The idea that the analysis of transference and of transference resistance is the central mode of therapeutic change in analysis is properly essential to the idea of change. By reliving the experience of the past in the transference, the patient can be helped to understand the distortions as well as the wishful elements that affect behavior (the totality of experience), thereby facilitating the creation of a new, freer, and more adaptive experience of the world. What changes people in analysis resides not only in the novelty of an interpretation, but in the new experience
of the analytic situation, an experience that contrasts with previous experience and with continued maladaptive patterns of behavior. It is a corrective emotional experience—although not in Alexander's10
sense of a manipulated experience in which the therapist takes a false and deliberate role to contradict a reexperienced transference. Words alone do not effect change. This principle is reflected in Rado's saying that the only thing that insight ever cured was ignorance. Words are powerful when they are expressed in an emotional context that leads to new experience.
I emphasize the element of transference manifested in the wish for a good, gratifying, supportive, valuing parent. This has been described by the Ornsteins as the “curative fantasy” with which many patients approach therapy.11
They speak of the unconscious fantasy of patients approaching treatment, that they will find the perfect parents they never had in childhood and will thereby be cured.12
I call this the wishful ideal parental transference
; it is an attempt to find a state of peace and a state of understanding to decrease the sense of isolation that neurotic symptoms and their distortions engender.
Clearly the experience of gratification of such a wish is a solution neither to intrapsychic conflict nor to life's problems. However, the full and rich affective reenactment of the discovery of the wished-for ideal parent, that is, the parent desired but never had, is potentially operative to a greater or lesser extent in a wide range of psychotherapeutic contacts—including brief consultations—and contributes to change in many therapeutic encounters. I distinguish here between a predominantly ideal
transference and a predominantly idealized
one; the latter is rooted in the conflict and is often a defense against aggression.12
My emphasis is not on repetition of a past experience, but on repair of a developmental disturbance, a new experience that contrasts markedly with the past and thus has a powerful effect. Hence it includes not only conflicted repetitions to be corrected through interpretation, but also wishful new experiences, enacted in the transference and crystallized by the pressure of the therapist.
Neither substrate nor catalyst is a suitable word for what I mean by presence, since both have the quality of inertness and are not dynamic. Presence emerges rather than being directly brought about.
One aspect of presence clearly has to do with interpretation or communicated understanding. Meaningful interpretations—interpretations that lead to insights—have the quality of emotional conviction and create changes in one's perception of oneself in the world. Of special importance are transference interpretations that modify distortions emerging from the past. Inevitably, this interpretive communication by the therapist reflecting understanding of the conflicts and predicament of the patient over time gives the therapist a special status in the patient's eyes. The therapist's involvement contributes to this effect. Emotional engagement is an important aspect of presence: the experience of a shared enterprise in which the patient feels valued by the therapist's respect for the patient's struggle adds to the experience of presence. In short, traditional analytic work contributes to the establishment of presence but does not encapsulate the idea that I am presenting.
Empathetic awareness of the patient's emotional state is a substrate for intervention and for communication. Schafer13
speaks of generative empathy
, taking the term from generativity, a concept in Erikson's stages of adult life.14
In my view, however, empathy leads to an understanding of the patient's predicament and thus prepares the terrain for a potential interaction with the patient that leads to establishing presence. Truax15
and Truax and Carkhuff16
establish an empirical basis for the therapeutic power of accurate empathetic understanding of the patient, unconditional positive warmth for the patient, and therapist genuineness. These elements lead to what I call presence. Empathy prepares the terrain for an active engagement of the patient.
But how does presence come about? Clearly it involves a positive attitude toward the patient, a sense that one likes the patient. In the real world, however, this is not always the case. If a patient is too hateful or evokes very negative feelings, problems are posed for the development of a working alliance. Yet emotional engagement is often possible at moments, thus having special meaning in its unexpected appearance. There are other circumstances in which presence can develop. I found myself working with a patient who was not especially articulate and was rather cut off from his feelings. I was frequently bored and felt absent. I began to actively construct scenarios from the experiences he was describing, to suggest motivations, conflicts and feelings, to fill in gaps, to provide a type of “connective tissue.” The patient began to ape my method, at times laughing as he recognized what he was doing, that he was speaking in my voice. Gradually it became his own, and he became enthusiastic in his endeavor as he began to recognize and acknowledge his inner life. As he did so, I became more alive, responsive, and present. (This experience echoes Goldberg's elegant paper on modes of interaction with patients,17
in which he uses the analogy of music in modes of interpretation. The experience I have just described would correspond to his playing variations on a theme.)
It is important to emphasize that by “presence” I do not mean a uniform or standard response to the patient. On the contrary, it is my view that every relationship, whether in life or in analysis, has unique characteristics that develop in the context of repeated interactions. Particular qualities in the patient evoke in the therapist a special type of responsiveness unique to that patient. We develop personal languages in our dialogues with patients: modes of speaking, of delivery, special ways of communicating whether by humor, idiosyncratic vocabularies, uses of metaphor, or tones of interaction that are unique to the particular dyad. This responsiveness is enriched progressively by the shared experience in the treatment, in the common language that develops between the two participants. (I use the idea of a personal language as distinguished from a tongue, the latter having to do with the general and formal rules of psychoanalytic interpretation.) The therapist's responsiveness in this regard is often automatic, intuitive, and without conscious awareness, particularly initially. It becomes a natural background for the dialogue. The therapeutic stance is also tailored and formulated on the basis of the therapist's knowledge of the patient's personality and what the patient can integrate and respond to at a moment in the analysis.
It is important to emphasize that these are experiential phenomena. They can be described and are in part shaped by conscious intent, although there is an important element of spontaneity. They must remain authentic and uncontrived. What has been described above has to do with the concept of intersubjectivity, and it touches on Pizer's18
concept of negotiating a relationship. The development of presence with an individual patient is affected by the repertoire of possibilities in the therapist, which inevitably has limitations. I do not imply that my “presence” has a universal quality that is useful in work with all patients. I am well aware that my capacity to interact properly with certain patients is limited by my inability to respond to certain implicit demands generated by them. Moreover, presence is not defined necessarily by behavior that would always be described as active. Certain patients require a quiet silence on the part of the therapist or interpretations offered in a particularly tentative way rather than as defined statements to which they can react. The combinations are endless, and it is here that the patient-therapist match becomes important.
Therapists have different aptitudes in their abilities to respond, to allow presence to develop. The process is further complicated by the conditions of training, which discourage personal expression as behavior that deviates from the rules (often experienced as constraints) of neutrality, anonymity, and nongratification. This may lead to rigidity. Many unsuccessful analyses or impasses in analysis, even in the context of what appears to be reasonable understanding and interpretation, become so because of the “absence” of what is necessary under the circumstances. The development of an aptitude for presence depends upon personality and requires experience, confidence, and a capacity for appropriate spontaneity. It may even become dangerous, for in the wrong hands it can create a chaotic situation or wild analysis.
Although “presence” is an elusive concept, it can be described. It is not to be considered a matter of personal style, although the form it takes is personal. It is not a technique, but involves behavior of the therapist that is generated spontaneously in the relationship between two people. As such, it reflects aspects of the “real relationship” as described by Greenson and Wexler,19
and others. It is related clearly to the findings of Truax and Carkhuff16
who have demonstrated the positive effect of warmth and genuineness as nonspecific factors in psychotherapy. Clearly, therapists vary in their emotional reactivity. Beyond this, I am speaking here of a progressive involvement on a personal level that goes beyond an intellectual curiosity about the process of psychotherapy. The involvement is unambiguously on the side of cure—though it is to be recognized that this wish for cure has potential pitfalls, not only in the form of negative therapeutic reactions, but also in the danger of imposition of the expectations of the therapist upon the patient. However, to recognize with Loewald20
that the analyst is on the side of change is not to impose the values of the analyst, but rather to create an environment in which the patient can develop according to his or her own potentiality.
“Presence” may be a stimulus for the analysis of unconscious conflict; it may be experienced as a threatening intimacy, which evokes anxiety and thus becomes a stimulus to further analysis. This was the case in a situation where a chance encounter with a patient in an elevator led to an interchange that evoked anxiety, which was subsequently analyzed.21
The only reference to the word presence
in the psychoanalytic literature is by Sasha Nacht.22,23
The patient is led to believe that the analytic environment is benign. Veszy-Wagner24
Under “presence” Nacht understands a “constant accessibility” (being at the patient's disposal), an “unconditional (kindly) reception,” an “unlimited patience,” and, what is most important, an “ability to give”… The patient should find “a good object” in the therapist and the effective management of the transference depends less on the technical abilities of the therapist than on his deeply felt and genuine attitude toward the patient. (p. 79)
This is a description of presence that echoes my own, although, as I will discuss below, I am referring to something much more variable and nuanced than a benevolent, nurturant attitude. Moreover, central to Nacht's idea of presence is that this is a requirement for proper analysis and the substrate on which the analysis rests. I agree but add that it may become a major agent for change in its own right.
More recently, the psychoanalytic literature has reflected a growing interest in themes pertaining to the model I have described.25
emphasizes the constant and inevitable enactment that characterizes the special dyadic relationship in analysis. He emphasizes spontaneity (of course, with awareness) and offers the analogy of a skier acted on by powerful forces but allowed a sort of freedom from excessive control—as would also be the case, he notes, in a good sexual relationship. Renik further speaks of the idealization of the therapist as a useful phenomenon; however, he does not distinguish between ideal and idealized transference. Jacobs27
also comments on the therapist's spontaneity and use of “intuitive understanding of the patient's state of mind and character to make unconscious adjustments in technique” (p. 12). Hoffman7
presents the constructionist's view and speaks of “the personal, spontaneous aspects…of the relationship…with the cultivation of intimacy” (p. 114). None of these observations are organized in the form of the model that I propose.
It is important to emphasize that by “presence” I mean much more than what has been described by Winnicott as the “holding environment.”28
“Presence” is not simply the direct experience of a warm and nurturant attitude; it may develop in a confrontatory or what may superficially appear to be an aggressive stance. Winnicott's holding environment differs from what I am describing in two important ways. First, the holding environment is an atmosphere generated by the experience of the therapist as a nurturant figure, much as described by Nacht. Second, it is essentially a re-evocation of a preverbal and primal experience.29
In this respect it is not interpreted and remains in the background.30
What I mean by “presence” has different configurations, generated by the interaction and based on the patient's needs as they evoke intuitive and spontaneous responses in the therapist. At times what may be seen as an aggressive confrontational stance may solidify the relationship and actually be experienced as a mentorship. At other times a contrasting approach is necessary; the therapist must modulate his or her expression of feeling in order to respect the patient's fear of emotionality and expectation of intrusion. These fears may be examined gradually as the analysis proceeds. Gradually a special quality of dialogue is established between patient and therapist, a dialogue that varies from one dyad to another. Most important is that this dialogue is in the experiential realm (in the domain of conscious and unconscious fantasy31
) and hence available for interpretation.
Multiple modes of interaction characterize human relationships. Levenson32
singles out two dichotomous modes of experiencing and acting in the world. He argues that both therapists and patients tend to cluster toward one of these modes and that their interaction in this context affects the nature of the therapeutic relationship and what happens in psychoanalysis. He defines the poetic mode
as one that involves an attention to the unconscious flow of ideas and says that a therapist working in this mode is more likely to encourage the flow, occasionally to raise questions about it but to be more passive regarding interpretation and active intervention. On the other hand, the pragmatic mode
focuses on skill in the world and touches on actualizing patients' feelings in a very active way in the analytic situation. The latter mode in many situations evokes “presence,” but the former stance is required at other times. This is the art of analysis, what makes “presence” so hard to describe. There is no single road to Jerusalem.
At this point another question must be posed. Will my analytic patient wish to perpetuate a dependent ideal transference in the form of an incomplete and interminable analysis? Why should a person wish to give up something that is comfortable and gratifying for something involving danger and the unknown? One might also wonder whether this experience would mute her ability to manifest angry transferences. These are questions that have permeated the psychoanalytic literature for years. The libidinal and economic hypotheses suggested that the discharge implicit in gratification would decrease motivation for the examination of behavior and for change, although a proper balance of frustration and gratification is more in keeping with current thinking. With my patient, the experience of the ideal transference did not prevent her from manifesting angry transference reactions and working them through.
There is a long tradition of awareness of the influence of the therapist in relationship to the powerful thrust for development throughout life, a movement toward change and increased complexity.1,20,33–35
emphasizes the role of idealization of the therapist in the young adult as a force leading to developmental progression. Loewald20
has argued that the analytic process is analogous to a developmental process, in which the therapist has a perception of the person that the analysand is becoming and helps to crystallize this perception for the patient as the analysis proceeds. This developmental process was expressly stated by my analytic patient, who described the multiple roles she had assigned and would in the future assign me. The sense of security often generated in our relationship permitted a new and richer exploration of the world endowed with new possibilities and replete with its own gratifications—not unlike aspects of the process of separation and individuation.
In each of the anecdotes described, the ideal transference took a paternal form that was concordant with the needs of the patient, reflective of his or her life experience as expressed at that moment in time. Did my gender effect this? Would an ideal maternal transference operate under other circumstances, or is it true that the maternal influence is directed toward affiliation and nurturance and the paternal one toward separation and independence?
A comment on the nature of change is indicated. By change I mean a modification of self and object representations that permits the patient to experience the world in a different way. My analytic patient, who had previously lacked an appropriate sense of entitlement to take and receive from others, was able in the context of the experience of analysis to find herself worthy and to comfortably take from others. This was a reflection of an increased valuation of herself that had been generated in the psychoanalytic process. It is difficult to establish absolute connections between specific aspects of process and outcome because analysis is so complex and involves understanding on many levels. Although the change that she experienced was influenced by what I have described, the process of interpretation of intrapsychic conflict played an important role as well.
In conclusion, presence and enactment as described here is neither the whole nor the end-all and be-all of change in the psychoanalytic process. In the past this has been seen as a substrate for successful analysis rather than as a force toward change in its own right. It poses the difficult problem of the personality of the therapist. Moreover, it has been viewed with suspicion because it seems to contradict the tragic view of reality,36
the view of the essential human experience of conflict and pain so pervasively insisted upon by Freud.37
Yet presence and enactment may lead to an important aspect of change that complements usual analytic technique. As such, it may explain the efficacy of many diverse psychotherapeutic endeavors based on different models of therapy. In this light, an aspect of the nonspecific effects of psychotherapy may be viewed as a specific one. Moreover, this model lends itself to an understanding of aspects of all therapeutic encounters, from brief therapy to psychoanalysis.