Wednesday, October 11, 2017

A Dream, about Agency?

or what the Continuing Case course participants make of a dream.

A man in his mid thirties, a successful professional in a helping profession, has been working on trying to change about himself his ‘passivity” and there has come to light a hint of his resentment about having had to be so passive all his life, passive viz a viz his parents, and his parents viz a viz his grandparents. In an earlier session he had shared how ‘coming out’ years before to his mother about his homosexuality had sent her --two hours later-- to the hospital. The man brings to his male, heterosexual, therapist the following dream:

              I am at the funeral of my parents and I don’t feel connected to the loss of them,
              and I am worried that others will see that I am not sad, that I am disconnected
              from loss. My ex-boyfriend and my cousin are also at the funeral and the priest
              will not allow my cousin, because she is female, to sit with me, because women
              must sit separately from the men. I get the priest to allow my cousin to sit by me.

The patient then begins to talk about how, if his parents were dead, what he would do with all the money, items, and property he would inherit. He would sell what did not fit or what was a burden and keep only what was precious to him. Perhaps, with all the money, he would not have to work anymore.

One candidate noted in this dream the patient’s previous theme of exposure: others would know his thoughts and deficiencies, and the patient would feel shame. Funerals are about death, but this patient has felt enlivened by the therapy.

This dream could be what Kohut might consider a self-state dream, heralding a change in the patient’s capacity to be active: he asserts himself and gets the priest to allow his cousin to sit by him.

Does the priest represent his father? His strict grandfather who made the father acquiesce? The patient is able to get this traditional priest to make an exception for him. Does the patient feel, though, that he must emotionally kill off his parents if he is to be able to assert himself? Or must kill them off if he is to be with his own feminine selves (sit with his female cousin)? Or does the dream also speak to his fear of loss of relationship if he were to assert himself and, also, if he were to be with his feminine self? Is it a forward edge to be able to assert himself, free himself from his parents? Ideally, would we not wish intersubjectivity for him (to be himself while in relationship with others, that is, to have both agency and negotiated relationships)? And what about the oedipal aspect of a male authority figure keeping him away from the female relative?

A rich and lively discussion for the presenting candidate to add to his experience with the patient and this dream.

Wednesday, October 4, 2017

“Mirror in the sky, what is love?”*

In discussing an analytic attitude with beginning trainees, I find analytic love and hate must be included. Analytic love is not to be confused with romantic love or parent-child love. As part of analytic love, I advocate for a welcoming attitude. Natterson elaborates 'what is love.' While not  having repeatedly made explicit throughout his paper -- to remind the reader what he means by love -- Natterson nonetheless defines it early on (p.510), relying on Hegel and Honneth: “love is a relationship of mutual recognition.” [I love that definition!] Another excellent ‘definition’ appears towards the end of the paper (p.520), this time from his patient: taking in and honoring the patient’s experience. [welcoming, if you will]

Recognition of our subjectivity, by a parent able to hold us in mind (Bion/Winnicott) and able to survive (Winnicott) our attacks, begins in infancy. Intersubjectivity, an always precariously held position, will inevitably fall to the side of treating the other as an object (called ‘negation’ by Benjamin), and we must continually right ourselves back to subject-to-subject relating. Doing so is an act of love. Despite love, there will be moments [or days] when intersubjectivity will fail and will cause the parent, lover, friend, or analyst to treat the other subject as an object: ‘You must do what I say, must meet my needs, you must sacrifice your Self in order to stay in relationship to me.’ What gives analytic love the edge is the analyst’s continued striving to be attuned to the patient’s response to us, be self-reflective, admit our contribution to ruptures, and make timely repair, that is, to re-establish intersubjectivity.

I must add that Natterson’s paper fell short for me on two counts. One was his continued use of terms like ‘individuation’ or ‘fusion.’ Dan Stern and later infant research tell us we are born individuated, not fused, not symbiotic. It is when our early subjectivity goes unrecognized (and we are treated like an object instead of a subject) that we have the experience of being usurped by the other. I doubt anyone wishes for fusion except as a way to maintain a threatened relational tie (or, momentarily, in love-making). Merger, fusion, lack of individuation are indicators of failure of recognition of subjectivity.

The other way this paper fell short for me was Natterson’s mention of the “Oedipal guilt” in his patient without including the reality of her childhood sexual abuse and its complications to the Oedipal configuration. I do not disagree that children often have a wish to marry the opposite sex parent, especially heterosexual children. It  seems to me that children who endure childhood sexual abuse require reconciliation and restitution to find a way back, as his patient did, to a loving relationship to her abusive father.

I am grateful to Natterson for providing a paper on analytic love and recognition of subjectivity.

Natterson, J.M. (2003). Love in Psychotherapy. Psychoanal. Psychol., 20(3):509-521.

*Landslide-Stevie Nicks

Sunday, October 1, 2017

Intergenerational Transmission of Trauma

We often hear that certain things, such as cocaine addiction or violent behavior, are inherited. Then there is the fascinating idea of epigenetics which, reminiscent of Lamarck, indicates that behavior can change genetic expression and can then be passed down in the genes. What seems to go under-emphasized outside psychological psychoanalytic circles is the intergenerational transmission of trauma, particularly relational (attachment) trauma. Schore puts intergenerational transmission of trauma like this: “...the infant is matching the rhythmic structures of the mother’s dysregulated arousal states.”

While two excellent, long-term studies have shown that violent behavior needs both the genetic vulnerability and the environmental exposure to violence in the home (the latter which is also a relational trauma, the relational trauma of a parent not seeing the child’s feelings, not regulating the child’s feelings, etc), why is it not also likely that drug addiction is not simply a genetic vulnerability but also a way of regulating one’s emotions? The addicted parent could not be sufficiently present to recognize, attune and regulate the child’s emotions and thus that child grows up with its own dysregulation, perhaps later likewise finding some soothing from substances. This dysregulation is not simply genetic. It is an intergenerational transmission of trauma, just like with a child who is sexually abused and unprotected and un-comforted, maybe even un-validated in her experience and pain, who grows up and becomes unable to protect her own child from sexual abuse.

A parent’s dissociated states from unbearable affect can create a dissociation in her infant (and disorganized attachment). The infant is then at risk for “a lack of integration of sensorimotor experiences, reactions, and functions” as seen in the common sequelae of somatic disorders (such as pelvic pain, fibromyalgia, migraines) resulting from childhood sexual abuse. Does one then say that sexual abuse of children is inherited? Not usually. Perhaps other behaviors, such as substance abuse, and even anxiety and depression, show up in the next generation and the generation after that because a parent who is not present (drunk, dissociated, anxious, or depressed) transmits these same self states to the infant, right brain to right brain.

Wednesday, September 27, 2017

More about the co-creation of transference

In teaching and learning more about the co-creation of ‘transference’ in our Intro to Psychoanalytic Concepts I course, we used papers by Fosshage and by Slochower to further our discussion. While Fosshage helped the class rethink anonymity and abstinence from a more contemporary view, and nicely explicated a more contemporary idea of transference as an organizing activity from the classical displacement model of transference, the candidates and I agreed that the distinction between pathological and non-pathological forms of transference may not add to our clinical experience. Regardless of its form, we agreed that transference is always co-created.

A lovely example came, again, from a candidate. The candidate described that her patient had insulted her, the analyst’s, competence, then the patient additionally complained that the analyst was a ‘blank screen.’ The candidate-analyst found it “harder to hear” that she was viewed by her patient as not so human (capable of feeling) than to hear she was not so skilled as a therapist. The candidate then explained to her peers [who had heretofore failed to see the co-creation of the patient’s latter comment] how she, the therapist, had “refused the discomfort” of the insult to her competence and so had remained unmoved. “I did not feel my anger” so “my answer was not human.” The patient, having expected hurt or anger, or some response, and having read -right brain to right brain-  the therapist’s dissociation from uncomfortable human feeling, then complained about the ‘blank screen.’  

This segued nicely into Slochower’s paper where we see Slochower on the cusp of struggling to recognize her own contribution to the patient’s ‘hateful’ness, and struggling to ‘wear the attributions’ of incompetence, manipulativeness, and greed as she negotiates with her patient an attempt at a mutual understanding. A second candidate noted aloud how Slochower’s interrogation of ‘Why would I want to do that?” nonetheless leads to a deeper revelation about the patient’s fears: “Obviously, to get as much money from me as possible.” Slochower gives us an illustrative case example of just how very hard it is for analysts to see our own contribution and acknowledge it to patients and, thus, validate the patients’ experience of us. This is one way our patients are our best supervisors.

Slochower, J. (1992). A Hateful Borderline Patient and the Holding Environment. Contemp. Psychoanal., 28:72-88.

Wednesday, September 20, 2017

When transference stinks

What we learn first stays with us the longest. 

In beginning a new cycle of first year courses this semester, TBIPS, in its Intro to Psa Concepts I, starts with a contemporary point of view. Asking candidates and students to think about what are some possible components of a psychoanalytic process, someone includes ‘transference.’ We have read for today’s class a paper by Lew Aron and one by Irwin Hoffman.

A psychoanalytic candidate expresses scepticism about the relational concept of mutual influence in the transference: ‘Doesn’t the patient bring things in her head that have been there before she ever met you?’ Of course the patient brings things that had nothing to do with the therapist, but what emerges with the therapist is constitutive of being with the therapist. The candidate gives an example: ‘I open the door to a first time patient and she says, “your building smells.” How could that not have come from her alone?’ I am curious. The candidate says this particular patient had had a traumatic past and had been physically disfigured-- her face, her gait-- in a fire. I inquire: what was his experience at the moment he opened the door to this patient whose face had been thus scarred. The candidate said that the film The Exorcist had come to his mind, her face horrifying, terrible.

Since microexpressions can be non-consciously communicated, right brain to right brain, and since horror can look like disgust, and disgust akin to bad smells, was it possible that this new patient recognized her new therapist’s look of disgust and her right brain registered it as ‘something stinks around here’? Maybe. The patient did not return after the initial consultation. What might have happened had the therapist spoken aloud to the trauma this patient endured as evident from her facial scars and, more important, had inquired about what it was like to see the initial shock of them on his face?

The class is inordinately grateful for this candidate’s example which helped us illustrate a more contemporary view-- that of mutual influence-- of transference. His example speaks to the readings:

From Aron:
The analytic situation is constituted by the mutual regulation of communication between patient and analyst in which both patient and analyst affect and are affected by each other. The relationship is mutual but asymmetrical.”
“the patient’s experience of the analyst’s subjectivity needs to be made conscious”
It is often useful to ask patients directly what they have noticed about the analyst, what they think the analyst is feeling or doing, what they think is going on in the analyst, or with what conflict they feel the analyst is struggling.”       
The exploration of the patient's experience of the analyst’s subjectivity represents only one aspect of the analysis of transference.”  

From Hoffman:
“For Langs what is wrong with the classical position is that it overestimates the prevalence of relatively pure, uncontaminated transference.”
“the implications of the patient's ability to interpret the analyst's manifest behavior as betraying latent countertransference.”

Aron, L. (1991). The Patient's Experience of the Analyst's Subjectivity. Psychoanal. Dial., 1(1):29-51.

Hoffman, I.Z. (1983). The Patient as Interpreter of the Analyst's Experience. Contemp. Psychoanal., 19:389-422.

Thursday, August 17, 2017

Requesting more Swift progress

I may not be very familiar with the music of Taylor Swift but I have, of course, heard of her stature in the music industry when she stood up for music artists’ income by pulling her music off Spotify (a streaming music service) in 2014. Now, in a victory that affects many more women and men, she is standing up “for...anyone who feels silenced by sexual assault.” On Monday (8-14-17), Swift won a victory [She was awarded what she asked for, a symbolic $1.] against a former DJ who blamed Swift for his firing when she accused him of groping her at a pre-concert photo shoot.

Our profession knows only too well the devastating effects on sexual assault survivors. Now, if only the U.S. President would stand up against bigotry and hatred. Many of us were more than chagrined at his waffling about such hatred evidenced last week in Charlottesville,VA with the death of Heather Heyer and injury to others. I do know one lyric attributed to Swift, “Haters gonna hate.” Unfortunately, many cannot “shake it off” and the consequences of hate also need to be given a voice. A voice is another important, empowering benefit of therapy.

Saturday, August 12, 2017

More about narrative, or narrating one’s story

American writer Richard Ford, who has recently written Between Them -- the memoir of his parents’ (Parker and Edna) life and love-- shared with PBS Newshour’s IMHO (In My Humble Opinion) on May 19, 2017 some of the reasons one writes a memoir:

“To render testimony
To bear witness
To make sense of a recollected life...
Substantiate ourselves to ourselves…
To utter what must not be erased…”
and because “I missed them” and some longings are “acted upon even long after it might be
supposed that enough time has passed for longing to subside.”

Furthermore, “Age is a winnowing process and sometimes what gets sifted out as we seek to know the important consequence of lives are the actual lives themselves.”  About his parents’ lives, he recognized that though “as most parents are, [they were] all but unnoticeable in the world’s disinterested eye,” they were of importance to him because of the love and relationship they shared with him. [I am reminded of the iconic play “Our Town” (1938) by Thornton Wilder where the ordinary town of Grover’s Corners and the ordinary lives of its citizens are made extraordinary by the relationships people share.] He said of them: “Being their son seemed a privilege, and almost mysteriously, they opened for me a world of immense possibility.”

Perhaps in response to the current political climate, he added, “In a world cloaked in supposition and opinion and misdirection and often in outright untruth, things do actually happen. My parents’ lives did take place.”

Some of Ford's reasons for writing this memoir speak to our work (witnessing, remembering and making sense, even instantiating authentic beings through actual experience). When we listen with reverence and love to the stories of the lives of our patients, we validate the importance of their memories, their feelings and their lives. For as Ford noted from Saint Augustine ‘Memory is a faculty of the soul.’

Wednesday, August 9, 2017

More on storytelling narrative, and on how to do so, literally, or literary

A lot has been written in contemporary psychoanalysis about the need to free ourselves from strict theory and technique in favor of the process of the moment to moment experience of two people intimately engaged in the collaborative construction of relationship and of meaning, primarily for the patient’s benefit. I was pleasantly struck to find the same ideas about uncertainty, spontaneity, surprise, and surrender in the process of one author’s writing.

Listen to what George Saunders, author of the critically acclaimed and New York Times best-selling novel Lincoln in the Bardo (2017), tells Jeffrey Brown on the Newshour Bookshelf (March 28, 2017) about the process of writing: “The holiest state is to be a little confused by what you are doing and you are guided by the energy that the story is actually giving you as it is revised. That’s kind of tricky because it means you have to abandon your ideas about organization or thematics and really submit [surrender] to the story… and hopefully it will result in some new mode of beauty.”

I thought it aptly put. (He is a wordsmith after all.)

By the way, Saunders additionally said in the same interview that he was inspired by Lincoln who had somehow been able to “transform... sorrow into a kind of expanding empathy for everybody” and whose “response to fear or hardship was expansiveness instead of shrinkage.” Were that we all were so heroic.

Sunday, August 6, 2017

The search for happiness, I mean, meaning.

Emily Esfahani Smith, author of “The Power of Meaning” reported in a PBS Newshour IMHO (In my humble opinion) segment on Mar 10, 2017 that psychologists have counterintuitively concluded that the chasing after happiness can leave people unhappy and lonely. It is instead the search for meaning and trying to figure out how to make our lives count which bring happiness. She cites the epic of Gilgamesh, one of the oldest known literary works (Mesopotamian, ~ 2500 BC), and sees in it the hero’s search for how to live knowing that he will die. Smith says his quest remains urgent.

Social scientists say meaning is found when we connect and contribute to something beyond ourselves, such as to family, work, nature, or god. Smith cites three conditions found in people who say they have meaningful lives: 1) They believe their lives matter; 2) They have a sense of purpose;  and 3) They think their lives are coherent and make sense. Storytelling itself gives meaning, she says, and offers clarity.

I am reminded of the work we psychoanalysts do, a connection which brings personal meaning to our lives, but also affords to our clients both a search for meaning and an attempt at a coherent story.  We know that a coherent narrative in Mary Main’s Adult Attachment Interview predicts secure attachment.  We know, too, that an important job in parenting is to convey to a child that she or he matters, has a right to exist, and is connected to something bigger (the family). Tomorrow, were he alive today, would be my father’s 96th birthday. I wanted to give a grateful shout out to my father for having always conveyed meaning to our lives by his love and dedication to his family (he was a great listener and storyteller himself) and to his work (he was a writer who showed joy and meaning could exist in one’s professional life), and by seeing his joy burgeon as he aged (through his interaction with his grandchildren).

Meaning through connection and narrative? Our profession was made for it.

Sunday, July 30, 2017

Container Function

Bion conceived of the analyst as a ‘container’ of projected parts of the other-- as mother is for infant-- particularly of intense, negative affects. The extruded parts and affects of the other are what is ‘contained.’ Analyst (as with mother) is not merely a receptive container, but a welcoming and validating one, and, moreover, accepts and modifies them (a part of the alpha function), but does not necessarily interpret them. The ‘container’ ideally dampens these overwhelming affects so that they are eventually amenable to regulation and self-reflection.

Thus, through projective identification (projection and response to what is projected) the analyst has come to know unwanted affects and painful relational patterns, and furthermore attempts to ‘digest’ them and re-present them in a more ‘palatable’ form. We might note the similarity to making use, after the fact, of enactments which bring to light nonconsciously encoded patterns of ‘how to be” in relationship-- except that enactments are made use of by both analyst and patient who intersubjectively process shared experience and co-create any meaning making. An example might be mutual recognition containing aggression because complementarity is no longer at work.

Spezzano adds a felicitous element to Bion’s ambiguous term ‘container’ when he intimates it is: to be held in the mind and meaning system of the other as a protection against psychic homelessness, meaninglessness and chaos. Putting parts of the self in the other may then be an attempt to create holding of the self in the analyst’s mind. In the analyst’s mind, there can be an increased opportunity to co-create context for them, and an increased capacity to safely play with these projected parts, as was the case with a young man-- an avid user of ‘spice’ or K2, but no longer a user of heroin -- who let me feel all the sadness, himself long indifferent (numb) to the pain experienced by the little boy whose mother had left him and his father when he was but six years old (he never saw her again). Tears could stream down his face when I described the plight of an abandoned six year old, but that boy’s sadness was not his own. Through approaching the loss and confusion of a child through the little boy I held in mind, my patient could begin to approach what might have been his own experience.