Robert E. Hooberman, Ph.D.
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 clinicians 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.
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 patients 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 learnings 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 patients 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 patients 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 childs 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 patients 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 patients 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 patients 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 operandian 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 mothera 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 patients 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 didnt 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 husbands 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 awarenesss 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 patients 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 analysts 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 analysts introjection of the patients idiom (when he is used as an object), then, develops a shadow ego which is crucial to the clinicians 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 patients 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 feelingssignificantly 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 dont 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. Schwabers 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 patients 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 patients 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 patients 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 patients struggles, at the moment, while keeping the context of the patients 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 patients 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 couldnt 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 patients 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 roommates door with a knife. She was quite surprised that the roommate was distressed and Ms. B. couldnt 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 familysilently. 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 therapists world view and how it is hoped that a mutual understanding of each others 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 didnt 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 cant 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 others 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 wasnt. 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 mothers response was quite interesting. As to her eating instead of feeling, her mother responded, "That is just what we do. We eat when were sad, we eat when were 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, "Havent 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.
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 mothers 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 workers 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.
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. With patients who defend against the recognition of painful realities, whether psychotic like Ms. K., or more narcissistic like Ms. S., it is generally fruitless for the analyst to become the arbiter of reality. These beliefs are held tenaciously and exist, particularly for the more disturbed, with good reasons. In the case of Ms. K., she was defending against ghastly memories and feelings of betrayal. Ms. S. was trying to maintain her sense of specialness under the internal assault of her childhood sense of shame and ineptitude. I would indicate, with Ms. S., some concern about what she was presenting but only once. Thereafter, I would ask her to question her own ambivalence and that prevented her from projecting one side onto me and then arguing the latter. Ms. K. provided more of a problem. Presenting my notion of reality was typically alienating and I tried to stay away from introducing my version at all. Instead I would try to direct her toward situations and/or affects that were uncomfortable that might be fueling any distortion.
Recently, Ms. S. described a fantasy about the child she is carrying, referring to the child as a girl. When I questioned her as to this, she told me that she thought that the odds were with her that she would have a girl. Why? Because she wanted to have a girl. This ability to foreclose aspects of reality (knowing that her chances of having a particular gender were 50-50) was part and parcel of her level of personality functioning and represented, in part, the manner in which she was taught to apprehend and to deal with reality. This propensity was not something that she could tell me about but was only identified through my close observation of her attempts to alter reality to her favor. Similarly, she developed what I, and others, refer to as a perverse transference. That is, she used the therapeutic relationship not as a way to gain insight and to feel better but to obtain pleasure. She imagined a special relationship with me and our sessions, for a period of time, became the most important part of her life. She perverted the relationship from the therapeutic to the fantasy based pleasurable. If I had not identified this implicit process, the treatment would have been false, with insights obtained only to gain favor with me, not for understanding and development. Attention to the implicit, to the implied, requires that the analyst keep his or her eye on the bigger picture, on the patients general level of personality functioning, while apprehending what is transpiring moment to moment in the session.
Trauma infuses ones life. Trauma interweaves through the persons psyche. Although we all are very aware of the horrible effects that trauma has on psychological functioning, I would like to focus on those elements that seem to have been overlooked. That is, the trauma creates a language of its own that must be understood and addressed. In many ways the effects of the trauma become internalized and helped to define the essence of the individual. The traumatic event, as internalized, takes on a life of its own. I would like to mention two theorists who have written about the traumatic experience of parents and the hidden but significant effects it has on children. Peter Shabad wrote "Repetition and Incomplete Mourning: The Intergenerational of Traumatic Themes." I would like to quote: "The traumatic theme is a chronic pattern of childhood experiences suffered at the hands of significant others, which, when repeated day after day over a number of years, may cumulatively take on the emotional significance of a trauma. The chronicity of the traumatic theme derives from the unmourned and, therefore, repeated aspects of the parents history that have become entrenched in the parents character and are continually enacted on the child; the helplessness engendered by the traumatic theme derives from the childs continuing incapacity to change the parent into a wished-for figure" (p.65). Similarly, Dori Laub at Yale has written on what he calls, "The Empty Circle", referring to destruction of aspects of the psyche from catastrophic trauma and the effect of this on the survivors children. Again to quote, "The empty circle&is a term that symbolizes the absence of representation, the rupture of the self, the erasure of memory, and the accompanying sense of void that are the core legacy of massive psychic trauma" (p. 507). "Children of survivors often grow up in an environment which is mysteriously permeated by the traumas of their parents, yet in which the harrowing events are never spoken about. Lacking their parents direct experience of devastating atrocities, they are faced with the task of assimilating such realities into consciousness through their own imagination. &at the center remains a hole, an emptiness caused by an event that defies representation and is experienced as a profound absence" (p.509). David Klein has also spoken to us about the organizing strands or themes that pervade patients psychologies.
These themes, whether generated by trauma, by parental trauma or in being used to structure and understand experience, provide a background to a patients life that needs to be addressed. Without attending to the context within which the patient has lived his or her life, the full texture and substance of the patients life are not fully addressed. These themes become part of the level of implicit, certainly can have unconscious roots but also have considerable presence in the preconscious. Drawing a patients attention to how trauma has infused his or her life or how these themes have been passed on intergenerationally can help free the patient from feelings, thoughts and fantasies that have been bewildering.
The Nature of Consciousness
I have had the thought that I would like to get through one treatment without using the word unconscious to a patient. In my experience, it is not a word introduced by patients. It is my feeling that much of the work that occurs in psychoanalytic treatment occurs, or should occur, in the preconscious, although I acknowledge that my notion of the preconscious may be broader than that of others. Frequent allusions to the past or to unconscious processes, particularly by the clinician, occur most often when a transference-countertransference issue has become activated resulting in a need to create distance from the immediacy of the moment. It is also my belief that a concentration on implicit issues, on the preconscious and on character structure can lead toward that material most difficult to obtain, that of the unconscious.
There is a lack of clarity when thinking of the unconscious. Are we talking about repressed material from the past? Or about current feelings and thoughts that are placed in the unconscious defensively? Or, are we speaking of experiences that are never really put together and obtain clarity and consciousness once conceptualized by the efforts of the analyst? How do present day experiences become acted upon by the unconscious? Is it accurate to think of the unconscious as being an active aspect of our functioning that has adaptive and integrative qualities? These are questions much beyond the scope of his paper. However, I would like to at least speak to some issues about the unconscious and its relation to the implicit and the preconscious.
The Freudian unconscious postulates that repression works to keep unacceptable thoughts and wishes out of consciousness. It is a dynamic unconscious in that it actively represses and has rules of operation unique to it. Unconscious fantasies, instinctual drives, hidden wishes and intrapsychic conflicts reside there. However, there is much more that can be considered "beyond awareness" in a persons psyche besides that which has been repressed, denied or otherwise defended against. Freud compared the sensitivity of an analyst to unconscious communication to a telephone receiving a transmission. "He must turn his own unconscious like a receptive organ toward the transmitting unconscious of the patient. He must adjust himself to the patient as a telephone receiver is adjusted to the transmitting microphone. Just as the receiver converts back into sound waves the electric oscillations in the telephone line, which were set up by sound waves, so the doctors unconscious is able, from the derivatives of the unconscious which are communicated to him, to reconstruct that unconscious, which has determined the patients free associations" (1912, pp.115-116). This remarkable insight indicates the level of importance that Freud attributed to communication that occurs in a non-verbal mode. In elaboration of Freud, I would say that an analyst is best assisted in understanding the unconscious communication if the context provided by the implicit allows the analyst to know which telephone line is ringing.
Donnel Stern speaks of the "Analysts Unformulated Experience of the Patient". To quote, "&Unformulated experience is experience that has never been articulated clearly enough to allow application of the traditional defensive operations. One can forget or distort only those experiences which are formed with a certain degree of clarity in the first place. The unformulated has not reached the stage of differentiation at which terms like memory and distortion are meaningful" (p. 10). According to Stern, this material could be subject to defense and distortion once made explicit but in the implicit mode is not sufficiently differentiated to enable defenses to become operational. The unformulated refers characteristics about the patient that have never been put together by the patient, ways of being that have never been directly thought about and consequently are not directly defended against. While I like his conception of the unformulated and, in fact, feel that much of what transpires in treatment is designed to formulate the unformulated, I do not agree with his conception that this material is not subject to distortion or defense. The patients way of thinking and being in the world is based upon self and object representations that contain, in encapsulated form, conflicts, unconscious fantasies and hidden pathological belief systems. Helping the patient to understand the unformulated or, in my language, the implicit is the opening gambit toward a greater elucidation of more hidden material. Repressed material is most accessible within the context that the implicit provides.
Stolorow and his colleagues have a position similar to that of Sterns. Let me quote: "Psychoanalysis, in this view, is no longer an archaeological excavation of ever deeper layers of an isolated and substantialized unconscious&It seeks comprehension of the network of convictions, the rules or principles that prereflectively organize the patients world and keep the patients experiencing confined to its frozen horizons and limiting perspectives. By illuminating such principles, in a dialogic process, and grasping their life-historical origins, psychoanalysis aims to expand the patients experiential horizons, thereby opening up the possibility of an enriched, more complex, and more flexible world" (pp.47-48). Again, I do believe that, at times, hidden, repressed or otherwise denied or defended against fantasies and conflicts also need to be addressed. In other words, there is also a specific content that is being defended against, in the moment.
Sandler and Sandler (1962, 1994) suggest that we are better off concentrating efforts on construction of the present unconscious rather than reconstruction of the past unconscious that they deem inaccessible. Their description of the present unconscious seems very similar to that which I am describing as the preconscious. They state: "We shall refer to unconscious fantasy, using this termfor the time being at any rateas a convenient representative of all thoughts, wishes, and impulsesthat is, all mental representations and their accompanying feeling statesas they exist in the present unconscious. As unconscious fantasies arise in the depths of the present unconsciousfantasies that can be considered to be, to varying degree, derivatives of the past unconsciousthey have to be dealt with by the person of the present, with the aim of maintaining equilibrium in the present" (p.285). From my perspective, this construction needs to occur in the context provided by attention to the implicit within the preconscious. The present unconscious uses the past unconscious as a model upon which fantasies and other unconscious processes develop. The Sandlers very much concentrate in the present, using the past to anchor present day understanding, and as a model for the manner in which a patient has formed present day fantasies and wishes. They emphasize that reconstruction of the past unconscious is still a reconstruction, not an excavation.
Using the present level of the patients implicit functioning provides a link between past and present, between conscious, preconscious and unconscious, between the transference-countertransference and past relationships. Issues and conflicts pervade the various levels of consciousness and the various aspects of personality. The issues that can be most meaningfully addressed are those that exist within the implicit aspect of the preconscious. Furthermore, the active organizing and structuralizing function of the unconscious can also be viewed within this perspective, as the unconscious works toward assisting in adjustment and in maintaining a sense of equilibrium. As such, it is important that this stabilizing function be kept in mind, assisting the analyst in understanding the purpose of the emergence of material.
Attention to these issues provides the context that enables more unconscious material to emerge. We are all aware that as therapy or analysis progresses, the material deepens and access to the unconscious increases. However, these forays into the hidden can only occur when the contextual variables are rightbe they related to the present day life experiences of the patient or to transference-countertransference issues. We need to know the correct phone number to listen in on.
Ms. S. entered treatment complaining of desperate unhappiness in her marriage. Her husband was drinking excessively, was verbally abusive and was unresponsive to her needs. As mentioned, he had refused to have sex throughout their 11-year marriage. Her conscious presentation was one of great anxiety and a sense of helplessness. As the treatment progressed, her underlying narcissistic character structure became more evident. She had felt cheated and betrayed all of her life, felt that others had treated her unfairly and that she was deserving of much better in life than she had obtained. This, of course, became manifest in the treatment where she became particularly demanding of my time, phoning me at all hours with imagined emergencies and imagining that if we had sexual contact that all her problems would disappear. When we examined her sexual life, she was adamant in maintaining a belief in her sexual dysfunction, the nature of which was unspecified. She idealized me and imagined that having intercourse with me would heal her. Much of the sessions concentrated on explicating these issues of entitlement and the resultant rage and anxiety by the lack of satisfaction of her desires.
Her family dynamic provided considerable helpful information. She was very attached to her family, clearly had idealized her father and had intense competitive feelings toward her mother and sisters. The family was quite religious and had difficulty in tolerating affects that they deemed unacceptable. Jealousy was not just disapproved of, it was deemed to be non-existent in the sense that her mother "didnt believe in jealousy." Her solution was to deny these feelings, to project them on others resulting in a feeling of hidden superiority and to portray herself as blameless and pure. The insistence on having a sexual dysfunction helped maintain her sense of purity, since her belief was that her parents would approve of her for being sexually pure and virginal. This fantasy of being virginal despite being sexually active again highlights her ability to disavow. In her late teens she became pregnant, didnt inform her parents until very late, traveled to New York for an abortion and lied to the physician as to the date of conception, trying to work against the truth. The present wish to have a child also seemed to be designed to assuage her guilt over the abortion.
Interestingly, her sexless marriage also seemed to augment both her masochism and her fantasy of being virginal. As the treatment continued, she made good progress, calmed down and began having more realistic relationships. The core sense of entitlement still seemed quite strong.
Let me now describe how attention to the implicit within the preconscious leads toward evocation of the unconscious, perhaps also a royal road to the unconscious. Eventually, as she struggled to get pregnant, she produced a dream of having a bowel movement and in the midst of the feces was a crucifix with part of the cross broken off. My interpretation of this dream was that she had had the childhood fantasy of cloacal birth, that she had imagined, in order to please her parents and to feed her own need for specialness, a possibility of giving birth to Christ and that her insistence on her purity was a further attempt to maintain an identification with the Virgin Mary, the paradigm of purity. The broken off cross seemed to represent her sense of having fallen off her idealized pedestal and her belief of being damaged, both related to her abortion and to her sense of imperfection. Her intense transference reaction can also be understood by her need to be special. By idealizing me she made me into a god-like figure, enabling her to maintain her fantasy of attaining divine status herself. This compelling need to be special and innocent was based on a number of different issues in childhood. She experienced considerable narcissistic injury from unattuned parents and was concerned that she had injured her mother through her hostility after her mother was hospitalized for a nervous breakdown when she was 5. This unfortunate past experience was discussed and I made some connections between past and present but the important and meaningful action seemed much more centered in the present. Furthermore, with her propensity to evade, an emphasis on the past would have been used as a defense against that which was most important, that being, her sense of herself in the present, the struggles to alter reality in order to replace it with fantasy, the need to create a perverse treatment that was in combat with her equally strong desire to get better and to feel better.
We can see how these central conflicts pervade all areas of her personalityin her everyday relationships, in her sense of self, in her relationship with me and in her expectations from life. Her self-representation included a sense of being pure and virginal while others were viewed as being deficient. Idealization and devaluation were prominent dynamics. Furthermore, these issues were interwoven into the various levels of consciousness and became the language of her psyche. Attention to her everyday way of functioning, attending to how these needs became manifest within her other relationships and within her transference, provided a pathway to the unconscious where he ultimate fantasies of divine ascension were brought into the open.
With Dr. R., we can also see how an orientation to the implicit within the preconscious was quite helpful. Her persona was often of someone who felt beleagured and overwhelmed by life who lacked the ability to run her life effectively. As she tried to convince us both of this, I would indicate to her that she knew what she knew that she didnt want to know. An orientation toward the unconscious processes without attention to the context provided by the preconscious would have reinforced her already prevalent attitude that what happened to her in life was beyond her ability to know or understand.
My emphasis on the preconscious and on the implicit suggests that much is knowable about us if only our attention is properly directed. The same could be said about what I hope I have achieved today. It is my wish that I am directing your attention to specific issues that I think need to be thought about in providing treatment. When we are working within the minutae of the material at hand, it is easy to lose the larger perspective of the patients personality, in toto. I believe strongly that we should be aware of what we are doing, why we are doing it and toward what end. As Stone (1954), has indicated, our scope of inquiry in psychoanalysis is continually expanding, moving beyond circumscribed symptomology into aspects of character and issues about authenticity. I feel that we should be aware of the framework of our own idiosyncratic thought and that we should be aware that we are choosing to concentrate on one aspect of the patient over another. Regardless of theoretical orientation or individual world view, an appreciation of the implicit level provides essential information to guide us in our journey. Thank you.
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