The Therapist's Use of the Self

When I was on sabbatical in 2018, I spent part of it on a fellowship at the Chicago Psychoanalytic Institute. There for the first time, in one of our seminars, I actually felt like I began to understand some of the thought of Chicago's most famous analyst, Heinz Kohut, pioneer of so-called self psychology. Prior to this, I had tried several times to read at least two of Kohut's books. And I did manage to read Charles Strozier's lovely biography of him, Heinz Kohut: the Making of a Psychoanalyst. But none of his theory was especially accessible or attractive until we read K. Newman's 2007 article, "Therapeutic Action in Self Psychology," The Psychoanalytic Quarterly 76. Newman managed to put Kohut's ideas into much clearer and far less jargon-riddled prose than Kohut seems able ever to have done. 

It was, I seem now to recall, in our discussion of this article afterwards where I first began to learn about the idea of how much of the therapist's usable self is available for the patient in the working alliance--how, that is, in Kohutian terms, the therapist becomes a selfobject [sic] to the patient. (In some ways this just strikes me as a needlessly complicated reworking of object-relations theory, and in far less felicitous English, but let that pass.)

I have been thinking about that concept of the usable self for a couple of months now, and this led me to pick up John Rowan and Michael Jacob's book, The Therapist's Use of Self (2002). 

It's not the book I thought it was going to be, but it is valuable nonetheless. I think my very mild irritation with the book comes from it being in some ways a literature review disguised as a monograph. I was anticipating more decided and conclusive views from the authors, who instead spend most of the book surveying about four different theoretical schools for their thoughts on such things as counter-transference, abstinence, self-disclosure, and related issues.

But this should not be allowed to detract from the overall utility of a relatively short and straightforward text written in clear and workmanlike prose. The fact that it makes good use of British object-relations theory--including Guntrip, Winnicott, Balint, Bollas, and especially Bion (whom I've come to appreciate a lot more this year)--only increases the value of the book in my view. 

The authors begin by noting that the will explore how the therapist might make use of his self in the therapeutic relationship, and then posit three ascending levels of such selfhood so used: the Instrumental self, the Authentic self, and the Transpersonal self. (I pictured these here like Maslow's famous hierarchy, with Instrumental on the bottom, and Transpersonal on the top.)

In their chapter on the Instrumental self, which they suggest may be the most common of the three approaches, they make a striking observation that, in slightly different ways, has come to me in the past six months or so of training: therapists "appreciate the fact that what they do...does not ask them to change themselves as much as it invites them to come closer to their best and frequently unrealized selves" (11-12). This has been an unexpected but reassuring realization for me this year. (This is augmented later in the book with a passage from Harry Guntrip: "real psychotherapy does as much for the therapist as for the patient.")

Judicious Soundings from the Counter-Transference:

It is within this chapter that they get into some very useful detail about the origins and development of the notion of the counter-transference. I have for some time been influenced in this area by Harold Searles, Otto Kernberg, and then especially Nina Coltart, who advises the therapist to take judicious soundings from the counter-transference as it may offer otherwise inaccessible clues to what is going on in the patient. But how is that possible? Isn't the idea of counter-transference that it pertains to what is going on inside the therapist? How, then, can it offer clues to what the patient might be thinking, feeling, avoiding, or even totally unaware of? Moreover, how certain can we be that what the therapist's mind throws up is in fact reliable or accurate or truthful at all? Maybe it's anxiety from almost getting run over during lunch hour a few minutes ago while fetching the pizza now giving one dyspepsia and making one long for the sweet release of violently expelling the offending food. 

Such questions have long haunted me. How does one know--can one know?--that what one thinks one knows is in fact reliable and real, truthful and objective, and not merely the convoluted production of ones own issues? 

In this light, perhaps the most useful part of this chapter--indeed, book--is the sixfold typology Rowan and Jacobs offer of unhelpful or unreliable counter-transfer reactions that are most likely unreliable and liable to lead the therapist astray: 

Defensive: esp. related to the therapist's unresolved issues around sex, aggression, etc.

Attachment: those that evoke the therapist's need to be admired, successful, loved, powerful, etc.

Transferential: when the therapist responds as though the patient's parent or sibling.

Reactive: when the distortions of the transference neurosis are taken to be true by the therapist who reacts accordingly

Induced: when the therapist is induced to take on the role of giving advice

Identification: when the therapist overidentifies with the patient and/or the patient's child

Displaced: when feelings from other parts of the therapist's life come to be placed onto the patient. (This would be the pizza-induced dyspepsia in my example above.)

The above strikes me as something useful to run through your mind as you are trying to discern your own reactions to the patient to see what might be reliable and trustworthy in them. Later on, drawing on the late Jungian theorist Michael Fordham, the authors note that even if your counter-transference reactions prove illusory, that is valuable nonetheless insofar as it may teach the therapist something about himself. 

In the next chapter, the authors draw on Winnicott (not least his thrilling 1947 essay "Hate in the Counter-Transference"), who apparently modified that 1947 view in the 1960s by insisting that one distinguish between a reaction to a patient and a full-blown counter-transference. It is not entirely clear here what the difference is, though to me it seems plausible that a reaction may be momentary or short-lived, or discreetly focused on one particular thing, and a counter-transference may be a more wholistic, longer-term "package" of reactions. 

Presence and Analysis:

The authors note that the therapist must strive to overcome whatever blocks his ability to be fully present in the session. At the same time, and elsewhere in the book, they equally insist that the therapist cannot become totally lost in his immersion in the patient's world, but must do that all the while maintaining a critical eye, maintaining his critical-observational self. To capture this, they quote the late American therapist James Grotstein who apparently once said the posture of the therapist here is like that of the Pieta: Mary holding the tortured body of her son! 

The challenge of remaining present is perhaps higher today than when these authors wrote thanks to our electronics-addled brains. This is a topic I want to think more about and return to another time.