Something New Under the Sun: E-Supervision

Allen Siegel & Eva Topel

The thing that has been,

it is that which shall be;

And that which is done

is that which shall be done:

And there is nothing new under the sun.

Is there any thing whereof it may be said,

“See, this is new?”

Kohelet (Eccleseastes) 1:9-10

Long valued for their ironic truth, Kohelet’s words have lost their hold on the 21^st century. eBay, email, eToys, eEveryThing - the sun no longer sets without a cyberspace headline. We learn of cyber-viruses that threaten our world, of cyber-entrepreneurs who morph into millionaires, and of mega-mergers between cyber-companies. Virtual University, Drugstore.com, surely something new is upon the land, only now the land is the entire planet. Expanded by cyberspace, borders have been swapped for Borders.com. Whether in a jungle or atop an ocean, we are no longer removed from office, school, or home.

In his recent book, Thomas Friedman, New York Times foreign correspondent, describes what he calls the ”democratization of finance, technology and information” and details how these developments have combined to create the world-changing revolution called globalization (Friedman, 1999). Revolutions do not occur without tension and the intriguing title of Friedman’s new book, The Lexus and the Olive Tree, conveys the tension that exists between old identities and new technologies. For his title Friedman chooses two of the many stories he tells about people who either participate in or sit out the global revolution. The Lexus refers to a new robotic Japanese automobile factory that produces cars of absolute perfection. The olive tree, on the other hand, an ancient specimen that has carried a Palestinian family’s identity for generations, was threatened with extinction by a new technological facility. Friedman describes the dilemma both people and countries experience when they are forced to choose between prosperity associated with new technology and the anchor to one’s sacred roots that comes with adherence to old ways.

We in the mental health field do not escape this evolutionary tension as we are confronted with the dilemma of whether to cling to tool and method pride or embrace the new in creative ways that enhance our growth yet retain our identity. We are confronted with the dilemma of whether to explore the use of electronic communication in what we do or insist on the face-to-face, or at least voice-to-voice, encounter as the only possible way to do our work.

The purpose in writing this chapter is to offer our electronically conducted supervisory experience as an example of one possible use of the new technology. We refer to our experience as eSupervision despite the fact that we began our work using a fax and completed it using email. We found the supervisory experience essentially identical using both technologies, although we did notice that the Internet created a sense of immediacy and connectedness that was not as present when we used the fax

Before moving to our clinical material, however, we will first discuss some of the current literature in an effort to highlight recent discussions concerning supervision and demonstrate that the elements of supervision described in those discussions were present in our work as well. Because there is no currently existing literature about eSupervision we hope to initiate and stimulate a conversation concerning the special issues involved in an electronic “non-face-to-face” supervisory experience.

We emphasize the non-face-to-face aspect of our work to call attention to the absence, for both supervisee and supervisor, of direct facial, nonverbal, and preverbal communications. Missing in overt expression from our work, for example, were the facial mirroring experiences, as well as the experiences of voice and gesture correspondence that are embedded in a visually related discourse. These informative reassuring and regulating nonverbal communications are the “basic interaction patterns” that usually operate outside the realm of awareness (Beebe and Lachmann, 1994; Lachmann, personal communication, 1999). These nonverbal communications underlie the face-to-face encounter and provide the participants with continuing regulatory information about the ongoing process in the cocreated field. Deprived initially of these early interactive communicative elements in our work, we each coincidentally developed a deeper appreciation of the subtle existence and power, both disruptive and soothing, of the nonverbal exchange. These issues of communication were especially poignant since we worked together on the treatment of a 13-year-old girl who preferred not to speak.

Conceptualization of the Supervisory Process

Defined in its most basic form, supervision is the consultative/tutorial process that involves the teaching and learning of psychotherapeutic work. It is a complex endeavor that requires the ability of the supervisor to teach a particular psychology and, in similar fashion, requires an ability on the part of the supervisee to grasp the theory’s affective components, as well as its cognitive elements. Further, supervision is a multitiered process that considers the interactive fields created by the patient/therapist couple, the therapist/supervisor couple, and the impact of each couple set upon the other.

Joshua Levy and Alan Kindler, editors of a recent volume of Psychoanalytic Inquiry dedicated to psychoanalytic supervision, note that ideas about psychoanalytic supervision have lagged behind developments in theory and technique (Levy and Kindler, 1995). They suggest that current ideas about supervision must consider recent paradigm shifts, including the interactive nature of the experience, as well as the older and much discussed ideas, such as the learning alliance, that has been described by earlier contributors (Dewald 1987, Ekstein & Wallerstein 1959).

The recent paradigm shift Levy and Kindler refer to is one that has been informed by principles embedded in the psychology of the self. It is a paradigm in which the therapeutic ambiance is shaped out of the therapist’s attempts to listen for and validate the subjective reality of his or her patient. In addition, it is a paradigm in which continuous attention is paid to the state of the patient’s self and to the co-constructed reality that is created out of the interaction between patient and therapist. Supervisors whose therapeutic work is informed by this paradigm approach their supervisory work with attitudes and concerns similar to those they carry into the treatment setting. They are attentive to and affirmative of their supervisee’s experiences and to the co-constructed reality that exists among all three participants in the supervisory experience. The stance toward both patient and supervisee suggested by this paradigm differs from the older omniscient psychoanalytic stance that adopts a “view from above” attitude.

The supervisory enterprise is a unique educational experience that involves affective as well as cognitive learning. Supervisory education usually includes an intense affective experience that is provoked when psychological issues within the patient resonate with similar issues within the therapist. Often, the awakened psychological issues within the therapist are expressed in a transferential form with the supervisor. This occurs as the therapist traverses a process in the supervision that parallels some aspects of the patient’s experiences in the therapy. Another situation that stirs intense affects within the supervisee occurs when the supervisee wishes to learn a new theory because he or she can no longer contain the long experienced disquiet over his or her previously valued theory’s limited explanatory power.

Jonathan Schindelheim describes the anxiety he experienced when he sought supervision to help him move beyond the authoritarian, “view from above” listening position he had been taught during his training (Schindelheim, 1995). He courageously describes his painful transition as he left the certainty and comfort afforded by his authoritarian theory to move to the uncertainty engendered by the new and unfamiliar listening stance he sought to learn. His anxiety began as he abandoned the formulaic understandings informed by listening from a position grounded in the analyst’s frame of reference and moved to listening from his patient’s perspective instead. Schindelheim found that developmental learning occurred within him when he participated in a supervisory experience that was informed by and conducted in accord with the new listening stance he hoped to learn. Comparing the supervisory experience informed by the theory he hoped to learn with the previous supervisory experiences informed by the authoritarian theory he hoped to leave, Schindelheim (1995) describes how it seemed that his new supervisor was, “searching to discover the supervisee in his or her experience rather than insisting that the supervisee find the supervisor in the assumed greater objectivity of a ‘higher theoretical reality’ ” (p.162).

While Schindelheim writes of the supervisee’s experience, Ernest Wolf, on the other hand, discusses the affective component of supervision from the self psychologically informed supervisor’s perspective. He (1995) writes,

Wolf (1995) sensitively discusses supervisees’ unexpected disequilibria in the supervisory situation where they,

Since psychoanalysis has not yet developed a theory about learning, Wolf suggests that we pay attention to the processes involved in structural change during treatment, as a step toward the development of such a theory. He asserts that learning involves a structural change and suggests that the process of structural change in supervision is similar to that of structural change in the treatment setting. Wolf conceives of structural change in both settings as the result of a "disruption/restoration" sequence (Wolf 1983, 1988, 1993). He further suggests that the supervisor who is aware of the disruption/restoration sequence is sensitive to the student’s vulnerable self-esteem and supports that self-esteem when appropriate. Wolf adds that this support need not be entirely verbal. He observes that, when the supervisor is sufficiently attuned to the supervisee’s vulnerability, the student-analyst senses the emotional safety that has been created and eventually relaxes within the supervisory setting. Wolf calls attention to the inevitable disruptions that will occur in supervision based upon the unavoidable expectations and disappointments experienced by both participants. He assigns the supervisor the responsibility of monitoring the experience and, equipped with sensitivity to these issues, the responsibility of shepherding the supervisory endeavor to a successful conclusion.

Paula Fuqua (1994), in her thoughtful contribution to the supervisory literature, approaches the same subject as Wolf; only she does so at a level of greater abstraction. In her conceptualization, Fuqua articulates several tenets of a supervisory learning model. Her first tenet is that “learning proceeds from a biological baseline and is an inner generated activity in which the innate need for a tolerable amount of novelty is the motivator” (p. 82). Her second tenet asserts that “learning involves a necessary dismantling of psychological structure,” which she believes “is just as much a definitive part of learning as are the adding and restructuring that follows” (p. 82). Fuqua’s third tenet addresses the role and function of the teacher. She writes, “The function of the teacher is to serve as a manager of the states of disruption which involves the teacher’s various selfobject functions for the learner as well as the presenter of the material that is to be learned” (p.83). Fuqua asserts that learning is (a) defined by a change in structure (b) facilitated by some structural disruption, (c) interfered with by too much disruption, and (d) facilitated by the presence of a knowledgeable selfobject who helps manage the level of the structural change.

James Fosshage (1997) considers some specific issues of which the supervisor must be cognizant in his or her function as manager of the supervisee’s experiences. Fosshage speaks of the intersubjective system that exists between “analysand, analyst and supervisor which is exceedingly complex and is probably rarely captured through addressing a single linear process” (p.192). He writes “The analysand’s transferences and, similarly, the analyst’s counter-transferences are not distortions but constructions. The analyst selects particular cues, ascribes meaning, and interactively constructs” (p.200). The awakened multiple transferences in both patient and therapist might, at times, prove overwhelming for the supervisee. In this event Fosshage suggests that ” when the analyst’s self needs come to the foreground, the supervisor must find a way, directly or indirectly, to attend to the analyst’s momentary disequilibrium in order to facilitate the supervisory process” (p.202). Additionally, Fosshage notes that “mismatches occur that make it difficult for the supervisor to understand the analyst’s approach, creating mutually frustrating and undermining scenarios” (p.197).

The supervisory approach of tending to and helping regulate the supervisee’s self state suggested by Wolf, Fuqua, and Fosshage touches on the issue of what has been called the ”teach-treat dilemma,” a seeming dichotomy between the student’s need to be taught versus the student’s need for treatment. Wolf and Fuqua have suggested that the learning experienced in a psychoanalytic supervision involves structural change and that the well-functioning supervisor is attuned to anxieties that attend such a change. They further suggest that affective learning requires the creation of an atmosphere in which the student feels safe and has the experience that his or her narcissistic vulnerabilities are understood and respected.

Sensitivity to a student’s vulnerability does not necessarily express a dichotomy between teaching and treating. In psychoanalytic supervision the supervisor’s teaching and the supervisor’s attunement to the student’s narcissistic equilibrium are two threads in the same cloth. They each lead to ongoing self and mutual regulation at differing levels. Thomas Rosbrow (1997) addresses this seeming dilemma when he writes, “The teach-treat dilemma is a false dichotomy . . .. In a developmental approach, the process of learning in supervision is itself mutative and, in a broader sense therapeutic” (p. 218).

The eSupervision

This chapter will present the early opening phase of a correspondence we conducted that spanned a period of 1-1/2 years and contained a total of 140 letters. Through the presentation of our early letters, we will demonstrate the way we communicated with each other, the ambiance we created, the regulatory attitude that guided the affective component of the supervision, and the nature of the teaching that informed the cognitive component. We underscore our attempt, in the opening phase, to establish a way to communicate in writing with an unseen, unknown other about very sensitive issues.

Letter 1, Eva

Dear Dr. Siegel,

Dr. Ernest Wolf wrote to let me know that you would be kind enough to do supervision with me through the mail. You will notice that my English is a little bit rusty but I hope that with practice and writing it will soon become better. I am sorry for my mistakes and maybe for inevitable misunderstandings at the beginning.

I have many questions to discuss so I would like to start soon. I, too, have a Fax so we could use this quick way to communicate if you agree to do that. Then I have questions about the payment and the setting possibilities, like when will you have time to work with me?

I never did supervision by mail and I felt quite enthusiastic about the idea when Dr. Wolf suggested it to me. Living in the countryside and a farming area, there is no one near me with whom I could talk about self psychological ideas on a regular basis so I am looking forward to doing this by mail.

In order to introduce myself I will tell you of my educational background and clinical experiences. After what you might call high school, I studied at the Freie Universitat von Berlin and eventually earned my MA degree in 1971 in psychology, sociology, and educational science. I worked in different educational institutions and psychosomatic clinics and I finished my analytic training at the Munich Akademie fur Psychoanalysis und Psychotherapie, e.V.

I first learned about Self Psychology at a congress, organized by Dr. Lotte Koehler, with Beatrice Beebe and Michael Basch in the summer of 1994. Listening to Beebe and Basch, I realized that there were possibilities for expanding my theoretical frame. I decided to join the International Self Psychology Symposium at Dreieich in 1995 organized by Hans-Peter Hartmann and Wolfgang Milch, where I met Ernest Wolf, Anna and Paul Ornstein, Joe Lichtenberg and Lotte Kohler all for the first time. This January, Frank Lachmann came to Konstanz for a workshop. Now my head is full of the information I obtained by reading and listening – but I feel that this is only one way of learning and not sufficient for understanding the full extent of what self psychology means, especially since my training and my analysis were based on drive psychology.

I am looking forward with excitement to your answer.

With best wishes,

Eva-Maria Topel

Letter 1, Allen

Dear Ms Topel,

I was delighted to learn from Dr. Wolf that you are interested in self psychology and wish to become involved in supervision through the mail. You needn’t worry about your English. Your ability to express yourself in your letter to me was excellent and I don’t anticipate that communication will be a serious problem for us. I hear your enthusiasm and am most happy to work with you. I hope that in time your self-consciousness about your English will diminish. There will be two of us involved in this experience and perhaps I should apologize for my lack of fluency in German, which I did study in college. Since America is essentially an island nation, I have not made use of my German since then and I’m afraid my German is way too rusty for us to make use of it in our work now.

To let you know something about me, I had my psychiatric training at Michael Reese Hospital in Chicago between 1966 and 1969. That was a time when Kohut was making his early transition from drive and ego psychology to his psychology of the self. A close relationship existed then between Michael Reese Hospital and the Chicago Institute for Psychoanalysis where Kohut taught, consequently many of my teachers were influenced by Kohut from the very beginning of his work. In 1976 I began my training at the Chicago Institute for Psychoanalysis and I completed it in 1985. Kohut became ill in 1971 and withdrew from his teaching responsibilities in order to spend his time writing, but his influence continued to be strongly felt at the Institute and elsewhere in Chicago. While the formal theory in my psychiatric training was drive and ego psychology, as was your experience, the leit motif that became an ever-growing theme for me was self psychology.

I have just completed a book entitled, Heinz Kohut and The Psychology of The Self (Siegel 1996). It describes the development and evolution of Kohut’s ideas from his first paper, written in 1948, to his last publicly spoken words three days before his death. It will be published in October of this year, as part of a series of works about various theoreticians. While self psychology has continued to develop since Kohut, I believe his ideas are seminal and worthy of direct study.

In terms of my own work, I do both psychotherapy and psychoanalysis with adolescents, college students and adults. I also have experience working with couples. I have formally taught psychodynamic psychotherapy and have supervised for many years, but I have never supervised by mail. This will be a new experience for us both. As in any relationship, the first issue will be one of getting to know each other. That will take a little time, as will our becoming accustomed to this form of supervision. I have a great curiosity about it, as do you, so we will see how it evolves. I will leave things open as to how you should begin. Begin any way that you wish and we will work from there. If you require more structure at this point, please let me know and I can provide some direction. For now I think it best for you to start your own way, with whatever you feel is important. In time the blank spaces will fill in.

It just occurred to me that I might use idioms that are unclear. If that happens, please ask me to explain myself. I will be happy to do so. In our work I will consider it my responsibility to be clear and to discuss the ideas and issues we will talk about in a way that is understandable to you. Please do not worry about the language. As I said earlier, your English will not be a problem.

In regard to my fee I do not know how much time will be involved as we work through the mail. I assume I will need more than 45 minutes to read your work and then respond. If you are comfortable with this suggestion, let’s keep the issue open for the moment and we will see how much time is involved. I can promise you that it will not be unreasonable in terms of US dollars. Please let me know if that is acceptable to you. Regarding the setting, I assume you are referring to the frequency. Let’s keep that open for now so that we can see what you need. I am interested in pursuing this new form of work and am willing to provide the time it requires.

I do have a fax and we certainly can communicate that way. I look forward to our work together. It is an exciting new venture for us both. I hope I can make it a rewarding experience for you.

Sincerely,

Allen M. Siegel, M.D.

P.S.: Please let me know how you would like me to address you.

Letter 2, Eva

Dear Dr. Siegel,

My excitement continued as I read your so very friendly response to my letter. It’s hard to express my feelings: joy, happiness, hope and curiosity to see what will happen in this process that is so new and strange. As I read I found myself smiling with the thought, “perhaps this is what I have always been looking for.” Then, in the next moment a fear comes up in me that I could be wrong. It was with the help of your words and sincere ideas, which I could read and re-read that I got the courage to collect my thoughts and begin to write.

Now I am in the middle of theoretical confusion. I have drive theory training in my mind yet I feel that empathic responsiveness is the key. My inner world feels like it is wanting change and I am having ideas I never thought of during my training analysis.

I chose the case of a young girl to present to you. She has come to see me once a week for 11 sessions because of selective mutism, accompanied by enuresis nocturna. Her mother told me that she has never been able to stop wetting her bed. Medical investigations have been made and they are without any physical result. Her last doctor worked with something we call “Klingelhose” which the girl wears at night. If it becomes wet it rings a bell. Now, at night, the whole family (she has a brother four years younger and a sister three years older) hears the bell ringing while the patient is firmly sleeping.

When I first saw the girl I could not believe that she is 13 years old. She looked more like 9, at the most. She walks with her head between her shoulders so that she seems to be smaller than she actually is. The only thing she really likes to do is swimming with some girl friends, until she is exhausted. She can speak fluently but she doesn’t respond to her teachers and adults outside her home. To her mother, she talks only in one word sentences, if at all. The girl is intelligent, as I learned by playing with her, but she withdraws at the very moment negative affect might come up, for instance while loosing a game. I have learned to know her very quick disappointments and her retreats by reacting to her inexpressive face and by listening to her nearly inaudible sighs. I react to this way of being in her by feeling stiff, even motionless at times, and I feel restricted in my comments.

At this moment we are able to talk to each other in short sentences and she allows me to talk to her about momentary feelings. For example, if we are playing a game I might tell her I think she feels without hope to win. She might nod her head, smiling in response, and then she continues to play her chosen game, quietly as usual.

Sometimes I feel she wants me to win. Sometimes she seems to like the way I lose or the way I let chances open up for her. Once, when I let her win, she took a deep breath and smiled but she hid her affect as soon as, I think, she felt I saw her smile. Because of this situation I’m no longer sure of what to do or say. At that moment I thought I should give her a response and that she really needs one, but a new one, different from the way it had always been before for her. I feel, if I can’t find a new way to connect, she will loose hope. This is the point where I am looking for help. Since I attended the congress in Cologne, I thought self psychology might be able to provide such help. I have the feeling that she is waiting for me and that this interaction will be decisive for the therapy, so I feel pressure and hope and fear arising in the same moment for both of us.

About one hour after our last session I reflected on our meeting and even felt afraid that she could be suicidal because she played as if she wanted to destroy everything she had constructed before. That was the last meeting before her Easter vacation. I will see her again next week, and I have no doubt that she will come! It seems to me though, that she is struggling for her self-state and that it can go either in a good direction or in an even worse direction.

When I met with the parents, the girl’s mother spoke with very low vitality and, reacting to her sadness over this child, she talked with a sudden, depressed sigh and a kind of smile, “With this girl there will always be sorrow.” Even if so, she told me, that her daughter gets on her nerves. The mother feels she will always have to look after her daughter! During our meeting, the girl’s father sat quite still in his chair and spoke only if I spoke to him. He was friendly but rigid in his words and movements.

It seems that one result of this sad situation of constant mutual displeasure is that the girl withdraws. She is behaving as if not listening to anyone, as if expecting only useless advice. It seems that she no longer wants to be confronted by people who are unable to understand her. When I reflected on one of our sessions I thought that she quietly, but endlessly, demands that if anyone ever wants to be heard by her and get a real reply in response, what they say must be exclusively for the girl and not for anyone else! I am troubled because I feel quite helpless when I sense this special need which now seems to be coming as if it were an angry demand.

I think I will stop here for now because I want to hear what you have to say.

It’s OK with me to leave the question about your fee open and to wait for your impression. Since you asked, I would like you to address me by my first name, Eva, if you would like to do that.

Now I anxiously await your reflections. Thanks for listening.

Sincerely

Eva

Letter 2, Allen

Dear Eva,

I was happy to receive your letter. Your enthusiasm for your work, your concern for the girl and your uncertainty about how to approach her all come through clearly. All of these will be helpful in our work, even your confusion. They all speak about your wish to learn and to understand this child so that you can be of help to her.

As I understand her at this very early point, the girl presents a very troublesome problem. She seems to be a very sad and depressed girl, living in an emotionally deadened home. She seems to be barely verbal but her silence is, nevertheless, a statement of something about her and we need to understand her silence that way. Her silence is a potential problem for the therapy but it does not have to be insurmountable if we understand the silence as a communication. For example, is the girl saying, "Why speak? No one will listen anyhow? Why should I assume this experience with you will be different from anything else I have experienced?"

I am impressed with the authoritarian and somewhat tyrannical way her enuresis has been approached. For me the central question in this problem is, "What does the enuresis mean?" I believe that understanding the meaning of the enuresis is more important than simply training her not to wet her bed. The girl has repeatedly been humiliated by her doctors and by her family for a problem that she is ashamed of herself. If she could control it she would. She certainly doesn’t need a cheering section that tells her how bad she is for something she cannot control. Her problems, of course, are much deeper than simply wetting her bed.

The first task in treating her is to come to some understanding of who she is as a person and what is the nature of the emotional environment in which she lives. To contrast drive theory and psychology of the self for you, drive theory would conceptualize this girl’s problems as emanating from a conflict between her forbidden unconscious wishes, contained in unconscious fantasy, and the defensive forces of the ego that oppose them. Drive psychology would view this child primarily as though she were a closed system with an assortment of sexual and aggressive wishes, present from birth. According to drive theory, these basic wishes or instincts must be tamed by the ego so that the child will eventually live in a civilized fashion. In this regard, drive theory mixes the values found in Western religions and principles borrowed from Darwin’s biology into its ideas about human mental states. Because of these intrusions into its theory, drive psychology is not a pure psychology. Instead, it is an amalgam of ideas from several different fields.

Kohut, on the other hand, defined psychology as the science that studies the internal life of humankind through the use of empathy, the only instrument we have available to gather data about human emotional experience. Empathy, as Kohut originally defined it, is the way one person can know something about the internal experience of another. Empathy, according to this definition, is a tool that allows us to gather data about other people’s emotional experiences. Empathy provides us with information. Once we have the information we need we can then decide what to do or what not do with or for another person. To respond appropriately to any person, we must first be informed about them and empathy is the tool that provides that information.

At this moment, the central issue for us in relation to this child is what is going on with her? Why is she so depressed? Why is she nonverbal? What information do you get when you sit with her, even when she is silent? What is the silence like? Is it calm? Is it angry? Does it make you anxious? What are its qualities?

The sense I get from your material is that this is a girl who has not been understood as a person. It seems that she has given up the hope that she will ever be understood and she has withdrawn. In response to this hopeless withdrawal, I would attempt to establish a kind, gentle and realistically friendly atmosphere with her. In an effort to help her talk about herself, an experience I assume she has not really known, I would comment on her sadness. I would say to her that she seems to be so very sad. Does she know why she is so unhappy? I would ask if she were able to put that into words? I would ask what makes her sad. What makes her mad? What sorts of things hurt her feelings? What things does she find herself thinking about when she is alone? What troubles her? What makes her happy? What is it like to live in her home? She might respond with one-word answers. If so I would encourage her to elaborate and I would help her do so, building upon anything she might offer in the way of revealing herself. I would not hesitate to ask her how she feels about her bed-wetting. What is that like for her? I would become her ally in the attempt to help her master it. I would stop the torture devices like the Klingelhose. She does not need to be further humiliated. I would treat the enuresis as the girl’s issue alone and, in an effort to get the parents “off her back,” I would try to educate them, as well as the girl, that the problem will go away in time. I would tell them, “there are worse things one can do than wet one’s bed, so let her be” and I say to you that the girl suffers her own humiliation every time she wets her bed, so let it become her problem with you to help her. Remove the rest of them from the situation, if that is possible.

I would add here that, of course, in working with children, one must have a good working relationship with the parents. The child does not exist alone. This is another point where self psychology differs from drive psychology. The child is not simply a bundle of instincts that must be tamed through an increase of ego capacity. The child lives in a milieu of responsive or non-responsive people. These people perform various psychological functions for the child that the child cannot provide for himself or herself. These psychological functions are essential for the healthy development of the self. The “objects” that provide these essential psychological functions are called selfobjects because they are experienced, by the child, as part of the self in terms of the psychological functions they perform. We will have opportunities to discuss questions concerning selfobjects over time. For now it will help me to know what literature you have read within the field of self psychology. I do not want to be condescending or redundant in what I write to you so I need to know what you know and what you wish to learn.

Returning to the girl, particularly in relation to the games she plays with you and the winning or losing issue, it is important for the game to be real. If she cannot win that is OK. If she is sad over losing then that experience will give you the opportunity to talk with her about how she feels when she loses. It will help us learn how she feels about herself. If you let her win, she will probably know what you are doing and that will diminish her trust in you. You must be real with her. If she loses, it’s OK. Losing has a meaning and that is what you are after. What is her experience when she loses? Don’t worry about protecting her feelings by helping her win. It will backfire. It does not protect her. What will protect her is the experience of being with someone who is truly interested in her and who wants to know what it is like to be her. This experience will provide her with hope over time and that is where the protection lies.

This is all I have to say for now. This is an interesting case with many problems. I am sure we will both learn over time as we attempt to understand her. I look forward to your response to what I have said.

Sincerely,

Allen Siegel

Letter 3, Eva

Dear Dr. Siegel,

Thanks a lot for your clarifying response. It gave me an opportunity to prepare for the next session with L. and I am happy to tell you that this time we both spoke even more together. What happened is that I simply did not stop when L. stopped speaking! For example, this is how it went.

Me: You look away, maybe you don’t like to speak with me today?

L: No, . . . it is just unusual for me.

Me: Unusual? . . . nobody talking to you like this?

L: She nods her head affirmatively.

Me: . . . reminds me of the time we talked about how speaking has not been a good experience for you.

L: Again she nods her head, but this time, since her eyes are more in contact with me and she seems a little curious, I took a chance and said:

Me: Could you tell me about your experiences talking and the reasons you do not speak?

L: Never thought about it.

Me: How could that be?

L: Nobody ever asked me.

Me: Oh . . . why speak if nobody asks as if nobody is interested?

L: She nods her head affirmatively again and sadly looks away. This time I am different and I continue despite her withdrawal.

Me: . . . makes you sad . . . maybe more?

L: Never thought about it.

Me: I had a hard time knowing how to go on but I noticed that I no longer was thinking about resistance but in terms of how she used her withdrawal. After some time waiting:

L: I will go swimming.

Me: Oh, you are going to meet your friends there?

L: More vitally engaged now (and I am too).

Yes, I joined a swimming group and we train for rescue!

Me: Responding to the proud tone in her voice, I said:

Oh, good! So you can save a life?

L: Not now. I am not strong enough yet, but I will!

Me: I see. So you are training very hard.

L: Proudly she nods her head.

Me: That’s fine. You will become strong. Your parents must like it too.

L: I don’t know.

Me: Why not?

L: They don’t talk about it.

Me: What do they talk about?

L: My taking good notes.

Me: Again I had a hard time knowing how to go on. Then I tried:

Good notes . . . hm . . . another area to feel good about?

L: Nods her head.

Me: I reflect for a moment and L takes out a game from the shelf. We play and she seems to be excited. I said:

Exciting, isn’t it?

L: She seems astonished and said: Nooo.

Me: No?

L: I don’t talk about such things.

Me: How do you feel then?

L: Never thought about it.

Me: Would you like to find out?

L: She nods her head vitally and after a while said:

Yeah, there is something that I feel. I don’t know how to describe it.

Me: Well, here we are now, in a situation where you could be winning the game. Could that be important to you?

L: She looks ambivalently at me, takes in a deep breath and answers:

Maybe. I don’t know. I feel nothing. Hmm . . . but yes, it is exciting.

And then, with more and more joy in her voice she talks about her experience as we play with comments about whether it is exciting for her or not. At the end she summarizes:

For me it is most exciting if both players are at the same point and either of them could win!

This time, at the end of our session, L. says good-bye, looks directly at me and shouts in a friendly voice:

Until next week, I guess?

Me: Yes, until next week!

I was very impressed by your formulation: a deadened home! It’s a touching symbol. I will write down the literature I have read, but as I am quite aware now, cognitive study does not imply emotional understanding. I really enjoyed your comments and the way you give them. They are a very clear integration of theory and its place in practice. Please go on this way. It is not condescending to me! Once again your letter made me smile. I like to listen to you very much. Furthermore, to have your answer written down is helpful for me, because I can study it as often as I want and need to and, if I need to after some time, I can check it again to see what you said or whether I missed something or mixed something up.

I noticed that my theoretical approach to the girl’s problem was not empathic according to your explanation of empathy. What I mean is that the “information” I obtained did not come from L. but from the theory I have in my mind. Even though I know about mirroring and the need for acceptance, as you can see I still reverted to the old way of thinking. That’s where your theoretical comments were so valuable for me.

At the beginning of L’s treatment I already got her mother to agree to stop the “Klingelhose.” She understood her humiliation when we talked about it but it was difficult for her to oppose doctors. In our area bed-wetting, even if still a quite usual symptom with children, is seen as a shameful disease and it is also still uncommon and equally shameful for people to apply for psychotherapy for it.

Until now I did not have a comfortable way to ask the girl about herself. As far as I understand you, however, it is possible to ask directly, especially when she does not speak and especially because nobody in her life has asked her about her own affairs. I tried to wait silently and not to interfere with the patient as I had learned to do. Guess we will talk about this issue too. I remember Paul Ornstein saying in a workshop, “Wonderful theory, but what did the patient say?”

It seems so easy to understand that empathy is not possible if you don’t know about the patient, but how does one get the data? The two approaches seem to differ so much. No explanation is possible if the therapist only tells about his own insides. I am left with confusion.

It was clarifying for me to think about what a “selfobject” is and what function it serves. I agree with you about what you said concerning being real with her and about what gives hope and what protects, especially after our last session. She lost one game after she was very close to winning. She became very excited and when I asked her about what she felt she said, “All over,” and ran to the shelf to fetch another game that she thought she could win. I was glad that she tried again.

I’m sorry that I didn’t ask you how you would like me to address you. And as I like having your letter very much, would you too want me to send you my original letter in addition to the fax?

Sincerely,

Eva.

Letter 3, Allen

Dear Eva,

Congratulations!

It seems that you and L are beginning to find a way to talk with each other. By the way, it would help me if you gave L a name. If you wish, it need not be her true name but I do need a name to help make the treatment and the girl more real. I find that relating to an initial is disruptive for me.

From what you have written it seems that you will need to overcome parts of your training. Since what we “know” is guided by our theories we tend to tell our favorite theory to the patient who learns our language and then spits our ideas back to us. In this way we get “proof” of the “correctness” of our theory and this gives us confidence that our theory is correct. With this confidence we march on creating a story for the patient who, because she probably has done so all his life, complies with what we say. Our treatment proves our theory but our patient does not benefit. The treatment becomes a repetition of the misunderstanding and compliance our patient has experienced early in life and continues to experience with us today. We need to help L tell us about herself so that we do not create her in our own image.

Your thought that the information you have about L has been coming from your brain and not from L is correct. From what you’ve written I see that this problem comes from what you have been taught. How can one learn about another person without asking questions? The critical technical issue is when and how to ask the question. The idea that one must wait silently, without interfering, until one can give an interpretation lies in at least two sources. One is the “scientific” medical model that approaches the clinical situation as though it were an experiment conducted in the totally “clean” environment of a vacuum. This view sees the patient as a pure specimen, not to be disturbed by the activities of the analyst. It assumes that the environment does not affect the subject. This is incorrect. In Chapter 2 of Kohut’s Restoration of the Self (1977), Kohut nicely discusses “scientific objectivity” and how the observer influences the observed. I recommend it to you.

It is a fantasy that we do not influence our patient. The mere fact of our presence as a listening, understanding and appropriately responding person has an effect upon the patient. There is no such thing as a “clean environment.” You and the patient exist in a dynamic system. There is a back and forth movement. You affect her, she affects you. We study what goes on in her, in you and between the two of you. There is an active, fluid dynamic in constant motion; even when there is silence. Sometimes the dynamic is present especially when there is silence and that seems to be the case right now with you and L.

Before I expand upon that point though, I said there were at least two sources for the practice of waiting silently one is until ready to make an interpretation. I want to comment on the second source, which I believe has its origin in one of the analyst’s own unconscious narcissistic issues. The issue I am referring to is the analyst’s unmodified unconscious demands for omniscience. It is a demand that requires one to know things with a priori knowledge. The truth is, however, that for example, one cannot know the full blooming of a rose when it is still an unfolded bud. Aside from their variation in color it seems that, at first glance, rose buds have much in common one with another. At that stage they all seem to look alike, but if you’ve ever grown roses you know that’s not the case. Rosebuds open into five petal roses and 40 petal roses, fragrant roses and non-fragrant roses, strong roses and fragile roses. One can never know the rose’s bloom by its bud. One can never know the unexposed world of the rose before it reveals its unique insides. That surprise is part of the joy of raising roses. The same is true with our patients. To believe we know the patient, without the patient revealing his or her insides to us, is a belief based upon fantasy. An analyst’s fantasized omniscience protects the analyst against the terrible anxiety that comes from not knowing, an anxiety that stems from an assault on one’s unconscious grandiosity. As an analyst develops and gradually becomes comfortable with not knowing, the acceptance of and comfort with one’s ignorance can become a valued part of our analytic selves. Rather than experienced as an assault on our expansiveness, the acceptance of our ignorance makes it possible for us to be an open receiver to what goes on in our patient, in ourselves and between our patient and ourselves.

Now lets look at your material.

You began on a good path with L when you said, "maybe you don’t like to speak" and L replied, "No . . . it is just unusual for me." That was an excellent start. Unfortunately, however, you jumped in as you have been trained to do and told L what she was thinking. You did this when you said, "You mean nobody talks to you like this?" That certainly is a true statement and maybe something you might say later on but L had just said something amazing. She told you something about herself when she volunteered that talking about herself was "unusual." I would have tried to help her expand that thought. Rather than give her an answer as you did, I might have responded with, "Tell me about that"or "What do you mean?" Or as you correctly said a little later, "Could you tell me about your experiences talking and the reasons you do not speak?" You were correct in what you said but I believe your impulse, which has been highly developed through your training, was to give her an answer immediately. Unless your patient is overwhelmed with anxiety, it is best to give her a little time and space to see what she does on her own. L seems to want to talk. She needs to learn how to talk about herself and to do this she needs the space to express herself. Her response, "Nobody asks me" is both startling and expectable, given what we know about her. It also is profound in its simplicity. I would pursue that line. To do this I might say, "What do you mean?" "How is that possible?" "Do you have thoughts and ideas that you keep to yourself?" "Would you like to talk about things inside of you?" Once you get the idea you will see that there are many ways to coax a bud into bloom.

I think you had a hard time continuing from this point forward because you had cut L off when you gave her an answer as you’ve been taught to do. Your observation that she looked sad is important but, again, you told her about it without encouraging her to talk about it herself and this left you with nowhere to go. Instead of closing a door by giving an answer, one might say instead, "You look sad as we talk about this. Is that how you feel?" She might respond with, "I don’t know." I would not be put off by that kind of remark. I would expect it since L does not know how to talk about feelings since no one ever helped her with that. I would encourage L to elaborate on her experience. I might help her with, "I know it’s hard to talk of feelings since you never have done so, but try, if you can, to put into words what your sadness is like for you." You might be surprised at what L will come up with. Again, once you get the idea it will flow for you.

The next material is very interesting and suggests that we are on the right track. Since L fell silent I might have asked her about her silence by saying something like, "what made you suddenly become quiet?" I believe she told you that she has joined a group that trains for rescue. That was not a chance association. She is talking about you and her. She has joined a group that is attempting to save her from drowning within a deadened existence. It is the group she is forming with you. L further said that she is not yet strong enough to save a life but, in a full and strong way that was brimming with hope and confidence, she said that she would become strong. I think she is talking of her hope that you will be able to help her. She senses your interest and your wish to reach her with the lifeline that your understanding provides.

In the next material you introduce the topic of her parents. What made you move in that direction? Why did you introduce the idea that her parents would like her rescue training too? L responded to that by saying that her parents don’t speak with her. She has no idea what they think about her interest. She added, in a concise way, that they are mostly concerned that she behave herself, work hard in school and take good notes. She infers here that they do not respond to her internal life, only her behavior. She must perform well. She became quiet and you felt stuck. I believe you were stuck because you touched on something that is difficult for L. Your statement about the notes, “another area to feel good about,” seems to be an attempt to enliven L and make her feel better. I don’t believe the good notes make her feel better. I think they make her feel worse because they remind her that her parents are not interested in who she is, what she is like, and in what her interests are. They are interested in how she performs. Her role is to be a "good girl" and that burden makes her sad. This is an interesting issue that will come up over and over. Watch for it and be prepared to gently explore it. Your task is to explore rather to provide answers. I predict that the effect of such an exploration will be to give her hope, rather than to frighten her. It frightens her more if she thinks you have all the answers. She has lived with people who have all the answers about her. They “know” what is best for her and they tell her so "for her own good."

L wants to play the game with you, but the game is the game of communication and relatedness. I believe she conveys this sense when she talks about the games. She said, "For me it is exciting if both players are at the point where either of them could win." She hungers for the exchange and the liveliness of the encounter. This exchange is like oxygen. Further, it is the light and warmth that will allow the bud to slowly come into bloom.

I believe I have given you much to think about so I will stop for now. It sounds as though your previous experience with analytic literature and training is not too different from L’s experience at home. The deadened literature you have read in the past strangled your lively interest. That is not an uncommon experience. I was impressed with what you have read so far and what you are reading in self psychology. Some of the material in the field is difficult to understand upon first or even second reading. If you have any questions I will try to answer them.

I am happy to send you the originals of my letters and yes, I would like to have yours, in addition to the fax. I am just thinking about how wonderful it is to have the fax technology that allows us to communicate this way. I believe it enhances our experience. I find that I look forward to your letters, curious about your response to what I have said. In regard to how to address me, please address me in the way that makes you most comfortable.

Sincerely,

Allen Siegel

Letter 4, Eva

Dear Mr. Siegel,

Thank you very much for the fax I received yesterday afternoon. I am glad, you gave me back my curiosity and my joy in my profession. I really would like to call you Allen, if you allow me. In doing so I do not want to be disrespectful, but I want to show my thankfulness for your caring in our working relationship.

When I saw Lisa this time I noticed that something had changed with her. After an initial silent period I realized that she seemed to have grown up. Her movements were more purposeful.

She looked at me somewhat shyly when she first came in. We shook hands as usual and she went to the shelf to find a game to play. As we started to play quietly I noticed that two things were in my mind. One was your touching question, ”Why should Lisa assume that this experience with me will be different from that with others in her life.” The other thought was your comment, “Let’s have some time to breathe.” Then Lisa’s stomach made a soft noise, she smiled gently and I began, smiling back at her.

Eva: You’re smiling?

Lisa: Her nodding head and quick glimpse at me through nearly closed eyes encourages me to go on.

Eva: What makes you smile?

Lisa: My stomach.

Eva: Hmm . . . ? Is anything going on?

Lisa: Nodding her head affirmatively again.

Hungry.

For me this was a highly symbolic answer and it made me think too much. Old answers came up, but this time I refused to listen. Without the old answers, however, I did not know how to respond. After a little while I was able to continue.

Eva: Hungry?

Lisa: Doesn’t matter!

As you can imagine, I again needed time to know how to respond. I thought; “What doesn’t matter?” Is it my speechlessness that doesn’t matter? Or is it being hungry that doesn’t matter - and hungry for what. Finally I said:

Eva: Hm . . . does not matter?”

Lisa: I am not ill.

I don’t remember exactly what Lisa said next. She played a little while, wrinkled her brow and I with a low voice asked:

Eva: What’s going on.

Lisa: Not so good!

Eva: Can you explain to me what you mean by “not so good?”

Lisa: Smiling a little

Not fine.

Eva: What’s not fine now?

Lisa: Looking at the game we are playing.

I have to go back.

Eva: Oh yes, I see . . . feel something right now?

Lisa: Looking at me somewhat carefully.

Angry!

Eva: You can imagine that I was (I can’t find the right word) content at this moment.

Oh yes, of course...

Lisa continued smiling for a long time. Her smile gave me the impression of her being a “good girl” so I asked:

You’re still angry, aren’t you?

Lisa: Nods her head affirmatively.

Eva: And as I see you, I see that you are smiling.

Lisa: Nods her head “yes” with her eyes nearly closed but looking in my direction.

Eva: It seems to me that you think it’s better not to show that you are angry.

Lisa: Smiling gently, she nods her head.

Eva: Usually there are good reasons if one does not want others to know about one’s feelings.

Lisa: Shakes her head “No.”

Eva: Do you think it could be possible there are good reasons that one would not want people to know?

Lisa: Yeah (Lisa continues playing.)

Eva: Stuff you do not want to talk about?

Lisa: Nods her head and goes on playing.

A little later the play has a possibility for me to win. Lisa moans a little and I ask:

Eva: . . . something is going on . . .

Lisa: Not so good.

Eva: What could that mean now?

Lisa: Unfair!

As you can imagine again, I had a hard moment before I could go on. Then I asked:

Eva: What is unfair?

Lisa: Two against one.

Eva: Yes, two against one. Teasingly I added: such unfairness, you know?

Lisa: Lisa then told me about a film she recently saw where three white boys beat up one black boy and hurt him badly. Lisa said she had much sympathy for the black boy. I did not know where she would want to move on to, so I waited and then tried:

Eva: I wonder what you are feeling now?

Lisa: Remains quiet, shaking her shoulders a little bit.

Eva: Not easy to find the words?

Lisa: Turns away from me.

Eva: I should not ask you?

Lisa: Nods her head and smiles

Eva: Hmm, I see. Maybe there will be another time to talk about it?

Lisa: Nods her head affirmatively and with this we went on playing.

I want to stop the verbatim report here because I do not remember the following very well. But I do remember Lisa’s serious mood which was more calm than quiet as we ended the session. When she left, Lisa turned toward me for a friendly goodbye. The next session will be on Monday.

I am impressed about how much Lisa told me this time. I do not remember exactly when it was in the session, but Lisa told me that she watches television when she feels bored. She said she experiences boredom in school too, even in subjects where she is capable like history. It would be easy to learn for her, but as you said, it does not make her feel happy. Although she has no practice speaking about herself, Lisa seems to have a rich internal life, full of feelings that she keeps carefully available only to herself.

This last thought leads me back to the idea of depression and the lack of selfobject relationships. At this moment, reading Kohut, reading your letters over and over, and thinking about myself, it is difficult, even in German, to find the words for what is going on in me. Affect and empathy are the key words.

Yes, using the fax gives me the chance to have your response as quickly as possible and it diminishes the time that goes by while so much is happening. It’s nearly like having supervision once a week and it’s quite different. For instance, when I write I often think, “Will this be understandable to him?” If it is not understandable I don’t think I can do any better. Therefore I find myself being very careful with the words that I use. That’s good. It gives me more time to think about what I really want to say. On the other hand, it seems to me that I can’t express these things sufficiently. But this is not only because of the English translation but because there is more here than I can write. That isn’t astonishing to you, is it? When I’m writing about something and think this is all too much I also think, “There will be time to discuss this too. It will not be lost.”

I will never pass roses again without thinking of your ideas, meditating about grandiosity and trying to become relatively comfortable with incompetence. Thank you.

Sincerely,

Eva.

Letter 4, Allen

Dear Eva,

It sounds as though Lisa and your work are both finding new lives. I am glad for you. Before I address your clinical material, however, I want to make a cautionary comment about theories in general and also about the battles people get into over their differing theories. I make these comments because I realize that, while you have not addressed this problem, I am certain that you have to live with it. It is a part of psychoanalytic life.

What I want to say is that the battles people get into over their theories are due to their narcissism, not to their theories. Some people forget that theories are merely the best attempts we have at a given moment to explain particular phenomena. Theories are temporary explanations. They will change with time. In your enthusiasm for the new ideas of self psychology it is crucial not to become wedded to these ideas, for they too will change with time. Twenty years from now we might laugh at how we thought a particular explanation was so important. At one time medical science asserted that the human body was composed of four humors. At one time all right thinking people were certain the earth was flat. All explanations are provisional. They simply represent the best way we have of understanding something at the present time. Kohut expresses this beautifully in the last three pages of Restoration of the Self when he suggests adopting the stance of the playful scientist; one who plays with ideas and is willing to change when better explanations come along. I can safely promise you that ideas within self psychology will eventually change.

In your last letter you sounded as though you are worrying about whether you are making yourself understood to me. Let me respond by saying that I have had no difficulty understanding what you have written. You are right in your thought that in time you will be able to articulate the ideas and experiences you are struggling with, even in English. It will not be lost.

Now To Lisa.

I believe her changing posture reflects how she feels about coming to see you. She seems less withdrawn in this session. Clearly you are beginning to get the idea of allowing Lisa to talk without intruding your ideas so that she will have the opportunity to reveal her own experience. You mention the struggle you are having setting your old theories aside as you work. Your experience reminds me of a tennis player who learns a new serve or a pianist who is learning to hold her hands a new way. For a while the change is terribly uncomfortable and self-conscious. In time it will become natural.

Lisa presents a difficult problem because she is not yet very verbal. Because of this she needs help in giving voice to her internal life. At the same time it is essential to stay out of her way and not provide her with answers. Since she is a compliant child she probably will agree to many of the things you might say. The best stance is one of curiosity and naturalness. Try to leave your theories at the door when you enter the room with Lisa. Let “common sense” guide you at this point, rather than theories. When you feel stuck reflect upon what makes sense to ask Lisa at that moment. Often, when we speak directly from our theories, what we say in a clinical moment doesn’t make much sense. At this point in your work with Lisa you are not in a position to apply any theory because theories provide explanations and we don’t have enough data yet to formulate an explanation. We are in a data gathering phase, a period of evaluation. After we know Lisa better we will formulate theories to help explain who she is. For now let your natural curiosity, your interest and your nonintrusive warmth be your guide. By doing this, you will gather the information we need and Lisa will benefit from the interest of another person in her well being. You will help her as she learns to talk about herself. All people have a deep wish to be listened to as we talk about our true selves. This is the case with Lisa and she will eventually respond to your efforts.

You are correct that Lisa's comment about hunger made you think too much. We haven’t any idea what the comment meant. It might not have been symbolic. Her stomach rumbled. She was hungry. It could be that simple. In response you could ask her natural questions like: "What makes you hungry? Why are you hungry? What do you do when you are hungry? Do you like to snack?" These questions might open a path in the direction of Lisa’s parents' attitude toward eating or snacking. If that path were to open we would learn about how they respond to Lisa and to her needs. In your work, I suggest that you adopt the attitude of the friendly detective. Find out as much as you can in your own nonintrusive way. Of course, I would not ask her so many questions all at one time. I want to be clear that when I list so many questions, as I often do in these letters, I am attempting to illustrate a few of the many possibilities. I am not suggesting that you bombard Lisa with a multitude of questions. That would be an assault.

When Lisa said, "It doesn’t matter," I wonder if she was responding in a compliant way. I wonder if Lisa is accustomed to not mattering. If that is so, perhaps she has learned to pass over things that relate to her and to her needs. If I am correct in this speculation, than we are in agreement about how Lisa’s parents respond to her. We will know this with time.

It would help me if you could describe the games you play with Lisa. Your description of Lisa becoming angry during the game tells me you are catching on to my way of working, however, you interrupted Lisa after she told you she was angry. I think you responded to her difficulty articulating what she felt when you offered her an explanation of why she had trouble talking about being angry. Your explanation came when you said, "One does not want others to know about one's feelings." In saying this you offered Lisa an explanation, and possibly a correct one, but it was not time for an explanation because, as I have implied, we do not yet know enough about her anger. My guess is that in the world outside the consultation room, if someone told you they were angry your natural inclination would be to ask them why they were angry. The same applies to Lisa. I would have asked her what made her angry. “What was it like to feel angry? When else did she feel angry? Does the way she feels now remind her of anything? Has she felt like this before? When?” Be a gentle detective of the internal world. Learn the facts for now, we'll formulate theories and explain meanings later.

Lisa revealed herself to you when you did function as a gentle detective and asked her what she meant by "Unfair!" She told you the story of the boy who was outnumbered by the hurtful people. Asking Lisa what she felt at that point was correct but you might have stayed with it a little longer even though Lisa was reluctant to talk about it. When you suggested that Lisa did not want you to ask her about it any more, she complied with your idea. Instead, you might have gently encouraged her to talk by saying something like, "Try to tell me what you are feeling now." "I know this is difficult, but give it a try." I might have asked Lisa what she thought it was like to be the black boy? How was it that she understood the boy's feelings? Did she ever feel ganged-up on like that? When? What was it like? By whom?

I understand that you are being careful with Lisa, as you should, but she has told us she wants to train and get strong. That comment is a communication that suggests to me that you can be more direct with her. Try it and see what happens. I think she will be encouraged by the chance to talk, even though it might be about things that frighten her. Good luck.

Sincerely,

Allen

Letter 6, Eva

Dear Allen,

Did you know what the next discovery would be? Doing treatment the new way I find my whole effort during the sessions goes to the question of how I can find a way to communicate with my patients so that they can speak about themselves. This leaves no time to formulate theoretical hypotheses.

Something is going on with me that is hard for me to describe. For instance, when I try to tell you about my feelings at the end of the last session with Lisa I find that I am unsure about myself. I try to find explanations for what is happening and I end up convinced that this is only a cognitive, rational task. Something else is coming up that I can’t identify right now. I try and new ideas come up. It’s as if I can’t validate things and I end up not trusting myself anymore. At one moment I feel bad and deserted about this and at the next moment I could laugh. I know that there is no absolute truth, but everything seems to change every moment for me now and that’s uncomfortable for me to feel. It seems that through this experience of change, sort of a cognitive dilemma that I am going through right now, I am able to understand the experience of fragmentation. It feels terrible and I run around in my head looking for some safe knowledge.

Now to Lisa and her mother

Monday morning Lisa’s mother rang me up. She wanted to see me the very next day. I asked if something had happened. No, she said, but she wanted to discuss some things. I had time on Wednesday and we met. First she asked me if Lisa would be a good “co-worker” because it sounded to her like she would not. I asked if she had any doubts about her capacity to work and why she was asking. She then spoke about her sorrow that Lisa is too quiet and therefore she does not expect that she will achieve, not in school and not with me. I again asked her what gave her such proof that Lisa will fail and she told me that she had done better in English but she fears Latin. She never learns and then she doesn’t want to go to school. In the morning she can’t stand up and coming back from school she is always tired. Soon there were tears to be seen so I tried to find out her feelings about herself.

She told me that she recognizes painfully Lisa’s separation from her. For example, she reported that she is not allowed to drink out of the same glass as Lisa anymore and when she took a piece of chocolate from her table Lisa threw the whole chocolate away. The mother very bravely said, “That is normal and I should learn not to do it any more.” Then she came to her feelings of guilt. She said that she often thinks, “What will Lisa say about her childhood when she is grown up? She has been ill so often and such an unhappy child.” This was a very intense moment between us where we looked at each other quietly.

I don’t remember how the next issue came up but she told me that she thinks Lisa is funny. Lisa can sing and make jokes, which the mother really enjoys. When the mother had to leave home for some days and when she called at night, Lisa had prepared some funny stories to read for her. Mother liked that very much. At the end of the session she said she wanted to come again and try to speak more about herself. I had the impression that it was helpful but difficult for her to speak about herself. Also, she was not used to being asked about herself and being listened to. She seems to be deeply depressed and in need of Lisa to stay her little girl. She suffers with Lisa going her own way but she is able to want Lisa to have her own life too.

Lisa’s Session

She began in quietness and with the barricade game. I tried to meet her quietness and how it feels. First it seemed empty, then, looking at her face, I noticed that she avoided looking at me. Every time she had the dice she returned it politely to me. I tried to meet her eyes but she avoided my gaze and looked to the ground. I decided to wait and see if there would be a chance to meet her. I felt alone at this time, like I think she might feel. Then she looked at me and meeting her glance I started with a very low voice.

Me: So quiet today?

Lisa: I’m always quiet.

Me: Aha . . .?

Lisa: . . . not always.

Me: after some time:

When not?

Lisa: Playing dolls.

Me: With whom do you play?

Lisa: Schoolbus . . . friends.

Me: Oh yes . . .

Lisa: Laughing cautiously:

With friends it’s always good.

Me: Hm . . . friends . . . ?

Lisa looks at the floor and I can feel her withdrawing again. I think she does not experience me as a friend right now. I can understand her hesitation.

After some silent time, looking at each other, I tried to connect again:

What’s the difference for you in being with friends or not? How do you feel about those situations?

Lisa: Looking around a little helpless.

Me: waiting: Hm?

Lisa: Shrugs her shoulders.

Me: How do you feel about being asked such questions?

Lisa: Sometimes good, sometimes bad.

Me: Could you explain that a little bit?

Lisa: Like in school, it’s bad.

Me: What’s happening in school?

Lisa: If I don’t know I wait for help from my friends.

Me: And they help you?

Lisa: Smiling:

Yes, if they know.

Me: And if not?

Lisa: I sit down.

Me: And how do you feel then?

Lisa: Don’t know.

Eva: Hm, how could that be . . . sitting down at such a moment?

Lisa: Looking at the ground.

Normal.

She returns to the game and is winning at this moment. She immediately fetches another stone to build up a barricade.

Me: You said “normal” and I wonder what normal means in your opinion.

Lisa: Looks at me with small eyes and a wrinkled mouth.

Eva: What’s the matter now?

Lisa: Don’t know what to say.

Eva: Oh . . .

Lisa: Sometimes it is better not to say.

Eva: When do you experience that?

Lisa: With Mom and Dad, school things, and what happens there.

Eva: What’s your experience with Mom and Dad?

Lisa: Looks around and shakes her head.

Eva: Something you don’t like to speak about right now?

Lisa: Nods her head.

Lisa: Yes . . . secrets.

Lisa: Sometimes good, sometimes not . . . I should tell.

Me: And why don’t you? What are your reasons not to do so?

Lisa: Hesitates for a long time:

These are bad things.

Me: What’s bad, in your opinion.

Lisa: Seems to be astonished about this question. She shakes her head again and I continue.

Me: Again, I don’t want to know things you don’t want me to know, right now, but what’s the meaning of bad? One can never know what another thinks is bad.

Lisa: Shaking her head and playing the game. Again we play without looking at each other. Lisa plays quickly and builds a real barricade. There are 5 minutes left so I start again, like talking to myself, not so much looking at her.

Me: Now I think about you . . . sitting in school at your desk, not speaking but thinking for yourself. I wonder how that will be for you, how can one feel?

Lisa: Speaking suddenly and quickly.

Misery!

I’ll give you the German word for this because maybe it explains my astonishment at hearing her use this old fashioned word: Elend. I pick that up, cautiously in a low voice:

Me: Misery . . .

Lisa: Looking at me and I think seeing my serious face, eyes kind of sad and filled with consternation at this moment she smiles quickly.

Not so important . . .

Me: Not . . . ?

Lisa: This word is too strong I guess. She hesitates but gives no new word.

Me: Misery . . . good word . . . sometimes things are like that.

Lisa: Nods her head and sighs.

Me: . . . nodding your head . . .

Lisa: Yeah . . .

Our time is over and she looks at her watch. We didn’t finish the game and I ask what she wants to do. Sometimes children wish to write up where we are so we can continue.

Can’t do anything more anyway.

And she returns the game.

As you know, it is very hard for me to say nothing but we stand up and go to the door. I recognize now that this feeling of misery, whatever it is, is Lisa’s own feeling and she has a right to feel it. I do not want to dissuade her anymore from such a feeling which possibly would give her the impression that I do not take seriously what she feels or do not want to listen to her experience, especially when she gives it to me in confidence. Lisa went to the door, gave me her hand, looked into my eyes directly and I felt her to be very near.

That’s it for now. It’s me who doesn’t know how to leave. If you were present maybe I couldn’t look into your eyes and I don’t know how I would manage to leave without deep sadness. I wasn’t aware how this would develop in our work.

Sincerely,

Eva

Letter 6, Allen

Dear Eva,

I read your letter with great interest and, before I respond, I want to tell you that it is absolutely natural and predictable that you would find yourself feeling upside-down as you try to do treatment in a way that is quite different from all that you have experienced previously. Everything that gave you a feeling of security when you entered the room with a patient is now called into question. I can understand that you would feel like Alice in Wonderland, finding nothing to be what it is supposed to be. As you said, your task now is to learn how to communicate so that your people can speak of who they truly are. If you can let yourself not worry about making formulations for now you will find the task is not as difficult as you might believe. We will work on making formulations later. Our first task is to understand who this person is and to do what we have to do in order to help her tell us about herself. As I said before, we can not develop a hypothesis about Lisa until we have sufficient data. We have plenty of time before we have to develop a formulation. In the meantime, Lisa is doing well with you and there is no rush. I certainly am not demanding that you formulate a theory about her. In fact, I'm suggesting the opposite. Take your time. We will learn a lot and Lisa will improve.

I'm not saying that we don't need a theory. We most certainly do. As I wrote earlier, all understanding is based on theories. One cannot listen without a theory to organize and make sense out of what is heard. In fact, my emphasis on helping Lisa talk about who she actually is represents the clinical application of a theory. It’s a theory that suggests that before we can explain a person's psychology, we first must understand that person in a deep way. The kind of understanding I am speaking of requires that we inquire about the patient in a very precise and careful way so that we can immerse ourselves in the quality of her emotional experience. Actually I'm describing the empathic process, a tool that we use to help us gather information we will need to make our formulation. Only after we have spent sufficient time in this manner, with a given person, can we begin to fashion a meaningful explanation for why that person is the way she is.

What I am suggesting means that we enter the room without the armor of explanations. We enter the room in a state of not knowing and, yes, this task requires all of our creativity and it also requires that we be in good emotional balance ourselves. It requires our ability to live in a state of not knowing. It seems that as a result of your training you are accustomed to believe that the analyst "knows" and that she is supposed to "know" right from the start. I fear that in your training there was not enough space to be uncertain. Many analysts hide behind the "certainty" of their theories and use them to protect their personal vulnerabilities from being touched by the interactive analytic process.

Now to Lisa

The visit from Lisa’s mother is quite interesting. The first thought that occurs to me is, "Why now?" What is she reacting to? My guess is that she is responding to something that is changing in Lisa. If I were pushed to say what I thought she was responding to I would say that she senses the positive feeling Lisa has with you. She senses something is different. I wonder if Lisa’s "sickness" is an expression of her depression and I wonder if the depression is showing early signs of lifting in response to the new relationship in her life? We don't know, but these are tentative speculations.

It is clear that Lisa’s mother has a need for Lisa to be a little girl. She has maintained a merged relationship with her that seems to be changing as Lisa lets it be known that she wants her own space. Perhaps Lisa’s mother is responding to the loss of Lisa as she moves forward. Perhaps the mother has needed Lisa to be little so that she could have the comforting company of her "baby girl." Your initial description of Lisa was of a little girl who had an immaturity inconsistent with her age. Lisa’s ability to make her mother laugh might serve a "sunshine" function, saving her mother from her depression. I would encourage you to see the mother for a session or two, if Lisa has no objection, in order to learn more about her and about their relationship. I would pay particular attention to the function Lisa has served for her mother since I believe Lisa has fulfilled some of her mother’s unrequited selfobject needs. My guess here is that mother has a long standing depression and also that her relationship with her husband is sterile at best. I have the hunch that the relationship might be more toxic than that, but time will tell us.

Regarding the session, I have little to say this time except that you have become a totally different therapist. You were able to listen to Lisa. You stayed with her affectively. You did not interrupt her. You were creative in your approach, you allowed her to feel what was within her and you made it possible for her to tell you more about herself than ever before. Well done! Her "misery" and her secrets are very interesting. I do not know the word Elend, but since it such an old fashioned word, one that you were surprised to hear from an adolescent, I wonder if it reflects something about her environment. Where did she get such a word? Does this reflect a quality of her home-life?

One technical suggestion. When Lisa told you that she had secrets you moved very quickly to say, "Of course secrets . . . I don't want you to give them away . . . instead could you tell me how it is to live with secrets?" This is not true. We do want her to tell you her secrets and she knows that. Don't let her go so easily. I believe she can manage more than you think she can. I would have asked her if she could tell me her secrets. I am aware that she might not be able to do that right now. The fact that she told you she had secrets is remarkable in itself. If after I asked her whether she could tell me her secrets, and she was not able to do so, I then would have asked what you so correctly asked, "What is it like to live with secrets? and "What is it about the secrets that make them hard to talk about?" She did say they were about her parents, which is no surprise to me. I think there is much about her family that we do not know. Hopefully, with time and with your sensitive approach to Lisa, she will eventually be able to tell us.

As Sherlock Holmes said to his colleague Dr. Watson when they began their detective work, "Watson, the game is afoot!" So it is with Lisa. “Eva, the game is afoot.” Our work has begun.

Sincerely,

Allen

Conclusion

In our experiment we found that it is possible, even advantageous, to conduct an eSupervision. We offer our experience as a contribution to those who might wish to do the same. With no literature to serve as a reference and no colleagues to consult, we had no alternative but to tentatively followed the path that seemed to unfold before us.

Several surprises emerged from our experiment. We speculate that the letters themselves functioned cross-modally and replaced the stabilizing internal image that would have formed out of a face and voice. In a unique way they helped manage some of the affects that were stimulated in the course of the supervision

The need for a visual image points to one of the major difficulties inherent in an eSupervision, namely the deprivation of the visual and auditory nonverbal elements of communication. Other users of the Internet, chatroom aficionados as well as those creating online study in virtual universities, have encountered this problem in email communications and what is referred to as the “digitally reconfigured world” (Essig, 2000). Slowly, a literature is beginning to develop in this field.

Interestingly, those working in the field of Internet communication are developing a language of visual symbols that communicate mood, affect state, rhythms of hesitation, surprise, or disgust and even explanations for silence. The most striking Internet symbol in relation to the problem of the missing face is the “smilie,” the symbol of a smiling face. In fact, this symbolic replacement of the human face is so well integrated into electronic communication that when one types a colon followed by a parenthesis, MSWord 97 has been configured to automatically display J , a smilie.

The creation of a safe milieu between two participants is, in part, dependent upon the regulative need for immediate knowledge of the other’s reaction, affect state, and emotional balance (Beebe and Lachmann, 1994). The absence of an immediate visual response once a message is sent into the dark silence of cyber-space creates a state in the sender that is reminiscent of the infant’s experience in the “still-face” experiment. In that infant observation experiment the infant is forced to cope with the frightening experience of a still-face (Tronick et al., 1978). We speculate that Internet users are developing their visual symbolic language to compensate for the missing nonverbal communication of visual relatedness.

While we did not discuss the communicative deprivation inherent in an eSupervision at the time of our correspondence, both of us responded to it with an intense effort to be open, direct, precise and clear in what we wrote. For Eva, precision and clarity meant being open with an unseen and unknown stranger. For Allen, eSupervision meant the assumption of responsibility for the treatment of a troubled child, using an unknown medium to work with an unknown and unseen analyst. It also meant teaching in a form that required precise articulation of both clinical and abstract theory, as well as tending to affect states expressed solely in written word.

In retrospect we see that open, explicit, precise and expanded communication was essential in the creation of an ambiance that made learning possible in face of the absent face. Allen responded to Eva’s report of her clinical material and her emotional state with explicit support and encouragement. While not substitutes for the missing nonverbal elements, Allen’s open support was a preconscious attempt to compensate for the visual reassurances that were absent in the eSupervision. Allen’s encouragement was heartfelt and not gratuitous, for gratuitous support would most likely have been experienced as condescending and belittling. While appropriately supportive, he also was direct and unhesitating when he needed to identify and discuss miscues and misunderstandings. Another nonverbal element of our communication was the rhythmic pattern that developed in the timing of our letters. Without an explicit plan, an inadvertent pattern formed in which we anticipated the arrival of each other’s letter, which began to arrive the same time each week. This unplanned patterning seemed to compensate for some of the missing, but anticipated communicative expectancies. Retrospectively, we are able to see our preconscious attempts to overcome the deprivation of a communicative system that normally functions out of awareness. We now see how these preconscious attempts helped us establish the ambiance of concern and respectful collegiality that makes supervisory learning possible.

Another surprise emerged from Allen’s perspective. Because the clinical material was entirely written, he, like Eva, was able to read the material as many times as he wished before crafting a response. This experience helped the patterns and responses of the therapeutic dyad emerge with greater than usual clarity and made it possible for Allen to formulate what he wanted to say with greater than usual precision. This opportunity, which enhanced both the supervisory and pedagogic experience for both, is an advantage of the eSupervisory experience.

In addition to the above, we found several other advantages of an eSupervision. One unique advantage is that, since all of the communication is written, the entire course of the work is available for microscopic study. Another unique aspect of eSupervision is the experience of working intensely with someone whom one has never seen or even heard. This experience magnifies the opportunities for transference elaboration by both supervisee and supervisor. We cannot explore this aspect of our experience at this time, but we certainly acknowledge its presence and suggest it as a matter for exploration by others who accept our recommendation to experiment with eSupervision.

In summary, we feel that the success of our experiment implies that geography no longer need be an obstacle to education. It is now possible to reach beyond one’s geographical borders and seek supervision from specific people with whom one wants to study. This is especially important for today’s expanding mental health community as professionals across the globe voice an interest in and a wish to learn the ideas embodied in the psychology of the self.

Eva’s Epilogue

Four years have passed since we began our shared work and I gratefully take this opportunity to describe the subsequent direction of my journey. During my deep involvement in the supervisory process I learned about narcissism and the empathic mode of observation from Heinz Kohut’s perspective. In the process, to my surprise, I simultaneously recovered my appreciation for Freud! The new path also led to my current interest in the work of infant researchers and theorists such as Beatrice Beebe, Frank Lachmann, Edward Tronick and many others. Their focus on the operation of an underlying, out of awareness, but inescapable presence of nonverbal and presymbolic aspects of ‘implicit procedural knowledge’ within and ‘early interactive regulation’ of communication became a valued and important addition to my work.

When I reflect upon my journey into the area of interactive regulation, I see that my interest in the coconstructed process began with the very first letter of the eSupervision. At that time I had clearly formed questions about the experience of narcissistic needs in the selfobject dimension and questions about motivational systems and attachment behavior. I realize now, however, that my first description of Lisa also contained elements of questions that I was not able to articulate at that time. These unarticulated questions addressed the problem of the ‘1/4 second response’ and all the dynamics of self and mutual regulation that Beebe and Lachmann (1998) have described.

My current perspective assumes that human interaction depends upon the meanings that people have for one another. Meanings derive from continuous social interaction that, in turn, is modified through ongoing, dialectically organized interactive processes. As far as I can see for now, these interactive processes also make for change.

In summary, our eSupervision helped me find a path that has led toward the new and therapeutically useful perspective that I had hoped I would find. Proceeding from the interactive perspective made it possible for me to work with my “difficult to reach” young patient and I wish to thank all those who have helped this hope come alive.

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