When Psychoanalysis Needs to Adapt to the Patient

An Interview with Robert Grossmark

Psychoanalysts increasingly find themselves working with patients who seem to defy verbal and dialogic engagement. Such patients are challenging for a psychoanalytic approach that assumes that the patient relates in the verbal realm and is capable of reflective functioning. Both the classical stance of neutrality and abstinence and a contemporary relational approach that works with mutuality and intersubjectivity, can often ask too much of patients.

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

Public Seminar [PS]: Why did you write The Unobtrusive Relational Analyst: Explorations in Psychoanalytic Companioning? Is there a gap, or hiatus, in psychoanalytic thought you wanted to address? In other words, what do you hope it might contribute to the field?

Robert Grossmark [RG]: More and more we psychoanalysts find ourselves working with patients who do not seem to be able to fully utilize contemporary psychoanalytic techniques. We are confronted with patients who struggle with a disrupted sense of self and identity, for whom time and space are fluid and disjointed phenomena, whose sense of self and other are fractured and blurred and who are often floating in altered states of consciousness or other worlds of experience. Such patients need not be manifestly disturbed individuals but we often find such phenomena tucked away in the inner private spaces of patients who have other areas of quite developed and adaptive functioning. These states are not available for verbal description because they are not represented or symbolized in clear thought and language, but reside in the realm of sensation and the unformulated. They are, if you will, deeply unconscious. Here I utilize the idea of the non-repressed unconscious and unformulated experience. This is to be distinguished from the customary conception of the unconscious as made up of thought and feelings that have been repressed due to the conflict and psychological pain that they cause. Freud himself hinted at other dimensions of consciousness and in this book I am addressing inner life that has yet to take form or to be represented due to ongoing or massive trauma and neglect.

Such patients and states have presented a challenge to psychoanalysis where there is an emphasis on the patient’s ability to reflect on their experience and to utilize words and thought in their treatment. This applies to the more classical approaches that lean on the analyst’s interpretation as the primary clinical intervention and agent of change as well as more contemporary relational and interpersonal approaches that, while offering a refreshingly egalitarian and collaborative approach to analysis, often rely on the patient’s ability to consider the interaction and experience of the analyst and to reflect on what arises in the clinical relationship. For the patients I am encountering and describing such approaches may not address their wordless pain and confusion. Such approaches may, in fact, cause the patient a degree of shame and hurt and may cause the patient to feel a private despair that their inner suffering will ever be known and engaged with by an other.

The book outlines an approach that tries to meet these patients and states in their own register and idiom and welcomes expressions and communications that arrive outside of the dialogic and cognizable. Primarily the book looks to the expression and emergence of these hidden areas of inner pain and confusion in the dimension of mutual enactment that emerges between the patient and analyst (or in the case of group psychoanalysis, within the group and between the group members and the group analyst).

This approach situates the analyst within a field that emerges from the analytic couple (or group), rather than on a perch outside the interaction with a “view from nowhere”. Hence the analyst is available to be moved and drawn into the world of the patient and to experience phenomena that arise as the treatment progresses. The analyst companions the patient into the expression of their inner worlds and idiom in a lived and shared space within the treatment. Rather than hurrying to understand such phenomena and put things into words, to make analytic material out of this, as is the tilt of most psychoanalysis – and most therapy interventions for that matter – the unobtrusive relational analyst will hear the call of the patient to be known in their inner world and will thus lend themselves to unobtrusively companion the patient in this world as it emerges in the treatment.

The analysis belongs to the patient, not the analyst, and is to be oriented to the patient’s needs and modes of self-representation. So rather than seeking to quickly move the patient out of their inner pain, confusion and disorganization into the world of supposed consensual reality, the analyst can enter into the patient’s world and seek to know that world from within, as it were, to know the patient on their own terms and in their own register. This process itself is at the core of what heals and what fertilizes the growth of mind and the expansion of human functioning that has been constrained and thwarted.

I offer this as a new register of psychoanalytic practice.

PS: How did the project evolve over time? Did your original idea go through many stages and changes? Can you describe them for us?

RG: These ideas developed over many years of practice working with many diverse populations, from Bellevue Hospital, a state psychiatric hospital, a public health clinic in the South Bronx, a college counseling center and eventually to many years in my private practice in Manhattan. The central focus is so simple and straight forward: when patients – whether in the South Bronx or the Upper West Side – feel respected and known for who they are, on their own terms, when they feel that it is their treatment, and they come to their own inner realizations, wonderful and surprising healing occurs.

Since the original papers on “The Unobtrusive Relational Analyst” I realized that when I could unobtrusively allow the emergent enactments to flow, unimpeded, and could companion the patient on these journeys in the treatment, I found myself living through uncanny, often disturbing and sometimes revelatory lived narratives. These were narratives that were not told in words but found expression in the lived, enactive dimension of the treatment. Often these were enacted “tellings” of early, unremembered trauma and neglect and sometimes enactments of parts of the patient’s inner world that had never found expression. It was as if patents were telling me – in action and evoked sensation that involved both of us – things about themselves and their lives that they were yet to even consider themselves. I call this “enactive co-narration” and describe such occurrences in the book.

PS: You began your psychotherapy journey in a resolutely behavioral program but found your way to psychoanalysis, to relational psychoanalysis in particular. Can you relay some of the experiences, events and realizations that prompted this transition?

RG: Yes: my original clinical training was in the early eighties in the UK. At that time the field of clinical psychology was largely undeveloped. There was no doctorate in clinical psychology and all the Masters Programs were Skinnerian behavioral in orientation. I found myself engaging in treatment relationships that can best be described as Monty Python-esque. For example I found myself standing with a patient on top of the highest building on campus in blustering wind and rain conducting systematic desensitization for fear of heights. After screaming through the elements as he answered the protocol questions about his current level of anxiety we returned to ground level and relative sanity and he talked and talked with much emotion about his life, his family and so forth. Over the short course of treatment he improved greatly and he and I were well aware that it was not due to the behavioral intervention, but rather through the meaningful and felt relationship that developed between us. I had countless other experiences like this with individual patients and with groups and became aware of the powerful potential for healing and transformation that human engagement contains.

This realization was embellished and expanded in so many ways as I completed my doctoral training and subsequent psychoanalytic training in New York. I always found the psychoanalytic convention of the neutral or abstinent analyst to be a jacket that never quite fit for me and for the patients I was treating. Like so many other psychoanalysts and also patients I found the relational turn to be a refreshing and enlivening development in the field. Psychoanalysis was now embraced as a mutual and egalitarian enterprise and the theory glowed with the input of post- modern theory, queer theory, feminism, trauma theory and multi-culturalism. However I have always taken much from psychoanalytic literature as a whole and have never sought to simply off-load older theory. Rather, as the books attests, I have sought to integrate, embellish and contemporize some of the classical psychoanalytic ideas, such as regression, free association, object relations, transference and so forth.

I am now proud to be a part of a psychoanalysis that is new, even hip, smart and on the cutting edge of culture and thought and most importantly, open for everyone. It is this psychoanalysis that I now live within, that enlivens my work and that I engage with as I try to find ways to expand our practice and engage with patients and states that have often struggled to find a place in psychoanalysis in the ways that I describe in the book.

PS: Reading your work, it becomes apparent that unobtrusive is polysemic. To borrow a turn of phrase from Wallace Stevens, how many ways are there of looking at what being unobtrusive in the analytic context might mean?

RG: Indeed, being unobtrusive is a psychological orientation of the analyst rather than a code of analytic conduct. The analyst is unobtrusive to the field that emerges in the treatment, to the full expression of the patient’s idiom and register, to the flow of mutual enactment and to the developmental needs of the patient at any given time. Hence being unobtrusive might mean waiting quietly and patiently as the patient talks or it could mean being very active and joining the patient in a register of expression or playfulness that emerges. From my perspective what is obtrusive is to tell a patient who is, let’s say, walking around the office while talking in session and fiddling with ornaments on my shelf, that he or she should sit on the couch and try to put what they are feeling into words. That might, actually, sound like ordinary psychoanalysis, but think about it. From my perspective, I would unobtrusively welcome this behavior as an expression and communication of the self from another dimension: the motoric and non-symbolized. Given that it is being expressed in this register, I would not seek to bring it into the dialogic register of words and relatedness. Quite the opposite: I would regard it as a call from another dimension within the patient, precisely, a dimension that cannot utilize words to find expression and representation. Hence I would be welcoming and unobtrusive to this and I would pay careful attention to what feelings this is evoking in myself. For instance I might feel uncomfortable, scared, entertained, angry and so forth. Further I would not expect to know what I myself felt immediately. After all, if one can answer the question: what are you feeling?, by definition one is not connecting to what is unconscious. Thus I would be unobtrusive to this and other expressions in these different dimensions and find where this takes us an analytic couple over time. Often, I have found, patients may continue with these kinds of expressions and over time, a narrative of peculiar, painful, or otherwise disturbing experience will emerge. And the remarkable thing is that it may emerge in my consciousness, the patient’s mind or in interactions that are totally unbidden and unpredicted. In a way, I would suggest that this kind of unobtrusive companioning of patients into these emergent enactments is a new royal road to the expression of the unconscious.

PS: Finally, which books, thinkers and ideas beyond psychoanalysis have inflected your psychoanalytic and writerly sensibility?

RG: I’ll keep this answer quick, but recently I have been reading the six-part novel, “My Struggle” by the Norwegian writer Karl Ove Knausgaard. I have found it mesmerizing and perplexing. I particularly appreciate the ordinariness of the tales of his development. The rendition of ordinary lived life resonates with how I conceive of psychoanalysis. The truth emerges on its own, as it were, without contrivance, plotting or interpretation. It is revealed in its own expression, unalloyed and unobtruded.

The Unobtrusive Relational Analyst: Explorations in Psychoanalytic Companioning is available for purchase on the Routledge website here, and on Amazon here.

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

Joshua Maserow is a PhD student in clinical psychology at the New School for Social Research and an editor at Public Seminar. His scholarly interests include Relational Psychoanalysis, therapist and common factors in psychotherapy research, and global contemporary literature.

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