Thursday, November 20, 2014

Dissociation and Enactment

Unlike Kohut, who believed in a unitary self and thought health was an increased cohesiveness in one’s sense of self, Bromberg says that we all exist in a multiplicity of self states, each with its own memory, experience, and unconscious. “Health is not integration. Health is the ability to stand in the spaces between realities without losing any of them.” (p.186), that is, it is simultaneous awareness of these many discrete selves.  The sense of a unitary self, writes Bromberg, is an adaptive illusion. Dissociation of certain self states, with their untenable affects (such as shame) occurs in all of us, often in response to the traumas of misattunement, misrecognition, or attacks on our reality. Bromberg recommends that analysts learn to see the validity of a patient’s psychic reality alongside their own, careful not to claim ownership of arbiter of reality. In this capacity to see both realities, space is made to construct consensual meaning. Their relationship is continually renegotiated.

Sometimes the only way to access dissociated experience is through enactments which can painfully draw the analyst into the early object relations of the patient. Sometimes these enactments additionally allow the patient to see his impact on the analyst. Enactments are

…an example of what Levi (1971) called “a powerful though perverted attempt at a self cure” (p.184). It involves a need to be known in the only way possible – intersubjectively—that is different from the old and fixed patterning of self-other interactions, a version of the situation that led to the original need for dissociation. (p.172)

For a patient in analysis to look into his own nature with perceptiveness, and to utilize creatively what is being enacted, there must exist a simultaneous opportunity for the patient to look into the analyst’s nature with an equivalent sense of freedom and security. (p.176)

In the clinical situation, those patients with the most dissociation, often called personality disorders, cannot resonate with interpretations which address conflict because, until contradictory self states are in simultaneous awareness, the contradiction/conflict cannot be 'seen' by the patient. Because psychic reality varies by self state, an issue already explored in one self state may come up again later in another self state. As one candidate noted to herself as her patient spoke, "Didn't we already go over this!" In this 'Groundhog Day' phenomenon, and the going over and over the same ground, is what I like to call 'the joy of Sisyphus,' and the candidate asks, "So where's the joy?"

From STANDING IN THE SPACES: Essays on Clinical Process, Trauma, and Dissociation (1998). Psychology Press. New York, London; Chap. 12, Shadow and Substance.

Tuesday, November 18, 2014

Envy as refused desire

Gerhardt’s rich paper on the intersubjective contribution of envy elucidates the part played by the mother’s (and analyst’s) failure to identify with the infant (later, analysand). Unlike Klein who saw envy as primary and related to aggression and the death instinct, Gerhardt frames envy in terms of refused desire. She sees envy as secondary to thwarting of this wish to be at one with the object, to both have and be the object, to matter to the object, as when the mother refuses to accept desire from the child as well as fails to help the child feel desired by her. The failure of the mother to adapt to the needs of the infant and her failure to see the infant’s demands for recognition as legitimate, renders her unable as well to experience maternal identification with the infant’s (secondary) envy. When the analyst (or mother) dissociates her own disavowed envy, dependence, and shame, she cannot identify with the patient’s split off self-states, and is less able to contain and transform them for the patient’s use. Gerhardt’s patient felt contained when Gerhardt invites and sustains a kind of one-ness, in part, through the analyst’s mutual identification with her patient, rendering horrible affects less terrifying.

Gerhardt writes that envy results when the “normal identificatory processes have gone awry,” and quotes Benjamin: “when desire to identify goes unanswered, envy takes its place.” [I think of penis envy and father’s rejection –or mother’s prohibition— of the female child’s identification with the father.] Envy, for Gerhardt, is an attempt at “denial of difference” and “repudiation of dependency” in response to the mother’s failure to identify with and manage the infant’s expelled and intolerable states, in particular those in which the infant (later, analysand) feels abject and defective, full of shame.  Envy, then, is also secondary to shame. Gerhardt also invokes Bion’s “protesting the separation between knower-known” [which calls to mind the humiliation engendered in the patient when the analyst insists on being the only ‘knower’ in the dyad]. [As an aside, she reminds us that Bion had noted that the mother’s failure to contain the infant’s fear evokes in the infant “nameless dread.”]

Oelsner takes the classic object relations approach, taking umbrage with Gerhardt seeing aggression and envy as secondary, and recommends the repeated analysis of aggression. He reminds us that Bion conceived of envy as an attack on linking. Envy destroys otherness by denying, through projective identification, recognition of separateness. Ornstein, on the other hand, as a self psychologist, agrees with Gerhardt that envy is secondary (this time, to empathic failure of participation of the analyst’s subjectivity and rejection of patient’s efforts) and sees Gerhardt’s eventual capacity to empathize with her patient— by giving up her “decoding interpretations” (experienced by the patient as “counter-attacks”) and by recognizing her part in thwarting the patient’s desires. Ornstein recommends seeing what transpired between them not as an attack by patient on analyst, but as a forward edge in terms of being able to make a demand of the analyst that the patient could not make as a child on her mother.

Gerhardt, J. (2009). The Roots of Envy: The Unaesthetic Experience of the Tantalized/ Dispossessed Self. Psa. Dial., 19:267-293
Oelsner, R. (2009). One Envy or Many?: Commentary on Paper by Julie Gerhardt. Psa. Dial., 19:297-308.
Ornstein, P.H. (2009). A Comparative Assessment of an Analysis of Envy: Commentary on Paper by Julie Gerhardt. Psa. Dial., 19:309-317

Saturday, November 15, 2014

Daniel Shaw on Traumatic Narcissism

If Freud said our personal ideologies are our “private religion” (convictions with unfaltering ritualization of behavior, repetition compulsion, if you will), Shaw adds that our private religions spring from our attachment story for we are all subjugated by our internal objects.  Shaw defines traumatic narcissism as the need to defend against dependency, for dependency is intolerably shameful and humiliating, and must be disavowed. Instead, dependency and neediness is seen in the other for the traumatic narcissist has everything within the self and needs no one. Traumatic narcissism is a relational dynamic requiring both the narcissist and its object to be subjugated. The easiest target is its child.

While all parents may sometimes attack the reality of their children, self aggrandize the child’s accomplishments, and have hope that the child will make up for their own failures, the traumatic narcissist can never admit fallibility, can never apologize, and continually  attempts to control and erase the subjectivity of their children. This is the cumulative relational trauma. The traumatic narcissist despises the child’s neediness, yet, paradoxically, any attempts by the child towards independence and agency are punished (by withdrawal or retaliation) for the narcissist requires the child to be the container for shameful neediness, Bateson’s classic double bind. This child, shamed for its dependence (and what is a child but dependent?), made to feel selfish and greedy, recognizing that only the attachment figure’s  needs are deemed valid, grows up to identify with the hated, but much needed, aggressor, an intergenerational transmission of traumatic narcissism.

Objectification of the child by the traumatic narcissist  is an absence of recognition, or a presence of negation. In analytic love, the therapist envisions the potential that cannot be realized, much like the good enough parent sees what the child can become. The children of traumatic narcissists, when they become our patients, demand not only that we recognize their trauma, but that we recognize our own disavowed traumatic narcissism! What a dangerously fraught journey for both patient and analyst as we struggle together toward freedom from the tyranny of our inner objects.

Tuesday, November 4, 2014

Lansky on Shame

Lansky delineates shame and guilt for us, and refers to the classical literature to make his points. He describes shame as resulting from failure to live up to one’s aspirations (ego ideal) and it signals fears of loss of relationship or separation and/or fears of exposure with concomitant humiliation. Weakness, defectiveness, vulnerability are all words patients might use to describe their shame. When shame is triggered, it may result in impulsive action, such as the intimidation of others (e.g. domestic violence) or compulsive binging, as one tries to regain control over one’s disorganizing sense of weakness. Guilt, on the other hand, results from failure to live up to superego expectations and can be used to defend against shame, for it gives a sense of action (some committed transgression) rather than the helplessness or powerlessness which evoke shame.

Shame is a hidden affect (there is shame in being ashamed), but Lansky says that it is not the affect itself which is hidden, but the consequences (social annihilation) of the affect. His idea alludes to the relational nature of shame, though when shame is consequent to failure to live up to one’s ego ideal it does not necessarily involve the other. Freud had previously noted that neurotic symptoms were an attempt to hide from awareness that which would evoke painful affect, as are defenses. (Not until 1926, in Inhibitions, Symptoms, and Anxiety, did Freud made explicit his signal theory of affect.)

Freud relegated shame to conflicts around toilet training, but Erickson spoke closer to the problem in his stage Autonomy v. Shame and Doubt, which is contemporaneous with Freud’s anal stage. Freud places guilt, and fear of retaliation (by castration), in the oedipal phase, whose heir, as you may recall, is the superego. Klein puts shame in the paranoid-schizoid position when, in addition to fear of attack and destruction, the expectation of one’s vulnerability being exploited by others with the intent to humiliate exists. Klein places guilt in the depressive position, which for her precedes the oedipal phase, when the infant becomes aware of the injury it inflicts on the mother. Kohut “divorced the notion of shame from any notion of conflict”, but Lansky opines that had Kohut linked ‘fragmentation anxiety’  in terms of its failure to live up to an ego ideal of maintenance of self image and self respect, Kohut might not have been so ostracized by the classical psychoanalysis of his day.  

My favorite nod to shame comes from Tomkins; He proposed that shame results from an interruption of joy. [How felicitous is that to remind us to meet our children’s joy with our own!] Many of the patients I see have indeed experienced the failure of their ‘love affair with the world’ to be met with attuned parental joy. Analysts, too, are called upon to meet our patients in the same direction affectively, though somewhat modified and without the disorganizing intensity, if lucky.

What Lansky might have elaborated more is the analyst’s shame, a powerful impetus to our dissociation, as when the struggle of our patients with their helplessness, their humiliation, and fears, trigger our own. He does note that “the shame of others makes us feel about ourselves what we do not like to feel: vulnerable, weak, powerless, dependent, contingent, disconnected, and valueless” and that “the emerging shame of the other stirs up our own difficulty bearing shame, our helplessness, and our anxiety that we may prove defective and fail in our professional roles because we, in facing the patient's incipient experience of shame, will be found to have nothing effective to offer.”

Lansky, M.R. (2005). Hidden Shame. J. Amer. Psychoanal. Assn., 53:865-890.

Tomkins, S. 1963 Affect, Imagery, Consciousness. Vol. II The Negative Affects New York: Springer.

Monday, October 27, 2014

Group Process 2

Additional important lessons for individual therapists to be taken from participation (procedural learning; 'the medium is the message') and understanding of group process as demonstrated by Roth on Oct 25, 2014 include:

1. The assignment (or acquisition) of authority (power).
The group facilitator often asked permission of the group and individuals to make comments on certain behaviors, e.g. pairing, before actually making said comments. He also, on occasion, made it clear that these were his point of view and open to review by the group with the possibility of a different outcome.

2. The use of data that was present and available for all to make use of.
The facilitator skillfully used exact words and phrases from group participants to call events of individuals to the entire group's attention, always reminding the group that one member may have been designated by the whole group to hold or contain something for the entire group (e.g. loss, trauma, sadness, aggression). Unfortunately, for some, this method was too exposing, felt to be too personal, and, therefore, narcissistically injurious, something the individual therapist strives to avoid but inevitably finds her/himself inflicting. Since injury is inevitable, what is valuable is the reparation. Reparation cannot occur if admitting injury is further humiliation. Likewise, the disappearance of the consultant, like the end of a session, feels, to some, being 'kicked to the curb' and we have no next session with the facilitator. The group will have to make use of the consultant through object constancy.

Sunday, October 26, 2014

Group Process

Many psychoanalysts eschew group therapy, but yesterday the Tampa Bay Psychoanalytic Society, Inc had an experiential look at group processes provided by its guest 'speaker' Jeffrey Roth, MD. Based on Wilfred Bion’s basic assumptions about groups, as taught in the U.S. by the A.K. Rice Institute for the Study of Social Systems, we had firsthand experience with the impact about how our behavior and unconscious processes organize experience intrapsychically, interpersonally and en masse.

Bion posited three basic assumptions for group behavior:
1)      Fight/flight, where the group hostilely engages authority
2)      Dependency, where the group does nothing but expect that the all powerful authority will provide for everything, and
3)      Pairing, where the group deems authority as incapable of providing what is needed and so two in the group are ‘elected’ as the pair who will now make provision of group needs.
A fourth group, the work group which functions to accomplish tasks, is often thwarted by these three basic assumptions, while paradoxically illuminating (through consultation) what the work group needs to address.

How did our use of group process help us in our work as individual therapists? We procedurally learned that everything that emerges (data) is useful and has meaning, contributing to the richness of the dyadic interaction, if the therapist welcomes it in, and can make use of it, instead of being bored as if nothing ‘deep’ is being related. All data signals what would like to be taken in or pushed away. Groups function around ‘BART’,  boundaries, authority, roles, and tasks. How these four entities are negotiated by the group are experienced, studied, elucidated, and may be transformative. While the group experience is transformative, and may continue to be so, old roles and skill sets (leader, scapegoat, etc) remain available. We are made up of multiple selves, after all.  

Sunday, October 19, 2014

Horror Film: The Orphanage, viewed and discussed 10-19-14

The Orphanage (2007), directed by Juan Antonio Bayona,  is about the unconscious, inadvertent, intergenerational transmission of trauma and it was deftly discussed today by Adriana Novoa, PhD at the Return of the Repressed Film Series.  She notes that most horror films place what is horrifying ‘outside’ or into the ‘Other’, but that this film places the horror inside the characters, and inside the audience through its emotionally resonating themes.

Laura (Belen Rueda), her husband Carlos and their adopted, seven year-old son Simon (Roger Princep) move to Laura’s childhood orphanage which she hopes to restore and reopen to care for five more children. Simon does not understand his mother’s need to take in more children. He has been told neither that he is adopted nor that he is HIV positive, but is understandably angry when he overhears this. When Laura and Carlos host a festive garden party for potential wards,  Simon disappears. Laura begins to suspect that the orphanage is haunted. Consulting a medium (Geraldine Chaplin), she learns that a number of orphans had been poisoned there. Perhaps Laura repressed any knowledge of Tomas who had drowned, a few days after Laura is adopted, as the result of a cruel prank played on him by the other orphans. These culpable children disappeared soon after.  

The audience can speculate that Laura’s dissociation of her early traumas (loss of childhood playmates, for example) made it difficult for her to recognize the losses Simon experiences. Her refusal (out of terror) to recognize her own son behind the mask, as well as his anger at her ‘lies’, lead to his unfortunate demise. His final attempts to communicate himself to her (through banging from the cellar where he is trapped) fail just as his previous communications about his discoveries of Tomas’ anguished world fail to get Laura’s understanding. Her misrecognition of Simon’s world is fatal. Laura’s unconscious wish to restore the lost (murdered) five children by caring for an additional five differently-abled children is thwarted. Likewise her unconscious knowledge of the accidental death of Tomas is recreated, poignantly, in Simon’s accidental death. Only in Neverland, in death, can the lost children be reunited with Wendy, now grown. Nowhere is the return of the repressed more dangerous.

Wednesday, October 15, 2014

The Developing Self and Origins of Shame

 Knox gives us a neurobiological explanation for the origins of shame. Should the mother register disgust for her infant or her infant’s agency, the infant’s sense of self and of agency is linked –through the insula (where mirror neurons may activate disgust) and the midline structures (where the sense of self is thought to be encoded) –with shame. A mother who cannot tolerate her infant’s distress may cause the infant to procedurally learn to hide pain in order to protect the attachment. This may result in a fear of love or Fairbairn’s schizoid personality, where shame has been linked to relationship.

A sensitively attuned mother is less likely to be disgusted by her infant and his needs. Winnicott speaks of the primary maternal preoccupation as a necessary requisite to allow for development of sufficient attunement of mother for baby. In doing so, we can infer that, he advocates for safeguarding the necessary space for the pregnant woman and new mother to acquire the necessary sensitivity to the needs of her infant. Should there be a failure to attune to the infant’s needs, the infant is in danger of a disruption of going on being, and of annihilation anxiety. Winnicott notes that in the early days of life, it is the mother who must identify with the baby, and not vive versa.

Lycia Alexander-Guerra
Tampa, FL

“…the need for the therapist to facilitate a process of disruption and repair (Beebe & Lachman 2002) in which the patient has an opportunity to correct the therapist's misattunements (Benjamin 2009)”  
I give an example from today’s session.
The client, in 8th year of therapy with me, tried to correct my misattunement saying that I had to listen [to]her need more, that is, she did not need my mirroring, but rather my opinion different [from] hers. While explaining that to me I asked her what she was experiencing my mind focused on. She replied, “I know you listen to me [with] so [much] concentration that I get love and affection.” Then gradually she started crying. After a little [while], I asked, ‘What was the correlation with your tears?’ She told me, “I asked for your opinion different [from] mine [and] you give me a different focus on me, compared to the not being focused [on by] my parents. How can I be so arrogant?”

 I think that was an example of disruption and repair where a part of herself was correcting me, paying attention to a self state I was ignoring, while another self state of hers was being repaired but was partially ignored by her!

 “What the mother does well is not in any way apprehended by the infant at this stage. This is a fact according to my thesis. Her failures are not felt as maternal failures, but they act as threats to personal self-existence”
I am not sure I agree with such a thesis. Although there is limited consciousness or self to perceive the mother as good enough, or bad enough, I think there is sufficient attachment-based relational need that is encoded preverbally via the body. If the mother attunes well or not well with the baby’s attachment needs, regulation/dysregulation is experienced via the body.
Stavros Charlambides
Athens, Greece

Knox, J. (2011). Dissociation and shame: shadow aspects of multiplicity. J. Anal. Psychol., 56:341-347.

Winnicott, D. (1956). Primary maternal preoccupation. In: Collected Papers, Through Pediatrics to Psychoanalysis. NY:Basic Books.

Thursday, October 2, 2014

More on Winnicott’s The capacity to be alone

I like, as always, the poetic rhythm Winnicott offers to the reader! As I was reading Winnicott’s The capacity to be alone, I questioned whether the author was trying to make explicit a narcissistic developmental issue or a schizoid developmental trauma? In my view, the latter was more likely.

The capacity to be alone is presented as a prerequisite of the capacity to be alone with your self. While he goes very deep in helping us understanding the issue I think the paper misses addressing the other side of the coin, that is, the capacity not only to be with your self but also the capacity to be without the other. This is in my view different from the former one. I did not see something written in the paper regarding dissociative phenomena, especially about those clients who are caught in between, partially being able to stay alone, and, simultaneously, stay without the other.

These clients can stay in silent moments in treatment for a while and give a glance to the analyst. They can stay partially alone in the presence of the analyst but cannot stay equally alone without his presence (that is evident via the glance). Many times as well these clients are alone psychically in the presence of the analyst: they are involved with the discussion but you sense their body is frozen (not in excitement attachment). This is an indication, I think, that they can be partially alone in the presence of the analyst, and with themselves, but not alone without him .

Winnicott, D. (1958). The capacity to be alone. Int.J.Psa., 39:416-420.

Stavros Charalambides
Athens, Greece

Wednesday, October 1, 2014

On Play and the Capacity to be Alone

[Winnicott writes]
·       The capacity to be alone is a highly sophisticated phenomenon and has many contributory factors. It is closely related to emotional maturity
·       Ego-relatedness refers to the relationship between two people, one of whom at any rate is alone; perhaps both are alone, yet the presence of each is important to the other
·       Gradually, the ego-supportive environment is introjected and built into the individual's personality, so that there comes about a capacity actually to be alone.
·       If the patient cannot play, then something needs to be done to enable the patient to become able to play, after which psychotherapy may begin. The reason why playing is essential is that it is in playing that the patient is being creative.
·       There is no need for the therapist to organize chaos all the time. Sometimes that behaviour covers and substitutes a real need for rest and empathic listening.

For example I have a patient deeply emotionally detached [who] tries to understand how to handle relationships. For that reason I proposed [to] him to join a group and indeed he accepted. He is in the group for 3 months and now he feels angry with other members because they talk and they do not allow time and space for him and others. When I asked him (in individual session) what do you want from others when they see that you are not talking? He replied "to give space to my silence. I do not want [them] to tell me anything but I need [them] to respect my silence and accompany me in that. I want to stay all in silence for some minutes in order to feel what I feel, to touch the depth of my sorrow that I cannot otherwise demonstrate."

At the previous session I "played", as Winnicot says, with him. I showed him a video from the web. In that video a man was seeing a woman from a distance and then tried to reach her by walking [across] a street. A car hit him, some glass from a window broke [and reached the woman]. However, they did not reach each other. The message was that all of that was only in the man’s fantasy. While my client was watching the video he cried and I did not ask him anything except one comment, "It seems that you at least reached out to something." So I was company, a silent company to his noisy loneliness.

Winnicott, D. (1958). The capacity to be alone. Int.J.Psa., 39:416-420.
Winnicott, D.W. (1956). D.W. Winnicott, Playing and Reality, London: Tavistock, Chap. 4  Playing: creative activity and the search for the self. 

Dimitrios Tsiakos, 
Athens, Greece