The Presence of 'Companioning' in Psychoanalysis with Robert Grossmark, PhD (New York)

My interest, picking this up, and you call it a deep dive, which I like, is to rather than continue with the psychoanalytic tilt, which has tended to be to try and find the words, to find the areas of the analyst that has words to engage with these states, and then to help the patient transform these states into something thinkable and communicable. My interest has been to take the patient where they are. It's kind of a radical way of saying, you know, meeting the patient where they are, and find our way and lend ourselves to engaging with them in their own idiom, if you like, using bonus system, in their own way of being, and to find ways to be with them that don't necessarily, but not always, rely on talking about things and making things known. Welcome to the IPA podcast, psychoanalysis on and off the couch. This podcast consists of conversations with psychoanalysts from around the world, who share with us their clinical and psychoanalytic work with individuals, both on and off the couch. And what we mean by off the couch is that they share with us their community involvement in many different venues, apart from their consultations. They describe their work in hospitals, in community clinics, in refugee centers, in classrooms, indeed in war zones. We also have conversations with psychoanalysts who are focusing their work on the couch, and they are continuing to refine both our familiar and novel understandings of the dynamic mind as it presents itself in the analytic situation. We've been talking to elders in our field, people who've been practicing for 50 plus years, and they share with us how they view this field evolving and where they see it going. We also talk to clinicians who had professions prior to becoming psychoanalysts, and they share with us their journeys to doing what they now love. These are just samplings of the psychoanalysts we've been talking with again from all corners of the globe. Please visit our website, IPAoffTheCouch.org, where you can subscribe, where you can see the recommended readings provided by our guests, and you can also leave a comment. I hope you enjoy these conversations and find them thoughtful and meaningful, and I appreciate you, Lissar. Thank you. Welcome to Derry's podcast. I'm Harvey Schwartz, and my guest today is Dr. Robert Grossmark. Dr. Grossmark is an analyst in New York City. He's on the teaching and supervising faculty at the New York University Postdoctoral Program in Psychotherapy and Psychoanalysis. Also at the National Institute for the Psychotherapies Program in Adult Analysis, the National Training Program in Psychoanalysis, the Flora Psychoanolytic Center, and he lectures very widely. He is the author of the book we discussed today, the unobtrusive relational analyst explorations in psychoanalytic companioning. He also co-edited the book, The One and the Many, Relational Approaches to Group Psychotherapy, and also heterosexual masculinities, contemporary perspectives from psychoanalytic gender theory. Our conversation today is around this book, The Unobtrusive Relational Analyst, and he really invites us into his understanding of how one best engages patients who don't experience themselves in the world around them as real. They don't feel themselves to be real people. They don't experience the analyst as a real person, and that is obviously a clinical challenge. And I don't want to overly summarize what we talk about because I want to invite you into listen to it, but in essence he tries to, and this is a quote, "create a space within which we could float, and he could come to himself." Now how he goes about engaging a patient so that we can float is really what we try to understand and unpack. And I think whether one agrees that this is the best way to engage patients, I think we all will benefit from understanding the richness of his immersion in this world, his understanding of this world, and the benefit he brings in offering himself in this way to his patients. Here's my conversation with Dr. Robert Grossmark. Robert, welcome to the podcast. So good to have you. Robert, we are familiar with patients who come to our offices, and, while in large, their difficulties that they're seeking care for are related to triangular levels of ego functioning. And what I mean by that is that for them, again, always more or less, metaphoric imagery is effectively alive for them. A sense of internal safety is more or less dependable. And their empathic awareness of the others' experience may be a stretch, but it's within reach. And there are patients, otherwise, who come to us where action is their mother tongue. And for them, trust is in play as a question, and the other is defined by certainty and danger. And your book that we're going to spend time talking about today, again, it's called the Unobtrusive Relational Analyst Explorations in Psychoanalytic Companioning. Your book and your work focuses on this latter group of patients, with caveats that we'll discuss. And you offer us a description of your deep dive in how to understand them and engage with them. Now your deep dive is of an interesting sort. It's without the usual safety oxygen tank that most of us use. Many clinicians use the safety tank in our work, and the form it takes is that we lean into the observing part of being a participant observer. In contrast, you lean into the participant part of participant observer. You don't rely as much on the usual safety tank to extend the metaphor. You free dive. And that's what we're going to take up today. We're going to talk about the ideas that make this up. We're going to discuss a patient that you've presented in the book, a disguised case. And we're also going to talk about you, and we're in you, this not only interest in this work comes from, but the capacity to do it, because it's not an everyday capacity. And to orient the listener to our topic, I'm going to read three very brief excerpts from the beginning of your book, and ask you to elaborate on it to start the bull rolling. Note number one, the challenge that I take up in this book is how to preserve and find the potential healing qualities of the human encounter in the psychoanalytic situation, with patients for whom the human encounter itself is deeply constrained. How do we work psychoanalytically with patients and states that are not available for verbal, cognitively, organized engagement and relatedness? That's quote one. Quote two, "The relational field has also struggled to find ways to work with patients who are constrained, sometimes severely, in their ability to engage in dialogic exploration, and who barely experience continuity of the self or subjectivity in themselves or in others, including the analyst. For such patients and interpretations about inner conflict or consideration of the dynamics in the treatment interaction with the analyst, are potentially voices from another world. Then why?" And utilize their verbal related selves, but their inner core will remain at best untouched and at worst shamed into disavow and inner sequestration. And finally, I outline the approach of the unobtrusive relational analyst who is neither neutral nor abstinent and is both deeply engaged with the patient and simultaneously surrenders to the developmental and archaic needs of the patient to be the analyst the patient needs him to be. This can also involve tolerating experiences and sessions that seem far from what we might otherwise regard as psychoanalysis. Robert, we needless to say, could spend our whole time on those quotes, but why don't you start a poem? Well, first of all, Harvey, thank you so much for having me on this podcast and I should that I love and treasure the podcast and listen to it often, you keep me company on long, lonely, uh, canutes in the morning. So it's a pleasure to be in the-- I'm the lucky dear that thank you. Now you start with these quotes and we do have a lot to talk about. You know, I think, let me say some things that with psychoanalytic and clinical theory has done so much in recent years to open up our idea-- our ideas about unrepresented states and different states of being. We're quite interested these days, I think, of the work of Howard Levine, on unrepresented states or in the more interpersonal relational world. We have Don Stern talking about unformulated experience. But really, there's a history to this with, uh, being uninterested in nonsense, you as an experienced, um, and you even maybe Andre Greene's interest in the negative, you know, uh, or bolus is unthought-no. We've done-- we've done well, I think, in articulating these different realms of being. And, um, and, and a thread that runs through them is aspects of, of, um, the human, and it's really pre-experience in the Bionion words world. So it's not even quite experienced. But aspects of human being that are not available to the verbal cogniz-- cognizon realm and exist much more in some-- the somatic realm and then, um, what I talk about in terms of the enacted realm and what becomes out through action, the somatic realm and so on. So I'm interested in-- I'm sort of picking this up and saying, "Well, how can we work in these realms?" And I think that so much of our psychoanalytic, uh, technique and our history, leads into bringing the patient into the world of what can be thought about, um, what can be represented. You say people who struggle with metaphoric imagery and don't have awareness of the other. I should also say something that's important, which is that we're not simply talking about a class of patients. I'm really interested in certainly there are patients who manifest and are manifestly really struggling with being a human, and that comes through with multiple kinds of symptomatology. But also we're talking about states, which we find these states of where continuity of self is not a given, where there is undifferentiated states where the boundaries between self and other are not clear and maybe not existent at all, where, um, the being alive is not taken as a given. People live in different realms of being, and the Winnecott was aware of these kind of states. So many, many other writers have. My interest picking this up, uh, and you call it a deep dive, which you would say, "I like," is to fight, to rather than continue with the the psychoanalytic tilt, which has tended to be to try and find the words, to find the areas of the analyst that has words to engage with these states, and then to help the patient transform these states into something thinkable and communicable. It's kind of a radical way of saying being, you know, meeting the patient where they are, and find our way and lend ourselves to engaging with them in their own idiom, if you like, using Bona's system, in their own way of being, and to find ways to be with them that don't necessarily, but not always, rely on talking about things and making things known. I mean, I think in the world of beyond this tremendous interest in, um, what is unknowable and what is lost in the knowing. Obviously, I don't diminish the value and containing function, organizing function of words and language. But those quotes you read, I'm already talking. I mean, I mentioned one of the quotes, and you and I have had a conversation about this, and I think what you're bringing forward is profound and vital. But I also think one has to take care. Needless to say, one has to take care, and everything one does or says in our work. But in particular, um, it seems to me that there, while there are terribly difficult challenges to engaging with patients in the way you're describing. It seems also that in some way there is an ease with it because it spares us certain things. For example, you use the term, you say, I outline the approach of the unobtrusive relational analyst who is neither neutral nor abstinent. Let me nudge you a little bit on this. It seems to me that those are very, very different words and concepts, and we may lose more than we gain by combining them. That is, abstinent as I understand it. These are my understandings, of course. It refers to abstaining, abstaining from doing something, abstaining usually refers to self-rivelation or sharing one's imaginings, and that dimension, personal history, or abstaining from action, that it's a behavioral reference to abstain. Neutral, on the other hand, is a state of mind. It's a state of mind that the analyst tries to be in. It's what makes it work, as opposed to something else, because it does take while spun to maybe. It also takes effort and focus and that certain kind of attention. To be neutral in the face of patients manifest conflicts, that's one thing, but of course, more importantly, to be neutral in the internal struggles that the patient may be having. We're neutral in the sense that we don't take sides with one or the other. We are interested in learning, in hearing, in elaborating all aspects of the patient's mind, understanding it, perhaps more deeply at various times and sharing it with the patient so that they can own it. That's what I understand neutral to be. From reading your book pretty carefully, my sense is that you do work from that neutrality. Without it, I don't know how you could do what you do. No? Yes, Harvey, I actually really appreciate that question, and I think you make a really valid point. Let me say, especially about neutrality. I'll come back to the abstinence, but in terms of neutrality, certainly, I'm almost interested in the kind of radical neutrality of really allowing oneself to and being non-judgmental about whatever it is the patient is bringing in. Indeed, absolutely not taking, as you say, taking sides in the terms of conflict or so often we can feel, well, you really should be more related. Right. But I think that there's complicate, and I agree with your formulation of neutrality, but of course, there are a couple of caveats. One is that we bring our own bias and context to the situation so that there are aspects that are simply content neutral. For instance, we do value and we're interested in the well-being of the patient. We do, I think, a lot of analysts who are being neutral in terms of not siding with conflicts, but they do want to be able to understand and put things into words. So that there is that presence. And of course, just to go to another level in our contemporary environment, we're interested in, you know, we're so aware of our historical, cultural context and all the aspects of power relations and so on that we're inhabiting and bringing that we don't totally unconsciously. So neutrality in terms of what we're doing consciously, I'm very much in agreement that we want to really try and orient ourselves to be as open, receptive, non-judgmental, and understanding that our own unconsciouses are always working all the time. But so in terms of abstinence, just a word, and maybe that's a rink to what I use the work of balance, Michael Balance in the book quite a bit. And I think that abstinence has had a sort of behavioural idea and has got like all good ideas they can, even if they're great ideas, they can become a kind of tyranny if unattended over a period of time. And I think, you know, you can't get the kind of feeling of, well, we don't do that here. This is psychoanalysis. What we do here is put things into words. Balance, you know, was writing in the 60s and commenting on the psychoanalysis of the time and struggling with the technique of the time. And he was describing, saying that abstinence seemed to come from the wish to not gratify. And he said, it's not simply about gratification of an instinct. Patients are not simply looking to gratify an instinct. And this is where he makes the manifests the sea change to object relations thinking. He says that patients are looking to create in the analytic relationship and an object relationship. And often he talked about primal objects and earlier objects. And his whole approach was to unobtrusively, and I take his word, allow regression to those earlier object relationships to the area of the basic fault. But that's a whole other conversation. But the thing is that he said, it's not simply that the patients are looking for gratification. They're looking for and they need to find a way to those early object relationships. Well, at the same time, our task is to help them see the obstacles that they put up to finding that very thing they feel they want. And that's part of our job, no? Right, that's an interesting comment because that's, and we're going to, because, uh, yes, and he's, there's something there in our task in helping patients see what they're, what they're not doing. One of the aspects of my work, right, we were trying to show them how they're. Oh, no, no, because that that that that leans into the critical judgmental part. If someone is eager to be in a love relation and is unaware of the ways that they make that very thing difficult for themselves, is it not a gift to them to shed light that we could discern from how they treat us in the office, the ways that they are counterproductive for their state at conscious goal, and that that unknowingly for them is what's leading them to be isolated in their life and painfully isolated. But if they became freer, if, for example, uh, you know, their potential love objects, and including the analyst, uh, remind them of childhood figures that were taboo forbidden, or were involved trauma, and they keep themselves apart while suffering that very thing they do, can it, and maybe this is a different type of patient, I'm not sure. But is it not something very helpful we can do to help them see that they're doing something other than they're aware of doing? I do look undoubtedly the answers, of course, yes, and we. Yeah, I guess that was a set of questions. Sorry. You know, but there are interesting links in what you're saying to other aspects, but before I jump into another, you're sitting with another question, because I. Oh, am I sitting with another question? Yeah, yeah, because I. Oh, I have a million questions, of course. Let me just jump into one of the questions, uh, to go back to Absend. I wasn't making the case four abstinence, by the way. I was just describing what I understood the word to mean. I think to choose an absolute position in all situations with all patients is not attuned to even a little. Number one. But two, the other thing is you said that, uh, analysts, uh, are focused on translating action into words. I mean, I know what you mean, of course, but I don't see it that way. My approach and what makes sense to me is that when someone's involved in action, our task is to understand what makes it difficult for them to have the choice about using action or using words. What's getting in the way of words being available to them? And there are many potential answers, including that they don't exist for the person, uh, which could mean all kinds of different things. But that's different than the stance of you're not doing it right, you're acting and why aren't you talking, which is also not very thoughtful. Yes, yes, yes, no, no, no, certainly. I think that if I can, let's see if I can take up one piece of that, I think that, um, I think that that I'm interested in. Maybe this jumps ahead a little in our conversation. That's right. I am interested in the idea of bolus. Christopher bolus really captures it. That human drive to represent the self and, you know, to, to, to, and, and I am interested in the multiple dimensions of representation. So, and coming back to the interest currently in what is unrepresented, non-symbolized, but I think that there still is this sort of way that in repetition and in, um, enactment in the treatment, there is a completely out of awareness, representation in action of what isn't yet in the patients. It doesn't exist yet, perhaps it's trauma that was never experienced. So, I'm interested in welcoming these other states and they're often states of unintegration, states that aren't, um, organized and allowing us welcoming them rather than quickly trying to engage myself and the patient in thinking about it, but to really welcome. And to see that as the patient trying to give, bring in and engage us with a representation of what is yet to have form. And it's another way of talking about what's unconscious. I think we lean into, um, trying to, to find the unconscious through, um, through interpreting what is happening rather than really, I think, in a more, rather than allowing the process to unfold. Oh, I think, I, I think you said it beautifully and clearly and agree. Let me, I think, we're finding our respective roles in this conversation and that's fine because I may elucidate new ones to it, but let me again nudge up against what you're saying. You know, there's an old saying and it's old and one doesn't hear it much anymore. And the saying is that nonverbal isn't equivalent to preverbal. That is, there are many reasons why people may be nonverbal, one of which may be that it's preverbal, but not necessarily that. And I think one is at risk for assuming that one knows what nonverbal means because it could come from all kinds of places. And I, I think that's true for action as well, because we're all familiar with patients who, of a, of a neurotic level. And again, I understand that's a generalization, but I don't think it's entirely inaccurate that people have different capacities. And when there's something that is registered as dangerous to them as risky, usually a transference related imagining fantasy desire that is linked with some danger in their mind, some presumably childhood danger, that a neurotic patient will also turn to action as a simple defense. I don't see simple derogatory, but, but as a, as a, as a clear defense against the awareness of that transference fantasy. And if we stay alert to that sequence, we can help them recognize that they're, they're living their life on the assumption that there's a danger if they speak something. There's a danger if they feel something. And that by turning it into an action, they're avoiding, they're living their life on the basis of that danger, which doesn't exist anymore. That is a neurotic level type of intervention. And there's that kind of action too, as well as action as you're representing. And I, I don't want to do an either or, but that there are differences with different patients at different times. And there clearly are people who only know how to live through action. I, I chose the term mother tongue, specifically because it is, one patients I have found that one patients come to us and English isn't their original language. There are times where they need to express a feeling in a language and they use their original mother tongue to say it, even though I don't know the meaning of it. They say, I need to say it in this language. And then I'll explain it to you. So that's true for action as well. I need to express it this way because that's its truth. And I get that. I just want to enlarge our repertoire of thinking about it. Yes. And I think that's that's kind of beautiful really. The idea of mother tongue and action, and enactment as a kind of mother tongue. I think about it in terms of, you know, there's, talking about action, there's a nice paper from some time ago by which Don Stern refers to in his book on unformulated experience by Le Corne Bouchard called the Dimensions of Mentalization. And they talk about mentalization. They have a number of different dimensions levels if you like of mentalization starting with, you know, the, the, the symbolic and verbal life. and so on. But then there is the non-symbolized, the motoric and the somatic, you know, and it is an interesting idea that these are in and of themselves, are obviously communications, but attempts to mentalize in and in the register. And I think when we're looking at situations of trauma, neglect, abstinence, suddenly there's so much interest these days in neglect and absence because these are things, you know, the things that did not happen, the mother who was not there and it's most extreme that that mother, but many variations, that these are things that, and obviously Andre Green worked so much to elucidate how they're not there to be represented and so that we find their expression of these kind of states in these other dimensions. And obviously they can come in point what is included in dreams and so forth. But to give you a clumsy example, you know, and and and emphasis here is on the field of the treatment. What it is that when we talk about enactment, we're talking about what emerges in the field, as it were, the third that is created between the analyst and the patient. What emerges not quite from from from the patient or analyst's unconscious, but it emerges. So you find something like a patient who late for a session misses a session. We could certainly go with an idea of the patient trying to manage their own fear, discomfort, as you say, a situation where there's something is going on in action to to help with the danger of what's happening. But there's also what is created in that absence and the analyst may find themselves feeling scared, worried, feeling a loss and absence. They may find themselves relieved, guilty about their relief that they can catch up on their emails and so forth. But all of which is part of a completely unconscious narrative. It may be the patient's only way, it may be the only way that the absence is going to be expressed in the in in that it takes a form. It actually happens in the treatment. So it's not just that a patient may avoid talking about difficulties in a relationship or once again comes in and one hears, you mentioned before someone who's gets in the way of successful relationship. But I would be interested in the experience that is emerging inside of me. I may be sitting with, you know, when I hear the tenth time, you know, or the second or third time that a very similar pattern goes on in a relationship and the experience that is emerging between us, I may find myself frustrated, I may find myself despairing, I may find myself angry, I may find myself with all kinds of states, I may myself dissociate a bit because oh boy here we are again. And that's true. I'm interested in that as a representation in the field of something that is completely not formulated and not represented. Perhaps I'm becoming the impatient mother or the or the callous parent or the parent who fobs off the infant and perhaps what is happening and as it were is telling its own story in the treatment is core to what it is that is happening in terms of these unsuccessful relationships. So by inviting that experience and that's my version of enactment by welcoming it and not rushing to close it down could be quite uncomfortable. Let me ask you, an example comes to mind and tell me if it fits what you're describing a patient again some time ago would have these repetitive self-destructive things and she had this conviction that she was frustrating me and she had a particular image of tearing my hair out which is curious because I don't have much but it was a very important image. We're doing well in that department. And I was interested just I think what you're saying that there's something maybe driving these repetitive self-destructive enactments in the wish to frustrate me and to explore what that was meaning to her and it evolved to a whole transference fantasy that was started off with my being enraged at her and that she was unconsciously trying to provoke that. Is that similar to what you mean? Well certainly certainly and it's such an interesting moment to describe the patient was interested and one found herself wanting to tear your hair out which is interesting because the phrase is I could tear my hair out right she dropped me so up the wall I was tearing my hair out so that which to me fascinating because it speaks to a kind of merger right and an undifferentiated something but I think that certainly you found yourself frustrated and angry and so forth certainly I mean I think we would all be interested and understand that that's a very powerful counter-transference and it's full of meaning and we don't yet know and to explore her initial unconscious intent to provoke that in me which was the beginning of a whole story for her indeed and and and and and how you know when you're describing work through went well right so to your in that suggesting and I'll read it. And always just to be clear. I guess the ones that come to mind are the ones that go well but trust me I share in the difficulties of this work. Well let's stay with the difficulty and let's play with that example because I think right that that you know we're clearly something was talked about and I and and the focus was directed to what was going on inside of her such that she could connect to something that had been out of her awareness in terms of wanting to provoke it in you and so forth which is speaking of quite a developed level of reflect function and metaphor function the ability to say oh right that this thing that I did is like this thing that I feared or that I wanted but I think my often that's not that's really difficult I did a consultation just this week with a man quite a successful man who was talking about a past treatment and was saying it was so difficult for him because the therapist would say wait what is it that's happening here you seem to shift state and he was telling me that he found it so difficult because he really didn't have a clue what to say about what you know the what's going on what he had very little connection to what he was feeling or what was going on telling me a snippet and but I think let's play with your example well but wait a second but let's let's not lose sight of that because it's a very important point we have all met people it may have happened to us it may happen to people we're close with who have had analyses that it's too much of a shorthand to say they were as if experiences but it borrows on the sense that compliance as opposed to being touched and I'm generally referring to that metaphorically is what took place between between the within the diet and people spend long times in treatment and it never gets to that and sometimes it's a function of the patient not being able to get to it and sometimes it's a function of the analyst not being able to get to it or who knows maybe a supervisor can't get to it but let's let's honor that experience because it's it's true and it our field has suffered might leave you and there are many many treatments of what one wants to be so respectful right no I'm sure in all of our treatments there is some compliance right like you know they needn't be just that that was the whole treatment yeah of course of course but see see if I can just elaborate a little um yeah and then I want to get to companioning which we don't want to leave because that's in the title of your book all right so but get ahead I think that there's sometimes when someone shifts state or they they go into action or they drift off or it seems like they've the analytic work somehow or another is not happening and often there might be the some form of something goes on around the frame and so on the way the way that I would see it or an out something breaks through in terms of something in the attitude towards the analyst some anger comes to obviously we're interested in welcoming and allowing a space for the elaboration of what is yet to have for. So in one piece in the book, I rely on, I have an idea called the flow of inactive engagement. - Yes. - And let me, if I can just say a little about that. - Please. - I work, I try and elaborate on Freud's idea about free association and there's a whole lot to say about this, but as all our listeners will know, you know, Freud told his patients to imagine that you're lying on a, you're sitting in a, on the train, you're by the way, and you're looking out the window and the train is moving, so the countryside is rushing by. And please just say whatever comes to mind, just as you would, read off everything that you see, you know, coming rushing by the way. And of course this was brilliant because Freud having connected to the idea, the powerful ideas and of the unconscious was really struggling with, so how do we access that? How do we find a way to that? And he sets up this kind of brilliant situation, the patient lies down, so they're in a bit of an altered looser state and they are to say whatever comes to mind and the analyst with his evenly hovering attention is gonna allow himself to him or herself to sort of absorb what is happening and to, you know, and to let the patients unconscious speak to the analyst, unconscious, without either of them knowing, right? He says it's remarkable how the unconscious of one person can impact the unconscious of another. These are the Lawrence Brown, right in Boston, so talks of that as the big bang psychoanalysis. So you wanna, we try in the analytic situation to debt the stage so that that part of what is unknown to the patient and may remain unknown to the analyst for some time can begin to manifest. Once we have the idea of unrepresented, unsimplised states and we have the idea of states of non-aliveness, of non-differentiation and so on, how do we set up the stage to let them flow in a kind of what is a different variation on a free association of state of action? I believe that that's why there's a flow of inactive engagement if we can stay out of the way and let these enactments, our engagements which may feel weird and bizarre and uncomfortable, but to let them flow and not interrupt them and ask what is happening or what might this mean? Just like Freud wasn't gonna say, oh, you mentioned this, what does that mean? He would have the free association and it has been sort of remarkable to me to see where one gets taken in your introduction you talked about. Now what I'm writing about is how the analyst then, along for this right because it's a participatory mutated flow may find themselves in these altered states, strange sensations and with a great compulsion to try and organize and turn whatever is happening into analytic material, but the thing is that this is the screen, the silent scream of the absence, the neglect, the pain that was never seen, recognized, or validated, such that it has formed in the mind and the only way that it can come through is by this flow of enactment. And it often involves issues around boundary, issues around action. You know, Low-Walt has a beautiful phrase, "Links in action," which he links to, in act what he calls inactive remembering, which is brilliant because he's saying that there's, and Bolas talks about the realm where thoughts arrive as actions. So this is really fascinating. - Like somatic memories too. - And obviously, so much. And we know, look, look, when a patient is talking and suddenly gets cold or feels they've vomited or suddenly a headache emerging, and we know this is. - Let me jump to the challenging question of, in outlining the nature of the person's mind, the next question, of course, is, and how can we be of help? And so far, you're describing by being present, unobtrusively, not having one's own agenda, not acting out on one's need for order, and not too excessively leaning into observer, but participating, which you've made beautifully clear. I do want to read a little bit about your use of the word, companioning, and then we're gonna talk about your patient, Bernard, where this was all lived out and is really beautifully demonstrated. You write, true healing often involves going further into our patients' worlds of suffering and private madness, rather than working to move them out of these states. I address how one works intersubjectively and authentically as a relational analyst with patients and states where there's no mutuality and no differentiation of self and other, where consciousness is dominated by part object-relatedness and fragmented, constricted, and bizarre experiences of self, other, and the world, and where symbolization and reflective functions are greatly limited. I offer a register of relational psychoanalytic engagement, wherein the analyst, companions, the patient, into the dark, archaic areas of functioning and regressed object relations that are not available for discursive interaction or mutual study, rather than seeking to foster greater relatedness and mutuality in the session. And you have a whole conversation as it were, distinguishing between what's a Lombardi calls who you quote at length, asymmetric logic, versus what you represent you're thinking as being symmetric engagement. I don't think we have time to go into that in detail, but let that be a teaser for listeners to read the book because just that exchange is so nuanced and so lovely that, I mean, the rest of the book has "Lovelyness and New Ones" too, but that especially engaged me. Let's talk about your patient Bernard. I'm gonna ask you to start us off by reading a description of your work with Bernard, and then I will pick up. Okay, in my work with Bernard, I was unobtrusive yet very engaged. I did not structure him beyond the beginning and end of sessions and payment, and allowed him within sessions to take us wherever his flow took us, talking of the flow of inactive engagement. I'd work as calmly as possible with him on whatever he brought in. I believe we created a space within which we could float and he could come to himself. I would join whatever and wherever he took us in a felt, mutually regressive way. What I said would embellish his images and flow rather than speak from outside of his experience. And in parentheses here, I'm working in this chapter off of some of what Winnicott wrote about in his amazing 1945 paper, Primitive Emotional Experience, and he talks about the mother embellishing the child's illusion rather than speaking from outside of it. I'm also coming off of the developmentalists like Travath and Entronic, who talk about companionship and the growth of the self and intersubjectivity in companionship. So that's by the way, so this may make better sense. - Okay. - When I said would embellish his images and flow rather than speak from outside of his experience, as I internally strove to find a place for whatever disturbing experience or altered state was growing inside of me. During the first years of our work, these states were chiefly one's of fusion and fragmentation. I recall feeling unfathomable dread and terror for my own sanity. When at one point I found us dressed identically and I had the sensation that my voice and my body were changing into his. In moments such as these, I was entering the darkness with him rather than fighting against it to echo Matthew's Sanford. I won't, we'll talk about reference. I'll read the book, you'll get the reference. There were many registers to these mutual regressions and unobtrusive relational position does not only mean quiet, patient waiting. This is not a question of withholding one's subjectivity, but the provision of a particular register of subjectivity. In time, he would evoke songs and movies that I was often familiar with. We would look at YouTube videos together and often sing songs as he recalled one band or another. As frightening as some of the violent and sadistic regressions were, these shared moments of song and laughter and joyous and tender. The theme is, we were in a room. in a shared accompanied register of the tactile, mobile, and vocal, rather than that of verbal and intellectual. And I would say symbolized, we were enjoying-- and here's a trivathan phrase-- we were enjoying our joint consciousness in companionship and sharing our subjective impulses in proto-conversations. Those are all phrases from trivathan and his wonderful work on the development of subjectivity, the development of the sense of being a subject. He would bring me food and drink. We'd snack together. He would send me music via email, links to books, films, and articles he liked. I would read them. I did not regard these as assaults on the boundary of treatment. Did not attempt to interpret and did not engage in consideration of what may be going on between us. I did not confront his absences or lateness. I did not want-- why did I not do that? Those things-- I did not want to stand outside of these experiences of illusion and comment on it. To try to make material out of this kind of engagement is to lose it, to do damage to these nascent moments of self-other definition and the comprehension of external reality that were beginning to grow. And then I recall when a couple of years that comprehension of external reality and the other subjectivity come not from the interjection of reality that breaks the illusion, but by enriching the illusion and living within it. That's when a conch talking about early development. Let me pick up and continue more about Bernard. Curiously speaking about letting the flow happen between us, I don't think I've ever come up with the idea that you start reading a case and I finish it. So there's a flow between us that matches the content of our conversation. Continue to go flow, let me say. Yes, me as well. So let me enact that by continuing to read. You write about Bernard. So gradually, Bernard has begin to appreciate his place in external reality and to feel that others are separate and have their own subjectivity. In amongst his flow, there were images of rebirth of escapes from subjugation, the attainment of independence and waking up. One day he said, I live in such a narrowed interior world, others explore the world around them. There was a gathering, images of pieces coming together. He remarked one day that walking across the park, he had suddenly realized that the different areas of the park that had always felt like separate not connected places were actually part of one whole park and were easily accessible one from the other. His emotional volatility calmed slowly. He sang a song about high, low, and in between. He talked of spacemen surviving in the heat of reentry, intact. And you go on to then reflect, I wonder if the way we have talked about using and offering the analyst's subjectivity in the relational literature. Has too often emphasized the knowing and exploratory aspects of one's subjectivity, the expression of subjectivity that aims to help develop the dialogic and reflective aspects of the patient. I am suggesting here that there are many other registers of the analyst's subjectivity, that the analyst can choose to offer in the course of treatment. And there are treatments with the kinds of patients that I am describing where a different register of the analyst's subjectivity is required. They may not be exploratory, but I would argue that they are certainly expressions of the analyst's subjectivity. The register of unobtrusive companioning in mutual regression involves the presence of a subjectivity whose signature is surrender, responsiveness, receptivity, and unknowing. That's quite something, Robert. Yeah, it's not bad, actually. No. Well, and that referred to both the writing and the clinical moment as well. But let me ask you a question. Honoring the special thing you're describing, you're talking about creating a joint illusion with the patient. And I understand that. You imply that the illusion sort of evolves, if not melts away to a more reality-based and less conflicted there, I use that term, less conflicted way of engaging you and the world and themselves. But at times, those illusions aren't given up so easily. They are often experienced as remedies for past two painful disillusions. And what's your take on that process of illusion and disillusionment? Well, and those are powerful words in terms of when it caught the issue of disillusionment. It's a powerful piece of development and again, the growth of the self-subjectivity and one's place among others in the world of, and reality itself. And I think, in the case of Bernard, you see, in the book, the cases that I mentioned are people who are really struggling massively. And Bernard was really a nod of functioning person. And he's, and then really got to a place of much greater effectiveness and functioning in his life. But we're talking here. I mean, what is going on? We're talking here about the development of interiority, the development of subjectivity, the development of aliveness that comes through being companion in the area of illusion. And I think that what happens, and this is why the development, the winicote developmental lens and the developmental is like to Vath and are so important, that coming to a self and a self among others in relation to others comes through the living in illusory states. And what happens in life is that they stay alive in us. They stay alive in our dreams, in our creativity, in our love relationships, in our joyful and ecstatic moments. And they get integrated, but we develop all these other areas of if you like ego functioning and effectiveness and engagement with the multiplicity of ourselves and others. But I think that you're asking-- I think in terms of the trajectory and the development of the case, the disillusion certainly came the many moments where Bernard came up against limit and finiteness. Right, that's what I was wondering. And which relates to the chapter, if I can mention this as well, that the chapter called everything happens at once. The chapter six in the book, where I talk about time and undifferentiatedness. And I use Einstein's famous quote, that if we had an invention invented time, everything would happen at once. And he doesn't mean simply the experience of time, but he means time. He means-- and that's a whole other podcast on what's going on there. But we find greater differentiation through the embrace of the undifferentiated. We find greater reality through the embrace of illusion, I think. We find-- right? Do you find as valuable as saying being open to whatever the patient is bringing or enacting and sharing it with him or her? You use the word limits. Patients will often want to do things that you may not be comfortable doing. It might involve physical contact. It might involve meeting or engaging outside the office. It might involve financial arrangements that are not to your liking. So when inevitably-- I'm saying inevitably, correct me if otherwise-- when inevitably, limits need to be imposed. We're the constraints of reality, not illusion, but reality. Force themselves on you and the two of you. How do you two embrace that? Yes, thanks for asking. And whenever I talk to people about companioning and unobtrusive relational analysts, there's always a very important question about limit and reality and boundaries and so on. And it's important to say that this is certainly not and anything goes, ideally, like whatever. And it's funny because I think paradoxically, one of the ways that I'm able to do this work and allow myself to be taken into these areas is because I'm quite old school about boundaries, which may sound a little paradoxical. But I think the case is in the book and Bernard, which is just reading. He may not have been in the session physically, but I'll come back to that in a second. on time but session. As far as I was concerned, sessions began and ended on time. He paid regularly. There was never an issue with that. I sort of ran a well put together shop. Certainly, it's what happens. Bernard Wood, walk around the office, would empty his pockets, would move my furniture around. I talk in the book about a patient who would go into the little pantry in my office, himself, a cup of tea, and so on. People who are going to utilize the office and the space in all kinds of tactile and motoric ways. I keep in mind when a cot's idea of the earliest relation to the mother's body, which is present in the office and the structure. But your question is, I think that ultimately the limit, the end of the session, the closed door, the breaks in treatment, my vacations, that these gradually take hold. And indeed, we're talking about the developments of self such that one can begin to comprehend one's own subjectivity and the subjectivity of the other. It is interesting how that takes hold. And it comes from within the patient. One can't be told that. And some of what you were reading felt to me like a correction to the kind of work where when a patient is not related, one wants to bring them into greater relate in this. The patients who are not seeming to comprehend your presence or take any interest in who you might be. But I think we welcome experiences of non-relatedness. They're really important. You say you were just describing your words, how you do this work. And you reference the mechanics important enough. But let's spend a few moments on how you do this work. Who are you that you are at this place in your life, in your career? A, that you're an analyst. And B, that you're an analyst who leans into participation and away from observation. Could you share with us your story such that you're comfortable of course sharing it? You know, I'm currently with some of my reading groups. We're reading "Never Simmington's Wonderful Book, Becoming a Person Through Psychonalysis" happened to go to the dentist. I was carrying the book. And he said, oh, you're becoming a person. I said, yeah, still working on it. Aren't we all, yeah. Which is to say, aren't we all? It's a really profound question. You ask Harvey, and I can say some things about it. There's not an analyst or to it. I would say, personally, I think, look, we all come obviously from our own psychological context. As I think about it, the thought that comes to me today is, you know, I grew up a second son. My older brother, 15 months older than me, we shared a bedroom growing up for all the years of our development. And I think that we were not twins, but we could sort of almost twins, such that I certainly would just be aware of his state. And we would know each other's thoughts before we almost had them as often before we spoke. And so on. So I think that that's a big part of it. I think that in my clinical story, my professional growth, I worked for many years. I'm from the UK originally. And I worked in the late '70s, early '80s. I started my career working in psychiatric hospitals. And then when I came to the US to do my clinical training at the city program in Harlem and New York, so the city university clinical psychology program, PhD, we were working in that environment of optal man happen of Harlem seeing many different kinds of patients. And my first job in the public health, in the South Bronx, Mauritania, family clinic, and then working in Bellevue Hospital in psychiatric emergency. And then state's hospital in Rockland County, state psychiatric hospital in the admissions unit with untreated psychosis, all of which is to say, and I'm rushing there over decade of experience. But often in clinical situations with patients that typically were not regarded as available for psychoanalytic work, people living in under-resourced impoverished environments, often immigrants, minorities, people not coming from environments oriented to psych-- to thinking psychologically, necessarily. And patients who on a quite a greater degree of cynicism about what the the clinic might offer and structures of power that were present in coming into mental health clinic and so forth. But I found, and I was doing it intuitively, I found ways to lend myself, to be myself, but participate in their world and in their language. And you mentioned before Mother Tongue, and like you said, the Mother Tongue, not only a language but of custom and engagement and forth. And because I was fortunate enough to be interested in doing group work in Mauritania, I ran a lot of groups, which were a whole other story. And for those interested in groups, I would-- My book-- And there's sections in the book. Yeah, three chapters in the book. And the four chapters are about my group work from this perspective. But because I was doing groups, I was meeting the numbers. It was that time when clinics were really crazy about you had to meet some numbers and et cetera, et cetera. So I was then free to work as I wished with these patients. So I would see patients who were, you know, access one diagnosed, often manifestly psychotic in multiple time-a-week treatment. And I would spend a lot of time with them and allowing them to just talk and finding my way to understanding them and being in their worlds. And took that with me into the Bellevue and the states like the Atreus Hospital. And those years were tremendous. You have shared also that you said growing up and even when you came here that you knew what it was like to be an other, a misunderstood, mischaracterized other, which has enabled you to relate on that level to your patients. Thanks for that, Harvey. An important part of my development, where I come from, is the very small and very tight Jewish community in Northwest London. For those of you, many of our listeners will have done the pilgrimage to London to the Freud Museum. And you probably got out the underground at the hamsters on the grounds. If you go one stop further or a couple of stops further, you'll be in Golders Green and Finchley, which is where that community is located. It is a tiny community these days. It's around 250,000 people, which is, you know, what if that's less than, certainly less than 100,000 families? So it's a very small community and like all small communities quite insular. But growing up in that environment, I was very aware of the inner and the outer of us and them. And our experience of otherness that was often invisible because we're not of a different color, or we're white, and so forth. And it was a primary source of my original identity coming from a close and warm and sometimes claustrophobic community. When I went to do my clinical training in the UK, I went to do a masters in clinical psychology, which I talk about in the prologue to my book at the University of Birmingham, which is in the middle of the country. And that is Birmingham, not Birmingham, as Americans. And if you want to say properly, you have to say it like they do in Birmingham, where it's always raining. So everyone always has a cold. So people say, "Birdium." Like that. Good to know. Right. We're very note to self, continue with the gesture. But in going to the clinical psychology program, that was only a two hour drive north from London. But it was an other planet in the 1981. And I found myself the only and the very first Jew in the clinical program. And was often in contact with people who had not only didn't know about Jews, but had never encountered a Jew in their lives. I should say England is much changed in multicultural country now than it was there. And I was very aware of my otherness. And was-- often witnessed to casual anti-Semitism, people without even knowing it would be anti-Semitic. But the thing is that in our clinical training we were working quite quickly in public clinics in psychiatric hospitals with the local population and the city of Birmingham was an entry point for many of the immigrant populations that came to the UK. Now it's the UK. So those populations were coming from India, Pakistan, Bangladesh, from what used to be called the British West Indies, and so forth, people of color. And in my training, and this is 1981, this is pre-cultural competency, pre-diversity, you know, it's so interesting because when there was no word to describe it, so it almost didn't exist and nobody saw it. So there was complete blindness to the people we were treating, complete an utter blindness to their culture and complete misreading of many of the things that were presenting as pathology which were never understood. You know, there wasn't even a thought that they might be understood through a cultural lens, but I was everyday painfully aware of it because I was aware being aware of my own ovenus, which being invisible in my ovenus, I was excruciatingly aware of how these people, the immigrant communities and often children of immigrants and all the conflicts and issues to go along with that were being treated and even marked, I should say, by the clinical faculty and supervisors. And I found it terribly, terribly troubling and it's not a small part of the reason that I came to the United States. Where? When I started at the clinical psychology program at City in Harlem, and I'll never forget the first day walking into that class, and I think there were 18 of us, the majority of whom were people of color, African-Americans, Puerto Ricans, Latinos, etc. A small number of white people, many of whom were Jews. And we were taught by, in that first semester, Steve Elman, who many of you will be familiar with, taught us, "A void, a class, and said, "Okay, we're going to doven on Freud, bringing together a Jewish sensibility, my complete compelling fascination with psychoanalysis." All of those experiences allowed me to breathe in a way that I was never able to breathe, certainly in Birmingham, or perhaps in some degree in the UK altogether. So there's a much longer story there. I did, but there was a paper called "Step Across That Line," which was in psychoanalytic perspectives, where I talk a little about that experience. Robert, I'm again so easily tempted to not only be interested more of your clinical thinking, but more of your story, which you're graciously sharing. Time limits us, but I want to make sure to thank you. Thank you for many things. One of which is your book. Yes, the writing is lovely, and I think I, and we have given a sample of that to the listener. Your thoughts are really clinically profound, and I think are a challenge. I mean, if it's not a challenge, we're not doing it right. I mean, this is challenging work, and that's true whether we're dealing with patients who use metaphor and are struggling with the challenges of the repression barrier, or whether the challenges of working with people in unrepresented states, there are different kinds of challenges, but it's very challenging work. And you bring us as close to it as I think the written word can, because the essence of it, of course, is experiential, and we need our own experiences with ourselves in our analyses and with our analysis to really know what approaching these areas is like. But you've done as good a job as I think one can do, short of enacting it with somebody themselves. But I also want to thank you for the chance. We've had to know each other. It's been brief. We've met once before this, and I meant what I said, it was it just spontaneously emerged that you should read part of Bernard, and I should read part of Bernard, because there's a truth in our in our duet, and that funny, I didn't know you have brother of close age. So there you go. Robert, the name of the book again is the unobtrusive relational analyst explorations and psychoanalytic companioning. I really recommend it. It will make any reader think hard, and we'll come back as I did after days work and said, you know, I was listening to this patient, and it reminded me of something that Robert wrote about. And what better thing can you say about a piece of clinical literature? So with that, I want to thank you. It's been a real pleasure. Harvey, it's been a terrific pleasure. I can't thank you enough for the opportunity to have this conversation with you to share my thoughts and then also just likewise, just the pleasure. This has been really fun. Yeah, yeah, it is really fun. But thank you so much. Thank you for listening. If I may, I'd like to ask you to help us publicize our podcast by rating us on iTunes or simply sharing it with a friend. You can also visit our web page, ipaoffthecouch.org, we can both subscribe and also add your comments. I'd also like to acknowledge the lovely rendition of Beethoven's Opus 18th String Quartet by the Allegri String Quartet on the VIVAT label.