Optimal Responsiveness: A Short Note on Howard Bacal's Book

I begin with a confession: So much of what many authors in this collection, and above all the rather self-impressed and heavy-handed editor himself (who not only writes an introduction to the book, but also superfluous and sometimes condescending introductions to every chapter, including the two chapters he himself wrote) are enthralled with (viz., the concept of optimal responsiveness) seems very commonplace to me now. To avoid such impatience on my part, I had constantly to remind myself while reading Optimal Responsiveness: How Therapists Heal Their Patients, ed. Howard Bacal (Jason Aronson, 1998) that a quarter-century is a very long time in psychotherapeutic history, and that in 1998 when the book was published (and in years earlier in that decade as these chapters were being written) the things we take for granted today--being on this side of the rise of two-person, interpersonal, relational, and self-psychology changes in our theorizing at the hands of people like Thomas Ogden especially--were, in fact, rather novel. 

But I firmly believe books have to be read in their original context as well as our own, and so I can see how valuable many of these chapters may have been 25 years ago. And, as I shall briefly show, some of them remain very valuable today.

For me, the largest overall value comes from how much of self-psychology, including Kohut's writings themselves, this book very skillfully manages to make clear. In doing so, it helps me finally find valuable material in him after struggling for close to a decade to read him, including a stint in 2018-19 when I was on a fellowship at his very own Chicago Psychoanalytic Institute, some of whose analysts on faculty also admitted (sotto voce) they could hardly understand his leaden and jargon-riddled Teutonic prose.

The book's virtues extend beyond making Kohut generally clearer into showing some key parts of his thought that are of direct clinical use to me in one of my hardest cases. I always remain grateful to authors who give practicing clinicians ways of reconceptualizing a case and adjusting their techniques for trying out in that ongoing feedback loop that Jonathan Shedler memorably talks about. 

Bacal's opening chapters lay out the idea of "optimal responsiveness" which seems to have begun as an explicit challenge to very early ideas of "optimal frustration" of various drives. Two of the chapters do an excellent job laying out the genesis and historical development of this latter concept from Freud who seems to have been reacting not just to patients but also his rather more careless colleagues, not least Jung and Ferenczi who instead of frustrating or denying patients' desires for more intimate contact, indulged those to sometimes disastrous effect. 

Bacal argues that "optimal" does not mean perfect, but means instead means "most favorable natural conditions for growth" and thus can include all kinds of responses by the therapist in the moment. Thus if the patient needs you to be mirroring or affirming, you do it; if withholding is indicated, you do that; if something needs to be directly challenged rather than "contained" then you do that. In some ways, as I noted above, this idea of such flexibility is more commonplace today than it seems to have been in the 1990s, when Bacal wrote that "optimal responsiveness of the analyst is determined by the position of the patient on the developmental line of self-selfobject relations, and on his position on the developmental line of internalization of, and capacity for, empathy" (p.32). 

Overall several authors in the book usefully reminded me that in some cases with serious developmental deficits, there are in essence holes in the internal self-structure and until and unless these are repaired, or at least attended to in the best (optimal!) way, little progress will be made, especially if the idea of progress is heavily insight-dependent. Thus Kenneth Newman's chapter (drawing on Winnicott's famous essay "The Use of an Object") reminds us that some patients cannot use the therapist adequately when they have such deficits (I immediately thought here of obesessive-compulsive personality disorders, about which I wrote at some length here, and Shedler brillantly discusses here). 

I joined this up with a much later chapter by Lynne Jacobs who offers a helpful caution that some "patients need to forcefully blot out the subjectivity of analysts in order to ensure that there is room for their own" (p.200). A little later she says that sometimes with some patients (and I again think of OCPD patients here) the therapist's independent existence needs to be "sturdy enough to be left in the background for long periods of time, to be refound at a later point unharmed and available for engagement" (p.201). 

In other words, to use a famous passage she does not quote here, therapists themselves need to remember that it can be a "joy to be hidden" and is not necessarily a disaster not to be found (for a while!).