Therapy in Exile
The emptiness at the heart of our cherished terms
“Understanding or its failure is like an event that happens to us.”
~ Gadamer, 2013/1960, p. 401.
I often think about psychoanalytic terms and how their uses differ in varying modalities and treatment pairings. There is for instance some controversy over the term empathy, and what it “really” means, given its frequent (mis?)use in relational circles, including with intersubjective-systems’ talk of sustained empathic investigation.
Critics of relational theory often claim the term is used as a synonym for sympathy: an ambience of sorts, giving the patient the benefit of the doubt to a fault, dampening our rigor of inquiry. This critique was of concern to Heinz Kohut, addressed in one of his final papers, including a mention of the sirens attached to Nazi dive bombers, to frighten the besieged citizens below. Such a tactic is, he says, but one use of empathy, itself a value-neutral term.
He feared empathy was becoming caricatured by more traditional critics as “vague sentimentality or mysticism” (1982, p. 397), a critique still surfacing today. My question is, how do we determine the correct definition, and who holds claim or authority in deeming it thus? (Freud? Mirriam-Webster?)
In a way any concept involving inference and interpretation, the realm of the psychoanalytic, is an empty one, awaiting valuation in dialogic exchange. At the same time, we make use of terms in such repeatedly familiar ways that it becomes nearly impossible to see them neutrally.
I recall a paper given at a conference many years ago, where the presenter (a self psychologist) described a case study involving a patient with a near-terminal condition; the analyst decided to travel with his patient (along with his own family) from the midwest to London, to see a theatrical adaptation of a book they both loved. The presenter quite obviously felt the entire trip was an empathic endeavor (the patient died not long after.) This sparked the liveliest of conference debates over what “empathic” might or might not mean in such a scenario. (I myself had questions about the co-pay.)
Kohut’s description of empathy as value neutral (2010/1981) detaches it, on one hand, from syrupy kindness; he envisioned a means of rigorous understanding, scientifically tested and re-tested: an accurately honed, developmental provision which consolidates the patient’s fragmented or traumatized self (or selfhood), now more reliably inhabited than warded off.
Yet I also find the idea of a term’s neutrality problematic, for reasons wholly separate from Kohut. It is a mistake that many of us make, in reaching for objectivity from within an analytic stance and tradition of our own.
“Value neutral” makes sense in light of Kohut’s intention to clarify his (at the time) novel perspective, via a specific language game or use of empathy. This as with Freudian theory is rigorous and scientific, he implies, not some hand-holding kumbaya.
Yet his notion of neutrality and the Nazi example strikes me as slightly off. We tend not to invoke the Nazis as an illustration of empathy. It is a possible but unusual use. Would we talk about the empathic rounding up of immigrants by ICE agents?
I think there is more than just the use of a term implied in critiques of self and relational psychology; more on that another day.
“Neutral” is misleading, when it comes to any linchpin term, as if we could stand outside our own perspective. And neutrality, after all, is a term with potential value of its own. (For Kohut it was scientific rigor and data gathering.)
We form attachment to terms over time via their familiarity, our immersion in the perspective of its employment. The context of Kohut’s argument was a shoring up of a self psychology, suffused by his warm, witty, often self-effacing presence (even more so in his later writings.)
It is ironic that in social media threads and online communities, clinicians frequently urge each other to avoid jargon with patients. Yes, but such jargon is still an aspect of the therapist’s own background, where via supervision, classwork, and reading, jargon is employed as shorthand.
We therefore say we “translate” our terms into analytic action and dialogue. How do we judge the efficacy of such translation? If, say, transference is not recognized by the patient as a useful framing, must we abandon it to some degree? What elements are not translating? If one aspect of any term is its usefulness is therapeutic impact, how do we evaluate the value or meaning of the term itself if our “translational” interventions fail to stick?
Or is “transference” also signifying our investment in a theory valuing transference?
A Freudian might believe that the analyst’s underlining the hard facts of reality, in the thwarting of patients’ unconscious drive derivations, is empathic. A Kohutian will have thoughts about this.
Our clinical situatedness (defined below) is deeply intertwined with the language games of our theories and sociocultural backgrounds, cutting against the idea of neutrality. Even Bion’s notion of working “without memory or desire” it itself a desire—for Zen-like openness, and tolerating doubt. But as Wittgenstein (1969) noted, doubt comes after certainty; some degree of certainty is needed just to proceed.
In my own modality of intersubjective-systems theory, empathy is an emergent property of the intersubjective field. What is understood, and how and by who, at what point and in what context, is a mutually influenced dynamic, subject to thorough investigation. It may be hard at times to parse out the source of systemic anxiety or unease, as empathic understanding takes on complexity.
What if the term carries different connotations for each participant? A pragmatic or acutely suffering patient may find empathy in receiving specific guidance, never mind the meaning of the interaction therein. Such definition may or may not preside once the dust settles.
The inevitable conclusion for this author is that empathy signifies an aspiration of sorts, a launch-point of an intention, a commitment to understanding the patient’s subjectivity, even as “subjectivity,” a personalized worldview, may mean little to the latter. (The definition is clear but its significance is not.)
Clinical dialogue is rife with ambiguity over the explicit and implicit meanings of thematic phrases, words, or stories, including the meaning of the mode and manner of communication itself. Wilfred Bion, keenly aware of such slipperiness, stated that participants “manufacture our means of communicating while we are communicating” (in Reiner, p. 45, 2012, itals mine.) What participants are forging, quite imperfectly, are meanings in common, or family resemblances.
Wittgenstein (2009) defined family resemblances as similar meanings of the same term or phrase. To say we love our partner is not the same as loving a type of sandwich (usually); time is another such word, of many uses.
We look for analogous definitions, understanding, or lived values with patients. How for instance to underline the value of having a perspective of one’s own, with those enslaved to others, or do addictive lifestyles? Often I discover, after months or years of treatment, that a patient is far more accommodative than I thought.
For some patients, empathy means a more solidly-reinforced disavowal or detouring of painful states, with stress on action or behavior. A “successful” treatment may be initially defined as a more effective dissociation or smoother accommodation of powerful others, or learning to use ketamine or porn more responsibly. Negotiations are off and running, including over the unfolding concept of treatment.
It is even harder than it sounds. Clinicians worth their salt have skin in the game when it comes to their theoretical worlds or backgrounds, of great investment and passion, which we believe to be helpful, especially when such modality has helped us.
Of course we need to suspend evaluation, confirm and test hypotheses, hold our ideas lightly (Orange, 2014), lest they become dogma. But the need to hold ideas lightly arises out of a deep commitment to a perspective and impulse to help—without which we should probably get out of the profession, per analyst Don Carveth (Haber, 2024.)
Orange (2014) reminds us that our chosen theories are like family, and each analyst is situated within a kind of family history.
Situatedness is a concept of Gadamer’s (2013), indicating our rootedness in various personal and sociohistorical contexts: economic, racial, sexual, intellectual, and especially clinical, which attempts to organize or make sense of all of the above, a distinctive ethos within which we are positioned.
Kohut was, to his credit, attempting to pivot from the classical “top down” approach, the analyst as ultimate authority, towards a provisional twinship (among other things), being with rather than at the patient: a benevolent attunement to painful experiences, including suboptimal frustration with the analyst, whose recognition of her own shortcomings disconfirms archaic patterns, we hope. It may in fact confirm patients’ entrenched beliefs that they “cause trouble” for others.
This reminds me of Kohut’s notion of tragic over guilty man (1982) where, in contrast to the original sin of our Oedipal desire for the mother, a monadic sentencing, Kohut implies a poignant fallibility. We cannot but fail each other at times, being human, with worldly contingencies and mortal imperfection. This requires humility on the analyst’s part, and we cannot but get it wrong, situated as participants are in often incommensurate or unfamiliar worlds. But such wrongness provides useful contrast.
There is an emptiness at the center of our concepts, whose definitions are but an overture. The crescendo of misunderstanding or impasse is inevitable, even crucial for the outlines of difference, giving shape to the patient’s ways of seeing and the lightning flashes of insight, when resemblances are found; in a way, they find us.
Discomforting uncertainties introduce separation from our theoretical family, with a taste of the alienation long felt or feared by patients (and by some of us, archaically.) This gives us a sense of the tragic fallibility Kohut describes; our shared dilemma.
Inevitably certainty loosens, unmoored in impasses or “crunches,” lured initially by the siren song of familiar assumptions, drawing us off course, as patients undergo analogous drift. Therapy begins in exile.
REFERENCES
Gadamer, H.G. (2013). Truth and method. Bloomsbury U.K. Originally published 1960.
Haber, D. (2024, March 29). Interview with Don Carveth (part 1). Substack post. https://darrenhaber.substack.com/publish/posts/detail/143050012?referrer=%2Fpublish%2Fposts%2Fpublished%3Fsearch%3Dcarveth
Kohut, H. (2010). On empathy. International Journal of Self Psychology. (5)(2): 122-131. Originally published 1981.
Kohut., H. (1982). Introspection, empathy, and the semi-circle of mental health. International Journal of psychoanalysis. (63): 395-407.
Orange, D. (2014). And we shall be changed: To hold assumptions lightly is to surrender assumptions: Discussion of clinical narrative by Steven Stern. International Journal of Psychoanalytic Self Psychology. (9)(3): 193-199.
Reiner, A. (2012). Bion and being. London: Karnac.
Wittgenstein, L. (2009). Philosophical Investigations (fourth edition). (G.E.M. Anscombe, P.M.S. Hacker, and J. Schulte, trans.) (P.M.S. Hacker and J. Schulte, eds.). Oxford, U.K.: Blackwell Publishing Ltd. Originally published 1953.
Wittgenstein, L. (1969). On Certainty (D. Paul and G.E.M. Anscombe, trans.) (G.E.M. Anscombe and G.H. Von Wright, eds.). Oxford, UK: Basil Blackwell.
Freud, S. (1920). Beyond the pleasure principle. (J. Strachey, trans., ed.) In The Standard Edition of the Complete Psychological Works of Sigmund Freud,18:1-64
Gadamer, H.G. (2013). Truth and method. Bloomsbury U.K. Originally published 1960.
Kohut, H. (2010). On empathy. International Journal of Self Psychology. (5)(2): 122-131. Originally published 1981.
Kohut., H. (1982). Introspection, empathy, and the semi-circle of mental health. International Journal of psychoanalysis. (63): 395-407.
Orange, D. (2014). And we shall be changed: To hold assumptions lightly is to surrender assumptions: Discussion of clinical narrative by Steven Stern. International Journal of Psychoanalytic Self Psychology. (9)(3): 193-199.
Reiner, A. (2012). Bion and being. London: Karnac.
Wittgenstein, L. (2009). Philosophical Investigations (fourth edition). (G.E.M. Anscombe, P.M.S. Hacker, and J. Schulte, trans.) (P.M.S. Hacker and J. Schulte, eds.). Oxford, U.K.: Blackwell Publishing Ltd. Originally published 1953.
Wittgenstein, L. (1969). On Certainty (D. Paul and G.E.M. Anscombe, trans.) (G.E.M. Anscombe and G.H. Von Wright, eds.). Oxford, UK: Basil Blackwell.