In The following is a paper written by the distinguished psychologist Dr. Lawrence Hedges. Whatever your theoretical bent is, I think that the paper will benefit you in your work with this very difficult treatment population.

I have had the pleasure of listening to Dr. Hedges speak and have heard from him ideas that responsible psychotherapists should embrace. To just paraphrase, when one does psychotherapy with a difficult treatment patient, there are actually four people in the room, the patient - therapist and the therapist - patient with the understanding that change should happen with all parties concerned.

Achieving Optimal Responsiveness in Transference Psychosis
© Lawrence E. Hedges, Ph.D., ABPP
Director, The Listening Perspectives Study Center
Orange, California 92866
Phone/fax (714) 633-3933, e-mail lhedges@pacbell.net

Abstract:

In the early 1980’s a group of California therapists began reporting on “organizing” transferences that could be studied in the context of well developed personalities during major psychotherapeutic regressions (Hedges 1983,2003). Organizing transferences are formulated as the earliest structures in personality that memorialize fetal and neonatal experiences of organizing physical and mental channels to the maternal body and to parental minds. Early impingements into the organizing processes range from environmental under-stimulation that causes forming channels to wither and withdraw, to environmental over-stimulation that causes the nascent channels to constrict and block. Intermediate forms of impingement can serve to create anomalies in cognitive and affective processing of psychotic proportions that have been reported in extensive case studies (Hedges 1994a,b,c; Hedges 2000a,b). Traumatic interruptions of organizing channels that might otherwise come to serve developmental processes of intersubjective connection such as nurturance, soothing, regulation, and evacuation, become inscribed in psyche as, “never reach in that way again.” Clinical research demonstrates that these records can be revived as organizing transferences and worked with during psychotherapeutic regressions that have often been characterized as transference psychosis. Whether the organizing pockets are large (i.e., pervasively affect functioning) or small, they can be engaged by the alert psychotherapist as the human desire to connect is activated in the therapeutic relationship and as the characteristic withering and/or constricting patterns re-assert themselves as transference and resistance structures that can be known and worked with intersubjectively. The theory of the organizing transference and its implications for the psychological treatment of more dramatic schizophrenic, psychotic, dissociative, autistic, and schizoid states is presented along with case illustrations.

Introduction: The Listening Perspectives Approach

What has been shunned for ages as madness can now be understood as a universal human experience traceable to the earliest internalized psychic experience of becoming terrifyingly disorganized or traumatized in face of failed interpersonal connection. The hallmark of what I will call the “organizing” or “psychotic” transference is a somatopsychic terror or horror that appears in various ways during experiences of interpersonal affective linking or contact. The specific manifestations of the dread of connection relate to one's personal history of reaching out affectively as an infant (or at an emotionally significant later point in one’s life) and being received in such a way as to have been traumatized to the point of refusing to reach out that way ever again.

The organizing transference is conceptualized here as a memory formation of the experience of the traumatizing other, an internalized representation of the failure of environmental responsiveness to be fully attuned in a timely manner to the nascent self's real and immediate need states. Resistance is to reexperiencing the transferential trauma that results from opening up in here-and-now relating the long-closed channels of potential relational experience that once proved terrifyingly life-threatening.

In Listening Perspectives in Psychotherapy (1983/2003) I set out to reformulate psychoanalytic psychology along lines that are compatible with a contemporary epistemology and philosophy of science—with the hope of liberating psychoanalytic theory and practice from the shackles of an obsolete nineteenth century scientific paradigm. The Listening Perspective approach abandons entirely the naïve view that we can ever objectively consider how “things really are” or that the human mind can ever be studied as an isolated unit separate from the bio-physical, socio-cultural and intersubjective fields in which human beings necessarily live. The perspectival view maintains that all we can ever do with any degree of certainty is to generate systematically helpful points of view, perceptual angles, and/or empathic stances from which to listen in order to frame (to experience in the broadest possible sense) what people have to tell us and to the ways in which two people engage each other in the analytic relationship.

Clinical research at the Listening Perspectives Study Center in Orange, California since the early 1980’s has reorganized the central aspects of psychoanalytic practice—transference, resistance, countertransference and counter-resistance—along the lines of progressively complex internalized self and other relationship possibilities. The Listening Perspective approach aids in framing for analysis differential qualities of internalized interpersonal relatedness experience as they arise in the here-and-now matrix of the analytic relationship. The Listening Perspective approach represents a radical shift in the conception and perception of the interpersonal relatedness experience itself. The critical importance of the treating psychotherapist thinking in terms of relational perspectives in terms of theoretically—rather than defined features of mind is nowhere more clearly illustrated than in work with what has been called transference psychosis.

The General Context: Four Relational Listening Perspectives

The number and ways of defining Listening Perspectives from which to study the interpersonal transactions of the analytic encounter is entirely open-ended and arbitrary. But a century of psychoanalytic study suggests four distinctly different relational Listening Perspectives that have served the purpose of framing self and other relatedness patterns that operate in the interpersonal field or, differently said, in the mutually created constructions arising from the transference/countertransference matrix. Traditional scientific-objective approaches pre-specify in various ways the presumed nature of psyche, what kinds of structures and contents an analytic observer is likely to encounter, and the ways in which the analytic search for transference and resistance memories are best framed. A more intersubjective-relational Listening Perspective approach simply defines an array of human relatedness possibilities that might serve to frame, for mutual understanding, whatever idiosyncratic narratives and narrational interactions in fact emerge in the course of the relationship development.

The Listening Perspectives that follow are derived from a series of four increasingly complex developmental metaphors describing how a growing child potentially engages and is engaged by others in interpersonal interactions that build internal habits, structures, or patterns of relational expectation. Differential framing secures for psychoanalytic study the structures, patterns, configurations, and/or modes of internalized interpersonal interaction that have characterized the past interactions of both participants and that are transferred into and resisted conscious awareness and expression of in the current mutually developing psychoanalytic relationship. Listening Perspectives thus formed do not represent a developmental schema, but rather serve to identify a general array of relatedness possibilities lived out each day by all people.

The four Listening Perspectives that serve to bring out the relatedness dimensions at play in the analytic relationship are summarized in tables that follow. Table 1 gives a paragraph summary of the developmental metaphors used to describe the four distinctly different types of patterns of self and other relationships to be listened for and responded to in the evolving self and other transference/countertransference matrix of the analytic listening situation. Table 2 summarizes in outline form the comparative features of each Listening Perspective in terms of: the traditionally held diagnosis, the developmental metaphor employed, the way the affects are thought to be organized, the varieties of transference which are commonly expected, the ways resistance and counter-resistance are thought to manifest, the mode of listening and responding believed to be most efficacious, the technical or therapeutic modality recommended for this mode of transference/resistance experiencing, and the ways that countertransference relatedness dilemmas are often perceived to arise. Achieving optimal empathy with what has been called the transference psychosis generally involves using Listening Perspective I. Placing this perspective in relation to the other three developmentally derived Listening perspectives provides an overall clinical context for this paper.
 
Four Relatedness Listening Perspectives

I. THE ORGANIZING EXPERIENCE: Infants require certain forms of connection and interconnection in order to remain psychologically alert and enlivened to themselves and to others. In their early relatedness they are busy "organizing” physical and mental channels of connection—first to mother's body, later to her mind and to the minds of others—for nurturance, stimulation, evacuation, and soothing. Framing organizing patterns for analysis entails studying how two people approach to make connections and then turn away, veer off, rupture, or dissipate the intensity of the connections.

II. THE SYMBIOTIC EXPERIENCE: Toddlers are busy learning how to make emotional relationships (both good and bad) work for them. They experience a sense of merger and reciprocity with their primary caregivers, thus establishing many knee-jerk, automatic, characterological, and role-reversible patterns or scenarios of relatedness. Framing the symbiotic relatedness structures entails noting how each person characteristically engages the other and how interactive scenarios evolve from two subjectively-formed sets of internalized self-and-other interaction patterns.

III. THE SELFOTHER EXPERIENCE: Three-year-olds are preoccupied with using the acceptance and approval of others for developing and enhancing self definitions, self skills and self-esteem. Their relatedness strivings use the admiring, confirming, and idealized responses of significant others to firm up their budding sense of self. Framing for analysis the self-other patterns used for affirming, confirming, and inspiring the self entails studying how the internalized mirroring, twinning, and idealizing patterns used in self development in the pasts of both participants play out to enhance and limit the possibilities for mutual self-to-selfother resonance in the emerging interpersonal engagement.

IV. THE INDEPENDENCE EXPERIENCE: Four-and-five-year-olds are dealing with triangular love-and-hate relationships and are moving toward more complex social relationships. In their relatedness they experience others as separate centers of initiative and themselves as independent agents in a socially-competitive environment. Framing the internalized patterns of independently interacting selves in both cooperative and competitive triangulations with real and fantasized third parties entails studying the emerging interaction patterns for evidence of repressive forces operating within each participant and between the analytic couple that work to limit or spoil the full interactive potential.

LISTENING PERSPECTIVES:
Developmental Frames or Modes of Inquiry

I. The Personality in Organization: The Search for Relatedness
•Traditional diagnosis: organizing personality/psychosis
•Developmental metaphor: + or - 4 months—focused attention vs. affective withdrawal
•Affects: connecting or disconnecting, but often appearing as an inconsistent, generalized or chaotic clamor to a casual observer
•Transference: connection vs. disconnection, rupture, discontinuity, and disjunction
•Resistance: to connections, to channels that are organizing or promise consistent bonds
•Listening mode: connecting, intercepting, linking
•Therapeutic modality: a focus on withdrawal, constriction, and/or destruction of links that results from mutually-connecting or from mutual engagement—interception
•Countertransference: fear of intensity of psychotic anxieties that arise from interpersonal and intrapersonal connections; withdrawal and defense
II. Symbiosis and Separation: Mutually-Dependent Relatedness
•Traditional diagnosis: borderline personality organization/character disorders
•Developmental metaphor: 4-24 months—symbiosis and separation-individuation
•Affects: split “all good” and "all bad"—ambitendent
•Transference: replicated dyadic interactions or scenarios
•Resistance: to assume responsibility for differentiating, for renouncing the scenarios
•Listening mode: interaction in replicated scenarios, followed by standing against them
•Therapeutic modality: replication and differentiation—reverberation
•Countertransference: participation in reciprocal mother and infant positions—a "royal road” to understanding merger relatedness
III. The Emergent Self: Unilaterally-Dependent Relatedness
•Traditional diagnosis: narcissistic personality organization
•Developmental metaphor: 24-36 months—rapprochement
•Affects: dependent upon empathy or optimal responsiveness of selfother
•Transference: selfothers (grandiose mirroring, twinship, idealizing)
•Resistance: shame and embarrassment over narcissism, narcissistic rage
•Listening mode: engagement with ebb and flow of experiences of self affirmation, confirmation, and inspiration
•Therapeutic modality: empathic attunement to self experiences—self-to-selfother resonance
•Countertransference: boredom, drowsiness, irritation—facilitating
IV. Self-And-Other Constancy: Independent Relatedness
•Traditional Diagnosis: neurotic personality organization
•Developmental metaphor: 36+ months—(oedipal) contingent triangulation; competitive and cooperative
•Affects: ambivalence; overstimulating affects and repressed drives
•Transference: constant, ambivalently-held self and others
•Resistance: to the return of the repressed
•Listening mode: evenly-hovering attention/free association/equidistance
•Therapeutic modality: verbal-symbolic interpretation—interpretive reflection
•Countertransference: overstimulation—generally an impediment or detraction
 
Listening Perspective I: Working the Organizing Experience
At the core of all personality functioning lie infantile experiences of environmental failure. The Listening Perspective for framing and responding to the organizing experience provides a relational way of defining a variety of transference experiences metaphorically conceptualized as arising from the infant's traumas and disappointments during the earliest months of life. From approximately four months before birth to four months after birth, the infant is actively searching, reaching out in various sensory/motor/affective ways, seeking to organize reliable physical and psychological channels to environmental sources of safety nurturance, stimulation, comfort, and evacuation. When an infant's reaching is met in a timely and pleasurable manner by the environment, that way of reaching out is thereby reinforced and is tried again until it gradually becomes a reliable channel for the development of mutually regulating internalized symbiotic or bonding interactions. But when, for whatever reason, the reaching is not met in a timely, satisfying manner, or is actively neglected or traumatized, it is as if a sign were posted in the nascent neurological system saying, "Never go there again. Never expect or reach out in that way again."

The organizing experience and organizing transference is, therefore, conceptualized as foundational and universal since no early environmental situation ever perfectly meets the baby's needs in the completely desired manner. In later psychoanalytic listening situations the concept of organizing transference is useful in considering the foundational ways a person remains reluctant or internally forbidden to reach out for various forms of emotional relatedness with the analytic listening partner. All people possess to a greater or lesser degree "pockets" of organizing experience that can be listened to as organizing transference (Hedges 1994a,c 1996, 2000b).

However, many people experienced actively traumatic intrauterine or postnatal situations [or later trauma] that have left them living pervasively organizing experiences because they have become terrified of human emotional connectedness. Not only did they fail to bond fully or adequately with their mothering partner, but they also have remained outside the pale of robust interpersonal emotional relatedness for a lifetime. Many of these people develop active psychotic pictures that betray something of the nature of the initial trauma as well as the early way in which the infant tried to solve the problem of not feeling free to fully enter human emotional-relatedness life and/or to be open to life’s many learning experiences that require interpersonal relatedness comfort and skills.

A convenient metaphor for conceptualizing how primordial organizing experiences are retained in psyche is to follow an imaginary path along which an infant might extend herself in search of the nurturing and holding environment. The channels for connection in utero are primarily physiological. After birth the somatopsychic extensions and contractions take physical form at first, only gradually shifting to more psychic connections and disconnections. At issue with human infants, as with all mammals, is survival, followed by safety, comfort, stimulation, and evacuation. Sufficiently hospitable environmental conditions are afforded most infants so that psychological paths can become organized to needed features in the human environment. These paths can develop and become organized into mutually satisfying symbiotic scenarios (Hedges 1983/2003 1992), interpersonal attachment dances that lead to emotional bonding with the mothering partners (Bowlby 1969, Beebe and Lachmann 2002, Siegal 1999, and Schore 1994, 2003), and to the intrapsychic experiences referred to by Mahler (1968) as symbiosis. The fragmenting experiences of reaching, not finding, and withering; or of reaching, feeling injured, and withdrawing, are universal and the impact of failed extensions leave their mark on our characters and our bodies in various ways (Johnson 1991, Stark 1993, Shapiro 1995).

Often strain, if not more considerable focal trauma, is experienced by infants in their efforts to organize and to sustain reliable channels (Khan 1963). We can observe in any mammal the terrified frenzy followed by collapse that results when the warmth and nurturance of the maternal body cannot be found. We assume that some sort of genetically based "survival instinct" operates that gives rise to frantic gross bodily reactions when the ongoing continuity of life seems threatened. When needful and desirous extensions are not met in a satisfactory or timely manner, or are met with abuse, we observe what Fraiberg (1982) calls the predefensive reactions of fight, flight, or freeze, which are common to all mammals. Human babies are no exception. These predefensive reactions to painful or frightening experiences set up memory barriers along paths of possible connection so that these paths are not selected again or are employed only with caution and trepidation. Francis Tustin (1984, 1987) describes various kinds of autistic responses that develop when the needed/desired interpersonal sensual connections cannot be established. Infant researchers (see D. N. Stern 1985, Siegal, 1999, Beebe and Lachmann 2002) describe many ways that early interaction schemas develop or fail to develop that might lead to satisfying and satisfactory bonding or symbiotic interactions. Current studies in neuroscience are coming to specify the various ways in which early relationships condition synapses throughout the neurological system so that even brain functions traditionally considered genetically hard-wired are increasingly understood as by-products of our personal relational histories (see LeDoux 1996, 2002, Edelman 1993, 2002 (with Tononi), Damasio 1994, 1999, 2003, and Pert 1997).

In psychoanalytic situations of later life, these predefensive reactions can be studied as organizing or psychotic transferences and/or countertransference and as resistances to establishing basic love, dependency, interdependency, or trust in relationships. Where love once was or might have been is now systematically blocked. The person in analysis moves In Search of the Lost Mother of Infancy (Hedges, 1994a) . Reviving the somatopsychic memories or blocks to reaching out for love necessarily entails reliving primitive agonizing experiences in the here-and-now relationship with the analyst (Hedges, 1994b,c, Van Sweden 1995). Here again neuroscientists support the notion that psychotherapy relationship experiences actually function to re-condition neuronal pathways (see LeDoux 1996, 2002, Edelman 1993, 2000 (with Tononi), Damasio 1994, 1999, 2003, and Pert 1997).

The central thesis regarding working the organizing experience revolves around the contact moment. The analytic listener's first task is to sort through the often complex and confusing content to determine where potential points of' real and safe interpersonal (cognitive-affective-motivational) connection may be possible. Then the analyst learns to track the person's movement toward contact moments that seem as inevitable as any mammal searching for a breast. But somewhere just before, during, or immediately after contact “something happens” to make contact or sustained connection impossible. It is the specificity of the contact-rupturing experience that must be framed for analytic study. The person's internal, idiosyncratic ways of rupturing contact are understood as the organizing or psychotic transference and can be fruitfully studied in the psychoanalytic setting. Resistance will come to be understood as the person's all-out efforts to avoid dealing with (a) the contact experience itself and/or (b) the traumatic life-and-death transference issues that terrifyingly must be relived if one is to sustain the connection.

As resistance and transference analysis proceed, the transference psychosis will gradually become established. This is a complex state of affairs in the analytic relationship in which the earliest mother-child relationship that prevented the person from developing further is being lived out in disorganizing, fragmenting, and terrifying proportions. This therapeutic breakdown (Winnicott 1974) has been written about in many ways including “regression to dependence” (see Van Sweden 1995). This listening tool of studying connections and disconnections is as useful for people living pervasive organizing experiences as it is for people who may be much better developed in many or most ways, but who need to explore some aspect of early organizing experience in the course of their analysis.

Freud's fundamental concept of cure in psychoneurosis is the establishment of the transference neurosis, meaning the full and conscious establishment of the triangular oedipal-incestual attitudes of childhood, in the here-and-now psychoanalytic relationship. In preneurotic, preoedipal states more than merely experiencing a return of the repressed in the analytic relationship is required for personality transformation. The reason is clear: the establishment of the transference psychosis marks not the “return of the repressed” but the appearance of the "unthought known” (Bollas 1987) in the analytic relationship—the appearance of totally different kinds of unconscious or nonconscious experiences. Early environmental failures and traumas cannot simply fade harmlessly into the past unless something in the present replaces them or fills in the gap left by disruptive, failed, or traumatized internalized relational experiences. The organizing transference does not yield to analytic work unless and until the analytic speaker feels clearly that he or she can indeed safely connect with the real person of the analyst and safely use the analyst's personality to organize around. For this kind of work to succeed, i.e., for a cohesive self to develop de novo, Kohut believes that the patient has to be willing and able to sustain long periods of prepsychological chaos alternating with long periods of borrowing heavily from the personality of the analyst (Kohut 1984). It is only within the context of reliable analytic relational holding that a person dares reexperience the terror of the once perceived life-threatening infantile trauma of the organizing period—which is still silently and self-destructively alive in the personality. Only as the analyst offers a new and better way of relating in the here-and-now can the ancient disconnecting traumas be relived and actively relinquished in favor of actualizing in the analytic relationship more complex and flexible relatedness modes (Mitchell, 1998; Aron, 1996; Maroda, 1999), Johnson, 1991, and Stark, 1999.)

Interpretation of organizing transferences and resistances is necessarily relational, i.e., paraverbal and concrete--usually simply a timely being with or an interpretive touch (visual, vocal, and/or tactile) that communicates the analytic listener's awareness of the present contact and the terrifying and/or painful urge to flee. Interpretive work includes a coaxing to stay fully present, to remain open to contact and connection, and the invitation to share together the sense of trauma and physical pain, trembling, twitching, itching and various reactive muscular constrictions that necessarily accompany the opening of blocked somatopsychic channels in the early memory structures studied in psychotherapy.
Countertransference to working the organizing experience may (1) deny the person's basic humanity (e.g., this person is untreatable) or (2) raise a fear in the analytic listener of opening up the primitive energies that are bound to be directed at the person of the listener. Working the organizing experience is (3) bound to stir up the analytic listener's own terrifying organizing experiences or (4) manifest itself as some form of withdrawing, seen as empathy with the speaker's terror of contact. Only practical considerations such as time, resource, and practicality place limits on working with organizing states, not the nature of the experience itself. The over-learned or internalized tendency to repeatedly break off contact according to a style once experienced in the primordial past (and often seen as psychotic, dissociative, autistic, or schizoid symptoms in the present) can best be framed or perceived against a background that promotes sustained contact between analytic speaker and listener.

Conclusions
The contemporary self and other relatedness paradigm in psychotherapy stands on new philosophical, epistemological, and interactional ground when perspectives are systematically generated for listening and responding to (i.e., framing) various levels of relational complexity possibility. This is especially evident when psychotherapy seeks to analyze the fundamental approach to and retreat from cognitive-affective-motivational contact in the transference/countertransference matrix of the organizing experience. Organizing structures can be brought into the light of day and relinquished by a dedicated speaker who is determined over time to learn not to retreat from developing contact with the analytic listener, even in the face of the disorientation, fragmentation, terror, and somatopsychic pain that both must in their own ways endure. The analytic listener who has developed staying power through his or her own analytic work and who is willing to be sustained by ongoing support from colleagues is in a position to hold steady and to coax connection. And, in the process, to frame for analysis the structures that emerge to block the interpersonal cognitive-affective-motivational exchanges that are limiting development in both participants.
Human attachment or bonding and the myriad forms of relational experience secure bounding patterns permit requires that two people be free to live a true, spontaneous, and very real life with each other, despite whatever limitations the reality of the analytic situation may place upon them. Analyzing the organizing transference/countertransference/resistance structures as somatopsychic memories clears the way for a wide range of bonding experiences in the psychotherapy relationship or for what Searles (1979) has called the development of a therapeutic symbiosis. Only the available internal and external resources of two people determine whether or not a treatment can be successfully formed and resolved—not the nature of the so-called pathology.

 
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