysis as delineated by Tolleson (1996). Reid, et al. (2005) stress that in this kind of study, results are not given as facts but are “grounded in examples from the data” (p. 20). Noting that the researcher assumes an interpretive/outsider position, they specify that the researcher is engaged in the process of meaning-making vis-à-vis the participants’ experiences and narrative, with a focus on the particular research question driving the study (p. 22). Examples from the data were drawn upon in the process of coding, the method of organizing integrating and interpreting data. Further goals in data analysis, included the prioritizing “transparency of results and reflexivity in the interpretive process” (p. 23). As prescribed by Tolleson (1996) this cross case analysis “[examined] . . . meaning categories . . . across subjects, in order to discern features of experience which [were] more or less general to the collective sample” (p. 116). Her work defines “categories of meaning” as the formulation of “idiographic generalizations based upon the thematic patterns which emerged from the subject's material” (p. 115). Consistent with the privileging of meaning over findings, this inquiry assumed a hermeneutic epistemological approach to data gathering and analysis. That is to say that this research inquiry assumed as foundational the idea that knowledge is attained through dialogue. Warnke (1987) writes of Gadamer’s ideas, Understanding—verstehen—for Gadamer is primarily coming to an understanding –verstandigung—with others . . . . In confronting texts, different views and

perspectives, alternative life forms and world-views, we can put our own prejudices in play and learn to enrich our own point of view. (p. 4) While Gadamer challenges the possibility of an objective knowledge, and takes into account the ways in which personal prejudice provides a stumbling block to accessing that which is true, he also believes one’s personal predilections can be mined for meaning-making. Warnke continues, “They become perspectives from which a gradual development of our knowledge becomes possible . . . . In coming to an understanding with others we can learn how to amend some of our assumptions and indeed how to move to a richer, more developed understanding of the issues in question” (p. 4). Gadamer’s writing regarding how one comprehends a text’s truth has bearings on the way I gathered and analyzed the data, treating participants’ narratives as one would a text. He (1975) writes, A person trying to understand a text is prepared for it to tell him something. That is why a hermeneutically trained consciousness must be, from the start, sensitive to the text’s alterity. But this kind of sensitivity involves neither “neutrality” with respect to the content nor the extinction of one’s self, but the foregrounding and appropriation of one’s own fore-meanings and prejudices. The important thing is to be aware of one’s own bias, so that the text can present itself in all its otherness and thus assert its own truth against one’s own fore-meanings. (pp. 281-282) In concert with the adoption of Gadamer’s hermeneutic approach to meaningmaking, I have considered and conceptualized my personal sensibility as it identifies an absence of neutrality in this study enterprise, and an awareness of my subjective presence

within the process of data gathering and analysis. This elucidation appears in the dissertation introduction, housed within the section on foregrounding.

Statement on Protecting the Rights of Human Subjects This researcher followed all IRB guidelines relating to the protection of the rights of human subjects. The researcher included protection of the rights of all human subjects.

Limitations of the Research Plan The research plan was subject to some limitations due to the subjectivity of the researcher. In the process of conducting in-depth interviews, the reviewing and transcription of tapes, and the culling and coding of thematic material this primary investigator inevitably was impacted by her foregrounding. It was the intent of this researcher to build safeguards into this research project to both increase awareness of the ways in which researcher subjectivity influenced the listening and data coding as the enterprise unfolded, and to self consciously note the ways in which this researcherâ&#x20AC;&#x2122;s unique internal understandings shaped her data analysis. This was attended to through field notes, cross-checking performed by committee members reviewing case study material in conjunction with the researcherâ&#x20AC;&#x2122;s conclusions, and member-checking.

Chapter IV

Findings

Case Study Introduction This research study is predicated upon a phenomenological-hermeneutic approach to data collection and analysis. In the process of attuning to the participants’ narratives, as well as in the construction of the case study documents, I experienced the literature of psychoanalytic theory occupying my imagination with a simultaneity that held sway over the ways I endeavored to make sense of the material. In his discussion of the nature of philosophical hermeneutics, Cushman (1995) explains, It is not possible to exist as a human being outside of a cultural context . . . The bombardment of perceptions and possibilities is like a forest, and the carved out space like a “clearing” in the forest. The clearing of a particular culture is created by the components of its conceptual systems . . . The clearing is both liberating because it makes room for certain possibilities, and limiting, because it closes off others. (pp. 20-21) In effect, I found myself drawing upon the cultural phenomenon of psychoanalytic theory abiding within my imagination in much the same way that participants’ imaginative, associative process engaged with cultural objects to inform the psychoanalytic process, of which they spoke in elaborate and articulate detail. In this way, the writings of thinkers that include Bollas, Ogden, Benjamin, Winnicott, Renik,

Stern, and others provided a “clearing” during the interview process and the data analysis. Citing Gadamer, Cushman (1995) writes, Because humans are always embedded in a particular historical and cultural frame of reference, Gadamer has argued that it is impossible to attain objectivity . . . A research agenda . . . is always framed by the shared understanding and limits of the researcher’s clearing: There is nowhere else to stand. As a result, researchers can only understand an object by attempting to place it within its larger context, and they can only understand the whole by studying its elements. Thus research is unavoidably a process of tacking between the part and the whole, between the researcher’s context and the object’s context, between the familiar and the unknown. This is the hermeneutic circle, and it is basic to the research process. What is familiar is always, first and foremost, what has been given to the researcher by his or her culture—the possibilities and limitations of the understandings that constitute the clearing. (p. 22) The case studies that follow reflect this phenomenon, unique to the characterologic make-up of this researcher: They intertwine with the psychoanalytic theories that inhabit my imagination, an ever-growing repository as I read and study, and which I draw upon in an explicit manner as I engage in the process of constructing meaning from the rich “forest” of data afforded me by the intelligent, insightful, forthright, and contemplative engagement of my research participants.

Case Study Sample The project sample was made up of five seasoned clinicians who self-identified as psychodynamic in orientation, privilege the use of unconscious phenomena in their psychoanalytic work, and have an affinity for some aspect of aesthetic experience that finds its way into their imaginative process both in and out of their sessions with clients. This study sample was made up of three men and two women. It consisted of two clinicians who received psychoanalytic training at a well-respected psychoanalytic institution, one of whom is a physician trained and practicing in a field other than psychiatry. Four of the five sample participants are trained as clinical social workers. Two of these practitioners also assume a key administrative role in their agency. Two of the five participants are solely in private practice, one is solely in an agency practice, and the other two balance their professional lives between agency work and private practice. The two practitioners solely engaged in a private practice setting, each see between six and eight patients weekly, many two to five times per week. The remaining three participants have caseloads of approximately 25 patients per week, and see only a very few more than once a week. Each of the five practitioners has been in practice at least 15 years. One participant has worked as a psychodynamically oriented psychotherapist for over 50 years; three others have worked as clinicians for over 30 years; and the fifth participant has 20 years of clinical experience.

Clinician 1 Case description. Clinical context. Clinician 1 is a male in midlife, who holds a Masters degree in clinical social

work, and has been in practice for over 20 years. At present he is the director of a small urban clinic situated near a college campus, which takes as its focus therapeutic work with people struggling with issues of grief and loss. The clinic was founded to care psychologically for individuals experiencing a dramatic impingement in their ability to engage meaningfully in life following traumatic loss. Clinicians work to facilitate individuals’ capacity to reconnect with their creative, generative parts of self in the wake of loss. Together with five other clinicians, he sees people across the lifespan, locating his practice primarily with adults in midlife. He sees 23 to 28 patients each week, using the remaining time for administrative responsibilities, including supervision. His career began in a community clinic, working with geriatric patients. He describes this work as his “first love.” Clinician 1 defined his practice as work with individuals struggling with anxiety and depression. Elaborating, he said, “the sort of life events that bring-- you know-anyone to therapy, really: Some form of separation or loss in their life. You know they don’t feel they’re moving forward in their lives, some sort of loss or stuck-ness: relationship break-ups, divorce, changing in family system; aging parents. A host of issues.” He paused, and then summed up, “Being human.” In addition a small part of his practice is made up of therapists looking to deepen self-knowledge as they engage in this work. Clinician 1 articulated a strong commitment to a therapist’s self-reflective practice, and feels this is a standard he holds for himself. Clinician 1 inherited the position of clinic director when his mentor, the director and clinic founder, died suddenly in mid-life. He spoke of this mentor as a deeply spiritual practitioner, whose presence still infuses his therapeutic practice, and the center

as a whole. By “spiritual,” Clinician 1 meant that his mentor’s work was shaped by a profound belief in unconscious processes, specifically unconscious communication, and a belief in the existence of a collective unconscious. His mentor, drawn to Eastern religions, also functioned as a lay monk in the Buddhist tradition. From his description, it was clear that spirituality is a key component of his conceptualization of his psychotherapeutic practice, and that of his mentor’s legacy. Adams (1995) illuminates the intersection between spiritual traditions and psychoanalysis when he writes, Appreciating the wisdom and transformative power of a living relationship with the depth dimensions, [psychoanalysis, existential phenomenology, and the great spiritual traditions] . . . endeavored to create reliable ways of going beyond the habitual, defensive, and surface. They developed analogous methods of practice involving a radical openness to what is. Psychoanalytic evenly suspended attention, the phenomenological attitude, and meditative awareness are consonant practices which aspire to cultivate a privileged mode of awareness, namely, revelatory openness wedded with the clarity of unknowing. (pp. 463-464) Clinician 1 deepens his clinical ideological background by reading extensively and participating in an ongoing study group. He identifies as having an affinity with Kohut’s work, but is also drawn to the inter-subjectivists and the relational school. In addition, he finds the work of infant researchers including Schore, Stern and the Boston Change Process Study Group meaningful and useful, as they offer an understanding of implicit relational knowing and unconscious communication that he finds applicable in his work, and whose ideas resonate with fiercely held tenets about his psychodynamic practice. In the course of the interview process, he brought in examples from the

psychoanalytic literature in an organic fashion, demonstrating that these ideas are actively alive in his imagination and thinking. In addition to the infant researchers, the clinicians and writers about whom he spoke included Casement, 16 Mitchell 17, Irwin Hoffman 18, and Alice Miller 19. At the same time, Clinician 1 outlined an interest in Carl Jung, specifically related to his work with archetype and the collective unconscious. In large measure, Clinician 1’s connection to the situation of cultural experience within the therapeutic relationship stems from a serious interest in Jung’s ideas. He feels that Jung’s work with symbols and archetypes, and the ways in which they carry universal human meaning provide a place of connection for him with his clients. He described Jung’s ideas coming into play in his work when he is engaged in both dream interpretation and symbols that come in from what he called “a day time story.” He suggested that joining in a connected way with his patient’s dream symbols allows for a “deeper knowing” which he said then leads to a “resonance in relationship.” Bridging psychodynamic theoretical models, he linked this experience to Kohut’s concept of the phenomenon of twinship transference. In addition to his own psychotherapy, Clinician 1 pursues several additional nourishing personal practices to care for himself, and to enhance his emotional availability to his patients. He described a variety of activities with overriding nonverbal components, including an ongoing Judo practice, time spent playing guitar and “making music,” as well as contemplative time spent in the natural world. Speaking specifically of

Casement, Patrick (1992). On Learning from the Patient. Guildford Press: New York. (1995). Hope and Dread in Psychoanalysis. Basic Books: New York. 18 Hoffman, Irwin W. (2001). Ritual and Spontaneity in the Psychoanalytic Process: A DialecticalConstructivist View. Routledge Press, New York. 19 Miller, Alice (1996). The Drama of the Gifted Child. Basic Books: New York. 17Among others he cited Mitchell, Stephen A.

his Judo practice, he said, “This particular class with this particular teacher at this time in my life is extraordinarily helpful, and one reason for that is that is that I don’t have to use language. I don’t have to use words. I don’t have to pile up language, one word on top of the next to express myself, to get ideas across. I can do that with my physicality. That’s always been an important part of my life.” He continued, “It’s like a whole different language without words. So I study it. It’s an intellectual enterprise for me. I get into the ethics of it, and the philosophy of it. And I also practice it in the dojo. And that restores me.” His description of his engagement with music, another nonverbal enterprise, elicited this comment: “Just [to] be grounded, like sitting in the grass by a campfire, music too. I’m a guitar player. Sometimes I get downright bullish about it like when I get home, I’m going straight for the guitar. I don’t care what’s going on: a lot of nonverbal for me.” In speaking about his time spent out of doors he said, “To be out in nature, to get re-harmonized with the natural rhythms of things, actually see the stars: We have a second little place out in the country which we go to, where it’s open and just soy bean fields and you know, you’re not subjected to projections of the human mind everywhere in the form of tall buildings and what not. It’s just open space. I find that really helpful.” When asked about his seeking nonverbal activities to recharge himself he said, “Yeah, a lot of nonverbal for me. This is all about Freud’s talking cure, right? I believe in (He paused to think.), I wouldn’t be doing it if I didn't’ believe in language, the power of language, choosing words, crafting sentences, thinking about what I’m saying, hopefully before I say it. But I also find it has its limits, and I also find it creates a whole lot of wheel turning and wheel spinning. And the nonverbal feels to me like a relief, a reprieve

from the activity. There are so many stories from my day, (He whistled, kind of sighing.) from my clients. And then there are the stories I tell myself about my clients, or that I tell myself about my life. All these narratives that are intersecting all the time, it’s downright exhausting at times.” In this way, Clinician 1 described how he facilitates his attunement to nonverbal unconscious communication within a session by re-tuning his own analytic instrument 20, in seeking nourishing nonverbal enterprises. Relationships are another key way Clinician 1 cares for himself, valuing connections in the context of the complex nature of being human and the strains this puts on him. Prioritizing a variety of relationships, he both privileges deep connections, and often engages interpersonally in the context of his proclivity for the nonverbal, his physicality, his love of the outdoors, his intellectual prowess, and his deeply held belief that he is part of something bigger. In a manner demonstrating his intellectual acumen and the ways in which cultural objects inhabit his imagination, and at the same time describing prioritizing friendships, he shared, “Also being a friend. I remember (He paused.) Did you ever see the Bill Moyers/ Joseph Campbell interviews about mythology, The Hero with a Thousand Faces? Really interesting. I remember being really compelled by those interviews. Anyway, one of the things I think he said to Moyers was, when they were discussing suffering and the world, sometimes it feels that it’s going to hell in a hand basket. I remember saying: ‘When things are falling apart, when you’re tired and you’re weary… that’s when you want to surround yourself with 20

Balter, Lothane, and Spencer (1980) define the term “analytic instrument,” attributing the concept to Isakower. They write, “Starting from certain unpublished remarks by Otto Isakower about "the analyzing instrument," we define it more precisely. The analyzing instrument has two constituents: a voluntary and controlled, situation-specific and goal-specific regressed state of mind in the analysand and a near-identical one of the same nature in the analyst. These parts function together through mutually evocative communication, leading to the elucidation of the analysand's unconscious fantasy-memory constellations (p. 474).

your friends. And I really believe that. And my wife and I are very, very fortunate to have nurtured very long lasting friendships over 20 years. These are extended family members really for us, and for my kids. So we have our traditions. Sometimes we think of ourselves as a little tribe. And it’s very restorative: Having fun. Volleyball on the beach in the summertime.”

Relationship to cultural objects, free association and reverie. This clinician spoke with animation and depth about the ways in which cultural objects infuse both his imagination and his therapeutic action with meaning. He drew upon examples from music, and “pop culture,” his practice of Judo, his mentor’s teachings and those of the therapeutic literature, as well as Biblical and other ancient foundational texts. He also asserted that the Yiddish language functions as a cultural object in his work. He said he frequently finds himself citing Tevya’s wisdom from “Fiddler on the Roof,” or that the addition of a Yiddish word or phrase enables him to best express himself. In addition, he shared an example from his own psychotherapy. He described a multiplicity of ways in which this phenomenon functions within himself, and between himself and his patients. He noted that if he’s been reading something which engages his imagination, it is more likely to enter his reverie when sitting with a client, although he also finds himself associating to cultural objects experienced in the distant past. Clinician 1’s foundational belief in archetype and collective unconscious belongs in part to his intimate identification with the Jewish traditions. Biblical stories hold a significant influence in his imagination. As we spoke, he thought out loud about the role of stories that enter his reverie while sitting with patients, conveying a resonance with the

collective human unconscious, as well as connecting with a patient’s unique subjective struggles. Because cultural objects often occupy a presence in Clinician 1’s imagination, he moved organically from descriptions of his associations to cultural experience to an elucidation of his privileging his free association and reverie within his therapeutic work. He drew upon significant moments in his own psychotherapy, as he experienced his therapist’s reverie as a useful tool in elucidating essential elements of both the implicit and explicit therapeutic process. In addition, he hearkened to his mentor’s teachings as key to his own evolution as a clinician who privileges his imagination and reverie, as he engages with his clients.

Relationship to the idea of unconscious communication: “It’s a tool . . . to be used in the treatment.” Clinician 1 demonstrated a comfort discussing unconscious processes as it comes into his clinical work. He stated, “There is that level of that work that I try to pay attention to with my clients. I privilege the unconscious mind on this level of unconscious communication. It’s a tool among other things to be used in the treatment. It’s a kind of a source of information to help gauge what’s going on interpersonally.” In addition he spoke openly about his belief in what he named the “vastness of the unconscious,” rooting this tenet in the teachings of his mentor, who valued the teachings of Jung, transpersonal psychology, mysticism, and Buddhism. In addition, he was characterized by a deeply held belief in the existence of a collective unconscious. Clinician 1 continued to develop this line of thinking, “Some of [my beliefs] come from the exposure that I had

to [my mentor’s] work and [his] influence, because he really did represent somebody who at that time for me [was] really almost wizard-like. (He took on a different serious, deep voice intonation as he invokes his mentor.) ‘The unconscious mind is a vast resource of creativity,’ is something that he would say, not just on the level of unconscious communication, but actually harnessing the power of the unconscious mind deliberately so he would talk about altered states of consciousness a great deal, and point to different cultural practices. Maybe particularly native peoples who have learned how to use the power of the unconscious in ritual and through ritual and community building and artwork and creativity and so on in different things whether it was through drumming and chanting or dancing and twirling. (He grew quiet for a time, thinking.) So [my mentor], he kind of rode that edge for some people, maybe being too far out there for me, maybe being grounded enough to talk anthropologically about those things and apply some of those values and teachings to Western culture and Western postmodern culture, and through the practice of psychotherapy.” It is of note that Clinician 1 both articulated an awareness that these ideas “raise eyebrows” when brought into traditional psychoanalytic circles, and spoke about them in a way that evidenced that they are deeply cherished personal tenets.

Co-constructing meaning: the interview process. The phenomenological-hermeneutic nature of this research inquiry, coupled with the distinctive qualities of researcher and participant, together determined the character of the interview process. Within the three 90-minute interviews, process and product were intertwined. Researcher and participant engaged in an enterprise of co-constructing

meaning in an organic fashion, as our collaborative work unfolded. Ogden’s (1997c) idea of the ways in which one makes use of language as a window into one’s sense of being human inspired this enterprise. He writes, “I am interested in the way such people think about and speak about encounters with other people's symbolic expressions/creations of the experience of being human” (p. 5). Clinician 1’s way of describing his experience of being human within and outside of his clinical work contributed to the findings of this study. Clinician 1 was self-reflective during each interview and in the intervening time between interviews. There was a rhythm and evolution in the processive nature of these three interviews. In interview 1, he dived in, and shared deeply about the topic at hand, offering many useful examples of cultural objects entering his imagination while sitting with a patient. He was also articulate in sharing the ways in which he employed his associations to enhance the work. He displayed an openness to consider the various functions this phenomenon served in the therapeutic process. The work together carried a comfortable feeling of camaraderie. We engaged easily in the spirit of the work: playing with ideas, analyzing an interaction, wondering aloud, and working to conceptualize the components of the therapeutic dynamic he was describing. In interview 2, he spoke in a deeply personal, self-disclosing manner about the ways in which this phenomenon was experienced in his own therapy. He also engaged in profound thinking about his relationship with his mentor and the ways in which his mentor’s philosophy and teachings dovetailed with this study, thus contributing to the meaning for him of engaging in this work together. In addition, he guided me through the cultural objects, imbued with relational meaning, that comprise his therapeutic space.

This interview was characterized primarily by an intimacy and depth of sharing on his part, and a quieter curiosity defined by empathic resonance on my part. Additionally, there were also moments that held the kind of camaraderie of analyzing his examples, which hearkened back to the first interview. In summing up at the close of the second interview, he noted that this deep sharing had surprised him, and I checked in with him gently about whether he felt able to comfortably conclude and go on with his day. He indicated that he had internal resources for self-care that he would elicit prior to seeing his next patient. As the third interview began, loss was already in the air, as this was the final interview, and he seemed more reluctant to begin the deep work he had so readily initiated in earlier weeks. This interview began with a lot of chit chat and seemingly superficial facts, and yet his narrative held allusions to the shifting in the seasons with summer shifting to fall; an influx of new clients as the holidays approach, carrying reminders of loss; talk about finding a good assistant director and being able to both relax and mentor someone new. I reflected a personal sense of sadness at the process concluding in this third interview. I was also aware, but did not explicitly state that he had shared in a profound personal way in the previous interview. Much of this interview was spent reflecting upon the work we had done together and striving together with granular detail to make meaning of the examples he had offered. In this way, we functioned more as partners sharing a common inquiry, engaged in the activity of meaning making. An overriding sense of pleasure, high energy, and a positive alliance characterized all three interviews. Each interview held moments of companionable laughter; deep

thinking identified by softer voice resonance and thoughtful moments of silence, alternating with a quick-paced, intense back-and-forth idea generating process. In addition there were moments of deep connection around shared passions, common resonant cultural objects in the form of stories and authors, and occasionally an uncanny, knowing shorthand of recognition. This could be attributed in part to a shared affinity for the Biblical story as well as a broader reverence for myth and its role in human imagination. And yet it was also present because of a jointly shared appreciation for the ways in which cultural objects take hold within one’s imagination, and the impact this can have on the therapeutic process.

Clinician’s articulated experience of the interview process. Over the course of the three interviews, Clinician 1 spoke openly about the process being meaningful to him. The significant aspects which he articulated included the luxury of feeling listened to well, “with empathy, and with interest, and with curiosity,” and having the opportunity to examine intricate aspects of his practice in some depth, enjoying the process of co-constructing meaning, as well as taking pleasure in the intersection of his privileging the unconscious process and that being the nature of this project. Further, Clinician 1’s engagement in this research endeavor awakened in him a wish to engage in a more ongoing way with colleagues about aspects of this work that he finds important. In a warm, connected moment he was playful about wishing for the two of us to lead ongoing professional discussions together. Further, he articulated that his participation touched a deep chord in him, resonating with his rich experience with his beloved mentor around this very topic. In no small measure, the nature of his personal

investment in the research question contributed to the depth of his involvement in these interviews.

Categories of meaning. An analysis of the data gleaned from interviews with Clinician 1 yielded two major categories of meaning. The first category of meaning consists of the meaning and use that Clinician 1 makes of the cultural object. The second category of meaning comprises themes which Clinician1 identifies under the rubric of his understanding of the therapeutic power of the cultural object. Each of these overarching categories of meaning consists of sub-categories of meaning, or motifs, which are described in detail in the findings that follow. The following themes are situated within the first category of meaning, the meaning and use of the cultural object: •

The nature of the cultural object.

•

The cultural object carries a metaphor.

•

The cultural object: An example of the therapist’s reverie and how he uses it, coupled with the ways in which the therapist’s reverie reverberates with the themes of the patient’s struggle.

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The cultural object exists as analogous to the therapeutic process.

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The process and how it works.

The following motifs are identified within the second category of meaning, the therapeutic power of the cultural object: •

The cultural object’s potency as it carries meanings from within the therapist’s relational experience.

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The cultural object’s power as it functions as the therapist’s provision of a part of self.

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The cultural object’s power as it functions as an indirect route to impart insight.

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The cultural object’s potency as it functions as an indirect route to foster a sense within the patient that the patient is seen, felt and known by the therapist.

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The cultural object’s power as it connects to a collective unconscious and staves off loneliness.

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The cultural object’s potency functions as a transitional object in the context of the experience of being told a story.

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The risks of the cultural object’s presence in the therapist’s imagination . Clinician 1 articulated a strong predilection for the spiritual and the uncanny.

He voiced a firm foundational belief in unconscious communication both within the consultation room and in his overall life. He connected his affinity for Buddhism, Jungian archetype, and the idea of collective unconscious to his deep, transformational connection with his mentor, as well as his profoundly personal relationship to Jewish traditions. He addressed the ways that the cultural objects which arise unbidden in his imaginative process while sitting with a client, and his passionately held psychodynamic understandings intricately intertwine with essential aspects of his core sense of self, and significantly impact on the nature of his therapeutic action. Asked how his mentor’s teachings influence his therapeutic work, he disclosed, “The image itself becomes a bit of a universe in a way, and it folds these other concerns into it, and it can inform the kinds of inquiries that [I] make and the statements that [I] make.”

The nature of the cultural object: “It’s a small object and yet it’s packed, it’s very dense; we’re communicating from unconscious to unconscious.” Clinician 1 elicited a number of cultural objects in the enterprise of elucidating the ways in which this phenomenon inhabits his work. His subjective well of cultural objects was drawn from Tibetan Buddhism, Biblical and other mythic traditions, wisdom adages, the practice and philosophy of Judo, his mentor’s teachings, as well as from psychoanalytic theory. However, the archetypal stories of Western culture heritage occupied a primary position in the examples he provided. In all cases, the cultural object was unbidden and yet linked in some substantial way to his client’s narrative. In addition these unexpected, impromptu images were profoundly bound up with his idiosyncratic repertoire, grounded as it is within his particularistic and subjective world-view. In this way, cultural objects called up by this clinician while engaged in both listening to his client and to his own internal musings, held deeply personal resonance. This phenomenon contributed to the experience’s power and potential. Clinician 1 was comfortable responding to my request for examples of the ways in which this process occurs within his imagination. He also demonstrated some ease elucidating the function of his associations within the therapeutic process, and was articulate in delineating the various components comprising this process. He was also movingly introspective when asked to reflect on these various components. In addition he spoke of a delight in having the opportunity to engage around a phenomenon so inherent in his work. This was evident from the outset in the screening interview. Clinician 1 understood the nature of the cultural object as a multi-layered phenomenon: “It’s such a small example and yet . . . it’s packed. It’s very dense.” He

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spoke of its metaphoric aspects, “I think that’s the code, part of the pre-symbolic, the preverbal.” He understood the evocation of a cultural object within his imagination as an unconscious phenomenon. In this regard he noted, “We’re communicating on many different levels and for that matter from unconscious to unconscious and there’s a certain kind of receptivity that is possible. I think it’s probably always happening on some level.”

The cultural object carries a metaphor: “If you really feel it, you do walk away hobbled.” In his description of his association to the Biblical story of Jacob wrestling with the angel, Clinician 1 emphasized the metaphor elicited from within the cultural object and the way it may have functioned for his client over time. He disclosed, “I have a fella who was a wrestler, and so we talk on that level, . . . and I think for him, because wrestling has been such an important part of his life and his development as a young man, and he has such intense interest in Judaism, I have shared with him the meaning of the word “Israel:” 21 Wrestling with God. And you know, we all kind of dread that one, and also are thrilled by it in some ways as well. It’s a terrifying, beautiful predicament, and I think if you really feel it, you do walk away hobbled, you know, to go back to the humility. For him, for this client, that became, and still is a very important metaphor . . . He struggles a lot trying to feel connected to some higher purpose in the universe, some (He paused to think.) searching for some source of renewal. Hope. And this idea of wrestling, wrestling with God, fits very well in that regard. That image of wrestling with

The Hebrew word “Yisrael” means “God wrestler.” God changes Jacob’s name to “Yisrael” after he vanquishes the angel in Genesis 32.

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Jacob has (He paused to think.) this is a struggle to find meaning in suffering, and here’s an analogy that seems to hold some promise. Some hope.” Clinician 1’s association offered his client a way to set his struggle within a larger context. While manifestly connected to the fact that his client is a wrestler, the image carried this young man’s psychic struggle in attuned fashion, and was richly received by the client who held the story over a period of years. In Clinician 1’s telling, the story offered both an accurate reading of the client’s challenges as well as his hope: That is, that the struggle he is engaged in has a higher purpose. Clinician 1 worked to define the cultural object as a condensed image along the lines conceptualized by Freud’s seminal study of dream-work. Freud (1965) writes, Our study of the dream of Irma’s injection has already enabled us to gain some insight into the processes of condensation during the formation of dreams. We have been able to observe certain of their details, such as how preference is given to elements that occur several times over in the dream-thoughts, how new unities are formed in the shape of collective figures and composite structures, and how intermediate common entities are constructed . . . We will be content for the present with recognizing the fact that dream-condensation is a notable characteristic of the relation between dream-thoughts and dream-content. (p. 330) Later in The Interpretation of Dreams, he expands his understanding: The intensities of the individual ideas become capable of discharge en bloc and pass over from one idea to another so that certain ideas are formed which are endowed with greater intensity. And since this process is repeated several times, the intensity of a whole train of thought may eventually be concentrated in a

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single ideational element. Here we have the fact of “compression” or “condensation” which has become familiar in the dream-work. . . . In the process of condensation . . . every psychical interconnection is transformed into an intensification of its ideational content. (p. 634) Along these lines, Bollas (1992), inspired by Freud’s conceptualization, writes, “The symbolic, its rules of engagement known to the unconscious, links signifiers in infinite chains of meaning, . . . each an intense condensation of many ideas thought simultaneously” (p. 48). Clinician 1’s image of Jacob wrestling with and ultimately vanquishing the angel, and yet hobbled in the process, functions as an exquisite example of this kind of condensation. It holds the therapist’s subjective experience, his experience of his patient, his patient’s subjective experience, and that of the collective unconscious as he draws upon this mythic image.

The cultural object: the therapist’s reverie reverberates with the themes of the patient’s struggle. As Clinician 1 spoke of the way his subjectivity contributes to his free associations in the context of his work with this particular client, he related his experience of layered imagistic aspects in his associations. He opened with an awareness of the overlap in his mind between Judo and his psychotherapeutic practice, employing his experience of actually being pinned by a huge opponent in the Dojo. His imaginative process arose in response to his understanding of his client’s experience as “being pinned

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by life,” and he found himself working within this meaningful metaphor, inspired by his Judo practice, in the service of his client’s process. Clinician 1 conceptualized that the overlap of his experience and that of his patient, that is, his identification with his patient’s struggle, led him to bring this personally infused metaphor into their dyadic work. Elucidating his internal process, he shared, “So he knows what it’s like to be pinned because he’s a wrestler, and I know what it’s like to be pinned. And I’ve been pinned by (He paused to think of how to explain this.) think of being pinned by N, who’s like 240 pounds and you know (He laughed, and I laughed kind of nervously.) and there’s this big police officer who’s been doing Judo for a long time. You know, and so to be pinned by N means that you’re going to get the air squeezed out of you. So there’s knowing what that’s like being on the bottom of that, and knowing what it’s like to try to escape from that, and what can be done to escape from that.” His thought process expanded to elicit the wisdom of his teacher, and consider how this might help his patient, “So the sensei says, ‘Well, yeah he’s bigger than you, but you know the small guy throws the big guy.’ If you know what you’re doing, right. That’s the whole thing: Kanō 22, that’s the small guy, he’s the guy who got bullied. He learned how to throw the big guy.” Clinician 1 demonstrated a deeply philosophical, meditative consideration of these themes in the context of the intersection of his experience and that of his client. He considered what could be gleaned and used, providing language for what was initially a set of nonverbally encoded body experiences. Thinking aloud he continued, “That’s the whole idea. So if you use the energy properly

Kanō Jigorō: This man founded modern day Judo practice.

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and in the case of a pin, if you make space, even an inch, if you move your body in such a way that you have even an inch of space between your body and you and your partner, then there’s a new possibility. There’s something different that can (He paused to think.) you don’t realize it of course at first because you’re panicked that you’re gonna pass out from a loss of oxygen. So if you could keep from panicking (His voice trailed off.) So, to see that that little inch of space can lead to some new possibility, that [thought] gives a certain hopefulness, a certain optimism, even if it’s cautious. And there’s a certain positive energy potential.” Clinician 1 drew upon his experience of “being pinned” in the context of an experience of his mentor’s wisdom increasing his capacity to regulate his own fear and anxiety. This process elicited a cautious, hopeful stance. Clinician 1’s internal reverie, containing as it did the cultural object of his Judo work’s wisdom, was summoned unconsciously in the service of engagement with this client. Within the interview, he considered his internal process in the context of this work, and then highlighted the ways in which meaningful themes in his life carried metaphoric nuance that offered a kind of communicative idiom that was usable with his client. Clinician 1 found a way to address his client’s struggle “from what [he was] thinking and feeling,” as Ogden (1997a) describes when he writes, I view reverie as simultaneously a personal/private event and an intersubjective one. As is the case with our other highly personal emotional experiences, we do not often speak with the analysand directly about these experiences but attempt to speak to the analysand from what we are thinking and feeling. That is, we attempt

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to inform what we say by our awareness of and groundedness in our emotional experience with the patient. (p. 568) The ways in which Clinician 1 spoke of his experience, it seemed that the layered metaphoric meanings comprising this cultural object were inherent in its nature, and function as a prominent aspect of this psychotherapist’s understanding of the way the cultural object reigns within his reverie. Ogden (1997b) writes of the power of poetic language as “the struggle for and against words to bear witness to unspeakable experience” (p. 638). As Clinician 1 offered examples of cultural objects that arise within his imagination, in this case the Biblical story of Jacob wrestling with the angel, he elicited the belief that the story entering his imagination provided him with insight. For this clinician, the story has the potential to function as a vehicle of therapeutic action, in some measure, due to its metaphoric sensibility. Ogden (1997c) captures this phenomenon’s essence, writing, The analytic discourse requires of the analytic pair the development of metaphorical language adequate to the creation of sounds and meanings that reflect what it feels like to think, feel, and physically experience (in short to be alive as a human being to the extent that one is capable) at a given moment. (p. 6) The metaphoric thread within Clinician 1’s stories function in just this way.

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The cultural object exists as analogous to the therapeutic process. “The art of it: it takes a long while to get into it and to use it properly, and when you do it right, it’s wonderful.” Within the context of this interview process, the ways in which Clinician 1 described his practice of Judo, and the ways in which its wisdom teachings coupled with his experience of this martial art, it seemed congruent to include this martial art under the rubric of cultural objects. At the outset of this study, the narrower definition of cultural object was established to include language, imagery, themes and character culled from literature; film, the visual arts, and music. For the purposes of this study, in the context of this clinician’s narrative, the art and teachings of Judo also function as a cultural object. Inherent in Clinician 1’s narrative was an overarching sense that the particular, reverentially held cultural object of his Judo practice comprises many elements analogous to his conceptualization of and experience within the psychotherapeutic process. This finding unfolded over the course of our interviews, and while offered in large part by the participant, provided us with a rich arena in which to play together, inspired by the fact that Judo is a dyadic sport. Clinician 1 described it this way, “What’s interesting about Judo, [and what] distinguishes it from wrestling is that both of those are –while they are both grappling arts—is that you wear a gi: a heavy jacket? (He ended this statement like it is a question—“Do you know what I mean?”) And this heavy jacket is sometimes double woven. You are grabbing cloth and you are using cloth to control and move your opponent. You literally come to grips with your opponent. It helps you to control and move the opponent around, so that the idea is to harmonize your movement with the opponent. And then in that moment when your opponent is off balance . . . that’s when

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you throw him.” Clinician 1 described this way of engaging with one’s “opponent” and making one’s move when he is “off balance” as reminiscent of Casement’s (1992) teaching about “optimal frustration” and working in a way characterized by a sensitivity to when and how a client is off balance. He explained, “There’s that one part: that analogy of the baby, who is trying to crawl and make that next developmental movement forward and the parent puts the rattle not too far and not too close (He paused between phrases, speaking softly and slowly) so that the effort that’s expended really [in] trying to reach that developmental milestone and reach that challenge. There is a certain amount of frustration there just in the activity and in the challenge, but it’s not that overwhelming frustration because it’s not placed too far and it’s not underwhelming because it’s not too close.” He developed his thinking regarding the Judo notion of regarding one’s partner as an opponent, and the parallels he understands with his psychotherapeutic practice. In fact, he revealed a hope for a “future self” to write about the “intersections” between a Judo practice and the practice of psychotherapy. He shared, “The whole business of knowing your opponent: I thought if and when I ever do write about this subject, one of my ideas is that while it doesn’t sound like the most friendly way of saying it, I do at times consider my client my opponent. So the two maxims of Judo [are] (one) efficient use of mind and body, and (two) mutual benefit. [Let’s consider] this business of mutual benefit: Is there a way to see your client as opponent and still hold on to the ethic of mutual benefit? The client is here and my focus is on benefitting my client primarily but if I am going to see my client as an opponent, and I think there truly are moments when my client truly is my opponent, perhaps more in a stereotypic way: There’s crashing and

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conflicting. There’s argumentation and misunderstanding. There’s anger and fury and I’m thinking in particular of borderline states of mind. And not just in borderline states of mind, that [staying in] the metaphor of Judo, and trying to harmonize with that movement, the movement of anger for example, and not resist. That’s the power of the principle of the efficiency part of it. The idea is no matter how hard you resist somebody that is stronger than you in their fury for example, you will get bowled over. You’ll get pushed over and you’ll get pushed down and that has a metaphoric meaning to it as well. So it’s not about resisting and pushing against. It’s about trying to find some way of being with that anger, dancing with that anger, moving with it, understanding, so on and so forth. So if you were to extend that metaphor [of one’s client as an opponent], I would encourage you to think about that dimension of the opponent.” He offered a second parallel describing the importance of being able to “read” the other in order to determine one’s own moves. He highlighted the fact that this endeavor has a strong nonverbal component, and he likened this to his attunement to a patient in an example he offered: Sharing out his association to a cultural object yielded a positive therapeutic experience for his patient because of the long-term connection between them. He said, “This is somebody I’ve known for a long time. We’ve been working together for a long time, and I think when there’s that history that’s been established, we’ve had our ‘back and forths’ and there’s enough trust in the relationship.” Later he added, “That’s the art right there. I think that the history and the implicit knowing that sometimes occurs [contribute to this phenomenon].” This clinician shifted comfortably from discussing the philosophy of Judo to his understanding of his psychotherapeutic practice, as if the descriptive language contained a fluidity of purpose for both enterprises.

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In the same vein, he spoke in depth about the Japanese Judo educational tradition of spending the entire first year “learning how to fall.” He offered, “So in Japan they teach the first year. There’s a whole thing. It’s called ‘break falls.’ It helps to slap your hand on the mat as you’re being thrown so it distributes the impact. And that too is a good metaphor.” Sharing a clinical example, he added, “I also remember speaking to him about the whole aspect of ‘break fall,’ and how I sometimes think about how important it is to know how to fall, not just physically, but in terms of disappointment. That just seems like it’s important to me in this work. He and I carried this metaphor further, speaking in depth about this phenomenon within the therapist in the newness of one’s work with a client. Initially, there are a lot of “misses” in one’s interactional patterns. Each is learning how to fall in the presence of the other. Together the psychoanalytic dyad gradually establishes a rapport. An essential part of a therapist’s training also involves “learning how to fall,” just as one works with one’s client to summon patience for the process. In referencing the artful nature of the work of both disciplines, Clinician 1 concluded, “The art of it: it takes a along while to get into it and to use it properly. And when you do it right, it’s wonderful.” In this way, Clinician 1 identified an overlap in the fields of Judo and psychodynamic psychotherapy. He carried his discourse concerning the provisions of Judo as a cultural object beyond metaphoric language to what he termed the “wisdom adage.” For him, such an adage has the capacity to contribute empathic avenues of articulating human experience. 23 Together, Clinician 1 and I played with the ways Judo’s themes are analogous to the psychotherapeutic enterprise. Hearkening to one of his sensei’s core teachings he

Personal communication, J. Tolleson, 2-14-15.

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explained, “[My sensei would say,] ‘Well yeah, [your opponent is] bigger than you, but you know the small guy throws the big guy.’ If you know what you’re doing, right? That’s the whole idea. So if you use the energy properly, and in the case of a pin, if you make space, even an inch. If you move your body in such a way that you have even an inch of space between your body and you and your partner, then there’s a new possibility.” Clinician 1 mined this teaching for its metaphoric resonance: Being human and vulnerable sets the individual at a disadvantage in the face of what he called “life’s ordeals.” And yet, the psychotherapeutic relationship and enterprise opens up the space to allow for new potential. Ogden (1985) cites Winnicott extensively in an attempt to elucidate his idea of potential space, which has relevance to Clinician 1’s description of both Judo and psychotherapy. Ogden writes, Playing, creativity, transitional phenomena, psychotherapy, and 'cultural' experience ('The accent is on experience', 1971ap. 99), all have a place in which they occur. That place, potential space, 'is not inside by any use of the word … Nor is it outside, that is to say, it is not part of the repudiated world, the not-me, that which the individual has decided to recognize (with whatever difficulty and even pain) as truly external, which is outside magical control' (1971cp. 41). Potential space is an intermediate area of experiencing that lies between (a) the inner world, 'inner psychic reality' (1971bp. 106) and (b) 'actual or external reality' (1971cp. 41). (Ogden, p. 129) This moment of co-constructing the parallels between these two personally meaningful practices provided a powerful connection between researcher and participant, as if it had been where we had been heading for some time. The focus of this research

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study is the way in which the clinician’s associations to cultural objects impacts his therapeutic practice. Clinician 1 eloquently articulated the ways in which he considers the cultural object of Judo to provide him with a metaphor for understanding key aspects of his psychotherapeutic work. As he played with the analogy, he shed valuable light on the ways in which he conceptualizes and crafts his practice. In effect, the cultural object provides him with a vehicle through which to consider his work in deep, personally meaningful ways as he engages with conscious and unconscious communication in the therapeutic hour.

The process and how it works: “A series of moments of recognition.” Clinician 1 noted that both his process of reverie and his explicit sharing out of a cultural object—primarily in the form of a story or wisdom adage—required certain prerequisites in order to be successful. First and foremost, he stated that he believes “the more important piece is the background, and all that’s been built up in all those little moments of empathic resonance that really I think leads to a larger context of interpersonal sharing and relating.” He continued, “By history I think what I mean is a series of moments of recognitions. Or those experiences over time not only help to create a history but help to create a positive history, one that hopefully pushes the client forward in his or her process so that down the line, when I am drawing from an inner resource or a cross reference in my brain, not knowing exactly whether or not it’s going to hit the mark or not, I just sort of let it out there. And because there’s this background or backdrop of mini recognitions over time creating a positive history, there’s more likelihood that there’s going to be some kind of if not profound enlightening moment, then much more

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likely, ‘Oh I hadn’t thought of it like that.’ Or ‘Oh that makes a lot of sense.’” His thinking that history over time of a connectedness constructed of moments of empathic recognition and relationship, allow for the possibility that he will (a) experience an association that can be characterized by some unconscious resonance; (b) trust the process enough to offer it up to his client for his consideration; and (c) the client will have a substantial sense of “positive history” with the clinician that his provision of an elicited story can be experienced by the client in some way as useful. Clinician 1 also addressed the reality that in some instances, the client is able to speak with the therapist about the provision failing to touch a resonant chord. He believes this too holds therapeutic possibilities as they work together around this experience of disruption.

The therapeutic power of the cultural object: the cultural object’s potency as it carries meanings from within the therapist’s relational experience. “The object is . . . deliverer of an experience.” 24 An overarching theme in Clinician 1’s narrative about his associations to cultural objects centered on the relational resonance carried by the object. The teaching, “Seven times thrown, eight times rise up,” derived from his Judo practice. As a result, Clinician 1 unfolded both the essential elements of this engagement, which nourish him, and, in response to my line of inquiry, taught me some facts about the history of this martial art. Bollas (1995a) writes of the therapist drawing upon his own subjective idiom in the service of responding to the patient’s communication, “Naturally I am in possession of

Bollas, 1987, p. 29.

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my own subjectivity. I will reconstruct what I hear from the other . . . My history as a subject makes me full of my own mental contents” (p. 25). Among the phenomena co-constructed from this example, the ways in which his Judo association was imbued with layered relational resonance felt primary: He described feeling deeply connected to his sensei who occupies a position as older fatherfigure/mentor in much the way the founding clinician, “J”, does for him. As he delineated his sensei’s role in his life, the quality of Clinician 1’s voice grew soft and contemplative, making it acutely clear that he was offering an example drawn from an experience he holds quite close. An attunement to this sense was derived in part from Ogden’s (1997c) idea that “Unconscious effects in language are generated at least as much through the way the patient (or analyst) is speaking as through what the patient (or analyst) is saying” (p. 1). In addition, Clinician 1 disclosed that he participates in this Judo practice together with his pre-adolescent son. He reflected, “I connected with [Judo] about 3 to 4 years ago, and the reason I did that was because I wanted my son who is now 14 to be in a martial art, and I wanted something more involved that was about standing your ground and so I got to looking on the internet and I found Sensei O (The name of his teacher was spoken very softly, with a different resonance in his voice, reverent, loving.) Wow this is a pretty rare opportunity. He holds an eighth degree black belt, which is the highest degree in the country. One or two others and an eighth degree. That meant, you know, he’s an older guy, (Again, his voice grew softer.) and he’s got this rank. It’s pretty astonishing, and to my mind that’s the guy to go to. So I dropped my son off, and I came to pick him up later that day after class, and I came about ten minutes early. I was curious

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about what I would see, and I found myself picking him up earlier and earlier (He was smiling sheepishly; he laughed and then I laughed.) This clinician provided an example of both associating to and sharing out one of his sensei’s teachings in the context of his work with a young man whom the clinician experiences as idealizing him. Attuning to this young man’s struggles, he offered, “The first thing that came to mind was I guess at times I find that my experience, well, let’s take Judo as a first example. Well, something that I’ve learned from or about or in Judo will apply to the conversation I’m having with my client. For example: Somebody who’s having a really tough time going through the hard part of the process [of psychotherapy]. Where the beginning felt really great: (Here he was conveying the voice of his client.) “I think I want to continue with this activity.” Encouragement from others, and then inevitably there’s this sort of reckoning, (Again, his client’s voice.) “Oh shit. This is really hard! I don’t know if I can do this.” And getting knocked down, and that whole business about getting knocked down. There’s this saying in judo, “Seven times thrown. Eight times rise up.” So I just said that, you know, in the context of this work. And it put a halt, a real pregnant pause into the conversation. He wound up saying, something to the effect of, “I never thought of it quite like that. And that’s a really good way of thinking about it.” And so every now and again something like that will happen. I’m just seeing or sensing a struggle and a piece of a struggle that applies to something or other that I’ve experienced. As he unfolded sharing this wisdom of encouragement, “Seven times thrown, eight times rise up,” with his client, I felt that the intimate relational resonance occupied an unspoken place in his telling. It seemed likely to me that this unconscious aspect of the

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clinician’s offering of the cultural object also may have been experienced implicitly by his client. His Judo is experienced within the relational context of father and son, layered with the intensity of Clinician 1’s deep connection to his sensei, and Clinician 1’s evenly hovering attention regarding his patient’s elucidation of his struggles unconsciously connected him to his sensei’s wisdom adage. Within the interview process, I was aware of the resonance in Clinician 1’s voice altering as he spoke of this important teacher, and noted that when he experienced this unbidden association within the therapy hour, he was carried to an intimate, internally housed, relational place. This phenomenon inhabits the space between them, perhaps even before the therapist elects with intentionality to bring the adage into the relational space between himself and his patient. Clinician 1’s intimate communication about his sensei, within the context of an activity shared with his son, was palpable to this researcher during the first interview, while remaining an implicit relational sense. In suggesting to this participant that that relational set of meanings may also have unconsciously traversed the border between himself and his patient in the offering of the cultural object, he paused to consider. Here we were working to coconstruct meaning. He proffered the detailed example, and we were both thinking. I had some analytic distance that allowed me to feel the nuances of what he was telling me. Researcher: I was thinking when you named your teacher, your voice, the quality of your voice changed, and I don’t know you that well, so that someone you’ve been working with for awhile, would know even the subtle change.

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Clinician 1: For sure, and there again [the question is] when does a therapist drop something like that, interject something like that into a conversation, [something] that has been useful perhaps to the therapist.

Researcher: Do you think it’s possible that your client might have felt that resonance even if it wasn’t experienced on a conscious language level, [sensed] the sort of the music of what happened between you? Clinician 1: I do and I think that’s the code, part of the pre-symbolic, the preverbal that we’re communicating on many different levels, and for that matter from unconscious to unconscious. And there’s a certain kind of receptivity that is possible. I think it’s probably always happening on some level. There’s that too. Like a regressive receptivity, which to a certain extent is necessary for good, deep work to occur. In this way, the cultural object, “Seven times thrown, eight times rise up,” derived from Clinician 1’s Judo practice, within a significant relational context, functioned as a conserved object alive within the psychotherapist’s imagination, and offered out to his patient in the service of the work. Bollas (1987), citing Greenson (1954), writes of this kind of phenomenon as a conserved object: All children store the quality of an experience that is beyond comprehension, and hold on to it in the form of the self-in-relation-to-object state, because events beyond comprehension are disturbing and yet seem life defining. I have described this process as the conservative process, and I have defined the event as an

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internal object: a conservative object because the child’s and then the adult’s aim is to preserve the experience unchanged. (p. 246) Additionally, one’s mood may carry object relations. Bollas continues by drawing upon Greenson’s (1954) thinking, “Moods are not only derived from the internal representatives of external objects, but are often the representatives of one’s own past state of mind: one’s conception of oneself in the past” (pp. 73-74, quoted in Bollas, pp. 101-102). Clinician 1’s emotional sensibility vis-à-vis his Judo teacher and his son are self-states that house memories of previously lived experience and arise, in this case, within the therapeutic dyad. They are conveyed by the cultural object’s presence between them, and enhance the therapeutic work they are engaged in. Bollas (1987) writes of the “transformational object” in a manner resonant with Clinician 1’s evocation of the cultural object of Judo wisdom “in the shadow of” 25 his experience of his sensei. Much as a maternal figure facilitates the infant’s ego capacities that consist of transformative experiences, so—Bollas believes—the adult’s longings and desires can be understood as a search for a transformational object. Clinician 1 is articulate about his unfolding search bringing him to the Dojo and to the tutelage of this esteemed and wise sensei, first in transporting his pre-adolescent son, and then in his decision to seek training as well. In parallel manner, his client draws upon the clinician’s capacity to nurture transformative experience in the wake of a profoundly-held personal struggle. Bollas writes, “I want to identify [the transformational object] with the object as a process, thus linking the first object with the infant’s experience of it” (p. 28). For him, the ego’s first experience is one of integrations—cognitive, affective, libidinal—and 25

Bollas (1997), nodding to Freud (1917), writes, “The human subject’s recording of his early experiences of the object [:] This is the shadow of the object as it falls on the ego, leaving some trace of its existence in the adult” (p. 3).

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therefore the first object is identified with these transformative growth experiences. He concludes, “The object is . . . deliverer of an experience” (p. 29).

The cultural object has power as it functions as the therapist’s provision of a part of self. Along similar lines, Clinician 1 disclosed that when his own psychotherapist shared a story with him, he felt the story belonged to his therapist’s imaginative storehouse, and experienced the offering up of the King Arthur tale as being given a personal piece of his therapist. In discussing his own sharing out of a myth with a patient, he both acknowledged and worried about overtly bringing a part of self into the treatment relationship. He stressed his awareness that the proffered story after all is elicited from within the therapist and serves as a form of self-disclosure, and may be experienced by the client in a variety of ways. Bollas (1983) discusses this at length, citing Winnicott’s “idiomatic, unintrusive” (p. 7) manner of offering his own subjective states to his client to be played with in the facilitating environment—the potential space—situated between them. Clinician 1 experienced his therapist’s story as a gift of himself in a way that provided him with an avenue to understand that his own struggle may have personal meaning for his therapist as well, coupled with the other meanings that he construed from the offered cultural object. He articulated an experience of the proffered story building a stronger bridge for him in connection to his psychotherapist. It also contributes to Clinician 1’s ongoing consideration of the ramifications of the therapeutic action of sharing out his associations to cultural objects with his own patients.

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Clinician 1 delineated his own imaginative enterprise that primarily elicited stories gleaned from intimately held internal storehouses of his memory. In addition he provided an example from his own psychotherapy, in which he experienced his therapist offering the story of the Gordian knot 26 from his repertoire in the context of Clinician 1’s personal themes. Clinician 1 surmised that his therapist had been holding this particular tale within his own imagination for some time before bringing it into the relational arena. In an example from his own psychotherapy practice, he set forth a vignette in which he recounted the Biblical story of Jacob Wrestling with the Angel. These two examples had several characteristics in common. In both cases the story came to the therapist uninvited, lived within the therapist for a period of time, was thematically resonant with the client’s emotional work, and was eventually brought by the therapist into the dyadic space. In Bollas’ (1983) language, the stories were examples of “a freely roused emotional sensibility [through which] the analyst welcomes news from within himself that is reported through his own hunches, feeling states, passing images, fantasies, and imagined interpretive interventions” (p. 3). In addition, in both cases, the client held the experience of receiving this story and playing with it together with his therapist over the lengthy trajectory of their work together, highlighting its significance as a therapeutic experience. This client’s experience of this relational dynamic echoes Ehrenberg’s (1974) concept of

The story of the Gordian Knot is attributed to Alexander the Great. The Gordian knot: knot that gave its name to a proverbial term for a problem solvable only by bold action. In 333 B.C., Alexander the Great, on his march through Anatolia, reached Gordium, the capital of Phrygia. There he was shown the chariot of the ancient founder of the city, Gordius, with its yoke lashed to the pole by means of an intricate knot with its end hidden. According to tradition, this knot was to be untied only by the future conqueror of Asia. In the popular account, probably invented as appropriate to an impetuous warrior, Alexander sliced through the knot with his sword, but, in earlier versions, he found the ends either by cutting into the knot or by drawing out the pole. The phrase “cutting the Gordian knot” has thus come to denote a bold solution to a complicated problem (http://www.britannica.com/topic/Gordian-knot)

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“the intimate edge” which she defines as “that point of maximum and acknowledged contact at any given moment in a relationship without fusion, without violation (p. 424, original emphasis). Citing Guntrip (1969), Ehrenberg writes, What is therapeutic when it is achieved, is "the moment of real meeting" of two persons as a new transforming experience for one of them and that transference analysis is the slow and painful experience of clearing the ground of left-overs from past experience, both in transference and countertransference, so that therapist and patient can at last meet "mentally face to face" and know that they know each other as two human beings (pp. 426-427).

The cultural object’s power as it functions as an indirect route to impart insight: “A story has soul.” Clinician 1 considered the therapeutic power of a story, as opposed to the proffering of some direct advice. For example, what does the tale of the Gordian Knot provide that a simple, direct statement like “Sometimes you just have to cut through all the bullshit” may not? Clinician 1 continued, “The first thing that came to mind was that a story is better than a fact for me. So a story holds my interest. A story captures my curiosity better than a fact. It’s not that facts aren’t important or pieces of advice aren’t important, but like there’s a Yiddish proverb that ‘A story has soul.’ So it’s deeper. It’s more meaningful to me. And if I can identify myself in that story or, there’s another level to it: To have somebody else be thinking about me carefully enough, and sensitively enough, and empathically so that they can identify me in a story, and then point that out to me, that’s really special. That’s, there’s something agentic [sic. about that. That kind

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of gives me a little extra ummppfff or something when I know that I am being thought of in that way.” The story’s power is multi-faceted: it “has soul,” by which he means it reverberates with affective resonance. It has the capacity to hold up a mirror to the patient insofar as he is able to see himself in this story, through the eyes of the other, the therapist. Further, it conveys a profound communication that the therapist is thinking about him; that he exists in his therapist’s mind. This understanding contributes to Clinician 1’s naming the intervention as “agentic” [sic].

The cultural object’s potency functions as an indirect route to foster a sense within the patient that the patient is seen, felt and known by the therapist. Clinician 1 reflected a complementary understanding regarding his patient’s experience when he shared out the story abiding in his imagination: Jacob wrestling with the angel. In this instance, the clinician again offers something from a very personally held storehouse that arises in his imagination while sitting with his patient. This vignette is drawn from early in the treatment: “He had brought this book in. He was reading about Judaism. He was reading about Israel. He wanted to know more. This was in an earlier state of our therapy. And knowing that he’s a wrestler, and knowing that he’s struggling, so these things were in some way kind of getting more and more entwined, and it was in that context that I asked him if he knew what the word ‘Israel’ meant. He said, ‘No, no, I hadn’t,’ so I told him about Israel, and I told him the story of Jacob wrestling with the angel. It was a new story, [and] it became a pretty big piece of the story from thereon in, and we still go back to it (He paused, thinking) 6 years later.” Clinician 1 uses the phrase “getting more entwined” to describe the strands of knowing his patient that interwove with his reverie. He was feeling his patient’s pain

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around his struggle; he held an awareness of his patient’s physical passion for wrestling and his intellectual and spiritual curiosity about Judaism. These ways of knowing his patient connected meaningfully as they resonated with some of the clinician’s own history and carried him to a story that has held significance for him over time. Clinician 1 spoke about the therapeutic impact of his patient being told this story, as indicated strikingly in that it is a story the client returns to again and again over the span of 6 years of treatment. He conveyed, “When it works, that’s the beauty of it: It is for him to feel felt or to know on some level that he’s being known, and I think that’s where maybe the curative aspect of the deeper psychoanalysis or psychotherapy comes from: It’s that feeling of really being known, or feeling felt that so many clients have been longing for and defending against (He laughed) at the same time, (He paused to think) with the fear of re-traumatization. That’s the opportunity. That’s the punch of it. That’s what you know is so exciting, when that works.” In this example, Clinician 1 conceptualizes that the experience of being felt and known is generated through the experience of the therapist’s offering his association to a cultural object in the context of his patient’s narrative. Bollas (1995b) writes about the curative aspect of the pleasure of feeling known through this kind of experience, This form of knowing and being known is profoundly pleasurable. It is blissful to free-associate in the sentient presence of the other who listens without making demands. To be received is to find something in the other that will receive the precise movements of one’s own unconscious life. (p. 47) In parallel fashion, he (2002) writes of the therapist’s free associative process: “Free association within the analytical relationship differs from the ordinary associations

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of everyday life due to the process of speaking oneself in the presence of the other” (p.63). The psychotherapist provides the patient with the experience of witnessing the representation of himself, receiving the patient’s self-representation: “Like the Biblical patriarch Jacob, you are a God-wrestler. You struggle to determine your destiny and the process hobbles you, as it did Jacob. And yet Jacob vanquishes the angel.” Bollas understands this therapeutic process as “maternal creativity” (p. 62). The self of the patient is being seen, experienced, held, contained, and known by the therapist in the context of his act of free association. This is a potent therapeutic ramification of the therapist’s association to cultural objects in the context of psychodynamic psychotherapy.

The cultural object’s power: it connects to a collective unconscious and staves off loneliness. Clinician 1 spoke at length about his privileging archetype and collective unconscious in his work. By and large the vignettes he shared were drawn from ancient stories and wisdom literature. The process between us mirrored the psychotherapeutic process at points when he offered a cultural image that held meaning for me as well. In those moments there was an added layer of connection, comfort and collaboration. A feeling of being in the presence of a like-minded individual steeped in some of the same cultural experiences was pleasurable, and often punctuated by laughter, by conjoint recitations from the texts, or by a playful conspiratorial sense of common knowing. In this way, I felt less lonely as the researcher seeking to elicit data relevant to my study in the presence of a stranger. I would conjecture that he may have experienced this in parallel fashion, perhaps needing less to fill in all the blanks and explain himself fully. A

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parallel process unfolded: We spoke about this phenomenon and offset our own loneliness and isolation in the work, in the experiencing of examples of reverie and in our highly subjective associations to cultural objects, in the acknowledgement of knowing existential loneliness, and in the enterprise of meaning-making. For this clinician, one factor impacting his decision to introduce his association to a cultural object in the form of a mythic story into the therapeutic dyadic realm, was the fact that he conceptualized this story as an archetype. He nodded both to Carl Jung and Joseph Campbell in the context of this identification. Implicit in his approach to “the story” in this way, is the notion of collective unconscious. Both Campbell (2008) and Jung understand certain themes and stories to contain deeply resonant human motifs, and hearken to this phenomenon to explain why these stories last over millennia and hold their power. He told me, “[It’s the] cultural artifact in and of itself. [It has] a kind of autonomous power or a potential apart from my relationship with it (He paused to think.) because I think whether I’m telling the story or someone else is telling the story, the story exists, in and of itself. And this is where I get very curious about Jung’s work. The potential within the archetype, and for that matter the archetype to begin with and the collective unconscious is myth, and the power of myth, and the [power of] archetype. And [there’s the fact] that the archetype exists really independently of me and of you. And it has some kind of deep ethnic, racial dimension to it that has potential for (He paused to think.) when it’s appreciated, and when it’s shared in a moment like that (pause) for transformation.” The theories Clinician 1 propounds also function as cultural objects in Clinician 1’s imagination, and are profoundly linked to his mentor’s teachings as part of this

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clinician’s early training, and are therefore infused with relational meanings as well. One outcome of the intertwining of these phenomena is the notion that the experience of a cultural object is its capacity to stave off existential loneliness for the “audience,” in this case both therapist and patient. He said, “[The story is] something that really essentializes or captures the truth about life, and also then kind of intersects with my own struggle and place, and my understanding. It’s just sometimes, it’s just (He paused to think.) bam! Very beautiful. Yes that’s it. I feel understood and I also feel like I’ve been offered something that I can use in the future. That’s right, and it connects to a much larger story. (He paused to think.) In that way I think it does help to combat that sense of loneliness and isolation. Like I’m the only person in the world who has ever gone through something like this and in a way that’s true because of our uniqueness. (He paused to think) but it’s a version of (more thinking) it’s an individualized version of something that is universally experienced.” He continued, “And I think that’s why clients can say, ‘Oh I see myself in that story and not just myself. I see others in that story,’ and it has this capacity to help a client broaden that perspective from feeling more isolated to a more universal perspective.” Clinician 1’s thinking jives with that of Campbell (2008), who writes, “The purpose and effect of [rituals and myth] was to conduct people across those difficult thresholds of transformation that demand a change in the patterns not only of conscious but also of unconscious life” (p.6). He continues, It has always been the prime function of mythology and rite to supply the symbols that carry the human spirit forward, in counteraction into those constant human fantasies that tend to tie it back . . . Apparently, there is something in these initiatory images so necessary to the psyche that if they are not supplied from

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without through myth and ritual, they will have to be announced again through dream, from within—lest our energies should remain locked in a banal, longoutmoded toy-room at the bottom of the sea. (pp. 7-9)

The cultural object’s potency functions as a transitional object in the context of the experience of being told a story. Clinician 1’s case vignette, elucidated earlier, which delineates his unfolding the Biblical story of Jacob wrestling with the angel, occurred in the work in the third year of a ten year treatment, to date. While the cultural object was elicited, unbidden, in the clinician’s imagination around a particular narrative, it may well have functioned as Bollas’ (1983) notion of the clinician’s expressive uses of the countertransference. Evoking Winnicott’s thinking, he writes, As Winnicott said (1974), the analyst needs to play with the patient, to put forth an idea as an object that exists in that potential space between the patient and the analyst, an object that is meant to be passed back and forth between the two, and, if it turns out to be of use to the patient, it will be stored away as that sort of objective object that has withstood a certain scrutiny . . . Winnicott regarded his own thoughts . . . [as] subjective objects, and he put them to the patient as objects between patient and analyst rather than as official psychoanalytic decodings of the person's unconscious life. The effect of his attitude is crucial as his interpretations were meant to be played with—kicked around, mulled over, torn to pieces— rather than regarded as other versions of the self, the official version. (p. 7)

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Along these lines, Clinician 1 explained, “For him, for this client, that became, and still is a very important metaphor. He really thinks about [that] he struggles a lot, trying to feel connected to some higher purpose in the universe, some, searching for some source of renewal. Hope. And this idea of wrestling with God fits very well in that regard because [of] the kind of gravity that that image of wrestling with Jacob has: This is a struggle to find meaning in suffering and here’s an analogy that seems to hold some promise. Some hope.” Clinician 1 emphasized that this client continued to evoke this proffered story 6 years later, finding applications for new developmental hurdles, as he parents two young sons at this point in his life. This clinician had a parallel experience with his own therapist’s offering of the Arthurian tale of the Gordian knot, elicited from his imaginative process. In both cases, the cultural object has the capacity to function as a Winnicottian (1953) transitional object, what he describes as “the original not-me possession, which I am calling the transitional object” (p. 91). He develops his thinking: My claim is that if there is a need for . . . the third part of the life of a human being, a part that we cannot ignore, is an intermediate area of experiencing, to which inner reality and external life both contribute. It is an area which is not challenged, because no claim is made on its behalf except that it shall exist as a resting-place for the individual engaged in the perpetual human task of keeping inner and outer reality separate yet inter-related. . . . I am here staking a claim for an intermediate state between a baby's inability and growing ability to recognize and accept reality. I am therefore studying the substance of illusion, that which is allowed to the infant, and which in adult life is inherent in art and religion. (p. 90, original emphasis)

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In effect, this story, or any cultural object when introduced into the potential space between therapist and client, has the capacity to function as a way for the dyad to hold each other in their individual subjective internal life when both actually present or absent from one another, and to continue to make use of it, to play with it in the service of therapeutic work.

The risks of the cultural object’s presence in the therapist’s imagination. While by and large Clinician 1 offered examples of his associations to cultural objects, primarily myths and stories, that enlivened the work, he was also thoughtful in regard to some of the more problematic aspects of this kind of therapeutic action. He wondered, at points, if his involvement with his reverie and/or his sharing out an association occupied too much space in the therapeutic work, intruding too much of himself and overshadowing the client’s narrative and agency. At points he pejoratively labeled this kind of work, “self-disclosure,” and articulated his quandary: “I continue to wonder about when to do that. How to do that. What for to do that. You know, for whom?” In the context of the question about “for whom” the offering is made, Clinician 1 spoke about the presence of the cultural object in his imagination, especially if it is carrying meaningful relational resonance, in effect inviting a beloved mentor or friend or family member to keep him company metaphorically in a difficult moment in the treatment. He understood this to possibly have a defensive role, although he also highlighted that one harvest of this kind of enterprise was the evocation of hope as derived from the associative aspects of the evoked cultural object, and the very real possibility that while defensive in nature, it held the potential to fuel the work. Taking the opportunity to explore the risks, overall he seemed to conclude that his reverie, as it

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pertained to cultural objects, fueled the work when working in a thoughtful, considered way with what arises within his imagination.

Clinician 2 Case description. Clinical context. Clinician 2 is a male in his early sixties, trained as a physician, with a medical specialty. He did, however, hold some psychotherapy patients while still a medical student. While he did not complete a psychiatry residency, he recently completed analytic training at an influential psychoanalytic institution in a major urban center. Clinician 2 was introduced to Freud’s writings as a first year medical student, which informed his interest in this work over the course of his lifetime. He has been treating patients in psychotherapy for over 35 years, following the completion of his residency. In addition to his psychoanalytic practice, Clinician 2’s professional life is defined by his faculty position in the psychiatry department of a major medical school, both teaching and supervising, as well as by his work as a consultant in his medical specialty. This clinician has a small analytic practice, and is selective about whom he sees. He attributes the considered way in which he takes on patients to both his conception that certain patients are better suited to this kind of work, and the luxury he has due to the variety of professional identities he assumes. He grounds his decision to consider a patient for analytic work on his intellectual interest in the ways in which “individuals think, and grow, and change.” While as a licensed physician he may prescribe medications for individuals, he chooses not to make psychopharmacology the focus of his

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practice. Patients referred to him seeking this aspect of a psychiatrist’s expertise, are generally referred elsewhere. In his work as a psychoanalyst, he does find the use of medication appropriate within the context of deeper analytic work. At present, Clinician 2’s practice ranges from six to eight patients. He sees three individuals four times a week; one individual five times each week; and several patients twice a week. In addition he has a patient who vacillates between one session per week and five sessions per week, which this clinician understands to be an aspect of this patient’s struggle. Often a patient will begin to see this clinician once a week, and as the work unfolds, elect to work with greater intensity, increasing the frequency of sessions per week. This can occur in response to a new understanding that emerges within the treatment, according to this clinician. In addition, Clinician 2 supervises psychiatry residents in the context of his faculty position at an urban university medical center. He understands his supervisory role to differ from that of a psychotherapist, and yet he believes he “treat[s] a different aspect of someone’s personal growth” in ways that dovetail with the psychotherapeutic enterprise. Clinician 2 defines himself as self-educated in the area of humanistic studies. While he was raised in a family in which the arts were respected, his undergraduate work was in a scientifically oriented university, with a focus on mathematics. He explained that he spent a lot of time in the library as an undergraduate, immersing himself in the liberal arts as an extra-curricular activity. Over the course of his life, he has been drawn to Biblical literature, mythology, and other foundational literary works. Historically he has enjoyed music, particularly chamber works, but at present finds that this musical art form no longer captures his imagination. He experiences the theater and film as cultural media

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that mirror the human condition in meaningful ways. In the course of the interview process, he moved seamlessly from citing Shakespeare, Homer, Biblical narrative, and contemporary fiction, as well as psychoanalytic literature. He also employed metaphors drawn from a musical language. Further, Clinician 2 demonstrated acuity for the nuances of language, as well as mathematical expressions. This clinician fine-tunes his capacity to attend to his psychoanalytic patients through a variety of personal practices. While initially believing he would bypass his own analytic work, he now experiences this as a critical aspect of his own training, and described both a refined attention to his own mood states and a privileging of his dream work as a result of this engagement. In addition he now adheres deeply to the tenet that a clinician must experience the same level of intensity of treatment for himself in order to engage in this kind of depth work with one’s patients. He spoke in a remarkable and unparalleled manner about an exquisite attentiveness to the degree to which he is accessible or unavailable to diurnal tasks, with a focus on the nature of his internal preoccupation inherent in this work. He disclosed, “I might decide on a particular day that I don’t feel safe operating an automobile at say, sixty miles an hour, [or] that my attention, availability, and so forth feel lowered to me at that time. Or I’m not sure there was ever a day when I said, ‘You know, I better not get behind the wheel today.’ You know, I’ve done that for other activities than driving, but if I’m preoccupied or caught up in something, I need to be self-observant enough to hold myself back (He paused for a moment to think.) There are two things that I suppose that I might notice: One is that at such times I may notice myself to be slower to my response to the world around me and something that may not be really separate. And to be more internally occupied, more

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likely to be sorting through thoughts than listening to the radio, or hearing the radio, for example. And I suppose in a way maybe it’s a measure of how much of my processing power is available to be focused on things outside of me.” In this way he offered an elucidating window into the kinds of energy and focus he experiences as requisite for this work, and the nature of internal demands placed on him as a psychoanalyst. Further developing this line of exploration, Clinician 2 spoke of the necessary way of being with oneself and one’s patient in order to engage well in the analytic work: “[I am] sort of thinking about: Am I available to be focused on things outside of myself, and what sort of things? And is my attention (His voice grew quiet here.) freely available? (And here his voice was even softer.) Driving. Driving is a useful example as well as a metaphor in another way. If you think of somebody learning to drive: At first the stimuli are overwhelming. The first time somebody drives on the expressway there’s too much going on. It’s too fast. So they haven’t yet learned ways to organize their experience of that activity, and I think something like that happens when we’re with patients.” He continued, “As we take in their experience, our own experience in the room, and finding ways to organize our understanding to recognize the organization in the inner and interpersonal experience. So [it’s essential] to be both available (Here his voice was soft and low.) to notice in all of these, in the outside activities, in the room with the patient. Something appears (His voice grew soft.) that wasn’t there before and you have to be not so flooded by the rest of what’s going on to notice (His voice here was soft again, and he paused to gather his thoughts.) Are we available to notice and, [then] we might notice the patients’ affect and our own.” (Again, his voice grew soft here.)

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When asked about his theoretical orientation, he elucidated his belief that “The real players here are the affects.” He said that he is on the lookout for the message in the story, not the facts. He tries to set his attentional focus on the meanings, the feelings. This is a fundamental aspect of the analytic attitude which he articulated. He explained that he is sensitive to the themes and issues his patient is bringing to the work, and crafts his interventions in attunement with this consideration. However he primarily draws upon relational data, and what relational phenomena are being enacted in his office within the therapeutic relationship. He stated that he enters the work within the relational matrix, and provided rich vignettes which exemplified the ways in which he prioritizes the unconscious and non conscious communications within the therapeutic space, electing not to prioritize the conscious surface, but rather employing unconscious process and conflicts with intentionality as he works: The psychodynamic riches are not founded on a thing that is seen or heard, but rather on a process that is inferred. He characterized his practice as “analysis or analytic thinking.” He exemplified this sensibility in a description of his experience with young clinicians whom he supervises. He said, “So we’re sitting with students. The students are physicians and they’ve learned lots of algorithmic things in their medical training but this is like. (By this he meant, “My intervention goes as follows:”) ‘Close the book and stop and think who is this person (He paused.) What is she telling you about herself? (Another pause.) How [does] she experience herself and [how is this] being expressed in a way that if you think the information is all verbal and explicit [you are missing something important]: There’s a lot being offered here that isn’t in that category.” This teaching was resonant with

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Ogden’s (1997c) analogy between experiencing a poem and experiencing a patient. He writes, The question “What is it like to read this poem?” focuses on the experience of reading, the experience of what it feels like to read, to listen to, to be spoken to (or written to) by the speaker/writer. I believe that there is an important and interesting overlap between the question, “What is it like to read this poem?” and the question “What is it like to be with this patient?” (pp. 4-5, original emphasis)

Relationship to free association and reverie. In the context of achieving an introduction to Clinician 2’s psychodynamic outlook while assessing his fit for this study, he described the controversial nature of the analyst’s privileging his reverie within the work. He shared an anecdote from a study session in which he and colleagues read Ogden’s (1997) article on reverie 27, and some of his cohort criticized Ogden for daydreaming during a session. Ogden (1999) defines reverie this way, I will use the term ‘reverie’ (Bion, 1962) to refer to the analyst's (or the analysand's) daydreams, fantasies, ruminations, bodily sensation and so on, which I view as representing derivatives of unconscious intersubjective constructions that are jointly, but asymmetrically, generated by the analytic pair. These intersubjective constructions, which I have termed ‘the analytic third’ (Ogden, 1994a, b, 1995, 1996a, b, 1997c, d, e), are a principal medium through which the

Ogden, T.H. (1997). Reverie and Interpretation. Psychoanalytic Quarterly, 66:567-595.

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unconscious of the analysand is brought to life in the analytic relationship. (p. 987) In contrast to what he understood to be his colleagues’ myopic view, he stressed that reverie and attunement to oneself has many different functions. He stressed that one needs to pay attention to what one is up to, for example defensive moves, countertransference feelings, as well as a therapeutically useful experiencing of relational data. His understanding of relational data is understood in Ogden’s elucidation, “an aspect of a jointly (but asymmetrically) created unconscious inter-subjective construction that I have termed ‘the inter-subjective analytic third’” (p. 569). In this way, Clinician 2’s capacity to consider this subject through a set of nuanced lenses was apparent.

Relationship to cultural objects. In the screening interview, Clinician 2 spoke with animation about his affinity for cultural objects, particularly literature and theater. Over the course of the three interviews he shared several wide-reaching examples of the role of cultural objects within his therapeutic work. He believes that Biblical narrative is rich with human behavior themes, and also mines Homer’s The Odyssey for themes resonant with his patients’ struggles. As he provided these examples, he incisively highlighted the inherent metaphors housed in the narrative as the nuggets that inspired. In addition, he asserted that an inherent musical sense enables him to attune to the rhythmic nature and tempo of a patient’s narrative: He said, “[My patient’s narrative] started out scherzo, and then moved to adagio,” as he described early mother child relational material. Continuing, he explained, “Music is about tone. When my patient shifts from scherzo to adagio I am realizing what [this

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association] feels like [to my patient].” This manner of thinking and feeling a patient’s narrative musically is reminiscent of Knoblauch’s (2000) ideas regarding “the musical edge of therapeutic dialogue.” Influenced by Beebe and Lachmann (1992), Stern (1985), Brandschaft (1987), Bromberg (1998), Ogden (1994, 1997), he writes, “The perspective afforded by attention to the musical dimensions of nonverbal activity on the part of either partner in a therapeutic treatment can be used to make some sense of the possible meanings to . . . affective shifts” (p. 157). It was clear in this first meeting that within the framework of his practice, this clinician’s imagination draws from the inspiration of cultural objects to access non conscious processes at work within both himself and his patient.

Co-constructing meaning: the interview process. From the outset, as well as in each subsequent interview, Clinician 2 expressed a reticence about his capacity to contribute meaningfully to this study. Initially he expressed a misconception gleaned from the referring clinician that this study was focused on images from the visual arts, which do not occupy his imaginative process with significance. With reassurance, he was quite articulate about his associations predominantly to the cultural objects of music, literature and theater. However, this concern surfaced periodically at times when he seemed to experience some challenge in responding to a question. In particular he felt that he had difficulty calling up examples from his own reverie, and making the leap from the cultural object to how he uses this phenomenon within his work. Even in the middle of the third interview, when many useful examples had been offered, he still held concern. At one point he said, “As I

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understand the complexity of what I’m being presented, (He grew very quiet.) I have to think a bit. You know (He paused to think.) I mean in a sense, this question: You know, can I link those up, [i.e. my association to a cultural object and what it yields for the work] is what made me wonder, ‘Gee, am I going to be helpful to you?’” In this way, he reflected some doubt as to his being well suited for the interests and focus of this study. This however was very much not the case as he offered rich, detailed, illustrative examples of the phenomenon at the core of this inquiry, and was articulately able to elucidate them by sharing key elements of his internal process. The articulated reticence and self-doubt may in part point to the challenging aspect of this inquiry, or perhaps his feeling off balance by engaging in an endeavor a bit outside his comfort zone. Interestingly, one of the first cultural objects he shared contained this theme of worry around whether what one has to say will be received. In speaking generically of texts that tend to inhabit his reverie, he said, “The stories that come to mind most often when I’m with patients are The Book of Jonah. (Here his voice went up in a questioning tone, as if to ask, “Do you know that text?”) You know, fleeing from what is experienced as somehow one’s destiny or the sense that a message will be, (He paused to clarify.) That there’ll be trouble after verbalizing a message, including if it’s accepted (Here his voice grew soft.) A patient I was with earlier today is struggling over that: afraid to speak the message—although the experience is that it’s been heard and welcomed.” In parallel fashion, while he articulated a worry that he had nothing worthwhile to contribute to this study, the rich examples he offered were both heard and welcomed. In the first interview, while we had contracted for a ninety-minute block of time in which to work, he abruptly curtailed the interview process after 45 minutes, noting that

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he has an internal clock nurtured in his analytic work, set exactly to the minutes of the analytic hour. Electing to continue for another 45 minutes, there was a lack of clarity about whether or not he had another commitment during this time. For the first portion of the next forty-five minutes there was a shadowed sense that we might be interrupted by a colleague who might ring his bell, for a meeting which he supposed to be tentative in nature. It was not clear what factors influenced this dynamic, but it seemed in some way connected to his ambivalence about the process and his concern that he would not have worthy data to contribute. Attuned to his misgivings, I punctuated some of our work with authentically inspired communications about the deeply relevant, fruitful nature of the examples he was providing. In addition, many of his offerings drew a palpable enthusiasm and curiosity from me that seemed to both encourage and comfort. Alternatively, this phenomenon may have been a function of another aspect of this clinicianâ&#x20AC;&#x2122;s personal idiom. His thoughts meandered a fair amount, characteristic of the work of free association. There were many times when I became lost in his narrative, wondering how we arrived at the subject at hand. He also seemed at times to speak in an inscrutable code, with an implicit assumption that I would know what he meant, leading me to at first feel lost and disoriented, and then to work to slow the process and ask for clarification. In an important way, we were reenacting the phenomenological experience of the meeting of two separate subjectivities, and the challenges inherent in this enterprise. In addition, some of the missed connections and wonderfully on target communications, being as they were around allusions to cultural objects, mirrored the kinds of sharing of cultural images that can occur within the therapeutic dyadic work.

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For example, at one point, describing a patient’s association to a novel, his mind wandered to the nature of her sib-ships, and then to Shakespeare’s King Lear. What followed was his ascribing a Shakespearean identity to this patient’s sister, commenting, “My patient’s sister might be a Goneril.” 28 This allusion left me lost as to what he wished to communicate. However, this quality seemed indicative of the intensity of his intellect and breadth of his associations to wide-ranging fields of knowledge. It also provided a window into how his mind works when he is sitting with a patient. As I grew accustomed to his idiom, I relaxed in my vigilance to follow his train of thought, electing over time to ride the current of his thought process along with him to both experience what it would yield, and gain increasing insight into his meditative imaginative process. Periodically, I would check in to clarify one of his points, or to bring him back to the subject that felt most pertinent to my investigation. One aspect of Clinician 2’s examples, drawn from his imagination and from his practice setting, was their synchrony with cultural objects familiar to me. This phenomenon over time contributed to a simpatico between us that fueled the interview process. When he would describe a metaphoric theme gleaned from an association to a cultural object, recognizing both the object and its set of potential meanings, this would energize our engagement with one another. One way this was felt was with a satisfied, playful smile on his part, or a gentle laugh emanating from one of us. At these times, my vigilant need to clarify gained a respite, since he was describing a cultural object that held familiarity and perhaps even power for me as well. In addition, a parallel process unfolded at times. As the two of us wondered aloud about how a shared cultural object

Goneril is one of Lear’s greedy, cruel and selfish daughters.

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between himself and his patient (for example that he was familiar with most of the literature she cited in her associative process) contributed to the work, this was happening between us as well. Often this experience provided a sense of harmonious collaboration as we worked to co-construct meaning. However, when he cited something beyond my ken, I found myself feeling a bit off balance and diminished in some way, as if my literary acumen would be found lacking. The second of three interviews proved to afford the most fertile work. We were able to build on the comfort of some familiarity with one another, and while his worry that he was ill suited for this inquiry re-surfaced, it was quieted more quickly. Several times early in this second interview, I revisited nuggets he had provided in the first interview, with an indication that I had been considering them in the intervening time and that they were nourishing my project. In addition, we were able to work straight through without interruption as we clarified the time frame at the outset, and I asked if he would like to take a break midway through, also checking in with him about the time of his next patient. This was in part driven by a wish to respect the ways in which he described needing to nurture his internal states. A salient theme, however, in this interview, was the challenge for this clinician of articulating the internal process that informs his therapeutic action. Clinician 2 noted, “I suppose it’s something I’m not used to describing in a very direct way,” and elaborated by stating that practitioners don’t often make their thought processes explicit by articulating their internal process. He went on to draw an analogy between this phenomenon and teaching someone to pilot a plane. He named this experience “jamais vu,” which describes an experience of a situation that one recognizes in some way but

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nonetheless seems unfamiliar. 29 In the case of his example, he was recounting an experience of teaching someone to pilot a plane by sitting in the right seat, when one ordinarily pilots a plane from the left seat; or playing baseball left handed. In this way he conveyed the challenge of coherently depicting the internal psychoanalytic process he engages in when sitting with a patient. This observation served to be consistent with the limited literature accessible on the subject of delineating in granular detail, step by step, the dyadic process of attuning to oneself while attuning to one’s patient. 30 Further, this sensibility proved to be echoed by other participants both explicitly and by circumventing my questions about this area of their work. When I asked how this phenomenon functions when he is supervising young clinicians, he told me that the question he asks is “What surface will be useful to speak to of what’s coming up in the room?” There was an element of strain on the collaborative aspect of the interview process related to the challenge of his articulating his internal process. It waxed and waned both in relation to his capacity to elicit rich material, and in my ability over time to relax and trust the process. It was within the second interview that he offered several examples of cultural objects entering into the work, and cogently broke the process down into a processive set of components in a deeply useful and meaningful way. In addition, we worked arduously together to construct an understanding of, (a) the functions of the cultural object within the therapeutic work; and, (b) the role and potency of metaphor within the therapeutic endeavor. The ways in which a subjectively rich metaphor is contained within and emerges from the cultural object’s nuanced, condensed images and meanings serves a 29

This definition is taken from http://en.wikipedia.org/wiki/Jamais_vu Arlow (1979), Lothane (2006) and Bollas (2002) and only a few others have ventured to parse the psychoanalytic process in granular detail. 30

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highly significant place in this inquiry. The co-construction of meaning within the last thirty minutes of the second interview, in effect the center of the interview process as a whole, yielded the deepest work, characterized by a driving curiosity on both our parts, and a productive collaboration. Interestingly, over time I grew accustomed to his idiosyncratic manner of both expressing himself and meandering in a way that enabled me to welcome his valuable offerings without growing frustrated, rigid, or controlling in the process, trusting my curiosity, intellect and the synchrony between us to carry the day. This clinician described thinking about our work together between interviews, and he opened the third interview with several very rich examples. The first was fueled by a film he had seen, the second by a cultural object brought into session by his patient during the intervening week. Since the two interviews were close together, and our engagement was fresh in his mind, there was a building energy for our joint project nourishing this interview, and an increased sense of collaboration around both investigating and co-constructing meaning. However, when I again queried him about cultural objects entering his reverie, it was difficult for him, and he resorted to citing texts that are meaningful to him without connecting them to a patientsâ&#x20AC;&#x2122; work.

Categories of meaning. An analysis of the data gleaned from interviews with Clinician 2 yielded two major categories of meaning. The first category of meaning consists of the meaning and use that Clinician 2 makes of the cultural object. The second category of meaning comprises themes in which Clinician 2 identifies his understanding of the therapeutic

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power of the cultural object. Each of these overarching categories of meaning consists of sub-categories of meaning, or themes, which are described in detail in the findings that follow. The following themes are situated within the first category of meaning, the meaning and use of the cultural object: •

The nature of the cultural object.

•

The cultural object houses layered, metaphoric meanings.

The following themes are identified within the second category of meaning, the therapeutic power of the cultural object: •

The cultural object abides within the therapist as an ongoing association to his patient.

•

The cultural object is a way to speak in code, and an indirect route to impart insight.

The nature of the cultural object: “How the poem enlists me and how I enlist the poem.” 31 Clinician 2 communicated a wide-reaching repertoire of cultural objects and experience that inhabit his clinical work. These manifestations were drawn from both his imagination and that of his patients. They included works of contemporary fiction, Homeric text, Biblical text, and psychoanalytic theory. In addition, the large picture window in his office facing out onto an elaborate park and museum campus had occasion to function as an evolving set of potent images. This clinician evidenced a sophisticated, nuanced way of approaching the cultural object’s power within the psychoanalytic work.

Ogden (1997b), p. 620

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His primary, eloquent set of understandings revolved around the inherent themes and metaphors housed within each cultural object, and the complex multiplicity of meanings each offered the work between analyst and patient. Within the context of our collaboration, his thinking ran deep and wide in what felt effortless, and congruent to his distinctive imaginative process. In this way he played with his patient’s and his own associations to a cultural object as Ogden (1997b) describes in his analysis of three poems by Robert Frost: I will not attempt to get “behind” the language being discussed, but will attempt to get into the language as deeply as I am able and to allow it to get deeply into me . . . I will experiment with a variety of ways of thinking and speaking about three Frost poems. To put it another way, I will be discussing . . how the poem enlists me and how I enlist the poem. (p. 620)

The cultural object houses layered, metaphoric meanings: “The literature brings another version into the discourse and then of course back to the question: Where are you in this?” Clinician 2 offered a clinical vignette in which a patient brought in many cultural objects, primarily films, novels and Shakespearean plays. The material’s commonality centered on stories of trauma. Within the work, he attended to what he called “the blackness of the stories, and what they’re being used to illustrate.” He chose to discuss the use of the South African writer, J. M. Coetzee’s novel Disgrace as it unfolded in this patient’s treatment. Within the context of his patient’s subjective experience, this clinician came to understand the novel through a different lens than the one through

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which he had previously read this novel. While this study set out to investigate the clinician’s associations to cultural objects, in this example and the one that follows, it is the patient who initiates the association to the cultural object. The clinician engaged with his patient’s association in a way that Bollas (2002) writes about, playing in his own imagination with the offered set of images contained within the cultural object’s implicit and explicit storehouse of narrative, infused with layered resonance: In free dialogue, when two people free associate in the course of a long conversation, as is typical of close friends, they create unconscious lines of thought, working associatively, as they jump from one topic to the next. This is easy to do because we are open to such unconscious mutual influence when relaxed in the presence of an other. Even as the analyst’s unconscious tracks associative logic. . . . On other paths he or she will dream-work the patient’s material: condensing words and images, substituting ideas; in other words, transforming the content according to his or her own unconscious reading. (pp. 19-20) Clinician 2 unfolded this vignette: “There’s a rape. But it begins with a white woman who is in a colonial role (He paused here.) and is raped. And who’s raped whom, when the colonialist gets raped? I think it’s one of the metaphoric questions in this book. Now I think the book sets it up: There’s the teacher, the student, the disgraced teacher at the beginning. But where the action is in the second act of the play [of the novel] here is what takes place out, away from quote ‘civilization.’ I didn’t think of the book that way until my discussion with that patient. But my patient, my patient’s head is filled with, if you like, white guilt and the Marxist critique of colonialism, and although it was I who

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articulated this question of who has colonized whom, and who is raped here, I think this recognition of that part of the concept set that I think comes with the book, [it] came as I sat with that patient. I don’t know why the patient read the book. I don’t know what brought the book to mind, to light, [or] when my patient read it, but I think that a real question for the patient is, if you like: Is there life after colonialism? And if you’ve been a child and a parent, and if you’ve been on both ends of that colonial trauma, to what extent do you need to reenact that trauma to feel traumatized by it? I think that really is an issue for this person. The literature brings another version of it into the discourse, and then of course back to the question in a sense: Are you a colonist or a colonizer? (He paused.) Where are you in this?” The experience of this patient, in the context of the shared novel and its evocative themes, brings potent aspects of Coetzee’s novel, Disgrace into high relief for the clinician. He works over the themes within himself, getting beyond his patient’s surface political preoccupations, honing in on some elemental aspects of her struggle. In addition to elucidating a set of feeling states in a new way for Clinician 2, this novel’s presence between them offers another way to discuss the patient’s very disquieting personally held themes. Importantly, a core question that informs the work arises within his imagination, inspired by the novel: “Are you the colonizer or the colonized? Who rapes whom?” And it offers him a new way to play with this significant personal resonance of the novel for her. In the discourse cited above, it was unclear about whom the pronoun “you” was referencing when he asked, “Are you a colonist or a colonizer? Where are you in this?” One lens he employs to experience the ways the novel’s potent question informs their

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work is relational in nature, between them. I asked for clarification, wondering if his phrasing of “Are you. . . ?” was quoting his own internal musings about a potential question from his patient to him, as his tone had a simulated accusatory inflection. He responded, “You, the patient (He paused.), or I. (There were sirens out his window.) And we have something of that between us: Is the patient shamed by paying me for services? And this is someone who feels so shamed by the relation that we haven’t yet worked out my [billing system.] My patient can’t bear the thought of receiving a bill. (He spoke with a softer voice) [She] would rather compute it and pay it if I could just, (Here he assumed a different voice, as if communicating his patient’s message.) ‘Please don’t send a bill.’ So (He hesitated.) so in a sense [her sense of shame vis-à-vis the monetary relationship between us] gets reflected back through the literature.” In this way the novels’ themes and metaphors, brought to the clinical enterprise by the patient, offers the dyad a veiled way in which to discuss the layers of relational meaning for this woman. Clinician 2 offered a new lens afforded by the themes that emerged from the presence of the cultural object within their dyadic work: “You know, I think with this particular patient perhaps more than with many, whether the object unites you or separates you (I noticed that he was speaking with some distance—second person, not first person, and his voice was soft] is an ongoing question. Of all of the literary images [brought in by this woman] that I recall, including ones that might not (He paused to think.) they were all of trauma even if we might not think of these stories as trauma. And it’s as if they were all used to say [to me], ‘I’ve suffered something terrible. Where were you!? Why didn’t you prot… why didn’t you step in to protect me!?’ And in that sense we aren’t looking at it together. It’s as if it’s sitting in between us. It’s the explanation not

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of what we have in common but what we probably can’t. (He spoke this last part very softly, empathically.) And so the stories, the cultural objects, while they have a communicative value, part of what’s communicated is the isolation and distance. What the patient feels.” The ways in which Clinician 2 parsed the layered communicative value of the shared cultural object of Coetzee’ novel Disgrace addresses this inquiry’s primary question: How does the psychoanalytic listener utilize his associations to cultural objects in the service of increased understanding of his patient’s non conscious processes? He elucidated this process in highlighting that the cultural object moves from a surface communication about her political leanings and literary savvy to offer a way to both feel and talk about core themes in the patient’s struggles within herself, but also between analyst and patient. While the patient is communicating traumatic feelings of abandonment and isolation, and the analyst experiences this as an accusation within the transference, the patient is simultaneously bringing these images, these stories which house unimaginable and unbearable feelings, into her relationship with her analyst. The dark tales are being brought into relationship, thus creating a complicated phenomenon of inviting the other’s company around one’s intense feelings of isolation, both experiencing the isolation and longing in the moment and approaching the possibility of companionship around these intense affects, vis-à-vis her relational knowing. He continued, “These are stories from long ago, from childhood. In the transference, was I rescuer or was I traumatizer? And (He hesitated here) and that’s a story in which the parents, there wasn’t, (He paused, searching for a way to say this generically.) there weren’t adequate protections experienced, growing up.” In an important way, the cultural

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object serves to provide the clinician with a deeper, richer sense of the nature of the patient’s struggles and pain. He proceeded to work to make meaning of this example, “As I’m sort of parsing through that, (He paused to think for several long seconds.) I think that’s correct that they’re being used [to elucidate her pain], and that’s the challenge being brought to the treatment. Can I, can the patient through the use of the treatment, construct more of a sense of safety in the world than this person heretofore has had? That’s not actually a communicative goal. That’s a goal for what this person would like to achieve. And the communication is then not a primary task, and I think the treatment that says, “You’re trying to tell me something” at that moment, it’s missing the primary task. I think that this is someone who is trying to construct something in their inner world and the primary goal is not to get a message through to (He paused here.) me. It’s to try to find something for her self.” Clinician 2 listened well to his patient’s communication through the vehicle of the cultural object as she introduced the Coetzee novel into their therapeutic relational space. As he articulated eloquently, the object’s layered meanings are played with within his own imagination and between them. This capacity to listen to his own internal musings as they play with his sense of his patient and the resonance of the novel’s thematic and affective states enables him to receive her communication within the transference, and as a depiction of the affective place she abides. He attunes to her associations and his own as a message about a self-state of isolation and emotional impoverishment, and as a communication about the safety for which she longs. He is cautious not to insert himself into the center of her work. He notes, “If I say, ‘What you’re trying to tell me is thus and so, I’ve put myself in the foreground of the story. But I’m not in the foreground of the

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story.” Instead, he holds the message within himself in ways that continue to inform their work. A second elaborate example involved what he described as a “powerful session” in which a patient cited a story from The Iliad, Book I 32 as what the patient noted was “the best way to illustrate what he was trying to tell me” about the complex nature of his relationship with colleagues in his workplace. As in the first example, the cultural object was familiar to the analyst. Clinician 2 summarized the story because it was not clearly remembered, “The issue had to do with a fight over a concubine. And Achilles was enraged. Agamemnon [who takes Achilles’ concubine as compensation for having to give up his own] was okay with his rage. He kept the girl but he was okay with [Achilles’] rage, whereas there’s another character whose rage [Agamemnon] was not okay with: He wasn’t entitled to be enraged with [Agamemnon].” Clinician 2 offered details of his internal process of sifting through the themes that emerged from this text. He considered these motifs through a variety of lenses in order to extract those relevant to his patient’s struggles, yielding five significant strands. His capacity to think abstractly about the text and his patient; to freely experience and read both patient and text on a metaphoric, thematic, affective plane enables him to consider what lies beneath the surface in ways that deeply enhance the therapeutic work. He asks, “What kinds of rage can be tolerated for my patient?” He considers, “The issue was my patient felt held in check by some people whom he experiences as powerful. But he also has some awareness that it is he who holds himself in check. And that they are frustrated rather than gratified by his being held back. So the question was ‘Where’s the 32

The Iliad opens, “Rage—Goddess, sing the rage of Peleus’ son Achilles, murderous, doomed, that cost the Achaeans countless losses . . . Begin, Muse when the two first broke and clashed,/Agamemnon lord of men and brilliant Achilles.”

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locus of this [holding of oneself in check]?’ And in some way finding the masochism disguised, in this sense being once again kept from realizing his ambitions.” Further working the images drawn from the cultural object, he suggests that this theme has reverberations within the patient’s marriage and erotic life, not dissimilar from those within the workplace. Finally, this clinician considers the way The Iliad’s themes reflect the relationship between analyst and patient. Clinician 2 believes his patient is questioning, “Who authorizes the authority [that he is held hostage to]?” in the way that Achilles was subjugated to Agamemnon’s authority, commanded to relinquish his concubine to him. The clinician’s musings then carry him to wonder, “Is [my patient] creating, projecting this role of authority?” This theme, carried into the session by the patient’s introduction of The Iliad, is held within the imagination of the analyst. He continues, “So in the next session, (He paused to think.) How did I put it to him? I had to remind him of that [theme]. And the patient’s comment is that leaders that he admires (He paused to think.) What was the word he used? (He paused to think.) They create an opportunity. They transform the organization of the people around them. But he has a sense of being saddled with unworthy people around him. And the question of course is, ‘How come it is that he projects and tries to flee from this unworthiness rather than transforming what seems unworthy in himself and those around him?’” Clinician 2 then segued to find analogies in the patient’s erotic life: “And as it happens, although the most explicit example in his mind is work, but the story that he tells as he’s playing with the baby, (He paused to think.) He’s very good at exciting the baby who says “Dada!” The baby isn’t so good at saying “Mama.” He’s trying to get the

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baby to say “Mama. Mama.” Mother comes out and does something that [the patient] experiences as misattuned to the baby. And as he tells me this story, I’m hearing a certain amount of contempt, like he’s winning the competition with mother [his wife] in my eyes, is what it feels like. He’s a better parent than his wife.” He continued, “In this context where what he wishes [is that] he could be a transformative leader, it’s costing the transfiguration he wants at work and it’s killing the erotic relationship at home (He paused.) That he’s destroying it through this projective competition and this is what we were talking about on Thursday (several days between interviews for this study) when he opened the session talking about The Iliad.” Understanding his patient to have offered him a condensed image, and holding a relational theoretical framework in mind, Clinician 2 also considered how this particular set of themes from The Iliad reflects the relationship between patient and therapist. “So I’m trying to find the resonance in the room here. But it’s not only in the room here of course. It’s between us in how he’s bringing in this competition: (Here he evoked a different voice to indicate this is his patient’s position toward him.) ‘But okay you’re a better sibling, and there’s no sex life and it’s because of this projection.’ There are some other things in the story. The question is ‘Why does he do this?’ And he’s noted that it interferes with close connection. But I think [his competitive edge is] also his reaction to risking close connection. And there’s some data in the past to support that. He’s a bright, experienced patient very late in the analysis. So he’ll work on that one.” In this way, Clinician 2 is indicating that the history they have between them, and his patient’s innate capacities contribute to the nature of therapeutic action this clinician is able to introduce

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into the work. In his example, the therapeutic action is his use of his patient’s association to a cultural object and his own associations to the themes housed within the object. Clinician 2 described the way he thinks about utilizing the cultural object’s layered meanings within the work. He recounted, “You know, if the story’s going to help me, it’s not because I’ll tell him, “Hey. You’re just like [the character in the story!” [Rather], I’ll say [to myself], ‘Well, how does that help me to understand them?’” He goes on, “It’s just a more useful image.” In this way, he employed the various strands drawn from the Agammenon-Achilles-Bresius saga drawn from the Homeric text, to more gain increased insight into his patient’s internal and relational life. The cultural object provides a condensed image from which to cull meaningful, useful, emotionally resonant elements in accord with the way in which Freud (1901/1952) considered dreams as “a sort of substitute for thought-processes, full of meaning and emotion” (p. 26, original emphasis). He wrote, In the first place, dreams take into account in a general way the connection which undeniably exists between all the portions of the dream-thoughts by combining the whole material into a single situation or event. They reproduce logical connection by simultaneity in time. Here they are acting like the painter who, in a picture of the School of Athens or of Parnassus, represents in one group all the philosophers or all the poets. It is true that they were never in fact assembled in a single hall or on a single mountain-top; but they certainly form a group in the conceptual sense. (p. 314)

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Freud (1965) further described the phenomenon of condensation in dream work: The first achievement of the dream-work is condensation. By that we understand the fact that the manifest dream has a smaller content than the latent one and is thus an abbreviated translation of it. . . . Condensation is brought about . . . by latent elements, which have something in common being combined and fused into a single unity . . . (pp. 210-211, original emphasis) Inspired by Freud, Bollas (2002) writes of dream-work condensing distinct patterns of thought (p. 11), and understands the work of free association to a dream as a method that “breaks up the unity of the dream into disparate lines of thought” (p. 11). He highlights this aspect of free association, which also aptly describes Clinician 2’s attention to the multiplicity of feeling states and relational idioms gleaned from the cultural object of The Iliad text offered by his patient. Bollas explains, “The postmodernist tenet that any truth deconstructs into smaller truths—themselves disseminating through further epistemic declensions to fractions of their former assertions—is an important outcome of the method of free association” (p. 11).

The therapeutic power of the cultural object: the cultural object abides within the therapist as an ongoing association to his patient. “Most often there will be patients that I associate with a particular work or set of works.” Clinician 2 shared that he often finds that he holds a particular image or metaphor within his imagination in connection with his patient in ways he finds informs their work together. He explained, “Most often there will be patients that I associate with a particular work or set of works. The patient has sometimes initiated that, like in this example [of

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The Iliad]. Actually with this particular patient early on I used mathematical and economic metaphors. The patient said, ‘Since when are you allowed to use those?’ (He related this with a pleasurable, humorous tone.) I said, ‘Well you’re allowed to talk about Freud.’ (At this point, he and I both laughed). If it’s a workable language, you can use them. He’s a very quantitative guy and there are some metaphors in mathematics that happen to be very well suited to ideas about connection being close but not intersecting, and so forth.” It is a significant finding of this inquiry into the therapist’s use of cultural objects that the psychotherapist captures “workable language” with which to describe for both himself and his patient an encapsulated understanding of central and fundamental themes in their work. Clinician 2 then unfolded a clinical vignette in which an image drawn from the psychoanalytic literature functioned as the cultural object inhabiting his imagination. He described a patient who was “quite literally dragged to [his] doorstep by the referral source” because of fist fighting. Several key pieces of information about the young man’s history surfaced during the analysis. The first was the sexual excitement he experienced in engaging in debasing and hostile behavior toward women whom he picked up in bars, in contrast to the challenges he experienced sustaining erotic feeling within a stable, longterm love relationship. The second was the revelation that his mother consistently initiated arguments around leave-taking. The clinician began to understand and share with his patient, “Maybe your mother uses fighting to avoid painful separations.” He disclosed, “And I was thinking about this, (He paused) about the person whose mother says, ‘Let’s make love by fighting, by doing something painful and degrading.’ And I didn’t say anything. I decided that that association of mine was too far outside the room

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and the present, but he proceeded with the thought that now that he has this real serious girlfriend, the only thing he misses is what he considers degrading, impersonal sex. Now it used to be, back in the day, he would cheat on his girlfriend and go find somebody he could do something that was sex without a relationship. And he doesn’t want to do that now, but he misses that sort of sex. And you know, well that’s interesting. I ask him,] ‘What would your girlfriend say? Could you do this within the relationship? Is this too kinky for her?’ And I don’t know whether, [if they were to enact this ritual], in her following him home, she too would be interested in this. I don’t know. (He paused.) I don’t think we know yet.” Clinician 2 continued by elucidating the image that abides within his imagination, one drawn from psychoanalytic literature, which in fact has its origin in ancient texts, which include Greek mythology and The New Testament. 33 His associations derive both from his work with this patient around this issue, and the universal nature of this theme. He explained, “The outside reference is to something of [my patient’s], not something in literature. But what I was reminded of, (He paused.) of course is the ‘Madonna/Whore question’ 34 as it’s sometimes termed in the old analytic literature. I wondered whether, he’s not a literary guy, but this guy has reinvented and rediscovered whole chunks of the analytic literature. There’ve been a few things where, (He paused.) well it’s as though he’s reading ahead! Well, you know he’s never heard of any of this literature, and yet for

33 Krims (2002) writes of this theme in Shakespeare’s “Troilus and Cressida”; Specter (1996) writes of the Medusa story in Greek mythology, as well as its presence in Freud’s (1922) writings; and Schapira (2003) discusses this theme’s presence in Shakespeare’s “Othello.” In addition, the New Testament treats of this theme in its complex rendition of Madonna/Virgin and Mary Magdalene. Similarly the Hebrew Bible’s Book of Joshua presents the character of Rahav as a righteous prostitute whom the Midrash then represents as Joshua’s wife. 34 Freud (1911) in “On the Universal Tendency of Debasement in the Sphere of Love," develops his thinking on this subject. A citation from this article illustrates his main point: “Where they love they do not desire and where they desire they cannot love” (p. 183).

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somebody who barely or if at all knows who Freud was, (He paused.) it’s interesting. He’ll take out, if I listen, every now and then, a question. You know it was the core subject of some paper of Freud’s that was in the room here.” He continued, “I mean you know Civilization and its Discontents? That was a couple of months ago: What does he have to give up? Well to think now, he’s coming to the point where he’d think about being married and committed. Could he limit himself to sex with one person for the rest of his life? And the first thought is that he’s struggling from some demands from outside. Are they really from outside? You know. And how much of a struggle is it? And what’s the price?” Clinician 2’s rich vignette exemplifies the psychoanalytic literature abiding in a useful way as a cultural object within his imagination. In addition, his illustration communicates the phenomenon of holding a particular theme or image within himself in connection with a particular patient at a specific place in the work. Initially he described Freud’s conceptualization of the “Madonna-Whore Question” as a way to encapsulate a complex clinical depiction of this young man. He went on to broaden his example to portray a much more finely layered thing: This patient brings in struggles that are congruent with several fundamental human struggles which Freud intricately renders in his writings, and are profoundly familiar and significant to this clinician. As he recounted the ways this young man initiates narrative material that echo Freud’s writings, Clinician 2’s voice tonality reflected a consonant pleasure in his work with his patient. In an important way the fact that the young man’s themes dovetailed with the psychoanalytic literature’s presence within this clinician’s repertoire of knowledge, as well as in his imagination, generated a feeling of enriched connection, as indicated by the tone and

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language he used as he described this scenario. He laughed with pleasure; he exclaimed playfully, “Well golly, it’s as if he’s reading ahead!” And the reality that this young man brings a dilemma to his analyst that is a generalizable human dilemma treated in the literature well before Freud, provided the analyst with a deeply embedded theme that lived within his imagination as they worked together. As he unfolded the “Madonna/Whore Question” within the interview process, he and I seamlessly cited contemporary authors who address this as well: Stephen Mitchell in his book Can Love Last, as well as the work of Robert Stoller. 35 In this way, there was an awareness running parallel to his clinical example, of the both deeply human personal and professional understanding of this struggle.

The cultural object is a way to speak in code, and an indirect route to impart insight: “Smuggling something across a border.” As evidenced in the previous examples, Clinician 2 adeptly attunes to the metaphoric meanings conveyed within his patient’s manifest narrative, as well as within his own associative process. He described in depth what the phenomenon of working within the metaphor offers the therapeutic endeavor, and we collaborated to understand this phenomenon. Researcher: In some ways, the cultural object has given you a more multidimensional way to formulate [your understanding of core themes in your patient’s life], which could have happened another way. 35

Dr. Stoller was also a pioneer in questioning the distinction between what is perverse and what is normal in sexual behavior. "He saw there was no firm line between what was sick and what was healthy except as it infringed other's rights. . . . "He was a courageous, independent thinker." (http://www.nytimes.com/1991/09/10/us/dr-robert-j-stoller-66-teacher-and-leading-sex-identitytheorist.html, citing Dr. Ethel Person, a psychiatrist at Columbia University Medical School.

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162 Clinician 2: To the extent that at some point you have to say, “There’s something that you do in life” to the patient, at least to think it. It’s pretty hard to do that without some metaphor handles: To think, “What is it this patient does. (He paused.) How do they operate in the world?” And it’s pretty hard to do that without metaphors. If we say somebody does something in a repeated and structured way, we usually use a metaphor to describe that in general, in the world. Clinician 2’s idea that the cultural object provides a metaphor to transmit the psychotherapist’s understanding in a usable way may also describe one of the ways the cultural object functions within the clinician’s reverie: It becomes a container or vehicle to convey a layered set of meanings that are accessible and usable to both members of the therapeutic pair. Clinician 2 has an affinity for the nature of language, and this too functions as a cultural object within his imagination. He continued, “Usually [the metaphor] provides a way to organize thought and activity. It’s no accident then that the metaphors that are relevant are metaphors of games or interactions. You know [metaphors that describe] the way people play.” He’s excited and he veers off on a seeming tangent to elucidate this point: “Language offers metaphor: ‘We’re jumping the gun.’ Most of us aren’t runners. We don’t go to the horse races. But ‘jumping the gun’ conveys a rich idea of being competitive, keyed up, ready to spring.” The metaphor offered by the cultural object carries a layered set of complex meanings, and this layered understanding has the potential to abide within the clinician and be shared out with his client in the service of

the work. He continued, “So we’re looking for pithy ways of doing something. In, [or] at the moment of clinical communication, one or both parties are somewhat regressed. It’s not a moment when complicated things are going to get taken in or used, so you need a way of smuggling a communication across the boundary. And so you can send in a complicated object. You can send one object in, but it can be a complicated one. So imagine if we stick with the metaphor of ‘smuggling something across a boundary.’ Say I brought you a present: ‘Here’s a football, but it’s unlaced. You know, if I just bring a football somebody says ‘Well, what’s that about?’ But an unlaced football! Now suddenly there’s a complicated image. When you said earlier [that the metaphor softens the message, I was thinking about softening [the clinician’s message/interpretation] emotionally. But I realize it does something else, which is: It reduces the intellectual work needed to gather it in.” In addition, he highlighted that a useful metaphoric image may contain a whole story, and offer the communication succinctly, in much the way an image in a dream is condensed in nature. Clinician 2 is thoughtfully breaking apart the interpretive process. He identifies a characterologic way in which he communicates an understanding to a patient, and strives to facilitate the potential for his offering to be accessible to his patient. He is sensitive to the ways in which a significant moment within a therapeutic session may occur at a time when both members of the analytic dyad are regressed, and identifies his awareness that what he offers to be used and processed needs to take this into account. He is cognizant that he may only be able to “smuggle one thing across the border,” suggesting that he needs to triage the multiplicity of understandings and associations that he may be experiencing while sitting with a patient. And then he identifies the following

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phenomenon: An element of playful working at the complexity of the image offered paradoxically may actually decrease the intellectual work necessary for the patient to take in the analyst’s interpretation. While it is not the predominant aspect of this set of ideas, he is advocating a playful dimension to the psychoanalyst’s intervention in his example of the unlaced football. This is palpable in his voice intonations and in his facial expressions. It is reminiscent of a personal communication that “it’s important to have a sense of humor. While the psychoanalytic enterprise is a serious business, it doesn’t have to be dreadful!” 36 In exploring the phenomenon of the clinician’s association to and use of cultural objects in his work, the notion that the cultural object provides metaphoric meanings and understandings with which to work is significant. Clinician 2 described the ways in which the metaphor furnished by the cultural object 37, enables the psychotherapist to communicate his understandings to his patient by employing an inherently playful aspect of language in which language is encoded with affective resonance. In this way, Clinician 2 was elucidating what one can do with language within the clinical setting. While the infant researchers have opened up the arena of implicit nonverbal communication within the therapeutic relationship, inclusive of facial expressions, body language, and vocal intonation, nevertheless language continues to function as the foundational communicative tool in this work. Clinician 2 addresses this aspect of the work with attention to the playful use of language one may employ to access and communicate meaning within the therapeutic enterprise. Donnel Stern (2002) articulately encapsulates this phenomenon when he writes, 36

Mark Berger, M.D., personal communication, 3-3-15. While the overriding presence of metaphor in this narrative is embedded in a literary phenomenon, metaphor’s presence in language itself is included in this understanding. 37

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To my mind, the inexhaustibility of both poetry and dreams is due to their embeddedness in unusually rich fields of the nonverbal. Language does what it does most eloquently and least destructively when we let go the reins and give it its head. . . . Giving language its head is not passivity, but active discipline: it is a matter of feeling our way into the tiniest crevices of what language wants to do. Especially on the emotional level we generally occupy in doing psychoanalytic work, words are not necessarily what we use in this surrender, at least not to begin with. In our private experience as well as in our work with our analysands, our willingness to let fantasy and feeling wash over us, especially the shades and nuances that may be the defining aspects of a moment's context, is not a verbally articulated thing at all, and usually cannot and should not be. . . To use language properly is not only to speak, but to allow words to sink into the background at appropriate moments. Language is not only words, then. Language is also all those parts of subjectivity that gather and hover, unformulated, around what we can already say. The most significant part of language is sometimes what it cannot yet speak. Such meanings are nevertheless made possible by language, partially created by reverberations of the meanings explicitly available to us. It is true, of course, that without the continuous infusion of the nonverbal and the vitality of the unconscious, language would be a dead thing. But it is just as true that without

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language, there would be no meaning at all, since even the nonverbal is defined by the possibility of speech and thought. (p. 523) Clinician 2’s elaboration on his use of metaphoric language, drawn from the cultural objects introduced by his unconscious process, and that of his patient and the analytic dyad, demonstrates a way of employing language’s vitality in the work: an amalgam of—in Stern’s words—the “meanings explicitly available to us,” along with “the nonverbal and the vitality of the unconscious” (p. 523). This clinician spoke of the moment when analyst and patient are regressed within a session and the need to “reduce the intellectual work necessary to gather [the therapist’s message] in.” This notion has analogies with dreaming and dream-work. Employing a metaphor, he spoke of smuggling something across a boundary, and having only one opportunity to succeed, and needing the vehicle for transferring something under cover from analyst to patient to be a very accessible, usable object. He offered a paradox insofar as the vehicle needs to be both complex and also reduce the intellectual energy required to take it in. His image of the unlaced football cogently conveyed this idea, and also employed the very phenomenon he was illuminating. A football is a simple object. Bestowing it to another in unlaced form suggests that the receiver has some work to do in order to make it usable. He is speaking of the therapist’s provision of a metaphor functioning as an offering to his patient of a riddle to solve. Mitchell (1997) writes, The analytic process is about expanding and enriching the patient’s experience of his own mind and facilitating his capacity to generate experience that he finds vitalizing and personally meaningful; . . What is important is engaging him. . .

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in a way that sparks and quickens his own analytic interest in himself (Bollas, 1987; Phillips, 1993). (p. 225) There is an explicit and implicit potential playfulness in this engagement. Both members of the analytic dyad need to be accomplished and comfortable playing with language and abiding on an abstract plane in order for this kind of intervention to thrive within the work. Ogden (1997c) elucidates the nature of language for the analytic pair in a manner resonant with Clinician 2’s thoughts about the use of metaphor. He writes, Language is at its most powerful when it disturbs, not by arriving at insights/understandings, but by creating possibilities: “billows or ripples … of the stream of tendency” (Emerson, 1841, p. 312). The analyst's language makes ripples in “the stream of tendency” in an effort to help analyst and analysand to break out of the circle of the eddy in which they are caught. The analytic pair never fully succeeds in this endeavor, but struggles in and through language to overcome itself (its own circling tendencies). (p. 12) He continues, I am suggesting that the analyst must actively struggle with language in an effort to create ideas and sentences and a voice of his own with which to speak them. This struggle to convey one's experience with one's own words, in one's own voice, is a very large part of what it means to be alive in an analytic relationship. (pp. 15-16) Drawing upon Ogden’s description here, Clinician 2’s “voice” within the analytic relationship employs the metaphoric nuance culled from the cultural objects present

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within his imagination and that of his patient. Ogden’s description captures the nature of Clinician 2’s work: Effects created in the use of language serve as a central medium of communication of unconscious experience in the analytic setting. Effects created in language of course coexist with the use of language to name, describe, and in other ways speak about one's experience. When I refer to effects created in language, I am placing emphasis on a dimension of language usage in which the creation and communication of meanings/feelings is indirect, that is, relatively independent of what is being said (at the level of the semantic content of language). Such effects in language are always in movement, always in the process of occurring, “always on the wing, so to speak and not to be glimpsed except in flight” (William James, 1890, p. 253). (p. 16, original emphasis) Clinician 2, as Ogden illustrates, chooses to center his discourse with his patient in an effort to “convey affective meaning.” He writes, Few have described as eloquently as William James (1890) in Principles of Psychology, the way in which language fails to convey meaning (especially affective meaning) when it is used in a fashion that is focused on what it is saying as opposed to what it is doing. James discusses what he felt to be a pull in our use of language toward the “substantives” of language (the nouns around which the meanings of sentences tend to be organized). Feelings, especially those without names (“all dumb or anonymous psychic states”) tend to get lost “in thoughts “about” this object or “about” that . . (p. 246)

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James believed that human experience is captured/expressed in language not so much through the power of its “substantives” to name or describe (to speak “about”), but, more indirectly, through the elements of language (more accurately, in language) that contribute to the creation of a sense of movement and transition, “a feeling of relation moving to its term” (p. 244). It is the “transitive parts” (p. 243) of language, “the places of flight” (p. 243), that come closest to capturing something of the texture and the aliveness of felt feelings and the movement of “the stream of thought” (p. 243): Thus, James attempts to explore the ways in which language can be used to do what it cannot say. (pp. 16-17, original emphasis) This research study set out to investigate the ways in which the clinician’s associations to cultural objects elucidate the clinical enterprise. Clinician 2’s examples and conceptualizations indicate the ways in which the cultural object provides metaphors whose employment deepens and enriches the therapeutic work in a myriad of significant ways. It is along these lines of employing metaphoric language to convey “something of the texture and aliveness of felt feelings” that Clinician 2 elucidates in his discussion of the regressed state of analyst and analysand; the parameters around being able to “smuggle only one thing across a border;” and the offering of a riddle to be worked in the form of an unlaced football. His clinical examples, both from Coetzee’s Disgrace and Homer’s The Iliad profoundly demonstrate this phenomenon. In this way he succeeds in accomplishing what Ogden encapsulates in a footnote: “F. R. Leavis (1947), in his discussion of Milton, usefully distinguishes between a display of a ‘feeling for words’ and the ability to create ‘feeling through words’” (p. 50).

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170 Clinician 3. Case description. Clinical context. Clinician 3 trained as a musician early in life, and has worked as a psychodynamic psychotherapist for over 50 years. He is tall, and soft-spoken, with long, straight white hair and beard. Nearing retirement, he defined his practice as an analytic practice consisting of 12 individuals, working 23 hours per week. He sees some of his patients once a week, while others he sees multiple times per week. Some use the couch, while others choose to sit. He described his practice as “off the beaten track” both geographically and metaphorically. He elaborated, “I don’t get the kind of people who come for you know, kind of quick deals. I mean I don’t advertise. My name is not in the any of the Psychology Today lists, or any other lists. Unless somebody knows me, they’re not going to find their way here. And that’s usually a pretty good screening. It doesn’t provide a ton of cases, but then at this point I don’t need a ton of cases. So now I’m in a position where I don’t have to worry about working, which means I can see people who need to be seen.” Over the years some of his clients have also been psychotherapists, seeking a deeper understanding of self, both as they pursue this work and engage deeply in their personal enterprise of living. Clinician 3 is committed to the importance of adjusting one’s fee, whenever possible, to accommodate one’s patient. This tenet is rooted in his deeply impactful experience as a young man, seeking to both enter this field and engage in his own psychotherapy. Financially impinged, he was either turned down outright by

psychotherapists, or needed to take breaks from the work when his funds ran low. As a result, he now sets a reduced fee for the therapists in his analytic practice. This is founded on his understanding that otherwise “they could not come. They couldn’t have this experience.” This decision is also influenced by his strongly held conviction that one must experience one’s own psychotherapy in order to practice adeptly. Clinician 3 cobbled together the training to become a psychodynamic psychotherapist and engaged in his own treatment, at a time when this kind of training was not easily accessible to social workers. He characterized himself in this way, “After all I’m not trained as a psychoanalyst. I have trained myself over 50 years with one thing or another to have a pretty good idea what it’s all about, you know, I don’t think I’m missing anything.” While Clinician 3 attended social work graduate school where he earned a Masters Degree in Social Work, he described himself as largely self-taught, coupled with some good supervision. He disclosed, “So when I graduated I went to a mental health center, and that was very good because it was run by an English analyst, retired, who had a very nice analytic library, and there wasn’t very much in those days. Mostly journals. And so I read my way through the library, and I began to see people, and I felt I was pretty good at it. I had some grasp of it and I had pretty good supervision and learned a lot. I think I learned a lot, and that’s what I wanted to do, and in those days of course there was no place to train.” He also shared several vignettes of learning about the therapeutic process in his own treatment, as well as in consultation. He said, “They only had to show me once. That was one of my strong points. I’m a quick study about these things, once somebody shows me something that really makes sense.” While he did not treat children, he received some analytic training by entering a highly regarded

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psychoanalytic institute’s child therapy program in the 1970s, which was the one analytic educational avenue available to social workers at that time. Subsequently he worked as a teacher and supervisor in this program, and over the years taught and supervised in other institutions of higher education as well. Clarifying the evolution of his theoretical orientation, having grown into a seasoned clinician in the course of more than 50 years in practice, he shared, “You know, I’ve kind of cranked out my own way of thinking about it, and I think I can back it all up, but it’s a mix of these things, a little of this, a little of that. People who have been around and are more experienced are more alike, than people who are in their training. [Early on] they can be very different, but by the time you get to [be this] experienced, [they] all pretty much are singing from the same hymnbook. You’re giving up what they told you, and finding out what it’s all about from your experience. . . . It’s the education you get from being and doing the kind of things we’ve talked about [i.e. thinking analytically and working therapeutically].” Clinician 3 is deeply engaged in musical performance, both as a passion and as an intermittent career over a lifetime. The overlap between music and his psychodynamic psychotherapeutic practice is significant in essential ways. In the process of exploring what his associations to music offer him, he unfolded his musical autobiography. This engagement with music is intricately interwoven with his relationship with his father, as both an idealized figure and one who disappointed. Clinician 3 asserted that music “is part of my DNA. You know, my father was a musician.” He disclosed, “Well, that’s an old story. You know, that’s a real complicated story that goes back a long, long, long, long way. (He sounded wistful, thoughtful, kind of sad, and he grew quiet.) I mean clearly

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music of a certain sort has meant a lot to me. My father was a trombone player, and I date myself a little bit here, but I was born just three weeks after the fall of the 1929 crash, [and] that was the end of [my father’s] work as a musician. When I was a little kid, 3 or 4 years old, he had some jobs he would play, and I would go to these things and I was very, [well] this was the first idealize-able picture in the midst of an otherwise pretty grim Depression, so I kind of grew up thinking I was going to be a trombone player like he was. I was going to take his horn: a good Oedipal identification. And then one day I heard him say that he had to get rid of the horn, because he had had to sell it, and I remember being heartbroken by that.” He continued, elaborating on his experience of both idealizing and feeling disenchanted with his paternal figure, “But the music thing does have that piece of it: that identification. And an attachment and some mix of depressive, wishful idealizing on one side and realizing that my elder memories of my father, I remember during the 1936 hurricane in Miami: My father had to go to work. . . . They had a WPA theater and he was in the band. So he had to go for a rehearsal and I still remember him walking down the street carrying this horn and his pants were rolled up above his knees because the water was flooding the streets, and he had to go to a rehearsal. So there’s these two images: one of him up on stage with a white suit on looking [great], and then there’s this one, this memory of this depressing, depressive, horrible time. My parents split up and all that. So you know the music goes back to that.” Clinician 3 left home “with the idea that I was going to be a musician before graduating high school. 38 I left home ‘cause I thought, well I didn’t know anything else, so I thought maybe I could do that. Well, it was a transitional experience to get out of, to 38

He completed his GED while in the Navy, along with his first year of college credit, and later completed his university studies and went on to social work graduate school.

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get away from home. It was something to hold onto. Well I found out that I wasn’t really good enough to do this, and I wound up here. Because of the circumstances and time and money, I never had any training [as a musician.] I had a teacher for a few weeks, but I never had any real good training, I could play. I was kind of good at the little bit I was able to do years later, but I didn't have the background and couldn’t be a musician, but I wanted to be.” He described himself, at the age of 19, slightly after World War II, as a “mediocre musician, but I could make a living. He travelled around the country, playing with bands throughout the Midwest. Drafted for the Korean War, he attached himself to a Navy band, and then continued to “play off and on over a lifetime.” He cut some records and a CD, and did not share his reasons for leaving music when he did. Concluding his story with an awareness of his stream of conscious narrative, which was characteristic of much of the interview process, he reflected, “but anyway that’s a long associative play.” Asked to consider the ways in which his musical engagement functioned for him as a transitional phenomenon, in the ways that Winnicott (1967) 39 discusses, he considered, “It was something like that, [a kind of playing in the potential space between 39

In his (1967) article, “The Location of Cultural Experience,” Winnicott (1967), reflecting Fairbairn’s influence, sets out to fill a gap in Freud’s psychoanalytic paradigm by offering a model to attend to the location of cultural experience within the human psyche by extending his thoughts on transitional phenomena, projection and introjection, and play to take cultural experience into account. Defining play as the transitional space between internal and external reality, he believes that an exploration of play as an aspect of life-in-transitional-space provides access to understanding and locating cultural experience within the mind. He reminds his reader that the transitional object, “the first not-me possession” (p.369), is the child’s first symbol and first play experience: It symbolizes the union between caregiver and infant, becoming developmentally possible once the infant is able to let in an awareness of maternal separateness, and has the capacity to experience the caregiver as a representational object. In effect, the transitional object functions as a symbol of the bond between these two autonomous persons.. An essential component of Winnicott’s conceptualization of the connection between transitional phenomena and cultural experience consists in his idea that it is within the experience of separation that the experience of union can be experienced (p. 369). Believing that play happens in this transitional space, Winnicott contends that “the place where cultural experience is located is in the potential space between the individual and the environment” (p. 371), a parallel to the space between infant and maternal figure: “It is these cultural experiences that provide the continuity in the human race which transcends personal existence” (p. 370), and what nourishes one’s vitality.

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subject and environment]: It was certainly a place for me to be, a framework in which I could develop a kind of persona. It did provide a mental formula, format and it you know, it helped.” Elaborating on his musical inclination, he continued, “I’d say my best shot was mostly improvising: I was a pretty good improviser. So that requires listening and interacting. And that quality, I really liked that part, being able to play with two or three people.” In this way, Clinician 3 connected these character traits and predilections to his transition to psychodynamic work. He was highly reflective, and resonated with a profound humility about the psychotherapeutic process. This curious, questioning, dialogic stance was characteristic of his engagement throughout. For example, he wondered aloud, “What does it mean to be a therapist? (He paused, briefly.) This has always been my puzzle. For years I’ve been pondering that question: If two people are sitting in a room, one is supposed to be the therapist. And one’s supposed to be the patient. What’s supposed to happen? And how do you do that? And what does it take to do that? And what does it take on both sides to do that?” In another instance, he queried, “I started thinking: Okay. Here’s two people. What is one supposed to do? You know, in relation to that statement. How do you get to know? How do you find out? And what is important? How do you know what’s important? How do you, how do we come to know what makes a difference and what doesn’t? And how does a person experience that? And how do they collect that? And how does it become useful and meaningful as opposed to not having it or something else? I mean that’s a lifetime work, right there. Just trying to unravel that statement.” Making a stab at answering his own questions, he began by identifying his clinical focus. He believes he “hover[s] knowingly, and whatever you know, it’s going to be in

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your ‘hover’. And my hover, I hope, is pretty broad.” Clinician 3 maintains an awareness of the context in which his patients live, and the ways this phenomenon intersects with the particulars of his patients’ intra-psychic and inter-psychic lives, what Cushman (1995) describes as “conceiv[ing] of psychotherapy as taking place within a larger cultural space or ‘terrain’ (p. 13). “I try to know about the world and how it works, and what the forces are and what the, you know, what common cultural norms are and that kind of thing. But I also know a lot about human development, and I try to bring as much of that into my understanding of a given person as I can. I try to see where they are in the world, and how well their grasp is of themselves and their situation. Where are their blind spots and what can I understand about those blind spots, and struggle from a kind of historical dynamic perspective.” Clinician 3 expounded extensively on the analytic nature of his practice. He drew a distinction between analytic thinking and therapeutic action, and explained how the two are intricately bound in his practice, and essential for good work to occur. “I try to think analytically and work therapeutically,” he delineated. He understands his work as focusing on “personality and character processes.” Working primarily in the positive transference, he understands people’s difficulties stemming primarily from the absence of an early “trustworthy experience.” He sees the work of therapy being to “encourage people to learn how to trust.” Drawing upon Stern (1998) and Langs 40 he revealed, “It

40 Following up with this clinician regarding Robert Langs’ work and writing, he communicated the following, “In my experience the Bipersonal Field book and one he wrote with Leo Stone: The Therapeutic Experience and its Setting was interesting. His main, for me, message is how to listen to a patients narrative. It is about the therapists interventions and errors (or successes) and how to hear the patients response which emphasizes his prioritizing the unconscious (personal communication 12/13/14). http://en.wikipedia.org/wiki/Robert_Langs provided the following, “ “According to Langs, the conscious mind thereby adapts, by surviving the event that seemed unbearable, but simultaneously fails to adapt, by leaving unconscious what it might have gained from the experience. Thus an important goal of adaptive therapy is to access the wisdom of the unconscious mind, which

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goes all the way from a model based on a kind of evolutionary thing. That is, people

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adapt randomly and unconsciously to circumstances, and they adapt in some kind of way.” While he does not overtly nod to Ferenczi 41 in his narrative, he conveys a central tenet akin to Ferenczi’s that the curative dimension of psychotherapy is situated in the reparative relationship with the therapist. He said, “We kind of know from just regular experience, [that] if you’re a pretty decent person with another person, the likelihood is that it’s gonna be pretty good. I mean that’s gonna somehow rub off. Say, like through osmosis: a sense of ‘better,’ a sense of ‘order,’ of better order. And you talk about that as some kind of identification, you know of some kind. You talk about it as some kind of an unconscious identification with the therapist’s management, or with their kind of way of being. So there is this sort of atmospheric osmosis, I suppose, that’s one thing.” Renik (1995) speaks with the same kind of language when he rails against analytic anonymity and articulates his “primary emphasis on the importance of healing interactions within the treatment relationship,” with the goal of “generat[ing] new experiences with a new object” (p. 475). Clinician 3 explained his distinction between thinking analytically and working therapeutically when he explained that while he analyzes the transference, he believes is denied at the conscious level due to the pain and anxiety associated with the traumatic event. According to Langs, the activities of unconscious processing reach the conscious mind solely through the encoded messages that are conveyed in narrative communications like dreams. He maintains that, as a rule, dreams are responses to current traumas and adaptive challenges and that their story lines characteristically convey two sets of meanings: the first expressed directly as the story qua story, while the second is expressed in code and implicitly, disguised in the story’s images. We can tap into our unconscious wisdom by properly decoding our dreams, i.e. by linking the dream to the traumas that have evoked them—a process Langs calls ‘trigger decoding.’ This process, according to Langs, is the essence of self-healing based on deep insight . . . . In summary, Langs' approach to psychotherapy is deeply rooted in the psychoanalytic tradition, but differs from mainstream psychoanalysis in significant ways: among he (1) draws his approach from evolutionary biology and the principle of adaptation; (2) treats the unconscious according to adaptive principles; (3) roots psychic conflict fundamentally in death anxiety and death-related traumas. 41

Rachman, 2007, p. 85, cites Ferenczi 1980i and 1988 to this effect.

this part of the work to be highly cerebral, what he called “a nice intellectual discussion,” in which we “[treat] the interactions as old business.” The problem with this methodology, however, is that “it winds up with an analysis and no therapy. What you get is that you get something analyzed, but it’s the wrong thing. And [historically] it neglects what has happened in between [within the therapeutic relationship], and doesn’t lead to any correction on the therapist’s part. So it is not really a dynamic process. It’s kind of a one way street.” In contrast, he elucidated the therapeutic action that grows out of his analytic attitude. He continued, “But for our purposes, for analytic purposes, that has to be, you have to get past [all the efforts people make to try to adapt to their misery and to adapt to their confusion]. If it’s all just about circumstantial stuff, that’s not going to be analytic. You gotta connect past the surface so the person can become aware of their resistance to being known and to [you] being trustworthy. And I think you do that whether you’re talking about [seeing] somebody five times a week on the couch, or once a week about anything. [The fear of being known, and one’s capacity to trust another person is] a human issue. So you’ve got to get below that, and I think the way that that happens, in my feeling anyway, is that it comes from an accumulation of trustworthy experience, and that’s not just a matter of being here, being regular and all that. But being able to hear what Bollas calls ‘the unthought known.’ 42 That’s a very good phrase, and I think [the therapeutic dyad has] to try to reach that ‘unthought known,’ and put some words to it. And if you can do that in a way that’s useful and timely, that breeds a little element, an

Christopher Bollas (1987) introduces this concept in The Shadow of the Object, p. 246.

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increment of trust because ordinarily that’s never happened to people. And so if you can do that, I think that starts the ball rolling.” Considering the interaction of analytic thinking and therapeutic action, and articulating his integration of a two-person psychology, Clinician 3 elucidated his theoretical orientation by conveying his personal integration of his psychoanalytic mentors. Firmly rooted in a deep understanding of Freud’s writings, Clinician 3’s theoretical underpinnings are drawn from his experience in his own psychotherapy, and a deep-seated belief that “in the Freudian style, when people tell you stories, you’re listening to it from the point of view of past history. And the transference derives from old objects, old relations.” Moving to a two-person psychology model, he cites Robert Langs as a significant influence. Working with his focus on the relational “in between,” he draws upon Bollas’ (1998) notion of the “unthought known,” in combination with Robert Langs’ significant internal theoretical voice. He continued, “But the point is that there is a recognition that there is another person in the room, that they’re reacting to you, and that what they’re telling you has meaning. So what Langs’ angle of course does is go to the notion of what is repressed. And what is repression and what is unconscious? The original Freudian model of course, the unconscious was a dynamic unconscious. It had been conscious and it’s repressed through defenses. Langs’ point is ‘Yeah, that may be so, but there’s an unconscious we come with and that’s got lots to say about what’s going on,’ although there’re obstacles to acknowledging saying so, ascribing feeling and so forth, and that’s the important part of a therapeutic process. When you can get hold of that kind of stuff, it begins to repair what is really broken.”

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This clinician chooses to emphasize, without discarding the analytic, the hereand-now interactional information gleaned within the therapeutic relationship. He attributed this manner of practice to Robert Langs’ thinking: “What Langs says, and what I think is more to the point and a better point is that unconsciously patients will recognize the unconscious stuff that you’re doing: your mistakes, your flaws, your blind spots, your seductions, your hostilities, or neglect or whatever it is. They’ll unconsciously get that, but they will not consciously know that. But they will tell you stories. If you listen, and you connect it up with what’s been going on, you can see that there’s something relevant. And that can be interpreted in terms of what’s going on and that is a trust building experience.” Clinician 3 afforded deep thinking about the relationship between one’s practice and one’s theoretical foundation. While well versed in theoretical orientations, and thoughtful about the influence of clinicians including Freud, Winnicott, Langs, Bollas, Daniel Stern, and others, he fundamentally believes that over the course of his life, his therapeutic action has been defined by an amalgam of his most fundamental sense of self, mingled with the theories that have resonated most deeply for him over a lifetime. The nature of his practice and his thinking was reflective of this articulated philosophical stance throughout.

Relationship to cultural objects: the cultural object is a vehicle for the unconscious to be known. Clinician 3 shared a number of examples of cultural objects inhabiting his imagination and that of his patients. In one example, he spoke of the meaning a patient

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made of a piece of art hanging in the office. In this way, a cultural object belonging originally to the psychotherapist and the shared therapeutic space was made use of by his patient, and shared between them in ways that enhanced the therapeutic work. Another extensive example focused on the creative process and artistic representations that grew out of one patient’s imaginative, artistic enterprise. This illustration demonstrated a set of cultural objects intimately imbued with personal meaning, shared from the patient to the therapist, and then abiding within each and between them in significant ways over the course of treatment. In this case, the psychoanalyst made meanings within his own imaginative and associative process of his patient’s creations, and felt they lent him significant windows into her psychic life. In a third example, this psychoanalyst associated to a tune in ways that contributed to enriched insights into himself, his patient and the psychotherapeutic process. He understands his rich musical sensibility to contribute to his capacity to both improvise and play within the therapeutic enterprise. He further understands cultural objects to have the capacity to function as vehicles of unconscious communication in the work.

Relationship to reverie and free association. A key component of Clinician 3’s therapeutic technique involves attending to what Bollas (1983) designates as “news from within” (p. 3). Bollas writes, “By cultivating a freely roused emotional sensibility the analyst welcomes news from within himself that is reported through his own hunches, feeling states, passing images, fantasies, and imagined interpretive interventions” (p. 3). This clinician was articulate about his understanding and use of this phenomenon. Adopting a pedagogic stance, he

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distinguished Ogden’s notion of “reverie” 43 from Freud’s conceptualization of “evenly hovering attention.” He elucidated, “The emphasis here is on educated, analytic attention, different from reverie. It is not just about paying attention to what comes along. It is a hovering of readiness to grasp what comes along within an analytic frame. It is like trying to capture a butterfly: You don’t just wave this thing around. You go after the butterfly in an active way. Reverie [in contrast] has a kind of passivity, like wandering around in the wilderness.” He stressed with passionate conviction, “You’ve got to be listening for something. You can’t just be floating so you have to have, (so what I wanted to add) is that it’s hovering attention. It’s the attention. It’s not just the hovering, and so, sure, with intuition we can say, ‘Well I’ve got a little sense about that,’ and so you pursue it. That’s good. But it only goes so far as you have some reason, so to speak, for doing it, for cathexis, (to keep with one of those old words) to focus attention.” Speaking personally regarding the unconscious communication gleaned from his musical associations, he confided, “My musical experiences led me to know hundreds and hundreds of songs. I’m old enough to know the Great American Songbook: words, 43

Thomas Ogden (1997) defines “reverie”, borrowing from Bion’s terminology, and writes about the ways he uses it and how it informs his work, by offering case examples and a useful discussion. Quoting Henry James (1884), he writes that experience [catches] “every air-borne particle in its tissue…” James uses the word “imaginative” to describe the mind when it is able “to [take] to itself the faintest hints of life” (p. 567). Ogden sets out to discuss his “experience of attempting to use [his] own states of reverie to further the analytic process. He demonstrates the ways in which he makes “analytic use of the ‘overlapping states of reverie’ of analyst and analysand” (p. 568). Ogden defines “reverie” as being made up of the stuff of ordinary life—the day-to-day concerns that accrue in the process of being alive as a human being. Reveries “are things made out of lives and the world that the lives inhabit … [they are about] people: people working, thinking about things, falling in love, taking naps … [about] the habit of the world, its strange ordinariness, its ordinary strangeness …” (Randall Jarrell [1955, p. 68] speaking about Frost's poetry). They are our ruminations, daydreams, fantasies, bodily sensations, fleeting perceptions, images emerging from states of half-sleep (Frayn, 1987), tunes (Boyer, 1992) and phrases (Flannery, 1979) that run through our minds, and so on (p. 568). He believes reverie to be simultaneously deeply personal and private and intersubjective. As he discusses his thoughts on how to use reverie, he stresses that he does not usually speak directly to the analysand from what he is thinking and feeling in the context of his reverie with his patient. Rather, he [attempts] “to inform what we say by our awareness of and groundedness in our emotional experience with the patient” (p. 568).

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melodies, [and the] emotional feelings in that music. Music is possibly always playing in my mind, constantly improvising in my mind. It’s another way of appearing in our own unconscious if we will catch it. It is allowing inner life to be stimulated with whatever associations are [present]. Not just wandering. [It’s a] complex response, translating [it] into useful interventions to whatever is going on. Reverie shortchanges the situation. It doesn’t lend itself to the therapeutic process model.”

Understanding of unconscious communication. This clinician, set contextually within his musical experience, understands his spontaneous associations to melodies, lyrics, song titles, rhythms and the like as “some reassurance that my unconscious is on my side.” He believes his musical imagination is “another opportunity for [my] unconscious to let [me] know what’s going on.” Elaborating on his experience of this phenomenon in his work, and placing it within the greater context of associations to cultural objects and experience, he continued, “These are all vehicles by which unconscious communication, our own unconscious can give some voice in some form and shed light into the world.” Clinician 3, early in his own treatment as a young man, experienced a significant moment in which he unconsciously drew upon his musical imagination in a free associative way. This formative experience confirmed for him the existence of the phenomenon of unconscious communication and his capacity to free associate, and became an iconic way of describing a significant moment in his development as a psychoanalyst. In addition, it provides an avenue to understanding the way this deeply personal and professional pursuit dovetailed with his characterologic musical imaginative

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repertoire. “I was seeing this [analyst]. We’re talking and he’s telling me that he’s going on this vacation and he tells me that he’s going to Buffalo, New York which is where he was from, and I’m sitting there and I’m noticing that in my head I’m playing this tune and I’m listening to this tune and I lock onto it and I see what the name of the tune is: “Shuffle Off to Buffalo.” And I just know that tune. It’s not that I care about it especially but it comes up out of my archive and I register this and I laugh. That’s when I began to recognize about unconscious communication, and how the unconscious works, and how things come into awareness, and how you’ve got to pay attention.” He was hard pressed at first to articulate his internal meanderings in the service of his client’s work, but over the trajectory of the interview process he began to articulate more explicitly the elements of his analytic process. He spoke with conviction about the defining impact of his own psychotherapy, and consultations with a variety of practitioners, on his own work. In one instance, he explained, a consultant taught him that an essential element to the work did not lie in a problem with technique. He unfolded, “I remember this consultant and I went to him one day, and I said, ‘Yeah. I’ve got a technical problem.’ (He laughed, remembering this interchange warmly.) It’s funny when I think about it now. He says, ‘Oh yeah what is it?’ So I tell him. He listens to me very patiently for a few minutes and he says, ‘You know, you don’t have a technical problem. Your problem is that you don’t understand your patient. When you understand your patient, you’ll know what to do. It is not a technical problem. It’s a problem of understanding. Pay attention to how you come to understand. Go back inside yourself and learn.’” As a result, his clinical learning led him to privilege his attention to the internal workings of his imagination while sitting with a client, and contributed to his

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foundational tenet to strive to understand his patient through the vehicle of unconscious communication. Clinician 3 draws upon Daniel Stern’s (1998) concept of “implicit relational knowing,” coupled with Bollas’ (1987) idea of “the unthought known” to ground his attention to unconscious relational data communicated through the transference. Hearkening to the work of Daniel Stern and the idea of “a model based on a kind of evolutionary thing, that is people adapt randomly and unconsciously to circumstances and they adapt in some kind of way,” he characterized this unconscious process as “a finer grained process, what’s happening at the tissue level, at the nerve level, at the deepest kind of thing that says, ‘Go this way and not that way.’ It’s the very, very tiny sensitivities that we all have, and if we don’t kind of recognize that during the therapeutic process, it gets all out of shape and we don’t know what hit us.” This sensibility and conceptual framework provides him with a sense of his patient’s experience of relationships, through the therapeutic relationship, and enables him to make use of this information as he attends in what he calls, with a nod to Freud, “a hovering way.” He continued, “Something comes up out of my archive.” It is possible to make meaning of these associations when one pays attention in a focused way, a “hovering” way. He advised, “You don't just hover emptily. You hover knowingly.” Speaking in this manner, he indicated in a distinctive fashion that one’s knowledge of one’s patient’s history, the place he or she is in the treatment, the nature of the transference all contribute to the way in which the therapist “hovers.” The examples he provided exemplify the ways in which his own associations to cultural objects, and those of his patients provide him with information about the “unthought known,” poised beneath the surface of

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subjective and inter-subjective experience. Clinician 3 eloquently delineated the usefulness of locating ways to engage with one’s patients around such elusive feeling states, intuited and experienced by the clinician in moments of analytic attentiveness.

Co-constructing meaning: the interview process. Clinician 3, a psychoanalyst and teacher, communicated a clear wish to provide useful information for this research study. This commitment was always present in some explicit or implicit way. He would periodically check in about whether what he was contributing was applicable to my research question. He would also, at points, reflect a concern that he was not offering suitable examples or musings. Initially, being as he is seasoned and nearing retirement, he seemed interested in employing the interview experience to impart his legacy vis-à-vis his theoretical and political predilections, and the compelling aspects of his career path as they interweave psychoanalytic practice and a rich engagement with music over his lifetime. At times it was challenging to keep the interview process focused on the dissertation subject. However, because of his musical predilections and profound psychoanalytic understandings, he was a fitting participant for this study, and I approached the prospect of working together with excitement and some idealization. In the first interview, when asked directly about his internal process, he responded, “You know, I don’t know that I can say that anymore. It’s so automatic. It’s so much a part of how my brain works. I mean that’s going on as we speak. I mean I am grasping, you know, who you are, naturally. And it’s automatic. I can’t tell you how to get there.” In conveying the “automatic” nature of his internal process, it seemed that as

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one matures in this work, one’s therapeutic moves are so intertwined with one’s persona that they are no longer consciously considered or weighed. However, as the interview process unfolded, and we established a rapport between us, he became more facile at articulating his internal process in ways that yielded rich data for this enterprise. Within the context of his engaging in a deep way about the components of his own internal process, he frequently counseled the need to maintain a humble stance about what one can actually access and know. He referred to this as “a maybe,” indicating the elusive nature of one’s capacity to know another in any real way, and the need for humility in attempts at interpretation. Increasingly, over the course of the trajectory of the interview process, a rapport developed between us, that was characterized by curiosity, candor and playfulness. Occasionally when he would insist I was asking him to articulate something that he had no words for, I would appeal to his affinity for improvisation and play and invite him to “just play with me a little bit,” and then something would shift. Several moments in the interview process were characterized by a poignant tenderness between us as he revealed sensitive case material that felt profoundly affecting. In one instance, he touched on feelings of despair around a particular client’s narrative, and I found myself moved to comfort him in his anguish. This shared intensity of feelings was also characterized by an excitement at what we were discovering together. At other times, he would veer from the subject matter when he seemed emotionally flooded by painful material. At these times, I would make a note of the phenomenon, maintain a respectful stance toward his willingness to delve deeply into the material and share openly, and eventually gently bring him back to the subject at hand.

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The interview process was also characterized by the fact that we shared a strong sense of camaraderie related to a jointly held affinity for the location of cultural objects in our imaginative lives, and in our work. I often reflected delight at what he was offering and the ways we were co-constructing meaning. At times, he would reflect surprise at what he was accessing within himself. At one point, he marveled, “I think I have a mind for the kind of thing that I kind of think you’re talking about. But in that respect it’s not, (He paused to consider.) it’s not, I don’t, well I’m not aware of using that except I am now aware that I’ve said that I do. So I’ve just learned something.” Factors contributing to this unfolding rapport between researcher and participant included a mutual and sustained stance of curiosity and pleasure, coupled with some disclosure on my part about my own associative process in the realm of cultural objects, as well as his increasing willingness to consider the questions at hand, contemplate them between interviews, and apply this area of inquiry to his own practice.

Categories of meaning. An analysis of the data gleaned from interviews with Clinician 3 yielded two major categories of meaning. The first category of meaning consists of the meaning and use that Clinician 3 makes of the cultural object. The second category of meaning comprises an example of a cultural object’s presence in the therapist’s imagination: What it yields, and the nature of the process. Each of these overarching categories of meaning consists of sub-categories of themes, which are described in detail in the findings that follow. The following themes are contained within the first category of meaning, the meaning and use of the cultural object:

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•

Therapeutic work is likened to the musical enterprise.

•

Therapeutic space functions as a musical space.

•

The cultural object works as a provision of therapeutic opportunity.

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The patient’s creation functions as a cultural object.

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Sharing a cultural object, created by the client.

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A therapist needs the capacity to play.

The following motifs are housed within the second category of meaning, an example of a cultural object’s presence in the therapist’s imagination: What it yields, and the nature of the process: •

“The Look of Love” and what it yields.

•

“The Look of Love”: parsing the process in which a musical association provides a useful tool “for the emergence of unconscious communication”

The meaning and use of the cultural object: therapeutic work is likened to the musical enterprise. “You gotta . . . listen in the bones.” Clinician 3 considers his musical process as an apt analogy to his understanding of the requisite psychodynamic artfulness of his clinical work. Narrating his musical autobiography, he addressed this phenomenon, “[Playing music] was great for me, but that was the transitional forum to this [psychodynamic] work. It seemed to me that of all the things I had ever tried, and I tried a bunch of different things, I gravitated to this in the most, you know, effective, meaningful way for me. I like the back and forth. I like having people [to] listen [to]. I like to be listened to as well. But I like to make music, and

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I think that’s at it’s best I think that [this psychodynamic work is] slower. It doesn’t swing quite as hard, but it’s still music. I feel that way about it. It’s an enlivening experience, like playing.” Continuing to play with the parallels between his musical practice and his psychotherapeutic work, he expounded, “This kind of work is the closest thing I could see to actually doing what music was all about for me, a kind of, you have to listen. It’s not a solo proposition. You’ve got to pay attention . . . and not [just] listen intently, but listen in the bones. Kind of, to know where you are. It’s creative and inventive and you don’t want to play too many wrong notes, so you want to think about where you’re going to play, and where you’re not, and what and how and stuff, and so there are a lot of parallels in my mind to qualities that I think I have as a musician that I think I also have as a shrink.” He added with a wry smile, “And it was a better living.” Identifying his predilection for play and improvisation in both areas of his expertise, Clinician 3 spoke of his musical sensibility lending him access to his unconscious process in ways that inform the work. He explicitly identified music as a vehicle “by which unconscious communication, our own unconscious can give some voice in some form and shed light into the world, so to speak.” Referencing the privileging of hovering attention as a therapeutic tool, he commented, “And I think that’s what music does in my mind for me. That’s one of my clues. But I think everybody’s got something like that. I’m sure we all have an unconscious. So the main point is to be able to find those things that give us access that we can readily use.” Referencing music entering his imagination as he sits with a patient, he noted, “[It provides me with] some reassurance that my unconscious is on my side. Things become clear if you wait and you

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trust. And [if] you don’t get too hornswaggled, 44 you can find ways eventually to know a little bit about what’s going on.”

Therapeutic space functions as a musical space. Clinician 3 invited me into his therapeutic space, and spoke of it as a “musical experience” he offers his patients. He spent some time introducing me to the cultural objects that appoint his office, regaling me with the stories and history of particular artifacts. There was a palpable sense that his office space functions as an extension of himself, and in some ways is a metaphor for his own complex internal life and history. His office is situated in the lower portion of his home, with a separate entrance. He has worked and lived in this building for over 40 years, and it is an important part of his identity that his practice is not located in the downtown area that houses most of this city’s psychoanalysts. Detailing aspects of his therapeutic space as a “musical environment,” he recounted, “So everything here is what I do. You can see the stuff on the walls. It’s not a barren room. The idea of being in what I would call a ‘musical environment,’ which I think this is, to me this is a musical environment. You have to play with it. You can listen to it. You can look at it. You can you know. Touch it. Pick it up and put it down. To me this is a musical room. So when I think that now I don’t consciously go about anything this way, but since you bring it up, I’m kind of reflecting on it. I suppose that there is also a sense with [my clients], that I am inevitably going to bring them into this room, and that atmospheric frame is a value to me. I remember I had a consultant one time: A very smart 44

“Hornswaggeled” originally referenced a pirate who’s had his booty stolen, and is a slang term used to communicate being bamboozled.

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guy, but kind of weird. He was an analyst, and he had an office in the old building there [downtown] there where the [psychoanalytic institute] used to be: a tiny little office probably a third the size of this, no windows, gray walls, a desk and two chairs. And I mean it was (His voice trailed off and he expressed distaste with his face.) and a globe light hanging from the ceiling, one of those office lights. I mean there was nothing in there stimulating, which is the idea, and that was I believe the classical idea. But people tried to cut down on stimulation, you know. And so that everything was out of the inside. Nothing came at you. I think that is a false notion. I think plenty comes at you from that kind of a place, and it’s almost all bad, (We both laughed.) because it’s a deprivation chamber. I don’t think deprivation is very good. [My space is] a dynamic setting which people interact with in a variety of ways and that’s interesting too. That’s part of the music. And you know, the point there is not to cram it down somebody’s throat, but that you did or didn’t notice, but let it seep in and become a part of their experience, and so in that way I think I have a mind for the kind of thing that I kind of think you’re talking about, [the role of cultural objects in the imagination of the psychoanalyst and the ways in which this influences the psychodynamic process]. In addition to crafting his therapeutic space as a nourishing maternal environment, he also notes that the space exists for his own sustenance: “I have to be in this. I’ve been in this room now since January 1971, almost every day. I’m never tired of it. Even I, you know, I can be in this room. So it’s not designed, it’s just evolved.” As he continued to reveal details of the history of important cultural objects inhabiting this lovely room, I reflected that the evolution of the space seems to have run parallel to the evolution of his life. He responded, “Having this place and being able to have this setup is exactly what I

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wanted. And I remember. You know you read about, of course, I’ve been to Freud’s place in Vienna you know. Everybody [in Freud’s era] lives and works in the same place.” Sometime later, as the interview process was drawing to a close, he shared that he had had this therapeutic space soundproofed, and that he practices his music in this space on a regular basis. This personal fact enhanced my understanding of his conceptualization of his therapeutic space as a musical space. The overlap he articulated between his psychoanalytic practice and his musical immersion is highlighted in his rendering of his office space in this way. It is a place of improvisation and play. A setting in which his personal idiom interfaces in significant ways with his clients’ implicit and explicit struggles. He clearly elucidated the intentionality with which he composed a “dynamic setting,” antithetical to the “deprivation chamber” of his mentor, one that holds the potential to nourish the endeavor of therapeutic play. In this way, Clinician 3 conceptualized his consultation room as a Winnicottian (1967) “potential space,” that runs parallel to that of the relational dimensions of the analyst-patient interactional engagement. His emphasis on providing his clients with “trustworthy experiences” jives with his conceptualization of his therapeutic space as both nourishing and musical in nature, and as a provision he has fashioned as an environment in which to engage in the play and improvisational work. This conceptualization, inherent in his understanding of the psychodynamic psychotherapeutic process, is harmonious with Winnicott’s (1967) thinking: I have tried to draw attention to the importance both in theory and in practice of a third area, that of play which expands into creative living and into the whole

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cultural life of man. This third area has been contrasted with inner or personal psychic reality and with the actual world in which the individual lives and that can be objectively perceived. I have located this important area of experience in the potential space between the individual and the environment, that which initially both joins and separates the baby and the mother when the mother's love, displayed as human reliability, does in fact give the baby a sense of trust, or of confidence in the environmental factor. Attention is drawn to the fact that this potential space is a highly variable factor (from individual to individual), whereas the two other locations—personal or psychic reality and the actual world—are relatively constant, one being biologically determined and the other being common property. The potential space between baby and mother, between child and family, between individual and society or the world, depends on experience, which leads to trust. It can be looked upon as sacred to the individual in that it is here that the individual experiences creative living . . . . It may perhaps be seen from this how important it can be for the analyst to recognize the existence of this place, the only place where play can start, a place that is at the continuitycontiguity moment, where transitional phenomena originate. (p. 372, original emphasis) Clinician 3’s engagement in the interview process, and his openness to exploring the ways cultural objects abide in his unconscious thought process, led him to explore his relationship with his therapeutic space as a cultural object which he has both consciously and unconsciously crafted for his patients’ use, and the enhancement of the dyadic

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therapeutic enterprise. This finding intersects meaningfully with the goal of this inquiry to research the clinician’s use of cultural objects within the therapeutic process.

The cultural object works as a provision of therapeutic opportunity: “[It] seeps in and becomes part of [this patient’s] experience.” Clinician 3 provided an example of the way one client used a piece of art which touched her deeply in unexpected ways, and led to important work around a deeply embedded, crippling issue. Sharing some history, he offered, “I’ve seen this [client] for a long time, and it took her a long time [to share this history.] And this is a woman who when she was eight was really seduced by her father. He gave her a great long somewhat seductive dissertation on masturbating and anal penetration and stuff like that.” He elucidated an awareness that this part of her history was deeply buried, but came to light in the context of a reaction she had to a print of an ancient Etruscan fresco which hangs over this analyst’s couch. The fresco is of a Greek god, naked from the waist down, dancing in a wild, Bacchanalian manner. In effect, the god’s nakedness has a presence over the analytic couch. He continued, “And for a long time she didn’t know this [had happened to her], but as it began to emerge, [it] emerge[d] as kind of a rage at me for, for seducing her, [in response to her stirred feelings vis-à-vis this cultural object in my office]. So we finally got that out in the open a little bit and could begin to see, you know, get back to the real point there. So we worked at this over the years, but [her reaction to this piece of art] was one of the first ways that she was able to come out with the emotional side [of her deeply buried childhood trauma]. I had some vague ideas. She’d told me little bits about

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something, but the whole experience has been [unfolding over time. She is working on] that experience, and [how to think about her experience of] the next day [following her traumatic exposure to her father’s masturbating, and his insistence that she join him in the bathroom and they masturbate together]. That’s been the subject matter of years of work: [Her profound worry about] what would happen the next day. Her father denied it. Her mother denied it. She’s stuck with this. She knows [and] she didn’t know she did it. She knew he did it. The hard part was in coming to realize that she [actually] walked into the room.” This patient has been working on “the life problem of how was it for her the next day when she had to go to school and she has this, all this, on her mind, and there was a whole subsequent drama about it.” Clinician 3’s narrative of this client’s early experience is vague and meandering, in some ways capturing the nuanced way in which it may have been experienced initially by his client through snippets of confused and confusing memory, and subsequently pieced together with the clinician. In constructing this section of the interview process, the narrative’s hazy nature conjures a feeling of bearing witness to traumatic events through a screen or fog. In this way the clinician’s use of language to reconstruct the profoundly emotional experience that occurred over time between himself and his patient is also significant. His telling, in a notable way, mirrors the experience of being present for his client’s gradual recognition of traumatic, dissociated early history. He summarized the point he was making through this case example by stating, “So that’s one way that she used that picture. Now think about how this room with that picture is going to [invite] transference stuff.” Attention to the role of the painting within the clinical context is worthy of note. In introducing the vignette, and orienting me to the

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collection of Etruscan fresco prints on the wall above the analytic couch, he gave the impression of being unaware initially of the seductive nature of this art. He described it, offering some history about how he came to own these prints: “[A friend had some business with a company that] came out with a portfolio of prints, Etruscan prints from Pompeii and Florence, the old Italian kind. They had this quite beautiful portfolio, and a friend of mine got the portfolio and I picked out these three. But these are very, very nicely beautifully produced things.” He continued to describe the lovely gold leaf frames he ordered, “I mean he did a beautiful job. I don’t think they’re mythological. Well, the one in the center looks like they might be. I don’t think they really know what the meaning of it is. They were, these were the gods and goddesses, the images of what was that, about 15 B.C., maybe earlier, so they’re pretty old.” In this way he was indicating that on a conscious level, he was drawn to the aesthetics of the works, to their ancient mythological qualities, the ways in which they were rendered, and the mystery surrounding them, but was not initially consciously aware of them being provocative. Working to set these cultural objects within the context of the analytic space, he continued, “I don’t use them, but sometimes patients do, particularly the one in the middle. (We both studied the half naked dancing god. He began to laugh.) This may be a blind spot to me. I thought these were just nice pictures. I thought people were used to seeing nudes and that kind of stuff. But when it’s in this place, it takes on new meaning.” His insight here provided a significant, layered contribution to this research inquiry. In the instance of this particular patient, within the context of this analyst’s therapeutic space, within the transference, the cultural object functions in disparate ways for patient and analyst. The cultural object provides an evocative, significant vehicle through which

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the analytic pair navigates the transference within the treatment. Clinician 3 set out to create what he identified as “a dynamic setting, which people interact with in a variety of ways, and that’s interesting too. That’s part of the music. And you know the point there is [to] let it seep in and become a part of their experience.” In contrast to his vision of a provision of a nourishing environment, the therapeutic space “seep[ed] in and [became] part of [this patient’s] experience,” at the moment he described in detail, more in line with Benjamin’s (1994) understanding, The historical shift to maternal imagery in psychoanalysis has not only been associated with more than the idea of holding or containing as opposed to penetrating with insight; specifically, this emphasis has been closely allied with another idea of analysis as the creation of a space. It is a space in which two subjectivities necessarily interact so that one subjectivity can be explored in detail (see Atwood and Stolorow, 1984). The mutual gazing, gesturing, and vocalizing we have come to associate with mother-infant interaction form a kind of erotic dance, which is a fundament of the mutual attunement and pleasure of adult sexuality as well. Many aspects of this preverbal dialogue—awareness of the other person's affect, the sense of having an impact, the contours of intensity, the kinetic timing, the choreography of turning toward and away from the other—can be represented internally in pre-symbolic form as interaction schemas (Beebe and Lachmann, 1989). They form the basis of our expectation of being either matched and met or violated and impinged upon. (pp. 545-546) Clinician 3 set out to create a therapeutic space, which offered a place to play, in a Winnicottian sense. He said, “This is a musical environment. You have to play with it.

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You can listen to it. You can look at it. You can you know, touch it. Pick it up and put it down. To me this is a musical room.” While his vision, like Winnicott’s, carries maternal valence, neither Clinician 3 nor Winnicott allows for the possibility of the “emergence of bad object expectations 45 within the therapeutic space. Benjamin makes the point that alternatively, the patient’s internally represented interactional schemas may carry expectations of violation and impingement. In this clinical vignette, the dyad must work to untangle the disequilibrium engendered in the meeting of these two dramatically variant sets of expectations emerging from an interface with a particular cultural object inhabiting the clinical space. “In this case the object (fresco) is inadvertent, or unwitting, outside the therapist’s intention. It is ‘found’ by the patient and only sort of unwittingly provided by the therapist.” 46 Clinician 3 is articulate in offering this case example demonstrating one way a cultural object’s presence in the imagination of therapist and client has the capacity to unleash long-buried relational trauma, opening up intensive treatment opportunities. His vignette enriches this research inquiry insofar as it elucidates the way in which a cultural object’s presence, and the associations generated in response to it by clinician and patient within the therapeutic work, contributes to the therapeutic endeavor. In this instance, the patient has a stirring response to a cultural object which the therapist understood to be infused with benign—if not nourishing—elements. For her, the cultural object evoked deeply buried trauma residue, providing opportunities for her to engage within the transference in meaningful work around her experience of violation.

45 46

J. Tolleson, personal communication, 5-14-15. J. Tolleson, personal communication, 5-14-15.

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200 The patient’s creation as a cultural object: from fragmented to “jewel-like and lovely.” Clinician 3 offered a case example in which he and his client, who is a visual artist, worked together plumbing her art for communications of self understanding, paying attention to the ways in which the nature of her art carried “news from within” 47 this young adult. He provided some history, “With this client, placing one’s self on exhibit was a key part of the work. Her experience, her parents were given to much nudity and screwing wherever they happened to be while she and her brother were around, and the father would play with him by pinning him down on the floor. You know: [Father’s] a great big guy, so this intimidation, if you show yourself, something bad’s gonna happen. Better to stay hidden.” Explaining how it happened that his client’s work began to make its way into sessions, he confided, “[This client bringing her art into therapy] didn’t start right away. She was referred to me by another artist who I was seeing at the time, and at that time she was living with a guy who was a very sadistic transference figure, living a very raunchy art, a lot of bad stuff going down and she was really getting out of control and when I first started seeing her she was a very fragile kind of emotional person. I asked to see some of her work. She showed it to me, and what it was kind of, she started with cutting [pictures into pieces], and then she began to make constructions, which were pretty large, but they were also pictures of her own body: sexual parts . . . and pretty clearly kind of demented exhibitionistic kinds of, ‘Look at me. I’m in pieces, and I’m a mess.’ But [this

Bollas (1983), p. 3.

kind of] ‘Look at me,’ [art] pre-dated [our work together].” This client initially brought her work to the therapist because he invited her to do so, and then “she started bringing it occasionally herself, when she’s doing something new, a new set of stuff. Every year or two will start a new trend and she’ll show me some examples, [and she’s now the initiator of that].” Clinician 3 described the nature of his client’s art and its evolution over the twenty year, once-a-week treatment, “Initially the work the client brought into therapy was black and white, and consisted of fragments of body parts in collage format.” He continued, “Now I’ve seen her for a number of years, and she’s evolved through her art. And one can read her history back and forth between the work that she does. So the work comes out of her personality. In the first years she was kind of repetitive about it, going over and over the same ground. Since then she has evolved and the work has changed dramatically: It’s colorful. It used to be black and white. Now it’s brilliant color, I mean it’s really beautiful! And we talk about the creative process. And she’s grown, hugely.” Explaining his therapeutic considerations, and the ways an engagement together about the creative process opened up therapeutic possibilities, he continued, “So [we are] trying to grapple with some pretty subtle things about the creative process, but I don't mean we are just having a conversation about this. This is all within an articulation of the dynamics of her early life, which were very complicated and filled with problems about exhibitionism. This is one of the big dynamic problems: That she could not show [her work publicly]. So from a personal point, her treatment is helping her to make her own artistic creativity work, not just to ward off and maintain lifestyle, but to be an artist. And I’m not articulating this very well actually but I guess my point is to make sure you understand

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that this is [psychotherapeutic dialogue] with an undertone, with an undercurrent which can often come with a comment from me or from her about something, some aspect of her own inner life that’s amplified or shed some light on it, or clarified or confusing or something. I mean there is a very, I would say a pretty rich mix.” Engagement around the cultural objects created by his client, is characterized by a textured experience, consisting of the manifest conversation about the art which they engage in together, and the psychotherapeutic dialogue “with an undertone,” which attends to the client’s amplified inner life through the vehicle of her art. Elaborating on what is gleaned from this kind of therapeutic play, and drawing upon the theoretical framework which informs his thinking, he identified the trust building that occurred under the aegis of the unconscious processes that were at work, “I mean it’s this kind of enlivening that comes from that, and I think that’s the kind of thing that really builds trust ’cause that’s stretching out a little bit, and before you know it you’ve said something that you didn’t know you were saying, and it sort of builds without you knowing it. It’s not just something you do consciously, but it’s something like, ‘Oh I didn’t know I could tell you that. I’ve never told you this before, but let me tell you.’ That awareness of new confidence, new trust, and [this relational experience] usually makes a lot of difference in various aspects of a person’s life, and something like that, [well, her] home life suddenly becomes a little better, or you feel a little better at work or something.” For this clinician, the unconscious processes at work that are communicated through the vehicle of his patient’s art, facilitate the possibility of a new relational paradigm in the spirit of Renik’s (1995) conceptualization of “generat[ing] new experiences with a new object” (p. 475).

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Drawing a compelling analogy between his patient and a cultural object, he expanded his conceptualization of this process, “She’s like an artifact, like a beautiful art object. Like the objects she’s creating. And she knows, she knows. I’ve told her. I‘ve said, ‘Your stuff frankly is simply beautiful,’ and it is! You know, I feel like this, I know, this is gonna come across the transference barrier.” And yet, this clinician is also highly aware that in order for their engagement to have healing, transformative components, his patient needs to transcend the potentiality for negative transference. He continued, “The anxiety that if I’m seeing her this way, I could also be intimidating to her. I could be [intimidating] like her father, and mak[e] her suffer. So I know in order for her to hear this, it takes work on her part, and that little bit of work is what makes for trust, and that’s what builds confidence and ego and all the rest of it. So that’s in a general way what I think about how to use these things [cultural objects]: I guess in play. Because that is the, well, I guess that’s as close as I can come to it: That [is the] art of [this work]!” Asked if the client’s artistic images abide in his imagination in and out of session, he responded, “Well, I don’t. I can. I don’t know that I hold it, but if you asked me, I can conjure a number of images that I remember. They might [come up for me in the context of her narrative.] I don’t know. (He grew quieter. This response was tonally different from his excitement describing his client’s artwork and his engagement with this work.) Those kind of things are floating around all the time, but I don’t really know how to answer that.” In this way, Clinician 3 was acknowledging the evanescent, tenuous nature of the cultural object’s location within his imagination. It is not quite nameable. He cannot quite grab hold of it. And yet, he has some fleeting sense of its presence within his imagination, in and out of session.

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In addition to explicating the ways in which the work is accomplished within the transference, this clinician holds a palpable understanding of the young woman’s sense of self as conveyed through the cultural objects she has fashioned. Clinician 3’s unconscious experience of his patient’s creations, both when they reflected an elemental fragmentation, and in their evolution to something wholly beautiful, are understood as a vehicle that potently conveys an experience of his patient’s internal world. The clinician communicated his understanding of this young woman’s traumatic history as embedded in the cultural objects she brings into treatment. He unfolds the details of the objects’ expressive elements with an intensity of empathic affect around their troubled nature. And then, as the work becomes imbued with the effects of healing and vitality, Clinician 3 is stirred to offer “the gleam in the mother’s eye,” 48 directed toward the creative product generated by the client, and rippling out to include the young artist’s integrated, enlivened, generative sense of self. This study seeks to discover the ways in which cultural objects abide within the imagination of the psychotherapist, and what these imaginings offer the clinical work. In this case vignette, Clinician 3 illustrated the ways he and his client attuned to her artwork for communications about her internal sense of self. Initially, this clinician held some grave concerns when interfacing with the fractured sense of self his client brought to him, both in the context of her art expressions, and in her narrative. Over time, Clinician 3 felt, in the context of a “trustworthy” relationship in which the clinician thoughtfully attended to his client, the shifts in her internal world became increasingly apparent via the aesthetically wondrous creations she brought to her analyst, which he describes in this

Kohut (2009), p. 117.

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way, “Her work is getting way more subtle, way more beautiful, and much less exhibitionistic, and at the same time, more exhibitionistic, more subtly, more artistically, more beautifully . . . (His voice trailed off here.) So the stuff she does now is almost jewel-like. It’s really beautiful, whereas it used to be kind of rough and broad.” Coupled with the creative evolution in her art, Clinician 3 marks a shift in narrative regarding daily life events and significant relationships. In attending to Clinician 3’s vignette, there was now a clarity emerging about the ways in which this client’s work abides in his imagination, inhabits the space between them as Ogden’s (1997)“inter-subjective analytic third” 49 (p. 569), and is reflective of Winnicott’s idea of play taking place in the potential space between self and other. In addition, this vignette exemplifies the ways in which the imaginative process between them holds the capacity to create what Mitchell (1988) describes as “a different interpersonal situation in which richer experiences of self and other are possible” (p. 290). Addressing this last phenomenon, Clinician 3 said, “I think that’s what I’ve been most impressed about, about this person, [and] how you can begin to enter into a brand new absolutely unique ball of communication that doesn’t belong anywhere else. That doesn’t belong to anybody else. It’s a purely, uniquely constructed and you realize that you’re in a, this is such a special insulated, private world. But it is a world in which there’s play.”

Ogden (1994) defines the analytic third as “a product of a unique dialectic generated by (between) the separate subjectivities of analyst and analysand within the analytic setting” (p. 4). Ogden (1997) describes this as the art of the work of listening both to oneself [introspection] and to one’s patient, with the express goal of “further[ing] the analytic process” (p. 568).

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Sharing a cultural object created by the client: It “catches the light” off of the therapeutic engagement. Clinician 3 spoke admiringly of his patient’s artwork as it evolved in the context of her once a week treatment extending over a twenty-year period. In the context of sharing this vignette, the following dialogue took place between us, addressing the feelings stirred in him in the context of his patient’s personal and artistic evolution. Within the framework of this research inquiry, regarding what an engagement with cultural objects on the part of the clinician can offer the treatment, this conversation imparts a variety of considered concomitant yields.

Researcher: When you named [her work] as “beautiful,” there was a quality in your voice that was different.

Clinician 3: How?

Researcher: I don’t…

Clinician 3: Emphatic!

Researcher: It was more than emphatic. There was, I don’t know, I had the feeling of approbation and . . .

Clinician 3: Oh yeah! Approval. Admiration! Admiration! Absolutely.

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Researcher: And for me, listening to you, you know as a third person, it felt palpable: the pleasure that you were taking in.

Clinician 3: It is. I feel, I give her absolute gold stars. I think her stuff is really, really something and very unusual.

Researcher: But I also hear, and you know, I may be making this up, so I trust you to tell me, to catch me if I am, but that in some ways you feel that it’s catching the light off of the work you guys have done together.

Clinician 3: Well, they’re entangled. They are certainly: It’s a payoff to me. In that sense I can say, “Okay. I had something to do with that.” So we have a narcissistic (He laughed with some embarrassment and delight.) mutual admiration society, I suppose. You know I get gratification from that experience. Sure. Absolutely

Researcher: And then it’s not just about you, although it has that too, but it’s about the nature of the collaboration.

Clinician 3: Yeah. Yeah. Well you see, I think you get as much from the person, the patient as they get from you. If you do a good job, it can only be because you [together] have created, in my view, a more trustworthy, reliable intimacy. And you can do the best job in the world, but if you haven’t done that, you’ve

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manipulated stuff and that can be helpful but it’s not the same. But when it’s, when you know that you’ve really entered somebody’s dark and shared it, you have also shared your own dark, because it doesn’t go one way. So I think that’s the gratification in this work, I think. Clinician 3 is clear in his description of the ways in which the collaboration between client and therapist around the client’s art reflects a parallel process with their therapeutic engagement. The patient’s art increases in discernable aesthetic measure, while the patient’s psyche evolves within the relational matrix which Clinician 3 cogently describes as “a more trustworthy, reliable intimacy.” In this way, the patient’s artifacts function as a vehicle for unconscious communication as well as explicit relational engagement: “Enter[ing] somebody’s dark and shar[ing] it, you have also shared your own dark.”

A therapist needs the capacity to play. Play, as an essential component of the therapeutic process, and as a key characteristic of the therapist’s repertoire of therapeutic action had overriding centrality across Clinician 3’s narrative. This seemed congruent with his identity as a musician, not coincidentally but with intentionality, as musicians “play” their music, and this clinician’s music is characterized by an improvisational style, a creative inventing. He revealed, “I would say that for me, [this work is] who I am. It’s what gives me a kind of inner (He paused to think.) I won’t call it ‘joyfulness,’ but I would say it has (He paused again.) a pleasure edge to it. A feeling—I guess where it comes to be like music: If you play something and it really comes off, and you like it, you did that. You know that’s an

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experience, and you’re not gonna, you won’t, can’t lose that experience. You won’t keep it on your mind all the time, but it goes into the reservoir of accumulated confidence I suppose: ‘I can do it.’ You can stretch out and it gives you something to build a little strength from, so I think, but I think that’s true whenever people accumulate confidence from how they do it, and everybody’s got their own music playing whatever it is.” His narrative here felt analogous to the patient-therapist play that yields an evanescent sense of possibility in terms of relationship. He also expanded the “playing field” for clinicians to include whatever the nature of the “play” is for an individual clinician, when he said, “Everybody’s got their own music playing.” In this way, the very way Clinician 3 understands his work as a psychodynamic clinician has embedded within it an identification with the musical enterprise. In effect, the way in which he works, characterized by playfulness, among other things, functions as a cultural experience which he draws upon. He described a self-conscious awareness of his unique, characterologic way of working. Focusing on what he called “the small nuances” of interactional moments in the treatment, he proffered, “You can see it in the treatment situation, when there are really moments. There are certain kinds of times when you understand each other and there’s a kind of capacity to think about it, to allow thoughts to come, to associate. That’s play! It's making something out of the grist. It’s turning something into something.” In his improvisational narrative, which focuses on the clinician’s capacity to play, his ideas echo Ehrenberg (1974), when she develops her concept of “the intimate edge.” By "intimate edge" I mean that point of maximum and acknowledged contact at any given moment in a relationship without fusion, without of the separateness

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and integrity of each participant. This point is not static, and may fluctuate from one moment to the next, so that being able to relate at this point requires ceaseless sensitivity to inner changes in oneself and in the other, and to changes at the interface of the interaction, as these occur in the context of the spiral of reciprocal impact. (p. 424-425, original emphasis) Proceeding with this line of discourse, he added, “And the question [is], ‘What’s required? What does a person have to have in order to do that [i.e. be able to play]? How do you do that with another person? How does that come up in the treatment? Is that something you can do, or is that something that happens? What do you do? How does it happen? Is it a good thing that you want that anyway?’” Responding to his own questions, he continued, “Well, I think you do, because I think that’s what gives some substance to feeling some trust. Those are the things that settle in our bones that we take away from the treatment experience. But that’s what that means: to be able to play with thoughts and ideas, rather than to be rigid and stern about it, rigid about it, dogmatic about it, formal about it.” When he delineates that the experience of playing with ideas and thoughts in this way is what “gives some substance of trust,” it feels as if he is identifying the experience itself as therapeutic. This idea resonates with the writing of Mitchell, Renik, Ehrenberg, Daniel Stern and others who point to the experience of new relational paradigms as a core element of the therapeutic experience. Ehrenberg (1974) addresses this concept through the writings of Buber (1957a, 1958), Winnicott (1971), and Guntrip (1969). Summarizing the Buberian view she wishes to privilege, she writes, Distance provides the human situation, relation provides man's becoming in that situation. Buber believed that "Human life and humanity come into being in

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genuine meetings" and that the "inmost growth of the self" can be accomplished "between the one and the other, between men." For him the most profound growth and change in the treatment situation can only occur in the context of this kind of "personal relation." This involves what he labels an "I—Thou" relation in contrast to an "I—It" relation. It requires mutual confrontation, and he calls its unfolding the "dialogical": that condition of genuine dialogue which involves bringing oneself fully into it, without reduction or shifting ground and without holding back relevant thoughts or withdrawing. In Buber's framework the meaning of the "interhuman" is to be found neither in one of the two partners, nor in both together, but only in the dialogue itself, in this "between" which they live together. (pp. 423-424, emphasis added) Her identification of the “in between” echoes Clinician 3’s focus on the significance of the provision of potential space to the treatment process. She goes on, much as Winnicott does, as well as this clinician, to liken this focus to art, “As in art, [Buber] states, it is the "realm of the between" which has become a form” (p. 424). Inviting Guntrip’s view into the conversation, she continues, Guntrip (1969) states that what is therapeutic when it is achieved, is "the moment of real meeting" of two persons as a new transforming experience for one of them . . . What I am suggesting is that Guntrip's idea of a "moment of real meeting" is not the end, but is itself an important starting point, and of continuing leverage in the analytic process. Focusing on the interface of the analyst—patient interaction is not the same as focusing on the transference or countertransference. Rather, the focus is on the nature of the integration, the dialogue, and the quality of contact.

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Associations to the moments of contact are as useful as associations to the moments when this kind of meeting is not achieved. Analytic work does not stop when contact is made, it takes on new dimensions. I believe that an effort for a sustained and enduring, increasingly developing intimacy over time, not isolated somewhat discrete moments of meeting, ultimately becomes the condition for maximum growth; and that the "intimate edge" is the point from which such intimacy can develop.” (p. 126) Here Ehrenberg, eliciting Buber and Guntrip’s voices, articulately names the phenomenon Clinician 3 is privileging: the new relational dimensions that are experienced in the “moment of real meeting.” This then becomes a touchstone for what is relationally possible within and beyond the treatment relationship. Clinician 3 suggested that each of us has a unique way of playing, a creative source, which we draw upon as we do our work. He believes that the following traits are essential for good therapy to occur: having a vehicle one can draw upon to receive messages from one’s own unconscious, being able to operate on many levels at once, as well as a mindfulness about how to get one’s message across. For him, these characteristics contribute to one’s capacity to play with thoughts and ideas within the treatment process. In addition, he stresses that drawing upon these gifts has the capacity to nourish the therapist as he works.

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An example of a cultural object’s presence in the therapist’s imagination: what it yields, and the nature of the process. A. “The look of love” 50 and what it yields: “I know that my unconscious processing is going to help me because it has.” Clinician 3 quietly, somewhat meditatively, unfolded a significant moment in which he experienced the phenomenon that is the focus of this research study, and that comprised the centerpiece of the interview process: an association to a musical melody that arose unbidden, and that held the possibility of contributing to the therapeutic work. While this vignette, which he identified and shared, occurred at a time between sessions, he acknowledged that it may also have initially entered his imagination while sitting with his client. He was not sure, and considered, “It may have [initially occurred to me] in the room. I didn’t notice it [then]. Music is frequently going on in the back of my head. It’s just that I’m not ordinarily paying attention to it.” His characterological unconscious experience of music occupying a place in his imagination makes him unable to identify the exact moment he grew aware of this association in relation to his patient’s material. Detailing his experience of associating to this tune in relation to a particular client’s material, he began, “Recently I noticed something like that [i.e. hearing a tune in conjunction with the work] the other night. (He paused, cleared his throat, and seemed to 50This song can be accessed at this website: https://www.youtube.com/watch?v=Tf1d65OHYXo.

The lyrics are as follows: The look of love/ Is in your eyes/The look your smile can't disguise/ The look of love/Is saying so much more/Than just words could ever say/ And what my heart has heard/Well it takes my breath away/ I can hardly wait to hold you/Feel my arms around you/How long I have waited/ Waited just to love you/Now that I have found you/You've got the look of love/ It's on your face/A look that time can't erase/Be mine tonight/Let this be just the start/Of so many nights like this/Let's take a lover's vow/And then seal it with a kiss/I can hardly wait to hold you/Feel my arms around you/How long I have waited/Waited just to love you/Now that I have found you/Don't ever go/ I can hardly wait to hold you/Feel my arms around you/How long I have waited/ Waited just to love you/Now that I have found you/Don't ever go/Don't ever go/I love you so.

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be thinking.) I can’t remember what it was but it was it was something like that, [and] . . . it clarified for me what I thought was happening [in my client’s treatment]. At least it was enough for the moment. It was just a moment in that process. But it was a moment. So it’s the sort of thing that happens so subliminally that I often don’t really notice it consciously. (He was speaking very quietly.) I can remember the tune, but I can’t remember the instant. The tune was called, ‘The Look Of Love.’ [A] pretty tune.” Asked to hum a few bars of the melody, he did so, and then continued, “It’s a pretty, pretty melody, and it was rumbling around in my head, and I was thinking about that, and [I began to ask myself], ‘What’s that got to do with anything? Why am I keeping after this?’ It kept bugging me. I couldn’t let go of it, and so I started [to wonder] about why I was [humming this tune], because it was related to kind of an ongoing thing with a patient. I don’t even remember what the deal was now. But I know that they went together.” Here Clinician 3 exemplified the process: The tune entered his imagination, and he began to pay attention. He had a series of questions he asked himself as to the origin of this reverie, and he continued to let his mind wander, in the manner of focused hovering which he had described in the screening interview, “It is like trying to capture a butterfly: You don’t just wave this thing around. You go after the butterfly in an active way.” At this point in the interview, he began to meander in his associative process. Quite unexpectedly, he segued to speak about a client he had already described in detail. One connection between this detour and the subject at hand was his description of his client’s “huge, complicated creative process. He wondered aloud, “How does it happen? How does it help?” In this way he seemed to be considering his own generative process,

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and inviting us onto the road of uncovering what it might offer the work, which is the focus of this research study. In another, he was forestalling mining his association, which eventually yielded painful material. Calling up the clinical problem that was weighing on him, followed by a period of quiet thought, he continued by offering some of this client’s history, “I [may have been thinking of] a particular woman that I’ve seen for many, many, many, many, years, and the problem that we were into at that point, or the business that we were into at that point, was a crucial moment in the trauma that I think effected her all her life. At five, and in the throes of a poorly evolved maternal connection, her father, who had been her kind of bosom buddy, took her and her mother out to spend the summer out of the city. And he would come back to town to work. And he came back [to the city], and she was very upset that he left, and there was very much turmoil in the family. Neither [she nor her mother] wanted to be there. He wanted to be there. So [there’s also] the question [of] why he wanted to be [away in the country] so much. Anyway, he comes into town, and in a way that’s not ever been too clear, [he] is run over by a truck. He steps right in front of a truck, and a truck hits him. She wakes up the Friday morning he’s supposed to come back. Her mother left Thursday night. She wasn’t there. Now there were other people there, but her mother was not there. So she wakes up and there’s no mother. The father’s supposed to be back, and he doesn’t come back either. A week follows in which she’s left with [strangers], and then [her family] comes and gets her. By now the funeral’s over, [and week of mourning is] over. Everything’s over. In that gap was a trauma. In that gap she was totally alone. And ambivalence and hatefulness and fear and anxiety were all packed into that.”

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He continued to describe the presenting problem, “Now the subsequent story has to do with when she came in to see me the first time, years ago. She tells me she was having a problem, a break up with her marriage. She tells me history, in passing: ‘My father died when I was 5. Only 5,’ she said. (But then he paused to correct himself, remembering his client’s exact language, feeling it to be important to get it right.) Oh no, ‘When I was 5,’ she said. (Continuing to quote his client, he went on,) And my mother remarried and we had a good life and everything was fine, really nice.’ Well you know. Click. I say [empathically], “Only five?” And that was the beginning of treatment.” Addressing this woman’s experience of maternal absence, Clinician 3 provided significant early history, “This mother was not really psychologically a mother. Really, her mother, for example was very sick when she was born, so she didn’t take care of her for the first month or two: She was cared for by nurses, so that that first bonding experience was missing. And then it was never really worked out. This mother never really wanted this child, and it was one of the big dramas in the marriage.” Having reviewed the clinical context, and feeling the affective resonance of the material, he began to connect his association to the tune that tiptoed into his imagination the evening before. His engagement, playing with what the tune had to offer, has several layers regarding the idea of “love” as it appears in the song’s title, “The Look of Love.” He considered the first layer of meaning in the context of the transference, against the backdrop of his client’s early trauma. “You know, that [song’s message is] what this [work] is about: What’s she really able to feel? Can she [feel love]? I mean, she would assert ‘til all hell freezes over that she loves me more than anything, and in a way I don’t doubt it. But in another way, I know that there’s a big empty place underneath that, which

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is not [love]. And so the question is, ‘How do we find that? How can she find something she couldn’t find at the time? How can she bear the hatefulness involved [in having been abandoned]? [And] how [are] we gonna patch this up?’” Connecting his musings to the subject at hand, he concluded, “And I think this tune somehow caught some of that. You know, what do we have here? Is it real love? What is love? What’s it all about?” A second layer of meaning was revealed as he moved deeper into the clinical material, touched by this song’s resonance. Clinician 3 elucidated elements of his countertransference feelings. He explained that this client, in addition to the challenges around the complex nuances of her capacity to love, is currently suffering from a very serious medical condition. Clarifying his worry, he stressed, “What does she have to fall back on? Now this is a woman with a lot of talent and all this, but here’s the problem: She’s always had respiratory problems. She now has [a degenerative neurological condition]. She’s now 70 [and] she’s got this terrible thing. I mean this is terrible. You gradually, you die from this, and this is a woman who was always very active. And so you can see, at a time when the bottom is falling out again, on top of this other trauma, I want her to have something called ‘love,’ something like that experience, a trustworthy experience. [And] I want her to have somebody there when the bottom falls out.” Here he invited the song’s message to illuminate his countertransference longings: his wish that she will have the experience of “the look of love” in the context of this crippling illness, in the wake of dramatic childhood trauma. And the song’s melancholy melody, coupled with the intimation of loss conveyed in the lyrics, has an unspoken presence as he describes their work, “How long I have waited/Waited just to love you/Now that I have found you/Don't ever go/Don't ever go.”

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A third layer of meaning gleaned from his associations to this song, took the form of this clinician’s revelation of an element of his own pain in the context of his clinical limitations in caring for this client who is suffering terribly. He identified the clinical task as “a therapeutic task. . . . not an analytic task.” Addressing and dismissing the analytic part, he noted, “She can say it, and I can say it, [i.e. identify the struggle], but the affect and the experience is not taken care of by that. That’s got to be something else, if anything.” Identifying his internal torment about the limitations of his curative capacities, and the ways the tune addresses his wishes to cure, he offered, “You know, I mean after all, [I] can’t necessarily fix everything. So that I think is where I was maybe wishful thinking [by imagining this song]. I hope [my capacity to provide her with something that comforts her] is so. I hope I can help. I hope we can do something. So I think maybe that’s where that [tune] came in, but I’m not sure.” His inner turmoil echoes what Donna Orange describes as “the experience of a patient’s trauma in the wake of our finiteness.” 51 Clinician 3 was emotional as he spoke, “The other side of my thinking about this is ‘Do I love her enough?’ You know, ‘Is mine [i.e. my “look of love”] gonna be good enough?’ Now obviously that’s a wishful fantasy, and I know of course that it won’t be. There’s no way in the world it could be good enough. There is no good enough.” At this point, his voice was shaky, and he shifted from speaking in first person, to speaking in a more removed second person. He continued, “So if it isn’t good enough, then what, you know, what do you have to offer therapeutically if you can’t make up for what was missing in a trauma like that? What do you have to offer? You know, there’s a real dilemma!”

Donna Orange, personal communication, 5-16-15.

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This clinician contributed one last layer of meaning to the discussion of how the provision of his association to the tune “The Look of Love” contributes to the work. Speaking in a pained manner, reflected in his face as well as in his vocal tonality, he identified the limitations of speech to assuage this woman’s misery and despair, “And what am I to say? I mean there is no something I can say. There’s just me saying something, whatever. It doesn’t really matter much. Talk about unconscious communication!” He seems to be saying, given the limitations of language to comfort and heal, the look of love is perhaps the sole provision he is able to proffer. He went on to reveal the intensity of his patient’s longings, and the ways this factor contributed to his terrible quandary, “But it’s not just a look [that she longs for]. I mean her story would be that she wants to be seated in my lap wrapped and tied in blankets. (As he spoke, the melody intoned now in my imagination, “I can hardly wait to hold you/Feel my arms around you.”) She will fall silent and turn away from me and the message is ‘I want you to do something. Do something. Do something. Say something. Do something.’” Despairing himself, he continued to speak of his self doubt about the benefits of the psychoanalytic process for someone like this patient who is nearing death, “This [kind of work] is exhausting, and maybe wrong. Sometimes I wonder, ‘Jesus, what am I doing here?’” And yet, he also acknowledged that the work, which has consisted of multiple times per week psychotherapy for many years, has nourished this woman, forestalling her total demise, “And on the other side, I know if she hadn’t done this, she’d be dead by now. She knows that too. She says, ‘I hate this, but if I weren’t here, I’d be dead.’ And we’ve talked about [this]: that [our work together] will help her at least to manage this illness.”

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Clinician 3 thought deeply about the role his musical imagination plays in the clinical relationship. In his first consideration he understood his association to reflect themes in the work. These consist of the client’s unconscious hesitancy to unearth the ambivalence and hatred underlying the love within the transference. He understood this as an important part of the work in order to delve beneath her surface story and unlock essential elements of her traumatic loss of father in the wake of maternal absence. In addition he was sensitive to her wider experience of the loss of life-as-she-knew-it in the moment of her father’s death. And yet, he was profoundly sensitive to the reasons why this work cannot be addressed in the larger context of his client’s fragility. In his second reflection he considered two elements of countertransference feelings. The first was his longing to provide her with “the look of love” to assuage her pain, and in the second he accessed his own painful feelings of helplessness around his inability to remedy this client’s agony in any real way, given the excruciating reality of her neurological condition. Here he was attending in a candid way to his internal life, and his strong desire that his provision of “psychoanalytic love” 52 might be enough to assuage this woman’s pain in some way. As he reflected upon the tune entering his imagination in a period of his own distress, he suggested the song has come to help him in some way. A last interpretation of the song’s presence for him centered on the absence of any significant maternal presence for his patient in her early life, i.e. the privation of the maternal “look of love”, the absence of the maternal gaze. 53 In a way, the song’s

Lawrence Friedman (2005) provides a comprehensive discussion of this concept in his article, Is There a Special Psychoanalytic Love? Journal of the American Psychoanalytic Association, 53:349-375. 53 Describing this phenomenon, Beebe and Lachmann (1988) cite Winnicott, Winnicott (1974) described mirroring: “… in individual development the precursor of the mirror is the mother's face; what does the infant see when he looks at his mother? He sees himself” (p. 131). A number of infant researchers also have suggested that some kind of mirroring (Papousek & Papousek, 1977, 1979),

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appearance signaled what he unconsciously experienced as a core lacuna in his patient’s psychological life, one which he harbors some hope to be able to compensate for within the therapeutic relationship, at least in small measure. This last understanding contains both diagnostic significance as well as countertransferential phenomena. The tune encapsulates within a rich, affectively laden code, the absence of this woman’s experience of the core element for psychological wellbeing, the maternal gaze. And the song’s emergence in his imagination elucidates his wish to provide a compensatory, healing “look of love.” Reik (1953), addressing the phenomenon of the melody uncovering “concealed and unconscious processes” (p. 10) describes characteristics of Clinician 3’s intimate engagement with this association, If a melody . . . occurs in the midst of clear, aim-directed ideas, the psychoanalytic investigation could perhaps discover not only what is on your mind without you being aware of it, but also what’s in your heart. A musical matching (Tronick, 1982), echo (Trevarthen, 1979), mimicry, imitation, and so on, is a key aspect of the mother—infant face-to-face exchange in the early months of life (p. 316).Beebe and Lachmann (1994) are more specific in their detailing aspects of this mother-infant dance, The study of the regulation of mother—infant interaction has been occupied to a considerable degree with detailing the various influences of each partner on the other's behavior. Numerous patterns of mutual regulation have been variously termed synchronization (Stern, 1971, 1977), behavioral dialogue (Bakeman & Brown, 1977), protoconversation (Beebe, Alson, Jaffe, Feldstein, & Crown, 1988; Beebe, Stern, & Jaffe, 1979), tracking (Kronen, 1982), accommodation (Jasnow & Feldstein, 1986), mutual dialogues (Tronick, 1980, 1982, 1989), reciprocal and compensatory mutual influence (Capella, 1981), and coordinated interpersonal timing (Beebe & Jaffe, 1992a, 1992b; Beebe et al., 1985; Jaffe et al., 1991). Patterns of mutual regulation have been demonstrated across various modalities, such as gaze, vocalization, facial expression, timing, and general affective involvement, at numerous ages across the first year, using diverse methods of coding and statistical procedures (see Beebe et al., 1992, for a review). Although bidirectional influences are preponderant in the literature (see, e.g., Beebe & Jaffe, 1992a; Cohn & Tronick, 1988; Jaffe et al., 1991; Stern, 1971, 1977, 1985), one-way influences—where one partner influences the other, but without reciprocation—can also be found (e.g., Gottman & Ringland, 1981; Thomas & Martin, 1976; Zelner, 1982). Using a definition of early representation as the storage of distinctive features, we proposed that the distinctive features of ongoing mutual regulations will be represented (Beebe & Lachmann, 1988b). This proposal depends on the crucial assumption that the patterns of mutual regulation that have been demonstrated by researchers are also perceived as salient by the infant (p. 135).

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passage flowing through your brain perhaps indicates your mood, expresses some feelings unknown to you, besides thoughts . . . In fleeting tunes whose wings have fluttered away into the unknown as in a melody that has a hold on you and will not release you for hours, that life, concealed from yourself has sent messages to the mental surface. In this inward singing, the voice of an unknown self conveys not only passing moods and impulses, but sometimes a disavowed or envied wish, a longing and a drive we do not like to admit to ourselves. (p. 10) Drawing this clinical example to a close, and wishing to comfort his despair in some way, I wondered if there was yet another “reading” of his association insofar as the song exists in the larger cultural arena. As he had remarked earlier, he is old enough to draw upon “The Great American Songbook.” Further, by virtue of the music’s ability to communicate this set of painful affects, it reflects a set of universal longings. Clinician 3 responded, “It’s a look. It’s a communication of a nonverbal, maybe unconscious communication. And that’s what we trade on. It’s not articulate-able. It’s something we know, we read in each other.” Here he suggested that his associating to the tune, “The Look of Love,” was a signal to more broadly pay attention to the unconscious communication, to remind himself that the psychotherapist’s access of unconscious communication is “what we trade on.” That is, one’s capacity to communicate with another on an unconscious plane, is the ticket in to accessing meaning and deepening connection in our work. In this way, Clinician 3’s contribution of this clinical vignette enriches the dissertation inquiry into the ramifications for the therapeutic process of the clinician’s associations to cultural objects.

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Because of this vignette’s poignancy, the despair it opened in the clinician and in myself, and then the ways in which I rallied to try to alleviate some of his sense of hopelessness, we took the vignette one step further, both of us finding the enterprise of intellectualizing to provide us with some distance from the intense affective resonance, and also to comfort us. Researcher: I’m playing with [the idea of “The Look of Love”], and I would invite you to play too. I think you’re often playing. Well, I think what’s happening to me is that I have this wish to comfort you around your despair…

Clinician 3: Ah! Okay.

Researcher: I think that’s what’s going on for me.

Clinician: Um hmm…

(We both grew very quiet.)

Researcher: I’m wondering how much the song comes to mind to comfort you. When a cultural object or experience enters our reverie, comes in our unconscious wanderings, one thing this experience can do is to just take us off course to kind of take our attention away from what’s unbearable, and another thing it can often do is comfort us, or propel us forward.

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Clinician 3: I think that has to do with our-- what we used to call-- narcissistic resources. You know, what we have to comfort ourselves when the going gets rough, and that’s based on experience. How good that experience was.

Researcher: And would you say kind of generally that that’s one of the functions music has for you. That it provides a source of comfort?

Clinician 3: Well, that’s an old story. You know: That’s a real complicated story. That goes back a long, long, long, long way. He sounded wistful with these last remarks, thoughtful, and kind of sad, and then he grew very quiet. At this point he offered his musical autobiography that appears earlier in this case study, in which he highlighted the complex nature of his music as an ambivalent connection to a father whom he experienced as powerful and then diminished, as well as a transitional phenomenon that he carried with him upon leaving home at an early age. Concluding he noted, “[Music] was certainly a place for me to be, [and] a framework in which I could develop a kind of persona. . . . [The music provides me with] some reassurance that my unconscious is on my side, [and] that I can count on [it], if I pay attention and wait.” In these moments, Clinician 3 and I experienced another dynamic of what one’s associations to cultural objects has to offer. By moving to an intellectual plane, addressing some theoretical implications, I, with my consideration of the countertransferential defensive move of eliciting a cultural object, and the clinician accessing the concept of “narcissistic resources,” we were able to pull one another out of the despairing feelings we had begun to take hold of us. As Lipson (2006) and others

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suggest, the cultural object also comes to comfort the therapist in a moment of unbearably painful affect. Lipson writes, Two examples by Rose (2004), however, support the contention that music produced by one's self can provide the illusion of the presence of a protective other. In one instance, a young boy reports humming to himself in the context of imagined danger, and directly connects the humming to his mother's singing to him (Rose 2004, p. 113). In a second example, a woman comforts herself in the face of isolation and loneliness by singing to herself, an act that for her creates the sense of having a companion who, Rose infers, represents her mother (p. 115). Many observers, psychoanalytic and otherwise (Bernstein 1975; A. Freud 1963; Greenson 1954; Rose 2004; Storr 1992), have commented upon music as a companion, as a comfort in the face of loss, and as filling a longing or a void (Oremland 1975), and have suggested a connection between mother—infant communication through the prosody of speech (Rose 2004, p. 116)—as well as actual singing—as a possible source of mature musical enjoyment. (p. 870) Clinician 3 offered an exceedingly rich case example of the phenomenon which is the focus of this research endeavor: An exploration of the ways in which psychodynamic psychotherapists’ associations to cultural experience contributes to the therapeutic enterprise. While initially stating that unpacking his unconscious process would not be possible, he clearly elucidated in a thoughtful and accessible manner the components comprising his association to the tune “The Look of Love” in the context of his deepseated concerns around a psychotherapeutic relationship. In addition, this clinician engaged with me to uncover a range of significant clinical understandings generated by

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his attunement to his internal musings. In this example, his association provided a plethora of reflections one might explore and mine for meaning, in the service of the work. These were drawn from his understanding of his musical association bringing him news from his unconscious. Clinician 3’s “’aural rode’ to unconscious content”, 54 likened to dreams in one section of his telling, provided insights regarding transference themes, diagnostic information, and nuanced countertransference motifs. Lipson (2006), writing of the “frequent or continuous spontaneous appearance of music in one's consciousness [as] a characterological mode of thinking,” (p. 862) highlights these phenomena as he writes of music offering “a collection of affects . . . in a parsimonious way by means of condensation” (p. 865); and permitting “an expanded view of [one’s] patient's struggle”(p. 862). In addition, he attends to the fact that “the melodies in the mind of the analyst at work can serve as outlets for inner needs, independent of those awakened by the analytic work, and in some ways may be protective of the latter” (p. 866). Further, Reik (1953) aptly describes Clinician 3’s engagement with his associative process as illuminated within this interview process when he writes that this kind of reflection requires “moral courage” to engage in the self-observation that comes with aimless conscious and unconscious thinking” (p. 9).

An example of a cultural object’s presence in the therapist’s imagination: what it yields, and the nature of the process. B. “The look of love:” parsing the process in which a musical association provides a useful tool “for the emergence of unconscious communication.”

Lipson (2006) citing Nagel (in press), p 867.

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Clinician 3 contributed a rich example in which his musical imagination generated an association to the contemporary tune, “The Look of Love,” in the context of contemplating themes related to a patient. This association took place between sessions. Within the interview process it was challenging for him to piece his set of memories about this phenomenon together for a variety of reasons. It is with intention that the following narrative is recorded to capture his process. He began by delineating the kinds of concerns regarding work with a patient that might precipitate a musical association. He revealed, “I sometimes find that when I’m having a tough time of some sort [with a patient]: Either I screwed up, or I don’t know what’s going on, or I’m upset, or they’re upset, or we’re in the middle of something, and I don’t know what it is, and I could lose a lot of sleep over it, which I do sometimes. You know, the patients who keep you up at night are the ones who you really have to think about. (He paused to gather his thoughts.) They’re the ones you really learn from.” For him, the first thing that occurs is that something in the patient’s work has brought an extra level of concern and preoccupation that spills over outside the clinical hour, and the analyst becomes aware that he is preoccupied. He punctuates this sensibility with the words, “So I, I notice.” What follows is a growing realization that a tune has entered his imagination: “I do notice that when I’m kind of in the throws of stewing, (He paused, drawing out this last word for emphasis.) that some kind of tune will come to mind.” This imaginative engagement heightens his awareness that he is gaining what Bollas (1983) identifies as “news from within” (p. 3). Clinician 3 then begins to engage in a conversation with himself, as if wakening himself from his reverie to self-observe and contemplate: “And often, (He then added parenthetically:) I say that hopefully, (And then he modified

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“often” to “sometimes.”) [Well] sometimes, I say [to myself], ‘Ah! Listen to that!’ And then I follow, [and] I learn something from the tune. But what did I learn? It’s the title or something about it, and then I can follow that and see.” His next identified task is to begin to wonder how his association dovetails with the context in which his client exists, as well as the quandary gnawing at him. He goes on, “[I then ask myself,] ‘What has that [tune] to do with the situation [in my client’s life story]?’” This clinician distinguished a number of factors that one must consider once he experiences, through his musical imagination, a hint of unconscious process emerging. He went on, “I think if we have these various tools that allow for the emergence of unconscious communication within ourselves, it’s useful. It’s the capacity and the willingness to go into our unconscious experience [that contributes to the work].” He cautioned, however, that one must be certain that one’s “hover” is on the patient’s material, noting the countertransferential phenomena that may interfere with accessing an increased understanding of one’s patient. He cautions, “[We need to] get to know more about our stories, and the things we make up that get in the way of understanding reality: the blind spots, the repetitious tales we give ourselves, the accumulation of pains and aches and miseries and all that that are hammering at us all the time. [The challenge is]: How do we find some kind of useful material from the unconscious that says something about what we’re doing here?” In this way he refocused his inquiry on the patient’s material, trying to sift through one’s own “aches and miseries.” He was not overtly stating that one’s countertransference is not a useful tool in and of itself for gleaning information about one’s patient’s struggle. He was however counseling the sorting through of what belongs to whom.

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Here he incorporated his firmly-held view that reverie has “a kind of passivity, like wandering around in the wilderness,” and that in Freud’s 55 conceptualization of “evenly hovering attention.” He asserted, “The emphasis is on educated, analytic attention . . . It is a hovering of readiness to grasp what comes along within an analytic frame.” Distinguishing between the analyst’s act of free-associating as a patient, and engaging in an attention to his internal musings in the service of the therapeutic enterprise, he stressed the vague and speculative nature of this kind of enterprise, and the necessity of humility, “It’s one thing to think about what I’m doing if I’m lying on the couch and I want to free associate. It’s another [when] I have a job to do here. So how do I make use of this in some way when we, at the same time know, that it’s all just ‘maybe’? You know it’s very effervescent.” There are two factors at play for this clinician, in his therapeutic stance. The first is that his unconscious imaginative enterprise must have some resonance with his client’s life and struggles, and not just be a solipsistic enterprise. He clarified, “To my mind it’s an example of the brain making context, organizing out of chaos. And the problem is ‘Can you trust it?’ (He paused.) Well, not by itself. You know that’s like saying, ‘I trust my intuition.’ Well, I say, ‘You’re a damn fool if you trust your intuition.’ Trust your intuition but find out what it’s about. Take the next step. If you take the next step, then you may know what you’re talking about. So I can know this is a resource. I know that my unconscious processing is going to help me because it has. And I know that if I just stick with it and am patient, eventually it will bubble up to the top and I can make some sense out of what’s happening. And you may not know right away, and you don’t jump to 55

Freud coined this phrase in his discourse on Little Hans (1909), and then expanded his thinking in his Recommendations to Physicians Practicing Psycho-Analysis (1912a).

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conclusions. Wait and see. Give it a chance. And that I guess is some pairing of psychoanalysis and therapy. It’s an analytic hovering, but with a therapeutic intent, and with some notion of how to use it. [By ‘how to use it’ I mean one must consider] all the context, [and] who you’re involved with, [and] what’s happening, what the moment [feels like].” The second factor he was insistent upon considering is a caution and humility about the ambiguity and uncertainty of this kind of enterprise, believing that there is much of the other’s subjective experience that cannot be known or accessed. He then attended to the issue of how one makes use of one’s window into an unconscious communication through the vehicle of this cultural experience. Continuing, he said, “Well the next question of course is how do you get some traction with this, and how does it become a useful new piece of business the patient can take and work with and make steps with. I think [this music thing is] a resource. I don’t think it’s by any means infallible. It helps me sometimes to know a little bit about what’s going on, and then I have to use it. I’ve found it’s useful sometimes if I reflect on the story that’s being told [by the musical experience.] Then I begin to know something about myself-- not just the tune, that’s a cue to this, but the story that has been laid down by that song. It’s not just the label. It’s the music [that’s] in you too.” In this way, the musical association has several parts that can be mined for meaning: the name of the song, its connections— relational and otherwise—in the clinician’s imagination, and the ways in which the music resonates with the clinician’s internal life. Once he has acknowledged the limitations of this endeavor, and the need to keep one’s subjectivity in check, he assumed a curious stance about the “news from within.” Identifying this phenomenon as a useful tool, he

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was also aware of its evanescent quality in his work: “It’s the sort of thing that happens so subliminally that I often don’t really notice it consciously.” This research inquiry sets out to investigate how the psychodynamically oriented psychotherapist utilizes his associations to cultural experience to enhance the work with clients. Clinician 3 unfolded a detailed process in which a melody, “The Look of Love,” entered his imagination unbidden between sessions. For him, the cultural object is treated as he would treat dream material. He counseled that in order to gain information “leading to the understanding of somebody else [i.e. one’s patient],” one must plumb the process for “whatever this message is, like a dream.” One must “discover what the story is. That is, [one must] make [the tune] meaningful in that way.” Drawing upon a hypothetical example, he continued, “You know where’s the thing in that story? [Let’s say] I’m singing this romantic story [in the context of a clinical experience]. Why am I? I start to think about [the] kind of experience that’s about, [asking myself questions like] ‘What kind of romance?’ And ‘What kind: good, bad, indifferent?’ So [I] begin to focus on the meaning of the story that’s being told by that association.” Likening his work to elucidate this musical association to dream-work, he continued, “In that way it’s like a good dream.” This clinician holds an awareness that the nature of his association within his unconscious process is characterized by what Reik (1953) identifies as “that [which] is intangible, that is invisible as well as untouchable [which] can still be audible, [that] can announce its presence and effect in tunes, faintly heard inside you” (p. 12). Significantly, he is also aware that the places in the work that this association may carry him are characterized by “a maybe,” by which he means that there is some possibility that what

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he has to offer may be of use, and it is only a fragile possibility. His realistic, respectful sense of the tentative feasibility of the usefulness of his associations is an important dimension of his contribution to this study. This clinician is conscious of associations to cultural experience, most often in the form of episodic musical experience. He is aware that attending to this experience, and working to connect his experience with that of his patient’s story, is predicated upon watching out keenly for countertransferential feelings that mingle with his patient’s areas of concern. And still, within the context of both his experience of this phenomenon and his conceptualization of its import, he communicates a profound sensibility of the nuanced nature of the possibility of this process being of use to his patient’s work.

Clinician 4 Case description. Clinical context. Clinician 4 is the director of an urban clinic, where she has worked for over 20 years, and currently sees approximately six to eight clients a week, some private and some clinic patients. Over the course of her work as a psychotherapist, she has treated clients struggling with addiction and recovery, trauma and mood disorders, depression and what she termed “other women’s issues.” In connection with her expertise around chemical dependency, she has led a variety of therapy groups. She also has worked with couples over the years: “Lots of concerns about closeness versus enmeshment, but kind of a variety. It’s nice. It’s kind of an eclectic group.” This clinician expressed a preference for work with deeply troubled individuals, as opposed to more “upbeat” work,

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and work with highly intellectualized clients. She disclosed, “There’s something about really being in the mix. There’s that Emily Dickinson line that says, ‘I like the look of agony/because I know it’s true/ across the holy forehead/the beads of anguish . . . ’ 56 There’s something about being with somebody when it’s very vital and alive and intense and difficult, but I love it. You know I love that aliveness in the room. I have trouble with people who are kind of intellectualized. Disconnected. No affect. Reporting their week (She lay back on her chair and threw her head back, looking like she was falling asleep from boredom, and we both laughed.) I love it. I love a lot when people (She paused.) I like the intensity of it. I feel like I’m making a difference. I’m engaging someone who’s hard to engage. That’s very gratifying. And it feels enlivening to me. It feels rich and meaty and it gives me a sense of vitality and connection, and that my experience and life and work is worth something.” Most of Clinician 4's professional life is consumed with directing the agency, attending to both administrative and financial concerns. While earlier in her career she was very involved as a supervisor, this is not the case at present. In her time directing this agency, it has grown from an office of ten clinicians to an agency offers seminars and training programs for professionals, employing thoughtful, influential clinicians as consultants. This clinician holds a Masters Degree in Social Work, completed her own analysis, and has taken courses in her field over the course of her lifetime. The trajectory of her psychoanalytic interests and predilections has run parallel to the evolution in the

241/I like a look of Agony,/Because I know it's true—/Men do not sham Convulsion,/Nor simulate, a Throe—/The Eyes glaze once—and that is Death—/Impossible to feign/ The Beads upon the Forehead/By homely Anguish strung./

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field. She completed course work at an influential psychoanalytic institution and has participated in study groups with psychoanalytic thinkers, one in particular taught by an important teacher and practitioner in the field of self-psychology. In addition, she attributes seminars in relational psychotherapy at The Eugene Baker Morris Center/The Stone Center at Wellesley College with clinicians like Judith Jordan to have been paradigm shifting in her clinical thinking. Several times she invoked a particularly influential teaching of Judith Jordan’s, which informs this clinician’s work, and specifically influences the ways she employs cultural objects within her work: “Judith Jordan talks about therapy as a process of ‘listening someone into voice;’ ‘listening into voice.’” 57 By this she means helping people find language to describe their experience and feelings with clarity of expression and conviction. She expounded on her understanding of this aspect of her therapeutic action: “The whole relation school out of Wellesley talks about how if you are really in authentic connection with someone, it is [that] you feel more alive, there’s a certain zest, a curiosity. There’s a mutuality. And you know, I think if I can elicit by using my own most real voice, elicit someone else’s more true voice, it’s a very (Her voice became quiet here on the word “very”.) vital (The word “vital” is drawn out.) exchange for both of us. In that school, the Stone Center, they talk about the measure of maturity or health being the clarity of one’s voice; that the more

Relational-cultural theory suggests that the primary source of suffering for most people is the experience of isolation and that healing occurs in growth-fostering connection. This model is built on an understanding of people that emphasizes a primary movement toward yearning for connection in people’s lives . . . (p. 95). Listening people into voice, into authenticity, into mutuality involves respect, deep understanding, and an appreciation of the forces that create isolation. This is at the heart of the healing connection (p. 102). [Jordan, Judith V. (2000). A Relational-cultural model: Healing through mutual empathy. In Bulletin of the Menninger Clinic, 65(1): 92-103. [Retrieved from http://sfprg.org/control_mastery/docs/heal_empathy.pdf]

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someone can describe their own internal experience, their own world, the more integrated they are. And I think about that, a lot with clients, and I think about . . . They use the phrase, ‘Listening someone into voice.’ As you listen and you pay attention and you reflect back on this question and the person is more able to name and describe and clarify and therefore their voice becomes more vivid, more their own, more authentic. And I respond with it.” Clinician 4’s unfolding of her understanding of therapeutic action is cogently linked with the cultural object of language itself and the art forms that engage language’s incisive, expressive capacities, such as poetry. One overlap between personal, clinical and administrative aspects of her life is the way in which her affinity for language in general, and more specifically poetic language, infuses these domains of her life. As a young woman she earned a masters degree in English literature, and taught high school English. A life-long reader of fiction, memoir and poetry, Clinician 4 explained, “I feel if I’m not deep into a book, I am less effective in my work and as a person, because I feel I am too (She paused here to think.) I don’t keep a bigger perspective. I get too caught up in the details that don’t matter so much? (Clinician 4 concluded many of her statements with a questioning intonation. As I grew to understand her style of self expression, this questioning tone felt as if it were punctuating her statement with the dialogic query, “Do you know what I mean?”) 58 When I get into a text, I am in another world. I find myself caught up in something. I have let go of my reality. I’ve entered into someone else’s world. And I’ve done it since I was a kid in a way that I have found very sustaining, refreshing. You know, it’s like coming up for air if you’ve been diving. And this to me is life.” She continued, “It’s also 58

In direct quotations from Clinician 4, a question mark will appear at the end of a sentence to indicate this aspect of her narrative style.

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a, it’s almost, it’s not only a safe haven and refuge. It’s also a stimulation, feeding, you know? Getting new ideas, imagining myself into someone else’s world.” Clinician 4’s intimate engagement with literature and poetry also houses a paradoxical element in that, while the aesthetic genre is language based, in significant measure, she experiences her immersion in this enterprise as non verbal in nature. She conveyed this sense by quoting a poem, “Was it Eliot who said, ‘Release me from the words that we with ourselves too much discuss, too much explain.’ 59 And I think we get lost in our own little ruminations, and I feel like when I read I enter another world. I am empathically engaged with someone, some things that are coming completely outside from me, and it’s like being on vacation, and I come back and it’s like a sleep. I’m refreshed. I’m restored. I have a new perspective. I can pay attention and refresh myself. It engages me and makes me feel alive. Yeah I am a kind of closet introvert. People think I am an extrovert, but I never have been my best self unless I am in a good book. I enjoy being home. I love people. I have a great time. But if I’m kind of lost (Here, her voice grew very quiet.) in a book and just curled up at home and I can just take it up.” She shared other examples as well of nonverbal personal practice that nourishes her in this way. Among them were cooking and caring for her dogs. She developed this line of thought, “I feel like this way (She paused to think.) It sounds like a silly analogy, but I feel this way about having dogs: I come home from work. I’m very much spinning in my head, and my dogs require me in a physical sense to enter their world. I have to pet them and feed them. I have to respond to them in a different way.”

T. S. Eliot, “Ash Wednesday”: These matters that with myself I too much discuss/ Too much explain

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While seeking the nonverbal as nourishment and balm when “spinning in [her] head,” this clinician conveyed an exquisite attunement to the nuances of language. She spoke of experiencing clinical language as “very dry, experience distant, polysyllabic, and it has no poetry!” She delineated her predilection for accessing clinical insight from literature, “I find a lot of life, insight, empathy, etc., and less prescriptive understanding from novels, fiction, memoir.” Later she introduced me to a book entitled The Novel Cure 60, which sets out to prescribe specific books to attend to particular human struggles and dilemmas. Clinician 4 whimsically noted that she wished she had written this book, as she frequently draws upon wide-reaching literature both with intentionality and in her associative musings in order to feel and understand her clients’ distress more fully. She exemplified and developed this point, “You know, I have a list [of literature that pertains to psychodynamic themes] because I sometimes teach, and when I do I will give people some academic stuff, and I will give people a list of novels and movies and I’ll say, ‘If you really want to get it, read this!’ There’s a memoir called Drinking: A Love Story 61 by a writer named Carolyn Knapp. And it’s just lovely. She was a writer for The Boston Globe. I believe her father was an analyst. Her mother was an artist. She was lovely and blonde and everything you’d want to be perfect, and she was quietly drinking herself to death. She actually died of lung cancer a few years after she got sober, at 35. But anyway, she’s so articulate in describing. I’ve used that to train other professionals. A couple of psychiatrists have said, ‘You know, I never like to work with alcoholics, I never got what it was. Her (Knapp’s) description of that internal landscape: I feel like I get it so much more.” 60 Berthoud, Ella and Elderkin, Susan (2013). The Novel Cure: From Abandonment to Zestlessness: 751 Books to Cure What Ails You. Penguin Press: New York. 61 Knapp, Carolyn (1996). Drinking: A Love Story. Dial Press: New York.

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238 Relationship to cultural objects, free association and reverie. Clinician 4 connected her affinity for the aesthetic and the beautiful to her childhood experience of Church. “We’re also just hungry for beauty and authenticity and (She paused to think.) especially, I mean I grew up very Roman Catholic, very devout genuine, in a very blue color town. So church was where you saw art, and where there was beautiful music and ritual and candles and incense and beautiful singing and Latin and it was the most beautiful, aesthetically rich place in the world. My dad sang in the choir. It was all kind of magical, and the rest of our lives were pretty, you know, fine but there wasn't’ really, well my dad was a big reader, but there wasn’t much of any art or music. My mom drew. My mom was interested in art. But [church] was the only community experience--until you know I was in college--of anything that was aesthetically, sensually, rich and enlivening.” Expanding her personal experience to a more global one, she continued by noting that church is traditionally where a marginalized person might receive recognition: “Well, if you think about it, if you go into poor neighborhoods the churches are often, Richard Rodriguez 62 writes about this. [The church is] the place that valued [individual’s] lives: You know births, deaths, etc. [Individuals were felt to be] important, in which the rest of the world they didn’t matter much.” She also linked her early affinity for the Latin liturgical hymns with her passion for poetic language, using similar descriptive terms to discuss both: “When I was growing up the whole thing was in Latin, which is very mysterious. You know, I don’t exactly know what the words are telling me but I feel something off of the words, and I 62

Richard Rodriguez (born July 31, 1944) is an American writer who became famous as the author of Hunger of Memory: The Education of Richard Rodriguez (1982), a narrative about his intellectual development. [http://en.wikipedia.org/wiki/Richard_Rodriguez]

wonder if it is beyond intellectual understanding. Just that rich, sensual experience of beauty and pleasure.” As the interview process unfolded, poetry’s significant role in Clinician 4’s imagination and in her work grew ever more evident as it became clear that poetic language and expression functions as an integral part of this clinician’s sense of self. I gathered a hint of this while sitting in the clinic’s waiting area, as the walls were adorned with beautifully framed eloquent poems.” 63 Clinician 4 shared a story of offering a poem to friends as a way of thanking them for sharing a birthday celebration: “And after the party, I wrote each of them a thank you note and I included this poem by Stanley Kunitz.” 64 For her, the poet’s words encapsulated the affective resonance of being embraced and celebrated by those she loves: “Oh, I have made myself a tribe/out of my true affections.” Another example of the way poetry functions as an integral extension of 63

The poem that greeted me upon entering the waiting room happened to be by a beloved friend of mine, Rosellen Brown. This phenomenon set a tone within me of intimate welcome and expectation: In Rooms/ I have been alone in rooms,/in houses, even—their doors barricaded/with snow, a month from the news./Nothing is like it:/Talk and you wonder if that could be a voice./And you lie lightly, skimming the cream/of sleep off the top of an endless night./I have been alone in rooms/with cats dozing—their bodies like snakes/coiled around air./Nothing is like it:/ Talk and they hear you and don’t hear you./And you sleep tacitly guarded by their claws,/at the side of their breathing that flows and flows like a/river./I have been alone in rooms,/seething with strangers—their presence demanding/my captured presence./Nothing is like it:/Talk and they blink and answer and do not hear you./And you see through a film like sleep how you are drifting/into a whirlpool, down, down to yourself. 64 The Layers/I have walked through many lives,/some of them my own,/ and I am not who I was,/though some principle of being/abides, from which I struggle/not to stray./When I look behind,/as I am compelled to look/ before I can gather strength/to proceed on my journey,/I see the milestones dwindling/toward the horizon/and the slow fires trailing/from the abandoned camp-sites,/over which scavenger angels/wheel on heavy wings./Oh, I have made myself a tribe/out of my true affections,/and my tribe is scattered!/ How shall the heart be reconciled/to its feast of losses?/In a rising wind/ the manic dust of my friends,/those who fell along the way,/bitterly stings my face./Yet I turn, I turn,/exulting somewhat,/with my will intact to go/ wherever I need to go,/and every stone on the road/precious to me./ In my darkest night,/when the moon was covered/and I roamed through wreckage,/a nimbusclouded voice/directed me:/“Live in the layers,/ not on the litter.”/Though I lack the art/to decipher it,/no doubt the next chapter/in my book of transformations/is already written./I am not done with my changes.

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self is the fact that she begins each week’s agency staff meeting by reading a poem. She described this phenomenon, “Well we have a certain ritual. We begin with kind of [format of] ‘Who’s got some news? Who’s got some news?’ I kind of privilege the interpersonal stuff: Somebody had a baby, somebody’s just leaving for Africa, somebody’s retiring. So that’s the kind of social fun part. Right? For a minute. And then I read a poem, and the whole temperature in the room drops. We do not discuss it. Billy Collins 65 has this whole thing about how you just drop it in the room and the whole room gets stiller, and more thoughtful. And we move to a deeper place together, and then we start working. And I believe, and I know I use a different poem voice [when I read poetry].” Over the course of the interview process, she often communicated her thoughts and details of her clinical work by organically and seamlessly reciting poetry. At these times, she would tilt her head back a bit, the tenor of her voice grew soft and contemplative, and an added vocal musicality enhanced her recitation. Still, she maintained a palpable connection with me at these times. Similarly, her predilection for language’s nuances was evidenced in case vignettes. In describing one woman whom she sees, depicting the quality of her expressive language was an integral part of how she understands this woman, “She’s someone who had been precociously independent, counter-dependent and it comes across so tough, very street smart, smart as a whip. Really almost a wonderful, but a savage use of language.” Her attunement to language as a pathway to understanding her patient is evocative of Bollas’ (1995) notion of a client’s personal “idiom”. He writes,

65Billy Collins, a poet, was the Poet Laureate of the United States from 2001-2003.

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Expression of one’s idiom, therefore, quietly develops that aspect of the separate sense that pertains to the aesthetics of a life rather than the specific mental contents of one’s existence. Each person’s way of conveying his or her inner experiences reflects unconscious formings as unique and special as a novelist’s when the novel shows us familiar situations but rendered so differently as to make each representation unique and new. (p. 45) In another instance she imparted her background in linguistics, coupled with the fact that she is an avid reader, and explained her sensitivity to both pronoun usage and verb tense. “You know, that whole idea of ‘active’ versus ‘passive voice.’ Verb tense. First person. Second person. Third person. And to go back to this lawyer [one of the clients she spoke of] for a minute, he talks about ‘you’ all the time instead of ‘I’. I think that’s really very diagnostic. Telling. You know the pronoun people choose to use. The verb tense they choose to use, how much they qualify. The cadence, all that, linguistically.” In this way Clinician 4’s sensitive attunement to the nature of language enables her to feel and experience the affective message as it is conveyed not solely in words, but also in the way the speaker employs language. Attuning to how a patient’s use of language expresses important information about her sense of self in this way is attended to by Ogden (1997c), writing, I hope to make a small contribution to an awareness of the life of words (and the life in words) that occurs in the analytic situation. Rather than attempting to look behind language, the effort here is to look into it: . . . one's attempts to use language to communicate that experience, and the effect (on oneself and on other people) of the words one uses and the sentences one makes in that effort . . . [This

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is] the experiment in thinking, feeling, and communicating that lies at the heart of the analytic experience. In the analytic hour, . . . we do use words and we do use our developed capacities for listening to language (both to the patient's and to our own) in its spoken and unspoken forms. (pp. 1-3) Clinician 4 conveyed that her work with clients was frequently enhanced and informed by a metaphor: “I think whenever I feel a connection with somebody there’s almost always some metaphor that comes to me, kind of early on that’s very sustaining. (She emphasized the word “sustaining,” speaking it slowly.) If I don’t have that, it’s a lot harder. I see a couple of [men in highly cerebral lines of work]. They’re so experience distant that it’s hard for me to be engaged, and I do have an image, but it’s kind of lifeless.” She explained that the metaphor’s emergence in her imagination nourishes the work, fueling “the connection and the relationship.” She offered many examples of the ways in which specific poetic texts enter her imagination while sitting with a client. She elucidated moments that engendered a deep positive connection and feeling of “being known” for a client around this kind of associative process, and instances when her association to and sharing of a cultural object resulted in a client’s emotionally distancing and shutting down, as well as growing enraged. She spoke candidly and freely about uncanny moments of connection both between herself and a client, and between herself and a colleague or friend. These occasions were drawn upon to illuminate her experience of and belief in unconscious communication. She used multiple kinds of terminology to speak of this phenomenon, including religious, spiritual, and relational/psychic. “There are more things in heaven and earth that (She paused to gather her thoughts.) I think there’s a lot that goes on that

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we do not understand, and I think there are ways in which you know grace works. Something works, some kind of transcendent experience: something that influences us that I do not pretend to understand, but I would expect that there are moments. You know you have a moment with somebody when you feel you just get something. You know, you have an experience where, anyway, my best friend from fourth grade [provides a good example]: We only talk about two times per year, but since we were in high school, there are times when I’ve picked up the phone and she’s picked up the phone to call me, and it’s been a year. You know, I just think there are things that we don’t understand, that are alive and vital and I don’t know if I’d call them unconscious communication, but I might call it oceanic experience, but I don’t know.” She continued, “There’s a great quote from Annie Dillard about how underneath all of the earth and the strata and everything there is some great substrate which she talks about which is our connecting to [and] caring for each other.” In another example of this she spoke of offering a new colleague a W. S. Merwin poem, entitled “Thanks” 66. As it turned out, this poem had been critically important to this young man earlier in his life. In reciprocal fashion, he offered her a quote from a book that, as it happened, she was currently reading. These kinds of uncanny phenomena, 66

Thanks/Listen/ with the night falling we are saying thank you/ we are stopping on the bridges to bow from the railings/ we are running out of the glass rooms/ with our mouths full of food to look at the sky/ and say thank you/ we are standing by the water thanking it/ smiling by the windows looking out/ in our directions/ back from a series of hospitals back from a mugging/ after funerals we are saying thank you/ after the news of the dead/ whether or not we knew them we are saying thank you/over telephones we are saying thank you/ in doorways and in the backs of cars and in elevators/ remembering wars and the police at the door/ and the beatings on stairs we are saying thank you/ in the banks we are saying thank you/ in the faces of the officials and the rich/and of all who will never change/we go on saying thank you thank you/with the animals dying around us/ our lost feelings we are saying thank you/ with the forests falling faster than the minutes/ of our lives we are saying thank you/ with the words going out like cells of a brain/ with the cities growing over us/ we are saying thank you faster and faster/ with nobody listening we are saying thank you/ we are saying thank you and waving/ dark though it is

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as they are reflective of unconscious communication, have a presence in Clinician 4’s clinical vignettes as well, and is described in the literature by Freud (1919), Bollas (1995), Ogden (1994), Mitchell (1998), Altman (2002), Stern (2002), and others. In one significant snippet amidst what Bollas (1995) describes as “a wonderfully complex piece of writing, both confusing and illuminating, Bollas suggests that Freud does not know what to make of the subject he has chosen” (p. 33). Freud describes telepathy: We must content ourselves with selecting those themes of uncanniness which are most prominent . . . These themes are all concerned with the phenomenon of the ‘double’, which appears in every shape and in every degree of development. Thus we have characters who are to be considered identical because they look alike. This relation is accentuated by mental processes leaping from one of these characters to another—by what we should call telepathy—so that the one possesses knowledge, feelings and experience in common with the other. (p. 234) A bit further on in his essay, he writes, If we take another class of things, it is easy to see that there, too, it is only this factor of involuntary repetition which surrounds what would otherwise be innocent enough with an uncanny atmosphere, and forces upon us the idea of something fateful and inescapable when otherwise we should have spoken only of “chance.” (p. 237) Bollas conceptualizes this phenomenon as unconscious communication. He writes, A patient is telling me about a colleague . . . [and] I am able to intuit the missing word. Magic? Not if we see this type of forgetting as a subtle elisionary act that

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enhances unconscious communication . . . Over time, as the analyst fills in the gaps with the right words, the patient unconsciously in-forms the analyst’s unconscious sensibility, which elicits signifiers that utter his thoughts or feelings. Through this type of play, the analytical couple creates thousands of potential spaces, maximizing and deepening unconscious communication . . . . In some respects I is an ordinary form of the uncanny, of one person speaking the other’s mind and the recipient not having to ask, “How did you know what I was going to say?” because this is assumed to be an ordinary part of relational knowing. (pp. 31-33) Altman (2002) provides an overview of some psychoanalytic thinking on the subject. Bollas (2001) believes that “in a good analysis, both participants find themselves consciously collaborating with the method that functions around unconscious intersubjectivity” (p. 96). Bollas' way of working bears the stamp of Winnicott's (1965) conception of “unconscious cooperation” between patient and analyst, as well as the Kleinian belief that in making an interpretation, the analyst speaks directly to the patient's unconscious. Bollas' approach also brings to mind Bion's (1965) notion of “O”— unknowable, ultimate reality that can be lived but not known. For Bollas, it seems that unconscious communication is itself therapeutic. Mitchell (2000) and Bass (2001) have drawn on Loewald's ideas of a “primal density” or unity that underlies interpersonal interaction. On a secondary process level there is a distinction between self and other, so that one needs to explain how communication occurs across the divide. On a primary process level, one that Loewald felt coexists with secondary process differentiation, there is no differentiation. The primal unity of self and other persists, so that patient and

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analyst are each part of a larger whole. From this point of view, one need not wonder how communication occurs from one person to another any more than one needs to wonder, or seek an explanation for, how I know what I am thinking. Mitchell gives an example of a patient who seemed to have an uncanny sense of the details of when his (Mitchell's) mother died. Bass (2001), using an idea from quantum theory—“spooky action at a distance”—gives case examples of patients who seemed to have uncanny knowledge of his life (e.g., his wife's miscarriage), and a case in which Bass dreams of his patient, a man who is terminally ill. In the dream, Bass calls his patient on the phone. The patient wonders “Why the call now? Some trouble with my dying?” (p. 699). Bass wakes up and calls his office answering machine, which is busy. At that exact moment, the patient was calling him to say he'd had some important revelations and to ask for extra sessions that week. Later that week he died. In his discussion of these cases, Bass speaks of a receptivity that he and his patients had to each other, one that reflects a basic connectedness between them. Something is being broadcast loud and clear, unbeknownst to the transmitter, but received nonetheless by the other person, who similarly may have no idea how she knows what she knows. Mayer (1996) has discussed similar phenomena. The implications for our ideas about the therapeutic action of psychoanalysis are suggested by Loewald (1988), who believed that secondary process differentiation, and primary process unity, were both essential modes of human being. Psychopathology, he believed, consisted in a disconnect between the primary process and secondary process modes. Psychic health consisted in having access to both modes, to a free flow of experience between the two forms of experience. From this point of view, believing that Western culture overvalues

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differentiation, many of our patients might benefit from a development of the unconscious links between people as it occurs in the analytic situation, but ultimately, for Loewald, what is key are links between primary and secondary process, between the conscious and unconscious levels of the mind. Verbalization remains crucial here, but verbalization that is not cut off from the primary process level. Another way of thinking about a kind of unity between patient and analyst is provided by Ogden (1994), who, in speaking of the “analytic third,” portrays patient and analyst as subsumed, on one level, by a larger entity constituted by their unconscious interaction. (pp. 504-505) Clinician 4 offered many clinical vignettes that capture some aspect of unconscious communication between herself and her clients. Not unlike the professional literature, she elaborated on this phenomenon through a multiplicity of languages, not certain she was comfortable naming it “unconscious communication.” She drew upon the religious-spiritual with the word “grace;” acknowledged its mysterious unknowable aspects; and organically citied a literary favorite, Annie Dillard, because Dillard’s notion abides within her imagination as an illustration of the mystical aspect of unconscious connections.

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Co-constructing meaning: the interview process. Before embarking on this research study, this clinician was known to me by reputation as a gifted therapist, deeply steeped in literary tradition. The ways in which she draws upon poetry with her staff was part of her legacy prior to meeting, and I anticipated, especially following the screening interview, that she would have much to contribute to my inquiry. In contrast, I was unknown to her prior to our engagement around this study, and while we had been connected by one of my teachers, also a colleague of hers, her reticence was apparent. Several times she articulated that she was trusting this connecting clinicianâ&#x20AC;&#x2122;s intuition that this would be worthwhile for her as well, but she also voiced a reluctance to speak in psychodynamic terms and seemed wary at the outset that our engagement would feel comfortable. As a result, the first interview began with reticence and reluctance on her part, which was evidenced in her body language and tone. More than once she told me that she was not drawn to the psychoanalytic literature, and in retrospect it seems that there was some concern on her part that our work together would be highly intellectualized and difficult for her to connect with. Thirty minutes into the first interview, this began to shift and was apparent in a shift in her facial expressions, body language, voice tonality, as well as in our shared laughter. The change seemed to occur in response to my curious stance about the nature of her work. In her recounting the emergence of a metaphor within her imagination, while sitting with a patient, she began to assume a less guarded posture, and as she recited the first of many poems that have entered her imagination in

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her work, our collaboration began to take on a palpable flow, 67 which continued to nourish and sustain the collaboration throughout. A significant aspect of our engagement with one another around coconstructing an understanding of the phenomenon of the presence of cultural objects within the clinician’s imagination was the deep connection that unfolded between us around the nature of her work with poetry, and her profound attunement to the nuances of language. Because these phenomena hold deep personal meaning for me as well, because one factor driving my study has been a search for a professional home in which to abide where this phenomenon is both experienced and utilized, and because much of our work together involved the sharing out of poetry in the service of this endeavor, I found myself meaningfully immersed in the interview process in a way that impacted the nature of the work in positive ways, and may also yield findings about what this kind of connection within a therapeutic relationship has the capacity to provide.

Articulated impact of the interview process. Clinician 4 spoke enthusiastically about the interview process. She noted that it was meaningful to be listened to with care and thoughtfulness, and the rarity of having the luxury to speak in such depth about the intricacies of her work. In addition, the interview process provided her with an opportunity to articulate long-held wishes for

67 In positive psychology, flow . . . is the mental state of operation in which a person performing an activity is fully immersed in a feeling of energized focus, full involvement, and enjoyment in the process of the activity. In essence, flow is characterized by complete absorption in what one does. Named by Mihály Csíkszentmihályi,, . . . flow is [understood to be] completely focused motivation. It is a single-minded immersion and represents perhaps the ultimate experience in harnessing the emotions in the service of performing and learning. In flow, the emotions are not just contained and channeled, but positive, energized, and aligned with the task at hand. (http://en.wikipedia.org/wiki/Flow)

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professional generativity in the form of both authoring a book, and launching a professional blog. She spoke of wishing to write a more satisfying version of The Novel Cure, a book which provides access to novels, poetry and memoir organizing around psychodynamic themes. In addition, inspired by the process of describing clinical vignettes in micro-moments, punctuated by her internal musings and motivations, she expressed an interest in authoring a contemporary version of The Fifty Minute Hour 68, describing intricate moments of her psychotherapeutic practice. She also spoke animatedly about the possibility of pioneering a book group at her agency, in which some of the works recommended in her version of The Novel Cure might be discussed. As an expression of a warm wish to continue our satisfying professional connection, we joked about beginning such a group together, or at least my being invited to join the group she hopes to initiate. Clearly, engagement for this clinician around this topic was enlivening, providing nourishing ingredients to carry her forward in other professional endeavors.

Categories of meaning. An analysis of the data gleaned from interviews with Clinician 4 yielded two major categories of meaning. The first category of meaning consists of the meaning and use that Clinician 4 makes of the cultural object. The second category of meaning comprises the therapeutic power she attributes to the cultural object. Each of these overarching categories of meaning consists of sub-categories of themes, which are

Lindner, Robert (1999). The Fifty Minute Hour is described on Amazon.com as ““A fascinating mixture of traditional psychoanalytic thinking with clinical strategies that even today would be considered creative and controversial, The Fifty-Minute Hour has never failed to capture the imagination. . . . No student’s education in psychotherapy is complete without reading this book. Decades after its original publication, it still stands as a pioneering landmark in the history of psychotherapy.”

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described in detail in the findings that follow. The following themes are contained within the first category of meaning, the meaning and use of the cultural object: •

The nature of the cultural object: The cultural object of language itself.”

•

The nature of the cultural object: The cultural object is immediate.

•

The nature of the cultural object: The cultural object carries relational resonance.

The following motifs are designated within the second category of meaning, the therapeutic power Clinician 4 attributes to the cultural object: •

The Therapeutic Power of the Cultural Object: The metaphor nourishes empathy in the clinician.

•

The Therapeutic Power of the Cultural Object: The accessed cultural objects of poetry and music expand access to the patient’s struggle as the clinician identifies her own feeling states and experiences empathy toward her client’s struggles.

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The Therapeutic Power of the Cultural Object: The cultural object functions as a transitional phenomenon.

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The Therapeutic Power of the Cultural Object: The cultural object functions as an indirect route to impart insight.

•

The Therapeutic Power of the Cultural Object: Sharing a cultural object’s nuanced meanings offers an experience of felt knowing.  An example, Bruce Springsteen’s “Stolen Car.”  When the clinician’s provision of a cultural object, the offering of “felt knowing,” is experienced as a misattunement.

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•

The Therapeutic Power of the Cultural Object: Sharing a cultural object’s nuanced meanings offsets loneliness.

•

The Therapeutic Power of the Cultural Object: The shared cultural object functions as a “A case of unconscious communication” 69

•

The Therapeutic Power of the Cultural Object: Sharing a cultural object’s nuanced meanings offers an experience of felt knowing characterized by playfulness, engendering new relational possibilities.

•

The Therapeutic Power of the Cultural Object: Sharing a cultural object’s nuanced meanings provides a mirror for the patient, facilitating the potential for true self-knowing.

•

The Therapeutic Power of the Cultural Object: The clinician’s provision of the cultural object functions as a provision of maternal nurturance.

•

The Therapeutic Power of the Cultural Object: The cultural object functions as a defensive maneuver: It quiets difficult affect and/or offers the clinician hope.

•

The Therapeutic Power of the Cultural Object: clinician’s articulated process.

The nature of the cultural object: the cultural object of language itself is “aesthetically, sensually rich and enlivening,” a means to “elicit one’s most true voice.” Clinician 4’s therapeutic action is significantly influenced by the work of Judith Jordan and her cohort of thinkers and practitioners associated with Relational-Cultural Theory, initially termed “The Stone Center Model.” This theoretical perspective is an appropriate match for her predilection for language’s subtleties, and more specifically for

Altman, Neil (2002), page 510.

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its capacity to function as a vehicle for authentic and vital ways of relating. As is evident in her narrative about her experience of her family’s church providing an experience that was “aesthetically, sensually, rich and enlivening,” she privileges these qualities as essential ingredients for emotional wellbeing. For her, the capacity to access one’s authentic voice is a measure of emotional health, and an essential commodity she aspires to nurture in her clients, even as they struggle. Elucidating Relational-Cultural Theory, she explained, “If you are really in authentic connection with someone, you feel more alive. There’s a certain zest, a curiosity. There’s a mutuality. And you know, I think if I can elicit by using my own most real voice, elicit someone else’s more true voice, it’s a very (Here her voice grew quiet here on the word “very”) vital (The word “vital” was drawn out as she speaks softly.) exchange for both of us. In that [Relational-Cultural] school, The Stone Center, they talk about the measure of maturity or health being the clarity of one’s voice. That the more someone can describe their own internal experience, their own world, the more integrated they are, and I think about that, about that a lot with clients, and I think about—they use the phrase, ‘listening someone into voice.’ As you listen and you pay attention and you reflect back on this question and the person is more able to name and describe and clarify, and therefore their voice becomes more vivid. More their own. More authentic.” She spoke eloquently about helping women bring experience into language in a way that evoked an image of midwifery, as if she were coaching her clients to give birth to an authentic sense by “language-ing” their experience. Ogden (1997c) describes this type of therapeutic action:

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The analytic discourse requires of the analytic pair the development of metaphorical language adequate to the creation of sounds and meanings that reflect what it feels like to think, feel, and physically experience (in short to be alive as a human being to the extent that one is capable) at a given moment. (p. 6) Just as Ogden speaks of “linguistic deadness” (p. 1), she delineated between “alive language” and “dead language” as she characterized the personal idioms of her clients, as well as the language of psychodynamic literature and aesthetic works. In this way, language is the foremost cultural object operative for this clinician. Citing the poet Thomas Lynch, she explained that she is “hungry for the good word.” Developing her thinking, she continued, “I think language (She paused.) I think words are life. Life giving. I think they allow us to name our experience, to connect with someone else about it. I mean (She sighed deeply.) I think in our business actually there’s so much dead wood: blah blah blah, words that words that are lively and apt and (She sighed again, working to consider the question and how to put her thoughts into words.) I don’t know, something in the, you know the Emily Dickinson thing, (She was talking so fast now that it was hard to follow her, as she drew upon a quote from this poet.) ‘I know poetry because it makes the back of the hairs on my head stand up. (She invoked a poetry recitation voice:) I know when I’ve read a good poem because my hair stands up and I have a shiver down my spine,’ 70 or something like that. Real physical description of how she knows when she’s read something good, and I think there’s a visceral reaction to

One of the most powerful definitions of poetry and my favorite may be found in Emily Dickinson's 1870 remark to Thomas Wentworth Higginson (1823-1911): “If I read a book and it makes my whole body so cold no fire can ever warm me, I know that is poetry. If I feel physically as if the top of my head were taken off, I know that is poetry. These are the only ways I know it. Is there any other way?” (http://www.wisdomportal.com/Poems/DickinsonDefinitionPoetry.html)

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hearing not necessarily beautiful [language, but] powerful language, exact language.” Ogden (1997c) attends to this aspect of literary language when he writes, There are important areas of overlap and important differences between a literary aesthetic and an analytic aesthetic. I believe that what is essential to literature is the attempt to capture/create something in language that is significant about the experience of being alive as a human being and the enjoyment of the play of words and sentences through which this is made to happen. (p.10) For this clinician, as well as for Ogden, language is a vehicle for bringing one’s experience into consciousness, and working it. Clinician 4 continued to emphasize the grave, essential, empowering matter of being able to bring experience into language in order to benefit one’s humanity: “In her book, Alexandra Fuller 71 talks about how in Zimbabwe. Is it Zimbabwe? You are not allowed to use words to name genitals. So when women have been raped, like by HIV squads, it’s a double damage because after they’ve been raped, they are not allowed to speak to anyone about what happened. They can’t even own the experience in words. I think there’s a great freedom that comes from being able to own your own experience. [As Judith Jordan writes about], ‘Listening someone into voice.’” In this discourse, Clinician 4 assumed concepts such as “freedom,” “vitality,” and “naming” to be essential components for living fully. Within her clinical and deeply personal stance these are inalienable rights. In her associative work, Clinician 4 drew primarily upon cultural objects that employ language: poetry, prose, song lyrics. And yet, while invoking language, she

Fuller, Alexandra (2015). Leaving Before the Rains Come. New York: Penguin Press.

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painted a picture that extended beyond language. The words she employed were a vehicle for very deep affective expressions, presenting a paradoxical phenomenon. Clinician 4 helps her clients bring their experience into language through the naming of experience, in a manner reminiscent of a birthing coach or midwife. She is committed to help her patients verbalize what Bollas terms “the unthought known.” Hearkening again to Judith Jordan’s work, she considered, “Well if you see it within the metaphor of [Judith] Jordan’s ‘listening someone into voice,’ it’s like helping someone else come into their voice and begin to feel things that maybe they didn’t even know they felt until they had some way into them. So I think part of what happens is that if you’re paying close attention, (She said these three words very fast.) and they’re paying close attention, (Again, these three words were delivered quickly.) and there’s language that’s being meaningful, then the ability to represent oneself more fully, more authentically is--you know-- begins to kind of blossom or open up. I have seen this one woman for 21 years. (She relayed these last three words very slowly, drawn out). When I started seeing her there was a day to day thing about was she sober: very accomplished academic parents, no emotion, in and out of hospital. Well anyway, I was thinking the other day sitting with her, ‘Twenty years later she can actually say, ‘Okay, I understand this what you’re saying and I’ve been thinking about it. That doesn’t quite feel right to me.’ It’s like 20 years for both of us of gut-busting work, but she can step back, observe herself, reflect, feel known. I mean instead of this just acting, acting, acting, like ‘I’m going to go to bed for a week. I dare you to come and get me.’ There was just this constant, very somatic, lots of enacting on the pain. And now we sit in the room. She talks about it. She reflects on it, laughing at this long history of not being able to say things.”

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257 The nature of the cultural object: the cultural object is immediate; it “takes you past your first layer of skin,” blows past intellectual defenses, touches our unconscious. This clinician offered many examples of a poem or song entering her imagination and the ways she used this phenomenon within herself and with her patients. In discussing the nature of poetic expression and how it functions in her therapeutic work, she parsed its nature in ways that dovetail both with her therapeutic theoretical conviction that language has the capacity to function as a vehicle for authenticity, and her profoundly personal affinity for this aspect of expressive language. She explained that the poetic images “are so immediate, (She said this one word very slowly, drawing it out.) and so personal that it kind of takes you past your own first layer of skin. It kind of gets to your unconscious in a way that a lot of intellectual or prose can’t get to.” Thinking deeply she continued, “And the power of the language cuts past defensiveness, conscious intellectual constructs. (She said these last three words like she was grabbing at old language, more intellectualized language.) Her idea is that poetry functions as an avenue to unconscious process, in much the way dream-work does: “I think a good poem kind of blows past intellectual defenses and cognition and touches our unconscious, our hearts, our souls, whatever you want to [name it]. There’s something so evocative.” Ogden (1997c) addresses this phenomenon when he notes, Effects created in the use of language serve as a central medium of communication of unconscious experience in the analytic setting. Effects created in language of course coexist with the use of language to name, describe, and in other ways speak about one’s experience. When I refer to effects created in

language, I am placing emphasis on a dimension of language usage in which the creation and communication of meanings/feelings is indirect, that is, relatively independent of what is being said (at the level of the semantic content of language). Such effects in language are always in movement, always in the process of occurring, “always on the wing, so to speak and not to be glimpsed except in flight” (William James, 1890, p. 253). . . . It is the “transitive parts” (p. 243) of language, “the places of flight” (p. 243), that come closest to capturing something of the texture and the aliveness of felt feelings and the movement of “the stream of thought” (p. 243): Thus, [William] James attempts to explore the ways in which language can be used to do what it cannot say. (pp.16-17) Winnicott (1971) describes early preverbal experience, difficult to articulate and yet at times captured by the poetic. He writes, What does the baby see there [while gazing at the mother’s face]? To get to the answer we must draw on our experience with psychoanalytic patients who reach back to very early phenomena and yet who can verbalize (when they feel they can do so) without insulting the delicacy of what is preverbal, unverbalized, and unverbalizable except perhaps in poetry. (p. 112) The ways in which she elicits poetry within her own imagination, and brings it into the relationship is an essential component of her therapeutic action. She articulated this when she spoke about the influence of the Stone Center Model on her already firmly held tenet that when she utilizes her own authentic voice, this enables her client to elicit her own “more true voice”, thus creating “ a vital exchange for both of us.” She believes that opening oneself to poetry enables one to be “so much livelier, more open, more

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affective.” She strongly suggested that the poem succeeds in describing affective states where one’s own capacities fail the individual, both clinician and patient. She elaborated, “Here’s a piece of writing that has so eloquently named some internal state, in a way that I find prose—or psycho-babble does not.” In concert with this view, George Eliot (1956) writes, To be a poet is to have a soul so quick to discern that no shade of quality escapes it, and so quick to feel, that discernment is but a hand playing with finely-ordered variety on the chords of emotion—a soul in which knowledge passes instantaneously into feeling, and feeling flashes back as a new organ of knowledge. (p. 166) Clinician 4 drew upon a clinical vignette to make her point: historically she would study poetry with a group of women in a chemical dependence program. On certain days, following their poetry session with her, they went on to a group therapy appointment. The clinician who received this group of women experienced them to be more affectively available following their poetry workshop. Lipson (2006), writing primarily about music, but in ways analogous to poetry, suggests that music “serves to express significant affective constellations” (p. 876). He also draws an analogy between this kind of internal musical association and the manifest content of dreams. He coins the term “aural road” as a pathway to unconscious content (p. 867), and notes that self-generated tunes are a characteristic way of thinking for some (p. 875), suggesting that musical sounds can represent an important aspect of one’s inner life. Jessica Benjamin (1994), citing the first of Rilke’s “Duino Elegies,” elicits the image of the Angel:

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Who, if I cried, would hear me among the angelic orders? And even if one of them suddenly pressed me against his heart, I should dissolve in his mightier Being. For Beauty's nothing but beginning of Terror, we're still just able to bear, and why we adore it so is because it serenely disdains to destroy us. Each single angel is terrible. And so I contain myself, and choke down the call of depth-dark sobbing. Alas, who is there we can make use of? She invites Rilke’s poetic voice to address the issue of erotic transference, and argues that “the desire to be recognized in one's true self-feeling, or ‘spontaneous gestures,’ fuels the creation of the Ideal and is as crucial as its identificatory and libidinal aspects” (p. 537). It is this desire that Clinician 4 holds in mind when she elicits her poetic imagination in the service of the therapeutic work. Benjamin continues, “A crucial part of this notion is that the Ideal is self-generated, and psychoanalysis aims at enabling a creative re-owning of it” (p. 537). Benjamin continues by setting the notion of ego Ideal to the side, rather centering her proposition on “a notion of the Ideal that includes the longing for recognition of creativity or true self-feeling” (p. 538). Here Benjamin, drawing upon Bollas’ (1989) combination of Winnicott’s (1969) concept of “object usage” and his rendition of “true self,” locates her Angel/Ideal within the inter-subjective realm. Adopting Bollas’ notion of therapeutic action, she writes, “[Bollas] has effectively reformulated the distinction between interpreting the patient's unconscious and letting the

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patient use the analyst for true self-expression.” The ways in which Clinician 4 contributes her associations to cultural objects, specifically poetic expression, within the therapeutic dyad, has the capacity to function in just this way. She believes that her eliciting of the poetic and bringing it into the consultation room, both implicitly and explicitly, aids in her patients growing ability to speak from a true, authentic place as well.

The nature of the cultural object: the cultural object carries relational resonance. “There’s a feeling of a kind of interwoven . . . a little internal community of caring.” Over the course of this interview process, Clinician 4 offered several examples of cultural objects that carried relational resonance in a condensed fashion characteristic of dream work, elicited from her imagination while sitting with a patient. In several cases the association was to her relationship with her analyst. On one occasion her association was connected to work with another patient. And multiple examples carried a mentor or consultant’s teachings within them. In some instances it was the cultural object itself: a poem by Denise Levertov brought to her by a previous patient, for example. In the instance of her analyst, the relational echo in one vignette was a specific intervention, that is the way he intervened and interpreted and not a specific cultural object, almost as if it were a choreographed dance move. In another instance it was the intersecting meaningmaking drawn from her analytic work that carried forward into her own therapeutic action. Eliciting a beloved mentor’s teachings similarly did not provide an exact match of poetic line and verse, but rather conveyed a complex and layered set of feeling states and

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ways of knowing that intertwined with that which she communicated implicitly and explicitly to her client. As a woman who reads voraciously, another relational aspect of her associative process vis-à-vis a cultural object within the context of her work is her relationship with characters in the novels and memoirs that inhabit her imagination. In several well-drawn examples, this clinician evoked the thoughts, feelings, language and actions of a fictional or nonfictional character in the service of her work with a client. When asked about this phenomenon within her imaginative process, she grew thoughtful because this was a new way for her to conceptualize this aspect of her work. Enchanted by this challenge, she observed, “There’s a feeling of a kind of interwoven, a little internal community of caring.” Davies (2004) writes about this “little internal community of caring” in the context of a shared cup of hot milk and tea brought to her by an analytic patient: Karen reaches down into her book bag and pulls out a large silver thermos and mug. As she opens the thermos and begins to pour, the warm smells of honey, vanilla, and cinnamon fill my office. I am mesmerized as I watch Karen, intrigued with her swift and competent movements. “This will be good for you,” she says. “My grandmother used to make it for me when I was sick. It is a combination of hot tea and hot milk with a lot of other wonderful stuff.” She holds the mug out to me, an expression of intense pleasure and hopefulness suffusing her face. As I reach for the mug, our fingers touch for an instant, and I recall that my own grandmother brought a similar recipe with her from Russia, one that she would prepare for us when someone in the family was sick with a cold. There are now two more personas squeezing into our already overcrowded analytic space:

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Karen's grandmother and my own. The evocation of both of our alternate mothers seems not accidental. (p.725) Altman (2002) describes a similar phenomenon: It seemed that whatever unconscious communication had developed between us was ready to emerge in precisely symbolized form; for example, the country music singer seemed the perfect symbol for our shared area of emotional responsiveness, for his mother, perhaps for my mother. She emerged between us like a mutually dreamed image. Verbal symbols were mere vehicles for this more profound dreaming. One might say that whatever passed between us, or whatever it was that subsumed us, existed in symbolized, but not verbalized, form. (p. 510)

The therapeutic power of the cultural object. Clinician 4 offered a panoply of lenses through which to consider the therapeutic power her associations to cultural objects offered the dyadic enterprise. Because her theoretical foundation is rooted in Relational-Cultural Theory, it would be artificial to divide these categories into what the cultural object offered the therapist and what the cultural object offered the client. Rather, for the purposes of this research, categories of meaning regarding the therapeutic power of associations to cultural objects will be intertwined as in most cases the nourishment provided is not clearly for one or the other member of the dyad. The categories in which she articulated a particular benefit for one member of the dyad specifically, it will be stated with a nod to the potential use for the other as well. However, for the most part, the therapeutic potency of the cultural object will be considered in terms of what it offers, in Ogden’s (1994) parlance “the analytic third:” “the inter-subjectively generated experience of the analytic pair” (p. 3). He writes,

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My own conception of analytic intersubjectivity places central emphasis on its dialectical nature (Ogden, 1979), (1982), (1985), (1986), (1988), (1989). This understanding represents an elaboration and extension of Winnicott's notion that '"There is no such thing as an infant" [apart from the maternal provision]' (quoted in Winnicott, 1960, p. 39, fn.). I believe that, in an analytic context, there is no such thing as an analysand apart from the relationship with the analyst, and no such thing as an analyst apart from the relationship with the analysand. In both the relationship of mother and infant and of analyst and analysand, the task is not to tease apart the elements constituting the relationship in an effort to determine which qualities belong to each individual participating in it; rather, from the point of view of the interdependence of subject and object, the analytic task involves an attempt to describe as fully as possible the specific nature of the experience of the interplay of individual subjectivity and intersubjectivity. (p. 4) Clinician 4 offered case vignettes in which she held an association within her imagination and worked with it without explicitly bringing it into the room. In addition she provided examples in which a cultural object had a presence in her reverie, and she explicitly introduced it into the therapeutic work. In addition, at times a client initiated the presence of a cultural object within the therapeutic space, and in these examples, she presents ways in which the clientâ&#x20AC;&#x2122;s association takes hold within her imagination as well and inhabits the therapeutic work.

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The therapeutic power of the cultural object: the metaphor nourishes empathy in the clinician. “Missing a layer of skin.” Clinician 4 unfolded a story of a young woman in her twenties: A child of alcoholics with trauma and neglect in her history. This clinician understands the young woman, who is just recently sober herself, to be in excruciating pain, as early traumatic memories are suddenly available to her in a new way. Clinician 4 describes her as suicidal at times, and “very raw and very gutsy. She’s someone who had been precociously independent, counter-dependent, and it comes across as so tough, very street-smart, smart as a whip. Really almost a wonderful, but a savage use of language.” Clinician 4 explained that because she has wide-reaching experience working with counter-dependent women, as well as with women wrestling with addiction, she understood that while her client “comes in literally kind of snarling, with her nose ring and her tattoos,” that in fact, “she’s terrified: I know she feels like she can’t live in her own skin.” In the process of eliciting compassion and tenderness toward her client, this clinician drew upon an image, a metaphor that could abide within her. Early in the interview process she described her internal process, “I’m trying to remember now what my associations were. (Her voice was very soft, very gentle; her face relaxed; she seemed more related to me; less apprehensive and anxious. She seemed in her element.) And as I was listening to her, I was thinking about (She paused to think.) something I had read: the idea, something about, you know, missing a layer of skin, and things are, you can’t filter. (Taking language very seriously she was reaching for the right word.) Not this word exactly. It doesn’t work. Doesn't’ come [to mind] but I was thinking about her. I was

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thinking. (Clinician 4 was stroking her own arm, up and down; She was very thoughtful about her word usage, and very attuned to others’ use of language. She wasn’t satisfied with this description—“can’t filter.” She was reaching for a better way to communicate her sense of this young woman.) But there was something about (She paused.) She had the protective layer of skin kind of beaten off her as a kid. She anaesthetized herself for a lot of years, and now here she is out like a, you know, a little animal without any fur on.” In discussing how this image informed her work with this client, Clinician 4 spoke of the young woman’s vulnerability and fragility. As she drew a picture of the bravado with which she presented, she conveyed the ways this elicited image enabled her to both maintain empathy with her and exercise a firm, protective stance in moments when she threatened to leave treatment, or required hospitalization. It also allowed her to receive her client’s counter-dependence and “Fuck you I don’t need anybody” attitude, and continue to approach her with tenderness. And yet, Clinician 4 comes to this work with a great deal of experience working with this kind of individual, so the question arises regarding what this elicited image of “missing a layer of skin” has the capacity to provide beyond her clinical and theoretical knowledge and experience. Clinician 4 explained that the image takes her “past [her] own first layer of skin” as well. It kind of gets to you.” She was explaining that knowing this young woman’s pain, and living with this image, opens her to a raw place inside herself. She communicated that accessing this personal, internal place enables her to do this work. In addition, significantly, the image elicited in her imagination connects this clinician with a piece of this young woman’s history, exemplifying the ways in which her elicited sustaining metaphor is communicated to her unconsciously. She continued, “It’s

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interesting, [this image] of not having skin. She described [in] one of the first few sessions: She said that when her father would be screaming at her and beating her, one way that she could get him to stop would be to start scratching herself and pulling her own hair out, making herself bleed so that he would back off. And he would not comfort her. He would get undone by her bleeding and walk away and close the door. She would hurt herself to get his attention, to get him to stop. And I think that’s in [my elicited image] too.” In fact, as this clinician began to talk about her client, she was rubbing her own arm as she spoke. In this way, Clinician 4 has conjured a compellingly vivid image—an animal missing its fur; a young woman missing a layer of skin—that dovetails with her client’s narrative of self-injury in the service of self-protection against a parental aggressor. In the present clinical moments of their work together, however, she sits in the company of a young woman missing a layer of skin, and—unlike the client’s father, and the familiar/familial relational paradigm—the clinician does not abandon this young woman, but stays to companion with and comfort her. Clinician 4’s elucidation of this image in the context of her work exemplified the way a cultural object elicited in an associative, imaginative moment holds the capacity to fuel empathy and compassion, mirror the patient’s trauma history, carry the clinician to a fragile internal place of her own, and offer a paradigm for healing insofar as a new relational paradigm can be composed over time. Like representations in dream-work, this image is condensed conveying a multiplicity of intersecting meanings and functions. The vignette nourishes this research inquiry as to the clinician’s associations to cultural objects and what this phenomenon offers the work, offering profound, expansive layers of meaning.

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Clinician 4 considers it “sustaining” to hold the image of someone missing a layer of skin within her imagination. Citing Irene Stiver 72, she noted the importance of locating “one true thing; one small true thing that might open something up” in the work. This image functions in this way for her. It is something “that might touch, connect, get past, that might elicit a true voice back.” Once again, she hearkened to the Relational-Cultural Theory’s valuation of the authentic, true voice as the key to therapeutic healing. Along similar lines, the relational psychotherapist Sherman (2014) writes of drawing upon a metaphor from Sleeping Beauty in the service of enlivening his work: Was there some way I might contain Steve’s frightening erotic desires (and my own) while more actively attending to his vulnerability and shame? Perhaps first processing erotic feelings within me while more explicitly addressing pre-Oedipal longings for recognition and mirroring would allow Steve to feel safer. If I could better understand and articulate early attachment needs, I might provide a holding environment, and a more fortified Steve could ultimately share his sexual longings in a way that felt organic rather than overstimulating. With this in mind, I considered an additional way of understanding Steve’s desires using a metaphor that encompassed both sexual and non-erotic components. As the treatment had deadened, we had both succumbed to a heavy slumber. To different degrees and with different levels of conflict, we both still

72 Irene Stiver was Director Emeritus of the Psychology Department, McLean Hospital and had been a senior clinician and teacher in major medical/educational institutions for more than 30 years. She was the co-author of Women's Growth in Connection and The Healing Connection: How Women Form Relationships in Therapy and in Life. Dr. Stiver had written and spoken widely on a range of topics relating to women's development and experience: work inhibitions in women, "dependency" in relationships between women and men, therapeutic impasse, the need to reframe treatment models, and disconnection in troubled families (http://www.jbmti.org/Founding-Scholars/irene-piercestiver-phd).

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yearned to be awakened. Thinking about slumber, I envisioned Steve as Sleeping Beauty hoping I would be Prince Charming to arouse him. It was a very different image than [the client’s dream image] of a rapist, yet it still encompassed romantic and sexual longings, as encapsulated by the word “arouse.” After all, Prince Charming awakens Sleeping Beauty with a kiss. (p. 201) Sherman’s article continues to unfold the shifts in treatment once this metaphor, drawn from the cultural object of the Sleeping Beauty fairy tale, inhabits his imagination: The image allowed him to invite Oedipal and pre-Oedipal longings to co-exist in his understanding of his patient’s yearnings and conflict; he found himself “more active and curious in the treatment” (p. 202); the therapist became more playful, using double entendres in his speech that carried a layer of sexual innuendo along with more surface meanings; he took some risks, sharing personal feelings vis-à-vis his client in ways that opened up the relational space and brought them into an increased sense of connectedness. Overall, Sherman’s associations to the Sleeping Beauty tale invited a creativity, playfulness, capacity for opposite strivings to co-exist, as well as an aliveness into the treatment. While the themes of Sherman’s client and Clinician 4’s client differ, each clinician draws upon a metaphor that nourishes their work by containing the patient’s idiom and gently circumventing the sentinels stationed to protect the client from his or her longing for and dread of connection.

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The therapeutic power of the cultural object: the accessed cultural objects of poetry and music expand access to the patient’s struggle as the clinician identifies her own feeling states and experiences empathy toward her client’s struggles. “Empathic Imagination.” Clinician 4, considering her evocation of a cultural object within her imagination in her work with her client, described her internal process of associating to a poem. She recounted, “ I was seeing someone who is just in so much pain, they are just living in a small world, and I’m thinking, “Awww… (very empathic resonance, like speaking to a baby) I know that. I know that little poem. I know that myself, that feeling of just hunkering down, holding on and trusting and hoping.” One of the factors contributing to her capacity to associate to a particular resonant cultural object is her own deep familiarity with a particular set of affects. Lipson (2006) attends to this phenomenon of empathic resonance: Jaffe (1983) reported a . . . related experience with melodies that occurred to him while analyzing. In the context of empathizing with his patients, he found “mood shifts at times getting signaled by specific musical themes. . . .The shift from a tone of lightness to one of pathos, for example, has regularly set off in my inner ear the sound of Mozart's G Minor Symphony” (p. 591). The emphasis here is on the usefulness of the melodies in revealing to the analyst his empathic response to his patient's feelings. Cognitive content is not addressed. (pp. 867-868) Clinician 4 credited her life experience and her own analysis as facilitating her ability to both recognize her own feeling states, and elicit them in the service of the clinical work. The cultural object—a song, poem, or metaphor-- comes forth in this

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context. She named this phenomenon when she noted, “I know this poem. I know this in myself.” She said, “I know something of what they’re [feeling]. Yeah, I hope so. I think so. It helps, I mean I’m grateful for some of the things I’ve done in my life. Not that I’m cavalier. You know, it’s not like I could go to Rwanda and not be undone, but I do think after all these years, and some of my own analysis, I don’t feel very afraid of anybody’s [pain, anybody’s struggle].” For Clinician 4, the poem provides language replete with descriptive feeling states that offer her a doorway into her client’s experience. She unfolded, “I saw someone recently who was very depressed unto despairing.” The beauty of her own language was striking here. She went on, “I did not share this with her. But there is a poem by Gwendolyn Brooks, called ‘My Life, My Works Must Wait Till After Hell.’ 73 And it’s about hunkering down. It begins ‘I hold my honey and I store my bread (She paused to remember the poem.) in little jars in cabinets of my will, I label (She paused again to remember the words.) I label each, (She was hesitating, trying to remember.) and close them firmly and label each (She was reciting fast in this previous phrase, once she remembered it clearly.) Be firm till I return from hell. I am very hungry. I am incomplete. No man can say when I will dine again, no one give me any word. But wait. That puny light: I keep eyes pointed in, hoping that when I resume, get up on such legs are left me, remember to go home. My taste will not have turned insensitive, to bread and honey, old purity and love.’” She said this poem elicited the following sensibility: “That’s what I 73

my dreams, my works, must wait till after hell/I hold my honey and I store my bread/ In little jars and cabinets of my will./ I label clearly, and each latch and lid/ I bid, Be firm till I return from hell./ I am very hungry. I am incomplete./ And none can tell when I may dine again. / No man can give me any word but Wait,/ The puny light. I keep eyes pointed in; / Hoping that, when the devil days of my hurt / Drag out to their last dregs and I resume / On such legs as are left me, in such heart / As I can manage, remember to go home,/My taste will not have turned insensitive / To honey and bread old purity could love.

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think: (She said this fast, in a slightly different, empathic voice, eliciting her internal musings.) ‘I’m hoping and you’re fearful.” [I am] holding on to that hope that you will resume: (Here she employed the language of the poem.) You will get back up, and remember to go home.”

The therapeutic power of the cultural object: the cultural object functions as a transitional phenomenon. Clinician 4 furnished a myriad of examples of cultural objects inhabiting her imagination as unbidden emanations from her unconscious storehouse, invited by the client’s implicit and explicit material. The majority of her examples centered on poetic evocations, and yet another key element of her imaginative engagement was drawn from psychoanalytic theory, primarily in the form of teachings of a beloved mentor. In her recounting, her elucidation of these moments—Judith Jordan, her analyst, a valued mentor, or a consultant—the feeling accompanying her associations was one akin to Winnicott’s (1953) conceptualization of transitional phenomena. 74 In effect, the cultural object was functioning as a way for her to bring this significant relational, theoretical, intellectual and affective connection into her work with her client. In parallel fashion, Clinician 4’s provision of cultural objects to her clients, is characterized by the capacity to function as a transitional object; and as a way for her client to hold her sense of her clinician’s presence, her clinician’s provision of felt knowing within a session, as well as between sessions. In one example, Clinician 4 74

Winnicott (1953) defines transitional phenomena as “the third part of the life of a human being, a part that we cannot ignore, is an intermediate area of experiencing, to which inner reality and external life both contribute. It is an area which is not challenged, because no claim is made on its behalf except that it shall exist as a resting-place for the individual engaged in the perpetual human task of keeping inner and outer reality separate yet inter-related” (p. 90).

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described a vulnerable woman in the midst of a traumatic divorce. Worried about her psychological wellbeing, this clinician recommended the young woman see her twice a week. When this was not possible, Clinician 4 found herself encouraging this client to read a novel that the clinician herself was reading. While this was unconsciously motivated to some degree, in reflecting upon this intervention, she discovered a wish to keep her client company between sessions in a more extensive fashion. She articulated a deep awareness of how a novel provides this function for her, and found herself hoping this would be the case for her client as well. She outlined her clinical thought process, “Well, you know I’ve probably been listening to [Alexandra Fuller 75] in the car [coming into work] and finding it very powerful and so I heard, . . . and one of the things Alexandra Fuller describes so beautifully is how long she struggled to figure out what to do. And this woman is so at sea, and I guess I thought about the clarity of Fuller’s voice. That [it] would be helpful. You know that’s the other thing you can do is kind of name your own experience. You don’t have the words. Someone else has the words. You borrow them and make them your own, and I was thinking that Fuller’s words, she might be able to use them to organize around. She desperately needs companionship.” In this example, Clinician 4, marshals the internal voices of Judith Jordan’s teachings: “name your own experience,” as well as the presence in her reverie of Fuller’s voice in a memoir whose themes dovetail with those of her client. They function as a transitional object for the clinician, and then her therapeutic action offers a parallel provision to her client.

Fuller, Alexandra (2015). Leaving Before the Rains Come. New York: Penguin Press.

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The therapeutic power of the cultural object the cultural object as an indirect route to impart insight: “It opens up a space that might have been too stirring before; it’s a “mediating object; it makes it a little safer; we are knitting this little tapestry together.” The image of missing a layer of skin abided within the clinician, informed her work and was not shared out, whereas she offered several examples of poems which she brought into sessions, which functioned as provisions for deepening the work. The first was a poem, “See Paris First” 76 which was initially gifted to her by a client, and then functioned as an offering she made in the service of another’s work. The second was the Denise Levertov poem “Talking to Grief,” 77 in which grief is likened to “a homeless dog . . . living/under my porch,” but who should be coaxed in and given its “own corner.” In both cases, these poems found their way into her awareness, in the context of her work with a particular client. In each example the poem was proffered as a clinical communication in a moment she assessed to be right for a well-timed intervention. Earlier in Clinician 4’s professional career, a client brought in the poem, “See Paris First” in the context of the work they were engaged in around her client’s trauma

76 See Paris First/ Suppose what you fear could be trapped/and held in Paris./Then you would have the courage/to go everywhere in the world./All the directions of the compass/open to you,/except the degrees east or west/of true north/that lead to Paris./Still, you wouldn’t dare/to put your toes smack dab/on the city limit line./ And you’re not really willing to stand on a mountainside/miles away/ and watch the Paris lights/come up at night./And just to be on the safe side, you decide to stay completely/out of France./But then danger/ seems too close/even to those boundaries,/and you feel the timid part of you/covering the whole globe again./You need the kind of friend/ who learns your secret and says,/“See Paris first.”/—M. Truman Cooper 77 Talking to Grief/Ah, Grief, I should not treat you/ like a homeless dog/who comes to the back door/for a crust, for a meatless bone./I should trust you./I should coax you/into the house and give you/your own corner,/a worn mat to lie on,/your own water dish./You think I don't know you've been living/under my porch./You long for your real place to be readied/ before winter comes. You need/your name,/your collar and tag. You need/the right to warn off intruders,/to consider/my house your own/and me your person/and yourself/my own dog.

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history. She explained that the poem clearly delineates the cost of walling off “an essential part of your experience that affects everything else.” One’s world becomes smaller, and one’s potential for pleasure is inhibited. This young woman had experienced “horrible, horrible early trauma that had really spilled over into the rest of her life.” In an effort to marshal her own courage to name her terrors in her sessions, she brought in this poem, which Clinician 4 then associated to in her work with another client. She wished to communicate to this second client a wisdom gleaned from her experience with the earlier young client: If you refuse to go into what you are deeply afraid of, it will continue to impinge on the quality of your life and your capacity for pleasure. Within the meta-process of the interview setting, some of the phenomena present within the clinical setting also took up residence between us, researcher and participant. As she unfolded this vignette, there was a heaviness, and a sadness between us, deeply feeling this young woman’s isolation from a core sense of self because of her emotional paralysis in the face of early injuries. But when Clinician 4 began to recite the poem and speak within the metaphor of the poem, she began to giggle and there was a palpable sense of pleasure in the metaphor of needing “the kind of friend/who learns your secret and says, /’See Paris first.’” In this moment, the load of trauma lightened as evidenced by the shift in tenor of both of our voices and our laughter, and as we spoke about helping this client address her trauma more directly through the image of “seeing Paris first.” In parallel fashion, Clinician 4 provided Levertov’s poem to make the same point. Rather than directly telling a patient that she needed to invite her grief in, in order to secure the possibility of healing, she provided this poem. As she delineated the difference between the direct statement and the poetic intervention, her voice altered: “Sometimes

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instead of me giving that kind of ‘POW!’ (Her voice here was commanding,) [By saying,] ‘You need to face your grief,’ (Now in a different, softer voice she employed the metaphor from the proffered poem,) [instead I use the poet’s language and recited, ‘Bring the dog out from under the porch.’” Together parsing what the poem’s metaphor provides, she elicited several different functions of the metaphor. The poem makes it a little bit safer to talk this young woman’s grief; it functions as a mediating object, a vehicle; it kind of clears the deck and allows us to see and feel more intensely, more clearly. Paradoxically, communicating through the vehicle of the poem softens the message at the same time that it is incisive. It initiates a third thing between clinician and client while simultaneously deeply connecting them more deeply in the sharing of the cultural object. It functions as a safe, mediating vehicle that indirectly and yet coherently and powerfully names very real, felt internal states. Concluding, she commented, “We’re responding to this piece of art together, or we’re knitting out this little tapestry together: We both are responding to it!”

The therapeutic power of the cultural object: sharing a cultural object’s nuanced meanings offers an experience of felt knowing. A. An Example, Bruce Springsteen’s “Stolen Car:” the cultural object functions as a “wink between old friends;” a way of speaking in code; a way of communicating a sense of knowing the other; it “is like sharing a meal.” In addition to associations to poetry, Clinician 4 also associates to music while sitting with clients. Defining an affinity for Rock and Blues, what she termed “Roots Music,” she went on, “One of the things I love are good lyrics. (She seemed to be coming

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alive. There was a fluidity to her speech and body language, as if she were about to get up and dance.) This seemed consistent with her passion for poetry. As we were discussing this, music with a distinct drumbeat from a parade wafted up from the city street below. She shared a vignette involving a patient, with whom she shares a passion for Bruce Springsteen’s music. His songs function as a shared cultural object and, in this vignette, serve as a way to speak in code, and deepen connection. Clinician 4 likened this interaction to “a shared joke or a wink between friends.” She unfolded this story in the context of explaining that musical lyrics enter her imagination while sitting with a client: “I have a patient who’s a big Bruce Springsteen fan, and Bruce Springsteen has a song called ‘Stolen Car.’ And [the protagonist in the song] has stolen a car, and he gets out every night, and he drives around the city, and he’s out in this stolen car, and he’s hoping he’s going to get caught, but he never does. And this client was talking about driving around at night and listening to a Bruce Springsteen song, and so I said, ‘I hope it wasn't’ a stolen car.’ And he kind of, we both laughed. You know it was a nice moment, and he knows those lyrics, and it is a dark song, and he’s in a dark place.” In this way she used just a few words to communicate an attunement to his dark affective state. In attending to what her association provided the work, she continued, “Well it’s kind of like a shared joke with a friend or a wink with somebody. It’s like ‘Well, I know you.’ You know, ‘I got something.’ We don’t have to parse [it out]. We don’t have to go into detail, but he loves that poem and I love that poem, and we’re the same age, and he loves Bruce Springsteen. I love Bruce Springsteen. It’s just a moment of some kind of a (She paused here.) being simpatico, being known, knowing.”

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This research inquiry set out to discover the ways in which a clinician’s associations to cultural objects impacts the psychotherapeutic enterprise. In this rich example, Clinician 4 delineated the ways in which her association to Springsteen’s “Stolen Car,” and her election to voice it, provided her client with a sense of feeling known and seen. This then enhanced their connection with one another in what Guntrip (1969) names as a “moment of real meeting” (p. 427, cited in Ehrenberg, 1974).

The therapeutic power of the cultural object: sharing a cultural object’s nuanced meanings offers an experience of felt knowing. B. When the clinician’s provision of a cultural object, the offering of “felt knowing,” is experienced as a misattunement: “Our longing to be known is equal to our terror of being known.” Clinician 4 was also articulate about moments when the patient rebuffed her provision of a cultural object, at times growing angry and resentful, at others responding with a “So what?” attitude and/or swiftly shifting the focus of attention back to their personal narrative. She provided a case example in which the ways in which her offering of her association to a cultural object, in an attempt to communicate knowing and seeing her patient, backfired. She disclosed, “Occasionally I have stumbled. I know I remember vaguely a woman I saw for a couple years, and I don’t remember even specifically the poem, but I do remember that there was one part that really threw her. She felt that I didn’t get it. It was intrusive. What was I thinking? I forget.” (She laughed an anxious, worried laugh.) Clinician 4 found herself at moments like this one worrying that the ways in which she draws upon her reverie within the clinical relationship has the capacity to

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take up too much space in the patient’s therapeutic work. This is reminiscent of Ogden’s (1989) caution, “One must not deprive [the patient] of his opportunity to write the . . . lines of his own analytic drama by burdening him with the analyst’s own unconscious contents” (p. 176). In this example, while the clinician may have been attuned in the knowing of her client in the context of the provision of a poem, in many instances, in this one, her provision seems to have invited dread around being known, rather than hope. Clinician 4 continued, “For some people, [the sense of] being known, that’s terrifying, I imagine.” She continued, “Judith Jordan says, ‘We’ve got a longing to be known and connected, only equal to the terror and fear of the same thing.’” Clinician 4 was thoughtful about how, even when this kind of provision generated feelings of disruption and anger, it provided useful clinical data as to her client’s struggles with the experience of being known, and could be employed in the service of the work. Sherman (2014) cites a moving section of Jennifer Egan’s book A Visit from the Good Squad, as it eloquently captures the phenomenon of a longing for closeness resulting in a terror that leads to shutting it down. He had taken the passion he felt for Susan and folded it in half, so he no longer had a drowning, helpless feeling when he glimpsed her beside him in bed. . . . Then he folded it in half again, so when he felt desire for Susan, it no longer brought with it an edgy terror of never being satisfied. Then in half again, so he hardly felt it. His desire was so small in the end that (he) could slip it inside his desk or pocket and forget about it, and this gave them a feeling of safety and accomplishment, of having dismantled a perilous apparatus that might have

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crushed them both. . . . All of this bolstered his awe at the gymnastic adaptability of the human mind (Sherman, p. 207, citing Egan). (pp. 210-211) Sherman continues, The desire for closeness and communion with another can, in fact feel terrifying, leading to the kind of shutdown that Egan describes . . . It is the mind’s gymnastic ability that leads to pathology as well as to change and daring acts of courage. Sometimes . . . the analyst’s willingness to risk rejection by utilizing his desire for intersubjectivity can be the catalyst to an aliveness in the dyad that could never have been envisioned before. (p. 207) Clinician 4’s evocation of a cultural object, such as a poem, in a moment of reverie during a therapeutic encounter, has the potential to be experienced as either attuned, or intrusive. Either way, however, it offers information to the clinician about the client’s longings and dreads vis-à-vis the experience of intimacy and relational knowing and feeling known. Clinician 4’s examples of a moment of simpatico in “The Stolen Car” vignette, and an experience of disruption and fear of re-traumatization in the second vignette, highlight the ways in which an engagement in play can inhabit the work of the therapeutic dyad, when the client has achieved the developmental availability to play. It also underlines a client’s incapacitation in the area of play, due to significant emotional impingements. The psychodynamic psychotherapist’s use of her reverie as it carries her to draw upon cultural phenomena is useful to a client who has the capacity to accept her therapist’s invitation to play. In this way the therapist gleans valuable information about her client. In contrast, a client who rebuffs such an invitation, experiencing it as an

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intrusion or other form of misattunement, is instructing her therapist about her internal constraints, which has its own therapeutic power when it is received by the clinician who is willing to manage the rejection of an offering of self, and mine it for information useful in the psychotherapeutic endeavor. Davies (2004) describes this phenomenon in this way, “When the therapist is experienced as nurturing it fills the patient with shame and not warmth” (p. 724).

The therapeutic power of the cultural object: sharing a cultural object’s nuanced meanings offsets loneliness. “This really matters to me, and I am bringing it to you.” A moment between client and therapist that Clinician 4 characterizes as “simpatico” holds the additional capacity to offset existential loneliness. This patient is unfolding a narrative of isolation and despair: Driving his car, alone in the night, listening to Springsteen. It is possible that, since he knows the therapist also loves this singer, he has invited her presence along on the ride by playing Springsteen’s music, in effect to keep him company. She alludes to Springsteen’s song “Stolen Car” in which the songwriter is hoping to be caught driving this stolen car, “Each night I wait to get caught/But I never do/ . . . /And I'm driving a stolen car/On a pitch black night/And I'm telling myself I'm gonna be alright/But I ride by night and I travel in fear/That in this darkness I will disappear.” Bringing his loneliness into the session in his narrative of driving at night listening to Springsteen, perhaps this patient hopes to be “caught”, and Clinician 4 did not disappoint. She provided connection, a form of knowing by nodding to the song’s title. Clinician 4 described this phenomenon, “Well you’re sharing an experience. It’s like you’re eating a meal together. (She was talking fast; she seemed

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excited.) you’re, you’re, There’s something that you’re experiencing together.” While the cultural object functions as a “third thing” in the therapeutic relationship abiding between them, it functions to bring the dyad closer. While clinician and client are engaging around feelings of isolation and aloneness, they are doing this with one another. And the fact that the cultural object provides a bridge between their respective imaginative processes serves to offset the loneliness that the client brings, coupled with the fact that it is also profoundly familiar to the therapist, for whom this music is also deeply resonant. In addition, through her association to this particular relationally significant cultural object, while nodding to her client’s sense of loneliness and isolation through her allusion to the Springsteen song, she is building a relational bridge. In effect she is saying to her client, “We are intertwined with one another. Being with you and feeling your affective communication, led me to think about you in yet a deeper, relationally significant manner. This song came to mind while I am thinking of and feeling your sense of self.” In this way, she is also communicating his importance to her, which holds the potential to offset a potent sense of existential aloneness. Clinician 4 spoke of this phenomenon as a way of introducing her most authentic self in the clinical environment. She said that when she elicits a poem from her internal imaginative repertoire, she is communicating to her patient, “This really matters to me, and I am bringing it to you.” Here she has elucidated another dimension to the therapeutic potency of a clinician’s associations to a cultural experience in the context of her therapeutic practice in the form of offsetting existential loneliness, perhaps for both members of the dyad.

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The therapeutic power of the cultural object: the shared cultural object functions as “a case of unconscious communication.” 78 Clinician 4 described a seamless flow of connection between herself and her client in a brief clinical moment in which her client unfolded his narrative about driving alone in the night, and she associated to Bruce Springsteen’s song, “Stolen Car.” 79 The nature of their connection is reminiscent of Altman’s (2002) rendition of a connection that unfolds between himself and his patient around an Emmy Lou Harris song. He writes, Mr. P and I had connected in a parallel, extremely powerful way, also mediated by a woman we both loved. This seems to me clearly a case of unconscious communication. Unbeknownst to both of us, we had located some shared emotional space in which, simultaneously, Mr. P. could find his father and we could find each other. Talking about what had happened seemed beside the point. Perhaps all the talking we had done up to that point had prepared the ground for this intersubjective resonance, but I suspect that it is more to the point to say that in our time together up to that moment, we had been unconsciously seeking points of shared resonance. (p. 510)

Altman, Neil (2002), page 510. Lyrics to “Stolen Car”: I met a little girl and I settled down/In a little house out on the edge of town/We got married, and swore we'd never part/Then little by little we drifted from each other's heart/At first I thought it was just restlessness/That would fade as time went by and our love grew deep/In the end it was something more I guess/That tore us apart and made us weep/And I'm driving a stolen car/Down on Eldridge Avenue/Each night I wait to get caught/But I never do/She asked if I remembered the letters I wrote/When our love was young and bold/She said last night she read those letters/And they made her feel one hundred years old/And I'm driving a stolen car/On a pitch black night/And I'm telling myself I'm gonna be alright/But I ride by night and I travel in fear/That in this darkness I will disappear/Songwriters: Barnes, Ted / Orton, Beth / Read, Sean / Blanchard, Will/Stolen Car lyrics © Warner/Chappell Music, Inc. 79

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In the context of discussing unconscious communication, Clinician 4 named the phenomenon of the clinician’s internal experience of “being with” her patient as felt, even when it’s not articulated, even when it’s not explicit. She said, “[What] Annie Dillard talks about is our connecting to caring for each other. And I don’t know what that is, this kind of holding, and I think it’s the most important thing: The felt sense of connection in the relationship. If it’s not there, I mean it can be there in very different ways, but if it’s not there, I think you can do an exercise with this whole set [of theories], but the most important thing is missing.” Altman continues discussing his example, which runs parallel to this one in many ways, likening the elicited cultural object to a dream image, and highlighting this “felt sense of connection.” He writes, All this occurred out of awareness, or at the very margins of awareness, and without verbalization. Yet, it seemed that whatever unconscious communication had developed between us was ready to emerge in precisely symbolized form; for example, the country music singer seemed the perfect symbol for our shared area of emotional responsiveness, for his mother, perhaps for my mother. She emerged between us like a mutually dreamed image. Verbal symbols were mere vehicles for this more profound dreaming. One might say that whatever passed between us, or whatever it was that subsumed us, existed in symbolized, but not verbalized, form. (p. 510) Altman’s conceptualization of this kind of experience of an unconscious association to a song, is as a “mutually dreamed image.” In this way, he transforms the verbal aspects of this experience into an emotionally resonant non-verbal phenomenon,

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likened to dream-work, likened to a condensed image carrying affect. In similar fashion, Lipson (2006) writes, I find it helpful to approach [the presence of the spontaneous emergence and presence of music] as we do dreams and dreaming. In my view, Freud's (1900) consideration of dreams as “a sort of substitute for thought-processes, full of meaning and emotion” (p. 640, italics in original) is equally applicable to the experience of internally heard music . . . One can use a melody or composition to express a collection of affects—i.e., feelings plus cognitive content—in a parsimonious way by means of condensation. Thus, the music may well express more than can easily be put into words. (p. 865) This condensation of material here, as in dream work, falls into Freud’s category of primary process thinking, opening therapist and client to essential themes within the client’s imagination and experienced by the therapist as well as a non conscious communicative phenomenon.

The therapeutic power of the cultural object: sharing a cultural object’s nuanced meanings offers an experience of felt knowing characterized by playfulness, engendering new relational possibilities. At a moment when feelings of loneliness and isolation were being articulated by the client the therapist joined him around this sensibility, and mitigated the loneliness in the moment of “winking;” initiating a sense of connection, of his “being known.” She set a cyclical, nonverbal relational loop in motion by responding to him in this way: She picked up on his nod to Bruce Springsteen in his narrative, and the fact that they shared

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an affinity for him, and built on it, extending the particular shared, loved song, “Stolen Car.” In this moment of provision, she held a strong intuitive sense that he would get it; that her association would land well within him, which it does. Together—client and therapist—shared a moment of “simpatico; of knowing and being known;” a sense of what he’s feeling along with a communication that she has a good sense of what he is feeling. It is also significant that the Springsteen song captured a feeling that they both know, a deep sense of loneliness and desperation. In addition, this significant clinical moment is facilitated by a shared playfulness of therapist and client. Mitchell (1988), exploring Balint’s understanding of a key clinical moment in which his patient performed a somersault in his office, writes, The mutual development with the analyst of new forms of relationship is ameliorative. The new forms reflect a playfulness, a spontaneity, a willingness to take risks. [Balint’s] clinical example of the somersault [offers] a crucial interactive meaning vis-à-vis the shifting relationship with the analyst. (p. 155) Clinician 4 has a light, playful touch here with her client, in response to his narrative and her evocation of the Springsteen song. Her intervention feels organic and improvisational in nature, responding in a manner that Symington (1990) discusses in terms of “what Bion understood by freedom and its transmission from one human being to another” (p. 95). Offering a case illustration in which a moment of therapeutic, interpersonal freedom facilitated an opportunity for a useful therapeutic experience within the treatment, he writes, The patient became calm after that and spoke in a co-operative manner for the remainder of the session. I think that was because she felt I had spoken to the real

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her. For a time then she and I were responding to one another. The real me was contacting the real her. In this mode of communication there is an intercourse between the two persons. One person responds to the other person. The response comes from his own thinking and feeling centre and yet it is at this moment that the one is available to the deepest intercourse with the other. It seems that even more than this is the case: that an intercourse between the centre of one person and that of another favours the capacity for freedom in the other. I think that we might state the matter more definitely: that the person seeking freedom needs to find the personal centre of another in order to be able to give free expression to him-or herself. Freedom arises out of the emotional intercourse between one person and another. (p. 102) Clinician 4, in the service of this research inquiry into the nature of the clinicianâ&#x20AC;&#x2122;s associations to cultural objects, and what her reverie offers the psychodynamic process, highlights a way in which associating to and offering a cultural object for dyadic use can be a playful quality of engagement that enhances relational possibilities as it offers another way to be in relationship with one another. This experience within the therapeutic process, works toward what Mitchell (1988) encapsulated as â&#x20AC;&#x153;a different interpersonal situation in which richer experiences of self and other are possibleâ&#x20AC;? (p. 290).

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The therapeutic power of the cultural object: sharing a cultural object’s nuanced

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meanings provides a mirror for the patient, facilitating the potential for true selfknowing. “I like to think of my work this way, and to think that if I do this well enough the patient will find his or her own self, and will be able to exist and to feel real.” 80 Winnicott (1971) writes about the provision of the maternal mirror: Now, at some point the baby takes a look round. Perhaps a baby at the breast does not look at the breast. Looking at the face is more likely to be a feature (Gough, 1962) . . . . What does the baby see when he or she looks at the mother's face? I am suggesting that, ordinarily, what the baby sees is himself or herself. In other words the mother is looking at the baby and what she looks like is related to what she sees there. (p. 112, original emphasis) He continues, When the mother’s face provides a mirror, what you have is apperception: that which might have been the beginning of a significant exchange with the world, a two-way process in which self-enrichment alternates with the discovery of meaning in the world of seen things. (p. 113) The exaggeration is of the task of getting the mirror to notice and approve. . . . I see that I am linking apperception with perception by postulating a historical process (in the individual) which depends on being seen: when I look I am seen, so I exist. I can now afford to look and see. I now look creatively and what I apperceive I also perceive. (p. 114)

Winnicott (1971), p. 117.

This glimpse of the baby's and child's seeing the self in the mother's face, and afterwards in a mirror, gives a way of looking at analysis and at the psychotherapeutic task. Psychotherapy is not making clever and apt interpretations; by and large it is a long-term giving the patient back what the patient brings. It is a complex derivative of the face that reflects what is there to be seen. I like to think of my work this way, and to think that if I do this well enough the patient will find his or her own self, and will be able to exist and to feel real. Feeling real is more than existing; it is finding a way to exist as oneself, and to relate to objects as oneself, and to have a self into which to retreat for relaxation. (p. 117) When the psychodynamic psychotherapist elicits a cultural object that resonates with her client, in the manner that Clinician 4’s evocation of Springsteen’s “Stolen Car” does, she provides a mirror for her patient. He looks at her face and sees how she sees him; he has an opportunity to feel seen and known. In this instance she feels his desperation, his aloneness and, while the experience of being seen has the capacity to offset his sense of isolation, in a profound way it functions along Winnicottian lines: “It is a long-term giving the patient back what the patient brings;” and thereby facilitating the potential for true self knowing.

The therapeutic power of the cultural object: the clinician’s provision of the cultural object functions as a provision of maternal nurturance. In the instances when Clinician 4 was reciting poetry, a parallel process unfolded in which I gained a window into a client’s experience of her attuned responsiveness through the vehicle of her poetic associations and recitations. I was deeply moved by the

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experience of Clinician 4’s poetic recitation. Within the transference, it mirrored positive experiences in my own psychotherapy when my therapist would read a poem to me, or unfold a tale. I experienced moments of feeling that she was telling a story selected just for me. This sharing out of the cultural object elicited an experience of maternal sharing, maternal provision. She employed metaphors to describe this process that carried creative, generative meanings: She likened the offering to weaving a tapestry together, and enjoying a meal together. She said, “It’s like, ‘Oh look we’re responding to this piece of art together, or we’re knitting out this little tapestry together: We both are responding to it.’” We wondered together about the client’s experience of hearing a story, or a poem told to him in the clinician’s voice, drawn from her imagination much as a mother reads to her child. This relational element was experienced in situ by this researcher, and when I wondered aloud about it, reflecting on my experience, Clinician 4 had not consciously considered it to be operative, but found the idea consistent with her sense of herself and the provision of a story or poem as carrying both nurturing and maternal resonance. This was apparent even in the musicality of her vocal recitations. This finding is also congruent with the philosophical underpinnings of the Relational-Cultural Theory insofar as it contains gendered feminist underpinnings. The provision of a cultural object by the clinician, one that arises within her unconscious meanderings, within the context of her relationship with her client, has the potential to offer positive maternal provisions in multifaceted ways. This finding elucidates another avenue that fosters positive transference within the psychotherapeutic relationship, inspired by the clinician’s presentation of her association to a cultural object within the treatment setting. This data furnishes an added dimension to the query as to

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how the psychodynamic psychotherapist’s associations to cultural objects contribute to the psychotherapeutic process.

The therapeutic power of the cultural object: the cultural object functions as a defensive maneuver, blocks affect and/or offers the clinician hope. “It throws me a rope.” She also spoke openly about times when her reverie brings her to a piece of poetic text and she believes she is engaged in a defensive maneuver, struggling to find an enlivening, authentic communication in the midst of a session which she described as characterized by “a lot of dead language. An example would be “when a client is resistant to affective expression, going on and on about the details of his day, the problems with the computer program that does the billing for example.” In these instances she said that the evocation of a cultural object is a way for her to distance from the deadness of the session, taking care of herself and fending off the unbearable feelings in the room, what Ogden (1997a) calls “a defensive withdrawal into emotional detachment, a psychic numbness” (p. 586). However, in the case of this clinician, she is seeking something enlivening to keep her company during a difficult moment with a client. Lipson (2006) attends to this phenomenon as well when he writes, The melodies in the mind of the analyst at work can serve as outlets for inner needs, independent of those awakened by the analytic work, and in some ways may be protective of the latter. Of course, this is just as true of other collateral activities, such as drinking tea, doodling, or taking notes. Contemporary psychoanalytic literature and panel discussions sometimes convey an ideal picture of the analyst at work: one who is attending to the patient's associations with

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empathic, evenly hovering attention; is alert to inevitable countertransferences; and who carefully monitors any gratifications understood as enactments. But there are many potential intrusions on this idealized state that do not emanate primarily from the patient's experience. These may include somatic sources, such as pain or illness; personal or professional concerns; or unfulfilled needs of the analyst that are less conscious. . . . It appears that the tunes express in their content—but also in their presence—that the music is a form of company to deal with feared aloneness or its accompanying loneliness. (pp. 865-866) This clinician also spoke of the cultural object’s presence in her imagination “throwing her a rope” when the material is evocative. She disclosed, “I think it allows me to not panic, not rush in, not feel like I have to act. But I see she’s in a great deal of pain, and I see her kind of holding herself t tightly together . . . I respect that, and I see the need for that, and I have faith that eventually she will get up again. But I think that poem is about you know, I get it. I see how much pain you’re in, and we’ll get through this.” In this way her unconsciously bidden association offers her hope. She revealed, “I think it is a way sometimes of providing life; giving something that I find sustaining me. Lifegiving. Offering something. It enlivens me. It makes me feel, “Oh! I got something!”

The therapeutic power of the cultural object: the clinician’s articulated process. Clinician 4 delineated the process she engages in once a cultural object begins to occupy her imagination. She also spoke of how it lands within her client. While the majority of her clinical examples provided instances in which the client experience was one of being attuned to well, she also spoke of instances when the client grew enraged

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with her when she brought a piece of poetry into a session. She described a very self-

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conscious process in which she feels cautious about taking up too much space in a session, or in a patient’s imaginative process. She broke her process down into the following components, beginning by noting, “Sometimes it’s pretty conscious. You know I’m also thinking, ‘Where are we in our relationship? Do we have enough of a history together and a way of being together that I can do something that’s a little off the beaten path? Is [sharing my internal reverie] premature? Would it feel injurious [to this client] because [she/he may understand me to be saying] that they’re way of describing experience is inadequate? I really do question myself before [sharing out].” However she also described times when she acts in a more spontaneous fashion: “Sometimes in the middle of a therapy, if a phrase or a line comes to mind that fits, then I’ll use it without all that processing: a chapter, or a poem, or recommending book, or whatever. And you know I think it’s a wonderful thing.” Seasoned as she is, Clinician 4 has a repertoire of an internal triage checklist that she often summons to help her assess the therapeutic potential of bringing her association to a cultural object explicitly into a session. She considers the history of the therapeutic relationship, and the client’s capacity to take it in. And she also articulated an improvisational aspect to her clinical work when she might introduce her internal musing without premeditation. In this way, she trusts herself and her sensibilities. What is not stated explicitly here, but arose in other parts of the interview process, is the added phenomenon that this clinician, in large part because of her comfort and experience with the therapeutic process, is not unduly afraid of making a misstep as she understands that this too may nourish the work in unexpected ways. When she says, “And you know, I

think it’s a wonderful thing” she seems to be referring to the psychotherapeutic process itself and the potential it carries for good work to occur. Summoning her associations to cultural objects in the service of the work is a significant aspect of the way Clinician 4 crafts her psychodynamic practice.

Clinician 5 Case description. Clinical context. Clinician 5, a woman in her late sixties, sees clients privately and within an agency setting where she has been affiliated for over 20 years. She currently holds a caseload of approximately 26 clients. Her clients span adult developmental phases, and about two thirds of her clients are women. Many of her clients are artists: writers, musicians, visual artists and actors. Because her son is a musician, she identified as having an interest in what she called “the musical process.” And she further noted, “The process of becoming a musician informs me too.” This clinician delineated the course of her career’s theoretical influences paralleling those of the field: She began her career in a hospital setting which she described as “a bastion of psychoanalytic thinking,” by which she meant classical psychoanalytic thinking, given the historical context in which her career was launched. As Kohut’s influence began to be felt in the 1970’s, she was exposed to his thinking both in her clinical setting at the hospital, and in courses pursued at a leading psychoanalytic institution. In the 1990’s, she participated, together with colleagues with whom she worked, in workshops at the Stone Center 81 with a focus on 81

The Stone Center and The Jean Baker Miller Training Institute are housed at Wellesley College.

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Relational-Cultural Theory. She attributed this theoretical model to providing a formative influence on her clinical thinking and practice. In addition, experiences shared with other clinicians in this agency are held in high regard as this clinician understands her professional life in this particular agency setting to be deeply enriching and personally meaningful. Relationships are very important to this clinician, in both her personal and professional arenas. She explained that the relationships she has in her workplace span 20 years: “The agency is a wonderful, wonderful place and some of my very dear friends: they become friends. I’ve been there over 20 years. So when I go there it’s like walking in to a, like a dormitory. It’s one of the things that keeps me from seriously thinking about retirement because I don’t want to give it up. The center, because of [the director], is a place where people work together. It’s a community. A lot of us are the same age. We’ve raised our kids together so we know . . . everybody knows everything about the other one.” This clinician was articulate about the possibility that this workplace may not abide in every employee’s experience as the valued, deeply meaningful place it occupies for her. She attributed this primarily to her significant connection with her director and long-time friend about whom she said, “I feel that place and [the director] have been

Their website states that they take “a multidisciplinary, feminist approach, informed by the Relational Cultural Theory as well as other theories and techniques.” Influential clinicians associated with this Center have included Judith Jordan and Irene Stiver. Relational-cultural theory suggests that the primary source of suffering for most people is the experience of isolation and that healing occurs in growth-fostering connection. This model is built on an understanding of people that emphasizes a primary movement toward yearning for connection in people’s lives . . . (p. 95). Listening people into voice, into authenticity, into mutuality involves respect, deep understanding, and an appreciation of the forces that create isolation. This is at the heart of the healing connection (p. 102). [Jordan, Judith V. (2000). A Relational-cultural model: Healing through mutual empathy. In Bulletin of the Menninger Clinic, 65[1]: 92-103. Retrieved from http://sfprg.org/control_mastery/docs/heal_empathy.pdf]

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pivotal in my development as an adult, and I mean that’s the way [the director] is herself, with literature and movies and everything just winding through, and I sort of, I mean I feel that place is my spiritual home.” She continued, “[She] has been with my kids since they were little. She was at my daughter’s wedding; she will be at my son’s wedding. She loves them all. So my family is woven into the life there, but I feel as if, and I bring that with me outside too. I mean I talk about the people from there, and it’s really interesting because many of us get together outside for dinners, and I consider them, a few of them, really dear friends.” Clinician 5 played down the meaning to her of her husband’s role in designing the current therapeutic space which her agency inhabits, as well as her own private office, yet it is more evidence of the deeply personal aspects of her connection with this agency. Further, she observed that their home, which houses one of her clinical office spaces— her living room in fact—and the place in which we met together, reflects her husband’s “eye” in a myriad of ways. This fact was multi-layered, and opened up to an understanding of Clinician 5’s life as highly integrated and fluid as regards the finer aspects of her way of being in the world. For example, there are two beloved pieces of art that hang on her living room wall, which were purchased on a vacation in the Southwest long ago. At that time she purchased two of each: One hangs in her home, and the other in her office. She described one of them, a print by R.C. Gorman, this way: “That’s just a group of women who are you know with each other, and in conversation, and I love that, [and I love the body poses] too and I love the colors, and I love the colors from the Southwest.” 82 Her experience of visual art has a palpable, sensual element. In describing

The second painting is by Irene Klar. http://www.ireneklar.com

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a painting on a greeting card she was planning to give her future daughter-in-law at a bridal shower, she waxed rhapsodic: “It’s like a whole body experience! I have a card: It’s a long picture of brightly dressed people with umbrellas, no faces, just sort of walking in the rain, but it looks happy and it reminds me of a piece that my son [who is a harpist] played when he was in high school, and I used to say to him, ‘This makes me think of people in New York walking in the rain, and looking in store windows.” In this way, she radiated a feeling about herself and the way she experiences the world: In her son’s harp music she heard a whole story, a whole sensibility. It’s the smell of the rain, the feel of the rain, the shop windows and the affective feeling which she connected with joy, which she insisted isn’t always true on a rainy day. This moment of self-description provided a very significant aspect to comprehending her personal idiom, and this characterological piece comes into her work in meaningful, wide-reaching ways. Much as Clinician 5 presents as a multi-faceted human being who brings all of herself into her clinical encounters, she delineated a curiosity about her clients’ layered lives. She disclosed that she holds a visual image in her imagination of the floor plan of each of her clients’ homes. Similarly, inspired by a clinical consultant’s mentoring, she maintains a curious stance about what her clients are reading, and what they are creating. Many of her clients are artists, writers, actors and musicians, and so the intricate nature of their creative lives has a presence in the clinical work, and in her imagination, as well. She indicated that her life is deeply enriched by knowing such a diverse group of human beings, and that she is always learning from them. “You know, one of the things I love about our profession is nothing surprises me. Almost nothing. I mean, I know so much about the continuum on which people [live]. My clients teach me things about restaurants

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or books or travel or families or anything. And I don’t know how many, I just don’t know how many other professions have a tie in like that in the world. You get to know how so many different people think, survive, what they’re experiences have been, what they do for a living. Don’t you love learning about what people’s professions are? I know more about the ad agency, or the insurance industry, or the food and beverage industry.” In this way she communicated an elasticity of thinking and knowing about what is true in the world. She is nourished by spending time with friends and family, watching movies, and reading good literature—primarily contemporary fiction. She said she loved to read as a child: “I was one of those kids who would lock myself in my room and read under the covers so nobody would know I was in there. I love contemporary fiction. I read a lot, like right now I am reading the second of three books that a man named Dinau Mengestu has written, and it talks about the immigrant Ethiopian experience and he is a beautiful (This word had a musicality when she said it.) writer. I’ve been in a book group for about 20 plus years. It’s wonderful. It’s one of those places where I love the people, and so we have read many many things which have informed me, you know, about life, not just about books.” For this clinician, reading is a relational experience, and it is an endeavor that teaches her about the nature of being human, rather than simply inhabiting a world of intellectualized ideas. In addition, she has an affinity for children’s literature, which interweaves with her own childhood, her experience as a mother and now as a grandmother. Over the course of the weeks we were working together, she paused to show me a new acquisition or share an anecdote about her daughter and grandchildren vis-à-vis the texts of particular

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children’s books. These books, and more importantly her experience of the books, inhabit her imagination when she sits with clients and were at the center of key clinical vignettes she shared during the interview process. The ways in which they arrived unbidden in her reverie provided compelling examples of the phenomenon being explored by this inquiry. Clinician 5 articulated a discomfort speaking in formal professional psychodynamic language, although she has a strong sense that her work reflects a deep immersion in analytic thinking. She reported, “I know the theory. I can’t talk it. Like some people can, but I feel as if I do it.” The language she employed to describe her work, and the ways in which she interwove the personal and the professional, reflected a profound maternal presence. Her adult children and her grandchildren were present in many of her associations. Her maternal mantra which abides on her bureau in her bedroom, “Children need two things: they need roots and they need wings,” functions for her as a guiding principal in her clinical work with adults. She attributes her evolution from the classical psychodynamic training as a young woman, to her awakening under the aegis of The Relational-Cultural School connected with The Stone Center at Wellesley College, as a good fit “because of who I am.” In elucidating the dynamic of her maternal idiom, she offered, “Is it because of who I am? I’m pretty sure that’s true. Even things that I’ll say to clients: You know, you hear these things over the years, I don’t even know where I hear them anymore, but (She sighed deeply.) you know you have two families [in your practice], and an infant who’s crying and in one family they pick up the infant, and in one they let it cry. And they let it cry because they think well that’s gonna teach them how to, but in fact the more you do, the less they’ll cry. So I talk to people about that a lot. [For example, clients] will say things to me like, ‘Oh, they tell

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me that my mother says I’m spoiled.’ And I’ll say, ‘Alright, let’s look at it in a little different way.” She explained that she has a foundational belief, perhaps rooted in attachment theory and infant research, but more likely embedded in her innate sense of relational requirements for wellbeing. In striking the balance between the roots and the wings from her poster, she confessed, “I think I’m better at the roots than at the wings, [but] my kids have wings, so…” She went on to explain that because of “what some people have lived through,” their need for the provision of a secure attachment foundation is the therapeutic action required to facilitate the potential to later develop their wings. Another example of her deeply embedded maternal idiom is the analogy she brought to bear in articulating the ineffable aspects of the therapeutic process and what it yields. In the service of explaining how it works, she elicited a metaphor of the provision of healthy nourishment, elaborating, “I’ve had clients who at the end of therapy say, ‘What happened?’ And I don’t know if I heard it someplace, or if I made it up. I think of [the therapeutic process] like digestion: If you eat foods that are good for you, it goes in there. You don’t really know where it goes, but you come out bigger and stronger at the end.” She disclosed that this maternal stance has its source in her own childhood experiences. “I will say that I had a mother who must have come from another planet. (She paused here.) I always as a young child I would look at her and think, “How did I get her for my mommy? (She became emotional in the telling.) And she was a struggle for me my whole life. I think after multiple decades of therapy that she was really born with some quirks. [I think now that she was a] “super sensor,” [one of those people] who

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are very responsive to sounds and tactile stuff and have a hard time with it. And I remember saying to my mother once, ‘You know the wind blows and you are [undone].’ Everything that came to her was a crisis. I think she was born that way, and I think she was born into a family that had absolutely no idea what to do with that. All the other kids were fine, and she was not a good mother. She was angry. She didn’t know what to do when I think about it, and so being a mother—a good mother—was really just really important. It gives me a lot of pleasure to see my daughter as a mother, because she’s a better mother than I am: She has much more patience. She did [have a better mom], and as I say, ‘We’re moving up on the Darwinian scale.’” From a young age, this clinician had the advantage of being in psychotherapy, and she unfolded a moving story in which her therapist empowered her to consider making an application to a prestigious women’s college out of state. This anecdote highlighted the many ways her therapist functioned for her as both an idealizable and mirroring presence, nurturing her wellbeing, and laying the groundwork for her crafting a therapeutic identity and practice for herself. Her implicit identity as “the good mother” comes into her work at her agency in what she labeled “initially unexpected ways.” She went on, “I think at the [agency], I know the head of intake is a very good friend of mine, and I know they have certain people they will funnel to different clinicians, and I have never asked who they funnel to me but they will send me people who need a good mother. I can just tell. Although, I do think I tend to keep people a little too long, or maybe those people do need to stay a long time. I have more people that sort of wind down over a certain amount of time rather than have a formal termination, that’s okay.” She related that this maternal identity permeates

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the center. She disclosed that on one occasion the director was giving out playful awards, and “she gave me one for the best mother of the group. I love to cook. I bring food in. I love to do it.” Clinician 5’s maternal sensibility infuses her work, and influences the ways in which she associates to and employs cultural objects in her therapeutic practice.

Relationship to cultural objects, free association and reverie. Clinician 5 described a comfort attuning to her own thoughts while sitting with a client. She said, “I can’t imagine not doing this.” She frequently finds herself associating to children’s literature. This art form spans several genres: the written word, illustrations, as well as the frequently present musicality of the language. She organically introduces her associations to particular children’s books into her sessions. In addition, she associates to adult fiction and theater. Because so many of her clients are artists, her therapeutic work with them frequently involves the sharing and examining of their generative cultural experiences. Further, because of the nature of her characterologic affinities, she holds images of the significant architectural spaces, which her clients inhabit in her imagination as well. When asked about her attitude regarding unconscious communication, this clinician offered many examples from both her personal and professional life to attest to her experience of this phenomenon. She noted several vignettes involving associations to cultural objects, which arose unbidden from the deep recesses of childhood. She described important clinical moments in which she and a client were thinking along the same lines in a way that felt uncanny to her. She reported, “I do think that things [come to

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my imagination unbidden.] (She laughed to herself softly.) One of my very first private patients: We met twice a week if I remember correctly, for several years, 4 or 5 years. 7:15 in the morning. And one day I’m driving to work and I’m thinking, ‘She’s going to say that she’s ready to stop today.’ And honest to God, I walked in the room and she walked in and said, ‘You’ll never believe what I was thinking about.’ It was really it was really something.” She continued to elucidate the ways she thinks about this kind of phenomenon: “You know I felt like we had moved together; had done a lot of work; this goes back so long, I don’t even know if I can [conjure it up]. And I remember being surprised by the thought when I was going downtown. And it had not been on my mind specifically but I think, I do think that for a while I had been thinking, ‘She’s in pretty good shape, let’s just kind of see where this goes now,’ and she must have felt the same thing. So how do I explain it? We both had a feeling that she was ready to stop.” She went on to share several additional examples in which clients who have been away from treatment for some time contact her around the time she has begun to think of them: “Now here’s another client. She’s an actor and she’s now 34 and I’ve seen her since she was a junior in college. I’ve seen her through many relationships. She’s somebody who I think has a hard time planting her feet. In the last few years all of the work she’s been getting, and it has been almost non stop, has been out of town. She still has an apartment [here in town], which she shares with a couple of roommates, and the roommates come and go. And she can’t give it up. And she was just in town and actually we had a session, a few sessions a few weeks ago. She was here and I had not had any contact with her since December. It’s like there are two things that anchor her. Three things. One is a cat, who she takes with her. One is me, and one is her apartment. She has

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huge issues around dependence and independence. She and I are tethered somehow. So talk about unconscious something. If I don’t hear from her for two or three months, I’ll send her a note saying ‘Just checking,’ and she’ll say, ‘Funny that you should check in, I was just about to email you.’ That’s happened a few times. So I must [believe in unconscious communication].” Explaining the meaning she attributes to this kind of uncanny phenomenon, Clinician 5 continues, “Well you know when you’re wanting to talk to your kids and it’s been a couple of days too long and you think, ‘Boy! I want to hear her voice’? With her it’s not like she’s a kid, I mean the last two months as opposed to three days or whatever so I don’t know if it’s something like that, and some concern that she can sort of fly off the tether which I think she does. . But she can fall off the radar, [and] you know, I’m like her mother I suppose.” Bollas (1995) attributes this phenomenon to one having a “separate sense” that attunes to unconscious communication. He likens the “sense of mutual time” (p. 36) of analyst and analysand to that of the mother-infant relationship: Freud astutely likened this situation to the helplessness of being in a dream, or returning to the mother’s body, an intelligent free-narrative association as the mother and the neonate develop their own sense of mutual time. Later the infant informs the mother of his own time sense: when to be fed, when to be held, when to be rocked, when to rest, when to wake up. Later the child’s moods inform the mother of the time she may relax, the time she can be usefully anxious, . . . the time for humor, the time for seriousness, the time for empathy, the time for confrontation, the time for intellection, the time for feelings, the time for being

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idealized, the time for being realized . . . the time for . . . “ these times are the times of time in human relations, out of which the parent develops his or her separate sense of the child’s time—a time sense not thought out, although not thoughtless, which operates at the level of the parent’s unconscious ego as he or she is instructed by the child’s timing of the self.” (pp. 36-37) Bollas here captures the nature of Clinician 5’s unconscious connection to this young woman. Clinician 5 connected this phenomenon to moments in her personal life as well. She unfolded, “I have a good friend and we’ve been friends since we were ten. She’s one of my best friends. Our mothers were friends before us, back in the day, and I’ll be thinking about her, and the phone will ring and it will be her.” These moments of uncanny connections are resonant with Freud’s (1919) exploration of the uncanny. He writes, We must content ourselves with selecting those themes of uncanniness which are most prominent, and with seeing whether they too can fairly be traced back to infantile sources. These themes are all concerned with the phenomenon of the ‘double’, which appears in every shape and in every degree of development. Thus we have characters who are to be considered identical because they look alike. This relation is accentuated by mental processes leaping from one of these characters to another—by what we should call telepathy—, so that the one possesses knowledge, feelings and experience in common with the other. (p. 234)

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He continues, The theme of the ‘double’ has been very thoroughly treated by Otto Rank (1914). He has gone into the connections which the ‘double’ has with reflections in mirrors, with shadows, with guardian spirits, with the belief in the soul and with the fear of death; but he also lets in a flood of light on the surprising evolution of the idea. For the ‘double’ was originally an insurance against the destruction of the ego, an ‘energetic denial of the power of death’, as Rank says; and probably the ‘immortal’ soul was the first ‘double’ of the body. (p. 235) Freud’s investigation of the uncanny plays with the notion of chance and coincidence as it is experienced as uncanny. He writes, If we take another class of things, it is easy to see that there, too, it is only this factor of involuntary repetition which surrounds what would otherwise be innocent enough with an uncanny atmosphere, and forces upon us the idea of something fateful and inescapable when otherwise we should have spoken only of ‘chance’ (p. 237) . . . [We] are never surprised at their invariably running up against someone they have just been thinking of, perhaps for the first time for a long while. If they say one day ‘I haven't had any news of so-and-so for a long time’, they will be sure to get a letter from him the next morning. (p. 239) Bollas (2002) understands unconscious communication to be “easy to do because we are open to such unconscious mutual influence when relaxed in the presence of an other” (p. 19). Drawing an analogy of two friends, consistent with Clinician 5’s experience both with her childhood friend, her children, and several clients, he writes,

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When two people free associate . . . as is typical of close friends, they create unconscious lines of thought, working associatively, as they jump from one topic to the next. This is easy to do because we are open to such unconscious mutual influence when relaxed in the presence of an other. (p. 19) Clinician 5’s professional and personal life is infused with a belief in unconscious processes operative between human beings. This intuitive process has analogies in the mother-infant pair as well. “There is this thing called unconscious mental life. Unconscious communication goes on between us. It is mystical, unexplainable. It is communicated both nonverbally and content-wise.” 83

Co-constructing meaning: the interview process. Clinician 5 and I met in her home office, which is situated in her living room. Her husband was at home as he also works out of their home, and on one occasion he brought her a cup of coffee and a bag of books that she had loaned a family member during our interview. On each occasion, we met following an appointment she had had with a client, and the material from the session was active for her. We connected very quickly, assuming a familiar, comfortable sense of one another. Our shared cultural, religious, and gender and generational identities, as well as some shared beloved mentors, nourished this ease almost from the outset. We discovered that my recent college graduate daughter attended the same college as this clinician, and spent some time reflecting on the way cultural shifts have affected the college’s deep-seated traditions; we could easily allude to a recent change in the format of the New York Times Magazine, as

S. Faigen, personal communication, 10-27-13.

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well as to numerous authors and works of fiction. However, the moment when the connection really crystalized was when I introduced a Yiddish word into my response to her. There was a subtle shift in the relationship that we both felt, and I remarked about the role of language as a cultural object that affectively connects individuals in potent ways. Still, there was a disparity between us insofar as she is a seasoned therapist in practice for almost 30 years, and I am a nascent therapist, albeit a doctoral student in clinical social work. While I looked to her as an expert who holds the capacity to further my research with her expertise, overtime it became apparent that my ease with the psychodynamic language, and my wish to formulate some of my questions, and play with her ideas and experience by employing this language made her uneasy. While I could not quite name the phenomenon early on as I was operating from a place of high regard for her, as well as curiosity, in the third interview, she articulated her uneasiness, and perhaps a feeling of being diminished in the presence of my ease with psychodynamic thinking, and perhaps my impending doctoral status. In response to one of my questions, she responded, “I know the theory. I can’t talk it. Like some people can, but I feel as if I do it.” At this point, as at others, I worked to reframe questions and to highlight that much of my learning has been from teachers who stressed “Say it in English,” as opposed to employing the professional jargon. Earlier in the interview process, I must have sensed this in a more implicit way, because I would periodically pause to emphasize my genuine excitement and delight at her providing me with rich clinical vignettes and thinking. At play in this instance was an instructive example of language actually creating a barrier

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between us, carrying implicit hierarchical status that was unconsciously divisive, and which I worked both unconsciously and consciously to overcome.

Articulated impact of the interview process. Clinician 5 brought a humility to the interview process as we co-created meaning in response to her case vignettes which exemplified the process of cultural experience inhabiting both her imagination, and the potential space between herself and her client. On one occasion specifics of a vignette she provided inspired me to think aloud about the implications of her example for my inquiry. She became enlivened by my musings, indicating an experience of being profoundly challenged to think about the nature of the intricacies of her work in new ways. On another occasion, she exclaimed, “You should really work at [my agency!] You would be perfect there.” And while I regret not asking directly what she meant by this, her implicit meaning seemed to suggest that she experienced a kinship with me in the nature of our thinking together about her work that was in line with the collegial experience she associates with her work in this unique agency. In yet another instance, she drew an analogy between the experience we were sharing, and positive experiences with a beloved consultant who will soon be retiring. She reflected that she found that the way I was building on her clinical vignette with theoretical underpinnings to be professionally significant and moving. In addition, she underscored that she found it useful to consider an impasse in the treatment through the lens of my thinking, vis-à-vis this research question regarding how clinicians think about their associations to cultural experience in the context of their clinical work. Finally, as our work together concluded, and I inquired about its impact, she stated, “Well I suppose,

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every time now that I make a reference to a book, or music or something, I think ‘Oh! Ellen.’ I think about it in a different way.”

Categories of meaning. An analysis of the data gleaned from interviews with Clinician 5 yielded two major categories of meaning. The first category of meaning consists of the meaning and use that Clinician 5 makes of the cultural object. The second category of meaning comprises the therapeutic power which Clinician 5 ascribes to the cultural object. Each of these overarching categories of meaning consists of sub-categories of themes which are described in detail in the findings that follow. The following themes are contained within the first category of meaning, the meaning and use of the cultural object: •

Children’s literature is like poetry.

•

The cultural object contains relational resonance and keeps the therapist company

•

The cultural object facilitates access to the imaginative process in the context of meaningful connection.

•

The cultural object of language.

•

The cultural object as it symbolizes a vehicle for authentic self expression, and authenticity.

The following motifs are found within the second category meaning, the therapeutic power of the cultural object: •

When a cultural object cannot be imagined.

•

The cultural object provides a defensive function.

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•

The cultural object universalizes the human experience, inspires the therapist to utilize the pronoun “we,” reflects a two person psychology.

•

The cultural object functions as a third thing that enables the dyad to speak about the patient’s inner world, and mirror the patient’s acts of creative expression

The meaning and use of the cultural object: children’s literature is like poetry. Clinician 5’s idiomatic associations to children’s literature garnered curiosity as it dovetails with the parameters of this inquiry as to how the psychotherapist’s associations to cultural objects impact the therapeutic action. This clinician was articulate and thoughtful regarding this query. She likened children’s picture books to poetry. She described them as containing affectively layered meanings. She noted that she experiences the books she draws upon in her reverie as conveying meaning through metaphoric communication. Describing the metaphoric layers, she said, “[The metaphor] gives a picture to what you’re trying to describe, or it just strikes a note. Sometimes that stuff is so hard to articulate. When you use a metaphor to describe an experience, it’s like you both understand what’s being said but sometimes you can’t, like poetry. You can’t quite yourself put it into words, but the metaphor or a poem or even a piece of music can just help you feel something.” And while the books are language based, there is often a musicality and rhythm to the language construct, and there are always pictures. It is her experience that children’s literature, while language bound in part, conveys meanings that abide beneath the surface. She encapsulated these as affective resonance, and implicit relational knowing. Speaking to this point, she characterized her experience of children’s

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literature, “It’s musical. It’s poetic. It’s touching. It’s a whole body experience!” For her, this sensibility in its entirety often inhabits her imagination while sitting with clients. A significant aspect of this phenomenon is the way it carries relational resonance, in particular vis-à-vis the characterologic maternal idiom she brings to her work. Often the vignettes she shared in which she associated to a children’s book, summoned her relationship with her own children and grandchildren into her imaginative sphere. This dynamic of her associative process contributed a felt sensibility to this researcher while attending to her narrative in ways that suggests they also hold the capacity to be experienced by her clients.

The cultural object contains relational resonance and keeps the therapist company. “There’s the story, and then there’s the relationship.” Clinician 5 described a difficult set of sessions with a couple from South America whom she was seeing in the context of a church-mandated, time-limited, pre-marital couples’ therapy. She has a great deal of experience working with couples of South American origin, but this couple was difficult to engage, chronically late, and frequently needed to change an appointment at the last minute. In the session she shared they were very late to an appointment which she had stretched to accommodate, and she was feeling disgruntled. In addition, their life circumstances are complex in terms of their contemplating marriage. She explained, “I really have a sense of how difficult things are for them because she essentially lives here and he lives there. And they are trying to figure out where they’re going to live, and it’s really a very difficult situation. I am worried about it. But I told them. Yesterday and last week, ‘Is there any reason you have

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to get married in May? Can this be delayed so that you can settle some things? I’m not saying you oughtn’t to get married, you know, just give yourselves a chance to breathe. Why don’t you do that?’” In the midst of this complicated therapeutic experience, Clinician 5 found herself associating to a children’s book. She disclosed, “The couple that I saw this morning are from South America. Well they’re South American. She was raised here and he was raised there. And they were talking about their extended families, and talking about the polygamous family structures a couple generations back. I remembered that and I hadn’t remembered this in I don’t know how long (She paused to gather her thoughts.) a book that I read when I was in third grade called Thirty One Brothers And Sisters 84, which was about a little girl who grew up in a family like this.” When I asked her about her experience of this book, and how long since she had last thought about it, she responded, “I was eight. It’s been probably 60 years.” We both laughed at this: the number of years, the fact that this was happening between us, and that it regularly happens for her, and that I am interested. I invited her to share what had happened to her in the moments of this association. She delineated, “First of all, the librarian. I loved the librarian at my school at that time. And she liked me. She plucked it off the shelf and said, ‘You’re going to like this book’”. She shared this with delight in her voice: There was a felt sense of pleasure at having someone special choose something just for her, with her in mind. Parenthetically, this is a phenomenon represented elsewhere, and expounded on later in this document: the experience of having a cultural object offered with personally meaningful intent. She

http://bookviewcafe.com/blog/2012/05/01/rereading-thirty-one-brothers-and-sisters/

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continued, “There’s the relationship. I can picture that librarian’s face. I can’t quite remember her name, and my age.” She went on, speaking quickly, “I told them about it. I said, ‘You know, I just thought of a book I read when I was a little girl, and I think it was from South America, and I remember it very clearly.’ And I told them the story of the librarian, and how much I loved it, and that I think what they were talking about in terms of their feelings was making me recall such an image, and they liked that. [And the feelings between us were] better when they left than when they came. I will tell you that. (We both laughed.) I think better for them because I don’t think they liked the way it started. [Yesterday, session two] was worse (She sounded disgusted when she said this.) because, yeah and this was part of my anger, which was at myself because they were so late on Thursday, because we could do nothing basically. I had to figure out a way to see them for the full three sessions. He wasn’t sure if he was going to be able to change his plans. He had to go back to South America, and he was going to go back on Saturday so he had to change his flights.” She continued to elaborate on her anger, and in this way demonstrate what the cultural object provided: “As it turned out I had a cancellation and I agreed to see them this afternoon. So they came 35 minutes late. Anyway. I was pissed at these people from the beginning. I was bending over backwards: Late! I was mad. And I was ranting this morning: They were half an hour late. [I felt] I have an obligation to them to say something about this because I’ve been concerned about their relationship, and I was wondering if this (her countertransference) could give me an inroad into something that I could use, and so I did say something about it: I said, ‘I don’t understand. You know I’ve really bent over backwards.’ [The woman] said, ‘I’m always late.’ I said, ‘You’ve got to

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stop it. It’s not good.’ He said, ‘Yeah I was mad at her too. I was ranting in the car.’ So I was trying to find a way to be in a better place with them [and] I think that that’s part of what made me sort of access [the children’s book] because that gave me a better, it gave me a better frame. (Here she was speaking loudly, animatedly.) Also, you know, (Here her voice softened.) she told me about her sister in her late 20’s [who has cancer], and it’s metastasized. So you know, I got a better picture. They weren’t horrible people.” This clinician was working to access some empathic connection with her clients. Asked to consider what her association to the children’s book from her childhood might have given her and offered the work, she noted, “It just maybe helped me [get a better picture] of what their, how they were raised. It made me feel kinder toward them.” Her evocation of this important book quieted something in her. She somehow unconsciously invited it in to keep her company, and the librarian too: “Yes! The relationship that I had with her: That’s exactly right. [There’s the story,] and then there’s the relationship.” In addition, it seems that her offering of the book as a significant cultural object in the context of an affectively meaningful relationship, may have facilitated her young client’s disclosure about her sister’s illness. The therapist’s revealing a personally meaningful vignette connected with someone important from her childhood possibly opened something in this young woman, enabling her to explain more fully the burden she holds that impacts her inability to keep an appointment, be punctual, and navigate certain aspects of her life at present. This inquiry takes as its focus the ways in which a therapist’s associations to cultural objects impacts the therapeutic enterprise. In this instance, the clinician’s association to a cultural experience in the context of a deeply meaningful relationship,

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facilitated her capacity to soften her stance toward difficult clients. Both the story and the relationship were invited into her imagination to companion with her in a challenging clinical moment. Once in the company of “old friends,” she was more able to attempt to build a bridge with this young couple, internally gaining ground for feeling connected. In the wake of this set of feelings, she shared the association with her clients, including the relational context. This in turn touched a fragile relational association regarding the client’s sister’s serious illness. In this way, the relationship between therapist and couple has deepened, and a stalemate of anger and blame was thwarted in large part due to the therapist’s association to a childhood experience of a cultural object offered in the context of a precious relationship. In the context of talking to me about her association to the book Thirty-one Brothers and Sisters, Clinician 5 instantly identified a wish to find the book on Google, and later expressed a yearning both to order it and to read it to her granddaughter. Wondering what it might be like, she said, “I should see if I can find it for my granddaughter. Although you know it’d be like probably going back into a house that you haven’t been in since you were little where the rooms become a lot smaller as you are older. It would be interesting to see what it’s like.” This possibility became a valued theme between us. In confirming our second interview via email, I wondered if she’d had any luck getting hold of a copy, and when we met for the second interview, she shared, “I just really liked [the first interview], and I went and ordered my book from when I was about [eight]. I had to get it used and it took weeks to get here and I haven’t even opened it up.” She communicated a lot of enthusiasm about this process: the love of a book, the love of this book, its role in our work together. She continued, “So I’m hoping maybe

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later this afternoon I may get a chance to look at it. I had hoped it would get here early enough so I could bring it out to my daughter (whom she was travelling to visit in the intervening weeks). Well it didn’t. I opened it and I looked at some of the pictures, [and] I do remember the pictures. I didn't remember the gist of it which is it’s about a little girl who wants to go on a wild animal hunt (She ended this sentence with a questioning tone, as if to say, “Pretty far removed from my life, right?) A wild animal hunt? Something that only boys do, but she does something that’s brave and they allow her to go, so I realize that it really had a lot of resonance for me.” In her telling, I had a longing to touch the book, and she found herself wishing it was an original copy, published in 1954. She went to the back room to retrieve it, and together we poured over it for a few moments, enjoying its familiar and yet vintage qualities, and the pleasure of holding a book in one’s hands and turning the pages. In this way, the pleasure of the cultural object and the experience of the cultural object facilitated a textured experience between us which expanded the shared interview experience and deepened our connection, thus offering a “meta moment” of the power a shared cultural object might offer in one’s clinical work. Taking this phenomenon to one last level of inquiry, I wondered why she thought she might have associated to this story with this couple at this time, noting that she has worked with many South American couples. Holding new information that the book carried a message of women’s empowerment: a little girl wanting to move into the male world of hunting and somehow succeeding in being accepted for this challenge, she wondered about her concerns for this young woman in the context of this complicated marriage arrangement. But more broadly, she had another association. She unfolded, “You know my only thought about it is that my daughter and a friend of hers just did this

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enormously successful kick start called ‘Princess Awesome.’ They are making dresses for girls that have more traditional boys’ themes on them: the symbol Pi; atomic circles, robots, all kinds of stuff like that and that has been very much on my mind and she is, I mean she has this fire in her about equality. And my head’s been full of that for the last month, so I don’t know if that also helped trigger it. This is about girls doing nontraditional things. My sort of take on it [before seeing it again] was that it was about the relationship between all these brothers and sisters, although I didn’t remember any specifics.” Clinician 5’s experience of her daughter’s moving project around women’s equality and empowerment in some delicate way may have awakened a latent experience wedged quietly in the recesses of memory that opened as she sat with this couple, and provided a textured companionship that impacted her therapeutic action. Her experience of this book has many layers, functioning as what Bollas (2002) and Freud (1909,1923) describe as a “condensed image,” characteristic of dream imagery and the aesthetic. The way it felt to have a significant Other choose it for her with intent; the love she felt for and which seems to have been reciprocated by the librarian; her experience of the book’s subtle message that with perseverance she could tackle confining boundaries which was a theme of her childhood with a challenging mother; her emotional involvement with and excitement regarding her daughter’s progressive and radical gender identity project; her disquiet in her work with this couple both in terms of the logistical challenges and their concerning narrative.

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The cultural object facilitates access to the imaginative process in the context of meaningful connection: Miss Rumphius, an example. Miss Rumphius is a children’s picture book that, within the context of the interview process, we discovered we both treasure. Compellingly, we each had a very different reason to love the book. Clinician 5 described the meaning she makes of Miss Rumphius while sitting with her client. “The ‘lupine lady’ 85: [I draw upon this when] I have either single or women with no children who are clients who have struggled to think about sort of what to leave behind. And so I have either loaned them my book or told them about it and said, ‘You know, you can be creative. And I also like Miss Rumphius because she was a single woman who travelled the world. And she didn’t stay home.” Initially in her telling, it seemed that the book did not function so much as an associative phenomenon, but rather was a conscious tool she employed with a patient who was struggling with issues of legacy in the wake of childlessness. However, as Clinician 5 unfolded a clinical example, there was a powerful, palpable sense of an event occurring between herself and her patient that enabled her to offer her client a window into the clinician’s own imaginative process in a way that served the work. She explained, “I have one woman whom I’ve known for many years, who has had just a horrible life. She’s a fragile woman; worked for the federal government for her whole career; and you know, has a marriage, a very long-lasting marriage: I think he’s probably as fragile as she is, but they’ve been good for each other, good to each other. And she retired, and she wants to do something to regenerate or something and so I

This is the epithet given to Miss Rumphius, the book’s protagonist, because she travels across the state of Maine sprinkling lupine seeds, with the express goal of “making the world a more beautiful place.” 85

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showed her that book. She’s very childlike herself. So it was a good shidach 86.” This clinician communicated that she wished to convey to her client, “Take a look at what this lady did: Think about what you can do. Flowers! What’s wrong with flowers? Can you think of anything that you could do that would make a dent in the world in a good way?” This being the message she wished to convey to her client, I was curious, “Why not just say it that way? What does her association to this book at this time with this client offer her, and how does it enhance the work?” She responded, “When books like that cross my mind I just offer the book because I can think about things and imagine things better than this woman can. Her vision, I think, about life and herself is more limited.” In this way she was offering her client an experience of her imaginative process. She continued, “I love those images and pictures, the words and feelings. And I love the feeling of sitting with my kids and reading those books to them and I (She paused.) I don’t know (She paused again.) I’m sure it’s not conscious that it’s in my mind, this idea about that book when I was reading it to my kids. (She put her arm around her imagined kids) I just, I don’t know. I think there’s something tangential, something they can see! I mean it’s like a metaphor. It takes it out of here. And it puts it somewhere else.” In this moment of the interview process, Clinician 5 articulated a host of phenomena operating for her at once in the context of her reverie. Sitting with her imaginatively limited, emotionally impinged client, who, in the context of her long term relationship with this clinician wishes for “something to regenerate her life” in the wake of her retirement, Clinician 5 associated to a cultural object that offered a rich imaginative process in both its narrative and its drawings. The association entered her imagination in connection with

Shidach is yet another Yiddish word that means “match made in Heaven.”

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her own maternal act of reading this book to her children, with her arm around them, snuggled close. In the moment of sharing out with her client the subject of her reverie, she offered a textured tapestry, a story interwoven with a profoundly held maternal relational matrix, intertwined with an enterprise of imagination. In my mind’s eye, as she reached her arm around her imagined children, now grown, I imagined each of them— she and her client-- imagining, inspired by both the illustrator’s breathtakingly beautiful drawings, the narrative of this generative older woman’s action, and the feelings of being nestled close to one another. In the moment of Clinician 5’s telling, the overarching resonance of her offering to her client was one of rich, imaginative possibility in the context of meaningful connection. All of these significant relational communications were conveyed by Clinician 5’s association to Barbara Cooney’s Miss Rumphius, in the context of her work with this client. As she unfolded these layers and we played with them together, these moments of engagement between us were characterized by, what Ehrenberg (1974), in her description of “the intimate edge” identifies, citing Guntrip (1969) as “’the moment of real meeting of two persons . . . a new transforming experience . . . so that therapist and patient can at last meet "mentally face to face" and know that they know each other as two human beings” (p. 427). Elaborating on her thinking by citing Buber (1957b) Ehrenberg writes, “The chief presupposition for the rise of genuine dialogue is that each should regard his partner as the very one he is (p. 436). The sense gleaned from this experience is that this phenomenon also occurred between client and therapist in the vignette she revealed. Daniel Stern et al. label this kind of intersubjective experience a “moment of meeting” or a “now moment.” Defining this concept, they write,

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The key concept, the “moment of meeting,” is the emergent property of the “moving along” process that alters the intersubjective environment, and thus the implicit relational knowing. In brief, moving along is comprised of a string of “present moments’, which are the subjective units marking the slight shifts in direction while proceeding forward. At times, a present moment becomes “hot” affectively, and full of portent for the therapeutic process. These moments are called “now moments”. When a now moment is seized, i.e. responded to with an authentic, specific, personal response from each partner, it becomes a “moment of meeting”. This is the emergent property that alters the subjective context. (pp. 909-910, original emphasis) Clinician 5’s implicit relational idiom is embedded in her telling here. It was a felt experience by this researcher, and I would conjecture, held a therapeutic potency for her client and the dyad, inviting her into a “moment of meeting” characterized by a generative imaginative process. This process is contained both in the cultural object of the Miss Rumphius tale, and in the inter-subjective experience of its being shared between them.

The cultural object of language: “I say ‘we’ a lot,” and “I use a lot of Yiddish words. They carry a lot of feeling and you just can’t translate them.” As clinician 5 was describing her countertransference feelings that brought up the Judith Viorst book, in one of my questions to her, I unconsciously chose to introduce the Yiddish word “kvetch,” rather than the English word “complain” or “whine.” Something shifted in our process in the wake of my introduction of this common cultural object. She

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got a twinkle in her eye, and there was a sense of our bodies both relaxing with one another a bit. Thinking that the shared cultural phenomenon had offered us something to investigate related to my inquiry, I focused on this meta-experience momentarily, sharing my awareness. She wasn’t sure, but as we spoke about it, she acknowledged, finishing the sentence I had begun with “There’s something about Yiddish . . .” by expressively remarking, “Oh! It says what it is. You can’t [exactly] translate it,” as it carries affective resonance. She continued by speaking about Yiddish expressions that come into her sessions, “I use Yiddish words a lot. I will often preface it with “Do you know what this means?” You know: mishegas 87, mazal tov 88. It’s true, and I will actually use those words. You know people will say, “What’s the matter with me?” And I will say ‘You’ve got a little mishegas. We all do.” (At this point we both laughed.) ‘Let’s figure out what yours is and what we can do about it!’” (We continued laughing.) She quickly followed up with a brief exploration of the Yiddish word, ferklempt 89: “Well how many clients have heard the word ferklempt on Saturday Night Live when Dana Carvey and Mike Meyers introduce it?” In this way she was indicating how these culturally significant words from Eastern European Jewry have found their way into American culture. Contrasting her employment of Yiddish in a session with psychodynamic terminology, she added, “I try not to use the language of the field although on occasion it’s the only words that come to mind.”

Mishegas is a Yiddish word that designates a lighthearted kind of “craziness,” in the sense of a universal human issue, rather than pathological. 88 Mazal tov is a Yiddish expression that literally means “good luck” and is used to wish someone congratulations. 89Ferklempt expresses a sense of being choked up with emotion. It is usually expressed with a sense of drama.

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Our investigation of this cultural object of the Yiddish language moved from lighthearted to serious-minded, as Clinician 5 offered a deeply personal family story from her childhood following World War II, in connection with the Yiddish daily paper The Forward. “[Yiddish is] not going away. It’s a very rich language. My grandmother, my father’s mother used to read The Forward all the time, and there were some relatives on my grandfathers’ side, and he had since died, who advertised in The Forward looking for relatives after the war. And they found each other that way, and stayed in touch. So I remember that story about The Forward. I remember what it looked like.” In this way she captured the sensibility contained within this cultural object: It carries feelings of loss and trauma; of the capacity for reunion; of a way to help individuals who have suffered and lost, reconnect with one another. And the affective tenor of the language carries both the personal and ethnic story interlaced with intense affective resonance. The experience of this cultural object shared between participant and researcher within the interview process mirrored the nature of such a shared cultural experience within the treatment modality. A gentle nod to the language on my part connected us more deeply, brought us to a new level of comfort with one another in the process, and opened up an avenue for this clinician to convey how language—in this case Yiddish— functions in her imagination and in her work. Similarly, there were several moments within the interview process when I formulated a question or interjected an understanding by employing psychodynamic language. Rather than functioning as my interjection of Yiddish had done, these instances inserted a subtle dividing wall between us. Clinician 5 was open in acknowledging her discomfort with psychodynamic language despite her wide-reaching education in the

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field and her seasoned status as a clinician. At one point in the interview process she alerted me to this phenomenon, “I know the theory. I can’t talk it like some people can, but I feel as if I do it.” Her capacity to self-reflect and name this phenomenon alerted me to its potential to stymie our process, and enabled me to circumvent it as a possibility for rupture. However, it provides a second cogent example of the ways in which language itself, as a cultural phenomenon, carries affective resonance and has the capacity to impact interactional moments, including those within the psychotherapeutic endeavor.

The cultural object as it symbolizes a vehicle for authentic self-expression and authenticity. In the context of the interview process, this clinician offered a case vignette concerning a client who is a musician. Over the course of his therapeutic work, he had begun to realize that while he loves his music, the “music scene” did not jive with his values and the way he longs to live a life of meaning and integrity. Describing his experience on the road as characterized by a lot of substance abuse, he sought his therapist’s help in validating aspects of his core self, helping him to sift his love of music from the experience of performance, under such constraining circumstances. As she described this piece of work, it seemed that in the context of this three-year therapeutic connection, he was growing to value his true parts of self, and finds it increasingly untenable to tolerate a life that compromises his sense of self. She disclosed, “I just saw a guy who, and he is a piano teacher, and he’s a composer and music is just in his blood. And he was talking about the experience of being on tour with the music and sort of how it has shifted over time for him and what was I thinking about, it became over time . . .

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not about the music, and he doesn’t like it anymore. Just thinking about the arc of his career and what he wants to do next, and he was saying that when his band finishes their last album which hopefully is soon, it will be the first time he’s not been in a band for 20 years and [struggling with] what he’s going to do then. [He was] just thinking about the meaning [of music] again in his life is all, and what music is all about. He grew up out of state in a very, very religious family and he and other siblings have left the Church, which was a very difficult transition with his family. He has a psychiatrically ill sister who he’s closest in age to her and they were very, very close when they were growing up and she had a break when she was in college and that has been a real loss to him, but his music took him also outside of the family and outside of the family context which his parents didn’t like, although they’ve come to be okay with what he does. But he was talking about how [back then] he always felt like he lived a dishonest life. With regard to for a long time his parents thinking he was still involved in the Church, and he wasn’t. Never saying to people things that he wanted to say, he was born following a still birth and the death of an infant from I forget if it was SIDS or some disease. And even though that’s always been known in the family I think there’s a way in which they don’t talk about it so there’s a lack of honesty in there. But he felt and he got more and more involved with drugs and liquor when he was out there and when he came here he’s just talking about this now he felt like what he wanted to have was an honest life. And when he goes on tour he feels it is not an honest life. Too much alcohol and pretending to like what he’s doing and he doesn’t. It takes him out of what he really wants to be doing. [And his passion for music] I think helped him exist in his family and it helped him get out of his family.” It seemed that the environment that surrounds his music isn’t working

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for him anymore. She continued, “And also that he’s really grown up in the last few years, it’s like he was sort of more involved in a younger culture, and he’s now engaged to be married and he’s become more serious.” It seemed plausible that his search for authenticity was also related to his relationship with his therapist, and how he feels in the context of their relationship. Clinician 5 agreed with this assessment, continuing, “In fact I said to him, I never quite thought about it before, but when he used the word “honest,” there’s something about him, not that my clients aren’t, but I can tell he is in the room with me. He tries absolutely to say what is honest. You can see him searching for the right ways to say it.” In this way, the therapeutic relationship functions as a safe place to be his most authentic, true, honest self. This phenomenon has analogies to his musical experience, which is another place, when it is pure and not sullied by the “music scene,” and which he longs to reclaim. This young man’s music, valued by his psychotherapist, provides a vehicle for self-expression, a reverberation of his truest self. Tolleson (2003) writes, "We might perhaps think of a drive towards self-expression, a need within the human subject to capture his experience in symbolic form. The articulation of the self is, after all, the supreme act of emotional freedom" (p. 2). It is this act of emotional freedom that Clinician 5’s client seeks in his work with her, and the ways in which they engage together around his personally meaningful cultural experience as an expression of self, fuels their work. This young man’s yearning for integrity of self, life’s work and environment conveyed a power on its own merit. It then doubled in potency in the context of the nature of Clinician 5’s personal and professional practice. Over the course of the three

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interviews, this clinician conveyed a compelling sense of integration and harmony of her home and work lives. Her children come readily to mind when sitting with a client, impacting on associations and interventions. Her home and office share beloved paintings; her husband designed the agency’s current home; and her most innate, authentic idiom is present in her clinical encounters. She highlighted this phenomenon when she explained, “I think about that the older I get. Maybe you have this experience too. Things just come together more, don’t you think?” Offering an example, she spoke poignantly about a mentor’s impact on this way of being because of the ways in which this is the case for this woman: “I don’t think [the agency] means the same to everybody that it means to me. But I feel that place and [my mentor] have been pivotal in my development as an adult and I mean that’s the way she, I want to say ‘goes’: That’s the way she is herself, with literature and movies and everything just winding through. And I feel that place is my spiritual home.” Clinician 5’s image of one’s predilections “just winding through,” provided a lovely image of how it feels to have the disparate aspects of one’s life in harmony with one another. Her musician client seeks this balance between his music and the environment in which he engages. Her psychodynamic practice impresses as her art, analogous to music, insofar as one section reverberates successfully with the others, and in Tolleson’s (2003) language, “[Her] articulation of the self is, after all, the supreme act of emotional freedom" (p. 2). In this example, music functions as the vehicle to convey a longing for integrity, authenticity and consonance in one’s life.

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The therapeutic power of the cultural object when a cultural object cannot be imagined: it’s diagnostic. Much as the cultural object has the capacity to open up an imaginative process, Clinician 5 elucidated a case example in which she was experiencing a dearth of reverie while sitting with one particular client, and the concomitant feelings of this phenomenon. On the heels of describing moving work with a client with whom she shared her associations to cultural phenomena, Clinician 5 explained that this way of working provides her with a way to “exercise my imagination”; freeing, “but in a quiet way.” She noted that sometimes her inviting an association into session falls flat, and then elaborated on her work with a young woman in which she was not even able to access her own imaginative process. She disclosed, “I can think of a client that I should do it more with. She’s one of the banes of my existence: a young woman, 25-ish, whom I’ve seen for a couple years. She is one of my more, I don’t know what word to use, ‘limited,’ not intellectually but psychologically. She’s so unknowledgeable about life. She grew up in this insane family. She’s chunky. She’s beautiful chunky. Never put anything in her mouth that somebody didn’t have a comment about, her mother, her father. Her parents went through one of the craziest divorces I have ever heard of, and both grandmothers, I think she’s like a feral child. She was raised by people who don’t know how to live in the world.” She quoted her consultant, about a year into the work, characterizing her client, “He was just talking about the absolute dearth of reasonable humanity and caring in her early life.” In light of all of this, she began to think, “And she could use more children’s books because it’s basic. It talks about what’s important, which is hard for me to do with her. It’s like I feel that I am hitting my head against the wall all the time, and that might

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mean I need to find another venue in which to say some things to her. I don’t know about her capacity to take it in.” When asked what holds her back from both imagining and offering a cultural object, in this case a children’s book, she responded, “That’s a good question! She is somebody who stops me dead in my tracks. I can’t remember working with someone like this before. She will talk and talk and talk about something, and I don’t even know how to get into it. It is so distorted. She is so not focused, not clear, like she’s not in the world. I don’t even know how to explain it. So I don’t know. I think when I’m with her, I’m like this,” (Her gesture revealed a deadened set of feelings.) “trying to figure out how to talk to her: What to say, how to soften her experience. I get tired because I can’t. I can’t whatsoever. So I do lose a lot of what I usually have when I’m with her, which is interesting to think about.” Together we worked to unpack this phenomenon. There was a sense in her telling that her client’s unconscious communication to her therapist is “Don’t be playful! Don’t be imaginative. Don’t do anything that’s going to push me out of this little tightly confined psychological space.” And this unconsciously communicated stance has totally shut down the therapist’s capacity to daydream and attend to her own reverie; shut the clinician down from her most authentic ways of expressing herself. Identifying the dynamic between them, and the uncharacteristic way in which the clinician was engaging with her client, enabled her to begin to employ this data as diagnostic. In reflecting on our interaction, Clinician 5 identified it as helpful the way a consultation is helpful. She began to shift her thinking even as we spoke, noting with greater empathy, “I think she’s just terrified all the time.” In this example, the clinician’s identification of the absence of

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reverie with a particular client awakened her to an awareness of a deadness for her in the sessions. When explored, she began to consider other ways to consciously attempt to be with this young woman, but more significantly began to access some empathic insight into her client’s subjective sense of self, “terrified all the time.” Clinician 5’s experience is reminiscent of Winnicott’s (1971) thinking when he writes, Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist. Psychotherapy has to do with two people playing together. The corollary of this is that where playing is not possible then the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play. (p. 51, original emphasis) In contemplating the unavailability of associations and reverie in her work with this particular client, this clinician was beginning to consider her experience as data in terms of her client’s limited capacity to play with her. The clinical information that this young woman “never put anything in her mouth that somebody didn’t have a comment about, her mother, her father,” contributes to a sense that her terror is of longing for and accepting nourishment. In this case, the nourishment being forestalled is that of the therapist’s imaginative process in the service of their work together. When Clinician 5 articulated her experience being with this patient as “she stops me dead in my tracks,” one understanding of this encapsulation of her experience is that Clinician 5 found herself unable to access enlivened parts of self while sitting with this young woman. A key aspect of feeling in touch with those authentic, vital parts of self lies in her capacity to associate to a cultural object while sitting with a patient. In this way, her awareness awakened a curiosity as to what’s transpiring in the relational space

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between them. Initially in her telling, she relays impatience and exasperation with, and a dislike of this patient. She disclosed, “She is the bane of my existence,” perhaps due to the way it feels to be with her, and the clinician’s inability to access key parts of self. Upon reflection, in the process of co-constructing meaning, her curiosity about this phenomenon took hold, and she grew to understand the psychic deficits within this young woman that impact the clinician’s ability to imagine. Addressing this phenomenon, Bion (1959), sheds some light as he writes about the patient’s inability to make use of “linking,” that is, the fostering of emotionally meaningful connections. He writes, The main conclusions of this paper relate to that state of mind in which the patient's psyche contains an internal object which is opposed to, and destructive of, all links whatsoever from the most primitive (which I have suggested is a normal degree of projective identification) to the most sophisticated forms of verbal communication and the arts. In this state of mind emotion is hated; it is felt to be too powerful to be contained by the immature psyche . . . These attacks on the linking function of emotion lead to an over-prominence in the psychotic part of the personality of links which appear to be logical, almost mathematical, but never emotionally reasonable. Consequently the links surviving are perverse, cruel, and sterile. (pp. 314-315) Bollas (1989), nodding to Bion’s concept of “linking,” writes of true self experience, When an experience arrives to express the true self, the individual is able to be spontaneous, to be tru(er) in that moment. The ordinary joy, found by linking a

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true self preconception with the object world, is a very special form of pleasure. I think of this factor as well served by the word jouissance, which is an important part of Lacan’s (1960) formulation of psychoanalysis. Jouissance is the subject’s inalienable right to ecstasy, a virtually legal imperative to pursue desire. Perhaps this is a good definition of the ruthless pleasure of the human subject to find joy in the choice and use of the object. Indeed, there is an urge to use objects through which to articulate—and hence be—the true self, and I term this the destiny drive. (pp. 19-20) He continues, Subsequent elaborations (of the idiom of the true self) though certainly using cultural objects, serve its own pleasure in articulating itself, rather than in understanding and conveying meaning of the cultural objects used. The true self listens to a Beethoven sonata, goes for a walk . . . not to know these ‘objects’ and then to cultivate this knowledge into a communication, but to use these objects to yield self experiences. (p. 20) Gaining hold of a new understanding of this phenomenon in the treatment of this client enabled Clinician 5 to access an empathic stance toward her, as she began to comprehend that the “deadness,” she names, what Bion labels “mathematical, never emotionally reasonable, . . . sterile,” (page 315) enables her to feel her patient’s sense that “emotion [may be] too powerful to be contained in [her] immature psyche” (Bion, p. 314). As a result, Clinician 5 then began to reconceptualize her therapeutic goal, which in Winnicott’s language, may be that “the work done by the therapist [will be] directed

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towards bringing the patient from a state of not being able to play into a state of being able to play (p. 51, original emphasis). It is significant for this study, which set out to investigate the role the clinician’s associations to cultural objects plays within the therapeutic enterprise, to attend to Clinician 5’s inherent (deep-rooted, essential, fundamental, natural) manner of attuning to her unconsciously guided associations to cultural objects in her work. The unavailability of this fundamental aspect of her clinical and personal idiom highlights the very real way this kind of work fuels and enlivens her work as a clinician when it is present, and provides a useful tool in clarifying significant psychic phenomena, both inter-psychic and intra-psychic for her clients. In her unfolding, the sensibility that overtook her was one of disliking the client bordering on dread, and feeling deadened in her presence. These internal states provided clues for her that a key gratifying relational element was wanting. As we worked the vignette, in ways she likened to consultation, she was able to come to understand significant diagnostic data vis-à-vis her client’s psychic lacunae as well as the ways this lack interferes with her capacity to serve as a useful clinical presence. As she contemplated moving forward in this work, she began to wonder how to play with her imaginative process; how, in a conscious, intentional way, to invite it into the session in the service of this therapeutic undertaking.

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The cultural object provides a defensive function: Alexander and the Terrible, Horrible, No Good, Very Bad Day. 90“It settles me down. If I can say it, it helps me.” Clinician 5 shared a number of examples of her associations to children’s picture books while attending to a client’s narrative. The clinical vignette highlighted the ways in which Judith Viorst’s well-known children’s book Alexander and the Terrible Horrible No Good Very Bad Day offered several examples of the cultural object’s role within the treatment process. The first phenomenon demonstrated the therapist’s use of her association as a defensive measure when her client’s narrative is experienced as whiney, “surface-y”, by which she means superficial, and lacking any potential for movement or growth. In this case, her countertransference feelings are primarily those of annoyance, boredom, and frustration, experiencing the patient’s monologue as a burden. She disclosed, “Some people, you know, they’re complaining. I have limited tolerance for that. [The cultural object] gives me a way to maybe cut off the complaining a little bit. Say “You know everybody has days like this, ‘even in Australia 91 ’ I suppose it gives me a way to moderate the way I feel a little bit. It’s the complaining where people don’t look at themselves, and they’re always putting it out there, and you know some days we all do it, but you don’t have to do it all the time.” Clinician 5 offered that she is not a complainer herself, and it seemed that she historically did not have permission to dwell on what was not quite right, and so a client’s—what she called—“kvetching” frustrates her. She quickly added, characteristically referencing her role as mother, “I had a ‘No Whining!” sign on my refrigerator when my kids were little.” We laughed together about how it would not be possible to hang such a sign in her office; however her association to 90

Viorst, Judith (1987). Alexander and the Terrible, Horrible, No Good, Very Bad Day. New York: Atheneum Books for Young Readers. 91 This is the closing line of the book.

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Alexander in a way communicates the same message. She went on, quoting her inner musings along with her own needs, and alluding to her countertransference feelings: “Well it feels like it’s too surface-y and you know we can just, well, [consider that] ‘this stuff happens to everybody, so let’s just get rid of it. Let’s figure out what else there is to talk about.’ And so I’ll say, ‘Do you know this book?’ And almost everybody says, ‘Oh, I know that book. I love that book!’ And I’ll say, ‘Some days are just like that.’” When asked what her offering up of her association provides the work, she considered, “Sometimes, not always, I think it kind of settles people down.” She paused, still thinking, and then confided, “It settles me down. If I can say it, it helps me.” For this clinician the unbidden reverie replete with lyrical language and humorous line and color drawings, enables her to quiet her inner turmoil in the presence of a client whose static, deadened narrative unsettles her. Another facet of this set of feelings is her impatience and an inability to maintain an empathic stance toward her client’s day-to-day struggles. There is a sense that this interruption in a capacity to empathize contributes to her feeling “unsettled.” In this way, the cultural object is used in a defensive manner to stave off intolerable feelings in the therapist. She feels that this imaginative enterprise enables her to more easily stay present with her client.

The cultural object “Alexander” universalizes the human experience, inspires the therapist to utilize the pronoun “we,” reflecting a two-person psychology: “We’re all in the same soup.” Clinician 5’s use of Alexander and the Terrible Horrible No Good Very Bad Day

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quiets her negative countertransference, and she also experienced it as offering a message to both her client and herself about the universality of struggle and challenge, and things not going as we had hoped and planned. She affirmed, “I guess I really believe we’re all in some ways in the same soup. And we all have days which we could kvetch about from now until Doom’s Day. You know, lots of people have horrible trauma, have all sorts of other stuff that they bring, and I think that [this children’s book] helps me have more empathy for a kvetchy day or whatever. And I think we're all in the same soup.” Continuing to articulate the intentionality of her use of language, she explained, “I [thoughtfully] use my language with clients: I’ve been aware over time: I use ‘we’ a lot to include myself because it’s true.” She developed this stance by hearkening to the shifts in psychodynamic thought and therapeutic action over the course of her career. In this way, the cultural object of the picture book dovetailed with a conscious drawing upon the cultural object of language, and also evoked with psychodynamic theory, a third cultural object. “Without exception people of this age [late 60s, in practice for 30 plus years] all say that we learned there was a hierarchy. We were to be quiet and remote –which I never could be because that’s not who I am—and that it was ‘us’ and ‘them.’ And it just isn’t. I mean that’s not the way the world is. And I was talking to somebody the other day, and I feel somehow in the last couple of years, I think it’s about getting older: That what happens to him, is happening to me at the same time. I don't’ mean that literally but that we all, we’re all together in this. (At this point her voice grew soft.) And I’m no better than you, but sometimes I know the right questions to ask. I also learn a lot. [My clients] teach me.”

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The cultural object functions as a third thing that enables the dyad to speak about the patient’s inner world, and it mirror the patient’s acts of creative expression: “Isabelle.” One of Clinician 5’s clients is an author, and she unfolded the details of her client’s main character’s presence in their sessions. As she spoke of the character, “Isabelle,” it was periodically challenging to discern about whom she was speaking. This was in part due to her use of the personal pronouns “she” and “her” in unfolding this narrative. However, this confusion also pointed to a sense that the two were quite intertwined for both client and therapist, thus pointing to another way that a cultural experience inhabits the internal dyadic space. In this case the artifact is one of the client’s creation, which begins to inhabit the clinician’s imagination and impact on the therapeutic endeavor. Clinician 5 began by describing a book that she and her client had both read, at her client’s recommendation, A Confederacy of Dunces. 92 Clinician 5 explained that her client “talk[ed] about the character, the main character: He never changed. He was exactly the same all the way through these multiple adventures. In contrast, she was writing a book about a woman named Isabelle. So we used to talk about Isabelle, but her character developed. Her character went somewhere. Her father and Isabelle ate at the same Chinese restaurant every night. But when the father died, Isabelle started to branch out, (Clinician 5 laughed through these two words, as if she is recalling with pleasure her engagement with this client around her creation.) and so it was always in counterpoint to A Confederacy of Dunces. I loved that book. Although she brought it to me, I didn’t

John Kennedy Toole (1987). A Confederacy of Dunces. New York: Grove Weidenfeld.

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bring it to her.” She continued, in response to my questions, beckoning for more details, “She never gave [her book about Isabelle] to me to read. But she would talk about it, and I would ask her about it because I felt that it was about her and very much wanted to, (Here she grew quiet). I was encouraging her. You know she wanted to be a writer, and that was a part of my interest as well, because she really wanted to write, and so I was very encouraging of that, and I think part of my interest in addition to it being autobiographical was to encourage her to do what she wanted to do.” In this way, Clinician 5 in a generative, maternal, therapeutic approach was valuing, and taking pleasure in her client’s use of her imagination. The client spoke about Isabelle, the clinician spoke about Isabelle. Isabelle was a third person in the room with them. Clinician 5 expanded on this, “It was very fun actually. When I hadn’t heard about Isabelle for a couple weeks, I wanted to know what was going on with her. You know, I think this was also happening as she was [preparing to move abroad with her husband]. So there was also a transitional piece about it. So I think the writing was also when I think about it now—I must have thought about it then—something she could take with her. You know she started the book here. She could finish the book there. And [Isabelle had a place in my imagination]. She was a character. You know, in the other sense of the word. She was a hoot. She loved to bake. Loved to bake! (She sighed with pleasure.) Loved to eat baked goods. Went to all these bakeries to taste things. And she would spend hours baking.” From the details proffered, it was clear that her client spoke in depth about her character, bringing her to sessions with her for her therapist’s approval, and to delight in together. This phenomenon is reminiscent of Winnicott’s concept of play in the potential space in between. His (1967) article, “The Location of Cultural

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Experience,” expands on his concept of transitional phenomena to include experiences of art and culture, the products of one’s vital generativity. When asked what their engagement around her client’s art, in particular her creation of the character of Isabelle, offered their work, she shared, “So her mother was a writer, now that I think about it. She was a journalist, and she was like, well, she was a child who, when she went to school on picture days? (Here her sentence ending with a question mark denoted, “You know what I mean by this?”) The teachers would pull her over and fix her up a little bit before she got before the camera. (Again she laughed affectionately through these last three words as this client’s dimensionality returned to her). She and her mother had tried writing something together, which didn’t work very well. So I think it was a way to encourage her to do something different [with me], or different from her mother. It was her own. I think she liked the fact that I got such a kick out of it. We were [working on it together]. That’s true. But I didn’t put anything in. I just, you know I was just thinking about that.” The overriding sense of this vignette is that Clinician 5’s client brought her character of Isabelle into session in order to experience what Kohut (2009) characterized as “the gleam in the mother’s eye” (p. 117) in her sharing Isabelle with her. In this way, Clinician 5 facilitated the possibility of a new relational paradigm, taking pleasure in this young woman. Mitchell (1988) describes this therapeutic action as working toward “a different interpersonal situation in which richer experiences of self and other are possible (p. 290). It was as if this client brought Isabelle into the room so that they could both admire her and take pleasure in her. Elucidating how she understood Isabelle’s presence in sessions to enrich the work, she responded, “[Isabelle was] a little bit of me and a little

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bit of her.” She was quirky and also extremely nurturing. Earlier Clinician 5 had unfolded a story of being endowed with a “mother of the agency” award in her workplace, because she is always baking for her colleagues. This similarity was not lost on her, and she continued to conceptualize the role Isabelle played for her client and for their work: “You know I thought of her, my client, as a woman who had to go it alone a lot in her life. She had a sister who was older and very successful. A physician I think, and she felt, they had been at odds their whole lives. The mother was working constantly. Travelled all the time. The father was a stay at home dad but he was seriously depressed, and for periods of time he was just in bed. And Isabelle was a (She paused to consider.) I don’t remember where the mother was. She was not there. She had died. And then her father died. (In this moment, as in much of this narrative, I was again not sure if Clinician 5 was describing her client or Isabelle.) So she was going it alone, but finding ways to be okay. She wasn’t going to be a static character. She was going to grow and change. You know, she liked to bake. She’d bring things to neighbors. I think she used to bring it to a place where her father had worked. He worked in a factory, and she knew some of the men and they were very kind to her and so she’d bring stuff to them, and so she was finding a way [to be in touch with her father’s compatriots now that her father was no longer alive]. Maybe that’s what it was about!” This case example illustrated the ways in which a cultural object, when introduced by the client, as an extension of the client’s sense of self, can begin to inhabit the clinician’s imagination and occupy the potential space between them. “Isabelle’s” presence in the individual and shared imaginations of client and therapist provided opportunities to both speak of the client’s struggles and longings through a third thing,

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and enable the client to seek and attain the much longed for “gleam in her mother’s eye” from her therapist, in response to her playful, creative, successful occupation. In addition, as this was a creation which client and therapist played with together, it had the capacity to function as a transitional phenomenon as the client prepared to separate from her therapist and move half way around the world.

Categories of Meaning: A Summary Clinician 1. I. The meaning and use of the cultural object The nature of the cultural object: “It’s a small object and yet it’s packed, it’s very dense; We’re communicating from unconscious to unconscious.” The cultural object carries a metaphor: “If you really feel it, you do walk away hobbled.” The cultural object: An example of the therapist’s reverie and how he uses it. OR The cultural object: The therapist’s reverie reverberates with the themes of the patient’s struggle. The cultural object exists as analogous to the therapeutic process: “The art of it: It takes a long while to get into it and to use it properly. And when you do it right, it’s wonderful.” The process and how it works: “A series of moments of recognition.”

II. The therapeutic power of the cultural object The cultural object’s potency as it carries meanings from within the therapist’s relational experience.

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The cultural object’s power functions as the therapist’s provision of a part of self. The cultural object’s power as an indirect route to impart insight: “A story has soul”. The cultural object’s potency functions as an indirect route to foster a sense within the patient that the patient is seen, felt and known by the therapist. The cultural object’s power: It connects to a collective unconscious and staves off loneliness. The cultural object’s potency functions as a transitional object in the context of the experience of being told a story. The risks of the cultural object’s presence in the therapist’s imagination.

Clinician 2. I. The meaning and use of the cultural object The nature of the cultural object: “How the poem enlists me and how I enlist the poem.” 93 The cultural object houses layered, metaphoric meanings: “The literature brings another version into the discourse and then of course back to the question: Where are you in this?” II. The Therapeutic Power of the Cultural Object The cultural object abides within therapist as an ongoing association to his patient: “Most often there will be patients that I associate with a particular work or set of works.” The cultural object is a way to speak in a code, and an indirect route to impart insight: “Smuggling something across a border”

Clinician 3. I. The meaning and use of the cultural object Therapeutic work is likened to the musical enterprise: “You gotta . . . listen in the bones.” 93

Ogden (1997b), p. 620

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344 Therapeutic space as a musical space. The cultural object functions as a provision of therapeutic opportunity” “[It] seeps in and becomes part of [this patient’s] experience.” The patient’s creation as a cultural object: From fragmented to “jewel-like and lovely.” Sharing a cultural object, created by the client: It “catches the light” off of the therapeutic engagement. A therapist needs the capacity to play. II. An example of a cultural object’s presence in the therapist’s imagination: what it yields, and the nature of the process A. “The Look of Love”, and what it yields: “I know that my unconscious processing is going to help me because it has.” B. “The Look of Love:” Parsing the Process in which a musical association provides a useful tool “for the emergence of unconscious communication.”

Clinician 4. I. The meaning and use of the cultural object The nature of the cultural object: The cultural object of language itself “Aesthetically, sensually rich and enlivening,” a means to “elicit one’s most true voice.” The nature of the cultural object: The cultural object is immediate. It “takes you past your first layer of skin,” blows past intellectual defenses, touches our unconscious. The nature of the cultural object: The cultural object carries relational resonance. “There’s a feeling of a kind of interwoven. . . a little internal community of caring.” II. The Therapeutic Power of the Cultural Object The Therapeutic Power of the Cultural Object: The metaphor nourishes empathy in the clinician.

“Missing a layer of skin.” The Therapeutic Power of the Cultural Object: The accessed cultural objects of poetry and music expand access to the patient’s struggle as the clinician identifies her own feeling states and experiences empathy toward her client’s struggles.

“Empathic imagination.” The Therapeutic Power of the Cultural Object: The cultural object functions as a transitional phenomenon.

The Therapeutic Power of the Cultural Object: The cultural object as an indirect route to impart insight. “It opens up a space that might have been too stirring before; it’s a “mediating object; it makes it a little safer; we are knitting this little tapestry together.” The Therapeutic Power of the Cultural Object: Sharing a cultural object’s nuanced meanings offers an experience of felt knowing. A. Bruce Springsteen’s “Stolen Car” The cultural object functions as a “wink between old friends”; a way of speaking in code; a way of communicating a sense of knowing the other; it “is like sharing a meal.” B. When the clinician’s provision of a cultural object, the offering of “felt knowing,” is experienced as a misattunement. “Our longing to be known is equal to our terror of being known.” The Therapeutic Power of the Cultural Object: Sharing a cultural object’s nuanced meanings offsets loneliness. “This really matters to me, and I am bringing it to you.” The Therapeutic Power of the Cultural Object: The shared cultural object functions as a “case of unconscious communication.” 94 The Therapeutic Power of the Cultural Object: Sharing a cultural object’s nuanced meanings offers an experience of felt knowing characterized by playfulness, engendering new relational possibilities.

Altman, Neil (2002), page 510.

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The Therapeutic Power of the Cultural Object: Sharing a cultural object’s nuanced meanings provides a mirror for the patient, facilitating the potential for true self-knowing. “I like to think of my work this way, and to think that if I do this well enough the patient will find his or her own self, and will be able to exist and to feel real.” The Therapeutic Power of the Cultural Object: The clinician’s provision of the cultural object functions as a provision of maternal nurturance. The Therapeutic Power of the Cultural Object: The cultural object functions as a defensive maneuver: It quiets difficult affect and/or offers the clinician hope. “It throws me a rope.” The Therapeutic Power of the Cultural Object: Clinician’s articulated process.

Clinician 5. I. The meaning and use of the cultural object Children’s literature is like poetry The cultural object contains relational resonance and keeps the therapist company: “There’s the story, and then there’s the relationship.” The cultural object facilitates access to the imaginative process in the context of meaningful connection. “Miss Rumphius,” an example. The cultural object of language. “I say ‘we’ a lot” and “I use a lot of Yiddish words. They carry a lot of feeling and you just can’t translate them.” The cultural object as it symbolizes a vehicle for authentic self expression, and authenticity. II. The Therapeutic Power of the Cultural Object When a cultural object cannot be imagined. It’s diagnostic. The cultural object provides a defensive function. “It settles me down. If I can say it, it helps me.”

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Alexander and the Terrible, Horrible, No Good, Very Bad Day 95. The cultural object universalizes the human experience, inspires the therapist to utilize the pronoun “we,” reflects a two person psychology. “We’re all in the same soup.” The cultural object functions as a third thing that enables the dyad to speak about the patient’s inner world, and mirror the patient’s acts of creative expression. “Isabelle.”

Viorst, Judith (1987). Alexander and the Terrible, Horrible, No Good, Very Bad Day. New York: Atheneum Books for Young Readers.

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Chapter V

Discussion Cross Case Analysis Greek Mythology96 relates an ancient story that Zeus cavorted with Mnemosyne, the goddess of, and personification of Great Memory. And Great Memory gave birth to nine muses, the muses of heroic, epic poetry, history, flutes and lyric poetry, comedy and pastoral poetry, tragedy, dance, love poetry, sacred poetry and astronomy. At play within the metaphor inherent in this classic myth is the notion that the arts and sciences are intricately bound up with Memory. That is, this myth communicates that the aesthetic is profoundly interconnected with the human capacity to hold things within the mind in the forms of consciousness, awareness, thought, recollection and mindfulness. In effect, according to this archetypal myth, the cultural arts have evolved to serve Great Memory. Deeply resonant with this research inquiry, this myth may have arisen in order to communicate an essential understanding of the nature of cultural experience: It contains and provides markers for life’s affectively charged moments, and the aesthetic aids in the enterprise of remembering and sustaining these aspects of one’s sense of self. This dissertation inquiry set out to explore the psychodynamic clinician’s associations to cultural objects and experience, and the ways these associations contribute 96

Allen Grossman (1992). Poetry: A Basic Course, Lecture 1. The Teaching Company: Audio Editions.

to the therapeutic enterprise. Clinicians participating in this study elucidated the following common themes in their unfolding of clinical vignettes and deeply held theoretical tenets. These meanings, offered at the outset by the clinicians, were coconstructed within the context of the dialogic and phenomenological nature of the interview format. This research study was guided by an epistemological orientation of a hermeneutic nature. The focus of this study was a generation of knowledge regarding the ways in which psychodynamically oriented psychotherapists make meaning of their associations to cultural objects within the context of their dyadic work. In the service of constructing meaning, this dissertation research endeavored to value characteristics which Cushman and Guilford (2000) identify, as absent in evidence based work: “‘ambiguity, complexity, uncertainty, perplexity, mystery, imperfection, and individual variation in treatment’” (p. 993)”, (Hoffman, 2009, p. 1047). This inquiry embraced a phenomenological approach as it considered what Hoffman (2009) describes as “the reality of the ambiguity of human experience [which] requires a creative dimension in the process of ‘making something of that experience (p. 1048). My role as researcher posited that the production of knowledge is invariably an interpretive process. The project’s findings were understood to be interpretive objects. My research took as its focus the ways in which the therapist constructs meaning as she engages in the process, and considered “the principle of consequential uniqueness” (p. 1050) as a philosophical cornerstone of this inquiry. Within the interview process, I articulated open-ended questions that built on one another. I contributed a willingness to listen for both direct and nuanced communication

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regarding the enterprise of psychoanalytic listening. I offered a curiosity and openness to the process, and adopted a stance which both welcomed the individual idiomatic communication of each participant, and anticipated that the element of surprise would enter into the reception of shared material within the interview process. The interview process was characterized by efforts to understand in a deep way that this research is predicated on the notion that there is an intricate and mysterious dynamic at work in the inter-psychic engagement of the therapeutic endeavor. It further maintained that the process of elucidating the nature of psychoanalytic listening within this context would potentially yield a rich subjective tapestry of responses to be culled, coded and interpreted in the service of deepening one’s understanding of the phenomenon of psychoanalytic listening, particularly insofar as it consists of spontaneous associations to cultural objects. The analysis of the data was approached from a psychoanalytically hermeneutic paradigm. I endeavored to make sense of the layered meanings which made up the data, and predicated my analysis on the belief that meaning is constructed through a particular kind of listening process which is interpretive in nature. I relied on a proscribed set of assumptions unique to the psychodynamic hermeneutic process. Key ingredients of this approach included what Stern (1991) articulates as the absence of a single truth; the belief that “analyst and patient are both participants in a process larger than either of them” (p. 53), that is both “egalitarian and interpersonal” (p. 53); as well as the belief that the therapist “is embedded in the interaction” (p. 54); and most importantly that the basic unit is understood “as the field and not the individual” (p. 54). He further states that “the ‘truth’ . . . is a mutual construction, an outcome of the interaction, always interpretive and

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only partially predetermined” (p. 54). My adoption of a psychodynamic hermeneutic approach to the analysis of research data mirrored the process, which this inquiry sets out to explore: the ways in which psychodynamically oriented clinicians listen to themselves and their patients within their therapeutic engagement. This investigation employed an interpretive phenomenological approach to both the interview process and the data analysis. It aimed “to capture and explore the meanings that participants assign to their experiences” (Tolleson, 1996, p. 20) from within their subjective realities. The interpretive phenomenological process dictated that data be coded and organized into discrete categories of meaning, yielding a significant set of findings emerging from this research inquiry. Tolleson (1996) defines “categories of meaning” as the formulation of “idiographic generalizations based upon the thematic patterns which emerged from the subject's material” (p. 115). Valuing the contribution of participants’ interview material was founded on the belief that the participants were experts in the area to be researched and that their insights, thoughts, experiences, priorities, ways of working, and feelings could elucidate the phenomenon being explored, as elucidated in Reid et al. (2005): a set of themes, often organized into some form such as a coding overview, a table of themes, a hierarchy, or model. The themes yielded provide the focus for data analysis to be recorded creatively (pp. 22-23). Common themes are located within the following categories of meaning: •

Characteristics of the interview process

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The therapist’s repertoire of cultural objects in the context of this study

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The relationship between the psychotherapist and her cultural objects

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The therapeutic potency of the cultural object as a vehicle for unconscious communication

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The nature of the process of using cultural objects in oneâ&#x20AC;&#x2122;s work

Characteristics of the interview process. As articulated earlier, the methodology for this research project dictated the determining criteria for participants of this study. All were seasoned clinicians who identified as psychodynamic in nature, privilege unconscious communication, and understand their lives to be enriched and informed by cultural experience. As these criteria also function as descriptors of my predilections, exclusive of the first criterion, being a clinician in practice for 15 or more years, each interview experience across participants was characterized by a simpatico that, over the course of three ninety-minute interviews contributed to a building sense of intimacy. Most of the participants articulated feelings of inspiration regarding the re-awakening of a previously highly valued but temporarily dormant part of self. The majority of the participants experienced a strong sense of being seen and heard in meaningful, and occasionally new ways that reconnected them to deeply privileged parts of self, and conveyed a wish to build upon the sensibility rekindled during the interview process in the form of a specific freshly conceived project. Most striking of all, however, was the phenomenon that for each participant, at some point in the interview process, a profoundly personal and emotionally affecting set of memories and associations emerged that felt to me to be intricately bound up with the material at hand. That is to say, the experience of revisiting clinical material in which the clinician experienced associations to her experience of one or more cultural objects

seemed to open the participant to material of an evocative nature. There are various ways to understand this phenomenon. Possibilities include, but are not limited to, the very nature of psychodynamic clinical work. Each participant invited me into her 97 work in deep ways and, most fundamentally, the way each clinician engages with the psychotherapeutic endeavor has the capacity to open up deeply personal material. A second consideration regarding this phenomenon of the surfacing of personal material within the interview process focuses on a related finding of this inquiry. That is, the process of interviewing these five participants yielded a finding that the elaborate manner in which these clinicians engage with simultaneity in their own internal processes and that of their client is predicated on the evocation of a deeply personal sensibility that defines the psychotherapeutic practice of each practitioner. In this way, the evocation of profoundly affecting emotional elements within the interview process reflects the integral way these individuals work within the singularly personal therapeutic milieu each has fashioned. A third consideration is that the clinician’s associative experience of cultural phenomena in the context of clinical work, characterized in this manner, held the potential to tap into essential personal experience because of the ways in which cultural experience contains affective resonance, in the spirit of Bollas’ (1987) conceptualization of the transformational object. He writes, In the aesthetic moment, when a person engages in deep subjective rapport with an object, the culture embodies in the arts varied symbolic equivalents to the search for transformation. In the quest for a deep subjective experience of an 97

Participants comprised members of both genders, three men and two women. For the sake of simplicity, the pronouns “she” and “her” will be employed whenever speaking in a generic sense of participants in singular format.

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object, the artist both remembers for us and provides us with occasions for the experience of ego memories of transformation. In a way, [in] the experience of the aesthetic moment . . .the object is sought out only as deliverer of an experience. Certain cultural objects afford memories of ego experiences that are now profoundly radical moments . . . . In the arts we have a location for such occasional recollections: intense memories of the process of selftransformation . . . aesthetic moments are not always beautiful or wonderful occasions –many are ugly and terrifying but nonetheless profoundly moving because of the existential memory tapped. (pp. 28-29) In these moments, my experience became affectively bound up with that of the participant, as I found myself leaning closer, speaking more softy, and feeling some element of the feeling state each was communicating, in an emotionally open manner analogous to the psychotherapeutic enterprise. At times I both implicitly and explicitly reflected on my experience in the context of what was unfolding within each of us, and between us. It is my sense that the affective experience held a clarity and intensity in part because the communication was intertwined with a palpable, sensual, imagistic aesthetic. Often, the aesthetic, in effect, amplified the emotionality of these moments. For example, in Clinician 3’s relating of his association to the tune “The Look of Love,” connecting his experience to his despair around the limits to what he can actually offer his patient, my experience of his anguish held a greater potency because of the tune’s presence between us, occupying a significant presence in my imagination.

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The therapist’s repertoire of cultural objects. Buechler (1998) writes of the necessity for the psychotherapist to have access to her imagination as she works. She stresses that within this imaginative process we maintain an awareness of our own “internal chorus [which] we bring into our offices every day” (p. 111). Prioritizing the clinician’s development of an internal chorus, Buechler believes the chorus is drawn upon for comfort, and it “must be sufficiently stimulating, to encourage the creative use of aloneness 98” (p. 111). Writing personally, Buechler (2008) clarifies that her internal chorus consists of formal theory, coupled with the voices and wisdom of mentors, supervisors, and analysts. She writes, “My own internal chorus includes many of my teachers, analysts, and supervisors, as well as theoreticians who have influenced me through their writing, such as Freud, Guntrip, Winicott, Sullivan, and Fromm” (p. 220). She adds, “Sullivan has long been a member of that chorus. In fact, for me, his voice is often distinctive enough to earn the part of a soloist (p. 223). She then further expands her personal “chorus” to include additional areas of cultural experience, “But it also includes the poet Rilke, the writer Dostoevsky, 98

Buechler founds this idea on an article by Fromm-Reichmann (1959), “In her classic, posthumously published article on loneliness, Fromm-Reichmann (1959) cites A. Courtauld's observations of isolation in a Greenland weather station. Courtauld (1932) recommends that ‘only persons with active, imaginative minds, who do not suffer from a nervous disposition and are not given to brooding, and who can occupy themselves by such means as reading, should go on polar expeditions’” (p. 91). She thoughtfully delineates between the therapist’s experience of aloneness and feelings of loneliness, and offers her thoughts about how to nourish one’s sense of aloneness: A creatively used aloneness is not loneliness. To be alone while with a patient is not painful, so long as we can retain a connection with a good sense of self, and a non-persecutory sense of the patient. Theoretical concepts can aid this process, by providing something to play with during alone times with the patient. A good, supportive internal chorus and enough to play with can, I believe, allow the analyst creative possibilities for the productive use of aloneness (p. 111, original emphasis). Likening this internal chorus to a “playroom and some toys” (p. 110), she maintains that the clinician requires “enough to play with” (p. 111). Elaborating on the nature of this internal chorus, or “playroom,” she writes, When left alone by the patient, the analyst must have a context in which to fit the experience, and some conceptual frameworks to tentatively explore as explanations . . . The isolated analyst must be able to find meaning in his experience, hope, and mental stimulation, to survive intact. Here is where theory can provide meaningful context, conceptual framework, and the stimulation of curiosity (p. 110).

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[and] the painter Rembrandt, . . . all of whom taught me something about living life as a human being” (pp. 220-221). For this clinician (1998), the presence of cultural experience within her imagination is fostered and drawn upon “to offset the loneliness [of analytic inquiry],” and to “encourage the creative use of aloneness” (p. 111). These individual voices are singled out by virtue of their ability to elaborately connect her to her humanity. Perhaps what she means by “the creative use of aloneness,” is her capacity to draw upon these voices in her work to serve this purpose. Buechler’s identification of this “internal chorus” serves to name a phenomenon present for all five participants, and which may be operative for all clinicians in some form, albeit unconsciously, insofar as it keeps one connected to one’s sense of one’s own humanity, as one engages in deep psychotherapeutic work. My study finds that the evocation of cultural phenomena, consciously and unconsciously, has the capacity to nurture an integral, sustaining sense of self. The study further finds that an awareness of this phenomenon was an essential element of the internal world of the seasoned clinicians participating in this study, enhancing one’s clinical repertoire as one grows and deepens both as a human being and more specifically as a clinician. In addition, the study finds that the clinician’s associations to cultural experience has the potential to elucidate both consciously and unconsciously communicated motifs inherent in the patient’s struggle, as well as within the intricate nature of the therapeutic relationship. In the context of this research inquiry, which set out to investigate the nature of clinicians’ associations to cultural objects, and the ways in which they employ them within their psychodynamic work, there are three categories of cultural experience that emerged as significant findings, and that function in ways that are inclusive of those

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which Buechler (1998, 2008) eludicates in her description of her “internal chorus.”

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Participants identified these experiences as both sustaining for themselves and illuminating in terms of essential themes in their patients’ work. These findings, drawn from clinical data, were not evidenced in the literature reviewed for this project, which suggests they may be significant offerings of this research study. The first unexpected category of cultural experience to emerge across most participants is an exquisite attention to that of language itself, it’s grammar and syntax, the ways in which pronouns are employed, and verb tense adopted. A further element within the category of language itself includes idiomatic expressions, and the introduction of a “foreign tongue” such as the Yiddish language. This finding is predicated on the conceptualization of human language as a cultural artifact. Chomsky (1968) was the first to identify human language as “a unique phenomenon, without significant analogue in the animal world.” Building a case for the study of language as a significant psychological phenomenon, he argued, It is quite natural to expect that a concern for language will remain central to the study of human nature, . . . Anyone concerned with the study of human nature and human capacities must somehow come to grips with the fact that all normal humans acquire language, As far as we know, possession of human language is associated with a specific type of mental organisation, not simply a higher degree of intelligence. [Language] is an example of true “emergence” – the appearance of a qualitatively different phenomenon at a specific stage of complexity of organisation. Recognition of this fact, though formulated in entirely different terms, is what motivated much of the classical study of language by those whose

primary concern was the nature of mind. And it seems to me that today there is no better or more promising way to explore the essential and distinctive properties of human intelligence than through the detailed investigation of the structure of this unique human possession. 99 Cushman’s (1995) conceptualization of language as a social construction augments the consideration of language as a cultural object. He writes, “We are embedded in a specific cultural matrix composed of language, symbols, moral understandings, rituals, rules, institutional arrangements of power and privilege, origin myths and explanatory stories, ritual songs, and costumes” (p. 17). He continues, “Culture is not indigenous ‘clothing’ that covers the universal human; rather it is an integral part of each individual’s psychological flesh and bones” (p. 18). The finding of this study that language itself—its syntax, idioms and multiplicity of “mother tongues”-functions as a cultural object holds Chomsky and Cushman’s conceptualization of language at its foundation. A second finding of this inquiry, also unanticipated, under the rubric of language as a cultural object within the clinician’s imagination, consists in the distinct element of the language and terminology of psychodynamic theory itself. Psychodynamic theory comprises a unique body of thinking and understanding, embedded within its respective unique and specific historical and cultural milieu. Psychodynamic language occupies a wide-reaching, potent position within the larger culture. Most significantly and distinctly, within the category of aspects of language itself that inhabited clinicians’ imaginative process and influenced therapeutic action, all five 99

This citation was harvested from the website https://www.marxists.org/reference/subject/philosophy/works/us/chomsky.htm and does not include pagination.

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clinicians spoke of the role of metaphor in their work. The concept of metaphor was employed meaningfully in a two-fold manner. First, participants spoke of employing metaphor in the familiar manner of a figure of speech. In this way they described a manner of communicating in a layered fashion, and employing a playful manner of communicating a potentially difficult message. Clinician 2 spoke of offering a complex image for his patient to work on, likening it to an “unlaced football.” More significantly, they spoke in granular detail of the ways in which the cultural object houses a metaphor that both elucidated and facilitated the therapeutic work. In this way, the cultural object of metaphor, a sub-set of language itself, functioned as a distinguishing element within the psychodynamic practitioner’s reverie, impacting on therapeutic action in important ways. The second category of cultural phenomena, which occupy the therapist’s imagination, is that of psychodynamic theory. As a study of the human psyche, it both draws upon and contributes to aesthetic and cultural experience, and therefore functions as a cultural phenomenon in its own right. Buechler (2008), in her discussion of an “internal chorus,” identifies the language and theory of mentors, supervisors, analyst and writers alongside influential painters like Rembrandt and writers like Dostoyevsky. Psychodynamic theoreticians and writers of each successive generation incorporate the thinking and language of those who preceded them, demonstrating the ways in which their predecessors’ writings abide within their imagination. For example, Bollas’ groundbreaking book The Shadow of the Object (1987) draws upon a citation from Freud’s article “Mourning and Melancholia” (1917) for its title. Clinicians participating in this research study similarly described the presence of psychodynamic theory as an

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enlivening set of voices functioning alongside other meaningful aesthetic experience. This was the case for all five participants. The third category, the one which this study anticipated from the outset, included the more commonly identified cultural objects drawn from the arts, as symbolized by the muses of Greek mythology: music, inclusive of melody, rhythm and lyrical verse; visual art, inclusive of sculpture, photography, and the graphic arts; poetry; theater; foundational classic texts, inclusive of Biblical and Ancient Greek text, and Shakespearean drama, contemporary literature; non-fiction; and children’s literature, inclusive of the narrative, both prose and lyrical poetry, as well as illustrations. One final cultural experience, that of a martial art—its history and wisdom teachings--emerged within the interview process for one clinician. While the martial art of Judo appears as a bit of an outlier, for the purposes of this research study, a case is made to locate it within the contingent of the nine muses insofar as it is in some manner akin to both dance and poetry, and is located within a cogent, meaningful narrative tradition.

The relationship between the psychotherapist and her cultural objects: the cultural object intertwines with the clinician’s formal theory. This research study set out to capture moments in which the psychodynamically oriented psychotherapist experiences the presence of a cultural object within her imagination in the context of her clinical work. A significant finding of this study identifies that for each, the clinician’s predilection for a particular aesthetic was intricately linked with her affinity for a formal psychodynamic theory. The study found that all five of the seasoned clinicians routinely experience this phenomenon in their

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clinical practice. All of them highlighted aspects of their cultural experience that dovetail with their psychodynamic theoretical foundations. For example, Clinician 1, who articulated a wide-reaching well of formal theory ranging from Self Psychology to an ardent belief in the existence of the universal unconscious, and a conviction that understandings may be gleaned utilizing Jungian archetype, drew upon foundational stories from both Biblical and Greek traditions, as well as those drawn from his Judo practice. His affinity for archetype and his belief in the collective unconscious is inextricably linked with his fascination with the elemental stories housed in ancient texts. Clinician 2, whose formal theoretical framework instructs him to attune to the relational information within his client’s narrative, describes himself as intimately engaged with metaphors of connection within the cultural objects of ancient texts, which include Biblical literature and Homeric text, as well as Shakespeare and contemporary fiction. Significantly, his professional idiom as a relationally oriented analyst finds expression in both the theory he is drawn to, and the particular literary themes that echo in his imagination in the context of his work. Clinician 3 was the most eloquent about his attention to unconscious communication in the therapeutic hour, drawing upon Freud’s foundational thinking on this subject, along with Bollas’ conceptualization of the “unthought known,” and Daniel Stern’s paradigm of “implicit relational knowing.” Clinician 3’s dominant cultural experience, primarily consisting of his musical imagination and the visual arts, is deeply intertwined with the affective resonance of relational communications, in his therapy practice and within his larger life. Bollas’ and Stern’s ideas, along with those of Robert Langs, thoroughly attend to the selfsame phenomenon embedded in Clinician 3’s cultural

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experience predilections: a consideration of the relational data housed within experience in general, and within the aesthetic in particular. Clinician 4, whose primary, formal theoretical frame emanates from the Feminist Cultural-Relational School, with a primary focus on Judith Jordan’s understanding of “listening someone into voice,” invokes poetic expression as her primary cultural object, both explicitly and implicitly. She communicated a firmly held belief in the primacy of the authentic, vital expression of self, and finds poetry to function in this way for her. These descriptors embody the hope she harbors for her clients, and the standard she holds herself to when working in her therapeutic milieu. While Clinician 5 gives voice to the influence of Jordan’s Cultural-Relational Theoretical Frame, and articulates its influence in her life as a clinician, mother and grandmother, her primary idiom, in and out of her office, is that of the maternal. This idiom, clearly and without ambivalence, inhabits her imagination both consciously and unconsciously. Bridging her predilection for theory and the cultural objects she associates to, she drew deeply from the wealth of children’s literature, eliciting the metaphoric messages of the stories and illustrations, interweaving the relational mother-child idiom in her associative enterprise and in her broader psychotherapy practice. Buechler (2004) probes the ramifications of theoretical immersion for the clinician. She cites Friedman’s (1988) critique that “theory is subjective, embraced for personal reasons” (pp. 159-160), and develops the subjective aspects of one’s theoretical leanings in light of how it reflects the clinician’s sense of self, and what this phenomenon offers clinicians and the work. Contextualizing her discussion within a supervisory relationship, she delineates what an engagement with theory offers the pair,

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Engaging [my supervisee] theoretically may help awaken her to her work. Making connections between a theory and the clinical moment it illuminates can help the clinician feel authentically involved. It provides a sense of integrity and wholeness in that mind, heart, and spirit are all engaged. . . [Theory] adds depth and personal resonance.” (p. 161) Continuing, she significantly notes the ways in which a clinician’s theoretical pursuits serves an ongoing exploration of the nature of one’s self, “Clinicians often test theories on themselves at first. Reading Guntrip (1969) I might first ask, does he explain me, to me? Does it feel right? And does it help me understand my patient better?” She goes on, Later, as I conduct a session and think of Guntrip, a host of personal associations comes to mind. Guntrip has bridged the gap between the patient and my own experience as a human being. This adds dimensions to what I experience clinically, lending it depth and personal meaning. [It] enlivens the material . . . . Another way to understand this is that I can feel I am getting several things for myself, from the session. I am understanding an aspect of myself better, as well as the patient, and enriching myself intellectually as I connect the clinical moment with a theoretical concept. Connecting theory and practice can give us an expansive, fulfilled feeling. Friedman (1988) concluded, after his extensive review of the uses of theory, that psychotherapy will “thrive where theory and practice do their intricate dance” (p. 563). (p. 161) Buechler’s thinking helps me elucidate this phenomenon as it emerged in my data collection, and clarify what its presence offers the clinical work: An analysis of the data yields the finding, congruent with Buechler’s thinking, that psychodynamic theory

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functions as a cultural experience in clinicians’ associations and in their self definition. Beyond Buechler’s thinking is the finding that the clinician’s chosen theory or theories resonates with her aesthetic sensibility. This alliance has the capacity to be enlivening; a spur for authentic engagement, personal resonance, integrity of “heart, mind and spirit” (p.161).

The relationship between the psychotherapist and her cultural objects: the practice of psychotherapy is analogous to art. In pursuit of the ways in which a clinician’s associations to cultural experience impact her clinical work, one significant finding, containing potent personal resonance for me as well, is that the clinician’s most integrated and authentic sense of self finds expression in her affinity for both her theoretical foundational underpinnings and the nature of her cultural affinities. The participants in this study deeply and broadly communicated an authentic, vital understanding of the profound human elements that define them, and the ways in which these components find expression in and are aligned with their theoretical and cultural affinities. Hoffman (2009) speaks of this phenomenon when he writes, “the whole person of the treatment provider, of the analyst, is at the heart of what is relevant in engaging with a person struggling with problems in living” (p. 1049). An additional component of this aspect of the findings is the ways in which many of the participants discussed the psychotherapeutic process as analogous to an aspect of the cultural experience that draws them. For example, Clinician 1 considered a series of parallels between his Judo practice and that of psychotherapy: Both are intimate dyadic

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engagements in which reading the “other” is a necessity for a fruitful process, as is one’s timing in terms of one’s “moves.” In addition the Judo metaphor provided rich analogies insofar as the first year is spent “learning how to fall,” there is a serious acknowledgement of the possibility of the “little guy vanquishing the big guy,” and it is an intellectual and relational enterprise, it has a history and a philosophy, and a set of ethical imperatives. Finally, the adage, “Seven times down eight times rising” also contains resonance for the therapeutic process for this clinician. Clinician 3 likened the musical enterprise to his therapeutic practice, when he said, “It’s not a solo proposition. You’ve got to pay attention, . . . and listen intently, but listen in the bones. Kind of . . . to know where you are . . . It’s creative and inventive and you don’t want to play too many wrong notes, so you want to think about where you’re going to play.” In similar fashion, Clinician 4 likened psychotherapy to dance when she said, “One of the reasons I like doing therapy is because it’s like dancing with different partners. You know, you gotta be able to take their lead, and you gotta be able to move with them. I think it’s an art, . . . and I think the more you practice your art, the more you trust it’s not watercolor. It is oil, [so] you can rework it.” In this way the study finds that the personally meaningful cultural object functions for the clinician as an instructive, nourishing metaphor for the psychoanalytic practice each has crafted. Each implicitly or explicitly conceptualizes herself as the practitioner of an art form in her daily work. This phenomenon has the capacity to enrich and enliven the work, and ground the practitioner in a narrative of the meaningful nature of her practice.

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The relationship between the psychotherapist and her cultural object: both cultural object and theoretical underpinnings intertwine with the clinician’s personal history. Quite unexpectedly, in my analysis of the data, it became clear across participants that the clinician’s personal history intertwined in an authentic, integral fashion with her affinity for particular cultural phenomena and the psychodynamic theory that she found most compelling. In considering each clinician’s predilection both for formal theory and for one or more genres of cultural experience, most had a determinative experience in early life that each identified as shaping her affinity for these profoundly personal and adhered to proclivities, as manifest in her theoretical predilections, personal idiom and the cultural objects inhabiting their imagination. In some cases, this aspect of their understanding unfolded during the interview process, punctuated with expressions like “I hadn’t realized this before, but . . . ” which suggests the particular affinities may have been unconscious in nature. Clinician 1 credits his first mentor, as well as his own psychotherapist, as formative influences on the theoretical underpinnings of his practice, coupled with the impactful role of “the mythic story” in his life and work. Clinician 2 identified an upbringing in a family where the humanities were highly valued, and despite his scientific and mathematical acuity, and immersion in an educational institution with this focus, he accounted spending hours alone in the university library deeply involved in the study of humanistic text. In his telling, it felt like the humanities provided an intellectual and spiritual home for him while pursuing mathematical studies as a university student. In a parallel way, he outlined this experience as a first year medical student introduced to Freud’s writings. Outside of the medical school curriculum, he

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pursued an investigation of Freud’s work. Clinician 3 identified his early experience of an idealized father figure who was a musician, coupled with the devastating experience of the decline of his father’s efficacy in the context of the Great Depression, and his longing to both compete with and identify with this potently clung to image of father. He additionally credited significant mentors and a formative experience of self-immersion, not unlike Clinician 2, in the study of psychodynamic thought, describing himself as “largely self taught.” Clinician 4, passionately engaged with the aesthetic, primarily in the forms of the poetic both in poetic text and musical lyrics, identified her experience of the Church as the predominant “colorful,” aesthetically vibrant experience of her early life, against the backdrop of an otherwise banal small town childhood. She likened the hold that the mystical nature of Latin liturgy to her passion for poetry. Profoundly intertwined with this early experience, she equates the aesthetic with the authentic and the vital in ways that significantly inspire her life and work. Clinician 5, growing up as she did with an aloof and troubled maternal figure, experienced a nurturing therapeutic relationship from a young age and idealized this nourishing “maternal” presence. She both internalized this relationship and longed to emulate her, thus intensely contributing to the development of her own maternal idiom. For Clinician 5, the early impactful experience of an idealize-able maternal figure interweaves potently with her theoretical and cultural predilections. The study yields that a multiplicity of strands contributes to the texture of participants’ self-definitions, and the distinguishing characteristics of their psychotherapeutic practice, and they are intricately intertwined with each one’s engagement with the aesthetic. These emerged in clear relief in the context of the in-

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depth interview process, which took as its focus the clinician’s associations to cultural experience while sitting with clients. The cultural objects and experiences that each clinician delineated as being drawn to, both consciously and unconsciously, provided an avenue to disclose intimate aspects of self-knowledge and self-definition. In concert with this finding, Winnicott (1967) writes “When one speaks of a man one speaks of him along with the summation of his cultural experiences. The whole forms a unit” (p. 370). In investigating the ways in which a clinician’s associations to cultural objects impacts her psychodynamic therapeutic practice, most participants revealed a powerful affinity between their preferred genre of cultural objects and their personal history. Notably, in many cases, a meaningfully held set of aesthetic experiences offered a refuge of authenticity and connection in childhood, adolescence or early adulthood. The study finds that the cultural object’s presence within clinicians’ therapeutic practice provides a vehicle for authentic self-expression in a fashion that holds the potential to contribute meaningfully to their work.

The relationship between the psychotherapist and her cultural objects: the clinician’s therapeutic environment functions as a cultural object. A surprising aspect of the research findings, not anticipated in the literature, is that each clinician articulated a strongly held tenet that her treatment space, reflective as it is of a distinct aesthetic, functions as a cultural experience in which the therapeutic relationship evolves. This phenomenon has both conscious and unconscious elements, and has the potential to resonate within the dyadic treatment. This finding is congruent with observation that the specific nature of a clinician’s associations to cultural objects

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provides a window into her sense of self. Each participant spoke of an intentionality in the construction of the therapeutic space. Clinician 1 inherited his office space, and much of the art that currently enriches it, from his mentor who died unexpectedly, leaving him in charge of the agency, and catapulting him into his mentor’s office space, as well. Even the chair he sits on in session belonged to this key mentor. For him, the Buddhist art conveys both his mentor’s teachings, and shared, deeply held tenets about what it means to be a human being. Clinician 2 conveyed a bond with his therapeutic space, primarily in the context of the view from his window, and what he called, “all that is part of my kingdom,” referencing the important architecture on view, which he noted he periodically visits to nourish himself between sessions. Some of his clinical examples included the ways patients have referenced the cultural experience on view through this sweeping picture window. Clinician 3 spent considerable time in the first interview orienting me to his space, which he dubbed “a musical environment,” consciously crafted for his patients’ use. Attuned to the therapeutic environments of his own therapists and mentors, he conceptualizes his space as a nourishing space, and an extension of himself. Of note is the fact that he practices his music in this space, which he has had soundproofed, and also crafted it with his own pleasure in mind. Clinician 4 inhabits a space that extends beyond her office to the larger agency, to which she administers, and which shares an aesthetic that is highly personal in nature. She identified a strong connection to the books on her shelves, and the beautifully framed poetry that hangs in significant locations in this larger space, and also has a home within her own office. In addition, she identified a playful soft sculpture in her office, which she cloaks in a range of shawls depending on the season,

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often the subject of commentary from patients and colleagues alike. Finally, Clinician 5 sees patients in a home office, which is an annex to her living room, as well as in an agency and a private office. She shared that some of the beloved art infused with personal meanings, which hangs in her home, has duplicates in her other offices, thus bridging home and work for her in a deeply meaningful way that speaks to her sense of personal continuity in her work and personal life. In addition, these professional spaces, her home office and the agency office, have been—to greater and lesser extents—inscribed with her husband’s artistic vision in ways that nourish her. In addition, several participants shared clinical vignettes in which a client made significant use of a cultural object present within the clinician’s therapeutic environment in the context of deep analytic work. Another subgroup of participants expanded on the ways in which they have drawn inspiration, comfort, and companionship from the cultural objects they have intentionally situated in their therapeutic environs. This phenomenon lends another insight into the elaborate composition of the psychotherapist’s internal and external environment and the ways in which aesthetic experience, concretely and metaphorically, provides expression for these remarkable, personally situated inter-psychic domains. Lothane (2006), makes a case “conjoining . . . [the] poets [with] the pragmatists and scientists” (p. 711), noting that in “no other science does the personal equation of the scientist weigh so heavily upon methodology as it does in psychoanalysis” (p. 723). Attending to the ways in which Isakower and Reik, two of Freud’s disciples, were both “poet[s] and . . . erstwhile neuropsychiatrist[s]. . . struggling to find the graphic—but forever elusive—locution to describe [reciprocal free association between analyst and patient],” he writes,

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Psychologically speaking, . . . the living-through of an experience and the reliving of it in memory . . . is akin to listening to music: To some extent during the act of listening, but more so after the sound has died down, we hold on to the phrase just heard, hold it in our memory, become receptive to further thoughts and to memories of past experiences. (p. 720) Writing of the interweaving of these two important psychoanalysts’ aesthetic sensibilities with their theoretical passions, he continues, Theodor Reik and Otto Isakower were two distinguished practitioners, theoreticians, and teachers of psychoanalysis who made important contributions to psychoanalytic methodology. . . . Both [were] at home in language, music, and literature; both endowed with the flair for the poetic, the imaginative, and the esthetic. . . . Reik called his method “listening with the third ear,” borrowing a phrase used by Nietzsche . . . To have the third ear (das dritte Ohr) is a common German idiom meaning to be endowed with a fine sensibility and discrimination, of reading or hearing between the lines . . . The affinity to listening to music is striking. In all languages the ear is literally the anatomical organ of hearing and figuratively the soul's instrument of discernment and understanding. A third ear has an even greater share of this psychological capability. (p. 714) The participants in this study, in their articulation of their respective personal idioms, as they are expressed through their associations to cultural experience within and outside of the treatment hour, elucidated the presence of a “third ear, . . . the soul’s

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instrument of discernment,” that attunes to the unconscious communication present “between the lines.” Enhancing the literature on this subject, the data analysis of this inquiry finds that this idiom is given voice through each one’s affinity to a unique aesthetic comprising the theoretical, the cultural, the crafting of one’s physical therapeutic environment, the fashioning of a personal narrative, and the evocation of a metaphor which employs imagery drawn from the arts to convey an articulation of their conceptualization of the therapeutic enterprise.

The relationship between the psychotherapist and her cultural objects: the cultural object houses significant relational resonance. Four of the five participants, at some point in the interview process, conveyed a clinical vignette in which the cultural experience, which arose unbidden in the participant’s imagination, contained powerfully moving relational resonance. That is to say that data analysis yields the finding that the aesthetic phenomenon that surfaced was intricately connected with a significant person or persons in the therapist’s relational sphere, past or present. This relational connection lent an added set of meanings to the cultural object’s nuanced signification. For some this phenomenon was elucidated once over the course of the interview process. For others it was prevalent many times. In each case, the relational meanings inhabiting the aesthetic experience were identified by the clinician as a significant aspect of the association. In each instance, as the clinician unfolded the vignette, my attention was drawn to the quality of his or her voice, as it grew softer, slower paced, somewhat dream-like at times. At times this vocal shift was

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accompanied by a body language communication as well. In some instances I wondered about the concomitant signs of relational importance. In others, the participant provided this element. Several examples stand out: Clinician 1, delineating how he drew upon the wisdom of a Judo teaching, while sitting with a despairing client, “Seven times down, eight times rise up,” unfolded the layered relational resonance associated with this teaching within the context of his personal involvement with this martial art form. He shared that his Judo practice is performed in the context of an admired, idealized sensei, and is enacted in the company of his adolescent son. In his unfolding of this vignette, the quality of his voice altered as he spoke about his sensei in ways that I conjectured would also be accessible to a client of long-standing who is attuned to the therapist’s communicative styles, thereby conveying nonverbally important textured relational information along with the wisdom adage of his Judo master. In this way, the association to and offering of this Judo wisdom contained within it the affectively meaningful sense of what Bollas (1997) labels “being-with.” He writes, As the aesthetic moment constitutes a deep rapport between subject and object, it provides the person with a generative illusion of fitting with an object . . . Such moments feel familiar, sacred, reverential, but are fundamentally outside cognitive coherence. They are registered through an experience in being, rather than mind, because they express that part of us where the experience of rapport with the other was the essence of life before words existed . . . the aesthetic moment constitutes part of the unthought known. The aesthetic experience is an existential recollection of the time when communicating took place primarily through this illusion of deep rapport of subject and object. Being-with, as a form

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of dialogue, enabled the baby’s adequate processing of his existence prior to his ability to process it through thought.” (p. 32) Clinician 5 provided a second compelling example of a cultural object’s infusion with a relational echo, in her recounting of an association while sitting with challenging clients, to a book she read when she was 8 years old, over 50 years ago. In her telling, the first associative connection she made to this book was that when she was 8 years old, this book was given to her by a beloved school librarian. She emphasized her feeling that this librarian had chosen the book specifically with her in mind. In recounting this early memory, her voice altered perceptibly. Similarly, in unfolding a second vignette in which she considered offering Cooney’s (1982) gorgeously illustrated children’s book, Miss Rumphius, to a client, she related her daydream of sitting reading this book to her own children, and, in her telling, moved her arm to wrap around an imagined daughter. Like Clinician 1’s Judo wisdom example, Clinician 5’s evocation of this cultural object invoked and conveyed the feeling of “being-with” that was palpable to me, and led me to wonder if this textured relational resonance was not also conveyed implicitly to her clients. In each instance, my reflections on the nuanced aspect of the clinician’s presentation came as a surprise. With some exploration and consideration, each acknowledged the existence of this added phenomenon as ringing true, thereby contributing to the clinician’s conceptualization of what the offering of cultural object experience within the clinical context may offer a client. This investigation, engaged in an in-depth interview process with seasoned clinicians, finds that clinicians participating in this dissertation research highlighted an intertwining of significant relational experience with their deeply affecting experience of

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cultural phenomena’s presence in their imaginative experience both within and outside of their clinical work. Along these lines, Fairbairn (1940a) understands a defining aspect of a cultural object to be its infusion with the experience of intense emotion. He believes the infusion of affect to be the element that is key to a creation’s “essential beauty” (p. 170). For him, intense affective experience is what inspires the artist to create, and what resonates within the beholder of an artist’s creation. The fact that participants in this study attributed a stirring relational texture to their cultural experience is consistent with Fairbairn and Winnicott’s (1967) conceptualization of cultural experience, and dovetails with Bollas’ (1987) understanding of “the conserved object” (p. 246).

The therapeutic potency of the cultural object: the cultural object is a vehicle for unconscious communication. This inquiry, focused on the clinician’s associations to aesthetic experience within the therapeutic encounter, is predicated on a belief in the existence of non conscious processes, as defined in an early footnote, as psychic phenomena that exist outside of conscious awareness. This understanding of the non conscious includes, but is not limited to, Freud’s (1912b) definition of the dynamic unconscious. It includes a category of psychic phenomena whose definition is influenced by Donnel Stern’s (1983) theory of “unformulated experience,” Bollas’ (1987) idea of “the unthought known” (p. 246), and the BCPSG’s (2005, 2008; D. N. Stern et al., 1998) understanding of ‘implicit relational knowing’ (p. 59). The category of non conscious mental contents includes “pre-verbal,” “nonverbal,” “pre-representational,” as well as “pre-symbolic” as delineated in the work of Beebe and Lachmann (1994), among others. This inquiry further assumes that

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unconscious communication, as defined by Isakower (1963b), Bollas (1987, 2002), Lothane (2006), and Altman (2006) normally occurs between persons, both within and outside of the consultation room. Balter, Lothane, and Spencer (1980), exploring Isakower’s (1963b) understanding of the nature of unconscious communication, offer that it is comprised of two states of consciousness or modes of awareness set in relation to each other” (p. 496, original emphasis). Participants in this study, to lesser and greater extents, expressed a belief in and awareness of the phenomenon of unconscious communication within their therapeutic work, and in the wider scope of their lives. All but one participant used the word with comfort and conviction. Clinicians 1 and 3 spoke spontaneously, without prompting about the presence of unconscious phenomena in their work and in their overall subjective experience. Clinician 2 addressed the phenomenon directly when asked, and otherwise spoke about the presence of unconscious communication in an implicit manner. Clinicians 4 and 5 responded with some depth of thinking when queried directly about the place unconscious communication has in their theoretical underpinnings and practical experience, although neither offered the specific terminology spontaneously in conjunction with clinical examples. All five participants elucidated an awareness of the presence of unconscious communication within their clinical work, both in terms of their capacity to elicit “news from within” as they attune to themselves, and in the ways they understand their clients’ communications. Clinician 1 harbors a deeply spiritual sensibility that comes into his work, and which is strongly influenced by his mentor’s teachings. His strong connection to beliefs about collective unconscious, Jungian archetype and Buddhist spiritual practice

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all contribute to his integral awareness of the unconscious within his work. In the screening interview, Clinician 2 reflected surprise that my dissertation topic was in part driven by a wish to resuscitate the prioritizing of non conscious material and unconscious communication in the therapeutic relationship. Trained as a physician and a psychoanalyst, he was the only participant in this study not rooted in a Clinical Social Work tradition. Yet, within the context of assessing his relationship to the concept of unconscious communication, he noted anecdotally with some dismay and judgment that colleagues at a reputed psychoanalytic institute had criticized Ogden for his privileging of “reverie” insofar as they felt strongly that he should not be “daydreaming” during sessions. This clinician did not spontaneously employ the concept of unconscious communication, but still he described his work as not prioritizing the “conscious surface,” of attending to unconscious processes and conflicts in his work, and cautioned that as one engages in reverie and evenly hovering attention in the analytic hour, one needs to pay attention to “what one is up to,” and in whose service this preoccupation with one’s musings is elicited. In concert with this clinical stance, over the course of the interview process he provided many well drawn vignettes in which employing associations to cultural objects yielded rich relational data that exemplified Bollas’ (1987) concept of “the unthought known” (p. 246), and his patient’s experience of “being-with” 100 (Bollas, 1987, p. 32). In addition, embedded in this clinician’s paradigm shifting image of offering a metaphor to “smuggle something across a border,” is a profound belief in and understanding of the unconscious processes at work in the clinical relationship. “Being-with, as a form of dialogue, enabled the baby’s adequate processing of his existence prior to his ability to process it through thought” (p. 32).

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Clinician 3 seamlessly considered the unconscious with breadth and depth in his discussion of his practice. When I pressed him about the centrality of his musical sensibility to his work, and wondered about the necessity of some kind of aesthetic predilection to do this work deeply, he corrected me with a passionate intensity characterized by an edge of instructive lecturing, “It seems to me that what we all have is an unconscious, [and] what we all struggle with is knowing about it . . . We have these various tools [i.e. our associations to cultural phenomena, among others] that allow for the emergence of unconscious communication within ourselves and it’s useful. . . . It’s the capacity and the willingness to go into our unconscious experience and get to know more about our stories, [in order to] find some kind of useful material from the unconscious that says something about what we’re doing here.” Clinician 4 disclosed many clinical vignettes in which a poem or song emerged in her imagination while in the presence of a client, in the context of particular themes and feeling states, in ways that fostered a deeper connection with her patient and their work together. She addressed the notion of unconscious communication in her delineation of the power of the poem, saying, “I think poetry is so immediate and so personal that it kind of takes you past your own first layer of skin. It kind of gets to you, to your unconscious in a way that a lot of intellectual or prose can’t get to.” Her thinking echoes that of Freud, Reik and others. And the way in which she spoke of this phenomenon conveyed an intensity of conviction founded on a wide breadth of experience. When asked directly about her relationship with the concept of unconscious communication, she offered moments of unexpectedly discovering her thinking to be in concert with

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another, one she is deeply connected with, often at a distance, in much the way Bollas (2002) writes of this phenomenon between friends, When two people free associate, … as is typical of close friends, they create unconscious lines of thought, working associatively, as they jump from one topic to the next. This is easy to do because we are open to such unconscious mutual influence when relaxed in the presence of an other. (p. 19) In her elucidation of this kind of unconscious connection, she employed spiritual, transcendent language, choosing not to use this clinical terminology. She disclosed, “I think there are ways in which, you know, grace works; something works, some kind of transcendent experience. Something that influences us that I do not pretend to understand—that are alive and vital. I don’t know if I’d call them unconscious communication, but I might call it oceanic experience.” Adams (1995) writes of the ways in which Clinician 4’s descriptive language harmonizes with that of psychoanalytic terminology. He writes, Psychoanalysis, existential phenomenology, and the great spiritual traditions are kindred disciplines devoted to discovering, exploring, and living in accordance with the depth dimensions of existence. Reverence for the depths of Being and being human serves as the guiding ethos of these traditions. The depth dimension is a metaphor for ways of being that transcend our usual ways, defenses, and identity, together with everything experienced thereby, including aspects of self and world still undiscovered. (p. 464)

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He continues, in a manner echoing Clinician 4’s sensibility, Reverence for the depth dimensions of existence seems to be central to all human cultures across all eras—with the possible exception of postmodern Western culture—and thus may be understood as composing an essential aspect of being fully human. (pp. 468-469) Clinician 5 provided a number of clinical vignettes, in the service of this research question, that incorporated compelling examples of unconscious communication between herself and her clients, and yet she conveyed a discomfort with psychoanalytic language. When asked directly about the ways in which she experiences this phenomenon in her work, she reflected a potent sense of self-knowledge and understanding, stating, “I know the theory. I can’t talk it like some people can, but I feel as if I do it.” Highly educated and trained, and a seasoned psychodynamically oriented psychotherapist, Clinician 5 may be representative of a body of clinicians who are aware of experiencing and utilizing their associations and those of their clients to access material that is out of their awareness, as exemplified by the myriad of examples she offered. And yet, she expresses a discomfort naming the phenomenon by employing psychodynamic terminology. In significant ways, the interview process was characterized by Clinician 5 unfolding these illustrative examples, and my reflecting the ways in which my specific area of interest was conveyed in her example. At these moments, she would grow excited and note that this was a new way of understanding what is transpiring in her clinical work. She described her work with language that accompanies this kind of conceptualization of unconscious communication. She would say, “They were telling me . . . and this just came to mind, and when I told them about what I was thinking, the work shifted.” In thinking aloud

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about how the therapeutic work was enhanced when she shared her association to a children’s book, she again employed language consistent with those clinicians who culminated in some statement of unconscious communication. At one point she said, “When [I] use a metaphor to describe an experience, it’s like [we] both understand what’s being said but sometimes [I] can’t quite [my]self put it into words. But the metaphor or a poem or even a piece of music can just help [us both] feel something.” This clinician also privileges the access of unconscious communication, and experiences her associations to cultural objects as a vehicle to further this enterprise, despite the fact that she is uncomfortable using theoretical formulations to describe her work. Participants of this study were screened prior to the interview process to assess each one’s suitability for this study, which adopted a criterion sampling approach. It is therefore difficult to assess whether these five clinicians provide a definitive sample of psychodynamic clinicians in the Twenty First century vis-à-vis their privileging of unconscious communication and their understanding that the cultural object functions as a vehicle for unconscious communication. Each member of this study, however, articulated her experience of associations to cultural objects having the capacity to provide a window into non conscious information, and to foster unconscious communication within the therapeutic dyad. Each one’s contribution underscores the significant finding that the cultural object has the capacity to function as a vehicle for unconscious communication.

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The therapeutic potency of the cultural object: the metaphoric resonance generated by the cultural object has layered functions. The single most significant finding across participants in this study, which investigated the ways in which therapists’ associations to cultural experience find expression in their clinical work, is the way in which each participant articulated the cultural object’s capacity to convey a usable metaphor both within her own imaginative process and in the more expansive inter-subjective therapeutic realm. Lakoff and Johnson (1980) shifted the way in which metaphor is understood within linguistic and philosophic domains as they ventured beyond metaphor’s traditional definition as a figure of speech, commonly understood to set two objects, drawn from differing spheres of life experience, beside one another in analogous fashion to enhance the meaning of one through the layered meanings of the other. The result of this collaboration between a linguist and a philosopher, Lakoff and Johnson, identified metaphor as “a matter of central concern, perhaps the key to giving an adequate account of understanding” (p. ix). Developing their thesis, they state that “Our ordinary conceptual system, in terms of which we both think and act, is fundamentally metaphorical in nature . . . The way we think, what we experience, and what we do every day is very much a matter of metaphor” (p. 3). Elucidating numerous examples of this phenomenon in their paradigm-shifting exploration, they conclude that Metaphorical thought is normal and ubiquitous in our mental life, both conscious and unconscious. The same mechanisms of metaphorical thought used throughout poetry are present in our most common concepts: time, events, causation, emotion, ethics . . . The heart of metaphor is inference. Conceptual metaphor

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allows inferences in sensory-motor domains (e.g. domains of space and objects) to be used to draw inferences about other domains (e.g. domains of subjective judgment, with concepts like intimacy, emotions, justice and so on). Because we reason in terms of metaphor, the metaphors we use determine a great deal about how we live our lives. (p. 244) Consistent with their thesis, all of the participants in this study identified the metaphoric resonance generated by cultural experience as an essential phenomenon in their work. They understood the metaphoric meanings drawn from the cultural object to function in the following ways: 1. The elicited metaphor conveys core themes in the patient’s narrative, and frequently provides the clinician with an affectively charged, highly evocative shorthand or “code” to conceptualize in an ongoing way a patient’s struggle or personal idiom. 2. The cultural object furnished a metaphor that provides a way to smuggle an important communication across a border in a way that it can be received, understood and used by the patient. 3. The metaphor supplies the client with something to work to untangle in a way that may yield an engrossing, intriguing, motivating challenge in the service of deeper understanding and connection. 4. The metaphor drawn from a cultural experience can function as a playful way of communicating painful, difficult information to one’s patient in a more acceptable and usable format.

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5. The metaphoric meaning inherent in a cultural object contributes a means to advance or receive a layered communication that delves (explore, probe, investigate) beneath surface meanings. 6. The metaphoric meaning offered by the cultural object is affectively dense and layered, providing opportunity for significant communication. Modell (2003), writing about metaphor as “the selective interpreter of corporeal experience” (xii), cites three writers on the significance of metaphor in a manner congruent with this study’s findings. He writes, Iris Murdoch observed, “The development of consciousness in human beings is inseparably connected with the use of metaphor. Metaphors are not merely peripheral decorations or even useful models, they are fundamental forms of our condition” (1970). (p. xii, emphasis added by Modell). Citing Yehuda Amichai, he writes, “’Metaphor is the great human revolution, at least on a par with the invention of the wheel . . . Metaphor is a weapon in the hand-tohand struggle with reality’” (p. 1). Finally, he cites Cynthia Ozick, “‘Metaphor [like the Delphic oracle] is a priest of interpretation, but what it interprets is memory’ (1991)” (p. 1). Data analysis yields this significant finding, congruent with the wisdom of poets and writers: The cultural object has the capacity to function as a metaphor which is drawn upon to communicate a multiplicity of significant information. Ozick’s articulation, like the Greek myth of Mnemosyne that preceded her, anticipates this inquiry’s valuable finding that the cultural object provides a vehicle for meaningful personal resonance, often housed within memory, yet “implicit,” “unthought,” and “unknown.”

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The therapeutic potency of the cultural object: the therapist self discloses when offering a cultural object for mutual consideration. Most of the therapists participating in this study described moments when they expanded an association to a cultural object, which bore “news from within,” venturing to share it with their patient. Clinicians articulated the understanding that such explicit communication was a form of self-disclosure insofar as they were speaking about an intimate subjective thought process drawn from a valued cultural experience outside of the clinical relationship, and yet intrinsically experienced within the inter-subjective field of the therapeutic dyad. Clinician 1 articulated it this way, “To have somebody else be thinking about me carefully enough, and sensitively enough, and empathically so that they can identify me in a story, and then point that out to me, that’s really special. That’s, there’s something agentic [sic] about that. That kind of gives me a little extra ummppfff or something when I know that I am being thought of in that way.” This study finds that the therapist’s offering conveys a profound communication that the therapist is thinking about her client; that the client exists in his therapist’s mind. The clinician brings her inter-subjectively elicited association into the dyadic space to be shared and considered. Participants understood this kind of therapeutic action as a complex psychodynamic communication that engendered a variety of experiences within and responses from their patients. Significantly, all the participants in the study who offered examples of this phenomenon shared vignettes in which their client experienced this moment as an authentic, meaningful experience of the therapist’s subjectivity in ways that generated a sense of intimacy and new relational possibility. Clinician 4 provided several descriptive metaphoric conceptualizations of this phenomenon as she likened it to “sitting down to

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share a meal” and “sharing a joke between friends.” These images illustrate her understanding of the intimate power of sharing a part of self, unconsciously evoked within the relational therapist-client experience. Several used the language of the client feeling “seen” and “known” by the clinician in this kind of moment. They understood this experience to hold the capacity to offset a sense of aloneness in the client, as well as initiating a confirmational experience that the client is important to the therapist. Three of the participants offered a companion story in which, as patients they experienced their own therapist disclosing an association to a cultural phenomenon in ways that deepened treatment. Each of them articulated a feeling of the therapist holding up a mirror reflecting the way she was understood by her therapist. One participant conveyed his feeling that his therapist had held this image within his own imagination for some period of time before sharing it. His fantasy that his therapist was thinking of him in an ongoing way in the context of a personally meaningful story evoked feelings of being held and known, as well as thoughtfully attuned to over time. In addition, this clinician disclosed his feelings of being important to his therapist in the context of this evocation. It is also important to note that several participants, in addition to communicating this positive aspect of self disclosure of her association to a cultural object, also shared examples in which the act of offering this kind of subjective response elicited anger, distancing, shutting down, and withdrawal on the part of the client. One clinician ventured to surmise that her patient experienced this as the therapist interjecting her subjectivity in a manner that was experienced as intrusive and ill timed, possibly resonant of experiences with an intrusive mother. A second participant conjectured that her client

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felt known and seen in ways that he was ill-prepared to experience in the moment for a variety of reasons which included a longing for intimacy coupled with a significant, historically rooted mistrust of this kind of closeness. This young man’s profound mistrust was coupled with a dread of being re-traumatized in the context of the therapist’s overture. While the therapist’s offering of her cultural association was a way to convey “seeing” and “knowing,” this possibility was terrifying to this particular client at that particular moment in treatment. A third aspect of self-disclosure, understood as embedded in the offering of a cultural association, was proffered by Clinician 1, who spoke of his reticence to share out a potent association to a foundational story for fear of taking up too much space in his client’s treatment, influencing his client unduly in terms of his own subjective predilections, and further fostering an already powerful idealizing transference, coupled with longing for twinship that would not serve his patient well were he to share out his association. This study’s findings provide an understanding of the cultural object’s capacity to function as a vehicle for meaningful relational experience, of both positive and negative valence.

The process of using the cultural object in one’s work: an articulation of the process of employing associations to cultural objects in her work. For the purposes of this study, the clinical and theoretical material discussed in the literature review offered by Reik (1949), Arlow (1979), Bollas (1987), and Lothane (2006), serve as paradigms for an elucidation of the nature of the clinician’s process of attending to her associative process as she listens to her patient. To lesser and greater

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extents, each participant in this study explained in some detail the nature of this process as it pertains to associations to cultural phenomena within the clinical milieu. In some clinical vignettes the association originated with the therapist, and in others the cultural experience was brought into session by the client, but then occupied a place in the clinician’s imagination as well, in ways that proved valuable. Three of the five participants expressed a difficulty in conceptualizing the delineated, progressive steps in the process of utilizing an association to a cultural object in their clinical work. Clinician 3 named an inability to explicitly name the components of this process, noting that the process happens automatically, and that even his reception of a cultural object may not be fully conscious. In conjunction with one clinical example, a tune that entered his imagination in the evening following a session, he said, “It may have [initially occurred to me] in the room. I didn’t notice it [then]. Music is frequently going on in the back of my head. It’s just that I’m not ordinarily paying attention to it.” Over time he coherently unfolded the intricate elements of his listening process. Clinician 2, in similar fashion, conveyed the challenge he experienced when asked to articulate his internal process that informs his therapeutic action. He drew several analogies to communicate the nature of the challenge, reflecting, “I suppose it’s something I’m not used to describing in a very direct way.” He drew an analogy between this phenomenon and teaching someone to pilot a plane. He named this “jamais vu,” 101 which describes an experience of a situation that one recognizes in some way but nonetheless seems unfamiliar. 102 In the case of his example, he was recounting an experience of teaching someone to pilot a plane by sitting in the right seat, when one

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This definition is taken from http://en.wikipedia.org/wiki/Jamais_vu

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ordinarily pilots a plane from the left seat. He also likened the process of explicitly reflecting on this aspect of therapeutic action to playing baseball left-handed. In this way he conveyed the challenge he experienced of coherently depicting the internal psychoanalytic process he engages in when sitting with a patient. Over time, he too, provided rich clinical material elucidating the intricacies of this process. Clinician 4’s reluctance to engage around the process in its intricacies was more short-lived than the others, and revolved around her aversion to psychoanalytic language insofar as she feels it does not adequately capture a phenomenon, but rather deadens it. Her reluctance did not seem to be about the actual exercise of parsing the process. As she quickly gained some comfort with the interview experience, she readily delineated essential components of her practice of attuning to herself and her imaginative associations to cultural experience as she attends to her client’s struggles. Components of this process are described in detail. They include: 1. An awareness of the presence of an association. 2. Considering the association. 3. Triaging the association to assess whether or not to share it. 4. The spontaneous offering of an association without conscious considering. 5. A consideration of the countertransferential elements of the association. 6. The therapist’s assessment of the client’s capacity to play with the association.

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An awareness of the presence of an association. In the context of explicitly analyzing the listening process, and considering it within the context of its essential components, the first element identified by all of the participants was an awareness of the presence of an association entering their imagination. They used a variety of ways to describe this. Clinician 1 said, “I am drawing from an inner resource or a cross reference in my brain,” to describe this experience. Clinician 2 reflected, “But what I was reminded of . . . is the ‘Madonna/Whore question.’” Clinician 3, revealed, “Something comes up out of my archive,” and asserted that it is possible for him to make meaning of these associations when one pays attention in a focused, “hovering” way.” In another context he offered, “I sometimes find that when I’m having a tough time of some sort [with a patient] . . . I notice . . . I do notice that when I’m kind of in the throws of stewing, that some kind of tune will come to mind.” Clinician 4 considered, “And as I was listening to her, I was thinking about something I had read: the idea, something about, you know, missing a layer of skin, and things are, you can’t filter. I was thinking about her. I was thinking. But there was something about [my sense that] she had the protective layer of skin kind of beaten off her as a kid. She anaesthetized herself for a lot of years, and now here she is out like a, you know, a little animal without any fur on.” In another context she reflected, “Sometimes in the middle of a therapy . . . a phrase or a line comes to mind that fits.” Clinician 5 described the phenomenon in this way, “The couple that I saw this morning are from South America . . . And they were talking about their extended families, and talking about the polygamous family structures a couple generations back. I remembered that and I hadn’t remembered this in I don’t know how long a book that I read when I

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was in third grade called Thirty One Brothers And Sisters, which was about a little girl who grew up in a family like this.” Research participants used a range of language: “I remembered;” “I was thinking;” “I notice;” “I was reminded of;” “Sometimes a phrase or line comes to mind;” “I am drawing from an inner resource.” All of them describe a moment when they became aware of an association introducing itself their imagination, in the context of the shared process between clinician and patient.

Considering. Each clinician spoke of doing some internal work around her experience. This involved some degree of triage as to the meaning to be gleaned from the association, and how to use it. Clinician 3 explained that at this point he began a conversation with himself, wakening himself from the reverie, to self observe and contemplate. He said, “[Well] sometimes, I say [to myself], ‘Ah! Listen to that!’ And then I follow, [and] I learn something from the tune. But what did I learn? It’s the title or something about it, and then I can follow that and see.” His next identified task was to begin to wonder how his association dovetails with the context in which his client exists, as well as the quandary gnawing at him. He continued, “[I then ask myself,] ‘What has that [tune] to do with the situation [in my client’s life story]?’” Within the context of assessing the nature of his reverie, Clinician 3 also pays close attention to the possibility that his own needs and themes may be driving the association. “[We need to] get to know more about our stories, and the things we make up that get in the way of understanding reality: the blind spots, the repetitious tales we give ourselves, the accumulation of pains

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and aches and miseries and all that that are hammering at us all the time. [The challenge is]: How do we find some kind of useful material from the unconscious that says something about what we’re doing here?” In this way he refocused his inquiry on the patient’s material, prioritizing a sifting through of his own “aches and miseries.” He was not overtly stating that one’s countertransference is not a useful tool in and of itself for gleaning information about one’s patient’s struggle. He was however counseling the sorting through of what belongs to whom in the service of the work. Clinician 2, in a more succinct manner, named this question as guiding him, “You know, if the story’s going to help me, I’ll say [to myself], ‘Well, how does that help me to understand [my patient]?’” He continued, “It’s just a more useful image.” Clinician 1 shared his reflections as he took into account his patient’s themes and the way they dovetailed with the story that entered his imagination, “Knowing that he’s a wrestler, and knowing that he’s struggling, . . . These things were in some way kind of getting more and more entwined.” Clinician 4, in the context of a vignette in which Springsteen’s song, “Stolen Car” entered her imagination noted, “He knows those lyrics, and it is a dark song, and he’s in a dark place.” In this way, she was attending to the ways the cultural object’s condensed images dovetailed with her client’s themes.

Triage: share it or work with it internally? History functioned as a factor. The next step in this analytic process, articulated in detail by several participants, was a process of assessing whether to use the object internally, or to metabolize it and explicitly introduce it into the therapeutic dialogue. Those who overtly addressed this issue articulated experiences of both phenomena, and delineated the criteria they bring to bear to determine how to use the cultural experience they have grown aware of. All five

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participants felt strongly that the history built up between patient and therapist, which some labeled as “trust,” contributed to their comfort and confidence offering an association. Clinician 1 stated, “This is somebody I’ve known for a long time. We’ve been working together for a long time, and I think when there’s that history that’s been established, we’ve had our ‘back and forths,’ and there’s enough trust in the relationship.” Later he added, “That’s the art right there. I think that the history and the implicit knowing that sometimes occurs [contribute to this phenomenon].” In another context, he stated, “The more important piece of it is the background and all that’s been built up in all those little moments of empathic resonance that really I think leads to a larger context of interpersonal sharing and relating.” He continued, “By history I think what I mean is a series of moments of recognitions. Or those experiences over time not only help to create a history but help to create a positive history, one that hopefully pushes the client forward in his or her process so that down the line when I am drawing from an inner resource or a cross reference in my brain, not knowing exactly whether or not it’s going to hit the mark or not I just sort of let it out there. And because there’s this background or backdrop of mini recognitions over time creating a positive history, there’s more likelihood that there’s going to be some kind of if not profound enlightening moment, then much more likely, ‘Oh I hadn’t thought of it like that.’ Similarly, Clinician 4 articulated her triage process, which included consideration of the history she and her patient have with one another, stating, “Sometimes it’s pretty conscious. You know I’m also thinking, ‘Where are we in our relationship? Do we have enough of a history together and a way of being together that I can do something that’s a little off the beaten path?’” Clinician 2 echoed this sentiment

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when he stated in the context of mining a shared cultural object for meaning, “He’s a bright, experienced patient very late in the analysis. So he’ll work on that one.”

Spontaneous sharing out without conscious consideration. Several also addressed the reality that while they often consider deeply and carefully, occasionally they will spontaneously, without much consideration, share out their reverie. Clinician 4 offered, “Sometimes in the middle of a therapy, if a phrase or a line comes to mind that fits, then I’ll use it without all that processing: a chapter, or a poem, or recommending book, or whatever. And you know I think it’s a wonderful thing.” What is not stated explicitly here, but arose in other parts of the interview process, is the added phenomenon that this clinician, in large part because of her comfort and experience with the therapeutic process, is not unduly afraid of misstepping as she understands that this too may nourish the work in unexpected ways. When she asserted, “And you know, I think it’s a wonderful thing,” she seems to be referring to the psychotherapeutic process itself and the potential it carries for good work to occur.

Other considerations regarding sharing out one’s association. Those who elucidated the process they engaged in to determine whether to speak their association aloud identified the following criteria. Clinician 2 considered, “I thought of this but I didn’t say anything. It was too far outside the room.” In this way, he is careful to use what is present, usable, “experience near,” and he is actively paying attention to particular priorities within the dyadic relationship. Clinician 3 examined the implications of sharing his association with his patient. In one instance, related to his

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reflections on his patient’s art, he delineated, “[There is] the anxiety that if I’m seeing him this way, I could also be intimidating to him. I could be [intimidating] like his father, and mak[e] him suffer. So I know in order for him to hear this, it takes work on his part, and that little bit of work is what makes for trust, and that’s what builds confidence and ego and all the rest of it. . . . That’s [the] art of [this work]!”

Consideration of countertransferential elements: defensive moves and selfdisclosure. A common theme among many of the participants, vis-à-vis sharing out an association to a cultural experience, included an assessment of the counter-transferential elements inherent in their association. Clinician 2 stressed the need to pay attention to what one is up to, for example defensive moves in accessing and utilizing one’s reverie. Clinician 1 was thoughtful in explicating the considerations he weighs before sharing out a cultural reference. In this instance he was paying attention to the ways in which the sharing out of this association was a form of self-disclosure. He indicated a caution about the impact this might have on his impressionable client, “I have a fella who was a wrestler, and so we talk on that level too and I think for him, he’s also interested in Judaism, and so he knows about me that I’m Jewish and he knows that I do judo, and he too has a very strong idealizing self object transference going. And I have to tread carefully ‘cause he’d come in and say, ‘Well, you know, I’m converting to Judaism,’ and ‘Well where’s your judo class?’ And he’ll be signing up.” In this way he expressed a caution about the impact of this kind of self-disclosure within the dyadic work.

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Along similar lines, Clinician 4 disclosed, “Occasionally I have stumbled. I know I remember vaguely a woman I saw for a couple years, and I don’t remember even specifically the poem, but I do remember that there was one part that really threw her. She felt that I didn’t get it. It was intrusive. What was I thinking? I forget.” Clinician 4 found herself at moments like this one worrying that the ways in which she draws upon her reverie within the clinical relationship has the capacity to take up too much space in the patient’s therapeutic work. This is reminiscent of Ogden’s (1989) caution, “One must not deprive [the patient] of his opportunity to write the . . . lines of his own analytic drama by burdening him with the analyst’s own unconscious contents” (p. 176).

Assessing the client’s capacity to play. Most of the participants considered their assessment of their patient’s capacity to play within their internal triage process, as they weighed whether to offer their association for shared engagement. The notion of playing and improvising within the therapeutic milieu was a key element to Clinician 3’s narrative. In one instance he mused, “And the question [is], ‘What’s required? What does a person have to have in order to do that [i.e. be able to play]? How do you do that with another person? Responding to his own questions, he continued, “Well, I think you do, because I think that’s what gives some substance to feeling some trust. Those are the things that settle in our bones that we take away from the treatment experience. But that’s what that means: to be able to play with thoughts and ideas, rather than to be rigid and stern about it, rigid about it, dogmatic about it, formal about it.” When he delineated that the experience of playing with ideas

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and thoughts in this way is what “gives some substance of trust,” he was identifying the experience of playing together itself as therapeutic. Clinician 4 considered moments when her offering of an association to a cultural experience did not go well. Leading a therapeutic group focused on grief work, she shared several intensely evocative poems. Describing what the experience of this kind of poem can offer, she shared, “I used to do a lot more explicit work in groups around grief and loss, and there are some poems around grief and loss that will just open up. There’s a poem by Denise Levertov, which describes grief as an old dog: 103 ‘I should not leave you out under the porch to fend for yourself: I should bring you in to make you my own dog.’ And I think when I have given that to people, who are [feeling], ‘I should be over this,’ . . . You know, the description of needing to own and bring in. I think it’s very evocative, opening up of a space.” She described an instance when a group member reacted with rage at her introduction of this poem. Her conjecture was that this client was too raw, too vulnerable to utilize the poetic message, and implicit in her assessment was this woman’s inability to play given the powerfully constricting, limiting nature of her grief process, so that she experienced the poem as a violation rather than a soothing salve, or an echo of a recognizable internal experience, and was unable to accept the invitation to play offered by this therapist with her provision of the poem.

103 Talking to Grief/Ah, Grief, I should not treat you/ like a homeless dog/who comes to the back door/ for a crust, for a meatless bone./I should trust you./I should coax you/into the house and give you your own corner,/a worn mat to lie on,/your own water dish./You think I don't know you've been living /under my porch./You long for your real place to be readied/before winter comes. You need/your name, /your collar and tag. You need/the right to warn off intruders,/to consider/my house your own/and me your person/and yourself/my own dog.

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Clinician 5 considered a clinical vignette in which she felt unable to associate to cultural experience in ways that are ordinarily integral to the nature of her therapeutic action. Consistent with Clinician 4’s assessment, Clinician 5 began to contemplate her client’s limited capacity to play as impacting the ways in which she as the clinician unconsciously limited her most authentic expression of self within the dyadic engagement. There was a sense in her telling that her client’s unconscious communication to her therapist was “Don’t be playful! Don’t be imaginative. Don’t do anything that’s going to push me out of this little tightly confined psychological space.” This clinician’s identification of the absence of reverie with a particular client awakened her to an awareness of a deadness for her in the sessions. Here she shared an unfolding learning of how to measure her offerings to be attuned to this client. Bollas (1995b) speaks to this phenomenon when he writes, Analysts listening to their patients, and then deciding what to say and how to say it, do so substantially unconsciously, and their decision about how to put something, and its ultimate form of expression, are unconsciously linked to the analysand’s receptive intelligence. In a good working alliance between analyst and patient, the former learns how to put things to the latter so that the communication reaches the patient in the most efficacious form possible. This intelligence is an important part of intuiting the other—a way of feeling the other out by forming and transforming contents until one develops a genre specific to the patient. (p. 45)

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Winnicott’s (1971) also speaks to this issue when he writes, Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist. Psychotherapy has to do with two people playing together. The corollary of this is that where playing is not possible then the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play. (p. 51, original emphasis) This study set out to engage five seasoned psychodynamic clinicians in three indepth ninety-minute interviews with the express purpose of elucidating the phenomenon of the therapist’s experience and use of her associations to cultural objects within the therapeutic milieu. It was my hope that the clinicians would illuminate their internal process of associating and utilizing their reverie in the service of the work. While most were initially reticent to attempt to break down this phenomenon of psychoanalytic listening into its intricate parts, often feeling that it was an automatic process, not subject to articulation, a comprehensive and thorough analysis of the data yielded this intricately detailed and valuable composite of clinicians’ articulation of their process.

Summary. Clinician 3 articulated, in intricate detail, the process of employing an association to a cultural experience in the service of the work. The other participants also communicated key elements of his elucidated process. All five participants understood an association to shine a light on both inter-psychic and inter-subjective phenomena. All five clinicians communicated a trust in the process of attuning to one’s internal musings, and a belief that this phenomenon holds the potential to highlight unconscious phenomena.

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Each of the therapists interviewed felt strongly that a history, over time with a patient, contributed to the capacity to both attune to and utilize an association in a beneficial fashion. Another significant finding is that the clinicians’ ways of knowing her patient connected meaningfully for each as they resonated with some of the clinician’s own history, predilections, and affinities. Each clinician’s approach to cultural experience is idiomatic, as is each clinician’s gravitation to a particular formal theory. How one draws upon cultural experience shapes one’s use of theory, and one’s penchant for a particular psychodynamic theory intertwines with one’s cultural affinities. These factors, as well as the clinician’s unique manner of crafting her therapeutic action, stem from her unique, personal sensibility.

Cross Case Analysis: Theoretical Summary This study set out to investigate clinicians’ associations to cultural objects, as they engage in a process of listening to their internal musings while simultaneously attuning to their client’s narrative. It set out to understand the ways these associations are used to elucidate the clinical work. Participants’ narratives yielded four essential findings. First and most impactful, the study identified the phenomenon that each clinician brings to her psychodynamic practice her unique personal idiom, which finds expression through, and is impacted by, her associations to her experience of cultural phenomena. It is the uniqueness of each individual clinician, and the ways in which these factors intertwine in her psyche, and within the explicit nature of the life each leads, that informs the nature of the practice each crafts. One way this finds expression is through the particular cultural vehicles which inhabit her imagination. It is these cultural objects—characterologically

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unique to each clinician—that are drawn upon in the service of the work. In addition, her unique forms of self-expression dovetail with the psychodynamic theory to which she gravitates, so that meaningful personal history and self-expression, aesthetic predilections and theoretical affinities align in a manner suggesting an integrated, authentic individual in meaningful engagement in the context of her professional psychodynamic practice. Second and quite significantly, this study yielded the finding that cultural objects serve to provide a metaphoric resonance within the treatment that has the capacity to enhance the work in a multiplicity of therapeutically valuable and far-reaching ways. The third finding that emerged across cases is that the clinician’s and the client’s associations to cultural experience hold the capacity to function as vehicles for unconscious communication in much the way dreams do, as they serve as condensed images laden with affective data. The fourth finding focused on the ways in which the clinician’s introduction of a personally meaningful cultural object into the dyadic relationship functions to be relationally meaningful in compelling ways. While participants for this study were selected by means of an intentional, purposive screening process as they identified as psychodynamic practitioners who value cultural experience, the ways in which cultural experience was elucidated within this study suggest that there may be a universality to this phenomenon. Specifically, language itself, a universal human resource, inclusive of its idiomatic expressions, nuanced meanings, and emotional resonance, emerged as a significant cultural phenomenon in participants’ narratives. Notably, psychoanalytic theory also emerged in this way, which suggests that other forms of knowledge, for example theories associated with other areas of expertise, function as cultural objects that share this capacity to serve as vehicles for

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unconscious communication. Clinician 1â&#x20AC;&#x2122;s Judo example as well as Clinician 4â&#x20AC;&#x2122;s example of the Springsteen song, suggest that all forms of cultural experience, embedded in any and all social, political, and cultural contexts may function in this way. These findings point to a sense that cultural phenomena regularly have a presence in the consultation room, within each member of the dyad and between them. This tendency points, as well, to the ongoing potential for the existence of non conscious communication within this sphere of human encounter, and it consistently holds the potential to offer itself as a resource to be mined in the service of therapeutic action. In his writing on aesthetics, Gadamer addresses aesthetic experience through a phenomenological lens, focusing on the ways in which art situates our experience of self and environment. An influential hermeneutist, he argues that oneâ&#x20AC;&#x2122;s experience of the aesthetic yields meaning, and believes the aesthetic to be a vehicle through which meanings are perceived. Gadamer (1975) writes, The pantheon of art is . . . the act of a mind and spirit that has collected and gathered itself historically. Our experience of the aesthetic is a mode of selfunderstanding. Self-understanding always occurs through understanding something other than the self, and includes the unity and integrity of the other. Since we meet the artwork in the world and encounter a world in the individual artwork, the work of art is not some alien universe into which we are magically transported for a time. Rather we learn to understand ourselves in and through it and this means that we sublate (aufheben) the discontinuity and atomism of isolated experiences in the continuity of our own existence . . . Art is knowledge, and experiencing an artwork means sharing in that knowledge. (pp. 87-88)

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Enchanted with Clinician 3’s ability to attune to the music within his imagination, and mine it for clinical data, both about himself and his patient in the context of their relationship, I wondered aloud if this phenomenon made him a better therapist. He responded, “It seems to me that what we all have is an unconscious, [and] what we all struggle with is knowing about it . . . I think if we have these various tools that allow for the emergence of unconscious communication within ourselves, . . . It’s useful . . . It’s the capacity and the willingness to go into our unconscious experience and get to know more about our stories [and figure out] how do we find some kind of useful material from the unconscious that says something about what we’re doing here.” By “what we’re doing here,” this clinician meant, how the psychodynamic psychotherapist utilizes her unconscious associations in the therapeutic work, which is the subject of this research project. Later he added, “I think if you don’t have something like that, the likelihood is that you won’t do this kind of work. I think in order to be this, if you’re going to be the kind of person I’m talking about . . . I think there has to be room for a playful experience. And you know, you don't get what you’re talking about out of nowhere. I mean that’s got to be derivative of some experience of yours. . . I wouldn’t call it a [cultural] object. I think it’s an action. It’s a process. It’s not a thing. It’s a way of being. It’s a way of doing, [of] thinking, of emerging and playing and creating. It’s a creative process.”

Clinical Implications The findings of this inquiry, which takes as its focus the psychotherapist’s use of her associations to cultural experience within her therapeutic work, offer significant

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relevance to the practice of psychotherapy. At a time when the medicalization and industrialization of the psychotherapeutic enterprise is gaining in authority, this study privileges the unique, humanistic, aesthetic nature of the clinician and the therapeutic endeavor. Data gathered from in-depth interviews with five seasoned psychodynamically oriented clinicians affirm the clinician’s privileging of unconscious communication, the notion that “all of psychotherapy is an engagement with an aesthetic,” 104 which includes psychodynamic theory itself as a cultural object; as well as an understanding that “the whole person of the treatment provider, of the analyst, is at the heart of what is relevant in engaging with a person struggling with problems in living” (Hoffman, 2009, p. 1049). In addition this dissertation study finds potent examples of clinicians’ understanding that the practice of psychotherapy is an art that draws upon the therapist’s unique sensibilities, as well as her capacity for improvisation and play in her therapeutic action. Implications of this study, both clinical and research, include the inquiry’s value for professional training, supervision and practice within the context of an evolving conversation regarding the nature of the psychotherapeutic enterprise and the ways in which the clinician’s “consequential uniqueness” (Hoffman, 2009, p. 1043) serves as an essential ingredient in psychodynamic work. Data findings suggest that elements privileged by clinician participants may function as key components in the education and supervision of new clinicians. Traditionally individuals pursuing this work are encouraged to engage in their own psychotherapy and immerse themselves in psychodynamic theory. This study’s findings also suggest that encouraging new clinicians to access personally meaningful aesthetic

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J. Tolleson, personal communication, 7-10-15

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experience in an attempt to gain entry to an essential authentic personal expressive capacity has the potential to enhance one’s clinical practice sensibility. Each clinician interviewed for this study articulated a conscious awareness of this phenomenon and the ways it enriches her work. Clinician 3 articulated this value when he said, “I think we bring these [associations to cultural experience which] are all vehicles by which unconscious communication, our own unconscious can give some voice in some form and shed light into the world. . . I think if you don’t have something like that, the likelihood is that you won’t do this kind of work. . . . It’s a process. It’s not a thing. It’s a way of being. It’s a way of doing, thinking, of emerging and playing and creating. It’s a creative process.” Buechler (1998) characterizes this phenomenon as one’s “internal chorus” (p.111). Including the voices of psychodynamic theory in her encapsulation of this chorus, and speaking to the mandate to nurture this in one’s students and supervisees, she (2004) writes, Engaging [my supervisee] theoretically may help awaken her to her work. Making connections between a theory and the clinical moment it illuminates can help the clinician feel authentically involved. It provides a sense of integrity and wholeness in that mind, heart, and spirit are all engaged . . . [Theory] adds depth and personal resonance. (p. 161) A significant finding in the data analysis identifies psychodynamic theory as a cultural object which inhabits the clinician’s imagination, functioning in the multiplicity of ways outlined in the cross case analysis. In an analogous manner, as I attended to participants’ narratives, relating theoretical, aesthetic and personal predilections, and

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providing clinical vignettes, I found myself associating to the voices of Bollas, Winnicott, and Ogden, Lipson, Reik, Lothane, Altman and others, along with Shakespeare, contemporary poets, and other aesthetic phenomena. The case studies, not unlike the clinician’s clinical vignettes, move seamlessly from narrative to association and back. In my own professional training, a valued consultant counseled me to find a way to enter my patient’s material playfully, perhaps by employing a resonant metaphor. 105 In this way she was inviting me to consider drawing from a personal idiom, or one that inhabited the dyad, as it dovetailed with my client’s narrative. Along the lines of this study’s findings, she was nurturing this aspect of myself in the service of my growth as a clinician. This study’s unanticipated finding that psychodynamic theory functions as a cultural object within the clinician’s imagination has implications for training and practice as well. It is consistent with Buechler’s (1998) concept of an “internal chorus,” (p. 111) and Casement’s (1992) concept of “an internal supervisor.” Considering theory in this way expands its potency, normalizes its presence in one’s imagination, facilitating its evocation not as a firmly adhered to, inflexible set of mandates, but as a condensed and conserved aesthetic object with the capacity to convey relational resonance and affective meanings. In this way, individuals immersing themselves in psychodynamic training gain increased and rich ways to imagine the theories presence in their imagination, in and out of session. Much as clinicians in training and those in practice are encouraged to consider their psychology in the service of their work with clients, attention to one’s distinguishing aesthetic sensibilities, both in terms of one’s dominantly privileged psychodynamic

105

B. Berger, personal communication,

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theory and the cultural sphere one inhabits also warrants attention within supervisory and mentoring relationships. This study’s findings suggest that such nurturance has the capacity to invite increasing authenticity into the process, which holds the capacity to contribute to a patient feeling seen and known. Further, privileging these phenomena facilitate an experience of engagement with a multifaceted human being, inviting her to play in the context of the therapeutic enterprise. This notion is consistent with a mentor who advised, “It’s important to have a sense of humor. While the psychoanalytic enterprise is a serious business, it doesn’t have to be dreadful!” 106 One might substitute “playful” for his assertion to “have a sense of humor.” His inherent message is that the therapist’s capacity to play holds the potential to enrich the work. Utilizing one’s associations to cultural objects, as elucidated by the participants of this study, can function in this way. Just as the clinician’s internal aesthetic offers nutrients, her physical environment provides these self-same ingredients. All of the participants of this study articulated a conscious awareness of the therapeutic environment they crafted. This phenomenon conveys implicit personal information about the clinician, offers the client potential aesthetic experience to draw upon, provides the clinician with sources of nourishment and stimulation, as well as a validating mirror of one’s subjective authenticity. Another essential finding of this study is the clinician’s privileging of unconscious communication within the therapeutic dyad, as well as within the larger sphere of their lives. It is significant in considering the implications of this study that participants drew upon a variety of vocabularies to elicit this phenomenon, as it inhabits

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Mark Berger, M.D., personal communication, 3-3-15.

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their lives. Three of the participants comfortably employed traditional psychotherapeutic language and named the phenomenon as “unconscious communication.” However, each of these three had her unique interpretation of what this meant. Clinician 1 was drawn to the notion of a collective unconscious and drew upon both Jungian thinking and Buddhist wisdom. Clinician 2 spoke in terms of relational data communicated in unconscious ways reminiscent of Daniel Stern’s conceptualization of “implicit relational knowing,” and Bollas’ “unthought known.” Clinician 3, also drawn to Daniel Stern and Bollas, as well as Donnel Stern and Langs, spoke most comfortably about this phenomenon in Freudian language. He accesses other theoreticians to enrich and expand on Freud’s fundamental conceptualization. Clinicians 4 and 5 were reluctant to employ classical psychodynamic language to discuss the phenomenon of unconscious communication, however both of these therapists spoke in ways that were wide and deep about the phenomenon occurring in both personal and professional domains. Clinician 4 employed spiritual and religious language, nodding to the uncanny, and invoking Annie Dillard’s spirituality as well as the Christian notion of “grace,” and the “oceanic feeling” 107 that Freud considered in his early work. Clinician 5 acknowledged a discomfort with formal psychodynamic terminology, but spoke animatedly about the phenomenon of unconscious communication in her clinical vignettes as well as personal life stories. While the wide use of and perhaps even belief in unconscious communication as a phenomenon within the therapeutic milieu is reportedly declining, participants in this study, screened and selected as psychodynamically oriented clinicians, demonstrated the employment of a variety of ways to speak about this essential phenomenon characteristic 107

See Simonds, J. G. (2006). The Oceanic Feeling and a Sea Change: Historical Challenges to Reductionist Attitudes to Religion and Spirit from Within Psychoanalysis.

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of human interactional life. This finding has relevance for teaching, supervision and practice insofar as an awareness of and comfort with the phenomenon of unconscious communication could be nurtured in clinicians through a flexibility of language and an invitation to search oneâ&#x20AC;&#x2122;s own subjective experience for examples of uncanny experience in an effort to validate, normalize and invite it into conversation. A significant aspect of these participantsâ&#x20AC;&#x2122; capacity to believe in and discuss the phenomenon of unconscious communication, as well as the overall privileging of the non conscious, stemmed from personal predilections defined by wide-reaching life experience, inclusive of but not limited to their own experience of analysis. One might conjecture that nascent students could be encouraged to plumb their comprehensive life experience to entertain the possibility of accessing moments of unconscious communication experience. As cultural objects house condensed images in much the same way that dream-work does, their presence within the psychotherapeutic conversation has the capacity to deepen clinicianâ&#x20AC;&#x2122;s comfort with and understanding of the phenomenon of unconscious communication. This is particularly critical at the beginning of this century when the spiritual and poetic has been exchanged for the mechanistic, the pragmatic, and the literal with the increasing medicalization of the psychotherapeutic enterprise.

Research Implications This dissertation study is an integral part of my learning, a component of a clinical social work doctoral program. Employing a qualitative research inquiry, one guided by the epistemological framework of hermeneutics, and adhering to a phenomenological approach, provided me with an opportunity to pursue a research

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inquiry in concert with my psychodynamically oriented, psychotherapeutic practice approach. As this study assumed “an analytic attitude” (Hoffman, 2009, p. 1047) in the service of constructing meaning, it valued “‘ambiguity, complexity, uncertainty, perplexity, mystery, imperfection, and individual variation in treatment’ (p. 993)”, (Hoffman, 2009, p. 1047, citing Cushman and Guilford (2000)), much as the practice of psychotherapy values these principles. Embracing a phenomenological approach, this inquiry considered what Hoffman (2009) describes as “the reality of the ambiguity of human experience [which] requires a creative dimension in the process of ‘making something’ of that experience” (p. 1048). In this way, my research endeavor served to nurture a deeper, wider capacity to listen, less impeded by judgment, and to co-construct meaning with participants within an inter-subjective dyadic format. This functioned in parallel to an inter-subjective co-constructed approach to psychotherapy. In this way, a qualitative research study serves to nurture the self-same qualities that the overall psychodynamic curricula seek to foster. Engaging with five seasoned, deeply thoughtful clinicians enriched my learning exponentially as it functioned to offer me wide exposure to elemental and creative aspects of this profession’s therapeutic action. Implications for further research studies growing out of this inquiry include, but are not limited to further investigation regarding the contemporary clinician’s privileging of non conscious phenomena in general, and unconscious communication specifically. This study drew upon a purposeful criterion sampling in which all individuals studied represent[ed] people who have experienced the phenomenon,” so that participants were selected on the basis that they were able “to purposefully inform an understanding of the research problem and central phenomenon in the study” (Cresswell, 2013, p. 156). It

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would be interesting to conduct a similar investigation employing a more random sample to discover the prevalence of elements of an “analytic attitude” in the wider therapeutic community. Along similar lines, while this study focused on seasoned clinicians who self-identify as psychodynamic in orientation, a study that engaged social work students focusing on the same lines of inquiry would additionally provide data with pedagogic implications elucidating the ways in which social work teachers, mentors, and supervisors could elicit nascent clinicians’ attunement to internal musings in the service of evoking an increased sense of authenticity in the psychotherapeutic dyad. Such an inquiry has the capacity to contribute to training implications for nascent clinical practitioners. This research study supports the primacy of hermeneutic methodology as it investigates in granular detail the nature of the psychodynamically oriented clinician’s engagement with herself and her client in their dyadic enterprise. It gleans findings that empirical data would be hard-pressed to discover. The phenomenon under investigation within this dyadic interview model, in which data was co-constructed, benefitted from the process identified between researcher and participant that ran parallel to phenomena which participants were simultaneously delineating regarding the clinical relationship. In this way, this researcher experienced in situ the phenomenon under investigation, facilitating in-depth insights into the phenomenon under investigation. In order to respond to critics who cite the absence of evidence one could bring to bear in order to shore up arguments that psychodynamic psychotherapy is of value in the marketplace, it would be important to point to the granular nature of this hermeneutically guided study’s investigation of the clinical encounter. Clinicians delineated in fine detail ways in which

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their attention to unconscious communication, and their attunement to “news from within” (Bollas, 1983) in the form of associations to cultural experience serves to enhance client’s capacity to feel “seen and known,” as well as companioned with. In addition, clinicians described the ways in which their clients experienced the clinician as an authentic other, and experienced a new relational paradigm in which a trustworthy and genuine capacity for self expression was experienced and honored as holding the potential to infuse the individual’s ongoing sense of self with meaning. It is my assumption that these phenomena, studied within a relational environment, are best measured by employing a hermeneutic methodology, predicated upon the self-same value system. Further this study’s findings evidence that these criteria, when expertly and sensitively fostered, have the capacity to stand up in the marketplace as phenomena that enhance an individual’s quality of life in the service of meaning making.

Conclusion This research inquiry explores the ways in which therapists utilize their associations to cultural objects and experience in their work. It was born out of a yearning to investigate an experience I have when sitting with clients, specifically in the context of returning to this work after many years, coupled with a life defined and deeply enriched by cultural experience. Four years ago, upon returning to this work as a psychotherapist, in a first session with one of my first clients, I found myself associating to a snippet from a film by Alan Rudolph entitled “Trouble in Mind,” 108 which I had seen with my husband 30 years prior, when our firstborn son was an infant. We had rented a video, a new

108

Rudolph, Alan (Writer and Director), (1985). Trouble in Mind [Film]. Pfeiffer/Blocker Production.

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technology at the time, and settled down to watch, having successfully tucked him in for the night. I can call up many details of the space we inhabited and the tender way it felt to be together that evening. In the context of this first session, this cultural object functioned as a metaphor to lend insight into my new client’s struggles. Within a relational context, this particular scene from Rudolph’s film came to mind, unbidden, while sitting with a lithe young mother, not unlike the protagonist in the film, and her two and a half year old son. My association from Rudolph’s film was to “Georgia,” a willowy, young mother; infant daughter on her hip; navigating her way through a sleepy, foggy Seattle night: lonely and alone, lost and abandoned; and haphazardly, albeit frantically, searching for safety. My new client resembled “Georgia” in her physical stature, and—I believe now—in the feeling state she was implicitly communicating, and those her presence in my office stirred in me. “Georgia,” called up from “my archive,” in the words of Clinician 3, had come to keep us company and to instruct me. “Georgia” arose unbidden, not solely as a defense against the feelings being with this young mother engendered in me, but as a way to awaken me to the bridge that connected the two of us. “Georgia” invited herself into my unconscious, in the words of Buechler (1998), in order for me to engage in “a creative use of [my] aloneness” (p. 111) in my work with my new client. My unconscious elicited these images, intertwined as they were with affective states, prompting me to reconnect with a vulnerable, lost part of self that intimately knows fear of abandonment, and the palpable sensibility of feeling lost and alone. She came to help me connect with this young mother. In this associative experience, I evoked Rudolph’s portrayal of “Georgia” within a context of a tender marital moment, a moment in which I felt companionship:

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physical, emotional, and intellectual. In this way, in the context of experiencing this

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snippet of the compelling film aptly titled “Trouble in Mind,” the evocative feelings of being alone and lost were attended to. My experience of this film snippet is multi-layered, and it came to mind after 30 years because it was personally so potently resonant in the first viewing. At that time, it must have tucked itself away along with a myriad of other childhood memories. And in the context of experiencing this new young woman, it surfaced to keep me company, and help me feel and begin to comprehend her struggle. There are many ways to understand this idea of “keeping me company” that do not include a defensive measure invoked to hold the client’s pain at bay. An existential humanist might suggest that “Georgia” came to remind me of the universal human condition of existential loneliness, and Clinician 1 would join her in asserting the existence of a collective unconscious that resonates with such universal human themes and images. Along these lines, Winnicott (1967) writes, “These cultural experiences . . . provide . . . continuity in the human race which transcends personal existence” (p. 370). A Self Psychologist would understand her presence in my imagination as the provision of a selfobject function, supplying me with “a sense of inner security and resilience, calm in [a time] of stress” (Kohut, 1984, cited in Banai, Mikulincer, and Shaver, 2005, p. 226). While not identifying along these theoretical lines, both Clinicians 4 and 5 spoke in a way consistent with this view. Neil Altman (2002) talks of the singer Emmy Lou Harris, evoked in a session with a young man grieving his father’s distant, dead-like emotional stance as a significant “route of access to . . . feeling . . . via a woman . . .” He describes this experience as the location of an “emotional space,” evoked at a point in treatment when he had “been unconsciously seeking points of shared resonance.” The evocation of

his cultural experience is conceptualized as a “dreamed image,” existing in “symbolized but not verbalized form” (p. 510). In some ways, Altman’s position is consistent with that of Clinician 2 who experienced cultural objects offered by a client to furnish them with a shared emotional space in which to explore unnamed relational data. Bollas (2002) teaches, “We are open to such unconscious mutual influence when relaxed in the presence of an other,” offering the analogy of two friends talking together: “When two people free associate . . . as is typical of close friends, they create unconscious lines of thought, working associatively, as they jump from one topic to the next” (p. 19). He suggests that the therapist is engaged in an activity he assigns the mystical term “dream-work[ing]” the patient’s material: condensing words and images. Winnicott (1967) locates cultural experience as “a third area, that of play which expands into creative living and into the whole cultural life of man” (p. 372). He continues, I have located this important area of experience in the potential space between the individual and the environment, that which initially both joins and separates the baby and the mother when the mother's love, displayed as human reliability, does in fact give the baby a sense of trust, or of confidence in the environmental factor. (p. 372) Likening his associative engagement to playing, Clinician 3 spoke of his associations to cultural objects in language that echoes Bollas and Winnicott, among others. My evocation of the young, vulnerable “Georgia” of Rudolph’s film, little girl baby on her hip, experienced in the context of a loving relationship was a way of playing in the space between myself and my young, fragile client, presenting as isolated and searching. It provided me with an experience of “creative living” (Winnicott, p. 372),

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keeping me company in the emotional space where the loneliness was palpable, enabling

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me to embark on a “creative use of [my own] aloneness” (Buechler, 1998, p. 111) in the service of the psychodynamic work with this young mother. In my effort to investigate the degree in which cultural experience has a presence in the clinician’s associations, and the ways in which she draws upon them to further the work, a significant finding concerns the manner in which the cultural object is intricately bound up with the clinician’s sense of self: her history, theoretical predilections, and cultural affinities. Lipson (2006), in reference to “the persistent presence (or intermittent but frequent presence) of self-generated tunes in consciousness” (p. 875) in the clinician’s thinking, proposes that clinicians experience “a characterological feature that is determined by genetic disposition plus life experience” (p. 877). In the context of this research, one may broaden Lipson’s ideas of musical experience to include other aesthetic experience. That is, thinking in images associated with visual arts and film, as well as stories, language, both poetic and prose, and syntactical and foreign language may also derive from both characterologic and genetic temperaments coupled with life experience. Reik expands the ways in which to consider this phenomenon within one’s thought process, likening it to dream-work. Associating to auditory and visual images in one’s mind’s eye and ear, he (1953) suggests is a “tapping [of] the wires of unconscious life” (p. 12). Clinicians who participated in this research study consistently described the ways in which their associations to cultural experience, within the context of the intersubjective, dyadic therapeutic experience, functioned as vehicles of unconscious

communication in a manner that significantly impacted the depth and breadth of the work that unfolds in their respective, self-consciously designated therapeutic environments.

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Appendix A Recruitment Flyer

Appendix A Recruitment Flyer Institute for Clinical Social Work Doctoral Student is seeking…. Seasoned Psychodynamically Oriented Clinicians for Research Study to Explore The ways in which therapists utilize their associations to experiences of the arts (such as literature, film, music and the visual arts) in their work If you … •

Are a seasoned clinician who has been in practice for 15 or more years

•

Self-identify as psychodynamic in your orientation

•

Work in a practice milieu that allows you to work in an open-ended fashion

•

Attuned to yourself as you listen to your clients

•

Feel comfortable discussing the ways in which you utilize your •

Attention to counter-transference

•

Imagination

•

Association to cultural objects such as music, movies, television, painting, sculpture, theatre, literature and poetry as you sit with your patients

…and you have an interest in discussing your practice with a curious and engaged doctoral student during three in-depth 60 to 90 minute interviews… Please contact Ellen Blumenthal 847 707 2135 ellenrblumenthal@gmail.com

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Appendix B Informed Consent Process

Appendix B Informed Consent Process The following is a script of what I was said to participants in my study: â&#x20AC;&#x153;My name is Ellen Blumenthal. I am a fourth year doctoral student at the Institute for Clinical Social Work. I have invited you to participate in my dissertation research which takes as its focus the ways therapists who have been in practice for at least 15 years listen to their own thoughts while simultaneously listening to their clients. I have an interest in the times your mind wanders while doing your work, and what meaning you make of the thoughts you have during sessions. I am hoping you will talk with me about what kinds of things you learn about the work you are doing with your client, and the work your client is doing with you when you pay attention to this phenomenon as it is happening, and when you think about it later. Even more specifically, I am interested in times your thoughts wander to an experience of art of some kind that you have had, either recently or in the past. For example, if you associate to a part of a movie, a refrain from a song, an image in a painting, or a character in a novel, I am curious how this affects your work. My plan is to meet with you for three 60 to 90 minute interviews, in which I will ask you some questions about this phenomenon in your work. I will audiotape our meetings, and ask that you disguise identifying case material that you share with me. All of what we discuss together will be confidentially protected. The tapes and transcripts from our meetings will be stored in a locked cabinet during and following the study. I am mandated to keep these materials for 5 years and then destroy them. In the interviews and transcripts, your name will not appear. Rather, I will be assigning you a number that will identify any materials gathered in your interview sessions with me. I would like to inform you of the names of the committee members working with me on my dissertation work so that you can assess your comfort level with any one of them being privy to the raw interview data, even though it will be disguised. In this way you will be able to evaluate whether you are comfortable participating in my study.â&#x20AC;? .

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Appendix C Consent Form

423 Appendix C Consent Form Institute for Clinical Social Work Research Information and Consent for Participation in Social Behavioral Research Title: Psychoanalytic Listening: How Therapists Utilize Their Associations to Cultural Objects in Their Work I, ___________________________, acting for myself, agree to take part in the research entitled: â&#x20AC;&#x153;Psychoanalytic Listening: How Therapists Utilize Their Associations to Cultural Objects in Their Work. This work will be carried out by Ellen R. Blumenthal, LSW, M Ed, under the supervision of Jennifer Tolleson, PhD, Dissertation Committee Chair. This work is conducted under the auspices of the Institute for Clinical Social Work, 401 S. State Street, Chicago, IL 60601, (312) 935-4232. Purpose The purpose of my research study is to complete a dissertation using a qualitative research design. The goal is to glean a deeper understanding of the ways in which psychotherapeutically oriented psychotherapists utilize their associations to cultural objects in their work. Findings will be included in a bound dissertation document and may also be used to develop papers for conference presentation or journal submission. This dissertation document will be available on-line. Procedures used in the study and the duration of participant engagement Participating in this study includes three to four interviews focused on your thinking about your use of reverie with your patients. Interviews will be recorded and transcribed by myself and/or a professional transcriber. Transcriptions will be used in a case study design method to organize your thinking into a study that engages in an exploration of the ways you utilize your associations to attend to your internal musings as you listen to your patient. These in-person interviews will take place over a course of several weeks depending on your availability. Each interview will last approximately 1 to 1 and onehalf hours. Benefits This research will contribute to the knowledge base of clinical social work and clinical process theory. There is no direct benefit to you for your participation beyond the opportunity to share and clarify some of your ideas about this phenomenon in your work.

Costs The cost to you for your participation is 3 to 4.5 hours of your time. Possible Risks and/or side effects The very limited risk of this study is the potential for feeling professionally exposed in relation to discussing the topic. However, your identity will be confidential; no one will know your identity except for this researcher. While this risk is extremely unlikely, the plan for responding to feeling exposed will be a de-briefing session(s) with this researcher or another person identified by you. Privacy and Confidentiality Procedures for insuring confidentiality are as follows. Privacy will be provided during interviews as they will take place in your home or office. I will not share your identity with anyone. No actual names will be used in the dissertation and other identifying information will be disguised as necessary. All tapes and transcribed data, identified only by number, will be kept in a locked cabinet where no one other than the researcher and her advisor may have access to them. Tapes will be destroyed after transcription. Selected sections of transcriptions without identifying information will be compared to researcher interpretations by the committee chair and by selected participants in order to minimize researcher bias and develop alternative views of the data. Subject Assurances The following is the format that should be followed in creating the assurances: By signing this consent form, I agree to take part in this study. I have not given up any of my rights (my child’s rights) or released this institution from responsibility for carelessness. I may cancel my consent and refuse to continue in this study (or take my child out of this study) at any time without penalty or loss of benefits. My relationship with the staff of the ICSW will not be affected in any way, now or in the future, if I (or my child) refuse to take part, or if I begin the study and then withdraw. If I have any questions about the research methods, I can contact Ellen R. Blumenthal, ellenrblumenthal@gmail.com, 847 707 2135, or Jennifer Tolleson, PhD, at (312) 9354244, jtolleson@icsw.edu. If I have any questions about my rights – or my child’s rights – as a research subject, I may contact John Ridings,PhD, Chair of Institutional Review Board; ICSW; At Robert Morris Center, 401 South State Street; Suite 822, Chicago, IL 60605; (312) 935-4232.

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Signatures [All consent forms must be signed and dated. They must be explained to the participants and witnessed by the person who is explaining the procedure.] I have read this consent form and I agree to take part (or, to have my child take part) in this study as it is explained in this consent form.

Signature of Participant

Date

Signature of child (if over 10 years)

Date

I certify that I have explained the research to (Name of subject or child) and believe that they understand and that they have agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward.

Signature of Researcher Revised 1 Feb 2014

Date

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Appendix D Consent Form Addendum

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Appendix D Consent Form Addendum Institute for Clinical Social Work Research Information and Consent for Participation in Social Behavioral Research Title: Psychoanalytic Listening: How Therapists Utilize Their Associations to Cultural Objects in Their Work I, ___________________________, acting for myself, agree to take part in the research entitled: “Psychoanalytic Listening: How Therapists Utilize Their Associations to Cultural Objects in Their Work. This work will be carried out by Ellen R. Blumenthal, LSW, M Ed, under the supervision of Jennifer Tolleson, PhD, Dissertation Committee Chair.This work is conducted under the auspices of the Institute for Clinical Social Work, 401 S. State Street, Chicago, IL 60601, (312) 935-4232. I am familiar with several members of the ICSW faculty comprising Ms. Blumenthal’s dissertation committee, and I give my consent for my data to be utilized and seen by them. I understand that they will have access to this data. I may cancel my consent and refuse to continue in this study (or take my child out of this study) at any time without penalty or loss of benefits. My relationship with the staff of the ICSW will not be affected in any way, now or in the future, if I (or my child) refuse to take part, or if I begin the study and then withdraw. If I have any questions about the research methods, I can contact Ellen R. Blumenthal, ellenrblumenthal@gmail.com, 847 707 2135, or Jennifer Tolleson, PhD, at (312) 9354244, jtolleson@icsw.edu. If I have any questions about my rights – or my child’s rights – as a research subject, I may contact John Ridings, PhD, Chair of Institutional Review Board; ICSW; At Robert Morris Center, 401 South State Street; Suite 822, Chicago, IL 60605; (312) 935-4232. Signatures I have read this consent form and I agree to take part in this study as it is explained in this consent form.

Signature of Participant

Date

Signature of Researcher

Date

428

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