Engaging, and Accompanying, the Pain of Others

Psychoanalysts increasingly find themselves working with patients and states that are not amenable to verbal and dialogic engagement. Such patients are challenging for a psychoanalytic approach that assumes that the patient relates in the verbal realm and is capable of reflective functioning. Both the classical stance of neutrality and abstinence and a contemporary relational approach that works with mutuality and intersubjectivity, can often ask too much of patients.

Robert Grossmark’s The Unobtrusive Relational Analyst introduces a new psychoanalytic register for working with such patients and states, involving a present and engaged analyst who is unobtrusive to the unfolding of the patient’s inner world and the flow of mutual enactments. For the unobtrusive relational analyst, the world and idiom of the patient becomes the defining signature of the clinical interaction and process. Rather than seeking to bring patients into greater dialogic relatedness, the analyst companions the patient in the flow of enactive engagement and into the damaged and constrained landscapes of their inner worlds. Being known and companioned in these areas of deep pain, shame and fragmentation is the foundation on which psychoanalytic transformation and healing rests.

Read an excerpt from the introduction to Robert Grossmark’s new book, The Unobtrusive Relational Analyst: Explorations in Psychoanalytic Companioning, below. 

States of consciousness that do not take the form of verbal and cognizable mental contents have always presented a challenge for psychoanalytic treatment and for mental health treatment in general. Freud’s great opus primarily addressed the repressed unconscious that lent itself to psychodynamic formulations, oedipal conflict, and the treatment of the neuroses. But as his delineation of the unrepressed unconscious suggests (Freud, 1923),[1] there are many more levels and dimensions to conscious and non-conscious life and experience. Many of these dimensions do not take the form of organized thoughts or cognitions and are not bound by the structures afforded by verbal language. Such areas typically become known via sensation, diffuse bodily experience, action and motility, dreams and hallucinatory phenomena, overwhelming anxiety states, and via what we now term enactment.

Psychoanalytic treatment has tended to struggle with these areas of the human and has generally tilted to creating form where there was diffusion, language where there was merely sound, thoughts where there was raw sensation, and consciousness where there was the unconscious. Often, psychoanalytic treatment eschewed patients who did not rely primarily on language and consequently could not engage with both the structure and the spirit of the psychoanalytic endeavor, seeing them as too narcissistic, disorganized, or primitive. Action, motility, and pure sensation tended to be classed as acting out, resistances, or assaults on the treatment.

In recent years, there has been a resurgence of interest in mental states and processes that lie outside of the organized and cognized dynamic unconscious. From the relational/interpersonal psychoanalytic world, Donnel Stern’s (1997, 2010, 2015) ground-breaking work on unformulated experience exercises a large influence here, as does Christopher Bollas’s (1987) conception of the unthought known, the work of Levine et al. (2013) on unrepresented states, Andre Green’s (1999) work on the negative, Sheldon Bach’s (1985, 2006, 2016) embrace of altered states of consciousness and existence, and many more.

The relational turn ushered in a new era of psychoanalysis. We now comfortably regard psychoanalytic process as a mutual and egalitarian endeavor. While this mutuality is not symmetrical (Aron, 1996), the contemporary relational psychoanalyst now uses expressions of his or her own subjectivity with a freedom and creativity and is not silenced by the arbitrary constraints of “abstinence” and “neutrality.” No longer regarded as situated on a perch outside of the interaction (D. B. Stern, 1997) with a “view from nowhere” (Nagel, 1986), the contemporary analyst gains insight and fosters the analytic process from a position that allows him or her to be “seen, moved, disrupted and reconfigured” within the treatment process (Wright, 2015). Moving beyond the view of the human mind as both unitary and sealed, current psychoanalytic process is viewed as hinging on the interaction of the subjectivities of both psychoanalyst and analysand and as embedded in complex social and historical contexts. In addition to the classical psychoanalytic focus on transference and its resolution as the fulcrum of the psychoanalytic cure, the relational turn privileged the centrality of enactments that involve both analyst and analysand, and the progress of many relational treatments often hinges on the emergence and resolution of these enactments. Overall, Relational theory seems to have picked up a climate change in contemporary psychoanalytic and psychotherapy culture that yearns for more human and egalitarian relatedness between patients and analysts, and a view that sees such relatedness as integral to psychoanalytic cure rather than as a contamination of a scientific process.

While all these transformations have enabled so many of us to breathe more easily as psychoanalysts and work with creativity and engagement, 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, interpretations about inner conflict or consideration of the dynamics in the treatment interaction with the analyst are potentially voices from another world. They may comply and utilize their verbal, related selves, but their inner core will remain at best untouched and at worst shamed into disavowal and inner sequestration. There are also patients who may appear to be more developed and may present with, and be able to engage in, what can appear to be intersubjective vitality. However, many patients who present in this way also harbor self-states that contain earlier undeveloped, empty, unspeakable, and profoundly non-related parts of themselves that can find no expression in language. These areas of the self are much less likely to be reached by dialogic engagement and are often chased underground or shamed by a psychoanalytic treatment that puts a premium on relatedness, thought, and verbal exploration.

This volume engages with these patients and states. The spirit of this volume is the endeavor to be unobtrusive to the incarnation of other states of consciousness and psychological organization as they emerge in the treatment. These are arisings of the non-represented, non-symbolized, and unformulated that announce their presence in alternate registers — motoric, sensory, hallucinatory, oneiric, reverie, and above all, action. Rather than orienting our analytic work to moving the patient out of these regressed areas into greater relatedness, we welcome these other dimensions and their full expression within the analytic sphere in mutual regression and mutual enactment. We orient ourselves to going further in to these emerging worlds of confusion, trauma, and pain rather than seeking to peremptorily draw the patient out of these areas. Such regressions and emergences in the analytic field are understood as silent screams from within the patient, who is crying out to be joined with and known in these inner worlds of torment and suffering, rather than pulled out of them and thus potentially shamed and abandoned. The treatment belongs to the patient, and it is the analyst’s work to find and join with the register and wavelength that is the truest expression of the patient’s inner world and experience. From this perspective, enactments are regarded as transpersonal narrations of what is beyond language and symbolization. They emerge as inscriptions on the field of the treatment and involve both participants (or all participants in group analysis) and often defy neat and organized verbal understanding and description. Hence psychoanalytic healing and psychological growth and differentiation take hold when the psychoanalyst can unobtrusively companion the patient into areas of non-developed, non-related, and non-represented inner life in the register that is organic to the patient at that time. In so doing, the unrepresented and unformulated take spontaneous form and are embellished in enactment between the analytic partners and in the field.

From this point of view, our understanding of our patients and clinical process takes into account both the ongoing and ineluctable intersubjective nature of the subject and honors and welcomes the private and secluded areas of the patient’s conscious and unconscious inner worlds. This embraces the paradoxes at the center of Winnicott’s (1958) rendition of the human condition: We are all embedded in our environments and we are all essentially isolates; the capacity to be alone is central to our ability to connect to others with vitality and authenticity.

In this book, I spell out a psychoanalytic register that seeks to work with these patients and states in their own idiom and form. In so doing, I have sought to square the circle of allowing — and welcoming — the patient to be free to manifest all the dimensions of their being — however diffuse and confused — unencumbered by the requirements of relatedness and for the analyst to be real and present while tilting their subjectivity to be receptive to the developmental and present needs of the patient. This is the work of the unobtrusive relational analyst.

This excerpt from the introduction to The Unobtrusive Relational Analyst: Explorations in Psychoanalytic Companioning is published with gratitude to, and permission from, Taylor & Francis Group. It is available for purchase on the Routledge website here, and on Amazon here.

Robert Grossmark is a psychoanalyst working with individuals, couples and groups in New York City. He is Adjunct Clinical Professor and Consultant at The New York University Postdoctoral Program in Psychoanalysis and Psychotherapy. He teaches at The National Institute for the Psychotherapies, the Clinical Psychology Doctoral Program at The City College of New York, and the Eastern Group Psychotherapy Society. His publications include The One And The Many: Relational Approaches to Group Psychotherapy and The Unobtrusive Relational Analyst: Explorations in Psychoanalytic Companioning.