Exploring the Therapist’s Use of Self: Enactments, Improvisation and Affect in Psychodynamic Psychotherapy

Introduction

Enactments are a well-known, nearly universal factor present in psychoanalytically oriented psychotherapy (Jacobs, 1986, McLaughlin, 1991, Chused, 1991). While the therapeutically effective response to these complex events is at the forefront of current debate and exploration, I argue that the therapist’s use of self through playful improvisation is a critical and often necessary vehicle for change and growth in the patient.

Enactments can be confusing and may lead to stalemates in treatment that result in distress for both the patient and therapist. The ubiquity and tenacity of enactments are generally understood by contemporary psychodynamic theorists to arise from the power of the unconscious to recreate familiar (and thus secure) patterns of relationship (Mitchell, 1988) wherein the therapist unconsciously participates in a re-experiencing of the patient’s dysfunctional attachment patterns. While the therapist’s selfawareness and self-reflective process is sometimes sufficient to understand, manage, and utilize countertransference forces (see McLaughlin, 1991), unconscious enactments are often difficult to see, curtail, and use to therapeutic advantage.

Improvisation, a concept that is relatively new to the psychoanalytic psychotherapy literature, has been written about most persuasively by Ringstrom (2001, 2007). He summarizes its use and effectiveness in the following quote: “improvisational moments seek not to replace the rest of the work of analysis, such as empathic exploration, affect attunement … insightfulness … but in fact to enliven all of these. By humanizing the dyad’s engagement, improvisational moments facilitate the dyad’s connection amidst its necessary faltering when confusion, uncertainty, deadness, detachment, avoidance, or frightening combat must hold sway” (Ringstrom, 2007, p. 94). I will present a detailed case study supporting Ringstrom’s formulation that improvisation can be a critical and necessary complement to a careful analysis of transference in a psychoanalytically oriented psychotherapy. Furthermore, I will argue that improvisation is most effective when it emerges from a countertransference-transference enactment and is rooted in the therapist’s genuine struggle to reach and know the patient’s darkest struggles. Improvisation is a therapeutic mode of interacting that is effective because it represents a shift in the therapist’s mode of being, and as such, activates a parallel shift in the patient. Improvisation draws upon the importance of the patient’s experience of the analyst’s subjectivity (Aron, 1991), an aspect of psychoanalytic epistemology that increasingly is understood as critical to an effective treatment. In short, using intuition developed through a careful, empathic immersion into the patient’s worldview, the therapist takes the lead by responding to the patient’s rigid pattern of relating with an emotionally authentic improvisation. Embedded in the therapist’s response is an alternative way of managing the vulnerable affect(s) at the core of the patient’s development of a rigid and maladaptive pattern of relating. Essential to the analytic effectiveness of improvisation is that it aides the patient in gaining greater ownership of disowned or dissociated affect, a greater level of insight into transference projections, a shift in his or her personal narrative, and a liberating perspective on what is possible.

Therapeutic Action in Psychoanalytic Psychotherapy

Therapeutic action in classical psychoanalytic psychotherapy occurs primarily through understanding the meanings and origins of transference distortions. The therapeutic goal is to use these insights to expand the patient’s capacity for self-observation, including ownership of unconscious wishes, fears, and conflicts (Freud, 1912a). Contemporary psychoanalytic theorists are heavily influenced by object relations theorists (Fairbairn, 1954, Winnicott, 1965, Loewald 1960), intersubjective theorists (Aron, 1991, 1996; Stolorow, Atwood, & Brandchaft, 1994), and attachment theorists (Fonagy, Gergly, Jurist, and Target, 2002; Lyons-Ruth, 1999; Schore 1994, 2011; Stern 1985; Wallin, 2007), all of whom emphasize that psychoanalytic psychotherapy is a two-person process in which mutual influence, often on an unconscious level, inevitably shapes the course of treatment. Despite these advances, theories on the therapist’s effective use of the countertransference experience are still evolving.

The approaches for utilizing the therapist’s affective experience in treatment include projective identification (Ogden, 1979, 2004), mutual projective identification (Fishman,1996), improvisation (Ringstrom, 2001, 2007), humor (Coen, 2005), playfulness (Winnicott, 1971; Robbins, 1988), sharing a personal signature (Stern et al., 1998), modeling affect tolerance (Wallin, 2007), and direct communication of the therapist’s struggle with confusing, countertransference-based emotional states (Ehrenberg, 1996). All of these approaches implicitly draw upon Loewald’s (1960) assertion that the analyst must be a new object for the cure of the transference neurosis to take place. Consistent across all of these approaches is the idea that because psychoanalytic psychotherapy involves mutual influence, the therapist must actively step outside of the transference projections not only by providing insight from deep within a familiar enactment, but also by offering some communication of his or her own unique internal response to the patient’s maladaptive patterns of coping and relating.

The importance of using the psychoanalytic therapist’s affective engagement was first recognized by Freud, who, in his paper on technique (1912b), said that the analyst must tune his unconscious towards the patient and draw upon the data that he finds resonating from this source. The manner in which this unconsciously or intuitively gathered data is transmitted to the patient is the crux of this paper. My intention is to illustrate how the very fundamentals of psychoanalytic psychotherapy—empathic exploration, calm reflection, and measured interpretation—can be subsumed into a countertransference enactment that may feed into the patient’s rigid expectations of others (see Jacobs, 1986). That is, there are instances in which the more the therapist holds fast to a standard technique to guide the patient to better self-understanding, the more the therapist actually lives out the patient’s maladaptive transference expectations. In particular, holding fast to “technique” may unintentionally serve as a rationale for the therapist to hide from more vulnerable feelings and associations to the patient’s experience (see McGlaughlin, 1991). In contrast, responding to an enactment using improvisation can be a critical element that promotes a shift in the patient’s personality organization, moving the patient “into considering the heretofore unimagined, unthought and unspoken” (Ringstrom, 2007, p. 69). In the case I describe below, it was my willingness to be flexible and offer a genuine shift in my way of interacting, including a window into my subjective experience, that led to a degree of change and insight in my patient that had previously defied our joint efforts.

Case Illustration

Robert, a tall, lanky 23-year-old in his final year of college, walks tentatively into the office. He looks worn down and defeated, and when asked, “What brings you here?” he responds, “I feel like I’m not really living life” and goes on to say, “It’s like I’m just going through the motions and struggling to get by … I’ve felt this way for a long time.” He carries himself a bit hunched, as if in a permanent protective stance, a shape that also suggests he is trying to minimize his presence in the world. His speech is clear but slow and methodical, with little inflection and revealing little affect. He feels stuck in terms of what direction to take in his career; he is considering becoming a teacher or a creative writer but can’t decide which to pursue.

Robert describes himself as socially isolated: “I keep people at arm’s length; I really have no social skills.” He lives with roommates but detaches himself from them. He was a straight-A student in high school and has continued this in college, and prides himself on his academic success. However, early in the treatment he underscores that such success is a protective cocoon for him, a zone of security that shields him from feelings of intense failure in the social and relational realm.

Although he identified as heterosexual, Robert never had a romantic relationship. He describes himself as shy and socially withdrawn, and I learned that he fears being assertive or enthusiastic because others might not like what they see and reject him. I reflected back to him that “it’s safer to remain aloof than experience derision and abandonment.” He also fears he would exhaust others or they would see him as selfish, a “pest,” “crazy and irrational,” “weak and vulnerable,” and “draining” if he asserts his needs or shows his enthusiasm.

He was dyslexic, and he stuttered as a child, something that contributed to his social reticence because his peers frequently teased him for being a “moron.” While no longer a frequent occurrence, he still stutters on occasion and fears stuttering, especially in intimate relationships where emotions come into play.

As we explore his state of depression and apathy, he states, “I won’t let myself be happy, it scares me.” I suggest that he may actively snuff out flickers of happiness or hopefulness lest he experience unexpected loss or rejection. As I listen to his descriptions, I conjure up an image of his life as a flat line highway, punctuated only by dips into anxiety and depression, with any upward slope into joy quickly diverted back into featureless desert-like flats, or, worse yet, into chasms of darkness and isolation. When I share this image, he nods in defeated agreement.

Consistent with a developmental-psychoanalytic approach, I explore Robert’s recollections of his childhood. While growing up he was close to his mother. He adds that she was concerned about his “depression” and encouraged him to go into therapy when he was 14 years old and then again a year ago, which lead to his finding me. During his childhood he saw his mother as generally calm and attuned to his emotions and needs, but she also displayed occasional angry outbursts, mainly in response to her frustration with his “emotionless” father. He elaborated that his father was a very reserved person who did not show emotions, was generally pessimistic, and had a touch of paranoia about others.

In our second session Robert tells me of a seminal event, one that he experienced with such shock and intensity that his “whole world crumbled.” He was about six years old when his parents announced their intention to divorce. He described vividly how he was in his basement playing with the train set his father had given him and assembled with him several months prior. He was playing alone, feeling secure and happy when his mother called him upstairs for a family meeting. His parents explained to Robert and his 12-year-old brother that they were splitting up; they took pains to emphasize that it was not the children’s fault and that things would be okay. Robert sat and listened in shocked silence, trying to make sense of the chasm that he felt widening beneath him. Sometime after this event, perhaps days or maybe weeks, he recalled an unrelated incident. He was crying because he was upset about something, and his brother pulled him aside and admonished: “Don’t complain so much, mom and dad are going through too much already, you’ll just upset them more, especially mom!” Robert took that advice with utmost seriousness for years to come, carefully shielding his family and then others from any display of emotion.

Curative Factors in the Treatment

I will now take a step back and consider Robert’s presenting complaints—depression, social anxiety, isolation and lack of social skills—and focus on the curative factors that I believe were operative during the course of four years of weekly psychoanalytically oriented psychotherapy. There are six therapeutic techniques that I believe were critical to the process which led Robert to a greater sense of comfort and security with the spontaneous expression of emotions in both work and relationships. They are:

This final mode of engagement had power in part because it shifted the frame, contained a personal signature of the therapist (see Stern et al., 1998), and modeled the open expression of affect that Robert had long disavowed, including fear, anger, joy, and an appreciation of intimacy. I will attempt to demonstrate how all of these therapeutic factors were key to Robert’s improvement.

During the first three months of treatment, Robert arrived at a number of crucial insights though primarily using the first five modes of intervention. These included understanding that his social detachment was in large part rooted in his relationship with his parents and his brother, including the traumatic event of their divorce, which led to making himself “as small as possible … I try to make as few waves a possible,” including never asking professors for assistance and never asserting his needs in relationships. He desperately wanted to ask questions in class, but instead made himself “invisible” because he feared he would exhaust the teacher or annoy other students with his “selfish questions.” In addition, he feared that his professors would not want to waste their time on him, or if he did open up with a question, “they’ll chip away at my façade of knowing everything.” In this instance, I helped Robert to see the protective grandiosity of pseudo-omniscience he had constructed, which allowed him a measure of self-preservation but at great cost to his being known and seen.

This dynamic of shielding others from his feelings and needs for fear that he would overwhelm them with his intensity, or, at the other pole, isolating himself from intimacy for fear that others would overwhelm him with their endless needs—the classic “schizoid dynamic” (Guntrip, 1969)—was most evident in the transference when he asserted halfway into a session “you must be exhausted by me, trying to draw me out, trying to understand me.” I responded, “You feel I’m exhausted, can you say more?” To which he said, “Yes … I think you don’t really care about me, you’re just waiting to get through the session for your next patient.” I responded, “With me too, you feel that your needs are too much, much like you feared overwhelming your parents with your needs and feelings after they divorced.”

In fact, as we explored his compromise to attachment, he veered toward assertions such as “maybe I’m different than other people, maybe I really don’t need anyone … Yes, I think I’m self-sufficient and that’s just how I am.” Such assertions emerged with vitality in the transference when, in the session after I had been away on week’s vacation, he stated “I think I should come every other week. I’m just too busy and I don’t think it’s worth it to come weekly.” I pointed out how he was perhaps retreating from appearing to need me as a response to my being unavailable for a week, and how that perhaps his assertion of independence and sudden improved functioning was a cover for more vulnerable, but less acceptable, feelings of dependency. While he outwardly rejected my interpretation, he agreed to continue to meet weekly. By reframing his intentions to cut back and asserting my commitment to him and the treatment, I passed his unconscious “test” of whether or not I found him strange and draining and reassured him that I would not slowly abandon him (as he felt so many others had).

While at times it seemed his desire for security so dictated his actions that it blinded any awareness of his need for attachment, rudiments of his wish to connect were not difficult to point out. I nearly always did so with a caveat to the vulnerability that this desire entailed and how it made sense that he might feel the need to deny such strivings. About nine months into the treatment I drew upon a metaphor that kept nagging at me as I listened to him. I said, “it’s like you have a warehouse of thoughts and feelings, and when you venture out into the world you leave them all behind, with heavy steel doors keeping the contents concealed; you won’t show people what’s inside, because you’re afraid they won’t care and will ignore you, or if they do care they’ll soon find your needs overwhelming and give up on you.” He embraced this metaphor and expanded upon it, stating, “yes, you’re right, it is like that, but I think that if I actually open up the warehouse to someone, all they’ll see is an empty cavern.” In response to my gently pushing back to remind him of his emerging awareness of sequestered emotions and needs, he conceded “well, maybe it’s not completely empty, but I’m afraid that all I have to show is junk.” The shame that he experienced about exposing his needs, emotions and desires was palpable, and I often came back to reminding him of how shame overwhelmed him and caused him to retreat.

I felt we were on track as Robert shifted towards increased ownership of his conflicts and needs. He allowed himself to become immersed in and was willing to examine the transference relationship as a means of understanding his approach to himself and significant others. Supporting evidence for this trend came about 10 months into our weekly sessions when he relayed the following dream:

He had few associations to the dream but was curious to learn what I thought about it. My interpretation focused mainly on his ambivalence about exploring his emotions and past experiences (as represented by the dust and cobweb covered boxes filled with stuff from the past) and his ambivalence about getting close to me (the wire fences, being lost on his circuitous route to see me, feeling shut out waiting all alone staring at my door yet also not sure if he wanted to see me at all).

As the therapy developed over the next year of treatment, paternal transference themes were pervasive, particularly around his expression of anger and frustration with me for being “withholding” and emotionally unavailable to him. For example, in one session he said, with an undertone of longing and sadness: “I feel so alone … and I feel that you are withholding. I’m calling out, but you don’t respond. It’s like I’m in the middle of the ocean, and you’re a ship. You pass by me once a week, but you don’t offer me anything real…. It’s like you’re a wall, I’m calling out for help and feedback. Do I see the world correctly? Do others see me as I see myself? I get no answer.” In response I asked, “Is this a familiar feeling to you?” and he responded, “Yes … I’ve felt this way all my life.” We explored how at moments like this he experienced me as similar to his father; this exploration helped Robert uncover not only his longing for connection with his father but also his anger with him for being unable to reciprocate. Validating both his awareness of his need for connection and his courage to reach out, I emphasized how he was doing something different this time by actually calling out to me, revealing his need for closeness instead of locking himself in a voiceless prison.

Over the course of the next several months of treatment I helped Robert take ownership of his long-denied need for intimacy and feelings of grief related to many years of living in isolation. Across a series of sessions, he stated that he could more clearly see how he continually avoided social interactions and he revealed that he developed this, in part, during childhood as a way to fend off the cruelty of kids mocking his stuttering. I reflected and added the following, “you closed yourself off at the expense of never revealing your social nature, your spontaneity, your humor.” As I said this, a flood of tears, something that was rare for him to share with me, rolled down his face, and he said, “It sucks to have to hold back and hide myself … but I have to do it, or I think I do, ’cause I don’t want to be rejected.” In the next session we quickly and seamlessly returned to these painful, long-buried feelings, and he continued: “When I look deep inside, I despise what I see—a stupid, confused, scared little kid” and he recalled being relentlessly ridiculed as “stupid” when he stuttered as a child. I asked, “What would you say now if you met a child like that, one who was scared, stuttered, and felt confused and stupid?” He sat silently, reflecting upon my question, clearly conjuring up that little child he once was, and then a flood of tears cascaded down his face “I’d tell him to be mute … it’s not worth the pain (of reaching out)… I don’t, uh, he doesn’t have the resilience.” As I sat with his feelings of grief, shame and fear, which clearly registered on my face as tears gathered in my eyes, he momentarily shifted, and said, in a defiant tone, “Maybe I would say ‘it’s okay, I am human and I stutter, so what?’” But then he quickly retreated, saying, “I’ve hit a brick wall. It’s beyond my ability. I don’t think I can accept that scared, confused, stupid little kid. It’s like me trying to run a 4-minute mile. Some people can, but for me it’s literally impossible.” At this point I reminded him of a metaphor I had introduced several months before, about learning to swim after sitting for years on the side of the pool. Embracing the metaphor he asked, “Will you be there for me when I jump in the water, will you show me the way?” As the session came to a close he said “I want the swagger of self-confidence that you have.” I responded by noting that he, unlike the little boy, was not afraid to ask for help, and, therefore, had some of what he wished for. He agreed, but then added, “Yeah, I did, but it’s different because it’s safe here”.

While Robert had clearly made significant strides in his life, including developing his first romantic relationship, he continued to experience deep conflict about intimacy and emotional exchange. After about six months of enjoyment with his romantic partner, he started to feel suffocated in the relationship, and described feeling “like a fly in the wind” of her emotions and needs. He started to pull away from her and broke off the relationship. Similarly, the tone of the therapeutic relationship was increasingly marked by Robert’s frustration with me for not being more emotionally responsive and not offering him any “practical skills” or “homework.” He noted that he was still, after two years of treatment, experiencing great difficulty reaching out to peers and potential mentors. He insisted that knowing why he was afraid to reach out was insufficient to motivate him to act differently, and he asked for guidance and tools to navigate these interactions. In response, I began to feel confused by his persistent frustration with and wish for more from me.

While it took some time and a different approach (improvisation) for me to fully grasp the nature of the dynamic that was unfolding, in retrospect I believe that this was a mutually constructed enactment—My conscious attempt to be therapeutic by remaining calm, thoughtful and optimistic in response to Robert’s anger and requests only served to reinforce his expectation that people are emotionally unavailable. For his part, Robert was consciously asking for help but unconsciously feared showing me the emotional intensity of his need (by focusing instead on his need for practical skills). We were increasingly locked in a dynamic which perpetuated Robert’s perception that I was just like his emotionally aloof and dismissive father, and where I perceived his fear of intimacy as the major barrier to his seeing me as different.

It was about three months later, or two and one half years into the treatment, when I began to have a better handle on the nature of the enactment that we had unconsciously created together. In one session Robert proudly shared a success at work and, when I responded with what he characterized as a rather flat response, he let me know that he was annoyed at my lack of emotional display, even calling me “fake” and “withholding”. Crucial to this interaction was the fact that I was puzzled by his perception of me as fake and withholding because I didn’t see myself that way. In fact, I experienced him as predominately this way. As if providing support for my perception, in the very next session he came in talking about his goals for therapy: “to feel confident, to have energy, to have friends.” When I noted that he stated these goals with very little energy or emotion in his voice (here again, focused on the goal for him to be more emotionally alive), he agreed, saying “I have no inflexion or enthusiasm in my voice.” We then explored the shame that he felt about needing therapy, and he stated, “I don’t like that I need someone to help me go through my boxes every week.” I noted the paradox of his situation—the shame of needing someone kept him from being emotionally alive, yet only through being in relationship (with me or others) could he feel alive and reach his goals. He agreed, but stated that he was too afraid to need someone and impose his emotions on others, in large part because he feared being seen as stupid and would then be rejected.

At this point, Robert unwittingly provided me with an opportunity to respond to the growing enactment when he told me of a failed attempt to connect in conversation with a male coworker whose pregnant wife was about to give birth. He explained that the conversation fell flat and he ended up walking away as he did not know what to say to keep things going. He then made a crucial request: “Will you role play with me? I think if we did it might help me to develop the social skills I’m lacking.”

Here I might have engaged him in a discussion of how his failure to connect with his coworker was related to his continued frustration to feel connected to me on a deeper level; however, I did not see this path at the time. Instead, I followed my intuition and diverged from my typical path of exploring his internal and our relational dynamics. My growing awareness of his inability to engage with others with emotion and enthusiasm, combined with my puzzling over how and why he was frustrated with me for being “flat and withholding” and not giving him “tools” for social interaction, led me to join him in what I hoped would be a playful exploration of his challenge with emotionally connected interchanges.

In the role play, he asked that I play his coworker while Robert played himself. He approached me as he would his coworker, and, not surprisingly, our conversation lacked affect and direction, falling flat and ending in much the same fashion as he described occurred in real life. Our role play mirrored his real-world experience, with the result that he felt isolated, emotionless (recall his presenting complaint—“I feel like I’m not really living life … it’s like I’m just going through the motions and struggling to get by.”) Interestingly, I felt that I too had become a two-dimensional being, lacking the depth of emotion that I usually feel in conversations with others.

Curious to understand his experience of the role-play, I asked him to reflect on what was going on inside his mind at the time. He replied, “I totally spaced out … I lost interest and focused on other things.” He added, “I felt like I was useless to you, so I stopped paying attention.” It occurred to me that this feeling might represent an intensification of the transference dynamic where he felt that I did not care about him, that I was a father who has more important things to do and who feels worn out by Robert. But instead of responding on this level I felt a draw to play this out in the transitional space of the play (see Winnicott, 1971). I said, “Yes, I sensed that you were ‘spacing out,’ and it felt to me that you did so because you were afraid to make yourself vulnerable to your emotions … doing so would mean you needed something from me, that you were connected to and needed me. Perhaps that idea scared you, so you shut down and spaced out.” He agreed. Then I said, “Okay, let’s try it again, but this time I want you to focus on the emotional thread of the conversation, follow the feeling tone of the interchange. I think that may make a difference and help you stay connected.” He agreed and we gave it a try.

When Robert opened the discussion during our second role play I shifted by intentionally letting my guard down. This shift was crucial and was the basis of what I believe constitutes an improvisational moment. I shifted out of my usual therapeutic stance and entered into the “transitional space” (Winnicott, 1971); I became the subject, in a sense metabolizing Robert’s projected affects (fear and excitement) by “play acting” emotional vulnerability. I drew upon my own emotionally vivid experience of the mix of excitement and fear that I had anticipating becoming a father for the first time (which had occurred some 10 years earlier). In response to his question about how I (as his coworker) was feeling about the fact that I was soon going to be a father, I said, “Well, you know it’s pretty amazing, it’s something I’ve imagined for a long time, and I feel mixed, I mean the thought of holding a baby in my arms is just amazing (smiling widely, pausing while I recreated the image in my mind’s eye) … I can imagine my baby responding, smiling at me … I can almost feel them in my arms.” He responded, also smiling, “yeah, wow, that sounds really cool.” I continued “but at the same time I wonder am I holding them right, I’m kind of scared, wondering if I’ll get it right? … It’s such a huge responsibility … so yeah, really both of those feelings.” This time Robert was much more animated, a smile slowly washed across his face, he fluently engaged and we carried a back-and-forth conversation along these lines for several minutes, including, at one point, his empathic statement “that must feel really good,” smiling in response to my sharing my excitement about becoming a father. The transformation in his presentation, including the flow, emotional tone and engaged eye contact of the conversation, was striking.

In processing the role play Robert stated that it worked out much, much better. When I asked him what he did differently, he said, surprisingly, “I was thinking about experiences I had as a child with my parents, times that I enjoyed, and I thought of the qualities in them that I liked. That helped me connect on an emotional level.” He also noted that I was different in the role play, more emotive, and that made a crucial difference in his ability to attend and stay engaged in the conversation. Over the remainder of the session we explored some of the “new,” positively toned memories of his parents that emerged during the role play. Perhaps more importantly, he began to articulate his experience of me as more emotionally animated and how this affected him.

In the following session Robert said he was so affected by the role play session that he experienced an “epiphany” during the week:

He went on to elaborate how he was intent on taking the risk to lead with his emotions in relationships. He had already started using the insight and motivation gained from our work, and to illustrate he said, “You know the coworker who you role-played? Well he plays in a band and I saw him play a few nights ago. And usually I wouldn’t say anything to him, but this time I went up to him and said, ‘you know, you were phenomenal,’ and he was really pleased. I felt really good telling him that, and I could tell he appreciated it.” The shift in the transference-countertransference pattern, sparked by my introducing improvisation into the relationship, clearly catalyzed in him a new self-experience, generated new insight, and infused him with a newfound investment in embracing his impact on others, intentionally “making waves” and relishing the results.

Improvisation as Antidote to Enactment

During the next year and a half of treatment, Robert began to enjoy life and take pleasure without needing to constrict himself; his need for emotional expression and attachment was no longer paralyzed by fear of abandonment or engulfment. He was able to assert and express himself more freely with supervisors and coworkers, seeking out support and guidance. He described feeling more comfortable and acting more spontaneous at work, even joking at times. He applied and was accepted into graduate school for a master’s program in early education. The discussion of the intimate relationship with the woman whom he loved but left (because he felt her needs were suffocating him) slowly re-emerged, with Robert expressing a deep longing for her, crying openly at his loss.

An indicator of the transformative power that the role play had in shifting Robert’s rigid transference expectations, and how it helped to build his capacity to bear deep and vulnerable feelings, occurred in a session 18 months after the “role play” session. He told me that after nearly a year of no contact with his former girlfriend he telephoned her because he was feeling ambivalent about the breakup and was considering recommitting to her. He asked me, “Should we go deeper, should I confide in her?” I responded “if you decide to, you risk commitment.” Suddenly he said, “I want to role play.” I said, “Okay.” Instead of asking me to play the girlfriend, Robert slipped seamlessly into a “dialogue” in which he imagined her, “speaking” to her, looking towards an empty chair (reminiscent of the Gestalt technique, but initiated by himself). He said, “I’m scared out of my mind, I’ve got so much work, it’s my first week of graduate school (he was projecting several months into the future, anticipating how he would feel in his first few weeks there) and I feel I’m in over my head.” As he spoke fluidly to “her,” tears streamed down his face; it seemed as if he was drawing upon his internalized image of her both to allow himself to anticipate the challenges of graduate school and to soothe and comfort himself. I was struck by his capacity to hold these emotions, imagine a discourse, and anticipate a need in the future, so I asked, “How did you evoke those feelings and imagine her all on your own?” He responded, “I just had a feeling about her, like I know that she’s there, it’s a feeling of safety, like I know you are there, every Thursday … I know this is a safe place for me to talk about my feelings.”

End of Treatment

Four months later treatment ended, precipitated by Robert’s move out of state to start graduate school. About six weeks before we ended, I actively pursued Robert’s thoughts and feelings about our ending. He gave a positive but rather superficial accounting of the meaning of our work together (he focused on my practical advice around applying to graduate school). I sensed he was holding something back and he acknowledged that his old habit of not daring to risk leading with his emotions for fear of overwhelming or losing me, was again rearing its head. He then ventured slightly deeper into this territory by asking me “what do you think I have gained in therapy?” I answered with a brief summary “I’ve seen you become more comfortable expressing your emotions, opening yourself up to others in intimate relationships, overcoming your paralysis around reaching out to mentors, and discerning and pursuing your professional direction.” He nodded in agreement but still had little to add. Sensing his difficulty taking the step to articulate his emotions, and knowing that over the course of the treatment he had by and large overcome his conflict around intimacy, I determined that he must be responding to the stress of the termination by reverting to old and safe habits. When I suggested this he agreed, which led to his admission that lately he had some dreams but had actively tried to forget them because dreams made him feel out of control and scared him. He added that he was also having difficulty sharing his emotions because he was carefully choosing his words to avoid stuttering, a tactic incompatible with the free-flowing nature of deeper emotional communication.

Because Robert was not only aware of his conflict over feeling out of control and being pulled into his unconscious world of dreams and emotions, but also struggling to find speech compatible with free flowing emotion, I suggested a guided visualization as a way to move beyond his difficulty. I came up with this idea in part because I had recently attended my high school reunion where I participated in a guided visualization led by a mentor of mine, and I recognized parallels between Robert’s situation and how I sometimes was unable to find words to describe the whirl of emotions I felt. I decided that a similar, visual and body-based exercise might help Robert access his more vulnerable feelings about the meaning of the therapy and our relationship. I shrugged off his question “why try this now?” with a response, “well, given what you’ve just told me I think it might be useful.” He consented.

I stated, “Close your eyes and recall the first day you came into my office, what you were feeling, what you said, what you hoped for . . .” I paused for a minute, and then proceeded, “Now, think about your experience of what this therapy has meant to you as a whole … take your time to see what emerges, what feelings you have, what images come to mind….” After several minutes he opened his eyes and I asked him what emerged. To the first question he said he recalled clearly the first day he walked into the office, how dead he felt inside, how afraid he was to let go, yet how he felt hopeful that he would learn to feel alive. To the latter question he responded thus:

Clearly this technique, derived from my own experience and growing from my resonance with his struggle to articulate the feelings he had about the meaning of our work together, was effective in scaffolding Robert’s capacity to give voice to his experience of the therapy.

In our final session, Robert looked back on the changes he had made:

“I can’t imagine being so silent and paralyzed like I used to be at work … I feel looser, I even joke with my co-workers now. They’ve noticed a change, too—one of them smiled at me the other day and said, ‘what happened to the shy kid?’”

As Robert walked out the door one final time he turned and looked at me and said, “thanks for everything, thanks for putting up with me” and I responded, “it was my pleasure.”

Postscript

How can we further understand the shifts that took place as a result of the improvisation via the role play? It is instructive to look at Robert’s retrospective response to this question, which came via an e-mail about a year after the treatment ended. The e-mail interchange was stimulated by an ongoing discussion Robert and I had about the therapeutic impact of the role play during the final two years of treatment. Towards the end of the treatment I asked Robert if I could use elements of the therapy to present some ideas on “outside-the-box” shifts in technique to my colleagues in the form of a presentation or paper. He eagerly gave his consent, and then about one year after the treatment ended I e-mailed him and asked him to respond to a number of questions about the treatment, including what was helpful, what was less helpful, and what specifically he felt had been valuable from the role play (which by then had occurred about three years prior). Here are excerpts from his e-mail response regarding the role play:

In terms of curative factors, Robert clearly stated that experiencing me share spontaneous emotions, and his sense that he was catching a glimpse of how I interacted with friends in everyday life, was a critical element. Robert’s experience of my subjectivity (Aron, 1991; Slavin, 1998), combined with my breaking out of the enactment within which he had experienced me as lacking a connection with him, served as a catalyst for him to shift his style of emotional expression. Furthermore, this shift in his experience led to a new insight (“I could only truly express my emotions if you did so first. . .”), one that I believe he could only truly grasp from the perspective of the shift in relationship with me and with himself. It also seems clear that the timing of this brief movement into improvisation was crucial. In fact, had I attempted something like this earlier in the therapy it might have conveyed the implicit message that showing fear and joy is easy and he should just “let it happen.” However, because I had worked for over two and one-half years to help Robert understand his transference distortions, he sensed that I understood the depth of his fears around being spontaneous. By briefly shifting out of the transference projection of a constricted and emotionally absent father, I provided Robert with an opening for his internalized object representations to shift. I offered an emotionally attuned model that allowed him to recall positive qualities in his parents, like finding jewels in an empty junkyard of his early attachments. From this “re-visioning” and retelling of his past sprung an experience of joy, security, and contentment. This crucial shift was akin to his beginning a new narrative of his past, one that mirrored and validated pleasure and joy. It also led Robert to feel anger and a commitment to discard habitual and constricting ways of relating to others.

I believe that another curative factor was rooted in my trust of my unconscious resonance with Robert, or what Schore calls “affectively driven clinical intuition” (2011, p. 75). That is, having deeply struggled to understand Robert’s dilemma around dependency and emotional expression, I was able to use the role play as a vehicle to better understand Robert’s early experience in relation to his withholding father (see Ehrenberg, 2003). In the first role play I experienced Robert as emotionally dead and uninterested, and he experienced me the same way. Over many years of seeking security by constricting his expression of emotion, and dismissing the need for significant attachments, Robert had unwittingly become just like his withholding, emotionally flat and seemingly uninterested father. My experience of Robert informed my intuitive sense that both he and his father needed the courage to be vulnerable in order to make a real connection, something that had consistently eluded him. By using his request to role play as an opportunity to creatively show the courage to share my fear, excitement, and joy, I gave Robert the support he needed to experience a complimentary release of joy, interest and engagement, or as he put it, “I was able to internally experience these emotions as well.”

Summary: Mutual Influence and the New Object Experience

While enactments are generally accepted as an inevitable part of a psychoanalytic psychotherapy, how to make use of them is the subject of ongoing discussion. Using a case study as an example, I described the therapist’s use of emotionally authentic improvisation as a vehicle to help thaw long-frozen patterns of interaction expected and enacted by the patient within the psychotherapy relationship. After struggling for months to understand my patient’s puzzling and entrenched pattern within and outside the therapeutic relationship, I responded with an intuitively based improvisation, a form of self-expression that defied my patient’s expectations. This active move allowed Robert to find, within the transference, a scaffold for his own spontaneity and, consequently, a reconstructed theory of possibility in relationships. Furthermore, this mutually constructed interactive moment brought new insight and shifted Robert’s internal narrative in a way that uncovered previously warded off memories of positive, supportive and fulfilling interactions with his parents early in his life.

Loewald (1960) essentially said that change in psychoanalytic therapy can only take place if the patient experiences the analyst as a “new object.” Recognizing that mutual influence on an unconscious level is inevitable in psychoanalytic psychotherapy, the nature of that new object experience must in large part be constructed together through the process of the therapist’s genuine struggle to both know and expand the patient’s internal world. This advancement in Loewald’s insight is clearly stated by Stern (2010), who asserts that enactments involve mutual dissociation and are the therapist’s primary route of access to the patient’s dissociated emotional pain. He states: “therapeutic action lies in [the therapist] becoming a different person, usually in a small way, in the here and now” (2010, p. 124). In the clinical example provided, Robert’s internal world was filled with fear, shame, loss, a dedication to isolation as security and a barely breathing hope for spontaneous life and acceptance by others. Robert needed to experience me both as the same as and different from his internalized objects, especially his internalization of his father. I learned about and elaborated upon the intricacies of Robert’s inner life, including his strongly constructed protective maneuvers, and at the same time owned the transference by “becoming” his father. Using my dual position as both a participant and agent of change, I set the stage for Robert to break out of his transference expectations. I demonstrated a capacity to tolerate affect and show interest in him in a manner that he could only dream of in the midst of an unconscious enactment. He experienced me as a “new object” in at least three ways: as his father showing the courage to share vulnerable feelings with his son (“corrective emotional experience” (Alexander and French, 1946)); as Robert, taking slow but sure steps to own and announce feelings of joy and fear (“twinship transference,” Kohut, 1971); and finally, as myself, taking a risk as a therapist, forging new ground with my patient, showing him that I genuinely cared and was willing and even eager to be moved by him. The result of this experience of me as a new object was a shift not only in our relationship but in Robert’s view of himself and in his capacity to take new risks towards his development as a more whole human being.

Improvisation, a technique designed to help move a therapy dyad beyond a confusing enactment, is a variation on a theme advanced by Winnicott (1971). He asserted that a fundamental goal of psychotherapy is to assist the patient in harnessing the capacity to play and be spontaneous, and drawing upon his belief that therapeutic action is primarily rooted in the quality of the dyadic relationship, added “if the therapist cannot play, then he is not suitable for the work” (1971, p. 72). In a similar vein, the narrative-constructivist therapist Michael White, drawing upon the work of Leo Vygotsky (1934), said that we must recognize that our task as therapists “is to scaffold the proximal zone of development in ways that support an incremental and progressive distancing from the known and familiar to what is possible to know” (White and Miller, 2006, p53). Inevitably, this process of providing a scaffold for something new draws upon the therapist’s empathic attunement to the patient; the therapist must simultaneously tune into the patient’s experience yet also search within him or herself for emotions elicited by the patient’s specific and nuanced manner of relating. The key then is to demonstrate a capacity to flexibly and spontaneously manage the emotions and conflicts which the patient has brought forth into the therapeutic arena. I suggest that part of the therapeutic effect of psychoanalytic psychotherapy occurs when the therapist judiciously provides brief windows into his or her own struggle with the patient’s projected affect(s) and conflicts; doing so within the context of a mutual enactment opens up a new field of affective interaction that ultimately can lead the patient to a greater integration of disavowed or dissociated affects and, consequently, greater insight and capacity for growth.