Wednesday, December 17, 2014

novel Blindness; blind to recognition, containment, acceptance?

In Blindness— the 1995 novel by the Portuguese (1998) Nobel laureate for literature Jose Saramago— an epidemic of “white blindness” mysteriously renders all people, save one, blind, and chaos and cruelty ensue. Written without much punctuation the reader must, much like a therapist trying to make sense of the patient’s narrative, discern who is speaking to whom and about what. Blindness teems with allusions to our metaphorical blindness, such as people “behave as if they were afraid of getting to know each other.”  Saramago speaks to the sanctity of reciprocity: “I have no right to look if the others cannot see me,” and to the wrath – “some will hate you for seeing” –  of being the one who sees what all others are blind to (or disavow, like a parent who attacks the seeing child’s reality). There are moments of tenderness, such as when two blind lovers reunite: “how did they recognize each other…love, which people say is blind, also has a voice of its own,” and moments of despair when one’s true self goes unrecognized: “what good would it do her beautiful bright eyes…if there is no one to see them.”

Because all, save one, are blind, there can be no witness, yet some manage to find affective sharing when the blight can “convert strangers into companions in misfortune.” Despair overtakes many in this dark novel for “what meaning do tears have when the world has lost all meaning.” Even the one who is spared this affliction is incredulous to what becomes of those around her: “what shocked her was her disappointment, she had unwittingly believed that…her neighbors would be blind in their eyes, but not in their understanding.”

If blindness is, in part, the blindness to the need of the other, then I am reminded of Stuart Pizer’s 2014 paper The Analyst’s Generous Involvement: Recognition and the “Tension of Tenderness” which eloquently joins with and departs from Emmanuel Levinas’ idea of putting the suffering other above oneself. If one is to lean towards another’s need, one must first see (recognize) the need. Pizer takes Sullivan’s concept of the ‘tension of tenderness’: “the analyst’s recognition of a need or an affect state in the patient evokes an internal tug constituting the analyst’s need to provide for what has been recognized.” He writes, “An instinctual tug toward tenderness, or a spirit of generosity, in response to a recognized state of need in the Other is an inherent feature of our functioning attachment system.”

But how does a blind person see the Levinasian strange, transcendent, unfathomable ‘face’ of the other? Pizer sees generosity as instinctual, but expects Levinas to “reject instinct in favor of a subjectivity open to interruption, surrender, and awakening by an encounter with the Other.” Pizer continues, [we are] “wired to seek community, relational embeddedness, or ‘we-ness.’” Generosity sometimes requires of the analyst, per Corpt, an “unsettling re-evaluation and openness to amending any and all aspects of analytic practice in light of the patient’s forward edge strivings.” Pizer learned from his grandfather the healing power of the affectively resonant, witnessing presence of someone who recognized his need, and accepted him just as he was. Saramago notes its opposite, “Blindness is also this, to live in a world where all hope is gone.” That is, no hope of being seen, recognized, contained and accepted.

Pizer, S. (2014). The Analyst’s Generous Involvement: Recognition and the “Tension of Tenderness”. Psychoanal. Dial., 24:1-13.

Tuesday, December 9, 2014

Whose responsibility, anyway?

The task of the analyst is to help the patient learn about himself (discover the many facets of himself, if you will), not to impose on the patient the necessity to prove the analyst’s pre-learned theories about human behavior. The analyst, then, has no corner on ‘truth’ and cannot privilege her perspective over that of the patient’s psychic reality. Instead, both analyst and patient struggle to negotiate a working relationship toward discovery. Faltering, fumbling, rupturing, both then strive to upright and repair what has been lost in the relationship. No matter how both analyst and analysand are implicated in the co-creation of the transference, countertransference, or resistance, whatever the patient does is always in the service of trying to heal himself. The patient tests the analyst for trustworthiness, commitment, and circumspection. Make no mistake, that whatever the outcome—whether impasse, acquiescence, failure to improve, getting worse, or stopping treatment – it is always the analyst’s responsibility. The analyst  welcomes in, then must contain what has been welcomed. The analyst’s failure to monitor interactions between patient and analyst, to recognize and correct misattunements, can have dire consequences. While both take responsibility for the discourse, any failure lies on the shoulders of the analyst alone.

Tuesday, December 2, 2014

Revenge and Forgiveness

Because we all seek to maintain [or create anew] a sense of individual meaning, Lafarge writes that disruption of our sense of self can lead to the wish for revenge, “a ubiquitous response to narcissistic injury.” Revenge “serves to represent and manage rage and to restore the disrupted sense of self [and restore the] internalized imaging audience [the other].” Narcissistic injury is a disruption to meaning and self value and to the story of one’s experience. In efforts to reestablish meaning and to construct a story, as well as create a witness to one’s story, the avenger uses anger and revenge to consolidate early experiences (a time when the “imagining parent” [like Bion] helped construct the infant’s mind with meaning and with its representations of self and others). Communicating experience and constructing its story is also present in the revenge. It is a way of being seen and heard and helps maintain the tie to the lost, imagining parent. Thus, revenge can ward off object loss [Searles] and hatred can be an early form of object constancy. “Giving up the wish for revenge requires the avenger to recognize the rage and helplessness that are warded off…[and] involves acknowledgement of a transient disruption of self experience” that they accompany.

Lansky tells us that shame gives rise to rage as a strategy to protect one’s sense of self from the awareness of helplessness, abandonment, betrayal. Sometimes, clinically, it is easier to analyze the visible rage and resentment than its underlying shame, but it is the detailed exploration of shame that sheds light on its unbearableness. When one’s sense of self is chronically disrupted from the betrayal by needed and beloved others, attachment is at risk. All future attachment is at risk, for who wants to be duped again, subject to humiliation and shame? The disrupted self, in valiant efforts to reconstitute a self representation that can be lived with, may need to withdraw and isolate, project, omnipotently control, split, or retaliate. The latter, as revenge, can seemingly restore a sense of power and effectiveness as well as protect against awareness of vulnerability. Revenge also protects against the uncertainty of forgiveness. Only awareness of loss and its mourning can circumvent the need to humiliate the other, leading to forgiveness both of self and other.

LaFarge, L. (2006). The wish for revenge. Psychoanal. Quart., LXXV, pp. 447-475.

Wednesday, November 26, 2014

Ferguson and Thanksgiving

In the wake of Ferguson, MO’s Grand Jury decision not to indict a white police officer’s killing of a black teenager, residents expressed their concerns. Whether police brutality or self defense, black young men are in danger, agravated by lack of accountability on too many sides. One mother tearfully asked, “What am I to tell my son when he grows up?...You try to have hope.” Another woman tearfully expressed a more universal need, “We just hope for one time that our lives will matter; that somebody will see that our lives are valuable.” This latter plea speaks to the human motivation to be seen, to be recognized for who we are and still be accepted.

As we gather around the Thanksgiving table with our families of origin and the families we have made, may we take a break from seeing what we expect and, instead, look anew from an other’s point of view, accepting her or him just the way they are, and, hopefully, being accepted in return. What might we be thankful for? That in the best of relationships we are loved, warts and all.

Wishing a Happy Thanksgiving to you and yours.

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.