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


Knox:
“…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!

Winicott:
 “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

Tuesday, September 30, 2014

Somatization and the subsymbolic

As we know, trauma increases blood flow to the amygdala while decreasing perfusion to the hippocampus with the effect that procedural, emotional and sensory memory take place without the benefit of symbolization in language and without contextualization (one physiological explanation for dissociation). This phenomenon informs how clinicians can work with experience that has no words. The narrative approach assumes that symbolization is already present. Trauma, including the trauma of chronic misattunement, can cause chronic autonomic nervous system activation (affecting respiration, heart rate, perspiration, muscle tension, etc) with its emphasis on sensory not symbolic representation.

Bucci proposed a multiple code theory of emotional processing, three systems of emotional schema: the subsymbolic (perceptual, sensory), symbolic imagery – both non-verbal— and the symbolic (verbal).  These three systems are separate, but through the relational attunement and secure attachment with caregivers, who use their own emotional and cognitive schema to help children name, accept and regulate their emotional states, connections between the three are forged. In somatization, subsymbolic somatic schema are activated but are dissociated, never linked, or have lost their link to symbolic representations.

Taylor contrasts conversion disorder with somatization disorders. In the former, symbolization is intact and emotions are represented, and symptoms are the result of repressed (by an active ego), conflictual fantasies. On the other hand, somatization, writes Taylor, lacks underlying fantasies, and emotions are poorly representable, sometimes called alexithymia. (The ego is made helpless by dissociation.) Two different therapeutic aims ensue. For conversion symptoms, Freud made conscious the unconscious conflict through interpretation, but with somatization symptoms, says Bucci, what is required is a strengthening of connections between the subsymbolic and symbolic.

Gottlieb gives a nice history of the way different psychoanalysts have conceived of psychosomatic symptoms. They argue causality, meaning, and treatment. Students might enjoy contrasting Janet, Freud and MacDougall, as well as distinguishing la pensee operatoire from alexithymia. Many agree that somatization involves dissociation. Where does a child turn when the very people who are to help regulate distressing feelings are also their source? Hopefully, we will, in class, add from our clinical experience the relational intersubjective component of psychosomatic disorders, with the understanding that caregivers powerfully affect one’s ability to symbolize, mentalize, and see the other as an equal center of subjectivity.

Gottlieb, R. (2003). Psychosomatic medicine: the divergent legacies of Freud and Janet. J. Amer. Psa. Assoc., 51:857-881.

Taylor, G. (2003). Somatization and conversion: distinct or overlapping constructs? J Amer Acad Psa, 31:487-508.

Monday, September 29, 2014

Developing sense of self

Winnicott and Knox both speak to the infant’s developing sense of self and both are relational in the import for this ascribed to the environment.  Winnicott wrote that only in play, being creative, can the individual discover [become] the self. Being creative is not about products of the body or mind, but rather a feature of total living. Play, for Winnicott, meant living in the potential space [sometimes called transitional space or the third], “an area that is intermediate between the inner reality of the individual and the shared reality of the world that is external…” Winnicott exhorts the therapist to create an environment which allows for this third space in which to play. The good enough therapist provides repeated experiences that allow the patient to trust as well as enters into the arena of play with the patient.

While Winnicott recommends refraining from getting in the patient’s way to self discovery, for example, by the therapist being more interested in being clever, the one who knows or makes sense of, than in following the patient’s formlessness, his example seems to belie that his patient came alive from her formlessness (and his restraint from interpretation). Instead, she seems to complain repeatedly that she did not matter to him and only became enlivened after he actually shared the contents of his mind with her. [The mother develops her baby’s mind, and co-creates meaning,by having him in her mind, and by engaging the infant in reciprocal turn-taking.] It was when Winnicott reflects back, nearly two hours later, his patient’s experience to her does her experience take on meaning for her. [It befuddles me how Kohut failed to cite Winnicott when writing about mirroring.]

Knox writes that the infant’s sense of self first comes in to being by the meaning attributed to its actions by its mother.  A child internalizes [develops its sense of self through] its mother’s attributions, positive or negative. Negative attributions, internalized, then, can generate a sense of a deficient self, with its concomitant shame. To bulwark a diminished self, grandiosity and narcissism may be self-protective as the child struggles to remain alive emotionally.

Knox, J. (2011). Dissociation and shame: shadow aspects of multiplicity. J. Anal. Psychol., 56:341-347.
Winnicott, D.W. (1956). D.W. Winnicott, Playing and Reality, London: Tavistock, Chapter 4. Playing: creative activity and the search for the self.  

           

Wednesday, September 24, 2014

the politics of inclusion

Two wonderful things happened this week in NYC:

Today The United Nations Security Council resolved unanimously to stem the flow of foreign terrorist fighters across borders, allowing Secretary General Ban Ki-Moon, in his address to the Council, to note how “enemies of faith…brutalize women and girls” and “target and slaughter minorities.”    He also said, “Eliminating terrorism requires international solidarity …[W]e must also tackle the underlying conditions…The biggest threat to terrorists is not the power of missiles. It is the politics of inclusion…and respect for human rights…Missiles may kill terrorists, but good governance kills terrorism…societies… free from suffering, oppression and occupation.”

And Melinda Gates highlighted the pressing need for gender equality (e.g. in education and health) around the world. [Despite the gender inequality unaddressed] in the Civil Rights movement, the tenet that ‘no one is free until we are all free’  still rings true, and women and girls have waited a long time for equality. Perhaps the wait is approaching closer its end.

Monday, September 22, 2014

Horror Film: The Ring, viewed and discussed 9-21-14

Scott Ferguson, PhD, Film Professor at USF, spoke to the “pleasure” of horror films—indulging viscerally, sensually-perceptually, and affectively in the “abject”— and about the pleasures and horrors of media. Evoking Marshall McLuhan, he noted that egalitarian access to information media destabilized roles and place, frightening some, while simultaneously allowing new freedoms for connections. How are we to negotiate being with one another in these new ways, all the while uncertain, our privacy threatened? There are ethical challenges to consider [and only Aidan pauses to ask about how our choices affect others].

Ferguson asked us to consider how a film engages the cultural moment, socially and historically, not merely to think psychologically about relationships and characters, but to additionally think about how these are also conditioned by electronic media. The winged shape of a ‘samara’ seed enables the wind to carry it farther away from the parent tree. Thus estranged from its origins, Samara – adopted, then killed, then killer— speaks to the futility of recapturing the nuclear family, if one ever existed.

Symbols in this film confound the viewer, first suggested, then disconfirmed, offered, then undermined. There is the ring left by a coffee cup or that formed by the mouth of the well, Samara’s tomb, and, of course, the fatal telephone ring. A ring can symbolize wholeness, closure, where beginning and end meet, but in this film there is no resolution. A lighthouse which is meant to give protective warning, leads to more danger. The island isolates and connects. Where medium is viewed as conduit, agency, means, The Ring depicts multi-media: telephones, boats, water.

Much was made of reproduction, whether the copying of the VHS tape or human procreation, both leading, in this film, to a deadly end. One audience member asked why do humans seek to procreate, particularly when children are so disruptive to their parents’ lives. Anna kills her adopted daughter Samara.  Thinking about the relational context depicted in the film, how are the children allowed to develop and then engage the world? Neither Samara nor Aidan were wanted by their fathers, Richard and Noah, respectively. Despite the exterior trappings of a normal home, there was no space for Samara to be herself. Samara was a child wanting to be heard, calling out to be saved. Her adoptive parents constrained her, not just in the barn, but in every way.  Samara’s agency frightened her parents. She had to produce herself, come in to being herself. Parents who disempower their children, dehumanize them, creating monsters.

The audience also appreciated the cinematography, comparing its chaotic black and white scenes to Picasso’s Cuernavaca, the isolation of the island buildings to Hopper, and the grayish-greenish imagery to our surreal nightmares. At other scenes, color was hyper-saturated, like neon invading our senses.

So many perspectives brought together, what a rich discussion followed the viewing of The Ring yesterday!