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The Psychodynamic Paradigm: Relational Perspectives

...they are not all exploring elephants. Some may be grappling with giraffes. To try to contain the same reports within one framework may lead to strange hybrids: four stout legs; a long, graceful neck; four thin legs; a long trunk; and so on.

-Stephen Mitchell

Although Freud’s drive psychology' served as the orienting paradigm in classical psychoanalytic thought through the first half of the 20th century, a growing number of thinkers challenged his vision of human nature and therapeutic action, introducing alternative perspectives that would broaden the scope of understanding and practice. In this chapter I trace the emergence of relational perspectives in Europe and North America, showing how thinkers reformulated ways of understanding mind and self, relationship and social life, vulnerability' and psychopathology', health and well-being, and the dynamics of therapeutic action. I describe the defining features of three schools of thought, broadly categorized as object relations psychology, interpersonal psychoanalysis, and self psychology', that have shaped the relational paradigm in contemporary' psychoanalysis. I review the orienting perspectives of the relational model and outline basic assumptions, core concepts, and essential concerns that guide formulations of therapeutic action, change, and growth. In doing so I consider points of connection with recent developments in the science of mind and the basic principles and values of clinical pragmatism.

Origins

Like Jung, Alfred Adler, Otto Rank, and Sandor Ferenczi—originally' members of Freud’s inner circle—also came to challenge the core propositions of classical drive psychology’. They' increasingly emphasized the role of relational life, social surrounds, and culture in fashioning their accounts of personality' development, vulnerability, and problems in living. They found the fundamental methods of classical psychoanalysis limiting and introduced more active forms of intervention focused on immediate concerns, emphasizing the crucial functions of collaboration, interpersonal interaction, and experiential learning. The

The Psychodynamic Paradigm: 2 89 following account, expanding earlier writings on the history of psychoanalysis, reviews the contributions of early revisionist thinkers who shaped the emergence of relational perspectives (Borden, 1999, 2000 2009, 2018; Borden & Clark, 2012).

Although Adler did not codify his theories in a systematic manner, as Freud had, he pursued fundamental concerns and themes over the course of his practice, introducing a relational perspective that would provide a radical alternative to drive psychology. He understood people as “social beings,” deeply connected and interdependent, and he focused on the fundamental role of relationship, community, and social life in formulating his conceptions of development, resilience, and the common good. He elaborated a holistic conception of personality that emphasized the unity of body and mind, agency and free will, the search for meaning, and social responsibility (Adler, 1927/1992). He increasingly engaged moral and ethical concerns as he shaped his point of view and elaborated a psychology' of values that would influence the humanistic perspectives of Abraham Maslow and Carl Rogers (see Chapter 8).

Over the course of development, Adler proposed in his accounts of social interest, we come to feel a deep sense of connection with humankind, recognizing our interconnectedness and interdependence, realizing that the welfare of any one individual depends on the well-being of the larger community. Constructive relationships and sustaining communities are characterized by mutual respect, attunement and empathy, trust, cooperation, and personal equality (Adler, 1927/1992).

Adler emphasized the importance of dialogue, narrative, and the co-creation of meaning in his conceptions of therapeutic action, anticipating the emergence of constructivist approaches in the cognitive paradigm (see Chapter 7). As a practitioner he preferred active and briefer forms of intervention, employing what we would now describe as cognitive, behavioral, educational, and taskcentered methods, emphasizing experiential learning and the practical outcomes of help and care. As an advocate of social justice he initiated reform in the fields of education, social welfare, and public health. He came to encompass family, group, and community perspectives in integrative models of practice.

Rank, known for his scholarship in art, literature, philosophy, and mythology, focused on existential concerns as he fashioned his humanistic models of personality. He centered on the dynamics of autonomy, dependency, and individuation in developing his relational perspective, introducing notions of agency, will, responsibility, and action in his formulations of therapeutic action, change, and growth (Rank, 1936). He came to think of the individual as an initiator of action and interpreter of meaning, emphasizing conscious motives and goals rather than unconscious realms of experience, focusing on present circumstances and on anticipated future rather than past events.

He assumed that maladaptive patterns of functioning established over the course of relational life would emerge in the therapeutic process, providing in-vivo occasions to work through earlier experience and strengthen capacities to act and negotiate problems in living. In accord with Dewey’s pragmatic thought, he saw the dynamics of experiential learning as fundamental mechanisms of change and growth. His ideas shaped the development of the field of brief psychotherapy and basic principles of intervention in the collective wisdom of social work practice. More broadly, his emphasis on relationship, will, and creativity influenced a range of existential thinkers in humanistic psychology, notably Rollo May and Irvin Yalom (see Chapter 8).

Like Adler, Ferenczi broadened the scope of the psychoanalytic paradigm, emphasizing the ways in which social, cultural, political, and economic conditions perpetuate restrictions of opportunity and problems in living. He founded a free clinic in Budapest, focusing his practice on marginalized and oppressed groups. He increasingly centered on the dynamics of family life and the concrete realities of actual experience in the outer world as he formulated his conceptions of vulnerability and trauma. He related a range of problems in functioning to lapses in earlier care, emphasizing the traumatic effects of empathic failings and deprivation in relational life.

Ferenczi recognized the crucial importance of the therapeutic alliance and the sustaining functions of the practitioner’s attunement, empathy, and responsiveness, viewing the relationship as a collaborative, mutually supportive partnership. He proposed that enactments, transference states, and countertransference reactions provide points of entry into the dynamics of earlier experience, creating in-vivo occasions to rework patterns of behavior and establish new ways of being and relating. He departed from the neutral stance that Freudians had advocated and introduced the “rule of empathy” as a fundamental principle of psychotherapy, coming to see emotion as the transformative element of change and growth (Ferenczi, 1932/1949). He outlined revisions of analytic technique in The development of psychoanalysis (1924), co-authored with Rank. He continued to expand concepts of therapeutic action in his later work, integrating behavioral strategies and relaxation techniques, seeking to reduce the length of treatment and improve outcomes, anticipating fundamental concerns that would shape the field of brief psychotherapy (Borden, 1999).

Although the contributions of these early thinkers remain absent or marginal in most accounts of the psychodynamic paradigm, they anticipate essential concerns in the emergence of relational understanding and prefigure the growing emphasis on active, integrative forms of therapy in contemporary practice.

The collective experience of trauma, loss, and mourning in Great Britain after World War I changed the course of psychoanalytic understanding and therapeutic practice through the 1920s. A diverse group of practitioners associated with the Tavistock Clinic in London, drawing on the work of Jung, Adler, and Ferenczi, increasingly focused on the dynamics of relational life as they cared for patients following the widespread experience of separation, loss, and grief. Ian Suttie, one of the most creative thinkers of the group, proposed that innate needs for relationship and love are the fundamental motivations of personality development, focusing on the generative functions of relationship and community life and the role of “social interest” in his notions of health, well-being, and the common good (Suttie, 1935). He argued that problems in

The Psychodynamic Paradigm: 2 91 living are shaped more by family dynamics, stressful circumstances, and social and cultural conditions than by universal biological forces. Like Ferenczi, he emphasized the healing functions of the therapeutic relationship, the role of emotion, and the dynamics of interactive experience in change and growth.

The generation of thinkers that followed, including Melanie Klein, W. R. D. Fairbairn, Donald W. Winnicott, and John Bowlby, continued to carry' out radical revisions of psychoanalytic thinking that would shape relational perspectives throughout the second half of the 20th century.

Working in the Freudian tradition, Klein preserved classical notions of drive and emphasized the dynamics of fantasy life in her conceptions of the self. Over the course of her work, however, she introduced concepts of internal representation (“internal objects”), defensive processes (“splitting” and “projective identification”), and self-organization that provided crucial points of departure for Fairbairn, Winnicott, and Bowlby as they elaborated their relational perspectives. While many thinkers criticize Klein for her failure to consider the role of interpersonal experience, social conditions, and cultural factors in her models of personality development, she provided a crucial bridge to the object relations tradition, emerging as a seminal figure in the transition from drive to relational perspectives.

Like Suttie, Fairbairn placed relationship at the center of human life, elaborating models of development that have come to serve as the foundation for contemporary object relations perspectives. We are inherently oriented to others at birth, he proposed, and fundamental needs for contact and relationship shape behavior throughout life (Fairbairn, 1952). In his developmental schema, the self is structured through the internalization and representation of interpersonal experience as schemas or models of relational life. He documents the ways in which lapses in care, neglect, abuse, and trauma compromise the course of development and perpetuate problems in living. Like Ferenczi, he emphasizes the crucial role of the therapeutic alliance and the dynamics of enactment, transference states, and interactive experience in working through the failings of relational life.

Winnicott centered on the emergence of the self as he formulated his accounts of development, emphasizing the ways in which the constancy of care in the holding environment of infancy and early childhood fosters maturation, health, and well-being. “There is no such thing as a baby,” Winnicott wrote, focusing on the intersubjective dynamics of care. “One sees a nursing couple” (1952/1975, p. 99). He proposed that we are born with an inherent motivation to actualize the “true self” and described the dynamics of the “maturational process” that governs the “drive towards integration” and the development of the individual (Winnicot, 1963/1965, p. 239; see Chapters 3 and 9, this volume). He described three processes that mediate the development of the self—“integration,” “personalization,” and “object relating”—and corresponding caretaking provisions that foster maturation of core structures, psyche-soma integration, and capacities to negotiate relational life: “holding,” “handling,” and “object relating” (for expanded review of developmental concepts see Borden, 2009, 2018). Although lapses and failings in care may undermine the integrative functions of the maturational process, Winnicott believed that we continue to search for conditions that earn' the potential to reinstate the course of development. He increasingly centered on subjective experience in elaborating his developmental psychology, most fully realized in his conceptions of embodiment and the “true self,” emphasizing our capacities for aliveness, inner coherence, authenticity, agency, personal meaning, creativity, and play.

In accord with the values and sensibilities of the Independent Tradition in the British Psycho-Analytic Society, Winnicott was committed to a pragmatist ethics in his approach to help and care, as noted in the Introduction. He refused to codify his ideas in a grand theory', explaining: “...my mind doesn’t work that way... I gather this and that, here and there, settle down to clinical experience...” (1945/1975, p. 145). He rejected standard models of psychoanalysis and remained steadfast in his efforts to carry' out “experiments in adapting to need,” using whatever ideas and methods offered purchase in light of the possibilities and constraints of the given case (Winnicott, 1971; see Chapter 9 this volume).

Bowlby joined the orienting perspectives of Darwinian thought, developmental biology, ethology, infant observation research, and dynamic systems theory' as he formed his conceptions of attachment, emphasizing close analysis of behavior, deepening our understanding of the bond between children and parents. He argued that the fundamental need to establish contact and connection has adaptive roots in biological survival; relational life, he believed, is grounded in the genetics and physiology' of human development. Drawing on cognitive psychology', he proposed that we internalize and represent fundamental elements of relational experience as mental structures, forming schemas or “working models” of self and others that guide ways of processing information and patterns of interpersonal behavior; in this sense his formulations converge with the basic proposals of Fairbairn and object relations psychology, described in the following section. He emphasized the ways in which the clinician provides a “secure base” as the patient processes earlier experiences of separation, trauma, and loss, reworking inner models of relational life that perpetuate problems in living, attending to transference states and particular patterns of behavior that emerge over the course of help and care (Bowlby, 1988).

Bowlby’s work informed the development of observational research that documented the ways in which infants actively' seek stimulation and promote attachment to primary' figures who provide protection and support. Mary' Ainsworth introduced the controlled setting of the “strange situation,” demonstrating different kinds of attachment styles seen in a novel circumstance of controlled separation from the primary' caretaking figure. Mary' Main studied the dynamics of attachment across generations, exploring the relationship between a parent’s early attachment experiences and the infant’s attachment status. Converging lines of study in developmental psychology and the fields of

The Psychodynamic Paradigm: 2 93 neuroscience have continued to explore the role of interactive experience in the maturation of the brain and the emergence of the self, influencing patterns of adaptation across the course of life (for expanded reviews see Fonagy, 2001; Schore, 2019a, 2019b; Siegel, 2020; Sroufe, 2016).

Harry Stack Sullivan, Karen Horney, Clara Thompson, Frieda Fromm-Rcichmann, and Eric Fromm shaped the emergence of interpersonal psychoanalysis in North America throughout the 1930s and 1940s, introducing social and cultural perspectives that enlarged conceptions of personality' development, relational life, and therapeutic action.

Sullivan drew on American pragmatism and divergent thinkers in the Chicago school of social science, including George Herbert Mead, W. 1. Thomas, and Edward Sapir, as he elaborated process-oriented models of personality and mind that centered on the dynamics of relational life and the social surround. Like Bowlby, he brought an empirical disposition to his work, attending to what we say' and do in the “me-you” patterns of interactive experience. He focused on the concrete particulars of life as sensed and felt, the formative role of social interaction in understanding and problem-solving, and the practical outcomes of ideas. Moved by' the example of Jane Addams, he set out to engage vulnerable, disenfranchised groups in help and care, focusing on real-life concerns, hoping to democratize psychotherapy.

In formulating his developmental psychology, Sullivan proposed that the experience of dependency and conditions of care through infancy and childhood inevitably generate vulnerability', fear, and anxiety' as we negotiate the possibilities and constraints of relational life in the social surround. Over the course of development, he theorized, we elaborate repetitive patterns of behavior in ongoing efforts to reduce fear and anxiety', increase security and satisfaction, and preserve connections with others (Sullivan, 1953). He described the dynamics of the “self system” that sanctions certain forms of behavior (the “good-me” self), prohibits other forms of behavior (the “bad me” self) and excludes from consciousness ways of being that are too threatening to imagine (the “not-me” self). He thought of the self-system as a filter for awareness, introducing the concept of “selective inattention” to describe unconscious refusals to register experience that intensifies fear and anxiety'.

Sullivan challenged reductive taxonomies of psychopathology', preferring to speak of “dynamisms of difficulty” and “problems in living” in accord with the “one genus postulate” that he introduced in his case seminars: “we are all much more simply human than otherwise” (Sullivan, 1953, p. 32). His formulations of problems in living center on the way's in which defensive processes perpetuate maladaptive patterns of thought, feeling, and action. He viewed the clinician as a participant-observer in the therapeutic process, emphasizing the role of interpersonal interaction, active forms of intervention, and experiential learning in change and growth.

Horney enlarged conceptions of self and relational life through the 1940s and 1950s, exploring the ways in which the dynamics of family life and social and cultural conditions influence the course of development, gender identity', patterns of interpersonal behavior, and problems in living. In her formulations of neurosis, fear and anxiety constrict ways of being, relating, and living, limiting realization of potential. She elaborated interpersonal conceptions of defense and described “vicious circles” of thought, feeling, and action that perpetuate problems in living (Wachtel expands these formulations in his integrative model, described in Chapter 6).

As she developed her relational perspective she came to think of the defining feature of neurosis—“a special form of human development antithetical to human growth”—as alienation from the core self, originating in pathogenic conditions in the social surround (Horney, 1950, p. 13). “It is the process of abandoning the real self for an idealized one: of trying to actualize this pseudoself instead of our given human potential...” (1950, p. 371). Abraham Maslow and Carl Rogers drew on her work in shaping their conceptions of humanistic psychology' (see Chapter 8). In line with her developmental formulations, Horney emphasized mutual sources of recognition, empathy, and influence in the therapeutic relationship; emotion and intuition as modes of knowing; and the role of experiential learning as the patient challenges neurotic patterns of behavior and re-appropriates the authenticity and authority' of self.

Heinz Kohut explored fundamental concerns in the realm of subjectivity' as he shaped his psychology’ of the self in North America in the 1970s and 1980s, focusing on the sense of cohesion and coherence in states of being; the feeling of aliveness and vitality; capacities for agency and initiative; and the ways in which we generate experience that we register as real, meaningful, and distinctly' our own. He centered on the fundamental need to establish a unitary, integrated sense of self and the crucial role of relational life in health, wellbeing, and optimal functioning. He focused on the ways in which the dynamics of mirroring and interactive experience foster the emergence of the self over the course of care, exploring the dyadic features of unconscious communication and regulation between the infant and caretakers, anticipating formulations of intersubjectivity'. He introduced the concept of the “selfobject” in his developmental schema, defining the construct as an intrapsychic experience of a person, object, or activity' that strengthens and sustains the self (Kohut, 1977). He proposed that the selfobject functions of caretakers are gradually' internalized as self-functions, or inner psychic structure, through the process of “transmuting internalization,” fostering the development of capacities for selfcohesion, self-regulation, and self-righting.

The fundamental aim of psychotherapy, from the perspective of self psychology, is to reinstate developmental processes that have been compromised by earlier lapses in care. The therapist’s empathic attunement and responsiveness as a selfobject strengthen the integrity' of the self. Kohut described three forms of selfobject transference—mirroring, idealizing, and twinship—that provide experiential opportunities for the restoration of the self. He emphasized the crucial role of “vicarious introspection” and “protracted empathic immersion” as the patient engages selfobject functions instrumental in healing, change, and growth (1971, p. 300).

The Psychodynamic Paradigm: 2 95

Relational Schools of Thought

The writings of the foregoing thinkers, placing relationship at the center of human experience, shaped the development of three schools of thought in the psychodynamic paradigm, broadly described as object relations theories, interpersonal psychoanalysis, and self psychology. Although scholars did not attempt to establish overarching frameworks, they emphasized overlapping concerns and themes in their developmental formulations and therapeutic approaches. I briefly review orienting perspectives that have guided understanding and practice in each tradition, expanding earlier accounts of the psychoanalytic paradigm (Borden, 2009; see Borden & Clark, 2012, for a review of relational models, empirical research, and implications for evidence-based practice).

Object Relations Perspectives

Contemporary' object relations perspectives, shaped by the developmental formulations of Ferenczi, Klein, Suttie, Fairbairn, and Bowlby, continue to center on the ways in which the dynamics of motivation, emotion, and cognition influence subjective states of self, perceptions of others, and patterns of interpersonal behavior. Clinical scholars propose that basic prototypes of connection, formed over the course of caretaking and early' relational life, are structured as internalized representations of self and others. Although thinkers assume that core representations originate in the dynamics of interpersonal experience, they' believe that inner models of relational life are also influenced by individual differences in constitution and temperament, regulatory functions, and unconscious fantasy processes. The dynamics of interoception and emotion, emerging needs, interpersonal interaction, and life circumstances are thought to influence the particular representations guiding perception and behavior at any' given time. We experience others as we perceive them, not necessarily as they' actually' are (Wachtel, 2011).

Conceptions of vulnerability' and psychopathology' focus on the ways in which inner models of self and others influence perceptions of relational life, activate defensive processes, and perpetuate maladaptive patterns of behavior. Thinkers have reformulated Klein’s accounts of “splitting” and “projective identification” from a relational point of view, expanding conceptions of defense. Models of therapeutic action center on the dynamics of interaction and experiential learning as patients process enactments, transference states, and countertransference reactions; reorganize maladaptive defenses; enlarge inner representations of self and others; and strengthen capacities to negotiate the course of relational life.

Object relations perspectives have guided empirical study' of personality' development, trauma, psychopathology', and therapeutic practice over the last three decades. Developmental lines of study have explored the dynamics of caretaking experience, patterns of attachment, interactive forms of communication and emotional regulation, and emerging capacities to negotiate relational life.

Research findings corroborate the assumption that infants are pre-adapted to form attachments and engage in complex forms of interaction with caretaking figures (Beebe & Lachmann, 2013; Fonagy, 2001; Fonagy & Target, 2007; Schore, 2019a, 2019b; Solms, 2018a, 2018b; Stern, 1985, 2004). Longitudinal studies document the ways in which attachment styles and dyadic caregiving systems influence development of personality organization, capacities to regulate emotion, interpersonal functioning, and patterns of coping and adaptation (see Fonagy, 2001; Fonagy & Target, 2007; Schore, 2019a, 2019b; Siegel, 2020; Solms, 2018a, 2018b; Sroufe, 2016; Sroufe, Egelund, Carlson & Collins, 2005).

Research on perception, learning, and memory in the field of cognitive neuroscience has provided considerable support for object relations formulations of unconscious mental processing and mental representations of self, others, and of relational life (Schore, 2019a; Solms, 2018a; Westen, 1998, 2005; Westen & Gabbard, 2002a, 2002b). Converging lines of study corroborate conceptions of transference, documenting the ways in which the dynamics of interpersonal interaction activate inner representations of self and others; motivational, emotional, and cognitive processes, and corresponding patterns of behavior (Gabbard & Westen, 2002a, 2002b; Schore, 2012, 2019a, 2019b; Sohns, 2018a, 2018b).

Clinical researchers have explored the ways in which inner models of relational experience and patterns of social cognition precipitate problems in functioning associated with depression, acute stress reactions, post-traumatic stress disorders, personality disorders, and other forms of developmental psychopathology' (see reviews by Blatt & Homan, 1992; Borden & Clark, 2012; Fonagy' 8c Target, 2007; Luborsky 8c Barrett, 2006; Masling 8c Bornstein, 1994; Messer 8c Kaslow, 2020; Roth 8c Fonagy', 2005; Westen, 1998, 2005, 2007; Westen, Novotny' 8c Thompson-Brenner, 2004).

Interpersonal Perspectives

Whereas object relations perspectives center on the role of internalization processes and mental representations of self and others, interpersonal approaches focus on overt patterns of behavior in the interactive fields of relational life, expanding the developmental models of Sullivan and Horney reviewed in the preceding section. Clinical scholars have continued to elaborate process-oriented conceptions of mind and self, exploring the way's in which the changing contexts of relational life influence subjective experience, the dynamics of defense, and patterns of behavior. Integrative thinkers assume that there is an isomorphic relationship between inner models of relational life and patterns of behavior in the outer world, viewing object relations and interpersonal approaches as complementary' perspectives.

In working from an interpersonal perspective, the patient and therapist explore the dynamics of anxiety, defense, enactments, and maladaptive patterns of behavior as they emerge in the clinical situation, engaging opportunities for

The Psychodynamic Paradigm: 2 97 experiential learning that foster the development of relational eapacities and interpersonal skills. As noted earlier, Sullivan views the clinician as a “participantobserver” in the interpersonal field of the therapeutic process. The concept of interpersonal complementarity is a basic principle of interpersonal theory: patterns of behavior tend to evoke particular types of reactions from others, which reinforce negative self-appraisals and expectations of others (Borden, 2009; Wachtel, 2008). Countertransference reactions emerge as role-responsive complements or counterparts to the patient’s ways of being and relating. As we will see, Sullivan’s formulations converge with concepts of therapeutic action in third-wave behavioral models of intervention, emphasizing the importance of experiential learning in change and growth (see Chapter 6).

The core concepts of interpersonal psychoanalysis have guided formulations of interactive experience in empirical studies of psychotherapy over the last three decades (see Benjamin, 1993; Curtis, 2020; Leichsenring, 2009; Levenson, 2017; Luborsky & Crits-Christoph, 1990; Strupp & Binder, 1984). Investigators have examined the relationship between social information processing and transference phenomena, documenting the dynamics of motivation, emotion, and cognition and the activation of “interpersonal scripts” or schemas that specify particular patterns of interpersonal behavior (see Shedler, 2010; Solms, 2018a, 2018b; Westen, 2005). Recent reviews of the literature document the effectiveness of interpersonal approaches for a range of conditions, including depression, anxiety' disorders, post-traumatic stress disorder, and personality' disorders (for reviews of empirical findings see Curtis, 2020; Gibbons, Crits-Christoph & Hearon, 2008; Leichsenring & Rabung 2009; Luborsky' & Barrett, 2006; Roth & Fonagy, 2005; Shedler, 2010; Solms, 2018a, 2018b).

Self Psychology

Clinical scholars have continued to expand Kohut’s formulations of development, psychopathology', and psychotherapy, exploring points of connection with object relations perspectives, interpersonal schools of thought, and conceptions of intersubjectivity'. Thinkers center on the fundamental need to establish a unitary, integrated sense of self and the sustaining functions of relationship across the course of life. Developmental formulations describe the ways in which the empathic attunement, responsiveness, and provisions of caretakers or selfobjects foster the emergence of a cohesive sense of self. Researchers have documented the dynamics of synchrony, rupture, and interactive repair in attachment and relational life, theorizing that caretaking functions are internalized as psychic structure, facilitating efforts to regulate states of self. Failures in empathic responsiveness are believed to compromise the development of the self, leading to structural deficits and defensive patterns of behavior. Clinicians describe a range of problems in functioning associated with disorders of the self, including difficulties in preserving cohesion and continuity' in subjective experience and sense of identity', regulating emotion, maintaining self-esteem and morale, negotiating interpersonal life, and pursuing meaningful goals and activities.

Following Kohut’s reformulations of therapeutic action, clinicians focus on the critical functions of relational provisions believed to strengthen the self and regulate the dynamics of inner life. The therapist’s empathic attunement and responsiveness as a selfobject foster the development of psychic structure through the process of “transmuting internalization,” strengthening the integrity and regulatory functions of the self. For Kohut, health, well-being, and the good life depend on the “responsive selfobject milieu” (1984, p. 21).

Over the last three decades, converging lines of study have corroborated core concepts of development, exploring the ways in which infants and caregivers mutually influence states of self through interactive communication and regulation of emotion. Daniel Stern described four “domains of relatedness,” influenced by constitution and temperament, innate maturational capacities, and the attunement and responsiveness of caretakers, that shape the emergence of the self (Stern, 1985, 2004). Beatrice Beebe and Frank Lachman documented the dynamics of ongoing regulation, rupture and repair, and heightened emotional moments over the course of their research (Beebe & Lachman, 2013). Allan Schore has drawn on core concepts from self psychology' in elaborating neurobiological models of development, focusing on the experience-dependent maturation of the right brain, as discussed in Chapter 3 (2003a, 2003b, 2012, 2019a, 2019b). Longitudinal studies show that patterns of emotion, cognition, and behavior established in infancy and early childhood continue to shape the course of interpersonal functioning and adjustment in adulthood (Fonagy & Target, 2007; Siegel, 2020; Sroufe, 2016; Westen, 1998).

Schore has reformulated conceptions of trauma, post-traumatic stress disorder, and borderline personality organization, exploring the ways in which interactive experience over the course of psychotherapy influences the neurobiology of regulatory structures (Schore, 2019b). A large body of research on the core conditions of the therapeutic relationship and management of strain and rupture in the therapeutic alliance documents the crucial role of the practitioner’s presence, empathic attunement, and responsiveness in determining the process and outcomes of treatment (see reviews by Curtis, 2020; Horvath, 2006; Roth & Fonagy, 2005; Schore, 2019a, 2019b; Wampold, 2015; Wolitzky, 2020).

The Relational Paradigm

The above perspectives emerged as independent schools of thought in Great Britain and North America over the second half of the 20th century’, and there was surprisingly little dialogue or collaboration among the members of the different groups as they elaborated their developmental formulations and concepts of therapeutic action. Although all of them rejected drive psychology and emphasized the crucial role of relational life in human experience, they did not explore shared concents or points of connection. Fairbairn and Sullivan, the principal architects of object relations psychology’ and interpersonal

The Psychodynamic Paradigm: 2 99 psychoanalysis, remained unaware of one another’s contributions over the course of their work; Kohut failed to explore connections between his psychology' of the self and the earlier writings of Suttie, Fairbairn, Wtnnicott, or Bowlby. In the early 1980s, however, clinical scholars began to carry’ out comparative studies of theoretical perspectives and clinical strategies, seeking to clarify' the defining features and overlapping elements of the different approaches.

In their seminal work, Object relations in psychoanalysis, Jay Greenberg and Stephen Mitchell distinguished two competing paradigms that had shaped the development of psychoanalytic thought, broadly' described as the drive model and the relational model (1983). They' had originally used the term “relational” to bridge the British versions of object relations psychology and the American school of interpersonal psychoanalysis. In time, however, Mitchell expanded the scope of the relational perspective, encompassing emerging lines of study' in self psychology and intersubjectivity', attachment research, social constructivism, narrative psychology', postmodern feminist thought, gender studies, and systems theory’. He continued to carry’ out comparative studies of ideas and methods across the schools of thought, reformulating Freudian conceptions of constitutionality, embodiment, sexuality, aggression, and meaning from a relational perspective.

Mitchell joined the orienting perspectives of self psychology', object relations theory', and interpersonal psychoanalysis in developing an integrative framework, focusing on core domains of experience in his conception of the relational matrix: self-organization, internal representations of self and others and models of interaction; and patterns of behavior in the changing contexts of interpersonal life. As he showed in his accounts of clinical practice, the relational schools of thought focus our attention on overlapping realms of experience from different points of view, shaping complementary ways of understanding therapeutic action, change, and growth.

Over the course of his work he fashioned a conceptual synthesis that would serve as the foundation of relational psychoanalysis, emphasizing the practical utility of theories (Mitchell, 1988, 1993, 1997, 2000). In doing so he recognized crucial points of connection with the pragmatism of William James (see Mitchell & Harris, 2004). In framing the editorial philosophy of the international journal he founded, Psychoanalytic Dialogues, he proposed: “We need to regard differences in theoretical perspectives not as unfortunate deviations from accurate understanding but as fortunate expressions of the complex way's in which human experience can be organized” (Mitchell, 1991, p. 6). Some thinkers may' be “exploring elephants,” he wrote, while others may be “grappling with giraffes. To try' to contain all reports within the same framework may lead to strange hybrids: four stout legs; a long, graceful neck; four tin legs; a long trunk; and so on” (1988, viii). In line with the principles of clinical pragmatism, he embraced theoretical pluralism and urged therapists to make use of ideas and methods from a range of perspectives as they carry' out their practice, fashioning a personal synthesis in the concrete particularity of the clinical situation. Mitchell died unexpectedly in 2000, at the peak of his intellectual powers, having documented “the emergence of a tradition” (Mitchell & Aron, 1999).

The relational paradigm has continued to evolve over the last two decades, shaped by a divergent group of scholars, researchers, and practitioners, expanding conceptions of mind, self, identity, gender, race, sexuality, relationship, social life, trauma, and therapeutic action. Thinkers continue to explore the multiplicity and diversity of human experience, emphasizing the importance of open-ended dialogue across the fields of neuroscience, developmental psychology, philosophy, social thought, political theory’, and the humanities (Barness, 2018). 1 briefly outline orienting perspectives, basic assumptions, and core concepts that guide understanding and practice across the relational paradigm, drawing on earlier accounts of the model (Borden, 2000, 2009; Borden & Clark, 2012; see Aron & Harris, 2011a, 2011b; Aron & Lechich, 2012; Curtis, 2020; for reviews of theoretical developments and clinical perspectives, see Harris, 2011; for accounts of relational psychoanalysis, gender, sexuality, race, class, ethnicity, and intersectionality, see Belkin & White, 2020).

Personality, Self, and Mind

Following the shift from Freud’s drive psychology to the relational paradigm, clinical scholars have focused on the ways in which the dynamics of relational life shape the development of personality, self, and mind. From this perspective, the core constituents of human experience are not biological instincts as Freud had proposed but relations with others. The self is constituted and constructed in a relational matrix, and the focal concern is the interactive field of self, others, and relational life. Researchers emphasize fundamental needs for attachment and relationship across the course of life in elaborating conceptions of motivation and development.

From the perspective of self psychology', as we have seen, thinkers center on the sustaining functions of caretaking figures and the dynamics of interactive experience believed to foster the emergence of a cohesive sense of self. From the perspective of object relations theory', theorists consider the way's in which the internalization of interpersonal experience shapes the organization of the self and capacities for relatedness. As described earlier, thinkers assume that prototypes of connection, established in infancy and childhood, are structured in the form of internalized representations of self and others, mediating subjective states, perceptions of others, and patterns of interpersonal behavior. From the perspective of interpersonal psychoanalysis, thinkers conceive of personality as process, emphasizing the ways in which the course of relational life and the changing contexts of social surrounds shape subjective experience, the dynamics of defense, and patterns of behavior. Relational scholars speak of a “two-person psychology',” emphasizing the intersubjective aspects of personality, self, and mind.

There is a dynamic organization to the ways in which we unconsciously' register experience, shaped by the course of relational life. Clinical scholars

The Psychodynamic Paradigm: 2 101 have expanded conceptions of unconscious structures and experience in the relational paradigm, distinguishing three forms of unconsciousness that Robert Stolorow and George Atwood had introduced in their original formulations of intersubjectivity: the pre-reflective unconscious, encompassing organizing principles that shape experience and meaning; the dynamic unconscious, encompassing experiences that were denied articulation because they were perceived as threatening conditions of care in relational life; and the unvalidated unconscious, encompassing experiences that could not be validated because they never evoked the validating responses from the surround (Stolorow & Atwood, 1992). Christopher Bollas described the experience of the “unthought known” in his elaborations of the Freudian unconscious (1989). Interpersonal thinkers have emphasized the dynamics of “selective inattention” that perpetuate gaps in awareness and dissociative states of self (Bromberg, 2011). Donnell Stern describes “unformulated” realms of experience that operate out of awareness, never having been articulated or integrated into the conscious sense of self (2015). Drawing on empirical lines of study in the fields of neuroscience, thinkers increasingly encompass the dynamics of interoception, emotion, and nonverbal modes of communication in formulations of implicit processes.

Over the years, relational thinkers have reformulated conceptions of defense, emphasizing the dynamics of anxiety, behavior, and interpersonal life. Adler had described “safeguarding tendencies” that regulate the experience of vulnerability and inferiority in developing his social perspective. Winnicott thought of the “false self” as a defensive mode of adaptation. Sullivan centered on protective restrictions of consciousness in the organization of the “self-system” and in his formulations of “selective inattention.” Interpersonal thinkers have continued to expand conceptions of dissociation and multiple self states. Object relations theorists, influenced by Klein and Fairbairn, have emphasized the defensive functions of splitting and projective identification.

Although a range of perspectives have shaped formulations of defense across the schools of thought, practitioners emphasize that any feelings, thoughts, or actions that shift attention from threatening experience can serve defensive functions. As Jonathan Shedler observes, “There is nothing at all mysterious about defensive processes. Defense is as simple as not noticing something, not thinking about something, not putting two and two together, or simply distracting ourselves with something else” (2006, p. 28).

Converging lines of study across the fields of neuroscience, developmental psychology', cognitive psychology, social psychology', and experimental psychology corroborate core propositions underlying conceptions of personality that shape understanding in the relational paradigm, emphasizing the fundamental role of attachment in the emergence of the self; mental representations of self, others, and modes of interactive experience; the origins of basic dispositions in childhood; and the ways in which unconscious motivations, emotions, and thoughts influence the dynamics of defensive processes and patterns of behavior (for reviews of empirical research see Curtis, 2020; Fonagy & Target, 2007; Fonagy', Roth & Higgitt, 2005; Luborsky & Barett, 2006; Schore, 2019a,

2019b; Shedler, 2010; Solms, 2018a, 2018b; Weinberg & Westen, 2001; Westen, 1998, 2005).

Health, Well-Being, and Optimal Functioning

Clinical scholars encompass subjective states of experience, inner representations of self and others, and patterns of interpersonal behavior in conceptions of health, well-being, and optimal functioning. Thinkers focus on the development of core structures of personality and corresponding capacities for relationship believed to influence patterns of feeling, thinking, and acting. The fully functioning person is characterized by a cohesive sense of self and identity; the capacity to regulate emotion and express the range of feeling; affirming but realistic views and expectations of self and others; stable patterns of interpersonal behavior, and fulfilling relationships. Flexible ways of being and relating facilitate efforts to form attachments, participate in social life, assimilate new experiences, and pursue meaningful goals. Some thinkers emphasize concepts of “effectance,” focusing on the development of capacities for mastery and self-efficacy (Curtis, 2020; Greenberg, 1991). As we have seen, Winnicott and Kohut encompass the realms of subjectivity in their accounts of health and well-being, focusing on the experience of cohesion, coherence, and continuity in states of self; embodiment and the sense of aliveness; capacities for agency, initiative, creativity, and play; and the ability to generate ways of being that we register as authentic and meaningful, originating deeply within us.

More broadly, relational thinkers recognize the sustaining functions of relationship and community across the course of life. Like Adler and Ferenczi, many of the early psychoanalysts were progressive activists, deeply engaged in social and cultural concerns. Horney, Sullivan and Fromm bridged psychological and social domains of concern in shaping their versions of interpersonal psychoanalysis, linking the health and well-being of the individual with values and patterns of life in community and culture. Paul Wachtel, continuing lines of social criticism established in the interpersonal school, has explored the dynamics of racism, class, individualism, and consumerism in American society over the last three decades. In doing so he has challenged scholars and clinicians to expand conceptions of health, well-being, and the common good, taking more account of the ways in which social, political, cultural, and economic conditions influence the course of development, health, vulnerability, and problems in living (Wachel, 1989, 1999, 2014; see Altman, 2009; Borden, 2009; Danto, 2005; and Safran, 2012, for expanded discussion of social criticism and activism in the psychoanalytic tradition).

Vtilnerability, Psychopathology, and Problems in Living

Thinkers distinguish predisposing, precipitating, and perpetuating conditions in formulating conceptions of vulnerability and psychopathology'. In accord with Freud’s notion of “overdetermination,” clinicians realize that problems in

The Psychodynamic Paradigm: 2 103 living are influenced by a range of factors, including constitution and temperament; the dynamics of attachment, relational life, social surrounds, and culture; traumatic events; restrictions of opportunity; and current stressors. In line with Freud’s formulation of “multiple function,” therapists assume that particular patterns of behavior potentially carry different meanings and serve a range of purposes. A recurring symptom, for example, may preserve coherence and continuity in sense of self, regulate fear and anxiety, reduce feelings of hopelessness and helplessness, and restore self-esteem (see McWilliams, 2004, 2020, on psychoanalytic conceptions of assessment, diagnosis, and case formulation).

Developmental perspectives continue to shape conceptions of vulnerability and problems in living across the different schools of thought. Some thinkers, drawing on the formulations of Winnicott and Kohut, emphasize “arrests” or “deficits” in the development of the self that compromise ways of being and relating. As we have seen, Winnicott centers on the ways in which cumulative trauma undermines the emergence of the self, and he distinguishes “true self” and “false self” states of experience in his formulations of authenticity, defensive processes, and psychopathology'. Kohut links structural deficits in the organization of the self to earlier lapses in care that limit the development of capacities to regulate emotion, generate meaning, and engage in relational life.

Object relations theorists center on internalized representations of interpersonal experience and defensive processes, such as splitting and projective identification, thought to perpetuate problems in living. Fairburn proposes that basic modes of connection, established in the past, are structured as representations of self and others, guiding perceptions of others and patterns of behavior. He describes “splits” in the representational world of relational life that compromise the integrity of the self. The individual interprets situations along the lines of earlier relationships, and the ongoing cycle of projection and re-internalization of self-other configurations shapes the course of relational life. Bowlby emphasizes the ways in which rigid working models of self, other, and modes of interactive experience distort perceptions of others and constrict ways of being, relating, and living.

Interpersonal thinkers center on outer domains of experience, attending to the dynamics of anxiety, dissociation, and particular patterns of “me-you” behavior that precipitate maladaptive patterns of feeling, thought, and action. Wachtel, drawing on Sullivan’s formulations, emphasizes the role of fear and defensive operations that lead to avoidance of experience, compromising the development of crucial skills in living. Sullivan was critical of the disease model inherited from medicine, preferring the phrase “problems in living” over diagnostic classifications of mental disorders. As noted, he speaks of “dynamisms of difficulty;” Horney and Wachtel describe “vicious circles” of behavior. They think of dysfunction as a dynamic, cyclical process in which “feared and anticipated relational events tend to be elicited and enacted” in interaction with others, who respond in complementary ways (Messer & Warren, 1995, p. 119-120). Ironically, patterns of interaction perpetuate negative perceptions of experience and reinforce maladaptive behavior. Sullivan and Wachtel emphasize the role of learning in development, change, and growth, converging with orienting perspectives in the behavioral paradigm, emphasizing the development of capacities and skills through in-vivo experience.

As we have seen, the relational field is the fundamental organizer of personality and self, and researchers have documented the ways in which the dynamics of attachment, interactive experience, and social surrounds shape the course of development. The first generation of relational thinkers focused largely on critical periods of care in infancy and early childhood in formulating their understanding of vulnerability and problems in functioning. Over the years, however, following critiques of theory and research, investigators have broadened the scope of study to consider the ways in which relationships, life events, trauma, and social conditions influence the dynamics of development and problems in living across the course of life (Borden, 2009; Curtis, 2020).

Although researchers continue to explore the adverse effects of deprivation and trauma, relational thinkers have increasingly recognized the organizing and sustaining functions of maladaptive behavior. Following Mitchell’s formulations, clinicians assume that psychopathology is self-perpetuating because it is embedded in global ways of being, relating, and living elaborated over the course of development. He emphasizes the “pervasive tendency to preserve the continuity', connections, and familiarity' of one’s personal, interactional world” (Mitchell, 1988, p. 33; see Borden, 2009, for case studies).

However limiting “vicious circles” of thought, feeling, and behavior may be, Mitchell proposes that established ways of being and relating serve crucial functions, helping us to preserve cohesion and continuity' in sense of self and subjective experience; maintain connections with internalized representations of others, and provide safety' and security' as we negotiate the dynamics of interpersonal life. From the perspective of object relations theory, we perpetuate particular patterns of behavior in efforts to preserve connections with internal representations and presences of others. “What is new is frightening because it requires what one experiences as the abandonment of old loyalties, through which one feels connected and devoted” (Mitchell, 1988, p. 291). In the domain of interpersonal life, we perpetuate particular patterns of interaction in efforts to regulate fear and anxiety' and maximize safety' and security’. Following Sullivan’s formulation, “security' operations steer (the individual) into familiar channels and away from the anxiety-shrouded unknown” (Mitchell, 1988, p. 291; see Borden, 2009, for expanded discussion and case studies).

Therapeutic Action

Although psychodynamically' oriented practitioners focus on circumscribed symptoms, concerns, and problems in living, the therapeutic process carries the potential to foster the development of capacities and skills instrumental in

The Psychodynamic Paradigm: 2 105 ongoing growth and individuation of the self. Clinicians assume that the core conditions and activities of psychodynamic therapy: 1) deepen awareness of unconscious realms of experience, encompassing motivations, sensations, feelings, thoughts, imagery', and behavior that perpetuate problems in functioning;

  • 2) strengthen capacities to register, process, and regulate subjective experience;
  • 3) reorganize unconscious associational networks that underlie structures of meaning, including motives, schemas, and models of self, others, and interactive experience; 4) engage inner and outer realms of experience that precipitate fear and anxiety', restricting ranges of behavior and opportunity; 5) expand coping capacities and problem-solving skills; and 6) strengthen relational capacities, patterns of interpersonal functioning, and social networks.

The relational schools of thought encompass orienting perspectives and fundamental concerns that have shaped psychoanalytic understanding from the beginning, and we rediscover points of connection with the contributions of Freud and Jung as we review formulations of therapeutic action across the broader paradigm.

Concepts of therapeutic action, change, and growth emphasize the role of the relationship and the dynamics of interactive experience; use of associative methods that foster processing of subjective experience, exploration of implicit memory, and the development of emotional insight; and various forms of activity' and experiential learning that strengthen capacities and skills instrumental in problem-solving, coping, and growth.

The Therapeutic Relationship and the Dynamics of Interactive Experience

Clinical scholars emphasize the multiple functions of the therapeutic relationship and the dynamics of interactive experience in efforts to negotiate problems in living, strengthen capacities and skills, and work toward change and growth. The therapeutic relationship facilitates growth in a variety' of way's, providing crucial sources of experience, learning, and understanding. Practitioners emphasize the critical functions of the therapeutic alliance and the constancy of care in the holding environment; the role of experiential learning through interpersonal interaction; and open-ended dialogue and co-creation of meaning that deepens understanding of self, interpersonal behavior, and life experience (see Norcross & Wampold, 2018).The concept of the therapeutic alliance originates in the psychodynamic tradition, as noted in Chapter 1. Researchers encompassed three domains of concern in their formulations of the alliance: the attachment bond between the patient and the therapist; mutual agreement on the goals of treatment; and shared understanding of the rationale and core activities of the therapeutic process (Horvath, 2006). Following the emergence of the relational paradigm, however, practitioners have come to think of the therapeutic alliance as an ongoing process of reflection and negotiation between the patient and therapist about the goals and activities of treatment, recognizing the mutuality' of the relationship and the collaborative nature of the therapeutic process (Borden, 2009; Safran, 2012).

From the perspective of self psychology, the practitioner’s empathic attune-ment and responsiveness as a “selfobject” strengthen the cohesion and integrity' of the self and the development of capacities to regulate emotion. The experience of presence, empathic attunement, and synchrony in therapeutic interaction and the constancy of care in the holding environment are thought to strengthen capacities to regulate sensation and emotion, emphasized in accounts of nonverbal, interactive forms of communication mediated by the right hemisphere of the brain (Schore, 2019b). In line with research on the dynamics of attachment and caregiving in infancy', the therapist and patient provide mutual regulation through reciprocal patterns of interaction and communication.

From the perspective of object relations psychology', the practitioner and patient co-create reparative experiences over the course of interaction that modify inner models of self and others, reorganize dysfunctional patterns of defense, and foster more functional ways of being, relating, and living. New and different ways of relating are thought to alter the associative pathways of neural networks that mediate subjective states, representations of self and others, and defensive processes.

From the perspective of the interpersonal school, the practitioner is inevitably engaged in the patient’s representative patterns of behavior in the relational field of the therapeutic process. Following Sullivan’s formulations, we think of the clinician as a participant-observer, and emphasize the reciprocal nature of therapeutic interaction. Ongoing interaction between the patient and therapist facilitates efforts to identify “vicious circles” of behavior and strengthen capacities to process experience, regulate emotion, and negotiate interpersonal life. The therapist encourages the patient to “try something different,” to explore new interpersonal situations where richer experiences of self and others are possible (Mitchell, 1988, p. 290).

Formulations of transference and countertransference states in object relations thought and interpersonal psychoanalysis center on inner models of relational life and the reciprocal nature of interactive experience in the social field. From the perspective of object relations theory', conceptions of transference emphasize the ways in which inner models of self and others influence perceptions of experience, constructions of meaning, and patterns of interpersonal behavior. From the perspective of the interpersonal school, formulations of transference emphasize patterns of learning and expectation established over the course of relational life. As noted earlier, research in the field of cognitive neuroscience provides empirical support for the foregoing formulations of transference. To the degree that the therapeutic relationship corresponds to prototypes of earlier relational life, it is likely' to activate similar patterns of motivation, emotion, thought, conflict, defense, and interpersonal behavior (Luborsky & Barrett, 2006; Shedler, 2010; Solms, 2018a; Westen, 2005; Westen & Gabbard, 2002a, 2002b).

Clinicians conceptualize countertransference states as role-responsive complements or counterparts to the patient’s way's of being and relating, generating experience that deepens understanding of inner life and interactive processes perpetuating dysfunctional patterns of thought, feeling, and action. Enactments

The Psychodynamic Paradigm: 2 107 of behavior in the therapeutic process, originating in intrapsychic conflict, earlier relationships, restrictions of opportunity, or trauma, facilitate efforts to clarify maladaptive modes of interaction and to strengthen capacities and skills in negotiating interpersonal life. In contrast to notions of neutrality that had shaped classical models of therapeutic action, contemporary relational thinkers assume that clinicians inevitably join patients in enactments, realizing the influence of complex, nonverbal, implicit patterns of communication that operate out of awareness.

Over the course of the therapeutic process, researchers propose, the patient internalizes positive elements of the therapeutic relationship, modifying inner representations of self and others, and develops capacities and skills through experiential learning that strengthen efforts to manage vulnerability and negotiate problems in living. From the perspective of neuroscience, as noted, the core activities of the therapeutic process are thought to alter the structure and function of associative networks established over the course of development, facilitating the reorganization and integration of neural pathways instrumental in emotional regulation and functional behavior. The intrapsychic domain of the relational matrix is transformed as the patient relinquishes ties to past forms of relation.

From the beginnings of psychotherapy, psychoanalytically oriented practitioners have recognized the fundamental importance of unstructured dialogue, narrative, and the creation of meaning in change and growth. Freud thought of the patient as a narrator and the therapist as a co-author, describing his ways of working as a literary method. Relational perspectives emphasize the ways in which the therapist and patient render experience into words and co-create narrative accounts of events through the ongoing construction and elaboration of stories. The aim of the process is to help patients reformulate life experience in ways that strengthen the sense of personal agency and deepen understanding of the origins, meanings, and implications of current concerns, and “to do so in a way that makes change conceivable and attainable” (Schafer, 1980, p. 38). What is crucial is not the “historical truthfulness” of the account but rather the “narrative coherence” and adaptive functions of the story (see Borden, 1999, 2000, 2009, 2010; Coles, 1997; Spence, 1982).

Following efforts to bridge psychodynamic and behavioral perspectives in integrative models of practice, clinicians have come to think of observational learning, modeling, and reinforcement as formative processes in the patienttherapist interaction. The working alliance serves as a catalyst, helping the patient more fully engage the core activities of the therapeutic process. As we will see shortly, practitioners increasingly emphasize use of tasks outside of sessions to facilitate development of crucial skills in living (Borden, 2009, 2014; Wachtel, 2011,2014).

In line with conceptions of therapeutic action proposed by Jung and Ferenczi, relational thinkers realize the ways in which the patient and the practitioner shape the process and outcomes of help and care, and conceptions of the relationship acknowledge mutual sources of recognition, empathy, and influence. In doing so, they deepen appreciation of intersubjectivity and mutuality' in the therapeutic process. The focus on the dynamics of the therapeutic relationship and current patterns of interaction distinguish contemporary relational models of intervention from classical Freudian approaches that emphasize principles of neutrality' and interpretation of transference and resistance in accord with the propositions of drive psychology'.

Clinical scholars have increasingly' recognized the personal characteristics and immediate emotional experience of the therapist. As Jon Mills observes in his account of relational psychoanalysis, practitioners emphasize “a natural, humane, and authentic” manner of engagement in the therapeutic process, finding therapists “more revelatory', interactive, and inclined to disclose accounts of their own experience, ... enlist and solicit perceptions from the patient about their own subjective comportment, and generally' acknowledge how a patient’s responsiveness and demeanor is triggered by' the purported attitudes, sensibility', and behavior” of the therapist (Mills, 2005, p. 155). The clinician’s ongoing exploration of enactments, transference and countertransference states, and the patient’s experience of the clinician has expanded conceptions of the therapeutic process.

Tree Association

Methods of free association allow the therapist and patient to explore the dynamics of unconscious processes that perpetuate particular ways of feeling, thinking, and acting. Drawing on techniques that Freud introduced in his formulations of therapeutic practice, clinicians use free association in efforts to process implicit realms of experience, advising patients to speak freely about whatever comes to mind, even if it does not seem to make sense, without judgment, much as we would instruct in mindfulness meditation. The goal is to help patients recognize and challenge defenses and resistance, bringing unconscious experience more fully into awareness, rendering implicit experience into words.

The clinician and patient process elements from the flow of associations, enactments, transference and countertransference states, and varying forms of resistance, bringing new meaning to experience. In formulating unconscious realms of experience, we assume, patients reorganize associative connections across neural networks and deepen awareness of motives, feelings, thoughts, dreams, fantasies, and goals that expand understanding of self, relational life, past experience, and anticipated future. Carefully focused questions, observations, and formulations convey the clinician’s efforts to understand the potential meanings carried in manifest content of words and actions operating out of awareness, deepening insight and understanding. Some practitioners have modified classical methods of free association in briefer forms of psychotherapy, selecting particular feelings, thoughts, or memories for associative exploration (Westen, 2005).

Although classical Freudian conceptions of therapeutic action continue to emphasize the curative functions of interpretation, relational thinkers have

The Psychodynamic Paradigm: 2 109 increasingly recognized the critical role of the therapeutic relationship, collaboration, and interactive experience in the mutual creation of meaning and understanding, focusing on the functional outcomes of formulations and narratives. In line with the constructivist perspectives that had shaped postmodern thought at the end of the 20th century, therapists have come to think of interpretations as co-created constructions of meaning rather than as authoritative accounts of underlying truths or realities. The patient and clinician collaborate in their efforts to make sense of experience, working to deepen awareness and understanding.

Practitioners make a distinction between cognitive insight and emotional insight, emphasizing the experiential features of the therapeutic process. Reviews of research comparing the outcomes of traditional cognitive-behavioral treatment and psychodynamic psychotherapy suggest that the beneficial effects of cognitive insight tend to diminish over time, whereas emotional insight, linking the domains of thought and feeling, is more likely to bring about enduring change and ongoing growth (Shedler, 2010, 2015; Solms, 2018a, 2018b). As noted in Chapter 3, the capacity’ to experience emotion and to tolerate “optimal stress” is thought to enhance neuroplasticity across the course of life.

Activity and Experiential Learning

Freud and Jung were more active in their ways of working than many clinicians realize, and the first generation of psychoanalytic thinkers recognized the critical importance of experiential learning and problem-solving in their conceptions of change and growth. As we have seen, Adler, Rank, and Ferenczi introduced active methods of intervention over the course of their practice. Psychodynamically oriented clinicians have increasingly drawn on cognitive and behavioral approaches in efforts to expand concepts of therapeutic action and help patients generate activity' in everyday life. Practitioners may challenge dysfunctional beliefs and fears that perpetuate avoidance of experiential opportunities, engage in mutual problem-solving, or propose activities that foster the development of capacities and skills. Clinicians increasingly emphasize the crucial role of activity' in efforts to deepen insight and strengthen the development of capacities and skills (Wachtel, 2014; see review of behavioral concepts of therapeutic action in Chapter 6, this volume). As Wachtel observes: “Overt behavior and intrapsychic processes are not really' separate realms. They' are most fully understood in relation to each other and in terms of the complex feedback loops that link and maintain them” (2011, p. 338).

Neuroscience and Therapeutic Action

As we have seen, psychodynamically oriented practitioners emphasize the crucial functions of the therapeutic relationship, interactive experience, and the constancy of care in the holding environment. Presumably, the empathic attunement and synchrony of the therapeutic relationship activate bonding processes that mediate the dynamics of attachment and carry the potential to reinstate neural growth, helping patients strengthen capacities to process and integrate subjective experience, regulate emotion, and negotiate relational life. Following developments in attachment research described in Chapters 2 and 3, practitioners increasingly consider the role of unconscious, non-verbal, right brain functions in their conceptions of the therapeutic alliance, intersubjectivity, communication, and change.

In accord with the proposal that moderate arousal or “optimal stress” enhances the properties of neuroplasticity, clinicians emphasize the role of emotion in conceptions of therapeutic action, change and growth, distinguishing “cognitive insight” from “emotional insight.” As discussed earlier, practitioners intensify emotion as they explore the dynamics of defense, process interactive experience, and offer formulations and interpretations of behavior. Thinkers describe various forms of challenge that carry implicit or explicit suggestions for change. Clinicians may explore beliefs and assumptions that fail to take account of actual circumstances, for example, or focus on feelings, thoughts, and experiences that perpetuate problems in living.

Some psychodynamically oriented clinicians integrate cognitive and behavioral methods in efforts to help patients engage aspects of inner life or outer experience they have avoided out of fear, as discussed earlier. In doing so practitioners encourage the patient to register, recognize, and express a wider range of feelings, creating conditions of mild to moderate stress thought to activate the production of neurotransmitters and neural growth hormones associated with long-term potentiation, learning, and cortical reorganization.

Psychodynamic approaches engage interoceptive, emotional, cognitive, and behavioral processes thought to be instrumental in “top-down” and “bottom-up” modes of integration, reorganizing the structures of associational networks established over the course of development, fostering the formation of new, adaptive linkages and patterns of behavior (Cozolino, 2017; Schore, 2019a, 2019b; Westen, 2005; Westen & Gabbard, 2002a, 2002b). The patient and clinician process experience in accord with Freud’s classic account of therapeutic action, “Remembering, repeating, and working through” (1914/1958), exploring the discontinuities and dissociations of unconscious and conscious processes through free association and interpretation, integrating and reorganizing neural networks that mediate the dynamics of motivation, emotion, thought, defense, and behavior.

From the perspective of cognitive neuroscience, therapeutic action challenges connections between mental processes that have become linked through experience over time, perpetuating problems in functioning. The core activities of the “working through” process are thought to weaken links between nodes of association that have been structured over the course of experience, lowering their levels of activation, fostering the development of new associative connections that strengthen underdeveloped links across neural structures instrumental in change and growth. Structural change does not replace earlier

The Psychodynamic Paradigm: 2 111 networks; rather, the reorganization of networks deactivates problematic links and activates new, adaptive connections (see Gabbard & Westen, 2003, pp. 827-829).

From a narrative perspective, as we have seen, the therapist and the patient collaborate in ongoing efforts to process experience, construct meaning, and elaborate life stories that foster change and growth. As noted, researchers propose that the dynamics of narrative engage the functions of the right and left hemispheres, fostering the integration of neural networks throughout the brain. The autonoetic, analogical, mentalizing functions of the right hemisphere shape the imagery and themes of narratives, while the left hemisphere mediates interpretive and linguistic processing of content (Siegel, 2020).

Beyond the experiential opportunities of the therapeutic process, as we have seen, thinkers have increasingly realized the ways in which the relationships, activities, and practices of everyday life carry' the potential to strengthen the development of capacities and skills, fostering neural integration, insight, and growth. Integrative conceptions of psychodynamic therapy increasingly combine cognitive and behavioral methods in efforts to generate new forms of action, experience, and learning in the outer world. As in the other foundational schools of thought, integrative approaches potentially include a range of “bottom-up” practices believed to engage subcortical regions of sensation and emotion, including use of the breath, mindfulness meditation, yoga, walking, and artistic and musical activities.

Concluding Comments

Over the last three decades, as we have seen, reformulations of psychodynamic thought have brought about major shifts in theoretical formulations, research, and practice. Clinical scholars have increasingly focused on conceptions of mind, self, relationship, and social life in their reformulations of theory, emphasizing the dynamics of unconscious emotional and cognitive processes and the crucial role of attachment and experiential learning across the course of development.

Pragmatic sensibilities shaped our earliest methods of therapeutic practice, and contemporary' approaches converge with essential concerns in the formulations of clinical pragmatism I have described here. Clinicians challenge reductive formulations of help and care based on a technical rationalism and standardized models of intervention in reductive versions of evidence-based practice, drawing on comparative approaches to understanding. Concepts of therapeutic action focus on the subjectivity' and agency of the individual; the crucial role of the relationship, collaboration, open-ended dialogue, and interactive experience; co-creation of narrative and meaning; and various kinds of experiential learning instrumental in the development of capacities, skills, and realization of potential. Practitioners continue to integrate ideas and methods from cognitive, behavioral, and humanistic schools of thought in efforts to strengthen the outcomes of help and care.

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