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(For reasons of readability, the male form is used with personal names, however the female form is also always intended.)

Meeting Patients

Author: Steven Stern


My recently published first book, Needed Relationships and Psychoanalytic Healing: A Holistic Relational Perspective on the Therapeutic Process (Routledge, 2017), has a complex narrative with many moving parts, but, at its core, it is about the deceptively simple idea of meeting patients: in the analytic moment, and cumulatively over time. I am not the first to use this term to characterize analytic engagement. Winnicott (e.g., 1960) wrote about analytic interaction as a “live adaptation to patients’ needs.” He understood that, for many patients, such adaptations required working outside of “standard” analytic technique, at least initially (Winnicott, 1962). More recently, the developmental researcher and theorist, Louis Sander (1962, 1995, 2008), introduced the phrase, “moments of meeting,” to characterize the collaboration and coordination between a parent and infant in service to the child’s developmental and emotional needs. Later, the Boston Change Process Study Group (D.N. Stern et al. 1998), of which Sander was a member, applied Sander’s concept to adult analytic therapy dyads. 

Sander’s concept of moments of meeting is one in a matrix of related process concepts and terms he generated in his attempt to capture the movement of a good-enough mother and infant, understood as a non-linear dynamic system, toward progressively effective coordination in the service of the infant’s development. His term for this evolving coordination was relational fittedness: a joining of directionalities which was achieved through progressive specificity of recognition by the caregiver of the infant’s states and needs, and with this recognition, progressive specificity of connection—i.e., the responsive behaviors aimed at meeting the child’s emergent states and needs. Listen to Sander’s (2008) frame-by-frame narrative of, and commentary on, a now often-cited video segment taken of a member of Daniel Stern’s research team—a father holding his baby daughter in his arms—as he is talking informally with other members of the team, standing together on a lawn during a home visit with one of their neonatal subjects:

…one sees the father glance down momentarily at the baby’s face. Strangely enough, in the same frames, the infant looks up at the father’s face. Then the infant’s left arm, which had been hanging down over the father’s left arm, begins to move upward. Miraculously in the same frame, the father’s right arm, which had been hanging down at his right side, begins to move upward. Frame by frame by frame, the baby’s hand and the father’s hand move upward simultaneously. Finally, just as they meet over the baby’s tummy, the baby’s left hand grasps the little finger of the father’s right hand. At that moment, the infant’s eyes close and she falls asleep, while the father continues talking, apparently totally unaware of the little miracle of specificity in time, place, and movement that had taken place in his arms.

Then, commenting on this interaction, Sander wonders:

Are we looking at some principle of wholeness—that is, building on an underlying principle of specificity in time, place, and movement that joins directionalities between component systems—a joining that is necessary to construct coherent wholeness in a “system” that can be said to “live”? (2008, pp.221-222)

Sander believed that the process principles he articulated were also applicable in adult psychoanalytic dyads. But what would such specificity look like in a moment, or more extended period, of analytic treatment? What would be required between an analyst and an adult patient with a history of developmental trauma to “join their directionalities” in such a way as to “construct coherent wholeness in a ‘system’ that can be said to ‘live’”? I have spent the last 4 years trying to answer this question, and have come to believe that psychoanalytic treatment, at its core, involves a recognition process comparable to, but far more complex than, that between good-enough parents and infants in moments of meeting like the one Sander captured on video.

Because adult patients who have been relationally traumatized in childhood have grown up in situations that were decidedly unfitted to their early developmental needs, analytic collaboration and fittedness must begin by meeting patients in spaces where being met is an alien, distrusted experience, which they may misread, avoid, negate, or attack, even as they unconsciously long for and seek it. The extreme delicacy, complexity, and often emotional turbulence, involved in meeting patients in such traumatized spaces requires sophisticated observational, processing, self-reflective, interpretive, and relational capacities, and these capacities come mainly from our immersion in and clinical mastery of psychoanalytic theories—the more the better. That is, what good-enough parents and their young children do relatively naturally and instinctively, analytic therapists of adult patients must learn to do through the inculcation of multiple analytic theories, personal treatment and supervision, and cumulative learning from clinical experience, all of which combine to produce a uniquely psychoanalytic form of wisdom.

Many of the things we actually say and do with patients do not fall neatly into established categories of analyst participation such as interpretation, empathic inquiry, confrontation, containment, holding, etc. Rather they are contoured to the patient and the analytic moment, drawing selectively and creatively on theoretical knowledge, but guided by one’s implicit effort to meet the patient in her or his unique complexity, at the point of analytic urgency, taking into account the current state of the patient, the therapist, and their system. I suspect many readers would respond: “Of course! Psychoanalytic treatment, almost by definition, is about meeting patients in this way.” I would agree, if “meeting” is taken to mean any theory’s conception of the optimal analytic operations involved in mutative change. In my conception, however, meeting patients often transcends theory, given the unique complexity of different patients’ psychological organizations and therapeutic needs, and therefore is always complex, unique to that patient, and essentially improvisational. Here is a relatively straightforward example.

My second analytic control case was a young woman in training to be a therapist, whose relational instincts and judgment, both in her personal and professional life, seemed to me to be almost always on target, but who, given her history, was too insecure to trust her own good judgment. Consequently, a transference developed wherein she demanded constant reassurance from me in the form of saying what I really thought about her inclinations, decisions, and actions. If I hedged at all, or gave her anything like the usual analytic dodge, her anxiety rapidly escalated, as did her insistence that I tell her what I really thought before she left that day! She knew she was pressuring me to give her something that went against psychoanalytic dogma in that era (I was at a mainstream institute of the American Psychoanalytic Association), and she could even empathize. Sometimes we joked about it. But when it came down to it, she was desperate and ruthless. So, despite my real concern that my work with her might be judged “not psychoanalysis” by the powers that be, I mostly did as she asked and gave her my opinions straight up, which were almost always authentically affirming of her own instincts. Whenever I did, which was at least once in every session, her anxiety immediately dissipated (think of the baby girl in Sander’s video) and she felt emboldened to go out and think or do whatever felt right to her. Over the two years of our analytic relationship, her confidence and sense of personal agency grew enormously, such that, by the time she left the state for a romance that seemed very promising, she expressed confidence that she was doing the right thing, no longer needing my validation. Subsequent correspondence confirmed her continuing and growing happiness and sense of fulfillment, personally and professionally. There was little doubt that, the psychoanalytic “rules” notwithstanding, my constant reassurance had been a primary change agent in this analytic case. Returning to the analogy of the mysterious coordination of Sander’s father and daughter caught on video: My patient and I “joined our directionalities” in a comparable, though more complex, way, enabling her ultimately to relax enough into her own, now strengthened, sense of self to let go of my analytic “finger” and fall back into the trajectory of her own life.

Of course this clinical story is an over-simplification. There was much more going on in this treatment than can be captured by a single principle. But the point I am trying to illustrate is that in this case the critical mode of intervention—a mode which, in my now 30-plus years of doing psychotherapy, was unlike any other in which I have ever engaged—emerged from the unique needs and requirements of the patient in the context of our particular analytic system and process.


Sander, L. (1962), Issues in early mother-child interaction. Journal of the American Academy of Child Psychiatry, 1: 144-166.

Sander, L. (1995). Identity and the experience of specificity in a process of recognition: Commentary on Seligman and Shanok. Psychoanalytic Dialogues, 5: 579-592.

Sander, L. (2008). Living systems, evolving consciousness, and the emerging person: A selection of papers from the life work of Louis Sander. (G. Amadei & I. Bianchi, Eds.). New York and London: Routledge.

Stern, D.N., Sander, L.W., Nahum, J.P., Harrison, A.M., Lyons-Ruth, K., Morgan, A.C., Bruschweiler-Stern, N. & Tronick, E.Z. (1998). Non-interpretive mechanisms in psychoanalytic therapy: the “something more” than interpretation. International Journal of Psychoanalysis, 79: 903-921.

Stern, S. (2017). Needed relationships and psychoanalytic healing: A holistic relational perspective on the therapeutic process. London: Routledge.

Winnicott, D.W. (1960). The theory of the parent-infant relationship. In The Maturational Processes and the Facilitating Environment (pp. 37-55). New York: International Universities Press, 1965.

Winnicott, D.W. (1962). The aims of psycho-analytic treatment. In The Maturational Processes and the Facilitating Environment (pp. 166-178). New York: International Universities Press, 1965.

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