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I would like to concentrate on describing my take on the process of making the inaccessible within patients’ psyches more available for articulation and analysis. This reflects my practice of often listening more to what is not being said than to what is being verbalized. 

What exactly do I mean by the  ‘implicit’?  The ‘implicit’ refers to the general manner in which a patient presents.  It represents both public and private selves.  It refers to aspects that create the sense of identity of the person, the essence, the sense of being in the world.  As residing, so to speak, in the preconscious, the ‘implicit’ relates to information that is potentially available to the patient and therapist but is unknown until explicitly identified.  Although my perspective certainly concentrates on character, the ‘implicit’ goes beyond character structure since it refers to qualities that transcend commonly described personality types.  Similarly, it does not solely refer to preconscious processes.  Rather it speaks to family identifications on an intimate and microscopic level. Every family has a particular language that each family member is taught ‘implicitly’ and is expected to be fluent in.  This language represents theories of the way in which the world and people function and of ideas of the workings of the mind.  The family language contains, yet obscures conflicts and compromise formations.  Family identifications, or internalized self and object representations, strongly influence the sense of identity and of course, create the family language.   All of these come together to create the ineffable sense one has of oneself, the idiosyncratic self.  A therapeutic focus on the ‘implicit’ helps to tease out the more hidden, embedded conflicts, beliefs and fantasies that make such contributions to patient distress.  The material that is attended to in the ‘implicit’ is often non-verbal.  It is not necessarily pre-verbal, although it may be.  As a consequence of the non-verbalized nature of their presentation, patients often do not have words available to describe themselves and their experiences.  The transference-countertransference matrix becomes of crucial importance in identifying these ‘implicit’ issues.  The elusiveness of the content requires great sensitivity on the clinician’s part in order to use countertransference experiences to identify barely noticed aspects of the patient.  Identification of the ‘implicit’ depends significantly on the therapist maintaining the widest possible perspective. 

            As residing in the preconscious, the ‘implicit’ provides a pathway to the unconscious which then helps to provide a deeper understanding of the patient.  It provides a synthesis of a variety of aspects of the personality and operates across theoretical lines.  An emphasis on the ‘implicit’ brings forth transference-countertransference issues, has an intersubjective framework, has emphasis on identity and self, looks at compromise formations embedded within the preconscious and provides avenues to explore unconscious material.  Furthermore, it explores internalized self and other representations that define the “I” ness of the person (Sandler and Rosenblatt, 1962; Joffe and Sandler, 1968). This perspective provides an inclusive context from which the patient can be better understood.   As I discuss these matters, I will use case examples for clarity and interest.  

World View   

            Everyone has a characteristic way of behaving and relating in the world, which I will call a \"world view.\" The world view includes belief systems about why and how people -- oneself and others -- operate. These beliefs are both conscious and unconscious, are very pervasive, and may cause considerable problems for the individuals who hold them, based as they so often are on childhood misconceptions, distortions, and fantasies. Yet such world views are not usually available for discussion, at least not early in treatment. Their roots are unconscious and their operation is pre-conscious; thus they are rarely articulated or even subjected to the patient’s consideration. They are often ego-syntonic, in that they do not necessarily appear to derive from psychic difficulties, but are felt to be intrinsic to the person\'s \"personality,\" sometimes even by the person\'s therapist, and may be dismissed as just personal beliefs, with no relevance to the therapeutic task.

            Furthermore, implicit beliefs like this form the basis of an individual\'s everyday thoughts, habits, and behaviors. We hold onto them dearly, and rightly so, since they contribute richly to our sense of individuality. This too makes them difficult to get at in therapy, yet the tenacious hold that some patients keep on such beliefs may be as much a matter of integrity as of resistance. For many people, the sense of individuality is a developmental accomplishment, achieved with difficulty in the face of parental attempts to dominate and subordinate. To surrender cherished beliefs may feel like failure, shame, or degradation -- in short, humiliation. This is why it is so important when working with implicit belief systems to keep in mind how much people need to maintain a hard-won sense of self, and to form an alliance around the exploration of such deeply built-in tendencies. Pine (1990) points out that patients strive for consistency in their sense of self, a desire for the familiar --the sense of being “home”-- even at the cost of considerable self-negation and pain. To this end they may hold onto self-defeating behaviors despite \"on the mark\" interpretations by a sensitive analyst, unless the analyst can convey a real respect for what the maladaptive behavior has done for the patient in the past, and what it continues to mean.

            Betty Joseph (1992) makes this point too. From her point of view, every analyst holds in mind a \"theory or theories of desirable psychic change, of what he hopes he may achieve in his work, which is his vertex. The patient consciously wishes to change, but dreads any disturbance to his sense of equilibrium, the way in which he deals with anxieties and defenses, the organization which he regards as best--this is his vertex\" (p. 237). In her words, every patient tries to \"maintain his psychic balance.\" Discordances between patient and analyst may result when an analyst tries to impose a personal sense of what the patient needs without taking into account the patient\'s own sense of these things. Contrariwise, when patients try to match their \"vertices\" to their analysts\', aspects of the self that require analysis will be obscured. Joseph suggests that the analyst must manage to match his or her theory of change (and, in my interpretation, theory of mind) to that of the patient, but not too perfectly, if change is to occur.

            Garcia Badaracco (1992) suggests that, \"The difficult patient is a specialist in non-change\" (p. 210). This is a wonderful description, and I would extend it to the more global, \"All patients are specialists in non-change, and difficult patients are the real experts.\"  Like most analysts, I firmly believe that psychoanalytic treatment offers the best opportunity for significant personal change, and have both witnessed and participated in this process. It is an arduous and difficult process, however, and we must not delude ourselves, or our patients, that it is anything but.  Psychological habits infiltrate to the deepest levels of the personality; enduring change occurs within attention to the details of thoughts, feelings, and fantasies. Each participant in the treatment brings to it an idiosyncratic way of seeing things. It is the coming together and separation of two individual belief systems that creates insight and change.  All individuals have strong needs for a consistent and stable sense of the self and its integrity, and these needs oppose the wish for change. For this reason a certain divergence between the attitudes of patient and therapist is necessary to effect change   Too much congruence means insufficient distance on the patient\'s character -- the therapist shares the patient\'s own blind spots, and may not recognize problems -- while too much distance creates discordance and a sense of isolation.

Family identifications and family language

Every patient, and every therapist, develop certain conceptions of how the world works, which includes these theories of the workings of the mind.  These beliefs reflect highly subjective but often rigidly held yet rarely formulated notions about cause and effect, about motivation and intentionality, about the nature of personality and of the etiology of psychological disturbance.  These world views are conflations of personal learning’s through experience and education, through idiosyncratic personality configurations and, perhaps most importantly, through family identifications.  Families create language in a fashion similar to those of different ethnicities.   These languages, both familial and ethnic, have their own rules of grammar and idiosyncrasies that are very difficult for an outsider to understand in the manner of native speaker.  As the patient and therapist come together, each must work to understand the language of the other.  The two participants develop an intimate, unarticulated way of communicating.  For the therapist to understand the patient to the fullest extent, it is necessary for the therapist to become immersed in the family language in which the patient was raised.

The individual develops a sense of self through internalized self and object representations.  These representations become part and parcel of the patient.  The intimate nature of the childhood self as well as those unarticulated, barely felt but crucial aspects of the significant parents (objects) coalesce to create the sense of the adult self.  Thus, within each patient, archaic remnants of the patient’s childhood personality remain active, as do ancient artifacts of the parent.   Since these are often experiential and have never been even articulated, it is unlikely that the patient is going to be able to talk directly about these issues.  Not only do we have to understand the complexity of the contemporary patient but also we have to come to understand the intricacies of his or her internalized object representations.  We need to understand patient and patient’s parents, in a particular way.   Furthermore, the representations do not always reflect veridical reality because of the distortions created by childhood egos and by the effects of trauma and stress on memory. 

Sandler and Rosenblatt (1962) refer to the “shape” of the internalizations that give texture and meaning within the specifics of the generalized internalizations.    They state, “ The representational world might be compared to a stage set within a theater.  The characters on the stage represent the child’s various objects, as well as the child himself.  Needless to say, the child is usually the hero of the piece…Whereas the characters on this stage correspond, in this model, to self-and-object representations, their particular form and expression at any one point in the play correspond to self-and-object images…the shape of a self-or-object representation or image is (used) to denote the particular form and character assumed by that representation or image in the representational world at any given moment” (pp.133-134).  I agree that it is most helpful to keep in mind the ‘shape’ of the self-representation within the here-and-now, while keeping in the back of the mind, the nature, as Sandler and Rosenblatt, point out, of the drama as a whole, as the context from which it emerges.    

At times we often attribute to intuition our ability to understand patients.    It is my feeling that intuition can be understood as the end product of a number of components.  Accurate assessment, tact, sensitivity, and varieties of unconscious communication combine to form that hard to define, and even more difficult to develop, quality of intuition.  The evaluation process should enable the therapist to have a thorough picture of the patient’s functioning, on a variety of levels.   Although it is extremely difficult to apprehend these complexities, we do have some ammunition.  First of all, we have to remember that every patient and every disorder has a logical consistency.  Every language has rules.  Once these rules of the family are understood, it becomes much easier to get a grasp on the patient’s internalized representations and of their origins.  Secondly, we have the transference-countertransference matrix that is greatly informative.  That which cannot be articulated becomes manifest within the relationship which then makes it available for verbalization.  Within the countertransference, the therapist becomes responsive to the patient’s projected internalized representations and the countertransference affects can be used as a vehicle to bring these internalizations out into the open.  Let me give an example:

Dr. R. was a superficially socially adept woman who lived in an internal world that felt objectless and vacant.  It was very difficult to ‘read between the lines’ within her associations since there never seemed to be any lines to read between.  I often felt adrift and inattentive as a result of our lack of affective connection.  She had experienced a very distant, alexithymic and eventually Alzheimer afflicted mother along with a domineering, brutal and sadistic father.  Her outward presentation reflected the internalized representation of her mother while her identification with her father remained hidden.  On one occasion I was able to find this obscured representation through my countertransference.  I found myself becoming irritated with her when she announced a long neglected vacation.  I was puzzled by my reaction until I realized that she was using this opportunity to be away to hide her vengeful feelings toward me for my vacations and for other shortcomings.   This was her modus operandi—an extremely punitive and, at times, rageful self that could become activated but was hidden under the identification with mother.  Another example: at other times, I found myself feeling bored with her and surprisingly wondered whether I should raise my fee.  I then realized that I wanted more from her, but understood that the request operated as a counteridentification.  That is, I was experiencing what she had experienced with mother—a sense of deprivation and a yearning for more but yet a defensive withdrawal due to her concern about depleting her already barely functional mother. I was experiencing her denied and projected greed, along with my own.  Her difficulty in asking more from me left me feeling unchallenged, similar to her feeling as she never allowed herself to demand more from others or from herself.

The more I began to understand her internalizations and their consequent behavioral manifestation, the family language, I was able to help her to address those aspects of personality that were so hidden yet so troublesome.  Since these internalizations were not subject to verbalization, she could not tell me these crucial aspects of her psyche and consequently I had to make interpretations about her internal state by my understanding of her family dynamics, language and identification. 

Based upon a comprehensive assessment, the analyst comes to certain etiological conclusions about the patient.  Once the basic underpinnings of the patient’s psychological state has been determined (although I am well aware that our understanding of the patient becomes greater and more sophisticated over time), it is expected that the patient will operate with a certain consistency, or as I like to think of it, a ‘logic’.  With Dr. R., I can, or need to, infer certain dynamics based upon what I know about her and about how she thinks and processes experiences.  For instance, while I, in part, thought that I should be paid more because of displaced need to be challenged, it also came to me that she was also portraying herself as in much more serious financial straits than was factual.  Certainly, perceived need becomes felt as reality but she was purposefully withholding salient financial information in order to convey a certain impoverished quality.  She didn’t only do this with me, of course.  She was an early widow and yet everyone was under the impression that she was destitute and was struggling greatly after her husband’s sudden death.  What she never told them and really never directly told me was that she characteristically kept her ‘cupboard bare’ and operated in life in a depleted and deprived manner, even if that was not financially accurate.  I was not at all surprised that she grieved little for her husband, understanding that her attachment to him was minimal, again replicating what she experienced at home. 

 As she described her life and gave hints as to her way of thinking and behaving, I would tie these descriptions in with her descriptions of the stinginess and emptiness of her parents. She identified outwardly with the depleted and empty mother and then used the more hidden identification with her domineering and abusive father to gain some satisfaction in the world.   I also knew that, as a child, that she had been quite troublesome to her family and to teachers at school.  She had been very cruel to her younger sister, apparently replicating the abuse experienced by her father.  In school, she was constantly in trouble, desiring attention and excitement through misbehavior.  I came to expect that in the treatment, with her desiring me to ‘fight’ with her in order to gain a sense of aliveness and a feeling of being cared about.  She imagined sexual satisfaction through these ‘fights’, ultimately describing her sadomasochistic primal scene fantasies(?).  This desire was available to us through my interpretation of her behavior and by my understanding of her family internalized representations, not by any of her direct verbalizations and associations.

 Although she could be considered ‘manipulative’, I did not experience her that way.  Rather, I saw a woman who had been raised in an abusive and deprived manner who had figured out ways to maintain a sense of safety while attaining a modicum of satisfaction in life.  Her sense of pleasure in life was greatly muted by her need to hide her true desires. 

 I realized that she was using previous traumas to make her way through the world, to turn these traumas into triumphs.  Consequently, I surmised that she was much more adept in life than she let on.  Again, this was not what she told me directly or even very indirectly, in the sense of denied or defended against material.  They represented awareness’s that I achieved through understanding her internalizations of the family dynamics.  Her father had told her never to divulge what went on in the family that, of course, meant not to disclose how he beat her mother.  Again, she turned this awful situation into something adaptive.  She followed the paternal injunction not to disclose, in order to maintain a familiar self-state that obscured her real financial and personal resources.  When I was finally able to draw her attention to her withholding of her truer financial situation and how she obscured her ‘true’ self, from herself and others, her response to me was, “You got me”.  Feeling caught and found out was embarrassing to her but also relieving in the sense that she no longer felt the need to maintain the fiction that had burdened her so but which she had also derived benefit from.  She pointed out the paradox of her wish to know more about herself while simultaneously maintaining the more hidden belief that she would get out of treatment untouched and unknown.

The Non-Verbal Dimension

             .  I would like to know discuss those aspects of non-verbal communication that function as ‘background music’ within all patient’s lives. 

            Let me briefly discuss others who have made contributions in this area.

            Bollas (1995) attends to some of the same issues that I am addressing.  Two quotes can give a sense of Bollas’ perspective.  “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 communications “ (p. 31).  As further support for the notion of the ‘implicit’, Bollas states, “The analyst’s introjection of the patient’s idiom (when he is used as an object), then, develops a shadow ego which is crucial to the clinician’s ability to create a separate sense for his patient” (p. 39). 

            Jacobs (1994) emphasizes the interplay of the non-verbal within and between both participants.  He attends to the inherent subjectivity that exists within the psychotherapeutic endeavor.   He states, in response to a case he struggled with, “Overlooked was the meta-communicational world and the messages it contained, messages conveyed not in words, but through the slightest of movements, the most minimal of sounds” (p.752).  A more successful treatment attends to all the complexity of data that is presented.  As Stone (1954) indicated so many years ago, the scope of psychoanalysis continues to expand requiring us to look to more and more subtleties within the patient’s presentation.

            Schwaber (1998) discusses what she refers to as “state”.  To quote, “Though its form or presentation may shift or vary, state is in its essence, a continuing underlying presence.  It may feel in harmony with the words, it may be in counterpoint, it may be in the foreground, or in the background, but, always, it provides the music by which words are understood.  Whether one feels calm, anxious, enlivened, deadened, engaged, bored, agitated, depressed, empty, ‘confused’, ‘standing upright’ or as if ‘blowing with the wind’…--or transmits these feelings—significantly affects the meaning and impact of the words being spoken” (p. 667).  Further, she says, “Attention to state sharpens our observance of nuances of data; it is a place from which we would deepen consideration of the nature of our clinical evidence.  If words and state don’t seem to us to match, or if unaccounted-for shifts in state take place, there is something more about which to inquire” (p. 669).    Tonal qualities, perhaps what Daniel Stern referred to as “vitality affects” need to be closely attended to because of the wealth of information that is conveyed through these states.  Schwaber’s stance is that there is something crucial hidden or embedded within the ‘state’ as demonstrated by the patient.  Her perspective is that embedded within ‘state’ qualities are obscured feelings and ideas about particular issues confronting the patient-therapist dyad.  In other words, the patient’s ‘state’ can be viewed as a defense against the emergence of important material.  She certainly ties these ‘state’ qualities with family dynamics but in a way that differs a bit from the way I am describing.        I am suggesting that these non-verbal, state qualities also convey much about the patient’s character structure, about the ‘implicit’ that needs to be elucidated.  With traumatized patients, we may think of their difficulties in verbalizing as relating to the trauma or developmental failure occurring pre-verbally.  Similarly, we often speak about the non-verbal dimension out of a deficit model, i.e., the patient does not have the words available to articulate his or her inner world because of environmental deprivation.    I am speaking of those issues but also of something more.  I am also referring to those aspects of self that are not verbalized because they never have been.  These are personal attributes and aspects that have not been scrutinized or identified as qualities that are subject to discussion.  In the implicit realm, I am speaking of the manner in which a patient thinks of him/herself in totality, the patient’s way of being in the world, not solely attending to their emotional ‘state’, nor even to those aspects of the patient that are overt.  Attention to the ‘implicit’ requires a continual appreciation of the patient’s struggles, at the moment, while keeping the context of the patient’s internalized self and object representations in mind continuously.  Attention to the ‘implicit’ requires attention to the matter at hand, what is the patient trying to communicate in the here and now, within the context of the patient’s character structure and related to transference and countertransference issues. 

              Let us again return to Dr. R who has been quite a challenge to me.  Her sense of detachment and ‘false selfness’ were such that identification of differing ‘states’ of affectivity felt impossible.  In fact, she seemed to have one ‘state’, one that was impenetrable, creating a sense of flatness and distance.  It was only through my understanding of her internalized representations and through my own countertransference that I was able to understand her everyday, every moment sense of emptiness and despair.  This was not a transitory state but ‘was were she lived’, so to speak.   Helping her to apprehend this everyday way of being in the world, conveying to her my own experience of her flatness was of great relief since she no longer felt so alone and un-understood.  As time went on, we were able to understand that this empty state was not really so empty after all.  Rather, it eventually became clear that this state of being, based on an identification with her depressed and depleted mother, obscured identifications with her brutal and domineering father.  But, we couldn’t get to that aspect until we were able to appreciate and identify the background of her empty and depleted self.  The sado-masochistic dynamic was embedded within these representations and eventually became interpreted in a variety of ways.   She never verbalized these issues in any direct way.  It was my attention to her manner of presentation, to her ‘state’, to my countertransference reactions along with an appreciation of her internalized representations that enabled me to be able to tell her about herself.  These characterological realities provided color, substance and depth to her self-understanding.  It also provided her with a much greater appreciation of why she had alternated from being a ‘spacey’, directionless child to one who was capable of some cruelty.  Her flat and distant presentation communicated a great deal, even if she were not aware of the underlying issues.  The quality of her presentation would seem as if it never varied but its effect on me would differ from day to day.     At times, I would experience her flatness and emptiness as difficult to tolerate, finding my mind wandering and feeling sleepy.  I would tell her about my reaction and that would help her focus in on what she was defending against.  When I felt sleepy and disconnected, she may have been feeling disconnected or abandoned from others, feeling very alone in the world.  At other times I would feel assaulted by her schizoid manner.  I felt like I was alone in the room, completely cut off from her, and it felt somehow aggressive.   Using my own feelings as a guide, I would query her as to any possible feelings of anger, focusing on any displeasure with me.  Invariably, she would associate to some wrong perpetrated by me upon her.  She was exquisitely sensitive to any observations or interpretations that I would make indicating responsibility for her own behavior.  She would vehemently defend herself, indicating that anything that she did, was not intentional, that her anger toward me was not purposively hurtful, therefore remaining blameless.  Understanding her internalized brutal representation from her assaultive father, I would appreciate her desperate need to remain blameless, that she feared ‘assault’ from the internalized paternal imago, and via displacement, from me.  Nevertheless, she did need to understand that she was responsible for herself, for her actions and feelings, although that did not mean she had to ‘blame’ or attack herself.  Attention to this ‘implicit’ aspect, the ‘shape’ as described by Sandler, was very helpful.

                        In many treatments, therapists and analysts feel uncomfortable bringing up material that is not verbalized within the patient’s associations.  My feeling is that this non-verbalized  material is quite inaccessible and that it is necessary for the clinician to introduce this ‘implicit’ material.   Dr. R. felt great relief and a sense of being understood when I pointed out these hidden identifications, although she was certainly uncomfortable owning her sadistic side.  My use of the countertransference, combined with my understanding of her internalized representations enabled me to bridge the gap between her conscious associations about her sense of powerlessness to her more unconscious desires to thwart and beat me.  This led to further understandings about her feelings about being a woman, about femininity and of the hidden feelings of rage and hurt over her past humiliations.   The issues and conflicts with which patients struggle infiltrate personality through various levels of consciousness.  With Dr. R., her explicit, or conscious feeling, at the beginning of treatment, was that she was very discontented and felt disadvantaged by being female.  On the more preconscious level, she could realize that her background made it difficult to feel comfortable in identifying with either parent, although she obviously did with both.  Also on the preconscious level, she could easily accept ideas about her sense of emptiness and detachment and of other elusive representations of her underlying personality constellations that she had never quite put together in any accessible way.   On an unconscious level, she had the fantasy that gender was alterable and a successful treatment would restore her somehow lost ability to choose.  Her hidden expectation was that, being a man, that I had the power to enable her to achieve that goal.  Imagine her anger and disparagement when she discovered my impotence. 

Another patient, Ms. B. came to me after having tried numerous previous therapists.  We seemed to hit it off and we began an intensive 4 times weekly treatment.  She is an immense woman, weighing well over 300 lbs. with numerous attendant health problems.  She had a history, along with morbid obesity, of extremely disturbed relationships, stormy job performance and intense affect storms.  One example that she provided stands out in my mind.  Prior to our treatment, she lived in another city with a roommate.  Having become angry with the roommate, she wrote a note to her in her own blood and attached it to the roommate’s door with a knife.  She was quite surprised that the roommate was distressed and Ms. B. couldn’t understand why the roommate refused to come into the apartment without an escort.  Recently, she came into one session in a rage at a telephone repairman who had parked in a spot that was known to her, but not to him, to be one of my reserved patient parking spaces.  She proceeded to berate him, blocked him in and then came up to my office spewing hatred and venom.   At this point, as she raged on, I contemplated both how to help her and how to understand her reaction.  I certainly knew that she had low frustration tolerance and that we had discussed how difficult it was to “wait” before eating or in searching for alternative solutions to problematic situations.    I knew that she felt incorporative desires, that she “owned” both the parking space and me.  Competitive feelings about her place in my life could have been active.  I wondered whether she was really angry with me for not protecting her space or for other reasons.  As I pondered all of these, and other alternatives, I suddenly realized that this poor repairman had broken a rule.  Much of her dynamics and her sense of ‘being’ in the world became much more clear. Her whole family was overweight yet rather than solely identifying with her parents and adopting their eating habits, she was also following a not articulated but extremely potent directive.  Her parents being exceptionally needy and controlling had made explicit the notion that she and mother would live together once father died, his early death an entrenched family myth.  Being obese and ‘difficult’ made it unlikely that she would find someone with whom to have a relationship or that she could pull away from the enmeshment within the family and then she would remain available for mother.    Many of her rage attacks at others were reflective of her opinion that others had broken rules; similar to the rules of which she was afraid of being beaten for violating.  As she projected the punitive rage that she had experienced in breaking rules, she was reenacting her early internalized self and object representations.  To act otherwise, was to, in and of itself, to break a rule since it represented forbidden independent thinking that could result in severe recriminations.  In fact, when she felt upset with herself, she would bang her forehead against a wall, replicating the abuse she had experienced.  Her expectation that her roommate should tolerate her outrageous and threatening behavior was a representation of how she was expected to deal with the abuse within her family—silently.  As she felt very positively toward me, she could not bring herself to question me or to express anger, as if she could not appreciate me and be upset with me simultaneously.  Any angry feelings were also expressed within the family language, by being externalized toward others or by her becoming self-punitive.  Within these identifications, were embedded hidden conflicts about sexuality and independence. 

Earlier I spoke about the patient and therapist’s world view and how it is hoped that a mutual understanding of each other’s view and language are achieved. Very real differences between Ms. B. and I were very quickly apparent.  Differences in our physiques were obvious and she quickly intuited that I came from a much different socioeconomic background from hers.  Having been raised in an abusive family, she was quite adept in ‘reading’ other people although she tended to err on the side of malevolence, attributing hostile intent where it probably didn’t belong.      Yet, she would often make assumptions about me that seemed somewhat different than the transference fantasies of other patients.  Musing over possibilities about my life, she reached the conclusion that I had grandchildren and that several absences were because of my need to see them.  Although probably operating out of a compromise formation in that it may have felt better to imagine me seeing my grandchildren over some other activity, there was a certainty about her fantasies.  Again this seemed reflective of her way of thinking.  She would make up her mind about certain ‘realities’ and then operate as if they were fact, not ideas for consideration.   Our views of the world and how people do and should operate were quite dissimilar.  The notion of waiting before acting, of self-reflection and consideration were alien to her and she was particularly incredulous when I suggested that she might want to allow herself to feel hunger before eating.  She joked with me that she hated the word, “wait”, a clever double meaning.  As I became more cognizant of her family language and she became more comfortable with mine, the relationship strengthened.  I can’t say that I began to identify with her way of thinking but I did feel that I was becoming a bit more bi-lingual and she did begin to appreciate the importance of self-reflection.  She did become more thoughtful and began to look at other’s motives in a less hostile and condemning way.  Concomitantly, she became less self-punitive.  Yet, her eating behavior proved quite intransigent.  Although she consciously knew that being so overweight was detrimental, she held out hope that it wasn’t.  Her sleep apnea was related to her obesity but she was quite disappointed when her doctor confirmed that it was a significant factor.  In fact, she indicated that what he told her was “not encouraging’ hoping to get confirmation that her overeating was not a serious problem.  Changing her eating habits required a whole scale repudiation of her family and their ways of attaching and of processing information and affects. She did try to speak with her mother about her struggle to lose weight and to become more productive.  Her mother’s response was quite interesting.  As to her eating instead of feeling, her mother responded,  “That is just what we do.  We eat when we’re sad, we eat when we’re angry, we eat whenever we feel anything.”  When she struggled to get out of bed in the morning and to get to work on time, her mother said, “Haven’t I taught you how to sleep?”, meaning sleeping should take priority over other activities.   

As she improved in other areas of her life, she continued to gain weight, reflecting the struggle to disengage from her parents yet to not become swallowed up by my way of being and thinking.  Her rebellious nature, again reflecting family patterns, caused her to stop on the way back to work, after our sessions when we discussed weight issues, to pick up a pack of “Debbie Cakes”.  However, she was not only angry and rebellious.  She was also communicating her feeling that I wanted her to be a certain way, not obese, and her continued overeating reflected a not unreasonable desire to decide her lifestyle for herself.  

Within these family internalizations and language, resided conflictual issues about sexuality and attachment.  While approving of gluttony, the family was very condemning of sexual behavior.  We were able to identify how other needs and feelings were subsumed and hidden under eating behavior.  At one point, she described being in a restaurant, feeling full yet suddenly desiring an ice cream sundae.  She became aware of a conversation of a father and a child nearby, with the father being patient and understanding with his daughter.  The pain of what was missed with her father and wished she had with me and that she imagined that I had with my child propelled her ‘hunger’.  Of course, it was quite significant that she was able to identify this. 

Elucidation of this ‘implicit’ way of being-- that of her feelings about breaking family rules and her struggle for independence and how these and other unarticulated issues contributed to her general personality style, opened up a significant avenue that enabled us to explore many areas of her life that had caused her great pain.  

             In working with both the ‘implicit’ qualities of being, along with the embedded conflicts and dynamic issues, it is important to remember that these often represent attempts to adapt to problematic solutions.  People have no choice but to identify with their caregivers.  Dr. R. was attempting to fashion a solution out of a dilemma; that being, how to feel a positive sense of self-regard in a family where women are denigrated.  Her solutions, at varying levels of consciousness, were attempts to work out a solution that salved her besieged ego.  Her belief that gender was alterable and her sadomasochistic ways of relating to me and to others were destructive but were the only avenues available to her.  Understanding these behavioral constellations as attempts to adapt and to solve psychic problems helped her to feel less self-critical over that which she felt was less than becoming. 

Cherished Beliefs

We all hold beliefs that are dear to our hearts.  Many operate in preconscious ways and are never really identified as being anything other than personal proclivities and preferences.  However, these beliefs are, in many ways, another way of speaking about the ‘implicit’.  Some of these beliefs become reified, held with great tenacity and have pathological roots that need to be identified.  Fonagy (1996) speaks of the importance of a child attaining the ability to ‘play’ with reality, to apprehend the difference between aspects of ‘reality’ that is externally verifiable and that which is playfully and creatively manipulated. This ability creates transitional space, or the analytic space necessary for metaphor and symbol.   Similarly, Britton (1995) states, “The…assumption that belief is knowledge is the basis of delusion and characterizes the paranoid-schizoid position” (p.21).  Some patients have great difficulty in examining their beliefs, acting as if they are verifiable aspects of reality as opposed to desperately clung to beliefs.  Take for example a patient of mine, Ms. K. who came to me suffering from a paranoid psychosis, believing that her husband was about to poison her and sexually assault her son.  The overt psychosis abated rather quickly but she maintained particular beliefs that were never really subject to discussion.  She said that, in relation to her trust of me, that she ‘suspended disbelief’ in some sort of fashion, meaning that she really knew that I was untrustworthy and unreliable but was willing to continue regardless.  What she also meant was that she ‘suspended’ the belief in that she always knew that I would betray her.  Throughout the treatment, during which she improved considerably, there were incidents where she imagined that I had violated the sanctity of our relationship.  One recent example stands out.  She was visiting her mother in her nursing home and discussing the mother’s care with the social worker.  She ‘saw’ the social worker write my name down and then cross it out.  The patient wanted to know whether I consulted there.  I told her no.   I assumed that she had mis-read the social worker’s handwriting, for reasons unknown.  But the point is, discussion of any possible mis-reading and likely reasons for such were impossible.  The patient made belief into knowledge and was absolutely convinced of her reality.  No analytic space existed for fruitful discussion.  Dynamically, there were many possible explanations for this and other delusions. Due to her psychotic qualities, I am convinced that she must have experienced traumas in her childhood far more extreme than disclosed.  By disbelieving me she could continue to disbelieve any insights and knowledge that we might achieve, therefore disbelieving any horrific memories from childhood.  The fear of an alternative version of reality was terrifying and she was not able to take the chance of us questioning her entrenched beliefs.   The analytic space was collapsed by this inability to ‘play with reality’.  Her way of apprehending the world was certainly not just apparent in our relationship.  It greatly affected her ability to navigate the world effectively.  She often felt at sea with others, feeling alienated and not understanding others and their motives. 

   From my perspective, the issues that she struggled with were not solely ones where she tried to rid herself of unacceptable thoughts and feelings by projecting them elsewhere.  She lived in a paranoid world and could only see things from that perspective.  In some essential way, everyone was a potential danger to her and she took steps necessary to defend herself.  As she described her daily activities and relationships, I could sense that something was ‘off’ but never could really specify what.  As she has improved, she is more able to consider this and she seems less odd.    

 Representing family identifications and held in order to protect her from other truths, these paranoid beliefs were rigidly and tightly held.  Forays into the depressive position where transitional space is a possibility is gradually enabling her to look at her beliefs and of their absolutely fixed nature.

Certainly, a paranoid patient provides relatively clear examples of deeply cherished beliefs and of the difficulty in considering alternatives.  There are other patients who also construct reality in such a way that consideration of options, alternatives and motivation are impossible.  We are all well familiar of the taboo of calling into question religious or political beliefs.  Other patients have established belief systems that are absolutely not open for discussion.  One patient had constructed his finances such that he was always living on the edge.  He often spoke of cash flow difficulties and became quite perturbed and anxious over these.  As became clear, these cash problems were only problems in the sense that he had allocated a certain amount of his resources to his everyday living expenses.  The rest he had invested and had a rather large portfolio.  When I would try to discuss this with him, including in reference to my fee, he responded to me as if I were ignoring the reality of his impoverished condition.  This demand that I adhere to his alternative view of reality spoke volumes of his internal world.  Internally, he was also impoverished, allowing himself little pleasure or enjoyment.  Although he gained satisfaction from thwarting me, it reflected more than just gratification of his aggression.  It spoke to his view of himself and of the world, of the stinginess of his internal world and of the lack of sustenance that he had received from his parents.  When I interpreted his reluctance to pay me more or to look at his finances from a broader perspective, or to connect his stinginess to his own difficulty in taking pleasure from life, I made sure that the connection to this internal, ‘implicit’ state is made, providing him with the context to understand the driven nature of his obstinacy

Britton suggests that the primary difficult that people have in distinguishing belief from knowledge relates to a difficulty in relinquishing archaic objects.  He makes clear that he does not mean solely mourning the loss of these objects but of coming to grips with object representations and relationships.  Thus, when we approach a patient, like Ms. K., we need to understand that we are asking her to give up a great deal, a whole way of life, of thinking, or apprehending the world, that although, seemingly painful and maladaptive, offers familiarity and comfort and helps define the sense of self.   

Vertical Splitting

Another area that provides insight into the ‘implicit’ level of functioning is related to the defense of disavowal.  Disavowal is much more of a conscious defense than those of repression, denial, etc.  Disavowal is an active pushing away of one aspect of reality in favor of fantasy.  Freud (1938) in, “Splitting of the Ego in the Process of Defense” speaks about the ‘rift in the ego’ where two contradictory percepts are held simultaneously.  This defensive maneuver can be thought of as a vertical split as opposed to a horizontal one, as seen in repression and denial.  In the horizontal, the percept is kept out of consciousness, via the ego repressing material in the id.  In the vertical, considered to operate within the ego, the two percepts operate in concert, yet as if one did not exist.  This occurrence is, to me, seen far more often than commonly believed.  Let me speak of Ms. S, who I will also speak about in the next section on consciousness.  Ms. S. sought out treatment with me in the context of severe marital discord.  She exhibited extreme anxiety, a sense of incompetence and ‘suffered’ from overwhelming and intrusive sexual fantasies.  Most interesting to our present discussion, she had come to me by way of her infertility doctor.  She had sought out his assistance in getting pregnant despite her awareness that she and her husband did not have intercourse, and, in fact, had never had intercourse throughout their 11-year marriage.  Throughout the treatment with me, time and again, this type of disavowal would emerge.    She has since divorced her husband and has remained single.   She was initially convinced that I represented all that she desired and if only I would leave my wife and marry her, all would be well.  After she worked through this, or at least seemed to, she became involved with a man who, through a variety of ways, communicated to her that, although he cared for her deeply, that he was not going to marry her.  Despite this, or perhaps because of this, she indulged in numerous fantasies prophesizing his ultimate recapitulation to her.  Evidence that supported the position contrary to her wishes was pushed aside, vigorously.  She would become furious with me when I would point out her disavowal.  More recently, she has decided to get pregnant through in vitro fertilization using a donor egg and sperm.  As she discussed this wish, I tried to have her think of the consequences of being pregnant while single and being close to 50. Regardless of my efforts, she pushed away any consideration.  As she has become pregnant, many of these thoughts and ambivalences are now coming to the fore, resulting in considerable anguish.  At first, she questioned whether she was really pregnant, believing that the doctor was going to tell her that she was not.  I imagined, silently, that she was giving voice to her ambivalence.  Her explanation was much more subtle.  She had expected to feel very special and wonderful once she became impregnated and sadly she did not achieve the degree of exhilaration expected.  Consequently, she must not be pregnant.  She also had the fixed belief, unalterable by discussion, that she had little validity as a person unless she was married and had a child.   She would not consider that having a child at her age would create problems, both from health, logistical and psychological points of view.  All of these concerns were swept away, with a literal flip of the hand.