Suffering, Relatedness and Transformation: Levinas and Relational Psychodynamic Theory

Abstract

Using the work of 20^th century French philosopher Emmanuel Levinas, the following article examines the theoretical basis for the clinical concepts of empathy, attunement, and responsiveness. It demonstrates that Levinas provides a crucial path for understanding human relatedness, a concept indispensible for social work practitioners. Examining relational psychodynamic literature, the author explores ways of viewing psychopathology, modes of psychosocial intervention, and opportunities for transformative results in psychotherapy, as informed by Levinasian concepts. The paper argues that by developing a basic understanding of Levinasian ethics, social work practitioners can gain a better understanding of pain and suffering, and of the transformative power of the therapeutic relationship.

In his writing on ethics, 20^th century French philosopher Emmanuel Levinas offers a theoretical backdrop against which to understand important concepts of relational life, ethical responsiveness, and the complexities of human uniqueness. By asking us to accept that every human is at the same time infinitely unique and hopelessly finite, Levinas presents a theory of ethical responsiveness that rests on both the profound connectedness of human life and the extreme vulnerability that permeates encounters with other human beings. Levinas’ ideas should, therefore, be seen as indispensible for any practitioner of social work, not only those whose clinical work is informed by psychodynamic theory.

Levinasian ethics provide crucial dimension from which to understand how psychotherapy can create a new experience for the client. By re-thinking the nature of suffering, clinicians can begin to see the possibilities for change inherent in the therapeutic relationship. To think that vulnerability and suffering could open the possibility of change seems counter-intuitive. Yet, examining relational psychodynamic theory from a Levinasian perspective makes it clear that these seemingly negative concepts can be transformative. When human relational growth becomes stunted, practitioners can look to Levinas to help clients find real hope for change in the transformative power of the encounter with the other.

Echoing Levinas’ conception of suffering as possibly transformative, Froma Walsh (2009, 42) alerts us to an important “paradox of resilience” in social work practice, namely, that, “the worst of times can also bring out our best. A crisis can lead to transformation and growth in unforeseen directions… In the midst of suffering, as we search more deeply within ourselves and reach out to others, the hardship endured opens ways for the spirit to grow.”

In the following pages, I will provide points of entry into Levinasian concepts to help social work practitioners conceptualize their everyday work. It is not my intention to develop a comprehensive Levinasian psychoanalytic theory, nor to elucidate the entirety of Levinas’ work.[1] To facilitate my investigation, I draw heavily on Borden’s (2009) work, as it provides an accessible, broad presentation of psychodynamic theory. For the purposes of the present article, I reference Borden’s elaborations of relational psychodynamic theories to provide the reader with clear, informed material. I begin with a general investigation of Levinasian concepts of human connection and uniqueness. From there, I explore conceptions of psychopathology and modes of psychosocial intervention. As a final examination, I investigate what transformative therapeutic results look like from a Levinasian perspective.

Understanding Human Relatedness

Levinas’ writing focuses on what he calls the “face-to-face encounter with the other,” an experience in which an individual is made aware of the other’s mortality and vulnerability, and is thus called upon to respond ethically to the other’s cries for help. When the other is seen in the vulnerability of the face-to-face encounter, it is “prior to any knowledge about death” (Levinas 1984, 130). The issue of mortality arises in the encounter because the individual recognizes the other’s imminent death, while at the same time the individual is made responsible for this death. Since the other person cannot see his or her own death, this recognition, writes Levinas, actually “calls me into question, as if, by my possible future indifference, I had become the accomplice of the death to which the other, who cannot see it, is exposed” (131). The knowledge of our shared mortality as human beings is one of the underlying sources of empathy.

Though Levinasian responsibility places a great deal of pressure on the individual to respond, this response calls on our sense of empathy and compassion. George Kunz (2007, 622) elaborates the connection to affective responses in his reading of Levinas, noting that, “the weakness of Others shames our self-indulgence and inspires us to be compassionate, to suffer others for the sake of their good” (emphasis in original). Guilt in the Levinasian conception leads not to pathology, but to compassionate, empathic responses to the other.

In the “extreme exposure” of the face-to-face encounter, the individual is called on to feel empathy for the other’s inevitable death, and thus ethical considerations demand that the individual responds in some way to the other person (Levinas 1983). By making the encounter with the other person a moment of profound human connection, Levinas provides a theoretical approach to explain one of the central tenets of relational psychodynamic thought: namely, that the focus of understanding is “not the individual but the interactive fields in which we work to establish connection, preserve ties, and differentiate ourselves” (Borden 2009, 150). For both Levinas and relational psychodynamic thinkers, it does not make sense to talk about a completely individual self, out of relation to others. The self is only conceivable as a self in relation to and distinguished by its proximity to others.

The Levinasian encounter describes the first establishment of such ties and the quality of such deep connections. For Levinas, human existence cannot occur without such a moment, for it is in the “inter-human” that the individual realizes the “impossibility of abandoning the other to his aloneness” (Levinas 1983, 146).  Levinas characterizes the inter-human world by the possibility of human compassion, but also by the terrifying claims the other makes on me and from which I cannot turn away. Responsibility springs forth from the demands made in this inter-human realm, and in the Levinasian conception, responsibility is not a choice, but rather a demand that binds me to the other. This “obligation [to the other] is prior to any reasoned construction of a principle of obligation” (Williams 2007, 691). That is to say, the encounter inspires affective responses of guilt and eventual compassionate responsiveness, not a cognitive decision-making process regarding whether the individual “ought” to respond.

Levinas’ conception of the inter-human will remind many of psychodynamics as described by Ian Suttie. Suttie, an underappreciated psychodynamic thinker and early relational theorist, regards the expression of psychic energies “not as an outpouring for its own sake, but as an overture demanding response from others,” and notes that “it is the absence of this response… that is the source of all anxiety and rage whose expression is thus wholly purposive” (Suttie 1935, 29-35, as cited in Borden 2009, 59). As in Levinas’ inter-human, Suttie describes a situation in which the expression of energy demands response from the individual.  In this passage, Suttie is directly refuting the Freudian notion of drive psychology, and proposing instead that the individual’s actions are always intricately and profoundly linked to others. For Levinas, the additional profundity of life arises due to the other’s impenetrable otherness.

Levinas details the ways in which the other’s “uncanniness” demands respect just as the other’s cries for help demand response. In the face-to-face encounter, the beauty of the other’s uniqueness must be combined with the realization that the other is completely and even frighteningly different from me. While this moment is a frightening encounter with complete alterity, it also provides the foundation for recognizing every individual is a unique expression of being. For Levinas, comparing two people to one another is looking at “what is in principle incomparable, for every being is unique; every other is unique” (Levinas 1982a, 104). Every other is unique, and yet the encounter also allows for the recognition of the pure finitude (mortality) and inherent connectedness that is at the heart of human experience.

Levinas asks us to hold these two pieces of human life (human finitude and infinite uniqueness) together at the same time. But the question for psychodynamic therapy is this: how are we to accept the multitude of responsibility for the other’s painfully finite life while also respecting the other’s infinite uniqueness as a being? Put another way, how are we to engage in an encounter with a completely unique and “un-me” being, while also beginning to feel empathy and respond to that being? In many ways, relational theory tries to answer just these questions. The goal is often to help clients develop socially and ethically responsible ways of being in the world that also respect the individuality of others and do not impinge on the client’s own sense of selfhood. Holding all of these pieces of the puzzle of human experience together demands insightful theoretical understanding of problems in living and interventions that rest on the crucial elements of attunement, empathy, and responsiveness.

Conceptions of Psychopathology or Problems in Living

Using a Levinasian perspective of human experience as a general framework can help illuminate different problems in living. Some psychodynamic thinkers, for example, have traced problems in living to the client’s inability to feel the crucial sense of responsibility for other people that is necessary in Levinasian ethics (Marcus 2007; Kunz 2007; Fryer 2007). For Paul Marcus (2007, 520) “Many problems in living and, in the extreme, psychopathology, emanate from the selfish self undermining, if not usurping, the ethical self. The needs and aspirations of the selfish self, the ego, have priority over the life-affirming needs of the other.” I argue that, for many clients, there is an inability to be open to simply engaging in meaningful encounters with other people, let alone feeling responsibility for these others. Indeed, many clients come to social work practitioners in the position of the suffering other. The others in the client’s own life have failed to respond to her pain, and as a result, the client has learned to expect a lack of responsiveness from the people in her surroundings.  Keeping these failings in mind, it should not be surprising to find that clients lack a sense of selfless responsibility for others.

Relational thinkers postulate that failings in responsiveness early in life are the main sources of subsequent problems in living. Winnicott, for example, discusses the “failings of the facilitating environment” and “absence of good enough care” as producing problems negotiating tasks necessary to healthy development. Kohut, likewise, “traces structural deficits in the organization of the self to earlier lapses and failings in care that compromise capacities to regulate emotion, integrate experience, and engage in relational life” (Borden 2009, 97, 154). The word engage is crucial to Borden’s formulation here. The suffering other suffers because she is not able to engage in the world with other people. Her cries for help have been unanswered, and as a result, she may become trapped in patterns that guard against intense exposure to the other.

Although responsiveness to the other is a core concept in Levinas’ writing, one interesting piece of the Levinasian conception (which is counter to psychodynamic thinkers like Suttie), is that this demand is completely asymmetrical. In Levinas’ inter-human realm, there is no reciprocity when the face of the other calls out, because “all men are responsible for one another, and ‘I more than anyone else’” (Levinas 1982a, 107).[2] Levinas thereby places an emphasis on the fact that, although I can see the other calling out to me for help, there should never be a call from me. I should never expect the other to feel ethically responsible for me, even though I feel the pressure of this responsibility. The asymmetry of the encounter makes it difficult to understand, especially because oftentimes in normal interactions we want to know we are cared about, just as we care for others.

For social work practitioners, the asymmetrical relationship is not unfamiliar. Clients enter the room asking for help; clinicians are not supposed to be asking the client for anything in return for the help they provide. The problems with Levinas’ asymmetry arise when it is applied to the client’s own problems. When we bring Levinas into dialogue with psychodynamic thinkers, the problems with a formulation driven not by reciprocity but by asymmetry are numerous. The question becomes: what happens when my calls to the other are not met with the responsiveness that is somehow demanded of me by every other in my surroundings? Or, as applied to the therapeutic setting: how can practitioners ask clients to assume complete responsibility for the other without expecting the other to meet any of the client’s own needs?

The asymmetry of the Levinasian encounter reveals some similarity to Melanie Klein’s psychoanalytic theory, especially in her discussion of the depressive position of childhood development. During the depressive position, the child begins to realize the object (the parent) which the child previously conceived as either good or bad, now actually has both characteristics. The child begins to feel depressive guilt and anxiety for possibly harming the good object and makes reparations. Klein writes of a “profound urge to make sacrifices” during this phase, an urge which has an interesting link to the Levinasian urge to respond to the other (Klein and Riviere 1964, 65; as cited in Borden 2009, 70).

Similar to the Kleinian notion of responsibility that the child feels for having felt aggression towards the good object, Levinas (1982b, 94) writes of the “just suffering in me for the unjustifiable suffering of the other.”  There is an urge in the individual to find a justification for his or her own suffering, while the other’s suffering is always seen as useless and unjustifiable. For both Klein and Levinas, the beginning of responsible relational life lies in the realization that the other’s suffering is unforgiveable, so much so that I must take responsibility for this suffering into myself.[3]

After becoming accustomed to certain patterns of relating to others, it may be difficult if not impossible for the individual to relax these structures enough to truly experience the other in all her uncanniness. Similarly, the concept of vicious circles, as elaborated by Karen Horney (1942) and Paul Wachtel (1993), explains how an individual can become trapped in a particular maladaptive pattern of relating, one that does not allow that individual to truly experience others in a meaningful way. Wachtel (1993, 19) calls on the therapist to pay attention to “how unconscious psychological structures and the patterns of daily life reciprocally interact with and maintain each other.” When clients become “stuck” in patterns of living that do not allow for deep human connection, the clinician must turn to the tools of psychosocial intervention.

Modes of Psychosocial Intervention

Intervention in relational psychotherapy is aimed at helping clients develop more adaptive ways of relating and being in the world with others, while also providing the empathy and responsiveness that may have been missing in the client’s early life. If psychopathology stems from failings in responsiveness, then the goal of psychotherapy will often be to provide the needed responsiveness for the client to develop new ways of relating where growth was previously stunted. In many cases, psychotherapy is a process which transforms vulnerability and anxiety into a new experience of selfhood and relational life.

As such, the Levinasian conception of accepting extreme vulnerability – found within the face-to-face encounter – in order to experience a more meaningful element of ethical life provides a theoretical place from which to understand how psychotherapy can create a new experience for the client. The concepts of attunement, empathy, and responsiveness provide the tools clinicians can use to help the client accept a degree of frightening vulnerability in order to develop more meaningful ways of relating to others.

Attunement. The beginning phase of relational psychotherapy and social work practice in general, calls for tuning in with the client and being “where the client is.” In addition, the clinician must establish a holding environment which “helps to stabilize clients, enables them to feel safe, assists them in containing and verbalizing their feelings, mobilizes their motivation, and facilitates their cooperation with and trust of the worker” (Goldstein 2001, 155). Attunement means more than simply listening to the client’s story, it means being willing to engage in a meaningful face-to-face encounter with human uniqueness. Client as well as clinician must be willing to accept the vulnerability of the ensuing relationship if growth and change are to occur.

The concept of countertransference helps with this initial acceptance on the part of the clinician. Just as the client hopes to achieve real change in the relationship with the clinician, the therapist must accept the reality that the relationship will be an encounter with vulnerability and human uniqueness, and a new experience of relational life. Although clients’ presenting problems may be similar in content, true attunement rests on respecting the client as an infinitely unique expression of being.

In his essay on Levinas and Winnicott, C. Fred Alford (2007, 534) defines attunement as “the sense one has of being in emotional contact with a separate human being,” and goes on to argue that, “[t]here is no attunement in Levinas.” In this construction, Alford reduces the Levinasian conception of relatedness in a way that does not allow for the eventual transformative power of the encounter with the other. By conceptualizing the Levinasian sense of human connection as “attunement of the hostage,” Alford fails to note that the tension between feeling profoundly connected to the other, while also recognizing that the other is completely unique, does not exclude the possibility of true attunement.

In the therapeutic relationship, this tension is exemplified in Patrick Casement’s (1991) explanation of a key position required by all therapists. Helping the client develop a new relational world depends on therapists’ own ability to “learn to be open to the ‘otherness’ of the other—being ready to feel whatever feelings result from being in touch with another person, however different that person is from themselves” (Casement 1991, 82). True attunement requires not only connection, but also an ability to be comfortable with a level of uncertainty regarding the client’s experience of the world. Providing an environment which facilitates growth and development does not mean becoming hostage to the other, but rather opening a space in which both the tragedy of human finitude and the infinite uniqueness of human life can be held at the same time.[4]

Empathy. A core concept for Heinz Kohut, empathy means affirming “the validity of the individual’s experience” and developing theoretical formulations that are “experience-near,” or “generated by empathic processing of the individual’s experiential world” rather than “based on external frames of reference” (Borden 2009, 142, 136). Empathy means looking into the face of the other and “seeing beyond the plastic forms which do not cease covering it like a mask with their presence in perception.” The encounter in which the clinician can feel empathy for the other’s suffering “incessantly penetrates these forms” (Levinas 1983, 144). Moving beyond the purely social world of expected roles and into a place where the clinician can validate the individual’s experiential world is an important step in the therapeutic process.

Rather than feeling everything the client feels, Kunz (2007, 635) reminds us that, “The patient does not ask the psychotherapist to suffer his suffering. The psychotherapist suffers empathy; she suffers because the patient suffers and because she cannot suffer the patient’s suffering.” When the client’s suffering presents itself in the face-to-face encounter, empathy offers an entry into the client’s world. The therapist must be willing not only to be present with the client, but to enter into the suffering that makes empathy possible.

Responsiveness. Levinas (1982b) explicates the concept of calling for or demanding response from the other in an essay entitled “Useless Suffering.” There, he writes:

Is not the evil of suffering—extreme passivity, helplessness, abandonment and solitude—also the unassumable, whence the possibility of a half opening, and, more precisely, the half opening that a moan, a cry, a groan or a sigh that slips through—the original call for aid, for curative help, help from the other me whose alterity, whose exteriority promises salvation? (93)

As members of a helping profession, social workers are called upon to respond more than most other members of society. Often, the recognition that suffering is indeed useless is what calls clinicians to the field. Passivity, helplessness, abandonment and solitude can be a depressing place to start, but in the Levinasian conception, there is also an almost beautiful moment in which the possibility of real help makes itself known in extreme suffering. The extreme suffering is itself a demonstration of need, and a chance for the other to express a cry for help. By responding to the original call for aid, the clinician opens up the moment of suffering as a true possibility for alleviation of pain.

Alfred Adler (1956, 341) writes of a “devotion to the patient’s needs” as an essential task in the therapeutic relationship (as cited in Borden 2009, 32). By restoring the client’s confidence in the responsiveness of others, the clinician helps the client in his or her effort to see others in a hopeful light. Responsiveness to the patient’s needs offers hope and the potential for new (more adaptive and fulfilling) expectations in relational encounters.

In addition, responsiveness offers the hope that “someone understands what I am feeling.” Adler (1998, 25) makes light of the concept of common understanding, stating that “[o]urvery thoughts and emotions are understandable only when we accept that they are not unique to ourselves.”  From a Levinasian perspective, the universality of human suffering, suffering that stares me in the face in the face-to-face encounter, is the beginning of a deep mode of human understanding and ethical life. Although unique as beings, the common theme of mortality opens the possibility of deep human connectedness.

Responsiveness in the therapeutic relationship can be more than simply responding in a way that is different from the client’s parents. What therapists provide, writes Casement (1991, 272), is “a security within the analytic relationship that allows the patient to feel understood, sensitively responded to, and analytically ‘held,’ by an analyst who can tolerate what is yet to come in the course of the analysis, without collapse or retaliation.” Using attunement, empathy, and responsiveness, social workers can create an environment in which the client feels safe enough to present her deep suffering, while also confident that the clinician will respect that individuality of her complex needs.

Transformative Results – What Clinicians Hope to Achieve

There is a very frightening element in the encounter with the other. The encounter places the individual in a position of feeling completely responsible for another being whose is suffering before them. Without engaging in this encounter, however, clients may remain stuck in the world of vicious circles and maladaptive patterns of relatedness. Levinas gives clinicians and clients alike a way to open out into the rest of humanity, even though his notion of the other can be almost terrifying.

Entering the realm of the Kleinian depressive position, much like entering the ambivalence of the encounter with the other, means entering a place where “self and other are vulnerable but potentially sustaining and enriching in a world of relationship and meaning” (Borden 2009, 73). Accepting the vulnerability of truly encountering the other being (as both good and bad) opens up a world of new meaning.

Writing of the process of curing a patient in psychotherapy, Suttie notes that it is not the skill of the practitioner, but “the willingness of the patient and his emboldenment to relax his defenses against expressing his hate and so running a risk of being hated” that is the root of the curative factor in therapy (Suttie 1935, 208). The other is revealed as a vulnerable, mortal being, and I am in the terrifying position of extreme exposure in a moment of “stripping away of expression as such…defenselessness, vulnerability itself” (Levinas 1983,145). This moment of defenselessness can be likened to Suttie’s description of the patient relaxing his or her defenses and in so doing, being vulnerable to possibly being hated by the other. Although it may be difficult to run risks which the client has learned to defend against, the opening of this vulnerability leads to more fulfilling ways of relating to others.

Social workers are in the unique position of being able to help clients learn to think about connection in a new way. To become ready to engage in meaningful encounters with others outside the therapy room, clients must learn to accept the vulnerability that goes along with an encounter that is not based on pre-conceived expectations about how the other will act. Rather than this vulnerability being terrifying, it can open up the possibilities of relational life without expectation.  The type of ethical healing that is possible from a Levinasian perspective should be a priority for social workers.

NOTES

            [1] This paper does not include any discussion of the phenomenological tradition out of which Levinas’ ideas developed and instead follows from a 2007 Psychoanalytic Review issue which examined Levinas’ work as it relates to psychoanalytic theory. I refer to several of the articles included in the Psychoanalytic Review throughout the present article. In addition, Kunz’s (1998) book, The paradox of power and weakness: Levinas and an alternative paradigm for psychology, provides an accessible exploration of Levinas’s connections to psychology.

            [2] Here, Levinas is quoting Dostoyevsky’s The Brothers Karamazov. Levinas references this line often in his writing.

            [3] For a more detailed exposition of Levinas’s relation to Klein, see B.C. Hutchens (2007). Hutchens argues that the differences between Levinas and Klein are more notable than the similarities.

            [4] Interestingly, my response to Alford’s conception of attunement may be slightly “out of tune,” as Alford’s reading of Levinas is quite different from my own. For example, Alford (2007, 545) argues that, “The face of the other is not an invitation to a relationship based upon deep appreciation of the unique otherness of the particular other. The face is a synonym for the shattering experience of infinity.”

References

Adler, Alfred. 1998. Social aspects of human life. In Understanding Human Nature, trans. Colin Brett, 21-47.Center City,MN: Hazelden.

–––. 1956. The individual psychology of Alfred Adler, eds. and trans. Heinz L Ansbacher and Rowena R Ansbacher.New York: Basic Books.

Alford, C. Fred. 2007. Levinas, Winnicott, and therapy. Psychoanalytic Review 94: 529-552.

Bergo, Bettina. 2008. Emmanuel Levinas. The Stanford Encyclopedia of Philosophy (Fall 2008 Edition), ed. Edward N. Zalta. http://plato.stanford.edu/archives/fall2008/entries/levinas/

Borden, William. 2009. Contemporary psychodynamic theory and practice.Chicago: Lyceum.

Casement, Patrick J. 1991. Learning from the patient.New York: TheGuilford Press.

Dostoyevsky, Fyodor. 1912. The Brothers Karamazov. Trans. Constance Garnett.New York: Macmillan.

Fryer, David Ross. 2007. What Levinas and psychoanalysis can teach each other, or how to be a mensch without going meshugah. Psychoanalytic Review 94: 577-594.

Goldstein, Eda. 2001. Beginning phase. In Object relations theory and self psychology in social work practice, 155-185.New York:Guilford Press.

Horney, Karen. 1942. Self Analysis.New York: W. W. Norton.

Hutchens, B.C. 2007. Is Levinas relevant to psychoanalysis? Psychoanalytic Review 94: 595-616.

Klein, Melanie, and Joan Riviere. 1964. Love, hate, and reparation.New York: Norton.

Kunz, George. 1998. The paradox of power and weakness: Levinas and an alternative paradigm for psychology.Albany,NY:StateUniversity ofNew York Press.

Kunz, George. 2007. An analysis of the psyche inspired by Emmanuel Levinas. Psychoanalytic Review 94: 617-638.

Levinas, Emmanuel. 1969. Totality and infinity: An essay on exteriority. Trans. Alphonso Lingis.Pittsburgh,PA:DuquesneUniversity Press.

–––. 1978. Otherwise than being or beyond essence. Trans. Alphonso Lingis.Dordrecht andBoston,MA: Kluwer Academic Publishers.

–––. 1982a. Philosophy, justice, and love. Interview by Fornetand A. Gomez. Reprinted in Entre nous: Thinking-of-the-other, trans. Michael B. Smith and Barbara Harshav, 103-121.New York:ColumbiaUniversity Press, 1998.

–––. 1982b. Useless suffering. Giornale di Metatisica 4: 13-26. Reprinted in Entre nous: Thinking-of-the-other, trans. Michael B. Smith and Barbara Harshav, 91-101.New York:ColumbiaUniversity Press, 1998.

–––. 1983. From the one to the other: Transcendence and time. Archivo di filosofia 51: 21-38. Reprinted in Entre nous: Thinking-of-the-other, trans. Michael B. Smith and Barbara Harshav,133-153.New York:ColumbiaUniversity Press, 1998.

–––. 1984. Ethics as first philosophy. Reprinted in The Continental philosophy reader, eds. Richard Kearney and Mara Rainwater, 124-135. New York: Routledge, 1996.

Marcus, Paul. 2007. “You are, therefore I am”: Emmanuel Levinas and psychoanalysis. Psychoanalytic Review 94: 515-527.

Suttie, Ian D. 1935. The origins of love and hate. London: Kegan Paul, Trench Trübner & Co. Reprinted byLondon: Free Association Books, 1988.

Wachtel, Paul. 1993. Cyclical psychodynamics I: Vicious circles. In Therapeutic communication: Principles and effective practice, 16-29.New York: TheGuilford Press.

Walsh, Froma. 2009. Integrating spirituality in family therapy: Wellsprings for health, healing and resilience. In Spiritual resources in family therapy, ed. Froma Walsh, 31-61.New York: TheGuilford Press.

Williams, Richard N. 2007. Levinas and psychoanalysis: The radical turn outward and upward. Psychoanalytic Review 94: 681-701.