Tuesday, October 18, 2016

Insights from Jane Hall, LCSW

            This past Saturday (10/15/16), psychoanalyst and author Jane Hall explored with the Tampa Bay Psychoanalytic Society the concept of “attachment to abuse,” specifically the incredible bind in which many patients abused as children find themselves as adults when seeking to live a freer, more constructive life.  Hall posed both psychological and physiological factors that continue to “haunt” abused children across their lifespan.  Psychologically, these children have internalized within both the abuse and the abuser, coloring how they will experience themselves, others, and themselves in relationship with others. Physiologically, the sustained dis-ease of home life triggers high levels of cortisol, now shown to negatively affect the developing brains of children.  Each of these factors alone, let alone the interactive effect of both together, shape the way in which these individuals think, feel, and behave in the world.  Hall noted that such individuals will respond somewhere on a continuum: from mild self-punishment all the way to psychopathy.  Put more succinctly, the sustained childhood abuse eventually will leave somebody dead. This death may manifest in extreme cases as either suicide or homicide, including acts of terrorism.  Other types of death include the loss of the self (an absence of self-esteem) and the loss of the object (an inability to form intimate relationships).

            Hall postulated that as psychoanalysts, our role is to listen – with benign curiosity, and this type of listening will, over time, enable the early childhood wound to form a scar, and with continued listening, that scar will eventually shrink.   Our consistent frame and benignly curious listening can ultimately allow not only the mind to change as noted above, but, Hall citing recent neurological research, posits that the very brain itself can change because of its inherent neuroplasticity. 

           The challenge for a patient to move from such a wound to a diminishing scar is significant.  Because of the painful parental treatment (e.g., controlling, neglecting, cold), these abused children fashion ways to protect themselves from such harm.  These defenses, however, keep out not only that which is harmful, but that which is necessary and good. As adults, these children are unable to absorb love, though they are desperate for it.  The challenge of treatment is to invite these children-turned-adults to “loosen ties to their original object,” as Hall explained.  This is the only path forward to prevent them from finding ways of repeating their abuse – as abuser/abused or both.  This way of safety and protection learned in childhood has become a character trait that prevents a fulfilling adult life.

            Contrasted with Winnicott’s “good enough mother,” Hall described the “bad enough mother,” who for a host of reasons may not have been able to meet the normal developmental needs of her child. This mother, herself, may have had a “bad enough mother,” passing onto the next generation the familiar and familial trauma.  Hall noted that we as therapists may find ourselves sucked into the role of the bad enough mother and, as a result, dealing with the patient punishing us in a variety of ways.  One of the most effective punishments, she illustrated, is the patient's refusal to get better, thereby torturing the analyst.

            Hall cautioned us that this move from the attachment to abuse to a more secure attachment with the analyst and others in the patient’s life is not easily achieved.  The patient will fight to hold onto that which is familiar while at the same time desperately longing for something healthier.  She suggested that we must find ways to survive the onslaught of the patient’s hopelessness, rage, and helplessness likely with the help of a support system ourselves. Hall concluded the morning presentation with two case studies with patients she had seen in analysis over many years, both of whom have found ways of living meaningful lives after living through significant traumata as children.

Steven D. Graham, PhD, DMin

Friday, October 14, 2016

Dylan wins Nobel Prize

Yesterday, it was announced that Bob Dylan, in keeping with Orpheus and other bards’ tradition of music and poetry, has won the 2016 Nobel Prize for literature, a first for a musician, but not, of course, for poetry. Dylan, born Robert Zimmerman in Minnesota in 1941, who denied he changed his name to Dylan because of another poet, Dylan Thomas, hit the folk scene in NYC in 1961 and became an icon for songs such as “Blowing in the Wind” made famous by the already renowned folk singers Peter, Paul, and Mary. In 1965, Dylan went electric, debuting his new style at the Newport Folk Festival, where the change was not well received by his folk music fans. Dylan also sung country, blues, and gospel, and rock and roll leading music biographer David Hajdu (Positively Forth Street) to say of Dylan, “He contains multitudes.” Dylan himself said, “You are constantly in the state of becoming.” Neuroplasticity agrees.

Dylan, who boasts over 60 albums, was awarded the Prize “for having created new poetic expressions within the great American song tradition.”   An American has not won the Nobel Prize for Literature since 1993 (Toni Morrison). This honor was added to his induction in the Rock and Roll Hall of Fame in 1988, and his Presidential Medal of Freedom in 2012.

Therapists know the necessity of not relying wholly on the narrative, the explicit, the spoken word. Dylan, too, understood something about words, “Words have their own meanings or they have different meanings. And then all words change their meanings.” (Scorsese, 2005, No Direction Home). He influenced countless musicians, James Taylor, Bruce Springsteen, and U2.

A personal note: A fan of his music since I was 8 years old, perhaps Dylan made us feel revolutionary, for even my civil rights demonstrating mother, more of a Bizet fan, upon hearing Bob Dylan on the stereo record player, said, only somewhat disparagingly, “He lows like a cow.”

Tuesday, October 11, 2016

Group Therapy Supervision and Confrontation

I am thankful to the instructor for trying to hold our dialogue in her mind and trying to find an answer to her dilemma. I want to state that I do not feel her comments as a confrontation. Rather, I experience her as passionately arguing her interests in the group which I run. Accordingly, I do not feel that I confront group members, but, rather that I am empathically attuned with patient’s needs to be hateful to the group and to be self-destructive.

Also, within this supervision, we have both chosen to co-create an experiment: the instructor to supervise and I to be supervised for a group by a supervisor who is not a group therapist. This is mutually confronting, I think, also for the class. Unless we have the courage to visit unvisited areas of our experience, therapy, and supervision, cannot take place. I find this experience anxious enough to help my growth and the bouts of shame that may occur as the necessary elements of that. Being humiliated for the badness is not the same thing as being empathically confronted for your need to be bad.

I think that there are many ways that confrontation can occur and it seems that, as a supervisory group, we have started exploring this range. As a supervisee I do not feel shame when you suggest something different. In a parallel process also, I think the group member had the courage to be hateful enough and the group was courageous enough to challenge empathically her destructiveness. The shame that may arise reflects the underlying shame she got when she wanted to attack her family and they did not let her be hateful enough. Now, in the group, she is starting to realize her destructiveness.

I quote a paragraph from a Darlene Ehrenberg paper and also the paper to perhaps assist us:

For some the realization that dealing with difficult feelings and tensions in immediate relation to the another can lead to both learning and growing and the relationship becoming stronger, rather than either or the relationship being threatened or diminished, may be a revelation (Ehrenberg, 1996). This kind of revelation is an “insight” that cannot be conveyed in words. It is the lived experience that that this is possible that is the “insight.” This kind of “insight” is in response to change, which is contrary to the idea that insight is what leads to change. Rather, the lived new experience, in all its profound emotional intensity, in the immediate analytic interaction is what is “mutative.” This has bearing on why research based on transcripts of the words spoken in sessions miss what might be going on experientially and emotionally between and within patient and analyst, and how powerful this dimension of what transpires, often without words or beyond words, ultimately is.
Stavros Charalambides, Candidate TBIPS, and Athens

Sunday, October 9, 2016

Group Therapy and Supervision

I find myself in the peculiar position of supervising a candidate who is conducting group therapy. The candidate, having previously been trained in Object Relations, has a penchant for confrontation of behavior and for going straight to the unconscious. I, on the other hand, prefer a more ginger approach, trying to keep in mind the useful purposes that otherwise untoward behaviors serve to protect the self from painful affect and from fragmentation. So I find myself in a dilemma about confrontation. On the one hand I wish to discourage its use in the candidate; on the other, I find myself confronting the candidate’s behavior of using confrontation. Because the medium is the message, here I am at crossed purposes with myself.

Webster says confrontation is to fight or oppose with anger; the candidate himself said confrontation serves to put the other in a difficult position. So is this what we therapists hope for our patients, that they will find themselves in a difficult position with us? While patients do need to experience some discomfort as motivation to come to treatment, I do not think we want to purposefully generate discomfort as a therapeutic tool.  We certainly do not wish a patient to feel shamed and unable to stay in treatment. Yes, we want an opportunity to be the old object so as to bring to the table and make available for exploration past shames, but we also need to be the new object who provides a corrective emotional experience (and gives the brain the opportunity to lay down new dendritic branchings and prune old ones). It is not our job to get a patient or group member to cease a certain unwelcome behavior, but rather it is our job to help identify the purpose served by such behaviors as well as what triggered such behaviors and our part or the group’s part in that trigger. But how to convey that to a candidate in a non-shaming way?

The continuing case course’s class itself forms a group, a group participating in the peer supervision, with the instructor as facilitator or group leader. Do I then address the entire group to inquire about what happened when X said this and Y said that? Do I ask how did it feel when candidate-group leader said this or that? It is interesting how the parallel process shows itself. The group as a class forms its alliances and subgroups just as the therapeutic group, led by the candidate, does. The class, too, as the therapeutic group does, seeks understanding and a sense of responsibility for our interpersonal interactions, hopes for knowledge and a universality of experience where belonging and sameness can coexist with an appreciation of uniqueness. The tricky dual role of course instructor and group facilitator becomes more evident as the course unfolds.

Thursday, October 6, 2016

Group Therapy

Supervising a group process at TBIPS has been challenging, for now I must treat many individual members as a single whole. In part, this means that each member of the group can be viewed as if a different self-state of the whole.  The group therapist, when he or she speaks, strives to address the group process and not any one individual member of the group. Still, it is tempting to do sequential individual therapy with varying individuals, especially if the therapist is more experienced in individual therapy. Also difficult is to remember that each member’s comments can speak to what the whole group might be feeling, a feeling of which the group, and each individual in the group, may be unaware and possibly projecting onto the member who speaks what others cannot say.

For example, one member may be quite angry and her anger seems to make everyone uncomfortable. Because it is the group therapist’s job to address the group process and not any single individual, the therapist could wonder aloud how person X came to be the one to hold all the anger for the group given that everyone carries anger and also to wonder aloud how the group came to designate person X as the vessel for its anger. In this way, person X does not have to be shamed for feeling angry, nor is she told to cease behavior that makes others uncomfortable. Not directly interpreting to person X about her anger may circumvent shaming her while at the same time leaving open the possibility to the group that person X might be the courageous one or the scape-goated one, and so on. That we have in common certain feelings serves to decrease isolation and alienation, as well as to bulwark self-esteem and validation.

Interpersonal competence can be learned in a safe environment. Group therapy has the benefit of exploring multiple permutations of interpersonal relationships in the very experience near here and now as they are formed and play out amongst group members. Because transference does not only arise between a member and the therapist but between members as well, other group members are responded to as if they are parents or siblings.

The group therapist is called upon to make her or his comments addressed to the group as a whole instead of having an individual session with one member in front of all the others members. Just as individual therapy includes not only understanding (insight, cognition left brain) but also the building of a relationship between the two members of the dyad, so group therapy includes the building of a group. A sense of belonging to the group can offer the much needed ‘twinship’ experience.

Friday, September 23, 2016

Dissociation and Trauma

One of the benefits of membership in the Tampa Bay Psychoanalytic Society is participating in its monthly discussion group. This year the group is reading Philip Bromberg's Awakening the Dreamer. In the Introduction, Bromberg reprises Standing in the Spaces: "Self-states are what the mind comprises. Dissociation is what the mind does. The relationship between self-states and dissociation is what the mind is."

Bromberg sees dissociation as normative in the structure of the mind, but also as a process by which psychological survival is preserved in the face of overwhelming threat to self-continuity. When parents disallow aspects of a child's self, these aspects are dissociated by the child in order to maintain the needed tie to the parent. As the child grows into adulthood, his sense of self includes "'his parents' child'"-- that is, he continues to dissociate these aspects. Unlike repression that disavows content which causes conflict, dissociation disavows parts of the self. Bromberg claims that this disavowal of parts of the self impairs intersubjectivity such that the self is "largely unable to see himself through the eyes of an other."

Psychoanalysis, writes Bromberg, includes an act of recognition (different from understanding) of the patient's disavowed self-states, states accessible within the intersubjective field through enactment. Repeated experience with recognition [and the welcoming in] of these disavowed self-states increases their accessibility. Once accessible, these self-states are available to symbolization and self-reflection, and to conflict [the stuff addressed by traditional psychoanalysis].

In contrast, self-states that are not recognized by the analyst thwart the patient's desire for recognition and acknowledgement, and lead to shame. "..[B]ecause it is not forthcoming, [it] supports the reality of their needs being illegitimate."  But "when the therapist is able to relate to each aspect...[t]his linking of self-states increases a person's sense of wholeness..." allowing one to live a fuller life.

Saturday, September 17, 2016

In Passing

The great American playwright Edward Albee died yesterday, September 16, 2016 at the age of 88. The theatre seems to me more than any other medium to reveal the human condition pointedly and in condensed fashion. Like so many great playwrights—Miller, Williams, Chekov, of course Shakespeare – before him, these artists show us a mirror of ourselves that we sometimes wish were left unrevealed (as when Albee’s 1962 play Who’s Afraid of Virginia Woolf, which won five Tony awards, was denied the Pulitzer by the advisory board despite being voted to receive it by the jurors.)  Freud, however, would have been proud of Albee’s explications of sex, aggression, and death.

In his first play Zoo Story (1958), Albee wrote about loneliness and miscommunication. In Woolf, he exposed the illusion of the prefect American family. [What couples therapist has not seen a George and Martha in the consulting room?] The Goat, Who is Sylvia? pushed the limits of liberal tolerance when Martin falls in love with a goat (bestiality) while being somewhat judgmental of his homosexual son. Albee received the Pulitzer Prize for Drama for A Delicate Balance (1967), Seascape (1975), and Three Tall Women (1994).


On September 17, 1787 (two hundred, twenty-nine years ago today), the U.S. Constitution was adopted by the Constitutional Convention in Philadelphia, PA. One of its important compromises –between the Virginia Plan and the New Jersey Plan— allowed states to be represented both by population (The House of Representatives, favoring the larger states) and by same number of votes per state (The Senate, leveling the playing field for smaller states.)  The Constitution was ratified by conventions in eleven states and was adopted (went into effect) in 1789.  It is the longest living Constitution in the world.

The beauty of the U.S. Constitution is it is alive; It allows for changes of itself through amendments— for example, the abolition of slavery (13th), and prohibiting denial of women the right to vote (19th)—and it is interpreted to fit the lives of people in the present moment to allow for freedoms as yet unconceived by its writers and ratifiers. (Its freedoms are often hard won such as in Brown v. Board of Education of Topeka (1954) establishing separate public schools for black and white students to be unconstitutional; and Giddeons v FL (1961) allowing the accused to obtain a public defender.) Yale Law Professor and Constitutional scholar Akhil Amar said about the Constitution, “It is this epic, flawed, spectacular conversation” and “it’s the job of our generation to make it more perfect still.”

Psychoanalysis, too, is a flawed and spectacular conversation. It, too, is governed by a set of principles and procedures, and like the U.S. Constitution, is a sacred forum for struggle and negotiation where the state of the self is improved, made richer because of increased accessibility to experience and emotion, and made freer as well by being so enriched. It is through struggle and argument that our country is made better. Sometimes I think the conversation of psychoanalysis, like the voice of the vote, ought to be a basic right. But who will provide and who will pay for such a service?           

Monday, September 12, 2016

Acting Out and Passage à l'acte

On Sept 10, 2016 the Tampa Bay Psychoanalytic Society hosted Donna Bentolila at its monthly, all day seminar where she presented two riveting cases. A native of Argentina and a Lacanian by self-report, Bentolila, despite the privileging of left brain (the Symbolic) over right, and despite her reluctance to locate herself squarely in the co-creation of the experience of her patients, nonetheless, worked closely and beautifully in the lives of these two patients and their analytic relationships with her. Due perhaps to the severity of their illnesses and to complicated issues in both cases, Bentolila found herself repeatedly having to bend the frame to fit both the needs of these two very disturbed people and the limits of her capacity to endure their demands. For confidentiality sake, I will give no details, but wish you all had been there to become wholly engrossed in the presentation.

Lacan, like Freud, chose phallocentric terms to explain human experience, and I was pleased to see Bentolila try to soften Lacan’s ideas as metaphor. For example, the ‘name of the father’, Bentolila claimed, is not necessarily the biological father, but the function that transcends him. Still, this function, in addition to “constraints and proscriptions,” is to “break the fusion between mother and child." [But the idea of ‘fusion’ (or merger or symbiosis) has been reassessed since the understanding by Stern (1985) -and Benjamin- of the normal development of a sense of separateness from a very early age.]

Bentolila explained Lacan’s  distinction between acting out and passage à l'acte: Acting out is done by a subject as an attempt to communicate something to the Other which could not be heard, or said, in words. Because it remains as an attempt at communication, it thus retains the Symbolic order. Passage à l'acte (passage to [into] action), on the other hand, exits from the Symbolic Order with behavior which is not meant to communicate to the Other (the Other does not enter into consideration in the act, sometimes because there has been a dissolution of connection to the Other) for even the subject is un-situated from the scene in a desperate and irreversible attempt to resolve some unbearable anxiety (this loss of self as subject sometimes heralds psychosis), such as in the case Bentolila described.

What a wonderful reminder, as her clinical examples depicted, of how being listened to about one’s impulses makes it less likely those impulses will be acted upon. Acting out is a message to the analyst: an appeal or demand for recognition from the analyst; an attempt to communicate what the analyst had heretofore been unable to hear; an unspoken and/or unconscious invitation to dialogue about a subject that could not find a place in their discourse, perhaps because it remained dissociated (or outside the Symbolic order per Lacanians). I suppose that were the analyst to disallow space for validation, or abdicate responsibility for her own location in the fray, the patient might feel so violated and destroyed as to abandon further attempts at communication and enter instead into the real passage à l'acte.

Thursday, September 8, 2016

Comment about Homesickness and the Analytic Home

Brothers and Lewis write: “…the analyst finds ways to communicate over and over again to a patient: ‘Yes, you can come home again. No matter what happened between us during your last session, no matter how different or similar we found one another, I will be here waiting for you when it is time for us to meet again.’ "

Brothers, D., Lewis, J., (2012) Homesickness, Exile, and the Self-Psychological Language of Homecoming. International J. Psychoanalytic Self Psychol. 7:180-195.