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Empathy in Psychoanalytic Theory andPracticeDonald Grant

a& Edwin Harari

b

a

Psychiatrist and Psychoanalyst in Private Practice in Melbourne ,AustraliabSt. Vincents Hospital Area Mental Health Service , Fitzroy,

Australia

Published online: 19 Jan 2011.

To cite this article:Donald Grant & Edwin Harari (2011) Empathy in Psychoanalytic Theory and

Practice, Psychoanalytic Inquiry: A Topical Journal for Mental Health Professionals, 31:1, 3-16, DOI:

10.1080/07351690.2010.512844

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Empathy in Psychoanalytic Theory and Practice

Donald Grant and Edwin Harari

With the exception of Self Psychology, empathy has not been a major theoretical concept in psycho-

analysis. Freuds (1921) definition of empathy implies it is a necessary condition for an analytic pro-

cess to develop (p. 110, n. 2). Most psychoanalytic theories have side-stepped this issue by includingempathy under various assumed names. We have discussed some of these in the theories of a number

of psychoanalysts within the BritishPsychoanalytical Society. We have illustrated some of these theo-

retical issues with a clinical example.

This discussion also raises the more general question of the nature of psychoanalytic theories. We

argue that no psychoanalytic theory is the exclusive repository ofthetruth, enabling it to dismiss

others as errors. We all need to remind ourselves of Freuds (1900) understanding of theory as use-

ful conceptual scaffolding to help us look for the truth, but the scaffolding is not the truth itself

(p. 536).

EMPATHY IN PSYCHOANALYTIC THEORIES

In TheInterpretation of Dreams, Freud (1900) points out that our theories are nothing more than

ways of conceptualizing what we observe and experience in the clinical encounter with our pa-

tients. He describes theories as the scaffolding we use to examine the thing that interests us, but

they are not the thing itself. If ongoing clinical observations conflict with our theories, then he

says, We must always be prepared to drop our conceptual scaffolding if we feel that we are in a

position to replace it by something that approximates more closely to the unknown reality

(Freud, 1900, p. 610). Unfortunately, psychoanalysts have not always operated within this view of

theory, and psychoanalytic theory wars raged for most of the twentieth century until RobertWallerstein (1988), during his presidency of the International Psychoanalytic Association, called

for a truce and more mutual respect between psychoanalysts with different theoretical views. This

created a situation of which psychoanalysts do not take full advantage. Ideally, we should now be

able to think about a clinical observation in the conceptual frameworks of a number of different

psychoanalytic theories and feel free to use the one that seems to offer the best understanding or

conceptual scaffolding for the clinical material with which we are working at the time. But we

need to remain mindful that whatever theoretical concepts we are using are not observed facts, but

just useful scaffolding to support our thinking. Paradoxically, such a demotion of theory requires

Psychoanalytic Inquiry, 31:316, 2011

Copyright Melvin Bornstein, Joseph Lichtenberg, Donald Silver

ISSN: 0735-1690 print/1940-9133 online

DOI: 10.1080/07351690.2010.512844

Donald Grant is a Psychiatrist and Psychoanalyst in Private Practice in Melbourne, Australia. Edwin Harari is a Con-

sultant Psychiatrist with St. Vincents Hospital Area Mental Health Service, Fitzroy, Australia.


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an even broader and deeper knowledge of more psychoanalytic theories in order to understand

their limitations, as well as their usefulness in work with individual patients.

A central claim by psychoanalysts is to be able to understand blocks and resistances to psycho-logical development in their patients and to facilitate the process of overcoming those blocks and

resistances. Different psychoanalytic theoreticians have conceptualized their facilitating role in

different ways, e.g., interpreting associations to dream images (Freud, 1900), interpreting trans-

ference states in the patient (Freud, 1912a), attention to countertransference feelings (Heiman,

1950), reverie (Bion, 1962), a state in the analyst comparable to primary maternal preoccupation

(Winnicott, 1956), and empathic attunement (Kohut, 1959) to name a few. These processes could

all be thought of as ways in which states of mind that act as unconscious blocks to psychic devel-

opment in the patient, can be recognized by the analyst. As such, they all fall within Freuds

(1921) definition of empathy, which is that empathy is the mechanism by means of which we are

enabled to take up any attitude at all towards another mental life (p. 110). It is surprising, giventhat the central task in psychoanalysis is to understand something about the mental life of another,

that this definition is to be found in a footnote, and that this is Freuds longest statement on the sub-

ject. Most other prominent psychoanalytic theorists also remain silent on the subject of empathy,

although their theoretical writings, particularly analysts of the British school (e.g., Klein,

Winnicott, Heiman, Bion), frequently circle around it without actually naming it. It remained for

Kohut (1959) to provide empathy with a central place in psychoanalytic theory.

Each of the theoretical concepts mentioned earlier offers an explanation for the central process

of psychoanalysis in which something that is unconscious in the mind of the patient is communi-

cated to, and becomes conscious in, the mind of the analyst. This process falls within Freuds defi-

nition of empathy. Importantly, they all provide empathy with an unconscious dimension, in that

the state of mind the patient is communicating to the analyst becomes conscious in the analystsmind while sometimes remaining unconscious in the patients mind. The analysts task then is to

reflect upon his or her emerging consciousness about the patient and when appropriate to commu-

nicate what he has understood to the patient. Empathy, then, remains a cornerstone of psychoana-

lytic observation, regardless of which theoretical scaffolding the analyst uses to think about what

is being unconsciously communicated by the patient. If this view is accepted, it becomes ex-

tremely curious that the wordempathyis rarely encountered in the writing of psychoanalysts be-

fore Kohut, who made it the central issue in his theory of the development of the Self. Psychoana-

lysts of all persuasions, in fact, dont deny that empathy is important; they just avoid the word,

almost as if it were taboo. Instead, they circle around it and call it something else (e.g., counter-

transference, reverie, primary maternal preoccupation, etc.).We now want to trace the developmental history of empathy (under various assumed names) in

the thinking of British psychoanalysts. We have chosen the British psychoanalysts for the simple

pragmatic reason that their theories are more familiar to us than those of the other streams of the-

ory and practice in psychoanalysis.

After Freud, technical and theoretical developments in the British Psycho-Analytical Society

owe more to Melanie Klein to than anyone else. She became the reference point by which British

psychoanalysts defined themselves: as being for or against her theories, or somewhere in the mid-

dle. Melanie Klein (1955b) saw the primitive object relations depicted in the childs play as repre-

sentations of the childs internal psychic state and as arising from essentially the same internal

processes as those described by Freud in his work with adults. That is to say, she proposed that

symptoms arose from conflict arising from instinctual forces as they interacted with environmen-

4 DONALD GRANT AND EDWIN HARARI


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tal factors. Her emphasis was on the pregenital vicissitudes of the death instinct, manifested as

anxiety and deflected outward as hostile and sadistic impulses, rather than the vicissitudes of eros,

which was where Freud put his emphasis in his proposals about the later developing Oedipus com-plex. Klein (1946) hypothesized that, in dealing with these conflicts, the infant made use of primi-

tive defenses of denial, splitting, idealization, and what she called projective identification. Pro-

jective identification is a state of mind in which part of the ego or self is projected into an object

either to get rid of bad parts of the self or to provide safe-keeping for good parts. We should note

that Klein (1946) used the termsegoandselfinterchangeably. Empathy was not a major theoreti-

cal concept for her. On the rare occasions when the word appears in her writings, she does not

seem to mean what is usually meant by empathy, i.e., to know something about the mental life of

another (Freud, 1921). Rather she (Klein, 1955a) sees projection playing a major role in empathy

and that empathy consists of the identification of projected internal objects as characteristics of

the other (Klein, 1959). This, of course, is her concept of projective identification, but she seemsto have conflated empathy with it.

Despite this lack of conceptual clarity, or perhaps because of it, one of Kleins closest col-

leagues, Paula Heiman (1950), described a psychological mechanism by which empathy (in

Freuds sense) might operate, but she did not use the word empathy, thus beginning a long tradi-

tion among British psychoanalysts, of writing about empathy but not naming it.

At the 16th International Psychoanalytic Conference in Zurich in 1949, Paula Heiman gave her

groundbreaking paper On Countertransference, which was later published in theInternational

Journal of Psychoanalysis(Heiman, 1950). In it, she introduced the idea of countertransference

having a dimension of unconscious communication from the patient. Heiman pointed out that the

emotional reactions of the analyst to the patient are more than just the analysts personal and idio-

syncratic reactions but are also the analysts particular reactions to that particular patient at thatparticular time and, as such, can tell us something about what is going on in the mental life of that

patient in that particular session. She did not use the word empathy, but it is empathy within

Freuds definition that she is talking about and most importantly giving an unconscious dimen-

sion, in that issues in the patient that are unconscious or cant be expressed in words can evokepar-

ticular conscious emotional states in the analyst. The analysts task then, is to refrain from acting

on these emotional states and to think about them and what if anything, they might mean about

what the patient is experiencing and doing, rather than saying. The unconscious dimension that

Heiman pointed to, can considerably deepen the analysts understanding of the patients states of

mind.

Bion (1962), who had analysis with Melanie Klein, developed Kleins theory of projectiveidentification further than Heiman. His view was that infant development was determined by the

interaction of an empathically attuned mother with the instinctual endowment of the infant, both

of which could vary considerably from one motherinfant pair to another. Bion, like Heiman, did

not use the termempathy. Instead, he spoke ofmaternal reverie. He (Bion, 1962) defined the

mothers reverie as that state of mind capable of reception of the infants projective identifica-

tions (p. 36). That falls within Freuds definition of empathy. He teased out in more detail how

this reverie or heightened empathic sensitivity might occur. First, he reminded us that projective

identification is an omnipotent phantasy that it is possible to relocate unwanted parts of the self in

an object or other. The infant (or patient) operating in this omnipotent way then relates to the ob-

ject or other as if what has been projected is really how the other is. This, in turn, engenders vari-

ous feelings in the mother (or analyst). The capacity of the mother (or the analyst) to allow herself

EMPATHY IN PSYCHOANALYTIC THEORY AND PRACTICE 5


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to become conscious of these feelings and then to think about them and what they might mean

about the infant (or patient) is the capacity for reverie. Bion, like Heiman, was describing a possi-

ble psychological mechanism for empathy and it is curious that neither of them used the word em-pathyfor what they were describing. Bions concept of reverie seems more a development of

Heimans concept of contertransference as communication than any specific idea in Kleins writ-

ings. Yet, to give Melanie Klein her due, without her concepts of splitting and projective identifi-

cation (Klein, 1946) neither Heimans norBions conceptual developments could haveoccurred.

Winnicott (1962), who had supervision but not analysis with Melanie Klein, was largely in

agreement with her formulations regarding pre-Oedipal development. Their areas of agreement

included that a childs play represents a projection of internal object relations; that primitive inter-

nal objects are split intogoodobjects andbadobjects, although Winnicott preferred to call them

benign objects andpersecutory objects; that these goodand badinternal objects have their origins

in satisfying or unsatisfying environmental (other/mother/caregiver) responses to instinctualneeds; and that thegoodtends to be introjected and becomes part of the Self/Ego and thebadpro-

jected into external objects. He agreed that the depressive position was a major developmental

achievement (although he preferred to call it the stage of concern) in which it was recognized by

the developing infant that the split good and bad objects were, in fact, aspects of a single other/

mother/breast whole object that was at times satisfying and at other times unsatisfying. He also

agreed that this led to a capacity to feel concern and guilt about attacks in phantasy, on the bad ob-

ject which, in fact, was one and the same as the good object. This, in turn, mobilized the life in-

stinct, eros, with urges to reparation and restitution directed towards the newly experienced whole

object. Winnicotts major difference from Klein was in the major emphasis he gave to the quality

of the maternal or primary caregivers capacity to provide good enough mothering. Despite

Kleins protest that she did take the mothering into account, Winnicott (1962) went as far as to saythat, in his opinion, She [Melanie Klein] was temperamentally incapable of paying full attention

to it [the environmental factor] (p. 177). No doubt this was in part a shot fired in the theory wars

that plagued the British Psycho-Analytical Society in the twentieth century, but Winnicott had a

point, as a reading of Kleins (1961) analysis of Richard will confirm. Klein, herself, acknowl-

edged that she had a particular emphasis on the vicissitudes of instinctual anxieties to the exclu-

sion of environmental influences, which is not to say she thought them unimportant. Klein (1946)

said, for example, Fairbairns approach was largely from the angle of Ego-development in rela-

tion to objects, while mine was predominantly from the angle of anxieties and their vicissitudes

Importantly, she added, I hold that anxiety arises from the operation of the death instinct within

the organism (p. 3). These comments suggest that she realized that her approach was only one ofa number of possible approaches.

Winnicott (1956) was able to marry the two theoretical positions of the instinctual origins of

mental life and behavior and that the development of the infants mental life is channeled by the at-

tention of a good enough [i.e., empathically attuned] mother. The ministrations of a good

enough mother will determine whether an instinctual need is met satisfactorily, creating a good

experience (i.e., a good or benign internal object), or not met satisfactorily, creating a bad experi-

ence (i.e., a bad or persecutory internal object). Winnicotts theories of primary maternal preoccu-

pation and good enough mothering release us from any need to choose between instinctual drives

and environmental influences as the hand that guides mental development. His theories point to

the interaction between nature and nurture as the crucial factor. This is congruent with modern

knowledge of genetics (Kandel, 1998), which has shown there is an even more intimate interplay



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between the environment and genes than was previously thought, with many genes needing to be

switched on by environmental experiences.

Somewhat apart in the British Psychoanalytical Society was Anna Freud. Like Winnicott, sheheld the view that psychological development took place through the interaction of instinctual

forcesand environmental factors. She held the view that when instinctual needs were met satisfac-

torily by the environment,development proceeded satisfactorily. However, when instinctual needs

were not met satisfactorily, developmental lines were disrupted. In her book (Freud, 1965),Nor-

mality and Pathology in Childhood, she expanded the concept of lines of development to include

almost every other area of the individuals personality (p. 63). In her emphasis on developmen-

tal lines, she could be seen as a precursor of Kohut. Yet, like her colleagues in the British Society,

she did not make empathy a major theoretical concept, leaving it as an implicit necessity in both

normal development and the psychoanalytic process.

The failure by most psychoanalysts to name empathy for what it is has led to a lack of psycho-analytic studies of empathy and its possible types and mechanisms. Kohut (1959) began the cor-

rection of this failure by placing empathy at the centre of his understanding of the psychoanalytic

process, but even he did not undertake the sort of detailed observation and study that might lead to

an understanding of possible different types of empathy and possible mechanisms by which em-

pathy might operate. Paradoxically, other psychoanalysts have arrived at an understanding of how

mechanisms facilitating empathy might operate without naming it as empathy, e.g., Freuds

(1912b) evenly suspended attention, Heimans (1950) countertransference as communication,

Winnicotts (1956) primary maternal preoccupation, Bions (1962) reverie, Loewalds (1986)

therapists observation of his own visceral reactions to the patient, McDougalls (1978) induced

countertransference emotions as preverbal communications, Ogdens (2004) the analytic third,

and Gabbards (1995) fit between the patients and therapists intrapsychic worlds. Most of theseformulations involve attention to countertrasference reactions and recognize their unconscious

communication aspect. Gabbard (1995) also pointed out that there is a growing common ground

among psychoanalysts of different theoretical orientations in their recognition that countertrans-

ference reactions can havean important dimension of communication. What has not been made so

explicit is that this is a psychological mechanism for empathy.

We believe that the theory wars that have raged among psychoanalysts of different theoretical

orientations have been very detrimental to psychoanalysis in that they have inhibited professional

dialogue in many areas, not least between Self Psychologists, whoname empathy, and psychoana-

lysts of the British school and others who have elucidated a psychological mechanism of empathy

without actually naming it as empathy. The result has been that serious study of empathy in psy-choanalysis has been restricted. It has been left largely to neuroscience, some of whose practitio-

ners are also psychoanalysts, to undertake serious studies of empathy.

The study of the neurological correlates of mental events is a relatively new field, made possi-

ble by a variety of new brain-scanning techniques. Despite still being in their infancy, cognitive

and affective neurosciences are providing us with new orientations and directions in the study of

the brain/mind. Now that their neurological correlates are becoming known, the study of subjec-

tive mental processes is being taken more seriously, particularly by those who previously doubted

the scientific credentials of studies of states of mind. Neuroscience is starting to give us important

new insights into even subtle mental processes like empathy.

Among the important emerging issues is the functional asymmetry of the brain, even though

the gross anatomy is symmetrical. It has long been known that the left cerebral hemisphere is the



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site of language functions. What the right hemisphere does has been less clear. There is now evi-

dence (Siegel, 2001), that the right hemisphere is dominant for processing conscious and uncon-

scious affects. Not only does it process the subjects own affects, but also it processes the recogni-tion of affect in others (Blair, 2003). These studies point to empathy being predominately a

function of the right cerebral hemisphere.

The discovery of mirror neurons by a group of researchers (di Pellegrino et al., 1992) at the

University of Parma in Italy has provided a pointer to more localized brain sites and a more spe-

cific neurological mechanism for understanding the neurological correlates of empathy. The

groups initial studies were of neurons in the inferior prefrontal cortex of the macaque monkey.

These neurons fired when a specific movement was made by the monkey. The researchers noticed

that these same cells also fired when the same movement was made by the experimenters and ob-

served by the monkey, even though the monkey was not performing the movement. The firing of

the neurons seemed to be related to understanding the movement, rather than performing themovement. Subsequently mirror neurons have been found to be more widespread in the monkey

brain (Gallese et al., 2001). Mirror neurons have also been found in the human brain (Fadiga et al.,

1995; Cochin et al., 1998; Hari et al., 1998). Vittorio Gallese (2001), a member of the team who

originally discovered mirror neurons, has noted that activation of mirror neurons is not limited to

motor actions but also occurs in situations of observed pain (Hutchison et al., 1999) and observed

emotion (Calder et al., 2000). Mirror neurons that respond to observed emotion provide a possible

neurological mechanism for empathy. Adolphs et al. (2000) came to a similar conclusion, saying,

We recognize another individuals emotional state by internally generating somatosensory repre-

sentations that stimulate how the individual would feel when displaying a certain facial expres-

sion (p. 2683).

Another important aspect of empathy which has not, to our knowledge, been addressed by psy-choanalysts is whether all empathy is the same or whether there are different types of it. A recent

neuroscience paper (Shamay-Tsoory, Aharon-Peretz, and Perry, 2009) has addressed this ques-

tion with conclusions that are significant for psychoanalysts. They found evidence for at least two

different types of empathy. One is what they called the basic emotional contagion system asso-

ciated with mirror neurons particularly in Brodmann area 44 of the cerebral cortex. The other they

called the cognitive perspective-taking system associated with Brodmann areas 10 and 11 of the

ventromedial prefrontal cortex.

EMPATHY IN CLINICAL PRACTICE

With these psychological and neurological issues in mind, we want to discuss some clinical work

with a patient whom we call H. H had a severe life-threatening physical illness in addition to an

eating disorder and depression. She was completely dependent on health professionals and hospi-

tals to survive. Her prognosis was not good but her physician asked me (D. G.) if there was any-

thing I could do that might help. I began seeing her twice a week as a hospital inpatient and later in

my private consulting rooms. A central question we have posed to ourselves about H is: How is it

that H became conscious of some of her subjective states of mind that were previously

unconscious?

The method of free association helps us to hear the conscious contents of the patients mind and

the links both conscious and unconscious between them and we can communicate these to the pa-



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tient. The constancy to the setting and the absence of interruptions assist the patients free associa-

tions. The analysts evenly suspended attention helps him or her to hear more subtle themes in

what the patient says. To this point, the work of the analyst is mostly cognitive and conscious. Butthere is more to psychoanalysis than that.

In the earliest stage of her treatment in my rooms, free association was not happening. H would

lie on the couch and writhe, moan, groan, and sob continually. Although she spoke no words, she

conveyed extreme distress in a very powerful way so that it became an extremely painful experi-

ence for me. I found it extremely difficult to stay in the room with her for 50 minutes. At this early

stage in her treatment, I tried a few times to make a verbal statement to the effect that she was an-

gry about her plight. Immediately following these attempts of mine, she would freeze as if some

unexpected noise had startled her. After a few seconds, she would resume writhing and sobbing

and moaning as if I had not spoken. My feeling was that this verbal interpretive approach was go-

ing nowhere. I felt deskilled, useless, and worthless, and even feared at times that I might be mak-ing her worse.

In contrast to these distressing countertransference feelings, which made me want to terminate

the therapy and flee, I also had a powerful sense that it was very important for H to be able to come

to therapy and be so distressed in my presence. Gradually, I came to understand that this primitive

transference/countertransference relationship, on a completely nonverbal level, nevertheless had

meaning in it. As well as having a powerful emotional experience herself, H was creating a situa-

tion in which a potential experience for me was embedded. What was required on my part was em-

pathic attunement. Kohut spelled this out, but did not offer an explanation of how it might happen.

Heimans (1950) theory of countertransference as communication fills this gap. Gradually, I came

to understand that my countertransference feelings were the real communication from H about

what she was experiencing. I came to understand that my countertransference feelings were notjust something about me, but also a reflection of how H felt, not only deskilled, useless, and worth-

less, but full of badness that was dangerous to others.

I abandoned the idea of interpretation and concentrated on surviving the unpleasant feelings

engendered in me and staying in the room with her. I think my most important empathic

attunement at this early stage was the realization that attempts at interpretation only bewildered

her. In these early sessions, she had regressed to a very primitive preconceptual level and words

were little more than noises to her. I made occasional empathic comments such as, You seem

more (or less) distressed today, but I am not sure that even such simple experience-near com-

ments were meaningful to her. Up to this point, the empathic attunement required seems to have

been the emotional contagion/mirror neuron type (Shamay-Tsoory et al., 2009), preverbal andcommunicated unconsciously by H. I became conscious of the distressed feelings that permeated

the analytic third (Ogden, 2004). Heiman (1950) suggested that these conscious counter-

transterence feelings can be exploredand interpretations formulated from them. My reflections on

my countertransference with H led me to a different conclusion. I realized that her distress, mir-

rored in my countertransference, was beyond words at that stage and that, for the time being, I had

to survive those experiences with her, not talk about them, which I believe would have been an in-

tellectualizing defense on my part.

Although I did not know it at the time, because H did not have the words to communicate it to

me, during this early stage of treatment she was going through a process of becoming conscious of

various differentiated states of her subjective self. This was not a result of interpretation. I have

suggested elsewhere (Grant, 2002) that Hs increasing consciousness of these subjective states of



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herself required that they occur in relation to a material object of the senses (the analyst in the ana-

lytic setting). Would any material object of the senses have done? I think not. I think the object

needed to be one who permitted the intense primitive emotions to be present and felt, and did notblock them or flee from them, which would have resulted in intense frustration for H. Her need

was for someone who could survive the inchoate and overwhelming expressions of her distress

without flight and without defensive talking to ward off the distress. Even if I made interpretations

that were correct, H was not functioning at the symbolic level of language and words were just in-

terruptions to her experience, rather than bearers of meaning. Yet she needed the object to be pres-

ent in order to experience the varying subjective states of herself. Much later, she was able to de-

scribe to me how she had wandered in a deadened and starved state of mind between these early

sessions just waiting for the time when she could come back to the next session and have alive ex-

periences of herself again. I did not know this in a verbal and cognitive way at the time it was hap-

pening. My empathic attunement was operating more at the emotional contagion/mirror neuronlevel. Without really understanding why, I realized that H needed me to be there, saying nothing or

very little, but as an object or other in relation to whom she could express (by moaning, writhing,

grunting, and screaming) subjective self experiences that ordinary relationships could not tolerate

without the other fleeing or trying to calm her, either of which just created high levels of frustra-

tion for her.

Gradually, H became able to give names to these subjective experiences. This developing abil-

ity seemed to me best conceptualized and thought about by making use of Bions (1967) theory to

thinking. The central process in Bions theory of thinking involves the idea of a preconception,

which is an expectant state of mind that can provide coherence to a complex sensory/emotional

experience. It is equivalent to Kants (1781)a prioriknowledge. Bion (1962) proposed that if a

preconception meets with a suitable realization in the world of objects, the preconception will pro-vide the coherence to join the elements of the sensory/emotional realization in a constant conjunc-

tion that Bion called a conception, e.g., the infant has an inherent instinctual expectation of a

source of food and if satisfied all of the sensory and emotional circumstances of the experience of

being fed become structured as a constant conjunction or a conception that we can call the

breast for short (Bion, 1962, p. 34). The conception, being an experience of a constant conjunc-

tion of sensory and emotional impressions is not yet part of language and, therefore, is not in a

form suitable for use in thinking. If, however, a preconception meets with a frustration, as many

preconceptions must, there are a number of possible outcomes. If the preconception of being fed

meets a realization of no breast, and the frustration is not too great, then the experience of no

breast may become a thought of the breasts temporary absence. That is to say, Bion (1967) pro-posed that thoughts arise from the frustration of desire provided it is not too great. The pressure of

thoughts, in turn, stimulates the development of an apparatus for thinking that, in turn, may be able

to modify the frustration to make it more tolerable.

In the experience of therapy, H found a situation that had a sufficiently low level of frustration

for thoughts to form in her mind. She felt alive when in the sessions with me and dead in the out-

side world between sessions. At first, these experiences were not represented in a verbal form but

were more in the nature of sensory/emotional constant conjunctions or what Bion (1967) called

conceptions, but they were sensory/emotional states that H could consciously recognize in herself.

The next step for H was to be able to name these new conscious subjectiveexperiences in language

to form what Bion has called thoughts or concepts. Once concepts were formed, thinking was

greatly facilitated, along with Hs ability to communicate what she experienced and thought.



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Gradually, over many months, the writhing and moaning and sobbing lessened and H began to

speak. She found some words to describe her inner experiences. Up to this point, the approach of

empathic attunement recommended by Kohut seemed to have been the most useful. However, asH progressed, more was needed. The words that she had begun to find were words describing her

states of subjective self consciousness. She felt empty or dead or like a hungry ghost wan-

dering, empty andunsatisfied, between therapy sessions. Shedescribed theanalytic room contain-

ing the analyst as the cocoon. In the cocoon, she became alive. This developing conscious-

ness of her subjectiveself and language to symbolize it occurred in relation to the therapist and the

setting, as material objects of the senses or realizations, as Bion (1967, p. 111) has called them.

At first, H had to be in a psychotherapy session to feel and name these varying states of her subjec-

tive self.

However, becoming conscious of the subjective self is not the same as mastering developmen-

tal tasks or resolving conflicts. Consciousness may emerge with these issues intact and unre-solved. I think this was the situation with H as consciousness of states of her subjective self

emerged. H was becoming conscious of states of her self in relation to the therapist as another, but

the other was a fantastic, highly idealized other.

This state of affairs went on for quite a long time, duringwhich H was calmerbut I becamecon-

scious of an increasing feeling of disquiet in my countertransference feelings. Reflecting on this, I

came to realize that H seemed content to continue the existing situation in which she related to me

as an idealized God-like figure who was the repository of everything good. In contrast, she felt she

contained overwhelming amounts of badness. She felt she could only experience anything good,

even about herself, when she was in the cocoon with me. At this stage, I offered an interpretation

that it was as if she left the good, creative parts of herself with me when she left the session and

could reconnect with them only when she returned to the next session in the cocoon. This, ofcourse, is what Klein (1946) described as the defenses of splitting, idealization, and projective

identification. This interpretation led into a new phase of treatment in which H engaged actively in

dialogue with me about her feeling of being full of something bad, which she envisaged as a black

and slimy substance inside of her, about how this badness was dangerous and had to be constantly

punished and controlled, about how she could not keep any good and creative parts inside herself

for fear the badness would destroy them, about how her anorexia was, in part, an attempt to kill the

badness by starving it and about how she had to garage the good creative parts of herself in me to

keep them safe. This latter was associated with the idealizing fantasy that I had only good things

inside me.

These interrelated issues required a great deal of interpretation and discussion. Clearly, we hadmoved to a new phase of Hs treatment in which interpretation in the Kleinian framework came to

the fore. That is not to say that empathy was no longer important. Interpretations that adequately

express the patients internal emotional experiences can only be formulated on the basis of em-

pathic attunement in the transferencecountertransference relationship. However, a new element

had been added to the nature of the empathic attunement required. As well as the emotional conta-

gion/mirror neuron level of empathy, a conscious cognitive perspective-taking level of empathy

also began to inform my interpretations. These interpretations arose from my thinking about the

experiences H and I were having, rather than just becoming conscious of them. Thinking, which

Freud described as understanding the relationships between things, can only be done using con-

cepts already created in the mind of the thinker. This inevitably put a restriction on the new ele-

ment in my empathic attunement, viz. that for use in thinking I had available to me only those con-



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cepts from the psychoanalytic theories with which I was familiar. Because of the biases of my

psychoanalytic training, my thinking about what was happening with H in this new phase of treat-

ment made use of many of the concepts of the British school of psychoanalysis, most notablysplitting, projective identification, and idealization (Klein, 1946) and Bions (1967) theory of

thinking. Psychoanalysts with other training and other concepts and theoretical constructs might

have thought differently about these same transferencecountertransference experiences with

equal success.

DISCUSSION AND CONCLUSIONS

Psychoanalysts of different theoretical persuasions have wasted a lot of time fighting each other

about who possesses the truth when, in fact, it is not a question of one psychoanalytic theory beingthe truth and others in error, but that the formulation used by the analyst or therapist must be a

close enough representation of the patients psychic truth to be meaningful to the patient. Freud

(19161917) said something very similar to this in 28th introductory lecture, in which he said that

a suggestion made to a patient must tally with what is real in him (p. 452), for it to be taken up as

something useful in the patients mind. Freud was not talking here about historical reality, as

Adolf Grunbaum (1984) claimed in his well-known and influential book, but about the psychic re-

ality in the mind of the patient. More importantly in line with our discussion here, Freud was not

claiming that the analyst can express the psychic reality in the patients mind, but only that the

suggestion must tally or be congruent with it. That is to say, it needs to be a truth not the truth, the

truth being beyond the possibilities of symbolic representation in language.

Bions (1965) formulations of O and K make a similar point. Bion calls the absolute truth of the

internal and external worlds O, and considers it unknowable. However, a limited representation of

O or aspects of O can be achieved, and Bion called these representations K. Many K formulations

can emerge from a single complex O of any patient, but each is only a partial representation of the

total truth of O.

These considerations should make us much more modest and circumspect about our favorite

psychoanalytic theories, which belong to K, not to O. K must be based on empathy of both types

for it to be an adequate representation of O that will tally with it and be useful to the patient in ap-

proaching and thinking about his internal psychic truth.

My approach with H was to include interpretation in the later stages of treatment, but I would

not claim that to be some sort of absolute necessity. It was my K of the situation. Others mightthink that empathy alone without interpretation would be sufficient to set in train developmental

processes leading to psychic maturation. My viewthat more than empathy was required was based

on my countertransference disquiet as H seemed to settle into a situation in which she could ga-

rage parts of herself in me for safekeeping and come and experience these parts of herself in the

sessions and just wander like a hungry ghost until the next session. Perhaps I was too impatient,

although this was a very long treatment over many years, and perhaps with further time, empathy

without interpretation might have been sufficient to set in train further maturational processes in

H. My view was that, with empathy alone, she would continue to become conscious of aspects of

herself that were previously unconscious, but it was a pathological experience of herself and her

object (the therapist). The boundary between what was herself and what was the therapist was

very porous to projection and introjection. This led me to adopt a more interpretiveapproach in the



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later stages of treatment, based on my empathic awareness of Hs contentedness to remain split

into good and bad parts and to house the good parts in me, where she could experience them as of-

ten as she could get me to see her. I am not claiming, however, that this formulation is the truth. It ismy K of the situation, not O.

These considerations have led us to a number of conclusions.

Our first, and perhaps most fundamental, conclusion is that, although the wordempathyis

rarely used in psychoanalysis, outside of Self Psychology, empathy is necessary for a psychoana-

lytic process to be generated. We only have to remind ourselves of Freuds (1921) definition of

empathy (the mechanism by means of which we are enabled to take up any attitude at all towards

another mental life, p. 110) to grasp how fundamental its various forms are to psychoanalysis. In

viewof this, it is curious that Freud, himself, and most other psychoanalysts havenot tried to study

empathy except indirectly under various assumed names. This omission is almost worth a study in

itself.Our second conclusion is that all empathy is probably not the same. Shamay-Tsoory et al.

(2009) make a compelling case that there are at least two types of empathy. This study was con-

ceived and undertaken by neuroscientists, not psychoanalysts. This does not mean that psychoan-

alysts are justified in ignoring it, especially given our failure to properly study empathy, ourselves.

Sometimes psychoanalysts have been known to eschew any knowledge that does not come from

the analytic process. We would argue against this view and consider that those of us who are psy-

choanalysts have much to learn from the sciences that border and overlap our field of study (the

human mind).

Our third conclusion is that theoretical differences among psychoanalysts are greater than dif-

ferences in their everyday language descriptions of experience-near clinical data. For example, al-

though the elaborations of Kleins and Kohuts theories are very different, it can be seen that at thebasic level of trying to conceptualize a clinical experience, there is an important similarity. Both

conceptualize the subject (the self or the ego) as relating to an object or other who has been dis-

torted by the subject mistaking parts of the self or ego for parts of the object or other. Despite this

agreement, the twotheoretical systems have been elaborated in different, seemingly incompatible,

ways. This, in turn, has lead to quite different techniques of therapy. We would argue that these dif-

ferences lie not so much in the attempts to describe and conceptualize the raw clinical experiences,

but in the theoretical assumptions espoused by Klein and Kohut.

Klein (1946) placed instinctual forces at the center of her theory. She theorized that anxiety

arose from the operation of the death instinct and that the fear of annihilation (death) immediately

attached itself to an object, albeit a phantastic one (the bad breast). She (Klein, 1946) proposedthat primitive defenses of splitting, projective identification, and idealization were then mobilized

against the feared object. We would argue that it is this theoretical position, rather than the raw

clinical experiences, that led Klein to recommend interpretation that should be both early and

deep.

Kohut (1966), on the other hand, placed the idea of a narcissistic developmental line at the cen-

ter of his theory. He theorized that symptoms arose from failures in it, with the development of

selfobjects, in which parts of the self were experienced as parts of the object. One cannot help but

notice how similar this is to Kleins concept of projective identification. He then theorized that

failures in this developmental line were caused by environmental failures, rather than instinctual

forcesor conflicts. Kohut (1966) saw thenormaldevelopment of thenarcissistic line as requiring a

caregiver who was empathically attuned to the developing infant and child to provide mirroring



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and an idealized imago, in order to meet the needs of the childs primary narcissism and its two de-

rivatives, thenarcissistic self, and the idealizedparent imago.We would argue that it was this theo-

retical position, rather than the raw clinical experiences, that lead Kohut to recommend thatempathically attuned mirroring and acceptance of idealization should be the basis of therapy, the

aim of which was to provide the correct environmental experiences to re-activate the normal pro-

cesses of the developmental lines.

Since in our view, it is their theoretical elaborations, not the raw clinical data, that have given

rise to the different treatment approaches of the Kleinian and Kohutian (and other) schools, we be-

lieve it is always necessary to return to the raw clinical experience and choose whichever theoreti-

cal framework seems most useful for that patient, but not to elevate any psychoanalytic theory to

the status of the truth. This means that psychoanalysts should have a good understanding of all of

the major theoretical frameworks within psychoanalysis so that the most useful way of thinking

about a particular clinical experience can be selected. Freud (1900) himself described theory asnothing more than useful scaffolding for the exploration of clinical material. To treat it as anything

more is a mistake. There can be no hard and fast rules about which theoretical framework is to be

used. It is a matter of having a good knowledge of all major theories within psychoanalysis and of

clinical experience, empathy and judgment, in selecting which psychoanalytic theory provides the

best representation of a particular clinical experience. It is paradoxical that this demotion of theory

actually requires a broader and deeper understanding of psychoanalytic theories to become aware

of their usefulness and their limitations.

Some might argue that it is impossible to chop and change around in different theoretical

frameworks such as those of Klein and Kohut for example. However, the work of Donald

Winnicott suggests that it might be surprisingly easy to think coherently about a patient using both

Kleins ideas about instinct and primitive defenses and Kohuts ideas about empathy and environ-mental failure. I think the work with H described earlier illustrates this.

Our fourthconclusion is that allpsychoanalysts need to constantly remind themselves that their

theories are only intellectual scaffolding to explore and investigate the phenomena of the psycho-

analytic encounter and are not the phenomena themselves. This statement is hardly new or origi-

nal on our part. As we havepointed out, Freud (1900) said exactly that in his first great psychoana-

lytic work, The Interpretation of Dreams. Nevertheless, many psychoanalysts seem to fall into the

error of mistaking their theories for observed facts. Clearly, more modesty about what we know or

what we think we know would be more becoming and actually more useful in our attempts to ap-

proach and symbolically represent a portion (Bions K) of the psychic reality (Bions O) of our pa-

tients minds.Our fifth and final conclusion, of which we hope to haveconvinced the reader by now, is that no

one and no specific psychoanalytic group have exclusive access to the truth. All of the major theo-

retical streams in psychoanalysis probably contain some truth, or it is unlikely that they would

have survived. As Freud (19161917) said in his 28th introductory lecture, suggestions put to the

patient by the psychoanalyst must tally with what is real in him, i.e., must tally with his psychic re-

ality, and if there is no truth in the suggestion and it is not congruent with the patients psychic real-

ity it will fade away. So it is, too, with the psychoanalytic theories used to formulate the

suggestions.

Most of us are too attached to our favorite psychoanalytic theories and too intent on denigrating

others. The failure to properly recognize and study the fundamental processes of empathy is only

one example of harm done when different schools of psychoanalysis do not engage in civilized



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scientific discourse and attack each other instead. We would argue that an excessive attachment to

the theories we have been taught has been a pervasive inhibiting force in the progress of psycho-

analysis towards becoming a truly rational and evidence based body of knowledge articulatedwith related bodies of knowledge. Each of us needs to loosen our mental grip on our particular pet

theories and reeducate ourselves to havea better understanding of all the major thinkers in psycho-

analysis. This will be no small or easy task.

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