Abstract
Janice Lieberman’s central thesis in this collection of her writings from 1991 to 2018 is that social reality, though routinely omitted from clinical formulations, can profoundly affect the intrapsychic and shape character. In her introduction, “Loss of Integrity in Contemporary Culture and Contemporary Psyche,” she asks how changes in social reality have impacted her patients and herself in her more than forty years of providing psychoanalysis and psychoanalytic psychotherapy in private practice. In keeping with her training as both a psychoanalyst and a social psychologist, she cites, inter alia, changes in the job market, gay rights, gender, and technology that have affected the definition of “the family,” the ways we communicate, and the pursuit of politics, relationships, and entertainment.
Whereas in her 2000 book, Body Talk: Looking and Being Looked at in Psychotherapy (two chapters of which are included here), she encouraged psychoanalysts to recognize the important role of vision in psychoanalytic treatment as “listening’s twin” (p. 279), here she urges they pay attention to changes in their patients’ moral sensibilities. As the book was completed shortly after the election of Donald Trump, its focus on morals might seem a reaction to the recent social, political, and ethical currents that he exploits, among them greed and the freedom to lie without consequence. Yet Lieberman asserts that such values and practices are not new; indeed, she has been writing about them for twenty-five years and more.
In this book Lieberman has organized some of her publications and presentations under three headings: Superego/Character Issues; Body, Skin, and Gender; and Relationships. A fourth section treats the reflection of these themes in works of art (she also works as a docent at the Whitney Museum of American Art in New York). Particularly useful are her clinical examples and technical suggestions for working with patients often thought to be untreatable by psychoanalytic methods.
The concept of a “new superego,” elaborated in the introduction and first chapter, is one of Lieberman’s important contributions. Though a majority of the patients she has worked with or heard about suffer from traditional complaints such as guilt, anxiety, depression, and inhibition, here she focuses on certain patients “far less guilt ridden (at least consciously) and governed by a different set of values, ideals, and standards of behavior” (p. 12). Compared to most patients, they express more ego-syntonic greed and envy and present with “more ignoble issues” (p. 1)—psychic emptiness, powerlessness, and despair. She views them as lacking in “moral fiber” (p. 13) and speculates that their superegos are malformed and weak, the result of a shift in child rearing. Such patients suffer from “masked deprivation.” Material things were lavishly provided without the psychological attunement needed for optimal development, and there was little consequence for bad behavior. Her focus is not on theoretical or metapsychological aspects of greed, envy, and the superego, but rather on what and at whom the greed and envy are directed, what the superego targets for punishment, and which aspects of the culture of the last three decades have fostered these developments. For example, the new superego is based on a morality that idealizes and values physical appearance, diet, fitness, and wealth rather than altruism and kindness; there is little regret for hurting others by lying, corruption, greed, and harassment.
Lieberman illustrates her technique for working with these patients: she asks them to think about the consequences of their behavior, works on displaced transference, and remains on a concrete level; for instance, when material possessions are coveted, she does not explore what they stand for. She maintains that with time, perhaps years, the patient will feel listened to and attuned to, and become more capable of self-reflection and symbolic thinking. Above all, she counsels the analyst to constantly monitor her countertransference in order to avoid accusing the patient or distancing herself.
At the end of the first chapter Lieberman raises some profound questions. What happens in treatment when the analyst’s personal values differ from the patient’s? What is the place of the analyst’s own values in treatment? She is aware that “her frustration with these patients and the materialism of our times” can sound like a “judgmental rant” (p. 26). She reports being told that she is “brave,” “a bit of a scold,” and “prone to moral indignation.” Her answer: “I regard myself as one who hopes that what is ‘moral’ will be considered with patients” (p. 6).
The analyst’s own superego does not escape Lieberman’s scrutiny. In two more chapters she considers the analyst’s responsibilities and wonders whether there is an “analytic superego” (p. 55). She has observed many variations in the amount of time analysts are away from their offices. Here she asks: How far in advance are vacations and cancelations communicated to patients and supervisees so that there is enough time before and after to analyze the experience of an absence? Does the analyst’s guilt or lack of it interfere with analyzing absences? Though she offers no ready answers, she insists that these matters be considered.
The papers collected in Part 2 highlight one of Lieberman’s most important contributions to the psychoanalytic literature—her work with women obsessed with thinness. I was eager to reread the two chapters adapted from her 2000 book, and found her line of thinking just as useful now as I did twenty years ago. Her concept of the analyst as “reluctant spectator” (p. 70) is especially useful. Here she writes about women who are diagnostically neither anorexic nor bulimic, but rather are captivated by an ideal of extreme thinness and muscle tone achieved by food deprivation, excessive exercise, and even plastic surgery, at the cost of health and time for other pursuits.
Lieberman outlines difficulties in the psychoanalytic treatment of these patients. The goal of thinness serves to compensate for chronic emptiness, and the behaviors help with tensions and difficult feelings. This unhealthy ideal is supported by social reality, including the media and significant others. The patient’s deeper layers remain impenetrable. The analyst’s countertransference can be extremely challenging. Lieberman describes feeling impatient, frustrated, and bored in sessions with such patients.
To be effective with them, Lieberman diverges from her usual psychoanalytic stance, in which she explores inner fantasy and conflict. Instead she looks at the patient’s body surface and comments on what she sees, taking what she calls the role of reluctant spectator. For example, with Barbara, a patient unable to work with the transference, obsessed with food, and focused on staying thin to be popular and admired, Lieberman pointed out that her symptoms jeopardized her health.
The concreteness of my suggestions provided something the patient needed at that moment, thus stimulating ego development. It demonstrated the mutative function of what I call “mundane interventions,” the kind that take place in many analyses but that do not find their way into the literature [p.72].
Later, when Barbara underwent plastic surgery for her eyes, Lieberman noticed that on entering the office before lying down the patient began to look at her more directly.
Her associations in those sessions made it apparent that the underlying activated dynamic was not competitive, exhibitionistic, or homoerotic (although it had aspects of all of these), but was connected to a need for my gaze, a need for me to look at her and to confirm that she was intact. Once I realized that need, I began to make occasional concrete references to the new appearance of her face and to the surgery. She was able to experience me as “seeing” her [pp. 72–73].
Lieberman reports that she was surprised that such interventions were helpful. The patient talked more freely of relationships, loss, and meaning, and for the first time expressed thoughts, feelings, and fantasies about her analyst.With another patient, Lieberman stated what she understood concretely, rather than symbolically, and did not address deeper meanings or possible genetic links. For example: “You feel disgusting and sweaty, yet you are wearing a wool sweater on a hot day” (p. 74).
It was difficult for me to make such statements. I felt the way I imagine an Orthodox Jew who eats bacon must feel. I asked myself: “What is an analyst doing in this territory?” I have since come to understand that interventions such as these are exactly what such patients need. They need to know concretely that the analyst sees what they are doing, that the analyst knows and notices, in a way their parents did not [pp. 74–75].
Lieberman explains that such interventions render the analyst a “spectator” rather than an interpreter; what the analyst sees is used, rather than her verbalized interpretations. Concrete language appropriate to the developmental period from which the narcissistic problem arose eventually permits the treatment to progress to the exploration of inner fantasy and conflict.
In another chapter taken from her 2000 book, Lieberman elaborates on the concurrent development of body narcissism and language at a time when intense parental involvement is needed. She explains that early deficits in attention to the care of the body are often reflected in disturbances in the capacity for metaphoric language when speaking about the body, its appearance, and its care. Lieberman presents more examples of the use of concrete language in treatment to provide immediate experience and contact between patient and analyst. Indeed, symbol and metaphor might be used by both patient and analyst to defend against primitive or uncomfortable material. The analyst gives up symbolic speech in order to communicate with a nonsymbolizing patient, although she does not relinquish the capacity to think symbolically or be aware of the psychological context. In some instances of the cases Lieberman presents, the patient begins with symbolic thought and speech, psychological mindedness, and involvement in an analytic process, then regresses to an intense preoccupation with body narcissism and a loss of the capacity for metaphoric thought and speech, and eventually shifts back to the use of symbol and metaphor. This is a crucial point: level of functioning can fluctuate over the course of treatment.
In an update on these two chapters about the body, Lieberman considers the role of shame in her patients’ experience of their body and in her own powerful countertransference reactions when working with these patients. The section ends with two papers that consider contemporary issues she has found in the psychoanalytic treatment of some women and men. In one, she proposes the term Cleopatra Complex for the character of certain women. Outrageous, narcissistic, and entitled, they are not inhibited, are full of rage, and can be tough, pushy, and loud, a profile that was discouraged in women in the past and currently can be encouraged. In the other paper, recognizing the variety of maleness in contemporary U.S. culture, she proposes that psychoanalytic treatment could aim to help men move out of traditional constraining roles.
In Part 3, one chapter provides formulations and techniques for working with single women over thirty, still helpful though first published in 1991. This is followed by three recent pieces that consider the pros and cons of using digitalization in treatment, dating, and family relationships.
In Part 4, Lieberman explores the themes of superego, gender, and body in art, applying psychoanalytic thinking to images that are particularly difficult to look at and think about. In “Violence against Women in the Work of Women Artists,” she contrasts the muted horror of some seventeenth-century works (e.g., graceful and beautiful depictions of rape) to the “concrete” and “in your face” portrayal of violence against women in art since the 1970s. This is followed by trenchant analyses of the work of Arshile Gorky, sometimes considered imposturous and deceitful; of pedophilic themes in the art of Balthus; and of appropriation in the work of Richard Prince. In line with her clinical papers, she considers the artists’ biographies and their contemporary culture as crucial to understanding and appreciating their work.
There is perhaps a limitation to the applicability of Lieberman’s ideas, in that she draws on her work with a middle and upper middle class group of patients in her private practice on the Upper East Side of Manhattan, limited in terms of social class and cultural background, and from her supervisees’ practices, which are somewhat more varied. Yet when she presents nationally and internationally, she reports, she finds much agreement with her observations. What stands out is that the papers collected in this volume show Lieberman’s work providing valuable updating and reinvigoration to psychoanalysis. She develops new theories and techniques for understanding and treating patients whom many psychoanalysts might turn away. These patients are at times concrete, regressed, and/or narcissistically impaired, and can show little capacity for self-reflection, a lack of access to unconscious fantasy, and ego-syntonic forms of aggression. Rather than relegate them to the category of borderline functioning, she works with the aim of developing their capacity for self-reflection and symbolic thinking by meeting them at their level of functioning, all the while thinking about them psychoanalytically. She cautions that in dealing with these patients, whether they are greedy, selfish, deceitful, or obsessed with thinness, “The analyst’s countertransference must be constantly monitored. It is very hard work” (p. 108).