Truth and method

The Maturational Processes and the Facilitating Environment

Relationality: From Attachment to Intersubjectivity

Through advances in both basic and clinical scientific research, Pavlovian fear conditioning and extinction have become an exemplary translational model for understanding and treating anxiety disorders. Discoveries in associative and neurobiological mechanisms underlying extinction have informed techniques for optimizing exposure therapy that enhance the formation of inhibitory associations and their consolidation and retrieval over time and context. Strategies that enhance formation include maximizing prediction-error correction by violating expectancies, deepened extinction, occasional reinforced extinction, attentional control and removal of safety signals/behaviours. Strategies that enhance consolidation include pharmacological agonists of NMDA (i.e. d-cycloserine) and mental rehearsal. Strategies that enhance retrieval include multiple contexts, retrieval cues, and pharmacological blockade of contextual encoding. Stimulus variability and positive affect are posited to influence the formation and the retrieval of inhibitory associations. Inhibitory regulation through affect labelling is considered a complement to extinction. The translational value of extinction will be increased by more investigation of elements central to extinction itself, such as extinction generalization, and interactions with other learning processes, such as instrumental avoidance reward learning, and with other clinically relevant cognitive-emotional processes, such as self-efficacy, threat appraisal and emotion regulation, will add translational value. Moreover, framing fear extinction and related processes within a developmental context will increase their clinical relevance.This article is part of a discussion meeting issue 'Of mice and mental health: facilitating dialogue between basic and clinical neuroscientists'.

https://royalsocietypublishing.org/doi/pdf/10.1098/rstb.2017.0025

State-of-the-art and future directions for extinction as a translational model for fear and anxiety

Ritual and Spontaneity in the Psychoanalytic Process: A Dialectical-Constructivist View

The author outlines his approach to the theory and practice of group psychotherapy. The emphasis is on therapy by the group rather than therapy in the group. The therapist's task is to help the group itself become the agent of change. The group is conceived as being composed of many multiple selves. The process of group psychotherapy unfolds through enactments that involve the whole group and the group therapist entering into the grip of repetitive and unmentalized self-states. These enactments are resolved when the group members, with the therapist's help and containment, can access alternative self-states that allow for new and unformulated experience to emerge. This dialectical movement between the rigid “familiar chaos” of enactment and the reflective and related working through is compared to the dynamic systems theory articulation of the tension between rigidity and chaos captured by Kauffman's notion that “life exists at the edge of chaos.” A group session is described that involves a painful enact...

The Edge of Chaos: Enactment, Disruption, and Emergence in Group Psychotherapy

I describe an unobtrusive relational approach to the psychoanalytic treatment of nonalive and nonspeakable states and ways of being. I build upon a contemporary relational sensibility that values the intersubjective engagement of analyst and patient and the enactment of dissociated and unformulated states, together with the concepts of regression and the unobtrusive analyst central to the work of the British independent analysts, with a special focus on Michael and Enid Balint. I stress that in being unobtrusive, the analyst is not neutral or abstinent, but deeply engaged and becomes the analyst the patient needs. A case is offered as an account of analytic work that was enhanced and made possible by my engaged but unobtrusive presence, and the privileging of the patient's own idiom, object relating and early developmental needs. I offer a contemporary rendition of regression that encompasses mutuality, regulation and accompaniment. I suggest a concept of “benign regressive mutual regulation” and outline ...

The Unobtrusive Relational Analyst

Heterosexual Masculinities : Contemporary Perspectives from Psychoanalytic Gender Theory

In this article, I offer a concept of therapeutic action that I call “the flow of enactive engagement.” I advance the idea that this flow of enactive engagement is the fulcrum of a contemporary psychoanalytic treatment, just as free association was once to classical psychoanalysis. Analyst and analysand live within the field of the treatment that is created by the two participants but is greater than the sum of its parts. Just as Freud saw free association as the road to psychoanalytic cure and advised the analyst to not intrude on the analysand's associations, I suggest that an unobtrusive Relational analyst can allow the process of the field to emerge and tell its own story. This approach is distinguished from the traditional Relational/Interpersonal approach that sees the constant examination of the therapeutic interaction as the key to therapeutic action. I offer a brief vignette that captures the analytic benefits that accrue when the analyst allows the flow of enactive engagement to unfold.

The Flow of Enactive Engagement

Psychoanalysts increasingly find themselves working with patients and states that are not amenable to verbal and dialogic engagement. Such patients are challenging for a psychoanalytic approach that assumes that the patient relates in the verbal realm and is capable of reflective function. Both the classical stance of neutrality and abstinence and a contemporary relational approach that works with mutuality and intersubjectivity, can often ask too much of patients. 
The Unobtrusive Relational Analyst introduces a new psychoanalytic register for working with such patients and states, involving a present and engaged analyst who is unobtrusive to the unfolding of the patient’s inner world and the flow of mutual enactments. For the unobtrusive relational analyst, the world and idiom of the patient becomes the defining signature of the clinical interaction and process. Rather than seeking to bring patients into greater dialogic relatedness, the analyst companions the patient in the flow of enactive engagement and into the damaged and constrained landscapes of their inner worlds. Being known and companioned in these areas of deep pain, shame and fragmentation is the foundation on which psychoanalytic transformation and healing rests. 
In a series of illuminating chapters that include vivid examples drawn from his work with individuals and with groups, Robert Grossmark illustrates the work of the unobtrusive relational analyst. He reconfigures the role of action and enactment in psychoanalysis and group-analysis, and expands the understanding of the analyst’s subjectivity to embrace receptivity, surrender and companioning. Offering fresh concepts regarding therapeutic action and psychoanalytic engagement, The Unobtrusive Relational Analyst will be of great interest to all psychoanalysts and psychoanalytic psychotherapists.

Robert Grossmark

Papers

The Edge of Chaos: Enactment, Disruption, and Emergence in Group Psychotherapy

The Unobtrusive Relational Analyst

Heterosexual Masculinities : Contemporary Perspectives from Psychoanalytic Gender Theory

The Flow of Enactive Engagement

The Unobtrusive Relational Analyst: Explorations in Psychoanalytic Companioning