empathy in psychoanalytic theory and practice

This article was downloaded by: [Memorial University of Newfoundland]On: 02 August 2014, At: 23:23Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Psychoanalytic Inquiry: A Topical Journalfor Mental Health ProfessionalsPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/hpsi20

Empathy in Psychoanalytic Theory andPracticeDonald Grant a & Edwin Harari ba Psychiatrist and Psychoanalyst in Private Practice in Melbourne ,Australiab St. Vincents Hospital Area Mental Health Service , Fitzroy,AustraliaPublished online: 19 Jan 2011.

To cite this article: Donald Grant & Edwin Harari (2011) Empathy in Psychoanalytic Theory andPractice, Psychoanalytic Inquiry: A Topical Journal for Mental Health Professionals, 31:1, 3-16, DOI:10.1080/07351690.2010.512844

To link to this article: http://dx.doi.org/10.1080/07351690.2010.512844

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

http://www.tandfonline.com/loi/hpsi20

http://www.tandfonline.com/action/showCitFormats?doi=10.1080/07351690.2010.512844

http://dx.doi.org/10.1080/07351690.2010.512844

http://www.tandfonline.com/page/terms-and-conditions

http://www.tandfonline.com/page/terms-and-conditions

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. Freud’s (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 numberof psychoanalysts within the British Psychoanalytical 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. Weargue that no psychoanalytic theory is the exclusive repository of the truth, enabling it to dismissothers as errors. We all need to remind ourselves of Freud’s (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 The Interpretation of Dreams, Freud (1900) points out that our theories are nothing more thanways 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, butthey are not the thing itself. If ongoing clinical observations conflict with our theories, then hesays, “We must always be prepared to drop our conceptual scaffolding if we feel that we are in aposition 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 oftheory, and psychoanalytic theory wars raged for most of the twentieth century until RobertWallerstein (1988), during his presidency of the International Psychoanalytic Association, calledfor a truce and more mutual respect between psychoanalysts with different theoretical views. Thiscreated a situation of which psychoanalysts do not take full advantage. Ideally, we should now beable to think about a clinical observation in the conceptual frameworks of a number of differentpsychoanalytic theories and feel free to use the one that seems to offer the best understanding orconceptual scaffolding for the clinical material with which we are working at the time. But weneed to remain mindful that whatever theoretical concepts we are using are not observed facts, butjust useful scaffolding to support our thinking. Paradoxically, such a demotion of theory requires

Psychoanalytic Inquiry, 31:3–16, 2011Copyright © Melvin Bornstein, Joseph Lichtenberg, Donald SilverISSN: 0735-1690 print/1940-9133 onlineDOI: 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.

Dow

nloa

ded

by [

Mem

oria

l Uni

vers

ity o

f N

ewfo

undl

and]

at 2

3:23

02

Aug

ust 2

014

an even broader and deeper knowledge of more psychoanalytic theories in order to understandtheir 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 andresistances. Different psychoanalytic theoreticians have conceptualized their facilitating role indifferent 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 couldall 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 Freud’s(1921) definition of empathy, which is that empathy is “the mechanism by means of which we areenabled 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 Freud’s 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 forKohut (1959) to provide empathy with a central place in psychoanalytic theory.

Each of the theoretical concepts mentioned earlier offers an explanation for the central processof 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 Freud’s defi-nition of empathy. Importantly, they all provide empathy with an unconscious dimension, in thatthe state of mind the patient is communicating to the analyst becomes conscious in the analyst’smind while sometimes remaining unconscious in the patient’s mind. The analyst’s task then is toreflect 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 whatis being unconsciously communicated by the patient. If this view is accepted, it becomes ex-tremely curious that the word empathy is 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, don’t 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) inthe thinking of British psychoanalysts. We have chosen the British psychoanalysts for the simplepragmatic 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 Societyowe more to Melanie Klein to than anyone else. She became the reference point by which Britishpsychoanalysts 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 child’s play as repre-sentations of the child’s internal psychic state and as arising from essentially the same internalprocesses as those described by Freud in his work with adults. That is to say, she proposed thatsymptoms arose from conflict arising from instinctual forces as they interacted with environmen-

4 DONALD GRANT AND EDWIN HARARI

Dow

nloa

ded

by [

Mem

oria

l Uni

vers

ity o

f N

ewfo

undl

and]

at 2

3:23

02

Aug

ust 2

014

tal factors. Her emphasis was on the pregenital vicissitudes of the death instinct, manifested asanxiety 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 objecteither to get rid of bad parts of the self or to provide safe-keeping for good parts. We should notethat Klein (1946) used the terms ego and self interchangeably. Empathy was not a major theoreti-cal concept for her. On the rare occasions when the word appears in her writings, she does notseem to mean what is usually meant by empathy, i.e., to know something about the mental life ofanother (Freud, 1921). Rather she (Klein, 1955a) sees projection playing a major role in empathyand that empathy consists of the identification of projected internal objects as characteristics ofthe 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 Klein’s closest col-leagues, Paula Heiman (1950), described a psychological mechanism by which empathy (inFreud’s 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 hergroundbreaking paper “On Countertransference,” which was later published in the InternationalJournal of Psychoanalysis (Heiman, 1950). In it, she introduced the idea of countertransferencehaving a dimension of unconscious communication from the patient. Heiman pointed out that theemotional reactions of the analyst to the patient are more than just the analyst’s personal and idio-syncratic reactions but are also the analyst’s 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 thatpatient in that particular session. She did not use the word empathy, but it is empathy withinFreud’s definition that she is talking about and most importantly giving an unconscious dimen-sion, in that issues in the patient that are unconscious or can’t be expressed in words can evoke par-ticular conscious emotional states in the analyst. The analyst’s task then, is to refrain from actingon these emotional states and to think about them and what if anything, they might mean aboutwhat the patient is experiencing and doing, rather than saying. The unconscious dimension thatHeiman pointed to, can considerably deepen the analyst’s understanding of the patient’s states ofmind.

Bion (1962), who had analysis with Melanie Klein, developed Klein’s theory of projectiveidentification further than Heiman. His view was that infant development was determined by theinteraction of an empathically attuned mother with the instinctual endowment of the infant, bothof which could vary considerably from one mother–infant pair to another. Bion, like Heiman, didnot use the term empathy. Instead, he spoke of maternal reverie. He (Bion, 1962) defined themother’s reverie as “that state of mind … capable of reception of the infant’s projective identifica-tions” (p. 36). That falls within Freud’s definition of empathy. He teased out in more detail howthis reverie or heightened empathic sensitivity might occur. First, he reminded us that projectiveidentification is an omnipotent phantasy that it is possible to relocate unwanted parts of the self inan 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

Dow

nloa

ded

by [

Mem

oria

l Uni

vers

ity o

f N

ewfo

undl

and]

at 2

3:23

02

Aug

ust 2

014

to become conscious of these feelings and then to think about them and what they might meanabout 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-pathy for what they were describing. Bion’s concept of reverie seems more a development ofHeiman’s concept of contertransference as communication than any specific idea in Klein’s writ-ings. Yet, to give Melanie Klein her due, without her concepts of splitting and projective identifi-cation (Klein, 1946) neither Heiman’s nor Bion’s conceptual developments could have occurred.

Winnicott (1962), who had supervision but not analysis with Melanie Klein, was largely inagreement with her formulations regarding pre-Oedipal development. Their areas of agreementincluded that a child’s play represents a projection of internal object relations; that primitive inter-nal objects are split into good objects and bad objects, although Winnicott preferred to call thembenign objects and persecutory objects; that these good and bad internal objects have their originsin satisfying or unsatisfying environmental (other/mother/caregiver) responses to instinctualneeds; and that the good tends to be introjected and becomes part of the Self/Ego and the bad pro-jected into external objects. He agreed that the depressive position was a major developmentalachievement (although he preferred to call it the stage of concern) in which it was recognized bythe 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 alsoagreed 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 wholeobject. Winnicott’s major difference from Klein was in the major emphasis he gave to the qualityof the maternal or primary caregiver’s capacity to provide good enough mothering. DespiteKlein’s 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 attentionto it [the environmental factor]” (p. 177). No doubt this was in part a shot fired in the theory warsthat plagued the British Psycho-Analytical Society in the twentieth century, but Winnicott had apoint, as a reading of Klein’s (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, “Fairbairn’s 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 withinthe 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 ofmental life and behavior and that the development of the infant’s mental life is channeled by the at-tention of a “good enough [i.e., empathically attuned] mother.” The ministrations of a goodenough mother will determine whether an instinctual need is met satisfactorily, creating a goodexperience (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). Winnicott’s theories of primary maternal preoccu-pation and good enough mothering release us from any need to choose between instinctual drivesand environmental influences as the hand that guides mental development. His theories point tothe interaction between nature and nurture as the crucial factor. This is congruent with modernknowledge of genetics (Kandel, 1998), which has shown there is an even more intimate interplay


Dow

nloa

ded

by [

Mem

oria

l Uni

vers

ity o

f N

ewfo

undl

and]

at 2

3:23

02

Aug

ust 2

014

between the environment and genes than was previously thought, with many genes needing to beswitched 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 instinctualforces and environmental factors. She held the view that when instinctual needs were met satisfac-torily by the environment, development proceeded satisfactorily. However, when instinctual needswere 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 individual’s 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 bothnormal 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 psychoanalyticprocess, but even he did not undertake the sort of detailed observation and study that might lead toan 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 howmechanisms facilitating empathy might operate without naming it as empathy, e.g., Freud’s(1912b) evenly suspended attention, Heiman’s (1950) countertransference as communication,Winnicott’s (1956) primary maternal preoccupation, Bion’s (1962) reverie, Loewald’s (1986)therapist’s observation of his own visceral reactions to the patient, McDougall’s (1978) inducedcountertransference emotions as preverbal communications, Ogden’s (2004) the analytic third,and Gabbard’s (1995) fit between the patient’s and therapist’s intrapsychic worlds. Most of theseformulations involve attention to countertrasference reactions and recognize their unconsciouscommunication aspect. Gabbard (1995) also pointed out that there is a growing common groundamong psychoanalysts of different theoretical orientations in their recognition that countertrans-ference reactions can have an important dimension of communication. What has not been made soexplicit is that this is a psychological mechanism for empathy.

We believe that the theory wars that have raged among psychoanalysts of different theoreticalorientations have been very detrimental to psychoanalysis in that they have inhibited professionaldialogue in many areas, not least between Self Psychologists, who name empathy, and psychoana-lysts of the British school and others who have elucidated a psychological mechanism of empathywithout 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, cognitiveand affective neurosciences are providing us with new orientations and directions in the study ofthe 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 doubtedthe scientific credentials of studies of states of mind. Neuroscience is starting to give us importantnew insights into even subtle mental processes like empathy.

Among the important emerging issues is the functional asymmetry of the brain, even thoughthe gross anatomy is symmetrical. It has long been known that the left cerebral hemisphere is the


Dow

nloa

ded

by [

Mem

oria

l Uni

vers

ity o

f N

ewfo

undl

and]

at 2

3:23

02

Aug

ust 2

014

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 subject’s own affects, but also it processes the recogni-tion of affect in others (Blair, 2003). These studies point to empathy being predominately afunction of the right cerebral hemisphere.

The discovery of mirror neurons by a group of researchers (di Pellegrino et al., 1992) at theUniversity 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. Thegroup’s 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 noticedthat 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 ofthe 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 monkeybrain (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 whooriginally discovered mirror neurons, has noted that activation of mirror neurons is not limited tomotor actions but also occurs in situations of observed pain (Hutchison et al., 1999) and observedemotion (Calder et al., 2000). Mirror neurons that respond to observed emotion provide a possibleneurological mechanism for empathy. Adolphs et al. (2000) came to a similar conclusion, saying,“We recognize another individual’s 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 recentneuroscience 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 twodifferent 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 theycalled the “cognitive perspective-taking system” associated with Brodmann areas 10 and 11 of theventromedial prefrontal cortex.

EMPATHY IN CLINICAL PRACTICE

With these psychological and neurological issues in mind, we want to discuss some clinical workwith a patient whom we call H. H had a severe life-threatening physical illness in addition to aneating 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 inmy private consulting rooms. A central question we have posed to ourselves about H is: How is itthat H became conscious of some of her subjective states of mind that were previouslyunconscious?

The method of free association helps us to hear the conscious contents of the patient’s mind andthe links both conscious and unconscious between them and we can communicate these to the pa-


Dow

nloa

ded

by [

Mem

oria

l Uni

vers

ity o

f N

ewfo

undl

and]

at 2

3:23

02

Aug

ust 2

014

tient. The constancy to the setting and the absence of interruptions assist the patient’s free associa-tions. The analyst’s evenly suspended attention helps him or her to hear more subtle themes inwhat 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 wouldlie on the couch and writhe, moan, groan, and sob continually. Although she spoke no words, sheconveyed 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 earlystage 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 someunexpected noise had startled her. After a few seconds, she would resume writhing and sobbingand 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 terminatethe therapy and flee, I also had a powerful sense that it was very important for H to be able to cometo therapy and be so distressed in my presence. Gradually, I came to understand that this primitivetransference/countertransference relationship, on a completely nonverbal level, nevertheless hadmeaning 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.Heiman’s (1950) theory of countertransference as communication fills this gap. Gradually, I cameto understand that my countertransference feelings were the real communication from H aboutwhat 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 feelingsengendered in me and staying in the room with her. I think my most important empathicattunement at this early stage was the realization that attempts at interpretation only bewilderedher. In these early sessions, she had regressed to a very primitive preconceptual level and wordswere little more than noises to her. I made occasional empathic comments such as, “You seemmore (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 havebeen the emotional contagion/mirror neuron type (Shamay-Tsoory et al., 2009), preverbal andcommunicated unconsciously by H. I became conscious of the distressed feelings that permeatedthe “analytic third” (Ogden, 2004). Heiman (1950) suggested that these conscious counter-transterence feelings can be explored and interpretations formulated from them. My reflections onmy 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 hadto 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 tome, during this early stage of treatment she was going through a process of becoming conscious ofvarious differentiated states of her subjective self. This was not a result of interpretation. I havesuggested elsewhere (Grant, 2002) that H’s increasing consciousness of these subjective states of


Dow

nloa

ded

by [

Mem

oria

l Uni

vers

ity o

f N

ewfo

undl

and]

at 2

3:23

02

Aug

ust 2

014

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 objectneeded 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 needwas for someone who could survive the inchoate and overwhelming expressions of her distresswithout flight and without defensive talking to ward off the distress. Even if I made interpretationsthat 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 earlysessions 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 orvery 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 toleratewithout 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 Bion’s (1967) theory tothinking. The central process in Bion’s theory of thinking involves the idea of a preconception,which is an expectant state of mind that can provide coherence to a complex sensory/emotionalexperience. It is equivalent to Kant’s (1781) a priori knowledge. Bion (1962) proposed that if apreconception 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 asource of food and if satisfied all of the sensory and emotional circumstances of the experience ofbeing fed become structured as a constant conjunction or a conception that we can call “thebreast” 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 aform suitable for use in thinking. If, however, a preconception meets with a frustration, as manypreconceptions must, there are a number of possible outcomes. If the preconception of being fedmeets a realization of no breast, and the frustration is not too great, then the experience of nobreast may become a thought of the breast’s 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 ofthoughts, in turn, stimulates the development of an apparatus for thinking that, in turn, may be ableto modify the frustration to make it more tolerable.

In the experience of therapy, H found a situation that had a sufficiently low level of frustrationfor 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 butwere more in the nature of sensory/emotional constant conjunctions or what Bion (1967) calledconceptions, 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 subjective experiences in languageto form what Bion has called thoughts or concepts. Once concepts were formed, thinking wasgreatly facilitated, along with H’s ability to communicate what she experienced and thought.


Dow

nloa

ded

by [

Mem

oria

l Uni

vers

ity o

f N

ewfo

undl

and]

at 2

3:23

02

Aug

ust 2

014

Gradually, over many months, the writhing and moaning and sobbing lessened and H began tospeak. She found some words to describe her inner experiences. Up to this point, the approach ofempathic 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 herstates of subjective self consciousness. She felt “empty” or “dead” or like a “hungry ghost” wan-dering, empty and unsatisfied, between therapy sessions. She described the analytic room contain-ing the analyst as the “cocoon.” In the “cocoon,” she became “alive.” This developing conscious-ness of her subjective self and language to symbolize it occurred in relation to the therapist and thesetting, 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 selfemerged. H was becoming conscious of states of her self in relation to the therapist as another, butthe other was a fantastic, highly idealized other.

This state of affairs went on for quite a long time, during which H was calmer but I became con-scious of an increasing feeling of disquiet in my countertransference feelings. Reflecting on this, Icame to realize that H seemed content to continue the existing situation in which she related to meas an idealized God-like figure who was the repository of everything good. In contrast, she felt shecontained 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 interpretationthat it was as if she left the good, creative parts of herself with me when she left the session andcould 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 projectiveidentification. This interpretation led into a new phase of treatment in which H engaged actively indialogue with me about her feeling of being full of something bad, which she envisaged as a blackand slimy substance inside of her, about how this badness was dangerous and had to be constantlypunished and controlled, about how she could not keep any good and creative parts inside herselffor fear the badness would destroy them, about how her anorexia was, in part, an attempt to kill thebadness by starving it and about how she had to garage the good creative parts of herself in me tokeep them safe. This latter was associated with the idealizing fantasy that I had only good thingsinside me.

These interrelated issues required a great deal of interpretation and discussion. Clearly, we hadmoved to a new phase of H’s treatment in which interpretation in the Kleinian framework came tothe fore. That is not to say that empathy was no longer important. Interpretations that adequatelyexpress the patient’s internal emotional experiences can only be formulated on the basis of em-pathic attunement in the transference–countertransference relationship. However, a new elementhad 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 empathyalso began to inform my interpretations. These interpretations arose from my thinking about theexperiences H and I were having, rather than just becoming conscious of them. Thinking, whichFreud 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-


Dow

nloa

ded

by [

Mem

oria

l Uni

vers

ity o

f N

ewfo

undl

and]

at 2

3:23

02

Aug

ust 2

014

cepts from the psychoanalytic theories with which I was familiar. Because of the biases of mypsychoanalytic 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 Bion’s (1967) theory ofthinking. Psychoanalysts with other training and other concepts and theoretical constructs mighthave thought differently about these same transference–countertransference experiences withequal success.

DISCUSSION AND CONCLUSIONS

Psychoanalysts of different theoretical persuasions have wasted a lot of time fighting each otherabout 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 aclose enough representation of the patient’s psychic truth to be meaningful to the patient. Freud(1916–1917) said something very similar to this in 28th introductory lecture, in which he said thata suggestion made to a patient must “tally with what is real in him” (p. 452), for it to be taken up assomething useful in the patient’s mind. Freud was not talking here about historical reality, asAdolf 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 notclaiming that the analyst can express the psychic reality in the patient’s mind, but only that thesuggestion must tally or be congruent with it. That is to say, it needs to be a truth not the truth, thetruth being beyond the possibilities of symbolic representation in language.

Bion’s (1965) formulations of O and K make a similar point. Bion calls the absolute truth of theinternal and external worlds O, and considers it unknowable. However, a limited representation ofO or aspects of O can be achieved, and Bion called these representations K. Many K formulationscan emerge from a single complex O of any patient, but each is only a partial representation of thetotal truth of O.

These considerations should make us much more modest and circumspect about our favoritepsychoanalytic theories, which belong to K, not to O. K must be based on empathy of both typesfor 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 wouldnot 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 developmentalprocesses leading to psychic maturation. My view that more than empathy was required was basedon 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 thesessions 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, empathywithout interpretation might have been sufficient to set in train further maturational processes inH. My view was that, with empathy alone, she would continue to become conscious of aspects ofherself that were previously unconscious, but it was a pathological experience of herself and herobject (the therapist). The boundary between what was herself and what was the therapist wasvery porous to projection and introjection. This led me to adopt a more interpretive approach in the


Dow

nloa

ded

by [

Mem

oria

l Uni

vers

ity o

f N

ewfo

undl

and]

at 2

3:23

02

Aug

ust 2

014

later stages of treatment, based on my empathic awareness of H’s contentedness to remain splitinto 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 word empathy is

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 Freud’s (1921) definition ofempathy (“the mechanism by means of which we are enabled to take up any attitude at all towardsanother mental life,” p. 110) to grasp how fundamental its various forms are to psychoanalysis. Inview of this, it is curious that Freud, himself, and most other psychoanalysts have not tried to studyempathy except indirectly under various assumed names. This omission is almost worth a study initself.

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 fromthe 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 (thehuman 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 Klein’s and Kohut’s theories are very different, it can be seen that at thebasic level of trying to conceptualize a clinical experience, there is an important similarity. Bothconceptualize 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 thisagreement, the two theoretical 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 anxietyarose from the operation of the death instinct and that the fear of annihilation (death) immediatelyattached 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 mobilizedagainst the feared object. We would argue that it is this theoretical position, rather than the rawclinical experiences, that led Klein to recommend interpretation that should be both early anddeep.

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 ofselfobjects, in which parts of the self were experienced as parts of the object. One cannot help butnotice how similar this is to Klein’s concept of projective identification. He then theorized thatfailures in this developmental line were caused by environmental failures, rather than instinctualforces or conflicts. Kohut (1966) saw the normal development of the narcissistic line as requiring acaregiver who was empathically attuned to the developing infant and child to provide mirroring


Dow

nloa

ded

by [

Mem

oria

l Uni

vers

ity o

f N

ewfo

undl

and]

at 2

3:23

02

Aug

ust 2

014

and an idealized imago, in order to meet the needs of the child’s primary narcissism and its two de-rivatives, the narcissistic self, and the idealized parent 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, theaim 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 givenrise 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 tothe status of the truth. This means that psychoanalysts should have a good understanding of all ofthe major theoretical frameworks within psychoanalysis so that the most useful way of thinkingabout 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 anythingmore is a mistake. There can be no hard and fast rules about which theoretical framework is to beused. It is a matter of having a good knowledge of all major theories within psychoanalysis and ofclinical experience, empathy and judgment, in selecting which psychoanalytic theory provides thebest representation of a particular clinical experience. It is paradoxical that this demotion of theoryactually requires a broader and deeper understanding of psychoanalytic theories to become awareof their usefulness and their limitations.

Some might argue that it is impossible to chop and change around in different theoreticalframeworks such as those of Klein and Kohut for example. However, the work of DonaldWinnicott suggests that it might be surprisingly easy to think coherently about a patient using bothKlein’s ideas about instinct and primitive defenses and Kohut’s ideas about empathy and environ-mental failure. I think the work with H described earlier illustrates this.

Our fourth conclusion is that all psychoanalysts need to constantly remind themselves that theirtheories 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 have pointed out, Freud (1900) said exactly that in his first great psychoana-lytic work, The Interpretation of Dreams. Nevertheless, many psychoanalysts seem to fall into theerror of mistaking their theories for observed facts. Clearly, more modesty about what we know orwhat we think we know would be more becoming and actually more useful in our attempts to ap-proach and symbolically represent a portion (Bion’s K) of the psychic reality (Bion’s O) of our pa-tients’ minds.

Our fifth and final conclusion, of which we hope to have convinced the reader by now, is that noone 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 wouldhave survived. As Freud (1916–1917) said in his 28th introductory lecture, suggestions put to thepatient 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 patient’s psychic real-ity it will fade away. So it is, too, with the psychoanalytic theories used to formulate thesuggestions.

Most of us are too attached to our favorite psychoanalytic theories and too intent on denigratingothers. The failure to properly recognize and study the fundamental processes of empathy is onlyone example of harm done when different schools of psychoanalysis do not engage in civilized


Dow

nloa

ded

by [

Mem

oria

l Uni

vers

ity o

f N

ewfo

undl

and]

at 2

3:23

02

Aug

ust 2

014

scientific discourse and attack each other instead. We would argue that an excessive attachment tothe 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 pettheories and reeducate ourselves to have a better understanding of all the major thinkers in psycho-analysis. This will be no small or easy task.

REFERENCES

Adolphs, H., D. Damasio, D. Tranel, G. Cooper, & A. Damasio. (2000), A role for somatosensory cortices in the visual rec-ognition of emotion as revealed by 3-D lesion mapping. J. Neuroscience, 20:2683–2690.

Bion, W. (1962), Learning From Experience. London: H. Karnac, 1991.—————. (1965), Transformations. New York: Jason Aronson, 1983.—————. (1967), Second Thoughts. London: H. Karnac, 1984.Blair, R. (2003), Facial expressions, their communicatory functions and neuro-cognitive substrates. Philosophical Trans-

actions of the Royal Society of London, Series B: Biological Sciences, 358:561–572.Calder, A., J. Keane, F. Manes, N. Antoun, & A. Young. (2000), Impaired recognition and experience of disgust following

brain injury. Nature Neuroscience, 3:1077–1078.Cochin, S., C. Barthelemy, B. Lejeune, S. Roux, & J. Martineau. (1998), Perception of motion and qEEG activity in human

adults. Electroenc. Clin. Neurophysiol., 107:287–295.di Pellegrino, G., L. Fadiga, L. Fogassi, V. Gallese, & G. Rizzolatti. (1992), Understanding motor events: A

neurophysiological study. Experimental Brain Research, 91:176–180.Fadiga, L., Fogassi, L., Pavesi, G. & Rizzolatti, G. (1995), Motor facilitation during action observation: A magnetic stimu-

lation study. J. Neurophysiol., 73:2608–2611.Freud, A. (1965), Normality and Pathology in Childhood. London: Hogarth Press, 1980.Freud, S. (1900), The interpretation of dreams. Standard Edition, 4 & 5. London: Hogarth Press, 1953.—————. (1912a), The dynamics of transference. Standard Edition, 12. London: Hogarth Press, 1958.—————. (1912b), Recommendations to physicians practicing psycho-analysis. Standard Edition, 12. London:

Hogarth Press, 1958.—————. (1916–1917), Analytic therapy. In Introductory lectures on psychoanalysis. Standard Edition, 16. London:

Hogarth Press, 1963.—————. (1921), Group psychology and the analysis of the Ego. Standard Edition, 18. London: Hogarth Press, 1955.Gabbard, G. (1995), Countertransference: The emerging common ground. Internat. J. Psycho-anal., 76:475–485.Gallese, V. (2001), The shared manifold hypothesis: From mirror neurons to empathy. J. Consciousness Studies, 8:33–50.—————, L. Fogassi, L. Fadiga, & G. Rizzolatti. (2001), Action representation and the inferior parietal lobule. In Com-

mon Mechanisms in Perception and Action Attention and Performance XIX, eds. W. Prinz & B. Hommel. Oxford: Ox-ford University Press, pp. 247–266.

Grant, D. (2002), Becoming conscious and schizophrenia. Neuro-psychoanalysis, 4:195–203.Grunbaum, A. (1984), The foundations of psychoanalysis: A philosophical critique. Berkeley, CA: University of Califor-

nia Press.Hari, R., N. Forss, S. Avikainen, S. Kirveskari, S. Salenius, & G. Rizzolatti. (1998), Activation of human primary motor

cortex during action observation: A neuromagnetic study. Proc. Natl. Acad. Sci. USA, 94:15061–15065.Heiman, P. (1950), On counter-transference. Internat. J. Psycho-Anal. 31:81–84.Hutchison, W., K. Davis, A. Lozano, R. Tasker, & J. Dostrovxky. (1999), Pain related neurons in the human cingulated cor-

tex. Nature Neuroscience, 2:403–405.Kandel, E. (1998), A new intellectual framework for psychiatry. Amer. J. Psychiat. 155:457–469.Kant, E. (1781), Critique of Pure Reason, trans. N. Smith. London: MacMillan, 1929.Klein, M. (1946), Notes on some schizoid mechanisms. In Envy and Gratitude and Other Works. New York: Delta, 1977,

pp. 1–24.—————. (1955a), On identification. In Envy and Gratitude and Other Works. New York: Delta, 1977, pp. 141–175.


Dow

nloa

ded

by [

Mem

oria

l Uni

vers

ity o

f N

ewfo

undl

and]

at 2

3:23

02

Aug

ust 2

014

—————. (1955a), The psycho-analytic play technique: Its history and significance. In Envy and Gratitude and OtherWorks. New York: Delta, 1977, pp. 122–140.

—————. (1959), Our adult world and its roots in infancy. In Envy and Gratitude and Other Works. New York: Delta,1977, pp. 247–263.

—————. (1961), Narrative of a Child Analysis. London: Hogarth Press, 1975.Kohut, H. (1959), Introspection, empathy and psychoanalysis—An examination of the relationship between mode of ob-

servation and theory. J. Amer. Psychoanal., 7:459–483.—————. (1966), Forms and transformations of narcissism. J. Amer. Psychoanal., 14: 243–272.Loewald, H. (1986), Transference–countertransference. J. Amer. Psychoanal., 34:275–287.McDougall, J. (1978), Primitive communication and the use of countertransference. Contemp. Psychoanal., 14:173–209.Ogden, T. (2004), The analytic third: Implications for psychoanalytic theory and technique. Psychoanal. Quart.,

73:167–195.Shamay-Tsoory, S., J. Aharon-Peretz, & D. Perry. (2009), Two systems for empathy: A double dissociation between emo-

tional and cognitive empathy in inferior frontal gyrus versus ventromedial prefrontal lesions. Brain, 132: 617–627.Siegel, D. (2001), Toward an interpersonal neurobiology of the developing mind: Attachment relationships, “mindsight,”

and neural integration. Infant Mental Health J., 22(1–2): 67–94.Wallerstein, R. (1988), One psychoanalysis or many. Internat. J. Psycho-Anal., 69:5–21.Winnicott, D. (1956), Primary maternal preoccupation. In Through Pediatrics to Psycho-Analysis. London: Hogarth Press,

1975, pp. 300–305.—————. (1962), A personal view of the Kleinian contribution. In The Maturational Processes and the Facilitating En-

vironment. London: Hogarth Press, 1979, pp. 171–178.

1021 Malvern Rd. ToorakVictoria, Australia [email protected]


Dow

nloa

ded

by [

Mem

oria

l Uni

vers

ity o

f N

ewfo

undl

and]

at 2

3:23

02

Aug

ust 2

014

empathy in psychoanalytic theory and practice

Documents