Mark B. Borg, Jr. PhD
Borg, Jr., M. B. (2005). Superblind: Supervising a Blind Therapist
with a Blind Analysand in a Community Mental Health Setting.
Psychoanalytic Psychology, 22 (1): 32-48.
THIS PAPER DESCRIBES THE THREE-YEAR psychoanalytic treatment of a blind female client by a blind female therapist supervised by a sighted male. The author focuses primarily on issues tied to each party's personal experience of blindness. Interpersonal psychoanalysis, which was the modality of supervision and therapy, is considered a "cultural" approach to psychoanalytic treatment. The author (the supervisor in the triad) suggests that the individuals involved had been treated with regard to their shared visual problems in ways that were influenced by their previous relationships. In the present, these relational expectations, influenced by the past, were played out between patient and therapist, between therapist and supervisor, and in the decisions and policies of the clinic system.
AS SHE BEGAN THRICE-WEEKLY PSYCHOANALYTIC sessions, Lynne (a pseudonym) told her new therapist: "I've been accused of being superblind myself." In the blind community, this term is used to describe blind people who function as if sighted. Lynne said that she had entered treatment for "depression." A sharp contrast existed between her bright affect and her detailed description of a family and personal history fraught with loss, disappointment, and alienation. Lynne described a deep sense of what she called "longing," but she could not identify what she longed for. Lynne's preoccupation with superblindness spotlighted the salience of her identity issues, and how the formation of a comfortable sense of identity had been influenced by her unique history and by the socially constructed views she had adopted regarding her blindness.
I supervised Lynne's therapist, Dr. C, and eventually found myself in a position to recognize how the dynamics we observed in Lynne's treatment were representative of the institutional and familial systems in which we operated. I will consider the matter of how systems recognize challenging realities, and look at how autonomy may sometimes be emphasized over healthy forms of dependence (Fairbairn, 1968; Fromm, 1968; Mitchell, 2000) a pervasive Western and psychoanalytic perspective (Richardson, Fowers, & Guignon, 1999) that has special meaning within the blind community (Vaughan, 1998). It can result in the enactment of patterns meant to decrease the threat represented by the needs and circumstances of the other; in this case, the threat that the patient's blindness represented to the therapist's and the supervisor's capacity to function in their accustomed roles. This enactment also affected the clinic's ability to accomplish its primary task  : the provision of psychotherapeutic and psychiatric treatment for patients and education for interns.
For most, dependence is a necessary precondition of independence; Wright (1983) noted that accepting a certain degree of daily dependence paradoxically allows many people with disabilities to be more self-sufficient. The many government-sponsored programs designed to promote self-sufficiency in persons with disabilities manifest our culture's traditional emphasis on independence and self-sufficiency. In this case, cultural, institutional, and personal values concerning dependency and autonomy played themselves out in various and sometimes conflicting ways. In fact, the issue of independence and autonomy was very important on a personal level to all members of the treatment triad, as well as to the clinic in which the therapy took place.
Issues of recognition and awareness were also important in the work with Lynne. Significant changes in the clinic system, which was taking in a new population of patients at the time that this casework was being done, triggered defensive, characterological reactions and dynamics in the impacted system (Borg, 2003a). As is frequently the case with such organizational reactions, new experience is dissociated, and awareness of its existence is displaced to another group or individual. These reactions are initially enacted rather than openly discussed, and only later (if at all) recognized and integrated into the system in question through open dialogue. In such cases, there is an urgency to maintain the dissociation (perhaps to the point of not recognizing the needs of the clients who are being served), since its breakdown inevitably results in confusion and anxiety. According to Grinberg and Grinberg (1989), such situations can awaken "persecution anxieties in the face of change, the new and the unknown; depressive anxieties which lead to mourning for the lost parts of self (or self-representative aspects of the system); and disorienting anxieties over the failure to distinguish between the 'old' and the 'new'" (p. 2).
Although there have been a number of articles highlighting particular ways in which an analyst and patient dyad might react to issues of physical disability in psychoanalysis (e.g., Cubbage & Thomas, 1989; Dalenberg, 2000; Thomas & Garske, 1995; Thomas & Siller, 1999), none of these articles addresses the context, specifically the clinic or culture, within which such treatment is conducted. Therefore, in the clinical discussion that follows, an illustration of these larger system-level dynamics, and how the clinical triad played out in microcosm issues that were being worked through on a larger scale at the clinic is presented. In this case, as sometimes happens, one part of the system became a targeted scapegoat, not only for the changes the system must respond to, but also for all of the anxieties and fears that are stirred up by these changes. The scapegoat in this case (the therapist-patient-supervisor triad) enacted the larger dynamics associated with perceived changes in the clinic.
Dr. C is a legally blind, heterosexual, Caucasian woman in her late 30s, who at the time of this work was a pre-doctoral intern at a community mental health center in New York City. Her degenerative blindness was related to other physical problems for which she had been in and out of hospitals since the age of seven. She had been born a twin, but her sister died at the age of twelve from physical disabilities similar to Dr. C's. I was responsible for supervising Dr. C's work with Lynne, a 42-year-old homosexual Caucasian woman who had been blind since birth. I am a sighted Caucasian heterosexual male psychologist in his mid-30s. At the time of our work together, I was an associate director at the community mental health center where Dr. C worked, and a candidate in psychoanalytic training at an interpersonally-oriented institute. My involvement in Lynne's treatment lasted three years.
According to the interpersonal model, supervisory relationships work best as collaborative efforts that enhance collaboration between therapist and patient (Harris & Gold, 2001; Kvarnes & Parloff, 1976; Levenson, 1991; Sugg, 1995). In both supervisory and treatment relationships, interpersonal psychoanalysis focuses on interactions in the consulting room, at the same time using detailed inquiries into the patient's historical and contemporary life experiences (Sullivan, 1954). My role as supervisor was to help Dr. C create an environment in which she could work to better understand her engagement with Lynne. Accomplishing this goal required an empathic link among the members of the treatment triad that would allow me and Dr. C to recognize the patient's symptoms, their history, and their underlying meaning (Bromberg, 1998; Levenson, 1983; Mitchell, 1993; Sullivan, 1953).
In our supervisory work, Dr. C and I saw transference as the manner in which the patient's reactions to the therapist were influenced by internalized representations of self and important others in her life, particularly those formed in early childhood and influenced by the larger institutions within which she lived. My dual focuses were on Lynne's transference to Dr. C, and on Dr. C's countertransference. One of my goals was to help Dr. C pay attention to her own feelings and reactions toward her patient, and to use this information to understand their interactions (Gill, 1987; Maroda, 1991; Racker, 1968). It turned out that our work with Lynne required that Dr. C and I confront our own personal issues with dependence and autonomy, acknowledge how they had been culturally formed, and address the preconceptions they embodied.
According to interpersonal psychoanalytic theory, preconceptions about dependence and autonomy are shaped by cultural norms (Fromm, 1956; Fromm-Reichmann, 1950; Sullivan, 1964; Thompson, 1964). In fact, interpersonal theorists view acculturation processes as fundamental in shaping personality. In the words of analyst and organizational consultant Kathleen White (2002),
- The self and the sense of self are not made of stone, and unless the self has gone stone dead, or has dropped out of consensus, the self and the sense of self are moved by the imperatives of development to commingle with the surround (p. 410)
Furthermore, the role that cultural values play (often through their institutionalization and enactment) are central to determining which aspects of the self are released into awareness, and which aspects are avoided to maintain security and reduce anxiety (Bromberg, 1992, 1998; Sullivan, 1953). Such issues of awareness and avoidance were crucial as well in the work with Lynne.
One way of viewing the patient-analyst-supervisor relationship involves the concept of parallel process: the supervised therapist's enactment, in the presence of the supervisor, of affective tones, cognitive processes, and interpersonal behaviors that mimic those of the patient (Levenson, 1991; Sugg, 1995; Teitelbaum, 1990; Wolkenfeld & Gediman, 1980). In analytic treatment, enactment is considered a co-created relational activation and manifestation of salient transference themes (of unconscious conflict and dissociated experience) in both the patient and analyst (Jacobs, 1986; Levenson, 1991). I have previously used the enactment concept to describe unconscious processes and interactional patterns that are characteristic of larger groups, including specific communities (Borg, 2004) and cultures (Borg, 2003a). Here I will use the concept of enactment to describe behavioral manifestations within the treatment dyad, including parallel process phenomena. I will also use the concept of enactment to tap into and describe group characteristics of the clinic environment, and how the transmission of cultural attitudes toward disability were communicated among those affected by the treatment.
The Treatment Triad: Inquiry and History
Lynne, the only child of white, middle-class Catholic parents, grew up in an upstate New York suburb. Her father owned a small business and worked long hours, and her mother stayed home and cared for her. Though Lynne was born blind, she said that her blindness was never discussed openly in her family; it seemed to her that it was never recognized which was how she felt in general. She recalled her father spending a considerable amount of time teaching her how to maneuver through her home, her neighborhood, and her world in general, which included church and school. She felt genuinely cared for by her father and understood his desire to protect her. At the same time, she felt that he was always "trying to teach [me] how to be normal" that is, sighted. Lynne said that she had few close friends outside her family, and that her father had been her closest companion.
As far back as she could remember, Lynne had memories of physical abuse by her mother. One evening when she was seven, her father in what seemed to be a rare moment of real recognition noticed a bruise on Lynne's face that showed the imprint of her mother's wedding ring. Lynne recalled that the ensuing argument was "intense," without offering any detailed explanation. After this confrontation, she "completely lost touch" with her mother. Her mother withheld physical and verbal affection from then on, although she never hit Lynne again: a high price to be paid for the sought-after recognition. The mother died of alcohol-related cirrhosis when Lynne was fourteen. She recalled feeling relieved when her mother died, but she also recalled strong guilt feelings. Lynne's other memories of her mother were vague and fragmented.
When she was eighteen, Lynne's traditional education led her to a New York City college, where she said that she neither "expected, nor accepted, any special treatment." During her freshman year, she joined several social organizations, established a circle of friends, and pursued her interests in poetry, politics, and creative writing. Her father died of a heart attack in her sophomore year, and she told Dr. C of feeling a sense of relief similar to the one she had felt when her mother died. She admitted to feeling disturbed by emotions that quickly swung between liberation and remorse.
After her father's death, Lynne became active in lesbian and gay political organizations, eventually identifying herself as a lesbian feminist. She made many new friends, and had a number of love affairs. Yet she felt that many members of her expanding community responded to her in the same way as her father had. That is, they disregarded the blindness-related struggles that were part of her life. In therapy, she described what had become for her the familiar sense that her blindness a central aspect of her life was going unrecognized. Of her success at living an independent life at a "sighted" school, Lynne told Dr. C, "I would have made my father proud." Lynne said that she had felt alive and free during her early college years, but that she also noted a sense of alienation taking root at that time, manifesting itself as recurring depressive symptoms.
Lynne's condition worsened to the point that she spent a brief period of time in a psychiatric hospital. She left college, withdrew from many of her social networks, and closed the door on life as a superblind woman. The hospital referred her to an organization that provided housing and case management; her disability status allowed her to move into a community residence for the blind. Lynne has been unemployed since her hospitalization, but she has held a number of elected positions in organizations within the blind community. She expressed anxiety about these elected posts, because they seemed to require that she once again function in a superblind manner that she feels is beyond her current capabilities. She repeatedly expressed disdain for blind people who "act as if they are sighted," and believes she was entitled to her increasing dependence upon members of her residence community. She claims that she is "incapable" of many daily activities that sighted people take for granted, and resents being told otherwise.
Lynne met her partner, Melissa, at her residence, and immediately relinquished control within the relationship. Melissa is legally blind, though apparently much more functional than Lynne. She takes Lynne to her appointments (including her sessions with Dr. C), and generally manages Lynne's personal and financial affairs; they do not live together. Lynne says the relationship is "more about companionship than romance," and describes a mostly nonexistent sex life. This aspect of the relationship is frustrating to Melissa, who periodically has affairs with other women. The affairs are a source of pain for Lynne, but she claims that she can accept them as long as Melissa continues to care for her in ways to which she has become accustomed.
Dr. C was born into a middle-class family consisting of second generation Italian-American parents, a sister two years her senior, and a twin sister who died at the age of twelve. Born with a degenerative condition that caused a gradual loss of eyesight, Dr. C also has a malfunctioning kidney, and requires regular dialysis. She has been receiving treatment for her medical conditions since the age of seven. In contrast to Lynne, Dr. C's problems seemed to be deeply recognized in her family system. She described her parents and older sibling as anxious and overbearing regarding her physical disabilities, especially following the death of her twin sister. By that time, she was already legally blind and using a walking cane. She received special education services from her public school, and became proficient in reading Braille.
Dr. C felt that her family consistently communicated to her the idea that she was "special," but she responded to that with ambivalence. She remembers thinking from a very early age that being special meant that her parents did not want her to grow up, live independently, or be exposed to the dangers of the sighted world. She felt very little support from anyone in her family for her achievements, and claims that they were excessively anxious about her stated desire to develop her mobility, her intelligence, and her ability to function in the sighted world. She lived at home while earning her BA, and then a Ph.D. in clinical psychology.
During our time together, Dr. C was completing her pre-doctoral requirements. She expressed anger at what she felt was "pampered" treatment throughout her clinical training, claiming that it had greatly extended her time in graduate school and had left her feeling unprepared for independent practice. She said that this special consideration was a very familiar scenario for her. In fact, it was "the very same tactic" that her family had used to slow her down. "It wasn't until I was eighteen and my father died that I actually thought that I would ever be able to leave home," she said. Since she was still living at home during the time of this supervision, she clarified her statement to indicate that her efforts constituted an attempt to "leave home psychologically." For Dr. C, being recognized often felt the same as being infantilized.
The Supervisor and the Clinic
I moved to New York City from Southern California to take a position as associate director of the community mental health center where Dr. C was doing her internship, and to begin psychoanalytic training. I was recruited by the clinic because of my background in community and organizational consultation. The clinic had been having trouble adapting to the managed care environment that was increasingly being implemented by Medicaid and Medicare, and one of my primary responsibilities was to serve as a liaison between the clinic and referring agencies, including psychiatric hospitals, group homes, and clinics that were closing their doors. Our success in these outreach efforts meant working with new kinds of patients, such as de-institutionalized severely mentally ill persons, chronic substance abusers, families, and diverse ethnic groups, who had some clinical issues with which the staff was unfamiliar. This change in clientele affected the organization in dramatic, unexpected, and anxiety-provoking ways. 
I was also responsible for reporting to the organization's board of directors on the progress and needs of interns at the clinic, and for communicating the board's concerns back to the interns. In short, I played an important intermediary role between the clinic as a whole and some of its subordinate parts. This role put me in a good position to observe the difficulties that the clinic system encountered during this period of adaptation to unprecedented situations, challenges, and crises. Eventually my work with Dr. C and Lynne became one of those unprecedented issues. The difficult interactions between the clinic and me about Dr. C and Lynne were reminders of how perceptions of a disability can challenge the efficiency, functioning, and framework of a system, whether that system is a family, a therapist-patient dyad (including a supervisor), or a clinic.
During her initial interview, Lynne said that her depressive symptoms had gotten worse in the preceding months, which was why she had decided to accept her case manager's referral to the clinic. She entered therapy feeling apprehensive about her increasing depression and unrelenting sense of isolation. She chose to work with Dr. C on the belief that "only a blind therapist" could understand her situation. However, as logical as this idea might seem, it denied the certainty that there would be differences between Lynne's experiences with blindness and Dr. C's. It also seemed odd in that Lynne had previously terminated work with another blind female therapist whom she described as "too superblind to be of any help." An additional issue was the fact that a sighted, heterosexual male was the third member of the triad. Dr. C informed Lynne about this supervisory relationship, but its implications were not discussed openly. As the analysis progressed, I contemplated whether the fact the implications of the supervisory relationship was not addressed might reflect an avoided aspect of the treatment.
Dr. C mirrored Lynne's strong adherence to one specific vector of identification between them their blindness. Although identification can promote a sense of connection, it frequently comes at the expense of the recognition of actual differences (Benjamin, 1995). An enactment, actually a series of transference-countertransference laden interactions, between Dr. C and Lynne brought this emerging identification to light. In the ongoing enactment, for several weeks, Dr. C and Lynne connected almost exclusively through the dynamic structure of Lynne's blindness, while disregarding many other aspects of the two parties' vast and complex internal landscapes and contrasting identities, as well as the patient's depression. Exploration of this enactment eventually allowed the acknowledgement, and then the working through, of their defensive identification.
Dr. C was very serious about Lynne's treatment, but Lynne disavowed the impact of her own history, trauma, and experience of blindness. Her defensive tactics included presenting herself as silly and confused. These tactics led to clashes between her tendency to evade and blow things off, and Dr. C's desire to address important areas of Lynne's experience. The more Dr. C persisted in trying to discuss Lynne's experience of herself, the more irritated and frustrated she became, while Lynne happily went off on one tangent after another. At one point in our supervisory meetings Dr. C said of her frustration with Lynne, "I give up." Dr. C also said she was "losing herself" in the process of trying to figure out how to deal with her patient. She also had an extremely difficult time confronting Lynne about these issues. I too felt frustrated and irritated over the many issues that Lynne avoided, including her relief over her father's death, her mother's alcoholism, and her family's lack of response to it. I also felt annoyed over Dr. C's increasing difficulty in following up on her early and unsuccessful attempts to get Lynne to talk about these issues.
As Dr. C and I explored her frustration and feeling of lostness, I shared my observation that while Lynne seemed to be responding to Dr. C's queries with comprehensible words, phrases, and sentences; it felt as though she was presenting herself as a series of punctuation marks, as a series of gaps of missing information. Dr. C responded by describing her sense of being "steered off course" on a regular basis, especially when she got anywhere near painful aspects of Lynne's history. Many of those aspects related to what we hypothesized was Lynne's ambivalence about being recognized. The same seemed true for Dr. C. Were the processes of identification that were being enacted in the treatment being used in defense of simultaneously dreaded and desired recognition? We began to focus on using the gaps as clues to Lynne's dissociated sense of self. We explored how Dr. C's feeling of being evaded, which I also felt, may have been a reflection of our own resistance to exploring similarly dissociated aspects of ourselves that challenged our own senses of competency and independence.
As Dr. C worked to address Lynne's issues in treatment, she discussed with me some her own struggles with countertransference. These included her identification with Lynne, especially concerning her own needs and the ways that they had been addressed by the outside world throughout her life. We noticed that she had begun enacting some of Lynne's behavioral characteristics (e.g., responding defensively to Lynne's dependency by "turning off emotionally," while being protective of Lynne's vulnerabilities). I became increasingly irritated with Dr. C's overprotective (at times pampering) treatment of Lynne. Yet I was unwilling to confront her about this behavior, and I began to consider whether my unconscious reluctance to address the issue was a replication of Dr. C's difficulty challenging Lynne, as well as the treatment that Dr. C received from her parents.
When we explored this topic in supervision, Dr. C became more aware of the complexity of her identification with Lynne. Through exploring the series of enactments between Dr. C and Lynne, we began to understand how a particular kind of identification can work for and against a therapist and her patient. On the one hand identification enhances a sense of closeness ("Only a blind therapist can understand me"), but on the other it acts as a barrier to sharing vital information. It turned out that Dr. C viewed herself as the recipient of transference material representing Lynne's disavowed need for autonomy and independence; this disavowed need created an intrapsychic conflict resulting in considerable confusion over how to proceed. The core problem was how to address the needs of the treatment participants when neither one was willing to state what they were. What Lynne wanted her desire to have her own needs recognized and responded to was what Dr. C possessed, but had experienced with great ambivalence. That is, Dr. C experienced it as not what she needed at all. What Dr C wanted to be treated as a competent and independent individual had been rejected by Lynne as supremely unempathic. Both Lynne and Dr. C experienced ambivalence about needs (about having them, about having them met, and about the possible consequences of having them met). This ambivalence, expressed as silence and evasion in therapy, subverted all attempts at more open relationships within our triad. As Dr. C became aware of her identification process, we understood better the strength of her identification with Lynne's dependency. Her enactment of a counterdependent stance with me reflected her fear of dependency in our supervisory relationship.
Before we could begin exploring this enactment, Dr. C reported a declining sense of empathy and concern for Lynne and what she described as feelings of "contempt" for her patient. In response to a comment I made about contempt being synonymous with disavowed shame (Winnicott, 1971), Dr. C acknowledged feeling shame over her own disowned dependency needs, as well as her opinion that Lynne was a "poor representation of the blind community." We looked at the mounting evidence coming into our awareness that issues of dependency, autonomy, and recognition were being enacted in the therapy in anxiety-provoking ways. During this time, I had to explore my counterdependency issues, especially whether my irritated sense that Lynne was being pampered might have caused me to overlook some important treatment issues. It seemed clear that we all wanted to be recognized for our efforts, but also, and paradoxically, that whatever it was we might need from this situation went consistently unarticulated.
About one year into Dr. C's supervision (and about a year into Lynne's treatment), a board of directors' meeting was called to discuss who among the interns should be offered staff positions. This was surprising because it was well known that the clinic's policy had always been to offer staff positions to virtually everyone who completed an internship there. It was even more surprising to me to realize that the only intern whose hiring was in dispute was Dr. C. Although certainly complicated and not without problems, I felt that Dr. C's progress, and her work with Lynne in particular, were well within expectable standards.
However, the other directors and supervisors began to reveal that Dr. C's presence in the clinic was much more disconcerting to the other interns and staff members than I was aware. Adding to the uncomfortable mixture of concerns over how to deal with disability and the fear that this induced (especially around how to deal with Dr. C and Lynne), it turned out that Dr. C had ways of subtly pulling for help from other staff. Without directly asking, she would get other staff to do her paperwork, get her from room to room, usher in her patients to their sessions, and so on. The consensus was that Dr. C's presence in the clinic was disruptive and taxing.
At the same time, the executive director brought up numerous problems that had been imported into the clinic through my outreach efforts, and the introduction of new patient populations that ensued from this outreach. Our successful new alliances with various agencies and the other resources necessary for our survival had brought in all kinds of patients and problems that we had never had to deal with before, and these affected the clinic administrators, staff, and therapists in dramatic, unexpected, and anxiety-provoking ways. We had to hire bilingual therapists, for instance, to cooperate with a number of family service agencies, and we had to obtain a license to work with children.
It seemed to me that Dr. C was being scapegoated as a primary source of all of the anxiety, frustration, and restructuring that the outreach efforts had entailed. This frustration made some sense because it would be very threatening to tackle the larger systems that were exporting their problems to us. These systems were too important, not to mention too large and overwhelming, to be dealt with directly. Furthermore, although she was the "official" scapegoat, I felt that it was made very clear in this meeting that I was to blame for the frustrations that had been visited upon the clinic. Though I was hired specifically to accomplish this work, the message now seemed to be that this clinic no longer knew how to deal with me, or the problems connected with my efforts. That these same efforts were implemented to assure the clinic's survival was no longer recognized.
I think now that the interaction at the directors' meeting was an enactment of this clinic's struggles in its transition into a new healthcare environment. It captures well Grinberg and Grinberg's (1989) statement about how change can induce persecutory, depressive, and disorienting anxieties in systems as well as in individuals.
At the end of that meeting, however, all I said was, "We did invite Dr. C." The executive director retorted, "No, Dr. Borg, you invited her...so you will deal with her." It was not true that I had invited Dr. C into the clinic. However, I had been responsible in many ways for setting up the invitations to the new agencies that had required the clinic to adjust to the new population of often very difficult patients. Right, I thought sarcastically and defensively. It's the fault of all those newcomers "I" invited in if the addicts from the rehabilitation programs would just stop relapsing, if the de-institutionalized psychotics would just stop decompensating, and if the blind people would just be superblind, we could all go on fantasizing that the dramatic changes in the healthcare system had not affected us, and we could still pick and choose our patients based on their "analyzability."
After much dispute, and not without significant hesitation and complaint, the directors did decide to offer Dr. C a position. However, this decision seemed to be based more on shame and guilt, as well as the fear of possible legal repercussions, than on any recognition of Dr. C's work, any sense of having learned how to deal with her (or us), or any recognition that the initial reason that we had expanded our services was for our own survival in an increasingly therapy-unfriendly healthcare system.
Dr. C accepted the staff position she was offered, and requested that I continue as her supervisor. I agreed, but I was feeling increasingly uneasy about our work together. In addition to my earlier frustration over her pampering approach to Lynne's therapy, I found myself feeling unrecognized for my supervisory work by Dr. C. which combined with my sense of being stigmatized for my association with her. Other areas of concern were Dr. C's lack of self-reliance in completing necessary administrative paperwork, her anger toward Lynne, and our difficulty addressing these problems openly. I increasingly doubted my ability to help Dr. C, who continued to struggle with feeling unrecognized by her patient. She told me, "I could be absent from the room without any significant change in the process," and I had to agree. The three of us all wanted recognition for our efforts, but none of us wanted to acknowledge the disruption we were causing to the clinic system.
During one supervisory session, Dr. C told me that she felt increasingly ambivalent about allowing herself to be seen by Lynne, and began expressing a sense of doubt about her ability to effect a positive treatment outcome. Throughout her supervision I had been aware of my tendency to use visual metaphors in our discussions, and Dr. C had assured me that she was accustomed to them and occasionally used them herself. However, this was the first time I had noticed her actually using one, and immediately asked whether it indicated that her complaint about her patient might reflect an intense ambivalence about Dr. C being "seen" being recognized for her needs, her strengths, her weaknesses, and even her sense of self. I considered whether her comment represented an ambivalence toward the treatment dyad that is, simultaneous and paradoxical desires to be seen/recognized and unseen/not recognized. I had certainly missed the many ways that Dr. C had secured help from others in the clinic; was my inability to see such incidents part of the reason why Dr. C wanted to continue working with me?
Without directly mentioning the ways in which she got help from other staff members, Dr. C said that she was feeling shut out because she received few referrals from the reception staff. When I asked whether she had requested more referrals, her response was "Why should I have to ask?" Angered by her sense of entitlement, I reframed her question as "Why should you, like all the interns and staff here, have to ask for help in building up your case load from the people who can actually help you in that area?" Without answering, she began talking about her feelings of disgust for "people who use their disability to attain special treatment," I asked, "People like Lynne?" This question allowed us to discuss Lynne as someone who was "cashing in on her disability." This was the first time that Dr. C considered the possibility that her anger toward Lynne had something to do with Lynne's ability to ask for and receive help without shame or guilt. Another insight was that for Dr. C to ask for help in any way was to admit defeat and accept her family's wish that she "submit to" her disability. In other words, she responded to her own needs in ways that were almost the exact opposite of Lynne's.
The lifelong intensity with which Dr. C had struggled against her self-perception as a disabled person had left her with an unrealistic sense of her own capacities. She therefore tended to dissociate experiences in which she actually was given help. When I asked what it was like for her to attend our weekly supervisory meetings as someone who needed instruction and guidance, her defiant response was "I have never asked you for anything." She began to consider that by not asking for help in becoming a skilled therapist, she was repeating a pattern of self-defeat that confirmed her parents' message that she would never be able to function like a sighted person. That is, she was critically reviewing her own ability to function based on the fantasy that sighted people function without social support, and that she should do so as well. Enacting this pattern often lead her to not only to question her own capacity to function, but to become highly anxious in her attempts to do so and, hence, to actually function less adequately. Dr. C also considered the idea of wanting her needs to be known and met without having to state them. Some other employees in the clinic responded to her perceived needs, based upon their assumptions of what her needs were. Her reaction to this assistance was generally hostile, however, as seemed to be confirmed by the complaints made in the board meeting. Toward the end of this supervisory session, I pointed out that she had "asked" me to supervise her, but that I could not help her unless she learned how to communicate her needs and accept my help.
Losing Sight of the Transference-Countertransference Enactment
A short while after this conversation, Dr. C abruptly lost her remaining eyesight. This loss resulted in significant changes in our supervisory relationship and in Lynne's treatment. Dr. C was reluctant to discuss her feelings about this event and the difference it might make in her life, but she did begin conveying more of her needs to me and to the clinic staff. Her collusive relationship with Lynne became increasingly clear, as Dr. C understood it as a mutual denial of characteristics that frightened them both. It seemed as if they had made an unspoken agreement to dissociate the effects they had on each other. Essentially, they agreed to shut out each other's experience that conflicted with their own cherished self-images Dr. C's desire to be free of all dependencies, and Lynne's experience of infinite needs. While Lynne's acceptance and trust of Dr. C's help was increasing, Dr. C began accepting (through her work with Lynne) certain aspects of her own identity that were attached to her own struggle with her blindness.
Still, there were certain aspects of Dr. C's collusion with Lynne that neither of us recognized. When Dr. C told Lynne about her lost vision, Lynne expressed empathy by saying that she knew what that was like. But upon reflection, we wondered how that could be true: Lynne had been blind from birth, and therefore couldn't really know what Dr. C had actually lost. Lynne's sense of knowing or understanding her therapist was based on an important, but fantasized, identification. In our supervisory meetings, Dr. C and I wondered what issues were being masked by this insinuation of "knowing" between patient and analyst. While trying to identify what Dr. C and Lynne were denying, the two of us explored in depth Dr. C's comment about "being seen," including the question of why she and Lynne had so thoroughly avoided any consideration of my (sighted) participation in Lynne's treatment. (During my own internship, my patients frequently asked about my supervisors.) I asked Dr. C to consider whether their omission held significance, and who I might represent.
Supervisors are expected to identify issues (i.e., "see things") that lesser experienced therapists cannot. In our unique triad, I began to wonder if I was representing a sighted father in the minds of these two women, both of whom were acting in ways that overtly contradicted their own respective fathers' expectations. These transferential expectations were in Dr. C's case, to accept her blindness, and in Lynne's, to disown it. Dr. C and I also explored the possibility that Lynne's father had encouraged her self-sufficiency as a means of compensating for what he could not give her in time and protection (from her mother), or for his inability to accept or recognize the specific care she actually needed as a blind child. Internalizing his demand for self-sufficiency would preserve her unconscious relationships with her parents by providing an eternal target to rebel against, while sustaining her resistance to acknowledging her own abilities. We then discussed how such a rebellion against deceased parents (Freud, 1917) might have kept Lynne from initiating a mourning process that would help her in her struggle against depression. On my part, I considered to what extent my experience at the director's meeting had resembled the two fathers' experiences as intermediaries between their blind daughters and the outside world. The visual problems of Lynne and Dr. C demanded that the clinic adapt to new circumstances.
The contradictory ways in which Lynne and Dr. C had dealt with their visual problems were apparently linked to the ways they internalized messages from their nuclear families messages that represented two of the most common ways that disabilities are addressed in our society. The two messages were similar in one respect: both families unconsciously conveyed the idea that "We don't know how to deal with you." Dr. C and Lynne conveyed the same message to each other. Dr. C and I did too, and so did the clinic's board of directors to the treatment triad. Not knowing how to deal with an issue engenders significant insecurity in a responsible caregiver, whether the caregiver is and individual or a system. When dissociated, such insecurity opens the possibility of enactments in response to feelings of powerlessness and shame over one's inability to parent a child, provide therapy to a patient, treat a new population of patients, and so on. 
Adam Phillips (1993) noted, "the profoundest way of recognizing something, or the only way of recognizing some things
is through hiding them from oneself
our unbearable self-knowledge leads a secret life" (pp. 16-17). From this starting point we can begin to understand why Lynne's depressive symptomatology was unreachable in the treatment setting; her unbearable self-knowledge was that no one, not even her family, knew how to deal with her. Lynne's eventual success in treatment may very well have hinged on Winnicott's (1965) assertion that "the development of a self may involve a sophisticated game of hide and seek in which it is a joy to be hidden but a disaster not to be found" (p. 186).
Lynne's choice of therapist reflected a belief that Dr. C would be able to recognize something deep and hidden in her, as if only another blind woman could have the power to recognize the unreachable. Complicating this desire for recognition, however, were the ways that collusive connections within the triad supported fantasies of symbiotic relationships, where symbiosis acts as a defense against recognition. Symbiosis does not require vision. It seemed as though the underlying message that each woman had received from her family of being too impaired to deal with, and the pain associated with this message, could be powerfully disavowed through the fantasy of symbiosis. By avoiding any discussion of these messages in treatment, both women could preserve the depths of their connections to their internalized fathers. Keeping this message and its messengers intact required that certain aspects of their experience and relationship remain unchallenged.
In addition to their symbiotic collusion, it seemed as though Lynne and Dr. C were sharing experiences of cross-identification, in which they recognized disavowed and dissociated aspects of themselves in each other. Until I reacted to the idea that what was not actually shared was nevertheless conveyed and understood, I was also implicitly agreeing to overlook their respective disavowals and dissociations. As these issues became apparent and we worked through the various enactments, we began to address important questions in the treatment: How were we acknowledging each other as people? Which unspoken aspects of our individual subjectivities were recognized, and which were insinuated? Which desires and needs were we willing to leave unattended? Our collusive agreement to not "see" these issues had been a source of deep anxiety. Not to see them meant not to deal with them, and all three of us knew what it was like to deal with seemingly incomprehensible systems (fathers, families, boards of directors). Therefore, instead of trying to penetrate directly into Lynne's unreachable parts, Dr. C and I began to discuss how Dr. C's efforts to reach Lynne might be evoking terrifying experiencing in her patient.
When we stopped trying to invade Lynne's defensive structure and tried instead to help her explore her own dependent experiences and her actual capacities for self-reliance, we became aware that our patient/analyst and analyst/supervisor interactions had shifted to a new kind of transference that was being played out across the treatment triad. For Dr. C to remain empathic to Lynne's sense of entitlement, she might have to re-experience her own family's perception of "we don't know how to deal with you." If she made that effort, it might help Lynne realize that she was a person who could be dealt with, but to do so required that both she and Dr. C acknowledge the full extent of their family-centered psychological wounds.
Dr. C's pampering of Lynne had made me reflect on the differences between sympathy and empathy the former akin to a patronizing pat on the head, the latter requiring an emotional connection with the other's experience that is likely to trigger memories of painful experiences of one's own. In their commentary on Sullivan's contributions to psychoanalysis and field theory, Murphy and Cattell (1952) asked, "What then specifically is the pathology that disturbs our everyday capacity for empathy, for constructive integrations with others? It is behavior engendered originally by demands too severe to be met, and by disapproval too poignant to be tolerated" (p. 168). In this case, empathy required that Dr. C relive the experience of knowing that others felt that she could not be dealt with satisfactorily. Accordingly, Lynne's enactments in treatment served to reinforce Dr. C's defenses against her own earlier (and much less tolerable) experiences.
Lynne's references to her disability served as an entry point to her transference reactions. When describing the connection between the concept of superblind and her history of "specialness," she also seemed to be describing a link between being special and the numerous losses in her life. For instance, Lynne experienced her father's confrontation of her mother as resulting from her blindness, not from her position as a child needing protection and understanding. Dr. C was eventually able to inquire about her patient's hidden needs within the transference-countertransference relationship, and she learned that any identification as a superblind woman triggered painful aspects of Lynne's internalized family system. By refusing to act in a superblind manner, she not only resisted past messages that she should disavow her true need for specialized care; she also gained access to the sense of dependence in early life that her parents had forced her to relinquish prematurely. We did not try to coerce Lynne into a superblind identity, which allowed her eventually to form a realistic reliance upon her therapist based on recognition rather than collusion. The three of us began to feel as though previously disavowed aspects of ourselves could be brought into the system and dealt with. Only when Lynne's feelings were consensually validated could they be metabolized and worked through.
Dr. C learned that her task with Lynne was to find a resolution for a repetitive and powerful homeostatic interaction pattern. It is possible that Lynne experienced Dr. C's level of functioning as representing an idealized object that Lynne had never achieved. In considering this possibility, Dr. C wondered if her own superblind role in the transference relationship had threatened to unearth the disavowed strengths and abilities that had been so threatening to Lynne when she entered treatment. In our supervisory meetings, we explored the possibility that Lynne experienced Dr. C as a rival who was able to function in the manner that Lynne's father had hoped she would attain. Once Lynne became willing to discuss her envy of superblind individuals, she allowed herself to access her own strengths, as well as some other conflicting aspects of her identity. In our struggle to broaden Lynne's engagement with her therapist, all three of us had to confront the disappointment of not having our own needs recognized: Lynne's dependencies, Dr. C's strengths, and my contributions. Accounting for these missed recognitions in supervision allowed Dr. C to be more receptive to what Lynne's needs were, and what previously threatening parts of Lynne, Dr. C, and me needed to be acknowledged and given space in the treatment process. Acknowledging the need for recognition that bound the treatment triad in turn helped foster the necessary space in the treatment to help Lynne review her perceptions of her early life, and to interact more vigorously with Dr. C, her partner, and others outside of therapy.
As these issues played out repeatedly in the treatment and supervisory dyads, what became ever clearer was the fundamental clash between the types of treatment these women had received from their families. Lynne was treated as though she could accomplish anything in spite of her disability, while Dr. C was treated as though she could accomplish nothing because of it. In some ways, I may have provided a point of intersection for their dissociated issues. By shifting her requests for help from me to other staff members, Dr. C was the daughter that Lynne's father had raised her to be (note again Wright's  dependence/self-sufficiency paradox), and Lynne in her refusal not to ask for help at least as she was presented to me was the daughter that Dr. C's father had raised (a perfect scenario for cross-identification).
The clinic struggled with the question of how to handle the three of us, at one point trying to displace and avoid the situation by simply getting rid of Dr. C. After distancing myself from the clinic long enough to understand the process, I realized that I was challenged by two issues: how to confront someone dealing with deeply traumatic circumstance of losing her sight without succumbing to the inclination to infantilize; and how to take her abilities into account without categorizing her as superblind when my own anxiety about her blindness-related limitations became uncomfortable. My wish to maintain high expectations for Dr. C conflicted to some degree with the clinic's interests. I had to consider both her capabilities and her restrictions, the clinic's ability and willingness to help her function, and the consequences of negotiating with both systems. Open and often trying discussions eventually led to greater clarity about Lynne's treatment, and about operating in the unprecedented situation we had created in the clinic.
The focus of interpersonal theory is human relationships. Its core commitment is to the idea that a person's sense of self, including experiences of self-defined "problems in living," cannot be separated from that person's relational contexts (Fromm, 1956; Levenson, 1983; Mitchell, 2000; Sullivan, 1953, 1964). In Lynne's case, her depression was linked to how her problems affected the care systems in which she had lived, and in which she currently lives. That issue touched for all of us on experiences concerning how we had or had not been adequately "dealt with" in our lives. In the therapeutic and supervisory dyads described in this case study, there was a persistent tendency initially to create articulate interpretations and intricate explanations that made at least intellectual sense of Lynne's problems. However, these explanations paradoxically worked against the forming of productive relationships among us until we were well into the third year of treatment, when collusive identifications were recognized and replaced with more accurate forms of understanding, and Lynne became more willing to experiment with alternative cognitive, emotional, and relational approaches to autonomy and dependence, and to use them in her relationships outside of treatment.
Toward the end of my supervisory work with Dr. C, Lynne had begun to address her ambivalent feelings toward her parents, and to respond to her own and her therapist's superblind characteristics. As her treatment progressed, the general description of her depression gained clarity in tandem with her willingness to look at specific details of her history, her chronic alienation and unreachability, and her guilt over presenting a problem that others especially her parents did not know how to address. Lynne also became aware that she maintained rigid separations among various parts of herself, which supported her unreachability, and that it was difficult to share important aspects of herself because she identified so strongly with only one single characteristic her blindness. As she learned to share broader aspects of her personal experience, she also learned to maintain a sense of hope, especially regarding the management and tolerance of her own feeling states.
By focusing on culturally constructed, stereotypical views of disability, Lynne avoided addressing how her sense of self had been informed by her unique and painful family experience. As a result, important aspects of her self were kept out of her awareness, thus sustaining the sense of unreachability that underlay her depression. Concurrently, Dr. C and I were struggling with similar socially constructed stereotypes that for two years prevented us from recognizing these dynamics. Their eventual illumination among the three of us, and within the larger clinic system, contributed to the sense of recognition within which Lynne could be reached. This recognition expanded aspects of her identity and experience, and an understanding of how they had been responded to, dissociated, or integrated into her sense of self. She became increasingly capable of initiating and sustaining a process of change that was both self-determined and socially supported.
1 The primary task of an organization is that purpose, vision, mission, etc. without which the organization would not exist (Gould, Stapley, & Stein, 2001; Miller, 1993). The survival of an organization is contingent upon the ongoing (at least minimal) accomplishment of its primary task.
2 Both organizational theorists (Jaques, 1955; Menzies, 1960) and psychoanalysts (Altman, 1995; Bion, 1961; Eisold, 1994) have described socially structured defense mechanisms against anxiety (such as this manic defense) on the group level. Others have proposed that disorganization or chaos in a group can itself serve as a defense against anxiety (Newton & Levenson, 1973).
3 Freud (1924) equated blindness with "castration anxiety" (p. 162). Therefore, as this case supports, it is possible that there was a fear of impotence experienced in the families, the treatment triad, and the clinic itself that was tainting the treatment, and being dissociated/enacted at the clinic level as well.
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