Thursday, July 4, 2019

4th of July, Citizens and Immigrants

No one needs to be reminded that, after killing off its Natives, our country was built by immigrants. Sometimes we forget, though, that those groups whose arrivals preceded other groups’ have historically ‘othered’ the later arrivals, and with the added intent to bar citizenship to people different in religion or country of origin or race, despite these characteristics are protected from discrimination under the law. Asylum seekers, too, have legal protection.
On The Daily Show withTrevor Noah (Sept 27, 2018) America Ferrera (actor, author --“American Like Me,” -- activist, and director) said  “...women and people of color and all sorts of marginalized people in this country are feeling we should be able to walk into spaces with our whole selves. We shouldn’t have to strip away the pieces of us that aren’t accepted by the mainstream culture to exist and be accepted in spaces. For me that means I’m an actress, that means I’m a director,  that means I’m a producer, that means I’m an engaged citizen and I get to be all of those things no matter what room I walk into.” [I have always liked this woman, in part because her immigrant parents so admired this country that they named her after it!]
The Second paragraph of our sacred Declaration of Independence says
We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. 
Fortunately, for women the liberal interpretation now includes us, but, of course, we are not all created equal. Some of us are taller or faster or smarter or more symmetrical. What is unalienable is that we are all entitled to equal treatment and protection under the law. This latter truth is often circumvented. Those with money are, as we know, treated and protected better than those without money. If USA could remedy this and have equal treatment under the law, perhaps global citizens could better be recognized as deserving of human rights, no matter their country of origin. If America wants to spread its values around the world, perhaps it should start at home.

Friday, June 28, 2019

Stonewall

Last week the American Psychoanalytic Association (APsaA) apologized for its part in formerly pathologizing homosexuality and for the “discrimination and trauma” doing so had inflicted on those who sought help from psychoanalysts. In 1991 homosexuality, under threat of an anti-discrimination lawsuit, was no longer classified as a mental disorder. The APsaA now stands against conversion therapy and supports LGBTQ civil rights.
Earlier this month NYC’s Police Commissioner apologized for the raid, fifty years ago today, on Stonewall Inn, a popular bar-nightclub for gay men and women. A riot ensued when patrons fought back by throwing bottles at police officers, and, days later, demonstrations for the civil rights of LGB Americans took place. Stonewall sparked the Gay Pride movement. President Bill Clinton was the first president to acknowledge Pride month in 2000.
Virginia Goldner said:
[I]n considering the history of gender-variant subjects, I am more struck by the trauma of stigma, which, along with the isolation of being/feeling different, and of coping with the unrelenting, embodied self-alienation of gender dysphoria, takes a far greater toll on the soul than I had initially understood. I still think it is these experiences of self-alienation, combined with an estrangement from one’s very own breathing body, that constitute the foundational trauma of gender variance.
Corbett, K. Dimen, M. Goldner, V. Harris, A. (2014). Talking Sex, Talking Gender—A Roundtable. Studies in Gender and Sexuality, 15(4):295-317.

Sunday, June 23, 2019

Reading Aloud and the Third

Children’s book author and two-time Newberry medalist Kate Dicamillo [Louisana’s Way Home -- described as “a story of discovering who you are — and deciding who you want to be”] recounts a momentary event that changed her outlook forever. 
In 1972, when she was eight years old at Clermont Elementary School in Clermont, FL, her second grade teacher Mrs Boyette was reading aloud to the class from Island of the Blue Dolphins. She says [Nov 19, 2018, PBS NewsHour, IMHO],
“I am literally on the edge of my seat ...caught up in the wonder of it all. I am a kid who loves a story. But also in that second grade classroom seated not too far away from me there’s a class bully. Because I am so terrified of this boy, he does not even seem real to me, he is in my mind less a boy and more … a monster. ...and I notice that he is listening too, that he is engaged by the story too, that he, like me, is leaning forward in his seat and listening with his whole heart.  I stare at him, open-mouthed. I’m struck with the sudden knowledge that this boy that I am so afraid of is, in fact, just like me. He is a kid who likes a story. The boy must feel my eyes on him because he turns. He sees me seeing him and something miraculous happens: he smiles at me, really. And then another miracle: I, unafraid, smile back. We’re two kids smiling at each other.
“Why have I never forgotten this small moment? Why, almost 50 years later, do I still recall every detail of it? I think it’s because that moment illustrates so beautifully the power of reading out loud. Reading aloud ushers us into a third place, a safe room. It’s a room where everyone involved, the  reader and the listener, can put down their defenses and lower their guard We humans long not just for story, not just for the flow of language, but for the connection that comes when words are read aloud. That connection provides illumination. It lets us see each other. When people talk about the importance of reading aloud they almost always mean an adult reading to a child. We forget about the surly adolescent and the confused young adult, and the weary middle aged, and the lonely old. We need it too. We all need that third place, that safe room, that reading provides. We all need that chance to see each other.”

Wednesday, June 19, 2019

Reparation, a way towards repair

H.R. 40 seeks to establish a commission to study the effects of slavery and its subsequent racial and economic discrimination, and its physical, economic, and psychological impact on African Americans today, and then make recommendations for repair and reconcilliation. In 1989 John Conyers, (D) Rep. MI, introduce H.R. 40 (40, from 40 acres and a mule) and today it might finally have some teeth. Therapists familiar with rupture and repair might have some insights to offer the US Congress on healing. While a few presidential candidates have come out in favor of reparation, one, Marianne Williamson, is an author and activist who actually knows a few things about healing the soul of our nation evident in her ideas about poverty alleviation, peace building, women’s advocacy, and feeding the hungry, to name a few.
Therapists are well aware of how insidious and pernicious intergenerational transmission of trauma is on families across time.  Attachment research and Infant-mother research have shown that anxiety and dissociation are not merely inherited but are created from experience, that is, encoded in the brain and built within central and peripheral neuronal connections that become a default position for future experience. Huge retrospective and prospective studies have documented the physical and psychological consequences of adverse childhood experiences (ACE).
Is any trauma so heinous or span centuries as slavery did in the United States? Dehumanization of people, the calculated splitting up of families (seen recently at our southern border), the terrorization to body and sense of self (continued by Jim Crowe segregation laws, the KKK, lynchings, and today, the inequitable incarceration and shooting of black men) all create long lasting sequelae to traume. Reparations (more than eigthy billion dollars) were paid by Germany to Jewish Holocaust survivors and refugees. The USA compensated Japanese interned during World War II (Civil Liberties Act of 1988). Is there a way to recognize the early economic prosperity of America established on the backs of unpaid slave labor that can heal the soul of America?

Sunday, April 14, 2019

Remembering Sidney Blatt

Yesterday (April 13, 2019) the Tampa Bay Psychoanalytic Society’s own John Auerbach, PhD gave tribute to the late psychoanalyst Sidney Blatt. Blatt put forth some interesting ideas such as that of two developmental lines, relatedness and self-definition which were linked to two types of depression, anaclitic (Greek for leaning against) and introjective depression, respectively. Those with anaclitic seemed dependent on others to love them while those with introjective were self-critical and riddled with guilt. Rather than seeing these two developmental lines as sequential, one more mature than the other -- as Blatt and other traditional psychoanalysts had originally conceived -- Blatt came to understand that relatedness (once considered infantile and hysterical personalities) and self-definition (paranoid or obsessive personalities) develop in parallel, one co-defining the other, opposites only relative to each other. Auerbach noted that, of Erickson’s eight developmental stages, only two (Trust v. mistrust and Intimacy v. isolation) were about relatedness, while the rest were about self definition (autonomy, initiative, industry, generativity, etc).
The personality develops in is a continuous dialectic between relatedness and self definition. Deficits in or over emphasis of either developmental line leads to psychopathology. These polarities of relatedness and self definition were applied by Blatt et al to attachment theory and separation, respectively, where avoidant attachment presumably correlated with introjective depression, and such patients better utilize the couch, while ambivalent-resistant were tied to anaclitic depression, and may benefit more from face to face treatment. [Consider that one patient may, in different self states, exhibit both polarities. Blatt actually posited impairment was initially greater with mixed type in-patients (they also improved more). Perhaps this is because of greater dissociation at work?]
Blatt et al integrated mental representations with Bowlby’s concept of  internal working models to better explicate insecure attachments and developed a number of research tools. The Object Relations Inventory asks the patient to describe mother, father, significant other, self, and their therapist at different points in time over the treatment. This inventory apparently allowed clinicians to measure therapeutic change in patients in the [Austin]Riggs-Yale Project study by measuring changes in the developmental organization of their mental representations of self and other. Blatt et al also developed the Differentiation-Relatedness Scale to rank where a patient, at any time in the treatment process, stood in her/his capacity to be both separate and attached, based, in part, on reflective capacity.

Monday, April 8, 2019

Clinical Use of Attachment Theory

A gifted therapist whom I supervise serendipitously provided a clinical example illustrating the usefulness of Attachment Theory. The therapist had just begun treatment with a nineteen year old female patient who stated in their very first meeting, ‘I had four previous therapists and they all irritated me by asking questions. Don’t ask me questions, just give me a task and then observe what I do and give me information on what you observe.’ She added, “when people irritate me, I do something to irritate them back.’ For the therapist it felt there was an unmistakable need of the patient to be in control.
Controlling behavior in Attachment Theory brings to mind the observation in six year olds who had a history of disorganized attachment at one year, disorganized, perhaps, because their attachment figures were frightened or frightening. These six year old children exhibit controlling caregiving or controlling punitive behavior. What might have led to the above patient’s need to control the therapy situation? Had her parents been too controlling (frightening) or had they been unable to ‘take control’ [regulate] of the situation (frightened) causing the patient to prematurely need to ‘stepup’ and take things into her own hands?
Both, said the therapist: The parents had frightened the patient as a little girl by beating her, and they had failed to attend to her emotional life. The patient says there is nothing she wants except death, but the patient must kill others before she kills herself. The patient recognizes that either action (suicide or homicide) will serve to indict the parents. Perhaps it is her parents she will kill. The parents confirm that it is their daughter who is now in control for they tip toe around her so as not to set her off. [It has become a life-death struggle for a child to save herself when faced with a dangerous onslaught against her developing self and her developing agency.]
The patent predicts whether her day will turn out poorly or well based on whether the calendar date is odd or even. [I muse that OCD symptoms give a sense of control, control about the future.] The patient cannot sleep before an exam or a doctor’s appointment or a trip. [Perhaps she must remain vigilant to predict what is coming. Predicting a beating or what she needed to do next would be important to a small child whose parents are frightening and frightened.]

Sunday, March 24, 2019

Dependency is not the same thing as Attachment

Inexperienced therapists --- and some patients, too --- often worry that patients will become ”dependent” on the therapist and unable to, one day, leave therapy. This worry may be confusing dependency with attachment. Bowlby, according to Sable, distinguishes the two by their observable, distinct behaviors. For example, babies are dependent on others for food, but eventually grow to be able to feed themselves; and the other who provides the bottle may be substituted. Attachment needs, however, are life long and are not related to immaturity. The attachment bond/attachment figure is not so easily interchangeable. Development of attachment bonds is an achievement, not something to be outgrown.
Furthermore, Bowlby thought that fears [on the part of the therapist] about dependency could obfuscate awareness of the universal human need for attachment [in their patients]. Therapists provide an attachment bond and a secure base [through affect regulation/attunement, through timely and consistent repair of ruptures, and through shared affective experience- per Beebe and Lachmann; and through a ‘moving along’ toward a shared intention- per Boston Change Process Study Group; by being emotionally present and honest, yes, and by being punctual]. This secure base allows the patient to explore novel, and ‘safe surprises’ [Bromberg], such as previously disavowed affective states.
Just as with children viz a viz the caregiver, secure attachment develops in patients an increased psychological self sufficiency from which to explore their inner and outer worlds, and, in relationship with the therapist, reconfigures ‘internal working models’ [Bowlby] --- internal working models being a kind of ‘implicit relational knowing’ [Lyons-Ruth] or relational paradigm [Herzog] encoded in the brain as a pattern of behavior or way of ‘being with’ another. While it may take years in the treatment for a secure attachment to develop, the existence of this secure attachment decreases, not increases, dependency. (Is it counterintuitive to learn that increased secure attachment decreases dependency?) The therapist, through self reflection and supervision, and through being attuned to patients’ needs, comes to terms with discomfort regarding being depended upon and being intimately, authentically related to the other.

Sable, P. (1994). Anxious Attachment in Adulthood: Therapeutic Implications. Psychoanal. Soc. Work, 2(1):5-24.

Tuesday, March 19, 2019

Relational Ideas and Attachment

Wallin explicates the dovetailing of Attachment Theory with relational and intersubjective clinical practice. For example, repair of ruptures and negotiation of differences are important both in the clinical situation and in building secure attachment. Development of a healthy, flexible, broadly experiencing, authentic self is an aim of treatment and of the loving caregiver toward the infant.  Relational therapy -- by therapists examining their own participation and influence, and by inviting the patient to aid the therapist’s self reflection-- recognizes the capacities of the adult patient.
Wallin highlights for us some of the important ideas in relational therapies:  Influence in relationship is mutual and reciprocal, though roles may be asymmetric, as with therapist-patient or parent-child. Thus, transference is co-created. Resistance, too, is co-created, and a communication to the therapist that some experiences remain too painful as yet for the patient, reminding the therapist to be more attuned. It is impossible, sometimes even harmful to attempt, to be neutral, abstinent, and anonymous. Mindful of the patient’s best interest, self disclosure can instead be useful, for -- just as it is important for a child to know the mind of the caregiver in order for the child to develop a mind of one’s own -- it is useful for a therapist to feel and contain affective experiences if the patient is to do so as well.
Self disclosure, knowing the mind of one’s therapist, can foster mentaization. Speaking to our affective experience viz a viz the patient experientially communicates to the patient that dissociated thoughts and feelings can be safely owned, discussed, integrated. It can let the patient know of her/his effect on the therapist, bulwarking agency. It can model the link between words, feelings, experience. It can be a step towards finding our way out of enactments.
Enactments are an opportunity to access dissociated experiences. Self states which are rejected by the caregiver tend to be dissociated by the child. Integrating dissociated experiences -- by welcoming in, containing, speaking to our own experience, etc -- are all part of relational therapy and allow the patient to experience the therapist as a new attachment figure.
Wallin, D.J. (2007) Attachment in Psychotherapy Chapter 10. Deepening the Clinical Dimension of AttachmentTheory. (Guilford Press, NY)

Saturday, March 16, 2019

Sufi Poem

THE GUEST HOUSE
This being human is a guest house. Every morning a new arrival.
A joy, a depression, a meanness ,some momentary awareness comes as an unexpected visitor.
Welcome and entertain them all! Even if they are a crowd of sorrows, who violently sweep your house empty of its furniture, still, treat each guest honorably. He may be clearing you out for some new delight.
The dark thought, the shame, the malice, meet them at the door laughing and invite them in.
Be grateful for whatever comes, because each has been sent as a guide from beyond.
-- Jelaluddin Rumi (1207-1273)
Trans: Coleman Barks

-- submitted by David Baker, Ph.D.

Tuesday, March 12, 2019

Attachment and Development of the Self

The TBIPS’ Attachment and Affect second year course continues to utilize David Wallin’s very readable and informative 2007 book Attachment in Psychotherapy. In Chapter 7. How Attachment Relationships Shape the Self, Wallin connects the child’s developing sense of self and agency with the caregiver’s capacity to participate in what Lyons-Ruth (1999) termed ‘collaborative communication,’ with its four main components of 1) being receptive to the child’s affects and experience; 2) initiating timely repair of inevitable failures in collaborative communication; 3) providing “scaffolding” [Kohut] to the child’s emerging capabilities; and 4) staying engaged [and/while struggling] with the child even across differences in experience and agendas. [Recall Beebe’s and Lachmann’s (1996) three principles of salience: ongoing affect regulation; timely and consistent repair of ruptures; shared heightened affective moments--providing both security and safe novelty]. It goes without saying that all four elements also serve the therapist and client well.

Being inclusive and open to the “entire array of affective communications” (Lyons-Ruth) of the child’s experience helps the child integrate its feelings, thoughts, and behaviors [unlike, for example, a dismissing parent who implicitly teaches the child that certain feelings or behaviors are unwelcome and thus to be dissociated as ‘not-me’ (Bromberg)]. Lyons-Ruth says a collaborative caregiver actively structures dialogue to elicit the child’s needs and desires. Consistent and timely repair implicitly shapes a child’s expectations about caregivers and the world [Recall Erikson’s first stage Trust v. Mistrust]. Scaffolding supports the child’s emerging sense of self and agency so that the child can safely explore, have experience of self confidence as well as experience that the self’s agency does not jeopardize the relationship. Staying engaged [e.g. surviving, ala Winnicott] fosters the experience of intersubjectivity, allowing for connection even within difference.

Parents of securely attached infants mirror and ‘mark’ [Gergely and Watson, 1996] vocalizations, affect, and facial expressions with midrange [Beebe and Lachmann, 1997] contingency, while low range contingency may predict avoidant and highest range contingency disorganized attachments.  Secure parents, flexibly respond to a child’s needs both for attachment and proximity and for autonomy and exploration. Their communication is collaborative, contingent and affectively attuned. Note that, like Main, Lyons-Ruth (1999) speaks to the coherence of dialogue, using Grice’s criteria for communication: quantity (e.g. succinct while complete), quality (truthfulness and internal consistency), relation and manner (collaborating with listener; relevant). The therapist’s responsiveness also enhances the client’s sense of having effect on the other, enhances agency.

Wallin notes that some (dismissing) patients -- obsessive, narcissistic, schizoid-- may have learned as children (avoidant attachment) to distance themselves from others and to rely on left-brain strategies. Their dismissing parents may have discouraged attachment behaviors. Conversely, hysterical and borderline individuals may hyperactively seek closeness, preoccupied with others, by maximizing emotional distress (ambivalent-resistant attachment as children). Their preoccupied parents may have discouraged autonomy. Unresolved adults, who as children had disorganized attachment without a consistent pattern of coping behaviors, may oscillate between distancing (“avoidance of closeness”) and preoccupation (“terror of abandonment”) and with dissociated affects.


Wallin, D.J. (2007) Attachment in Psychotherapy Chapter 7. How Attachment Relationships Shape the Self. (Guilford Press, NY)
Lyons-Ruth, K. (1999). The Two-Person Unconscious. Psychoanal. Inq., 19(4):576-617