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knowledge of, and the ability to make use of, alternative theories and techniques to assist us in treating those individuals whose particular difficulties are not responsive to our accustomed approach. And to help us in this daunting effort, there is no better teacher and guide than Stefano Bolognini, and no better text than his illuminating new book, Secret Passages: The Theory and Technique of Interpsychic Relations.
Theodore J. Jacobs 18 East 87th Street, New York, NY 10021, USA E-mail: theojmd@aol.com

References
Arlow J (1969). Fantasy, memory and reality testing. Psychoanal Q 38:2851. Bolognini S (2004). Psychoanalytic empathy, Gareld M, translator. London: Free Association Books. Bolognini S (2006). Like wind, like wave: Fables from the land of the repressed, Gareld M, translator. New York, NY: Other Press. Deutsch H (1926). Occult processes occurring during psychoanalysis. In: Devereux G, editor. Psychoanalysis and the occult. New York, NY: International UP, 1953. Gabbard GO, Westen D (2003). Rethinking therapeutic action. Int J Psychoanal 84:82341. Isakower O (1963). Minutes of the New York Psychoanalytic Institute Faculty Meeting, 20 November. (Unpublished)

Change in Psychotherapy: A Unifying Paradigm

by The Boston Change Process Study Group, Nadia Bruschweiler-Stern, Karlen Lyons-Ruth, Alexander C. Morgan, Jeremy P. Nahum, Louis W. Sander, Daniel N. Stern Norton, New York, 2010; 235 pp; 26.00

The Boston Change Process Study Group, a group of six creative minds drawn from the fields of psychoanalysis, child development, and attachment theory (Nadia Bruschweiler-Stern, Karlen Lyons-Ruth, Alexander C. Morgan, Jeremy P. Nahum, Louis W. Sander and Daniel N. Stern) have joined forces to present a new, engaging, conception of the process of change in psychotherapy. Their ongoing investigations and evolving conclusions have been published in psychoanalytic journals over the past 13 years and are now collected in this volume. The book includes brief orienting introductions to each chapter, additional material in some of the chapters and portions of commentaries by three critical analysts (with responses by the authors). Though occasionally repetitive, this format aids understanding of a radically new perspective on therapeutic change and allows us to see the development and the increasing complexity of the authors ideas. The authors subject is the clinical situation of patient and analyst. The origins of the authors beliefs concerning change in psychotherapy are in the findings of motherinfant research and in the organizing principles of Dynamic Systems Theory. Topographic and structural theory are unmentioned as are Self Psychology, Kleinian, Lacanian, and Bionian therapy, sexual and aggressive drives, the pleasure principle, psychosexual stages and the ego. The authors view the organizing abstractions of these and other previous formulations as obstructions that confuse and distract. The
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theory contains echos of intersubjectivism, Schaffers action language, and Piagetian psychology though only intersubjectivism is mentioned. What emerges is a well thought-out, impressive, action and process oriented approach to the foundational components of change in psychotherapy and in daily life. To explain their ideas, the authors must devise a language that has no previous counterpart in psychoanalytic discourse. It is a language of action, of spontaneity, and of emotion, equally applicable to preverbal child and mature adult. Its central concept is implicit relational knowing, descriptively unconscious, nonverbal knowledge of the intentions, attitudes and emotions of an other. Its prototype and model is the intricate, moment to moment, mutual, nonverbal, unconscious communication between an in tune mother and her infant, a mode of communication which has been inferred from innumerable video recordings of motherinfant research. This nonverbal relationship provides evidence of anticipation, expectation, surprise, upset, violations of the expected, and much else. A prevailing intersubjective environment is shared (p. 7). It becomes a mutually constructed regulatory pattern. This intersubjective meeting is a kind of actual knowledge, known implicitly, that includes a great deal about the other person and specifically includes states of activation, affect, feeling, arousal, desire, belief and motivation as well as content of thought. Implicit relational knowing (in the early chapters) is outside transferencecountertransference, is nonsymbolic, and, for those reasons, is not open to interpretation. The authors believe that this implicit nonverbal communication is the ongoing foundation of all relationships throughout life. It remains unconscious, not through repression but because that is its mode of organization. They maintain that it is the basis of all successful psychotherapy; it is the long-sought something beyond interpretation of psychotherapy research. Though there is value in verbal interpretation and understanding of dynamic issues (the explicit domain), the most insightful of interpretations, taken alone, is rarely if ever effective in bringing a patient to a point of change. Explicit, conscious understanding or insight is an addendum to change via implicit relational knowing. Insight is the icing on the cake not the cake itself. It is common knowledge that patients may consciously know a great deal and understand a great deal but do not change. What is missing is a change in implicit relational knowing. The difference between the two kinds of knowing, the implicit and the explicit, is comparable, though not equivalent, to the difference between procedural knowledge and declarative knowledge. Implicit relational knowing through intersubjective meeting can be thought of as one form of procedural knowledge, the form of procedural knowledge that concerns the formation and elaboration of human relationships. The mutual regulatory moves between infant and mother negotiate a series of adaptive challenges that emerge during the early years resulting in greater complexity and in emergent possibilities of new forms of interaction. An example would be each partners moves in a peekaboo game with subsequent playing with that form by violating established expectations.
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Feeding, sleeping, diaper-changing, and playful interactions are examples of interactions that engage in this sort of regulation. Many pages are devoted to discussion of the various stages and forms of implicit relational knowing in the therapeutic relationship and in life. Seen within the framework of the therapeutic process, moving along is their term for a goal-oriented linear movement without knowing exactly how to get to the goal. Often the goal shifts. Each step in this moving along process is called a present moment. For example, the therapist or patient brings up new topics with minor discontinuities though with coherent progress. Present moments last only as long as is needed to grasp the sense of what is happening. As with the motherinfant interactive process, free play without a specified goal leads to ad-libbed variations. Much can happen in such moments, for example, ruptures and corrections as well as re-directions. Such moments of potential or actual change are spoken of as now moments. With any duo who engages in implicit relational knowing schemes of ways of being with another develop. These schemes are examples of implicit relational knowings. These schemes of ways of being with another are similar to the unthought known of Bollas, the un-reflected unconscious of Stolorow, and the past unconscious of Sandler and Fonagy. Now moments are suddenly different and unpredicted moments such as a joke that both laugh at, or an unanticipated stomach grumble or reaction to a spider on the ceiling. If such a moment is seized and recognized it can become a moment of meeting. Such a moment of meeting is an emergent property of the system; if grasped by the duo it alters the intersubjective landscape of the patients implicit relational knowing much as an interpretation can alter the intrapsychic landscape of the patients explicit knowing. Paradoxically, if the therapist knows what to do at such moments he has probably missed the now moment or he has hidden behind technique. Proper handling requires the spontaneity and free activity of the unconscious implicit mind. The authors use Dynamic Systems Theory (Thelan and Smith, 1994) as a means of understanding how such moments of creative potentiality arise. It is not inevitable that moments of meeting are recognized. They may be avoided, rejected or treated as times of unwanted disturbance. If mishandled they may also be repaired. This straightforward presentation of the authors understanding of the therapeutic process becomes more complex through inclusion of the recognition process as originally developed by Lewis Sander, an eminent child development researcher and theoretician. He speaks of human beings striving to achieve coherence of biological organization, of biological organization with psychological organization, and of both with the environment or ecological organization. The achievement of coherence of organization is central to human development. This implies an increased inclusiveness with the various aspects of the individual integrated into an overall adaptive wholeness. The individual must organize at the dyadic level, that is, in being together with another. There is a similar tension at the level of individual psychological organization, that is, in being separate. For Sander, recognition process is a device that bridges these levels. Communication with the
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mother allows for reciprocal coordination. These interactive exchanges lead to the beginnings of self-awareness tinged with consciousness of the others reactions to it (p. 61). Sander makes an interesting suggestion that within the first 18 months the child straightforwardly expresses his inner world of intentions and plans but then, during the second 18 months, this expression becomes more conflicted until, at about 48 months, there is general concealment of the inner world. It is at 18 months or thereabouts that the child develops an accurate and externally validated self-representation (and, reciprocally, object representations), a time that coincides with conflicted expression of an inner life. There is a parallel with the therapeutic process. Recognition process occurs with a meeting of the implicit relational knowing needs of both patient and therapist and results in an intersubjective field with a reasonably accurate sense of each persons ways of being with others. Sander emphasizes the importance of a sense of developed fittedness between the partners, a fittedness which may be unreflected upon and unavailable to introspection. Sanders biological ideas have points of variance with descriptions of implicit relational knowing elsewhere in the book. A new term, the local level (more intuitively, the micro level) is now introduced. The local level refers to the immediate direct interchange between patient and analyst. It is a continuous process of negotiation toward or away from fittedness of intentions and states. It requires continual action reaction interaction, most of which (needless to say) proceeds at an implicit (therefore unconscious) level. This interactive process consists of relational moves, units of intentionality, slices of behavior from which an intention can be inferred. Such moments may be short (a second) or up to several seconds. Such moments feel as if something important has just happened. To stay at the local level means staying with the interaction in this immediate sense; the alternative is to abandon it. All this implies that the interaction in analysis, though inaccessible to immediate reflective awareness by the participants, may be open to observational study in a manner that is analogous to the micro-observations of motherinfant research. Again, Dynamic Systems Theory provides a coherent way of understanding this process. Emergent properties are changes in an organism that are not prespecified by the organisms design but evolve as an aspect of an organism-context relationship, allowing for new forms and unanticipated changes in the relationship (p. 90). The authors avoid the term co-constructive for this process in therapy, seeing it as more accurately creative in its result. Processes of change also have attractor states. These provide stability and a measure of resistance to change. The process of achieving emergent properties is not neat and logical. Indeed, the authors use the term sloppy as a technical term for the indeterminacy of the process, thus anticipating novelty and avoiding stereotypy. In this process the partners must infer intentions or meanings from actions, a task which is central to how the brain works (p. 88). Further, sloppiness is to two-person psychology what free association is to one-person psychology. It adds details, surprise, discovery, uniqueness. However, free association proceeds from pre-existing meanings whereas sloppiness is not part of
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any prior organization though influenced by the past. The constraints of a dyadic system allow sloppiness to be creative rather than chaotic. To summarize the discussion: the authors point out that the notion of motivated behavior so central to psychoanalytic theory is not the level of intersubjective regulation at the local level (p. 91). They believe the concept of the local level is at least as important to therapy as such concepts as transferencecountertransference and the unconscious. At this level emotional procedures or implicit relational knowings are established and recognized throughout life. Implicit relational knowing includes affect evaluations regarding how to proceed with others. The past is carried along, engagement is regulated, and meaning generated (p. 91). In the second half of the book, Chapters 5 to 8, there is a shift toward a more conceptual discussion of such issues and questions as co-creativity in the psychoanalytic encounter; the role of the past; what is deep and what is surface; the nature, origin and locus of meaning; psychodynamic conflict and defense; and the relationship between the implicit and reflective verbal domains. In the final chapter the authors revisit, enlarge, and summarize the implicit relational understanding of therapeutic action. There are also two game-changing revisions in the second half of the book. Early in the book highly emotionally charged moments were assumed to be times of maximal therapeutic effect. Later, it is recognized that change may also occur as a result of interactions that proceed quietly. In Chapter 5 the authors extend this influence to a continuously changing therapeutic engagement at the implicit level. A related change in the locus of change also occurs. Up to this point the authors see the dyad of patient and analyst as two independent persons engaged in an implicit unconscious relational as well as an explicit conscious process; now the dyad itself is an entity and it is this entity, not two individuals, that undergoes continuous incremental change. Lived life exists within relationships. Just as Winnicott taught us that: There is no such thing as a baby, to indicate the unity of the motherbaby relationship, now, in much the same sense, there is no such thing as an analysand or, for that matter, an analyst. It is the unified relationship that is the subject of continuous change. The Dynamic Systems framework helps to understand this change. According to the Dynamic Systems framework, it is the self-organizing properties of analyst and patient together, as a dyad, that constitutes the dynamic engine of therapy. Analyst and patient contribute other shaped input to the interaction. Input may be congruent, in opposition, or complementary. The trajectory of the duo is unpredictable and includes the emergent properties that pop up from the interaction of the input variables. This emergent content will be constrained by the initial conditions of the relationship. Needless to say, all this proceeds as a procedural, unconscious, implicit relationship at the local level. This interaction may be full of psychodynamic meaning but is not part of the dynamic unconscious. Although, as previously noted, what we are describing is similar to the preverbal functioning of infancy, it is not to be equated with a regression to preverbal functioning but is, in fact, the dominant aspect of adult mental life. Another way of putting it is that the mental life of both participants (analyst and analysand) is constantly being reorganized within the
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relationship. These reorganizations result in new ways of being together, co-created in the treatment. They describe the process:
The analyst enters the therapy with a general and abstract notion of where she might like to see the patient progress in relation to the resolution of conflict, the enlarging of areas of effective functioning, the reduction of anxiety, or the flexible expression of affect. The patient also enters with only very general ideas of where he might like to end up. Neither analyst nor patient knows in any detail what they need to do together to reach their goals. Indeed, both analyst and patient can only grapple with the immediate dilemma of what to do to take the next step in the interactive process. [In this] all of the analysts training and humanity come into play. It is here that the analysts grasp of some healing direction, some selection of what to recognize in the patients words and actions, will be operationalized. But this indeterminacy of the how to of therapy is inescapable both patient and analyst are sources of independent agency and subjectivity and at the same time are constantly co-determining each other. (p. 101)

Actions can be observed, intentions and meanings must be heard. Something new is created. New meanings, feelings, and intentions are co-created in the dyadic process. What is the role of the past? The organization derived from the past influences the present but is being continually updated. It is updated in small ways with each encounter: The recontextualization and reorganization process at the local level is subtle and occurs in tiny shifts that would not be easily visible until they have cumulated in the treatment (p. 119). The past provides constraints, including transference and countertransference, in the form of expectancies from the past. In their approach to the subject of meaning they first attempt to establish the presence of meaning prior to clear-cut semantic signs or symbolic elements. They note that a smile may be a sign but is also a performance that carries it beyond the conventional sign and provides the authenticity of the associated affect. They note that mirror neuron functioning suggests that facial expression is not a signal but the initiator of contagion. Communication is in the performance. Performance forms the basis of face-toface exchanges of affect that are a unique feature of early communication. In this sense the infant creates meaning prior to the use of symbols. Analysts must consider the possibility that the most important levels of psychodynamic meaning can be carried, and acted, and expressed through non-symbolizing processes (p. 130). There is a strong claim that personal culture does not require language and the repressed. Rules governing interactions are negotiated by affect clues in the beginning of life and are rarely raised to the level of conscious verbal description but remain part of our implicit relational knowing. As these rules include what can and cannot be expressed openly in a relationship, conflict, defense and unconscious fantasy reside in the implicit domain. Like the syntax governing language, we derive and use these rules from very early in life as part of procedural knowledge long before any conscious verbal description of the rules is possible.
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At this point they are explicit about an aspect of meaning which has been implicit all along: The deepest level of meaning, from which all later forms of meaning emerge and refer, is the level of lived engagement with others around central developmental needs, as these engagements are represented in implicit, procedural forms of memory (p. 133). Traditionally, they claim, analystpatient interactions at the local level have been seen as superficial and explanatory abstractions as deep. They reverse this understanding. They seek a different language in order to begin to distinguish between that which is conveyed explicitly (through semiotic vehicles) and the more implicit level at which the patient recognizes the therapists adjustment to the most important level of meaning (p. 134). Semiotic forms are superficial, therapist or patient adjustments are deep. An adjustment could be a silence, a rising tone or other subtle event including what is left uncommented on or is taken up. Being fitted or not fitted is negotiated by these small moves. Interpretation is often a summary of what has happened implicitly. It therefore emerges that the linked sequence of affective valuation and intentional action is the primary source of meaning and is separable from the words and symbols of the semiotic function. Conflict is also redefined as implicit and interactive. Conflict is within the relational space; it is a contradiction in the intentional direction of the self and of an important other. The ongoing present implicit cannot, by definition, include structures such as ego, id and superego and thus there is no intrapsychic conflict. Conflict may be brought to the verbal reflective level of words and symbols but that is not where it originates. Similar considerations redefine defense as originating in implicit intended action as in avoidance maneuvers by an infant in a painful relationship with his mother. Intrapsychic emerges from the interactive matrix, there is no other separate intrapsychic domain (p. 155). There are additional, interesting discussions that support their belief in a deep and continuing significance of the forms in which experience is organized during the first three years. They point to the importance given to enactments in both child and adult therapy. Enactments highlight the relationship of the implicit to the reflective verbal modes. I particularly enjoyed the discussion of embodied minds, an impressive effort to wear down the persisting bodymind duality of our thinking. Quoting Sander, they further explain the relationship of the implicit domain with the reflective verbal domain Sequences of intentions give motivated human behavior its psychological existence, its coherence, and finally its meaning (p. 167). Motives or wishes are expressed in sequences of intentions, a foundational process, whether at the implicit local level or at the reflective verbal level of language. A second commonality is that both modes share the same microforms, the basic unit of which is the present moment. And a third commonality concerns mirror neurons which involve parallel activation of language centers with motor and perceptual centers. Verbal labels are processed at the language center while activated motor perceptual centers help us to understand the ability to read another persons state of mind, his intentions, his
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emotions. The mirror neuron system ties the word to the movement. The reflective verbal domain emerges from the implicit domain. Again turning to Dynamic Systems Theory, they speak of the reflective verbal process as a qualitatively different system which emerges from the encounter of implicit knowing with other minds. They continue the discussion by pointing out that human language involves extensive paralinguistics, the sloppy work of finding the right words to communicate what one wishes (pp. 175176). When we speak there is something in mind such as an idea, a movement, or feeling. There is an intention to link this image to words followed by a dynamic process of finding the language that best fits. This unfolding process is a nonlinear dynamic process. The fit is always only good enough. The implicit and the reflective verbal are not isomorphic. There is a wonderful quote from Merleau-Ponty:
The meaning is not on the phrase like the butter on the bread, like a second layer of psychic reality spread over the sound; it is the totality of what is said, the integral of all the differentiations of the verbal chain; it is given with the words for those who have ears to hear. (p. 181)

The upshot of this discussion is a deepening of our understanding of meaning: The gestalt of implicit experience, emergent reflective-verbalization, and the relation between these two that, all three taken together, make up meaning (p. 183). As we might expect, this process of meaning making takes place in the two-person implicit relational unity. The final chapter relates the relational process approach to therapeutic action. They quote studies which indicate that therapeutic action tends to be independent of any particular technical activity or any particular school of psychoanalysis. Terms such as therapeutic alliance do not advance our conceptual understanding of the complex multimodal process of exchange. They see psychoanalysis as moving toward a new set of concepts in which the relationship between patient and therapist is at the center. As a result emphasis is placed on the emerging dynamic process rather than on the content of therapeutic technique. Not surprisingly, the task of therapy is to change implicit relational knowing, a process that does not include set techniques. We have learned that meanings are communicated through multiple simultaneous channels with split-second timing, too rapid to be rendered in words. Active implicit negotiation between the relational partners is required to move forward. There must be fittedness. The analyst cannot bring these qualities to a treatment except as an orientation and allowing for the interactive communication with the patient as together they seek directionality and fittedness. With increasing fittedness the patients world becomes relational bound, bringing the patient into another world of new relational possibilities. He she senses a greater validity as an agent, experiences more complex and inclusive affective experiences and may find that a more coherent self is created within him. The patient becomes more himself.
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They point out that psychoanalysis has always emphasized the importance of bringing as much of the mental process as possible into a free associative mode. This book reframes this goal within a two-person perspective. The more felt experiences are shared with the responses of another, the more ones thoughts and feelings are experienced as human and relational, that is, capable of being included in ones relationships with others and thereby with oneself. The sharing converts experiences of shame, guilt, or deviance into expressions of joint humanity. Mental life becomes acceptable and bearable. The authors wish to shift our conceptual framework away from the notion that change depends on the quality of the interventions of the analyst. Working from a dyadic perspective, quality resides within a relational union; it stresses features of a process between two persons. These qualities include an engaged search for directionality and fittedness; a creative negotiation of sloppiness and indeterminacy; and an effort to increase the breadth of the affectively charged experiences that can broaden the relationship. To the extent that this occurs they expect to see an emerging feeling in the treatment relationship of trust and mutual vitalization. They move toward increasing integration, coherence and fluency in making experiences relational. Both patient and analyst can be guided by their own feelings and directions in a balanced way when in significant interchanges with others. My initial reactions to the book included admiration for the audacity of its conceptions and for bringing the truly revolutionary findings of infant research concerning early mental life to the psychotherapy endeavor. There is a breath-taking lack of continuity of the Boston Change Process Study Groups paradigm with the most fundamental of traditional psychoanalytic conceptions. Aside from a deep commitment to healing psychological distress, nothing remains. And the change has strikingly American qualities. It purports to rest on a strictly empirical foundation, the mountain of videotaped data that has been acquired from direct study of human interactions (e.g. infant research) and a method of organizing that data (Dynamic Systems Theory) that accounts for novelty, creativity, and therapeutic success. The long Continental tradition of structuralist thinking, inherent in Freud, Piaget, Klein, and in French approaches to mental life are set aside. There are no principles, structures, mechanisms, intrapsychic conflicts, introjected objects, or other hypothesized mental entities or mechanisms. Everything is in process; everything is now. The past is not a time-place to which one regresses or recollects: the past delineates, constrains and shapes the present as a natural out of consciousness process. Taken literally there is virtually no sense of oneself as a separate individual, only a sense of self in relationships. The privileging of the implicit procedural life of the preverbal child reflects a profoundly optimistic, even sentimental yearning to regain the Garden of Eden of that life. It is difficult to escape the conclusion that, for the authors, words, rationality, precision and the organization that comes from balanced differentiation and integration, do not promote emotional health or authenticity. The green revolution of the 1960s lives again. There is a foundational issue that is not directly addressed. Assuming that there is a physiology of mental life, by what criteria do we differentiate,
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specify and confirm the existence of a psychological mental life? An action does not prove an intention: for example, an infants smile does not prove positive affect or any affect; infant imitation does not prove awareness of self and other; an infants preference for mothers voice or odor or way of holding him, does not prove he knows her as a separate person, distinguished from all others. Synchronous infant movement with the cadence of mothers voice has implicit meaning to her as she experiences their mutual rhythm and may be experienced with pleasure by him but does not, in itself, contain relational meaning for him. Each of these infant competencies and the environments response to them assists in establishing a psychological relationship but cannot initially be registered as psychologically meaningful. Sanders answer, that sequences of intentions give motivated human behavior its psychological existence (p. 167), provides helpful direction in resolving this issue. There are facts that are avoided. The psychoanalytic relationship, like all relationships, consists of a great deal more than working toward a common goal; it includes embracing and making sense of all the manifold ways in which that goal is rejected or sabotaged. Deception, seduction, sado-masochistic delight, murder, surrender and high anxiety are in the air; pleasure and triumph are forces to be reckoned with; the anguish of lonely conflict can be immobilizing; the thrill of lonely fantasy is absorbing. It is not quite fair but it is also not inaccurate to say that the authors find an answer to lifes complexities in a return to a presumed (but unlikely) conflict-free, deception-free relationship with a loving, intuitive mother. The analyst is to be the newly sensitive, responsive mother with whom one makes meaning. But these limitations do not diminish the intent and accomplishment of the authors. This is an amazing, thought-provoking book. It directs attention in an intelligent and useful fashion to what is lacking in many therapies and in some organizing theories, a willingness to enter into and actively engage the patient at the level of his intuitive and affect-full inner life. They find a path to that inner life in the continued presence in humans of every age of the mutuality of the emotional relationships of early childhood.
Scott Dowling 2300 S. Woodland Road, Shaker Heights, Ohio 44122-3067, USA E-mail: asdowling@gmail.com

Reference
Thelan E, Smith I (1994). A dynamic systems approach to the development of cognition and action. Cambridge, MA: MIT Press.

Invasive Objects: Minds Under Siege

by Paul Williams Routledge, New York and London, 2010; 252 pp; 22.99

The power of Paul Williamss Invasive Objects: Minds Under Siege takes the reader by surprise. Williamss subject the psychoanalytic (and or psychoCopyright 2011 Institute of Psychoanalysis Int J Psychoanal (2011) 92

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.