To trust, or remain vigilant. Is that the question!?

Beginning and indeed enduring the process of writing is not something I relish however determined I might be to develop an understanding for this psychoanalytic endeavour. In scrutinising it’s theory, I have no doubt that I am also seeking self-understanding for that which underpins this striving, otherwise why would I bother?!

Also, I am unsure as to whom I might be conversing with here? A prospective client; a fellow professional or a layperson? Either way I suppose, the purpose of writing something is to attempt to clarify my thoughts and not necessarily convince anyone else of such musings. Only, to hope that my thoughts are heard and in such a way that someone else may attempt to understand them.

Perhaps the conflict of wanting to be understood but not disclose reflects how, in a single session or over the course of a piece of therapeutic work, a patient may on the one hand want to be speak and at the very same time, not.

Ambivalence in psychotherapy has been extensively analysed and described, so this is not the goal of what I’m about to consider. Psychoanalytic psychotherapy intends in part and pogniantly to remain focused on a goal, and precisely. The contents of the ‘here and now’ within an intimate analytic hour, is the work. Within this, one is open to experiencing a greater understanding for the patient’s emotional world. Occasionally however, when there arises ambivalence towards the therapeutic endeavour, uncertainty can relate more to the (external) social and cultural context of the time, than some therapists might give credit.

To explain this idea further I’d like to propose that although the initial broad task in psychotherapy is to develop trust between the parties - to form a therapeutic alliance that is - establishing this relational platform is not always possible or indeed maintainable. On reflection, knowledge born of the encounter is recognised, discussed and utilised, and varies widely (but not always of course). Obtaining useful knowledge is also dependant on the broad vigilance of the patient and perhaps that of the therapist. Indeed why should an infant trust a parent, when he can see that the parent is simply not to be trusted?

Trust, whether engendered or presumed from professional standing, that is to say assumed agentic or endorsed by another trusted source, can nevertheless become disturbed. Especially if, the therapist fails to recognise that his own vigilance is a necessary component for trust to develop.

With this in mind I want to consider the paper by Peter Fonagy noted in the footer, who we might regard as the UK’s most eminent and “scientific” psychoanalyst. I want to state from outset that most if not all clinical references should be credited to the author and his sources, and not to myself. I intend to step (perhaps clumsily) through this significant text, highlighting points and passages that stand out to me, while making comments and holding the title of this blog piece in mind.

In his paper Fonagy explores the transmission of cultural knowledge within the confines of the psychoanalytic frame. He describes in detail, the conditions necessary for cultural knowledge to be passed on and highlights where he believes mental disorder interrupts this process.

An initial point raised is that of coherence and of therapist’s being perceived as cultural agents of trust. Without the assumption that one’s therapist offers a coherent perspective on the world, one might immediately reject their standing. Further he suggests - calling on Freud - that this assumption whether in phantasy or through disclosure is as necessary as an ‘unbroken mirror’, for which the patient might project his or her concerns, hoping to receive adequate reciprocal dotage.

He describes with concern (in a vignette) the distinct lack of object consistency from a disturbed suicidal patient. Where fragmentation and confusion around external factors unsettled his thinking. He reflects that from within the patient’s despair, was concern that both analyst and patient might be pulled “into this black hole”. A passage, whilst highlighting the incongruent nature of the work with disturbed patients, also passes a nod to the analyst’s openness to rest outside of normal awareness thus activating the patients recognition of his mind (indeed parts he might be unaware of) being present in his analyst.

He notes how the analyst is able to distance himself from transference interpretations - recognising the essence of the disturbance - and thus placing himself alongside his patient in a process of understanding, something which might impact them both equally.

He then goes on to highlight the importance of consciousness about the world, in our capacity to receive and transmit cultural information. He proposes that consciousness is socially created, suggesting that early caregiver relationships are therefore crucial and open the door to the psychosocial and what Bion termed a “groupishness” in the psyche - culture being present in all of us.

He notes Winnicott offers similar ideas and reflects on the historic psychoanalytic focus of rather “illness or absence of illness but consideration for the impact of the water we all swim in”. In covering the familiar Winnicottian notions he also makes the point that within a trusting environment the subject begins to notice and tolerate the subjectivity of the object (the Mother, etc).

He goes on to point out that due to the inherent helplessness of humans we require more than just the safety of the caregiver, but an coherent indication that the world beyond this dyadic experience is assured. This I reflected, begins to draw on a notion of cultural world views beyond the treatment space.

The development of epistemic trust - that is to say the ‘trusting bonds’ that are tested in the teaching and acquisition of knowledge - is usually a smooth process. However some patients do present in a state of hyper-vigilence, much like the patient highlighted above. Fonagy explains the biological and anthropological distinction in how epistemic trust is deployed. For the sake of brevity let’s assume we understand that humans are distinct from most other mammals in our ability to pass on knowledge about our culture from person to person, from generation to generation, as long as epistemic trust is possible.

He argues that in a darwinian sense knowledge is passed on developmentally, where better ideas survive. He reasserts the necessity that underpins culture, is the transmission of knowledge and thus the presence of epistemic trust. He goes on to review dual inheritance theory where human evolution more broadly is explained by biological and cultural phenomena. I reflected however that in the context of historical events and indeed within social cultural norms and the psychoanalytic tradition, repetition (compulsion) appears to be the name of game?

He goes on to highlight selection pressure toward complexity, born of our ability to transmit cultural knowledge and thus perhaps our capacity to embrace technology, advancing the limits of our biology.

He restates how mentalizing - that is to say demonstrating an accurate description of the others state of mind - is foundational to the production of epistemic trust. In contrast he notes that epistemic vigilance is essential to avoid being misled. He writes,

“we are more likely to survive and thrive if we do not forget that not everyone will teach us things that are true or indeed in our interest to learn”.

In this regard we might assume that all psychotherapists have no intention of misleading patients however, what happens when psychotherapist’s themselves, have been or are being misled? What happens when their trust or viglience about the world around them is in conflict with that of their client?

Ostensive signals or cues are learnt in early childhood. Cues such as joint attentional focus on shared goals and receiving a response where your attention to something is recognised. Also, being treated as an individual.

Trust for ostensive cues creates a sense of having someone alongside you, sharing in your experience. All of which we can imagine as being vital ingredients to the therapeutic endeavour and the expectations of a learning environment where one is safe to expose ones mind to new knowledge.

The watering of time establishes and fosters growth of this environment. However when this situation is misaligned, as the vigilance of both parties is undermined by social or group division, how do we cope?

To put it more simply, as Fonagy suggests, if one feels understood by the teacher, one will be disposed to learn from the teacher. This will include learning about oneself and about the world outside. However if the teacher is unable to understand the experience of the learners vigilant perspective, due to the activation of their own viligence towards the learners perspective on the outside world, how can the teacher be trusted? This might otherwise be named as the cognitive dissonance in the teacher.

As a cure to this impasse Fonagy suggests a term coined by Daniel Stern et al (1998), a “moment of meeting”. This is where both patient and analyst are reunited in common experience, such as an outside disturbance to the session - and where agreement and experience of feeling are shared toward this external event.

He also suggests the importance of discovering unconscious understanding, rather than conscious. That is to say recognising the emotionally positioned vigilance of both parties rather than focusing on any ordinary conscious experience. The vigilance required to react to the disturbance in the session and/or the news that their views on the social world are significantly divergent.

The paper suggests that psychoanalytic work is concerned with truth and the desires of the patient, rather than finding cures and an “alleviating of symptoms”. In this endeavour it comments that psychoanalysis, within the frame of the transference one might consider the patient as child and analyst as super ego in phantasy. A parental figure.

However, it doesn’t necessarily follow that emotional education of the patient is what the patient actually needs, especially when society imposes itself such that this super-ego arrangement is overwhelmed by what one might term an “ultra ego”.

By imagining the patients reality, the analyst creates a potential space for that experience in the patients mind, in the form of a mirroring process.

However what occurs when societal trauma such as lockdowns and wars instil hyper-vigilance in the patient, but not the therapist. How can the truth of things be understood? Indeed the paper recognises the impact of hostile environments on patients whose trust networks have been repaired through therapy, especially when the therapist dosen’t acknowledge the true nature of the environment that both may be confronted by. It highlights the Winnocotian notion that therapy is a process of mirroring. A reinstatement or replacing of the mother (caregiver) / infant experience. He reflects on Winnicott’s statement that “I think the most important thing, is that you easily feel that your baby is worth getting to know as a person”.

This last statement I feel conceptualises one of my concerns with psychotherapeutic work. We might discern that due to a developmental problem our patients’ arrive hypervigalent and are unable to trust the therapeutic endeavour or indeed any relationship with another person.

However, this doesn’t mean that their pervasive hyper vigilance in turn doesn't hold a significant advantage when their current environment is hostile. We may feel uncomfortable reinforcing such concrete thinking by appreciating their circumstances, however does this mean we are defending against this vigilance as a signal for our own benefit and that of the work. Moments of meeting aren’t just benign and broadly digestible enough for us to expedite epistemic trust in our work. Perhaps they also highlight adversity and how we cope with it - how we interogate it. Sometimes our clients are hyper-vigilent because it serves them to be, especially when the world outside is deceptive and seeks to mislead. Perhaps in this instance vigilance becomes a resource, a striving and not a defence against knowledge, but a sensible strategy in seeking the truth.

1 Peter Fonagy & Elizabeth Allison (2023) Beyond Mentalizing: Epistemic

Trust and the Transmission of Culture, The Psychoanalytic Quarterly, 92:4, 599-640, DOI:

10.1080/00332828.2023.2290023

To link to this article: https://doi.org/10.1080/00332828.2023.2290023