This article was downloaded by: [Memorial University of Newfoundland]

On: 02 August 2014, At: 23:23

Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered
office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Psychoanalytic Inquiry: A Topical Journal
for Mental Health Professionals
Publication details, including instructions for authors and
subscription information:
http://www.tandfonline.com/loi/hpsi20
Empathy in Psychoanalytic Theory and
Practice
Donald Grant
a
& Edwin Harari
b
a
Psychiatrist and Psychoanalyst in Private Practice in Melbourne ,
Australia
b
St. Vincents Hospital Area Mental Health Service , Fitzroy,
Australia
Published online: 19 Jan 2011.
To cite this article: Donald Grant & Edwin Harari (2011) Empathy in Psychoanalytic Theory and
Practice, Psychoanalytic Inquiry: A Topical Journal for Mental Health Professionals, 31:1, 3-16, DOI:
10.1080/07351690.2010.512844
To link to this article: http://dx.doi.org/10.1080/07351690.2010.512844
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information (the
Content) contained in the publications on our platform. However, Taylor & Francis,
our agents, and our licensors make no representations or warranties whatsoever as to
the accuracy, completeness, or suitability for any purpose of the Content. Any opinions
and views expressed in this publication are the opinions and views of the authors,
and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content
should not be relied upon and should be independently verified with primary sources
of information. Taylor and Francis shall not be liable for any losses, actions, claims,
proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or
howsoever caused arising directly or indirectly in connection with, in relation to or arising
out of the use of the Content.
This article may be used for research, teaching, and private study purposes. Any
substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,
systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Conditions of access and use can be found at http://www.tandfonline.com/page/terms-
and-conditions
Empathy in Psychoanalytic Theory and Practice
Donald Grant and Edwin Harari
With the exception of Self Psychology, empathy has not been a major theoretical concept in psycho-
analysis. Freuds (1921) definition of empathy implies it is a necessary condition for an analytic pro-
cess to develop (p. 110, n. 2). Most psychoanalytic theories have side-stepped this issue by including
empathy under various assumed names. We have discussed some of these in the theories of a number
of psychoanalysts within the British Psychoanalytical Society. We have illustrated some of these theo-
retical issues with a clinical example.
This discussion also raises the more general question of the nature of psychoanalytic theories. We
argue that no psychoanalytic theory is the exclusive repository of the truth, enabling it to dismiss
others as errors. We all need to remind ourselves of Freuds (1900) understanding of theory as use-
ful conceptual scaffolding to help us look for the truth, but the scaffolding is not the truth itself
(p. 536).
EMPATHY IN PSYCHOANALYTIC THEORIES
In The Interpretation of Dreams, Freud (1900) points out that our theories are nothing more than
ways of conceptualizing what we observe and experience in the clinical encounter with our pa-
tients. He describes theories as the scaffolding we use to examine the thing that interests us, but
they are not the thing itself. If ongoing clinical observations conflict with our theories, then he
says, We must always be prepared to drop our conceptual scaffolding if we feel that we are in a
position to replace it by something that approximates more closely to the unknown reality
(Freud, 1900, p. 610). Unfortunately, psychoanalysts have not always operated within this viewof
theory, and psychoanalytic theory wars raged for most of the twentieth century until Robert
Wallerstein (1988), during his presidency of the International Psychoanalytic Association, called
for a truce and more mutual respect between psychoanalysts with different theoretical views. This
created a situation of which psychoanalysts do not take full advantage. Ideally, we should now be
able to think about a clinical observation in the conceptual frameworks of a number of different
psychoanalytic theories and feel free to use the one that seems to offer the best understanding or
conceptual scaffolding for the clinical material with which we are working at the time. But we
need to remain mindful that whatever theoretical concepts we are using are not observed facts, but
just useful scaffolding to support our thinking. Paradoxically, such a demotion of theory requires
Psychoanalytic Inquiry, 31:316, 2011
Copyright Melvin Bornstein, Joseph Lichtenberg, Donald Silver
ISSN: 0735-1690 print/1940-9133 online
DOI: 10.1080/07351690.2010.512844
Donald Grant is a Psychiatrist and Psychoanalyst in Private Practice in Melbourne, Australia. Edwin Harari is a Con-
sultant Psychiatrist with St. Vincents Hospital Area Mental Health Service, Fitzroy, Australia.
D
o
w
n
l
o
a
d
e
d

b
y

[
M
e
m
o
r
i
a
l

U
n
i
v
e
r
s
i
t
y

o
f

N
e
w
f
o
u
n
d
l
a
n
d
]

a
t

2
3
:
2
3

0
2

A
u
g
u
s
t

2
0
1
4

an even broader and deeper knowledge of more psychoanalytic theories in order to understand
their limitations, as well as their usefulness in work with individual patients.
Acentral claimby psychoanalysts is to be able to understand blocks and resistances to psycho-
logical development in their patients and to facilitate the process of overcoming those blocks and
resistances. Different psychoanalytic theoreticians have conceptualized their facilitating role in
different ways, e.g., interpreting associations to dream images (Freud, 1900), interpreting trans-
ference states in the patient (Freud, 1912a), attention to countertransference feelings (Heiman,
1950), reverie (Bion, 1962), a state in the analyst comparable to primary maternal preoccupation
(Winnicott, 1956), and empathic attunement (Kohut, 1959) to name a few. These processes could
all be thought of as ways in which states of mind that act as unconscious blocks to psychic devel-
opment in the patient, can be recognized by the analyst. As such, they all fall within Freuds
(1921) definition of empathy, which is that empathy is the mechanism by means of which we are
enabled to take up any attitude at all towards another mental life (p. 110). It is surprising, given
that the central task in psychoanalysis is to understand something about the mental life of another,
that this definition is to be found in a footnote, and that this is Freuds longest statement on the sub-
ject. Most other prominent psychoanalytic theorists also remain silent on the subject of empathy,
although their theoretical writings, particularly analysts of the British school (e.g., Klein,
Winnicott, Heiman, Bion), frequently circle around it without actually naming it. It remained for
Kohut (1959) to provide empathy with a central place in psychoanalytic theory.
Each of the theoretical concepts mentioned earlier offers an explanation for the central process
of psychoanalysis in which something that is unconscious in the mind of the patient is communi-
cated to, and becomes conscious in, the mind of the analyst. This process falls within Freuds defi-
nition of empathy. Importantly, they all provide empathy with an unconscious dimension, in that
the state of mind the patient is communicating to the analyst becomes conscious in the analysts
mind while sometimes remaining unconscious in the patients mind. The analysts task then is to
reflect upon his or her emerging consciousness about the patient and when appropriate to commu-
nicate what he has understood to the patient. Empathy, then, remains a cornerstone of psychoana-
lytic observation, regardless of which theoretical scaffolding the analyst uses to think about what
is being unconsciously communicated by the patient. If this view is accepted, it becomes ex-
tremely curious that the word empathy is rarely encountered in the writing of psychoanalysts be-
fore Kohut, who made it the central issue in his theory of the development of the Self. Psychoana-
lysts of all persuasions, in fact, dont deny that empathy is important; they just avoid the word,
almost as if it were taboo. Instead, they circle around it and call it something else (e.g., counter-
transference, reverie, primary maternal preoccupation, etc.).
We nowwant to trace the developmental history of empathy (under various assumed names) in
the thinking of British psychoanalysts. We have chosen the British psychoanalysts for the simple
pragmatic reason that their theories are more familiar to us than those of the other streams of the-
ory and practice in psychoanalysis.
After Freud, technical and theoretical developments in the British Psycho-Analytical Society
owe more to Melanie Klein to than anyone else. She became the reference point by which British
psychoanalysts defined themselves: as being for or against her theories, or somewhere in the mid-
dle. Melanie Klein (1955b) sawthe primitive object relations depicted in the childs play as repre-
sentations of the childs internal psychic state and as arising from essentially the same internal
processes as those described by Freud in his work with adults. That is to say, she proposed that
symptoms arose from conflict arising from instinctual forces as they interacted with environmen-
4 DONALD GRANT AND EDWIN HARARI
D
o
w
n
l
o
a
d
e
d

b
y

[
M
e
m
o
r
i
a
l

U
n
i
v
e
r
s
i
t
y

o
f

N
e
w
f
o
u
n
d
l
a
n
d
]

a
t

2
3
:
2
3

0
2

A
u
g
u
s
t

2
0
1
4

tal factors. Her emphasis was on the pregenital vicissitudes of the death instinct, manifested as
anxiety and deflected outward as hostile and sadistic impulses, rather than the vicissitudes of eros,
which was where Freud put his emphasis in his proposals about the later developing Oedipus com-
plex. Klein (1946) hypothesized that, in dealing with these conflicts, the infant made use of primi-
tive defenses of denial, splitting, idealization, and what she called projective identification. Pro-
jective identification is a state of mind in which part of the ego or self is projected into an object
either to get rid of bad parts of the self or to provide safe-keeping for good parts. We should note
that Klein (1946) used the terms ego and self interchangeably. Empathy was not a major theoreti-
cal concept for her. On the rare occasions when the word appears in her writings, she does not
seem to mean what is usually meant by empathy, i.e., to know something about the mental life of
another (Freud, 1921). Rather she (Klein, 1955a) sees projection playing a major role in empathy
and that empathy consists of the identification of projected internal objects as characteristics of
the other (Klein, 1959). This, of course, is her concept of projective identification, but she seems
to have conflated empathy with it.
Despite this lack of conceptual clarity, or perhaps because of it, one of Kleins closest col-
leagues, Paula Heiman (1950), described a psychological mechanism by which empathy (in
Freuds sense) might operate, but she did not use the word empathy, thus beginning a long tradi-
tion among British psychoanalysts, of writing about empathy but not naming it.
At the 16th International Psychoanalytic Conference in Zurich in 1949, Paula Heiman gave her
groundbreaking paper On Countertransference, which was later published in the International
Journal of Psychoanalysis (Heiman, 1950). In it, she introduced the idea of countertransference
having a dimension of unconscious communication from the patient. Heiman pointed out that the
emotional reactions of the analyst to the patient are more than just the analysts personal and idio-
syncratic reactions but are also the analysts particular reactions to that particular patient at that
particular time and, as such, can tell us something about what is going on in the mental life of that
patient in that particular session. She did not use the word empathy, but it is empathy within
Freuds definition that she is talking about and most importantly giving an unconscious dimen-
sion, in that issues in the patient that are unconscious or cant be expressed in words can evoke par-
ticular conscious emotional states in the analyst. The analysts task then, is to refrain from acting
on these emotional states and to think about them and what if anything, they might mean about
what the patient is experiencing and doing, rather than saying. The unconscious dimension that
Heiman pointed to, can considerably deepen the analysts understanding of the patients states of
mind.
Bion (1962), who had analysis with Melanie Klein, developed Kleins theory of projective
identification further than Heiman. His view was that infant development was determined by the
interaction of an empathically attuned mother with the instinctual endowment of the infant, both
of which could vary considerably from one motherinfant pair to another. Bion, like Heiman, did
not use the term empathy. Instead, he spoke of maternal reverie. He (Bion, 1962) defined the
mothers reverie as that state of mind capable of reception of the infants projective identifica-
tions (p. 36). That falls within Freuds definition of empathy. He teased out in more detail how
this reverie or heightened empathic sensitivity might occur. First, he reminded us that projective
identification is an omnipotent phantasy that it is possible to relocate unwanted parts of the self in
an object or other. The infant (or patient) operating in this omnipotent way then relates to the ob-
ject or other as if what has been projected is really how the other is. This, in turn, engenders vari-
ous feelings in the mother (or analyst). The capacity of the mother (or the analyst) to allow herself
EMPATHY IN PSYCHOANALYTIC THEORY AND PRACTICE 5
D
o
w
n
l
o
a
d
e
d

b
y

[
M
e
m
o
r
i
a
l

U
n
i
v
e
r
s
i
t
y

o
f

N
e
w
f
o
u
n
d
l
a
n
d
]

a
t

2
3
:
2
3

0
2

A
u
g
u
s
t

2
0
1
4

to become conscious of these feelings and then to think about them and what they might mean
about the infant (or patient) is the capacity for reverie. Bion, like Heiman, was describing a possi-
ble psychological mechanismfor empathy and it is curious that neither of themused the word em-
pathy for what they were describing. Bions concept of reverie seems more a development of
Heimans concept of contertransference as communication than any specific idea in Kleins writ-
ings. Yet, to give Melanie Klein her due, without her concepts of splitting and projective identifi-
cation (Klein, 1946) neither Heimans nor Bions conceptual developments could have occurred.
Winnicott (1962), who had supervision but not analysis with Melanie Klein, was largely in
agreement with her formulations regarding pre-Oedipal development. Their areas of agreement
included that a childs play represents a projection of internal object relations; that primitive inter-
nal objects are split into good objects and bad objects, although Winnicott preferred to call them
benign objects and persecutory objects; that these good and bad internal objects have their origins
in satisfying or unsatisfying environmental (other/mother/caregiver) responses to instinctual
needs; and that the good tends to be introjected and becomes part of the Self/Ego and the bad pro-
jected into external objects. He agreed that the depressive position was a major developmental
achievement (although he preferred to call it the stage of concern) in which it was recognized by
the developing infant that the split good and bad objects were, in fact, aspects of a single other/
mother/breast whole object that was at times satisfying and at other times unsatisfying. He also
agreed that this led to a capacity to feel concern and guilt about attacks in phantasy, on the bad ob-
ject which, in fact, was one and the same as the good object. This, in turn, mobilized the life in-
stinct, eros, with urges to reparation and restitution directed towards the newly experienced whole
object. Winnicotts major difference from Klein was in the major emphasis he gave to the quality
of the maternal or primary caregivers capacity to provide good enough mothering. Despite
Kleins protest that she did take the mothering into account, Winnicott (1962) went as far as to say
that, in his opinion, She [Melanie Klein] was temperamentally incapable of paying full attention
to it [the environmental factor] (p. 177). No doubt this was in part a shot fired in the theory wars
that plagued the British Psycho-Analytical Society in the twentieth century, but Winnicott had a
point, as a reading of Kleins (1961) analysis of Richard will confirm. Klein, herself, acknowl-
edged that she had a particular emphasis on the vicissitudes of instinctual anxieties to the exclu-
sion of environmental influences, which is not to say she thought them unimportant. Klein (1946)
said, for example, Fairbairns approach was largely from the angle of Ego-development in rela-
tion to objects, while mine was predominantly from the angle of anxieties and their vicissitudes
Importantly, she added, I hold that anxiety arises from the operation of the death instinct within
the organism (p. 3). These comments suggest that she realized that her approach was only one of
a number of possible approaches.
Winnicott (1956) was able to marry the two theoretical positions of the instinctual origins of
mental life and behavior and that the development of the infants mental life is channeled by the at-
tention of a good enough [i.e., empathically attuned] mother. The ministrations of a good
enough mother will determine whether an instinctual need is met satisfactorily, creating a good
experience (i.e., a good or benign internal object), or not met satisfactorily, creating a bad experi-
ence (i.e., a bad or persecutory internal object). Winnicotts theories of primary maternal preoccu-
pation and good enough mothering release us from any need to choose between instinctual drives
and environmental influences as the hand that guides mental development. His theories point to
the interaction between nature and nurture as the crucial factor. This is congruent with modern
knowledge of genetics (Kandel, 1998), which has shown there is an even more intimate interplay
6 DONALD GRANT AND EDWIN HARARI
D
o
w
n
l
o
a
d
e
d

b
y

[
M
e
m
o
r
i
a
l

U
n
i
v
e
r
s
i
t
y

o
f

N
e
w
f
o
u
n
d
l
a
n
d
]

a
t

2
3
:
2
3

0
2

A
u
g
u
s
t

2
0
1
4

between the environment and genes than was previously thought, with many genes needing to be
switched on by environmental experiences.
Somewhat apart in the British Psychoanalytical Society was Anna Freud. Like Winnicott, she
held the view that psychological development took place through the interaction of instinctual
forces and environmental factors. She held the viewthat when instinctual needs were met satisfac-
torily by the environment, development proceeded satisfactorily. However, when instinctual needs
were not met satisfactorily, developmental lines were disrupted. In her book (Freud, 1965), Nor-
mality and Pathology in Childhood, she expanded the concept of lines of development to include
almost every other area of the individuals personality (p. 63). In her emphasis on developmen-
tal lines, she could be seen as a precursor of Kohut. Yet, like her colleagues in the British Society,
she did not make empathy a major theoretical concept, leaving it as an implicit necessity in both
normal development and the psychoanalytic process.
The failure by most psychoanalysts to name empathy for what it is has led to a lack of psycho-
analytic studies of empathy and its possible types and mechanisms. Kohut (1959) began the cor-
rection of this failure by placing empathy at the centre of his understanding of the psychoanalytic
process, but even he did not undertake the sort of detailed observation and study that might lead to
an understanding of possible different types of empathy and possible mechanisms by which em-
pathy might operate. Paradoxically, other psychoanalysts have arrived at an understanding of how
mechanisms facilitating empathy might operate without naming it as empathy, e.g., Freuds
(1912b) evenly suspended attention, Heimans (1950) countertransference as communication,
Winnicotts (1956) primary maternal preoccupation, Bions (1962) reverie, Loewalds (1986)
therapists observation of his own visceral reactions to the patient, McDougalls (1978) induced
countertransference emotions as preverbal communications, Ogdens (2004) the analytic third,
and Gabbards (1995) fit between the patients and therapists intrapsychic worlds. Most of these
formulations involve attention to countertrasference reactions and recognize their unconscious
communication aspect. Gabbard (1995) also pointed out that there is a growing common ground
among psychoanalysts of different theoretical orientations in their recognition that countertrans-
ference reactions can have an important dimension of communication. What has not been made so
explicit is that this is a psychological mechanism for empathy.
We believe that the theory wars that have raged among psychoanalysts of different theoretical
orientations have been very detrimental to psychoanalysis in that they have inhibited professional
dialogue in many areas, not least between Self Psychologists, who name empathy, and psychoana-
lysts of the British school and others who have elucidated a psychological mechanismof empathy
without actually naming it as empathy. The result has been that serious study of empathy in psy-
choanalysis has been restricted. It has been left largely to neuroscience, some of whose practitio-
ners are also psychoanalysts, to undertake serious studies of empathy.
The study of the neurological correlates of mental events is a relatively new field, made possi-
ble by a variety of new brain-scanning techniques. Despite still being in their infancy, cognitive
and affective neurosciences are providing us with new orientations and directions in the study of
the brain/mind. Now that their neurological correlates are becoming known, the study of subjec-
tive mental processes is being taken more seriously, particularly by those who previously doubted
the scientific credentials of studies of states of mind. Neuroscience is starting to give us important
new insights into even subtle mental processes like empathy.
Among the important emerging issues is the functional asymmetry of the brain, even though
the gross anatomy is symmetrical. It has long been known that the left cerebral hemisphere is the
EMPATHY IN PSYCHOANALYTIC THEORY AND PRACTICE 7
D
o
w
n
l
o
a
d
e
d

b
y

[
M
e
m
o
r
i
a
l

U
n
i
v
e
r
s
i
t
y

o
f

N
e
w
f
o
u
n
d
l
a
n
d
]

a
t

2
3
:
2
3

0
2

A
u
g
u
s
t

2
0
1
4

site of language functions. What the right hemisphere does has been less clear. There is now evi-
dence (Siegel, 2001), that the right hemisphere is dominant for processing conscious and uncon-
scious affects. Not only does it process the subjects own affects, but also it processes the recogni-
tion of affect in others (Blair, 2003). These studies point to empathy being predominately a
function of the right cerebral hemisphere.
The discovery of mirror neurons by a group of researchers (di Pellegrino et al., 1992) at the
University of Parma in Italy has provided a pointer to more localized brain sites and a more spe-
cific neurological mechanism for understanding the neurological correlates of empathy. The
groups initial studies were of neurons in the inferior prefrontal cortex of the macaque monkey.
These neurons fired when a specific movement was made by the monkey. The researchers noticed
that these same cells also fired when the same movement was made by the experimenters and ob-
served by the monkey, even though the monkey was not performing the movement. The firing of
the neurons seemed to be related to understanding the movement, rather than performing the
movement. Subsequently mirror neurons have been found to be more widespread in the monkey
brain (Gallese et al., 2001). Mirror neurons have also been found in the human brain (Fadiga et al.,
1995; Cochin et al., 1998; Hari et al., 1998). Vittorio Gallese (2001), a member of the team who
originally discovered mirror neurons, has noted that activation of mirror neurons is not limited to
motor actions but also occurs in situations of observed pain (Hutchison et al., 1999) and observed
emotion (Calder et al., 2000). Mirror neurons that respond to observed emotion provide a possible
neurological mechanism for empathy. Adolphs et al. (2000) came to a similar conclusion, saying,
We recognize another individuals emotional state by internally generating somatosensory repre-
sentations that stimulate how the individual would feel when displaying a certain facial expres-
sion (p. 2683).
Another important aspect of empathy which has not, to our knowledge, been addressed by psy-
choanalysts is whether all empathy is the same or whether there are different types of it. A recent
neuroscience paper (Shamay-Tsoory, Aharon-Peretz, and Perry, 2009) has addressed this ques-
tion with conclusions that are significant for psychoanalysts. They found evidence for at least two
different types of empathy. One is what they called the basic emotional contagion system asso-
ciated with mirror neurons particularly in Brodmann area 44 of the cerebral cortex. The other they
called the cognitive perspective-taking system associated with Brodmann areas 10 and 11 of the
ventromedial prefrontal cortex.
EMPATHY IN CLINICAL PRACTICE
With these psychological and neurological issues in mind, we want to discuss some clinical work
with a patient whom we call H. H had a severe life-threatening physical illness in addition to an
eating disorder and depression. She was completely dependent on health professionals and hospi-
tals to survive. Her prognosis was not good but her physician asked me (D. G.) if there was any-
thing I could do that might help. I began seeing her twice a week as a hospital inpatient and later in
my private consulting rooms. A central question we have posed to ourselves about H is: How is it
that H became conscious of some of her subjective states of mind that were previously
unconscious?
The method of free association helps us to hear the conscious contents of the patients mind and
the links both conscious and unconscious between them and we can communicate these to the pa-
8 DONALD GRANT AND EDWIN HARARI
D
o
w
n
l
o
a
d
e
d

b
y

[
M
e
m
o
r
i
a
l

U
n
i
v
e
r
s
i
t
y

o
f

N
e
w
f
o
u
n
d
l
a
n
d
]

a
t

2
3
:
2
3

0
2

A
u
g
u
s
t

2
0
1
4

tient. The constancy to the setting and the absence of interruptions assist the patients free associa-
tions. The analysts evenly suspended attention helps him or her to hear more subtle themes in
what the patient says. To this point, the work of the analyst is mostly cognitive and conscious. But
there is more to psychoanalysis than that.
In the earliest stage of her treatment in my rooms, free association was not happening. Hwould
lie on the couch and writhe, moan, groan, and sob continually. Although she spoke no words, she
conveyed extreme distress in a very powerful way so that it became an extremely painful experi-
ence for me. I found it extremely difficult to stay in the roomwith her for 50 minutes. At this early
stage in her treatment, I tried a few times to make a verbal statement to the effect that she was an-
gry about her plight. Immediately following these attempts of mine, she would freeze as if some
unexpected noise had startled her. After a few seconds, she would resume writhing and sobbing
and moaning as if I had not spoken. My feeling was that this verbal interpretive approach was go-
ing nowhere. I felt deskilled, useless, and worthless, and even feared at times that I might be mak-
ing her worse.
In contrast to these distressing countertransference feelings, which made me want to terminate
the therapy and flee, I also had a powerful sense that it was very important for Hto be able to come
to therapy and be so distressed in my presence. Gradually, I came to understand that this primitive
transference/countertransference relationship, on a completely nonverbal level, nevertheless had
meaning in it. As well as having a powerful emotional experience herself, H was creating a situa-
tion in which a potential experience for me was embedded. What was required on my part was em-
pathic attunement. Kohut spelled this out, but did not offer an explanation of howit might happen.
Heimans (1950) theory of countertransference as communication fills this gap. Gradually, I came
to understand that my countertransference feelings were the real communication from H about
what she was experiencing. I came to understand that my countertransference feelings were not
just something about me, but also a reflection of howHfelt, not only deskilled, useless, and worth-
less, but full of badness that was dangerous to others.
I abandoned the idea of interpretation and concentrated on surviving the unpleasant feelings
engendered in me and staying in the room with her. I think my most important empathic
attunement at this early stage was the realization that attempts at interpretation only bewildered
her. In these early sessions, she had regressed to a very primitive preconceptual level and words
were little more than noises to her. I made occasional empathic comments such as, You seem
more (or less) distressed today, but I am not sure that even such simple experience-near com-
ments were meaningful to her. Up to this point, the empathic attunement required seems to have
been the emotional contagion/mirror neuron type (Shamay-Tsoory et al., 2009), preverbal and
communicated unconsciously by H. I became conscious of the distressed feelings that permeated
the analytic third (Ogden, 2004). Heiman (1950) suggested that these conscious counter-
transterence feelings can be explored and interpretations formulated fromthem. My reflections on
my countertransference with H led me to a different conclusion. I realized that her distress, mir-
rored in my countertransference, was beyond words at that stage and that, for the time being, I had
to survive those experiences with her, not talk about them, which I believe would have been an in-
tellectualizing defense on my part.
Although I did not know it at the time, because H did not have the words to communicate it to
me, during this early stage of treatment she was going through a process of becoming conscious of
various differentiated states of her subjective self. This was not a result of interpretation. I have
suggested elsewhere (Grant, 2002) that Hs increasing consciousness of these subjective states of
EMPATHY IN PSYCHOANALYTIC THEORY AND PRACTICE 9
D
o
w
n
l
o
a
d
e
d

b
y

[
M
e
m
o
r
i
a
l

U
n
i
v
e
r
s
i
t
y

o
f

N
e
w
f
o
u
n
d
l
a
n
d
]

a
t

2
3
:
2
3

0
2

A
u
g
u
s
t

2
0
1
4

herself required that they occur in relation to a material object of the senses (the analyst in the ana-
lytic setting). Would any material object of the senses have done? I think not. I think the object
needed to be one who permitted the intense primitive emotions to be present and felt, and did not
block them or flee from them, which would have resulted in intense frustration for H. Her need
was for someone who could survive the inchoate and overwhelming expressions of her distress
without flight and without defensive talking to ward off the distress. Even if I made interpretations
that were correct, H was not functioning at the symbolic level of language and words were just in-
terruptions to her experience, rather than bearers of meaning. Yet she needed the object to be pres-
ent in order to experience the varying subjective states of herself. Much later, she was able to de-
scribe to me how she had wandered in a deadened and starved state of mind between these early
sessions just waiting for the time when she could come back to the next session and have alive ex-
periences of herself again. I did not know this in a verbal and cognitive way at the time it was hap-
pening. My empathic attunement was operating more at the emotional contagion/mirror neuron
level. Without really understanding why, I realized that Hneeded me to be there, saying nothing or
very little, but as an object or other in relation to whom she could express (by moaning, writhing,
grunting, and screaming) subjective self experiences that ordinary relationships could not tolerate
without the other fleeing or trying to calm her, either of which just created high levels of frustra-
tion for her.
Gradually, H became able to give names to these subjective experiences. This developing abil-
ity seemed to me best conceptualized and thought about by making use of Bions (1967) theory to
thinking. The central process in Bions theory of thinking involves the idea of a preconception,
which is an expectant state of mind that can provide coherence to a complex sensory/emotional
experience. It is equivalent to Kants (1781) a priori knowledge. Bion (1962) proposed that if a
preconception meets with a suitable realization in the world of objects, the preconception will pro-
vide the coherence to join the elements of the sensory/emotional realization in a constant conjunc-
tion that Bion called a conception, e.g., the infant has an inherent instinctual expectation of a
source of food and if satisfied all of the sensory and emotional circumstances of the experience of
being fed become structured as a constant conjunction or a conception that we can call the
breast for short (Bion, 1962, p. 34). The conception, being an experience of a constant conjunc-
tion of sensory and emotional impressions is not yet part of language and, therefore, is not in a
form suitable for use in thinking. If, however, a preconception meets with a frustration, as many
preconceptions must, there are a number of possible outcomes. If the preconception of being fed
meets a realization of no breast, and the frustration is not too great, then the experience of no
breast may become a thought of the breasts temporary absence. That is to say, Bion (1967) pro-
posed that thoughts arise fromthe frustration of desire provided it is not too great. The pressure of
thoughts, in turn, stimulates the development of an apparatus for thinking that, in turn, may be able
to modify the frustration to make it more tolerable.
In the experience of therapy, H found a situation that had a sufficiently low level of frustration
for thoughts to form in her mind. She felt alive when in the sessions with me and dead in the out-
side world between sessions. At first, these experiences were not represented in a verbal form but
were more in the nature of sensory/emotional constant conjunctions or what Bion (1967) called
conceptions, but they were sensory/emotional states that Hcould consciously recognize in herself.
The next step for Hwas to be able to name these newconscious subjective experiences in language
to form what Bion has called thoughts or concepts. Once concepts were formed, thinking was
greatly facilitated, along with Hs ability to communicate what she experienced and thought.
10 DONALD GRANT AND EDWIN HARARI
D
o
w
n
l
o
a
d
e
d

b
y

[
M
e
m
o
r
i
a
l

U
n
i
v
e
r
s
i
t
y

o
f

N
e
w
f
o
u
n
d
l
a
n
d
]

a
t

2
3
:
2
3

0
2

A
u
g
u
s
t

2
0
1
4

Gradually, over many months, the writhing and moaning and sobbing lessened and H began to
speak. She found some words to describe her inner experiences. Up to this point, the approach of
empathic attunement recommended by Kohut seemed to have been the most useful. However, as
H progressed, more was needed. The words that she had begun to find were words describing her
states of subjective self consciousness. She felt empty or dead or like a hungry ghost wan-
dering, empty and unsatisfied, between therapy sessions. She described the analytic roomcontain-
ing the analyst as the cocoon. In the cocoon, she became alive. This developing conscious-
ness of her subjective self and language to symbolize it occurred in relation to the therapist and the
setting, as material objects of the senses or realizations, as Bion (1967, p. 111) has called them.
At first, Hhad to be in a psychotherapy session to feel and name these varying states of her subjec-
tive self.
However, becoming conscious of the subjective self is not the same as mastering developmen-
tal tasks or resolving conflicts. Consciousness may emerge with these issues intact and unre-
solved. I think this was the situation with H as consciousness of states of her subjective self
emerged. Hwas becoming conscious of states of her self in relation to the therapist as another, but
the other was a fantastic, highly idealized other.
This state of affairs went on for quite a long time, during which Hwas calmer but I became con-
scious of an increasing feeling of disquiet in my countertransference feelings. Reflecting on this, I
came to realize that Hseemed content to continue the existing situation in which she related to me
as an idealized God-like figure who was the repository of everything good. In contrast, she felt she
contained overwhelming amounts of badness. She felt she could only experience anything good,
even about herself, when she was in the cocoon with me. At this stage, I offered an interpretation
that it was as if she left the good, creative parts of herself with me when she left the session and
could reconnect with them only when she returned to the next session in the cocoon. This, of
course, is what Klein (1946) described as the defenses of splitting, idealization, and projective
identification. This interpretation led into a newphase of treatment in which Hengaged actively in
dialogue with me about her feeling of being full of something bad, which she envisaged as a black
and slimy substance inside of her, about how this badness was dangerous and had to be constantly
punished and controlled, about how she could not keep any good and creative parts inside herself
for fear the badness would destroy them, about howher anorexia was, in part, an attempt to kill the
badness by starving it and about how she had to garage the good creative parts of herself in me to
keep them safe. This latter was associated with the idealizing fantasy that I had only good things
inside me.
These interrelated issues required a great deal of interpretation and discussion. Clearly, we had
moved to a new phase of Hs treatment in which interpretation in the Kleinian framework came to
the fore. That is not to say that empathy was no longer important. Interpretations that adequately
express the patients internal emotional experiences can only be formulated on the basis of em-
pathic attunement in the transferencecountertransference relationship. However, a new element
had been added to the nature of the empathic attunement required. As well as the emotional conta-
gion/mirror neuron level of empathy, a conscious cognitive perspective-taking level of empathy
also began to inform my interpretations. These interpretations arose from my thinking about the
experiences H and I were having, rather than just becoming conscious of them. Thinking, which
Freud described as understanding the relationships between things, can only be done using con-
cepts already created in the mind of the thinker. This inevitably put a restriction on the new ele-
ment in my empathic attunement, viz. that for use in thinking I had available to me only those con-
EMPATHY IN PSYCHOANALYTIC THEORY AND PRACTICE 11
D
o
w
n
l
o
a
d
e
d

b
y

[
M
e
m
o
r
i
a
l

U
n
i
v
e
r
s
i
t
y

o
f

N
e
w
f
o
u
n
d
l
a
n
d
]

a
t

2
3
:
2
3

0
2

A
u
g
u
s
t

2
0
1
4

cepts from the psychoanalytic theories with which I was familiar. Because of the biases of my
psychoanalytic training, my thinking about what was happening with Hin this newphase of treat-
ment made use of many of the concepts of the British school of psychoanalysis, most notably
splitting, projective identification, and idealization (Klein, 1946) and Bions (1967) theory of
thinking. Psychoanalysts with other training and other concepts and theoretical constructs might
have thought differently about these same transferencecountertransference experiences with
equal success.
DISCUSSION AND CONCLUSIONS
Psychoanalysts of different theoretical persuasions have wasted a lot of time fighting each other
about who possesses the truth when, in fact, it is not a question of one psychoanalytic theory being
the truth and others in error, but that the formulation used by the analyst or therapist must be a
close enough representation of the patients psychic truth to be meaningful to the patient. Freud
(19161917) said something very similar to this in 28th introductory lecture, in which he said that
a suggestion made to a patient must tally with what is real in him (p. 452), for it to be taken up as
something useful in the patients mind. Freud was not talking here about historical reality, as
Adolf Grunbaum(1984) claimed in his well-known and influential book, but about the psychic re-
ality in the mind of the patient. More importantly in line with our discussion here, Freud was not
claiming that the analyst can express the psychic reality in the patients mind, but only that the
suggestion must tally or be congruent with it. That is to say, it needs to be a truth not the truth, the
truth being beyond the possibilities of symbolic representation in language.
Bions (1965) formulations of Oand Kmake a similar point. Bion calls the absolute truth of the
internal and external worlds O, and considers it unknowable. However, a limited representation of
O or aspects of O can be achieved, and Bion called these representations K. Many K formulations
can emerge from a single complex O of any patient, but each is only a partial representation of the
total truth of O.
These considerations should make us much more modest and circumspect about our favorite
psychoanalytic theories, which belong to K, not to O. K must be based on empathy of both types
for it to be an adequate representation of O that will tally with it and be useful to the patient in ap-
proaching and thinking about his internal psychic truth.
My approach with H was to include interpretation in the later stages of treatment, but I would
not claim that to be some sort of absolute necessity. It was my K of the situation. Others might
think that empathy alone without interpretation would be sufficient to set in train developmental
processes leading to psychic maturation. My viewthat more than empathy was required was based
on my countertransference disquiet as H seemed to settle into a situation in which she could ga-
rage parts of herself in me for safekeeping and come and experience these parts of herself in the
sessions and just wander like a hungry ghost until the next session. Perhaps I was too impatient,
although this was a very long treatment over many years, and perhaps with further time, empathy
without interpretation might have been sufficient to set in train further maturational processes in
H. My view was that, with empathy alone, she would continue to become conscious of aspects of
herself that were previously unconscious, but it was a pathological experience of herself and her
object (the therapist). The boundary between what was herself and what was the therapist was
very porous to projection and introjection. This led me to adopt a more interpretive approach in the
12 DONALD GRANT AND EDWIN HARARI
D
o
w
n
l
o
a
d
e
d

b
y

[
M
e
m
o
r
i
a
l

U
n
i
v
e
r
s
i
t
y

o
f

N
e
w
f
o
u
n
d
l
a
n
d
]

a
t

2
3
:
2
3

0
2

A
u
g
u
s
t

2
0
1
4

later stages of treatment, based on my empathic awareness of Hs contentedness to remain split
into good and bad parts and to house the good parts in me, where she could experience themas of-
ten as she could get me to see her. I amnot claiming, however, that this formulation is the truth. It is
my K of the situation, not O.
These considerations have led us to a number of conclusions.
Our first, and perhaps most fundamental, conclusion is that, although the word empathy is
rarely used in psychoanalysis, outside of Self Psychology, empathy is necessary for a psychoana-
lytic process to be generated. We only have to remind ourselves of Freuds (1921) definition of
empathy (the mechanismby means of which we are enabled to take up any attitude at all towards
another mental life, p. 110) to grasp how fundamental its various forms are to psychoanalysis. In
viewof this, it is curious that Freud, himself, and most other psychoanalysts have not tried to study
empathy except indirectly under various assumed names. This omission is almost worth a study in
itself.
Our second conclusion is that all empathy is probably not the same. Shamay-Tsoory et al.
(2009) make a compelling case that there are at least two types of empathy. This study was con-
ceived and undertaken by neuroscientists, not psychoanalysts. This does not mean that psychoan-
alysts are justified in ignoring it, especially given our failure to properly study empathy, ourselves.
Sometimes psychoanalysts have been known to eschew any knowledge that does not come from
the analytic process. We would argue against this view and consider that those of us who are psy-
choanalysts have much to learn from the sciences that border and overlap our field of study (the
human mind).
Our third conclusion is that theoretical differences among psychoanalysts are greater than dif-
ferences in their everyday language descriptions of experience-near clinical data. For example, al-
though the elaborations of Kleins and Kohuts theories are very different, it can be seen that at the
basic level of trying to conceptualize a clinical experience, there is an important similarity. Both
conceptualize the subject (the self or the ego) as relating to an object or other who has been dis-
torted by the subject mistaking parts of the self or ego for parts of the object or other. Despite this
agreement, the two theoretical systems have been elaborated in different, seemingly incompatible,
ways. This, in turn, has lead to quite different techniques of therapy. We would argue that these dif-
ferences lie not so much in the attempts to describe and conceptualize the rawclinical experiences,
but in the theoretical assumptions espoused by Klein and Kohut.
Klein (1946) placed instinctual forces at the center of her theory. She theorized that anxiety
arose from the operation of the death instinct and that the fear of annihilation (death) immediately
attached itself to an object, albeit a phantastic one (the bad breast). She (Klein, 1946) proposed
that primitive defenses of splitting, projective identification, and idealization were then mobilized
against the feared object. We would argue that it is this theoretical position, rather than the raw
clinical experiences, that led Klein to recommend interpretation that should be both early and
deep.
Kohut (1966), on the other hand, placed the idea of a narcissistic developmental line at the cen-
ter of his theory. He theorized that symptoms arose from failures in it, with the development of
selfobjects, in which parts of the self were experienced as parts of the object. One cannot help but
notice how similar this is to Kleins concept of projective identification. He then theorized that
failures in this developmental line were caused by environmental failures, rather than instinctual
forces or conflicts. Kohut (1966) sawthe normal development of the narcissistic line as requiring a
caregiver who was empathically attuned to the developing infant and child to provide mirroring
EMPATHY IN PSYCHOANALYTIC THEORY AND PRACTICE 13
D
o
w
n
l
o
a
d
e
d

b
y

[
M
e
m
o
r
i
a
l

U
n
i
v
e
r
s
i
t
y

o
f

N
e
w
f
o
u
n
d
l
a
n
d
]

a
t

2
3
:
2
3

0
2

A
u
g
u
s
t

2
0
1
4

and an idealized imago, in order to meet the needs of the childs primary narcissismand its two de-
rivatives, the narcissistic self, and the idealized parent imago. We would argue that it was this theo-
retical position, rather than the raw clinical experiences, that lead Kohut to recommend that
empathically attuned mirroring and acceptance of idealization should be the basis of therapy, the
aim of which was to provide the correct environmental experiences to re-activate the normal pro-
cesses of the developmental lines.
Since in our view, it is their theoretical elaborations, not the raw clinical data, that have given
rise to the different treatment approaches of the Kleinian and Kohutian (and other) schools, we be-
lieve it is always necessary to return to the rawclinical experience and choose whichever theoreti-
cal framework seems most useful for that patient, but not to elevate any psychoanalytic theory to
the status of the truth. This means that psychoanalysts should have a good understanding of all of
the major theoretical frameworks within psychoanalysis so that the most useful way of thinking
about a particular clinical experience can be selected. Freud (1900) himself described theory as
nothing more than useful scaffolding for the exploration of clinical material. To treat it as anything
more is a mistake. There can be no hard and fast rules about which theoretical framework is to be
used. It is a matter of having a good knowledge of all major theories within psychoanalysis and of
clinical experience, empathy and judgment, in selecting which psychoanalytic theory provides the
best representation of a particular clinical experience. It is paradoxical that this demotion of theory
actually requires a broader and deeper understanding of psychoanalytic theories to become aware
of their usefulness and their limitations.
Some might argue that it is impossible to chop and change around in different theoretical
frameworks such as those of Klein and Kohut for example. However, the work of Donald
Winnicott suggests that it might be surprisingly easy to think coherently about a patient using both
Kleins ideas about instinct and primitive defenses and Kohuts ideas about empathy and environ-
mental failure. I think the work with H described earlier illustrates this.
Our fourth conclusion is that all psychoanalysts need to constantly remind themselves that their
theories are only intellectual scaffolding to explore and investigate the phenomena of the psycho-
analytic encounter and are not the phenomena themselves. This statement is hardly new or origi-
nal on our part. As we have pointed out, Freud (1900) said exactly that in his first great psychoana-
lytic work, The Interpretation of Dreams. Nevertheless, many psychoanalysts seemto fall into the
error of mistaking their theories for observed facts. Clearly, more modesty about what we knowor
what we think we know would be more becoming and actually more useful in our attempts to ap-
proach and symbolically represent a portion (Bions K) of the psychic reality (Bions O) of our pa-
tients minds.
Our fifth and final conclusion, of which we hope to have convinced the reader by now, is that no
one and no specific psychoanalytic group have exclusive access to the truth. All of the major theo-
retical streams in psychoanalysis probably contain some truth, or it is unlikely that they would
have survived. As Freud (19161917) said in his 28th introductory lecture, suggestions put to the
patient by the psychoanalyst must tally with what is real in him, i.e., must tally with his psychic re-
ality, and if there is no truth in the suggestion and it is not congruent with the patients psychic real-
ity it will fade away. So it is, too, with the psychoanalytic theories used to formulate the
suggestions.
Most of us are too attached to our favorite psychoanalytic theories and too intent on denigrating
others. The failure to properly recognize and study the fundamental processes of empathy is only
one example of harm done when different schools of psychoanalysis do not engage in civilized
14 DONALD GRANT AND EDWIN HARARI
D
o
w
n
l
o
a
d
e
d

b
y

[
M
e
m
o
r
i
a
l

U
n
i
v
e
r
s
i
t
y

o
f

N
e
w
f
o
u
n
d
l
a
n
d
]

a
t

2
3
:
2
3

0
2

A
u
g
u
s
t

2
0
1
4

scientific discourse and attack each other instead. We would argue that an excessive attachment to
the theories we have been taught has been a pervasive inhibiting force in the progress of psycho-
analysis towards becoming a truly rational and evidence based body of knowledge articulated
with related bodies of knowledge. Each of us needs to loosen our mental grip on our particular pet
theories and reeducate ourselves to have a better understanding of all the major thinkers in psycho-
analysis. This will be no small or easy task.
REFERENCES
Adolphs, H., D. Damasio, D. Tranel, G. Cooper, &A. Damasio. (2000), Arole for somatosensory cortices in the visual rec-
ognition of emotion as revealed by 3-D lesion mapping. J. Neuroscience, 20:26832690.
Bion, W. (1962), Learning From Experience. London: H. Karnac, 1991.
. (1965), Transformations. New York: Jason Aronson, 1983.
. (1967), Second Thoughts. London: H. Karnac, 1984.
Blair, R. (2003), Facial expressions, their communicatory functions and neuro-cognitive substrates. Philosophical Trans-
actions of the Royal Society of London, Series B: Biological Sciences, 358:561572.
Calder, A., J. Keane, F. Manes, N. Antoun, & A. Young. (2000), Impaired recognition and experience of disgust following
brain injury. Nature Neuroscience, 3:10771078.
Cochin, S., C. Barthelemy, B. Lejeune, S. Roux, &J. Martineau. (1998), Perception of motion and qEEGactivity in human
adults. Electroenc. Clin. Neurophysiol., 107:287295.
di Pellegrino, G., L. Fadiga, L. Fogassi, V. Gallese, & G. Rizzolatti. (1992), Understanding motor events: A
neurophysiological study. Experimental Brain Research, 91:176180.
Fadiga, L., Fogassi, L., Pavesi, G. &Rizzolatti, G. (1995), Motor facilitation during action observation: Amagnetic stimu-
lation study. J. Neurophysiol., 73:26082611.
Freud, A. (1965), Normality and Pathology in Childhood. London: Hogarth Press, 1980.
Freud, S. (1900), The interpretation of dreams. Standard Edition, 4 & 5. London: Hogarth Press, 1953.
. (1912a), The dynamics of transference. Standard Edition, 12. London: Hogarth Press, 1958.
. (1912b), Recommendations to physicians practicing psycho-analysis. Standard Edition, 12. London:
Hogarth Press, 1958.
. (19161917), Analytic therapy. In Introductory lectures on psychoanalysis. Standard Edition, 16. London:
Hogarth Press, 1963.
. (1921), Group psychology and the analysis of the Ego. Standard Edition, 18. London: Hogarth Press, 1955.
Gabbard, G. (1995), Countertransference: The emerging common ground. Internat. J. Psycho-anal., 76:475485.
Gallese, V. (2001), The shared manifold hypothesis: Frommirror neurons to empathy. J. Consciousness Studies, 8:3350.
, L. Fogassi, L. Fadiga, &G. Rizzolatti. (2001), Action representation and the inferior parietal lobule. In Com-
mon Mechanisms in Perception and Action Attention and Performance XIX, eds. W. Prinz & B. Hommel. Oxford: Ox-
ford University Press, pp. 247266.
Grant, D. (2002), Becoming conscious and schizophrenia. Neuro-psychoanalysis, 4:195203.
Grunbaum, A. (1984), The foundations of psychoanalysis: A philosophical critique. Berkeley, CA: University of Califor-
nia Press.
Hari, R., N. Forss, S. Avikainen, S. Kirveskari, S. Salenius, & G. Rizzolatti. (1998), Activation of human primary motor
cortex during action observation: A neuromagnetic study. Proc. Natl. Acad. Sci. USA, 94:1506115065.
Heiman, P. (1950), On counter-transference. Internat. J. Psycho-Anal. 31:8184.
Hutchison, W., K. Davis, A. Lozano, R. Tasker, &J. Dostrovxky. (1999), Pain related neurons in the human cingulated cor-
tex. Nature Neuroscience, 2:403405.
Kandel, E. (1998), A new intellectual framework for psychiatry. Amer. J. Psychiat. 155:457469.
Kant, E. (1781), Critique of Pure Reason, trans. N. Smith. London: MacMillan, 1929.
Klein, M. (1946), Notes on some schizoid mechanisms. In Envy and Gratitude and Other Works. New York: Delta, 1977,
pp. 124.
. (1955a), On identification. In Envy and Gratitude and Other Works. NewYork: Delta, 1977, pp. 141175.
EMPATHY IN PSYCHOANALYTIC THEORY AND PRACTICE 15
D
o
w
n
l
o
a
d
e
d

b
y

[
M
e
m
o
r
i
a
l

U
n
i
v
e
r
s
i
t
y

o
f

N
e
w
f
o
u
n
d
l
a
n
d
]

a
t

2
3
:
2
3

0
2

A
u
g
u
s
t

2
0
1
4

. (1955a), The psycho-analytic play technique: Its history and significance. In Envy and Gratitude and Other
Works. New York: Delta, 1977, pp. 122140.
. (1959), Our adult world and its roots in infancy. In Envy and Gratitude and Other Works. New York: Delta,
1977, pp. 247263.
. (1961), Narrative of a Child Analysis. London: Hogarth Press, 1975.
Kohut, H. (1959), Introspection, empathy and psychoanalysisAn examination of the relationship between mode of ob-
servation and theory. J. Amer. Psychoanal., 7:459483.
. (1966), Forms and transformations of narcissism. J. Amer. Psychoanal., 14: 243272.
Loewald, H. (1986), Transferencecountertransference. J. Amer. Psychoanal., 34:275287.
McDougall, J. (1978), Primitive communication and the use of countertransference. Contemp. Psychoanal., 14:173209.
Ogden, T. (2004), The analytic third: Implications for psychoanalytic theory and technique. Psychoanal. Quart.,
73:167195.
Shamay-Tsoory, S., J. Aharon-Peretz, & D. Perry. (2009), Two systems for empathy: A double dissociation between emo-
tional and cognitive empathy in inferior frontal gyrus versus ventromedial prefrontal lesions. Brain, 132: 617627.
Siegel, D. (2001), Toward an interpersonal neurobiology of the developing mind: Attachment relationships, mindsight,
and neural integration. Infant Mental Health J., 22(12): 6794.
Wallerstein, R. (1988), One psychoanalysis or many. Internat. J. Psycho-Anal., 69:521.
Winnicott, D. (1956), Primary maternal preoccupation. In Through Pediatrics to Psycho-Analysis. London: Hogarth Press,
1975, pp. 300305.
. (1962), Apersonal viewof the Kleinian contribution. In The Maturational Processes and the Facilitating En-
vironment. London: Hogarth Press, 1979, pp. 171178.
1021 Malvern Rd. Toorak
Victoria, Australia 3142
dcgrant@ausdoctors.ne
16 DONALD GRANT AND EDWIN HARARI
D
o
w
n
l
o
a
d
e
d

b
y

[
M
e
m
o
r
i
a
l

U
n
i
v
e
r
s
i
t
y

o
f

N
e
w
f
o
u
n
d
l
a
n
d
]

a
t

2
3
:
2
3

0
2

A
u
g
u
s
t

2
0
1
4