Thursday, February 14, 2019

Relational really resonates

A candidate at the Tampa Bay Institute for Psychoanalytic Studies, a contemporary institute which emphasizes relational and interpersonal ideas, recently attended a conference on shame in another major city. The presenters were mostly classical/Freudian analysts. A case session was presented and discussed. The TBIPS candidate was flabbergasted to hear how others thought about the female patient, and he felt very isolated when all the attendees seemed to agree with what they were hearing from the discussants. The candidate had learned to listen in a different way from Freudian analysts. He was thinking about attachment, a second year course taught here at TBIPS in which he is currently enrolled.

This particular female patient had been separated at birth for many days due to a postpartum illness in the mother. On reunion, the mother did not believe the baby returned to her was her baby. Then, due to a death in the family and other catastrophes, the girl was separated from her parents again for three years.

In the session presented, the female patient came late and then asked for some water. The Freudian analysts all commented that she was a very aggressive patient. When the patient asked the therapist ‘what do you want me to talk about?’ the discussants reiterated what a very aggressive patient she was, ‘trying to control everything.’ The analyst remained silent and the patient began to talk about things in her life and the discussants complained that she was spewing ‘useless’ information, information of no value or importance in attempt to ‘disorient’ and confuse her therapist. They complained that she did not talk about her trauma and so did not allow them to give interpretations that would ‘create space’ inside of her.

The TBIPS candidate was bewildered by the comments, for the patient had, to him, been saying very meaningful things. She had been talking about her school days when she had always felt forgotten by others, for example, her name being left off the class rosters such that she had not even been assigned to a classroom teacher. The candidate felt the patient was talking about the trauma, about having been ‘forgotten’ by her own parents, left out of/ absent from their minds, if you will.
The candidate, feeling the patient had been unduly re-traumatized, felt he had to speak up and add a different point of view  to that of drive theory and aggression. He thought that, just as the the patient had been raised in a family where her feelings had no value for her family, so, too, had the analysts been seeing her words as valueless, and the therapist had been feeling ‘useless’ to ply the wares of the classical analytic trade, interpretation. The candidate wanted to think with the attendees about the need to establish between therapist and patient -- a patient with attachment traumas -- a secure attachment, a safe space from which to explore one’s inner life.  

The candidate had been disappointed by the conference. It had seemed unimaginative, lacking in curiosity and narrow in its scope, failing to take into account infant-caregiver research and attachment theory. I was sorry for the candidate’s suffering through that seminar but inordinately proud of his broadened perspective, as if TBIPS courses had ‘created space,’ opened up something inside of him.

Wednesday, February 6, 2019

IMHO and Film: Roma

I don’t think of a movie as ‘good’ based on my enjoyment of it. (My enjoyment does not mean it a good movie. I might enjoy a romantic comedy even while finding it predictable.)  A ‘good’ movie, for me, is intelligent or provocative or beautiful or juxtaposes disparate elements such that I think about something in a new way. I like literary elements -- foreshadowing or metaphor -- to be subtle. Sometimes I don’t mind being hit over the head with something if it is in spoof (such as the cartoon-blood scenes in Tarantino’s Kill Bill). I like to be gripped, engrossed, feel the delight or the suspense or the tension. I like to be surprised.

This is not a year with a lot to choose from. Not like 2017 which had Three Billboards, Shape of Water, Get Out, Lady Bird, Mudbound, and more excellent films. Even so, I do not understand how A Star is Born was so copiously nominated. The only interesting note in that film was -- after having previously heard Bradley Cooper say in an interview that he wanted his character to have Sam Elliot’s voice and so practiced using Elliot’s voice --- Cooper’s singer Jackson Maine telling his older brother Bobby (played by Elliott) that it was Bobby’s voice he’d always wanted.

With Roma (2018, written and directed by Alfonso Cuarón) -- nominated by Academy for Best Picture, having already won Golden Globes for Best Director and Best Foreign Film-- I did not know what to expect, and I liked that. While I was uncertain why Cuarón lingered on certain scenes for as long as he did -- I did not always get their significance, even in retrospect-- still I found the images compellingly lulling. The opening scene of soapy water repeatedly being sloshed across bricks set me up to expect redemption or a cleansing of some sort. But none came. So I imagined it meant that Cleo (Yalitza Aparicio Martínez, nominated for Best Actress -- as is her female employee, played by Marina de Tavira) was the one to wash away all the shit (the brick walkway was continually littered with dog shit) which in her quiet, soulful way, I guess she did. As the camera takes in more we see the brick floor is a courtyard which, as we watch Cleo walk with her bucket through it, we note numerous caged birds. Will she turn out to be a caged bird? Later, I pondered the metaphor of the broken vessel, spilling pulque (a disgusting -- IMO-- , viscous, fermented --alcoholic--beverage made from maguey/agave juice): was the unwanted fetus’ male progenitor’s seman the pulque? was its spilling a protection of the developing fetus whose pregnant mother should be avoiding alcohol?

The juxtaposition of disparate elements: Cleo is the servant, an Indigenous, quiet, brown, young woman from Oaxaca (wah-ha-ca) working for a white, Mexican family with four children. She is both a caged woman and the one who is most at peace, most free if you will, with her calm strength, her courage. She is the only one of many able to hold the yoga pose, the tree with closed eyes. And she saves her wards from drowning. Bearing with equanimity-- all traumas in the film are born thus, as if matter-of-fact, daily life-- an earthquake, a fire, an abandonment, and a death (for which -- with use of magical thinking/psychic reality -- she feels guilty, until bathed in the love of her employers.)
This film portrays class/race disparity: the servants who are brown and the middle class whites who employ them. There is also a feminist element: a mother abandoned by her physician husband and receives no child support for their four children; a pregnant, young woman whose boyfriend disappears upon learning of the pregnancy; Her obstetrician reassures her this is not uncommon.

I was completely engrossed by the quiet, plodding Roma -- a Ravel’s “Bolero” that never get louder -- wondering what would happen next. I was delighted by it being a ‘period piece’ set in Mexico City in 1970-71 and shot in black and white. Cuarón was ten years old in 1971 and the film is purported to be semi-autobiographical. ‘Roma’ refers to the district in which he grew up, Colonia Roma, filmed, in part, of the street where he grew up. Cuarón includes the June 10, 1971 Corpus Christi massacre in the plot as nonchalantly as all the other events. His equanimity I found fascinating. [Perhaps as a boy he had felt secure attachments and safety while the world outside swirled about.]

Cuarón also directed and co-wrote Y Tu Mamá También (2001), Children of Men (2006) and Gravity (2013), and directed Harry Potter and the Prisoner of Azkaban (2004). He is the first Latin American director to win the Academy Award for Best Director (for Gravity).

Sunday, February 3, 2019

Daniel Shaw on Traumatic Narcissism

Daniel Shaw advocated for transparency and demystification when speaking to the Tampa Bay Psychoanalytic Society, on Saturday, February 2, 2019, about traumatic narcissism. He noted patients can benefit from both psychoeducation about the therapeutic process and from understanding of how negating, narcissistic parents can make both separation and connection unsafe-- engendering a disorganized attachment, Mary Main’s ‘fright without a solution.’  Likewise, patients can benefit from understanding something about the analyst’s mind. One part of psychoeducation includes how narcissists disavow and project their own shame and dependency needs, then degrade the other (child, follower) in order to uphold their own delusions of superiority and grandiosity.

Shaw, himself a cult survivor, became interested in how sociopathic, malignantly narcissistic leaders fashion their abusive, exploitative relationships with their followers. He came to recognize that families, workplaces, houses of worship, and politics can also function like cults, where a charismatic leader denigrates others to preserve the delusion of omnipotence. The traumatizing narcissist grooms others to believe that they are the ones who desire what it is that the traumatizing narcissist is desiring. The relationship of the traumatizing narcissist is subjugation, and it is maintained through shame and fear. Sometimes patients may want to subjugate themselves to an idealized, ‘omnipotent’ therapist, while a therapist may prefer to negotiate power and authority. In moving toward transparency, the therapist may eschew defensive opacity and not be the silent, still faced analyst of old who turned the patient’s complaints back on the patient.

The negating, narcissistic parent calls the child ‘selfish, weak, immoral’ for having needs. Only the narcissistic parent’s needs are valid. They do not apologize or admit wrong doing. There is no recognition of the child’s subjectivity. Abandonment is a looming threat. The child may then grow up to disown her/his childhood rather than feel its shame (as Eugene O’Neill did ). To survive, the child  may also externalize their shame and dependency, later becoming traumatizers themselves; or they may internalize the ‘badness’ [Fairbairn] and remain objectified and subjugated in subsequent relationships. Just as the child was ‘gaslighted’ by the parents who denied their cruelty, so, later, the rejected, betrayed part of self may give way to the traumatizer part of the self which attacks and blames the self (‘It’s your own fault.’) or others (who can never do enough to compensate for what has been done to the child self). In therapy, these multiple, disparate parts may be encouraged to be in conversation with one another, so that disavowed shame might be openly mitigated and defensive grandiosity might be tamed.

Saturday, January 26, 2019

Attachment in Clinical Practice

The third Development course in the TBIPS curriculum is ‘Attachment and Affect.’ It utilizes David J. Wallin’s (2007) book Attachment in Psychotherapy (Guilford Press, NY) with its accessible style and clinically applicable explanations.

In Chapter 11, Wallin explicates how patients require our empathy, but they also need to experience within relationship with us that overwhelming feelings can be managed. Because attachment is affect regulation, patients need to experience us as able to cope with their most difficult feelings, feelings their parents may have rejected, ignored, or punished. Therapists, in order to be able to welcome in and cope with their patients’ difficult feelings, must, of course, be capable of managing their own in order to consistently communicate a desire to understand and to help.

When failings or ruptures occur, the therapist must often be the one to initiate repair -- through intersubjective negotiation -- so that the patient can experience that the relationship with the therapist can survive disappointment, anger, and disagreement (difference). This repair of ruptures strengthens the ‘secure base’ and the patient develops an increasing “confidence that the relationship can be relied on to contain difficult feelings and help resolve them.”

Managing affects together (mutual regulation) not only embodies the secure attachment, it may also, for the patient, maybe for the first time, give a new experience of having one’s feelings and intentions be consistently of interest and concern to the other (the therapist). These new experiences challenge a patient’s expectations that others are disinterested in their feelings and inner lives.

Also in Chapter 11 we find an introduction to attachment styles seen in adult patients (using separation and termination responses as indicative). Relying on the momentous research of Ainsworth in the Strange Situation and of Main in the Adult Attachment Interview (AAI) and the Strange Situation, Wallin describes what may be seen in insecurely attached (dismissing, preoccupied, and unresolved) adult patients, and imagines their attachment styles in childhood (avoidant, anxious-resistant, and disorganized, respectively).

Avoidant attachment styles, as observed in one year old toddlers in the Strange Situation, avoid turning to caregivers for comfort when distressed and avoid showing distress (emotion) because they have already learned from experience that their parents will be dismissing of their distress. These toddlers are at risk as adults to be dismissing of their own feelings and desires and to take comfort in solitary endeavors. Their narratives may be brief, and devoid of emotional language, as seen in obsessive persons.

Preoccupied adult patients, corresponding to an anxious-resistant or anxious-ambivalent attachment style in toddlerhood, may be intensely expressive of their emotions, having learned in childhood that it took a giant display to get the attention of their preoccupied caregivers.They often see themselves as helpless to external forces. Their narratives are often copious, tangential, and hard to follow.

Unresolved adult patients can often show lapses in communication as exhibited by changes in self states (dissociation) and lapses in coherence and logic. They likely had disorganized styles of attachment as toddlers with caregivers who had unresolved trauma in their own childhoods [leading the unresolved parent to behave in a frightened or frightening manner].

Wednesday, January 23, 2019

Right brain-to-right brain Communication and Attachment

From Bowlby we learn that attachment is a primary motivation (for survival), not secondary to oral gratification (feeding) as Anna Freud and Klein surmised. Bowlby also highlights the importance of environmental factors in human development.

Schore states that attachment is affect regulation, achieved especially through right brain-to-right brain communication. Beebe’s research shows us that infants ‘talk’ even before they have words and that, for secure attachment to develop, the caregiver must be able to decode the infant’s communications. If the caregiver is contingently responsive to the baby’s cues, then the baby’s social and cognitive development is enhanced. The infant’s emotional, social, and cognitive development depends on being recognized both in positive moments and in distress (negative) moments.

Preoccupied mothers  are less able to respond to their babies’ cues and less able to empathize with their babies’ distress. This can lead to insecure attachment. (avoidant attachment with dismissing--of the child’s distress-- mothers; anxious-resistant attachment with preoccupied mothers; and disorganized attachment with frightened/frightening --with a history of their own childhood trauma-- dissociated mothers).

Interactions in the early months of life can predict attachment styles at one year and predict social and academic success in the school years. The flexible, rapidly developing brain of the infant wires itself based on environmental (social relationship) interactions.

Sunday, January 20, 2019

Attachment and Affect course at TBIPS

Because, this week, the Tampa Bay Institute for Psychoanalytic Studies’ second year class will begin its Attachment and Affect course, I thought this would be a good time to remind students about Shore’s (2001) ideas on attachment as affect regulation: 1. Affect regulation and the unconscious are primarily the purview of the right hemisphere of the brain.  [Here Schore means by unconscious that which is automatically processed by mostly subcortical structures, and does not refer to Freud’s dynamic unconscious where a conflict was once conscious, however fleetingly, and then repressed]. 2. The essential task of the first year of life is to establish a secure attachment to a primary caregiver.

The primary caregiver facilitates affect regulation and hence attachment through contingent responsivity, attuning, synchronizing, up or down regulating accordingly, repairing ruptures, and by managing her/his own affect. [In doing so s/he contributes to the infant’s brain growth, stimulating neuronal connections and important neurotransmitters for self control and affect regulation, while promoting in the infant a sense of going on being and meaning making.]

The patient must form an attachment (part of the working or therapeutic alliance) with the therapist. This attachment comes into being via affect regulation. This attachment may explain the therapeutic efficacy seen across differing theoretical schools. Schore writes, “The major contribution of attachment theory to clinical models is its elucidation of the nonconscious dyadic affect-transacting mechanisms that mediate a positive working alliance between the patient and the empathic therapist.”

Schore, A.N. (2001). Minds in the Making: Attachment, the Self-Organizing Brain, and Developmentally-Oriented Psychoanalytic Psychotherapy. Brit. J. Psychother., 17(3):299-328.

Saturday, January 12, 2019

Substance Abuse is an attempt at Affect Regulation

First, a Happy New Year! to the readers after a holiday break from posts here on Contemporary Psychoanalytic Musings.

This morning, January 12, 2019, the Tampa Bay Psychoanalytic Society hosts me-- Lycia Alexander-Guerra, MD-- and a colleague, Paulina Robalino, LCSW, to speak about how psychoanalytic psychotherapy contributes to substance abuse treatment in a talk “A Psychoanalytic Dimension to Substance Abuse Treatment.” My premise is:
Substance abuse is an attempt to affect regulation. The inability to self regulate affect is a  result of failure in infancy and childhood of sufficient experiences with mutual regulation. Psychoanalytic psychotherapy is about mutual regulation and therefore is an important adjunct to treatment of people with substance abuse problems.

Joyful and loving interactions with others stimulate feel good chemicals in the brain (dopamine, serotonin, oxytocin) and the soothing or calming of distress/stress prevents ‘priming’ of the autonomic nervous system -- with its sympathetic and parasympathetic fight-flight-freeze reactions-- by reducing cortisol. Affect regulation (e.g. up-regulating a lethargic, passive infant, or down-regulating a distressed infant) of adverse childhood experiences protect from (decrease the risk for) all kinds of maladies: cardiac and pulmonary disease, cancer, depression, anxiety disorders like PTSD, and, substance abuse.

Psychoanalytic psychotherapy today recognizes the the importance of right brain communication, attachment, and affect regulation in bringing about a more coherent, cohesive, continuous sense of self. By participation in mutual regulation of affect, both members of the analytic dyad have the physiological experience of increased dopamine and oxytocin, ‘exercising’ the brain to more easily produce these neurotransmitters, and increasing the capacity for self regulation. An improved sense of self and an increased capacity for self regulation are important assets on the road to recovery.

Wednesday, December 19, 2018

The Local Level (and the negotiation toward a path of shared intention)

The candidate/presenter in the Continuing Case Conference started out warning the class that in taking process notes she had gotten confused about who had said what. It turns out that this comment would foreshadow the theme of the session.

The patient had cancelled, due to her work schedule, an appointment with her specialist for a medical concern that warranted follow-up. The therapist had already been concerned about the patient’s possible, serious medical problem, but had not before said anything to the patient about her worries. In this session, the therapist makes her concern explicit, then asks a couple of questions: do your parents know? Were there other reasons to cancel besides work? After this interchange there was some silence. The patient commented that she will bring a letter she is writing to the next session so that the two will have something to discuss. The therapist offered to discuss the process of the letter’s composition. The patient declined, saying she would bring it in when completed. More silence. The therapist inquired if the silence is experienced as a punishment [there is a history of the patient’s mother giving the patient the ‘silent treatment’ when angry at the patient.] The patient says she used to feel that way with the therapist but not anymore. [a new way of being together had already transpired]

The therapist then says she has something she would like to discuss [the patient has offered something, the letter, to bring in to discuss, now the therapist reciprocates, as the two move along the same path toward shared intention ---to not ‘suffer in silence?’], a recent session that had an effect on the therapist and possibly on the patient, but worries she (the therapist) will be too much like the patient’s mother, always setting the agenda. The patient asks if it is appropriate to ask what are the therapist’s feelings about the patient. The therapist explains that what is between them is ‘fair game’ to discuss, and using the word “mutuality,” discloses relief that she (the therapist) is not “crazy” (a word and worry often used by the patient) for they both are on the ‘same page’ about having accidently seen each other in public places. The patient is happy about this mutual understanding but says she prefers the word “solidarity” to “mutuality.”

The class mused about the colloquial (in the therapist’s city) connotations of the word ‘solidarity’ which includes ‘an otherness to our togetherness.’ The class --  aware of the patient’s fears that her Self and her agency would be subsumed under the mother’s -- noted how the patient helps co-create the boundaries between herself and her therapist. The class discussed how a new way of being together [the patient can assert her own agency for the therapist can reflect and make explicit her own contributions to enactments], that is, a change in implicit relational knowing is slowly being forged despite the therapist being pulled into micro-enactments to be concerned, advise, participate, or intrude. The crux of the negotiation has been about moving toward a shared intention. 

The gestalt or arc of the session had been the slow, steady, quiet negotiation around ‘Can we be close and still be separate?’/ ‘May we be close and I not have to subsume my Self and my agency?’  (the theme) While it may have seemed to the therapist and to the class that not very much was happening in the session, it turns out -- as the Boston Change Process Study Group notes -- that change in implicit relational knowing can also, maybe usually, occur even in the quieter moments, and not only in the moments of heightened affect (now moments) and their potential, subsequent moments of meeting.

Change in Psychotherapy: A Unifying Paradigm. (2010). The Boston Change Process Study Group. New York: Norton.

Thursday, December 13, 2018

Fittedness and Implicit Relational Knowing: What is Mutative

In co-creating fittedness, the therapist and the patient implicitly move toward a shared intention. In a beautiful explicit, concrete example, a colleague shared how she and a pre-teen, female patient were drawing a story together on a large whiteboard [an example of the therapist joining or following the patient]. After awhile, the young patient became embarrassed and moved away from the shared task, but then, looking over her shoulder and seeing the therapist still drawing, the patient returned to the whiteboard for some finishing touches [an example of the patient joining the therapist]. That is, the two moved closer and closer toward a shared intention. Moving toward a greater ‘fittedness’ leads to an increased coherence within the dyad, which, in turn, expands implicit relational knowing.

Expanding implicit relational knowing widens the possibilities of how to behave with one another and enriches the repertoire of relational patterns. Likewise, flexibility increases, as does the hope for spontaneity. This is mutative. This is change. Change opens the way to insight, when, after comfortability with a new way of being with an other, one notices that and how things are different.
This is to say that change precedes insight, not follows it.

The Boston Change Process Study Group [BCPSG] has turned psychoanalytic thinking on its head in another way with their explication of how relational patterning is primary and the foundation of psychological life, while conflict and defense are secondary. They cite attachment patterns at age twelve months (seen in the Strange Situation) as evidence for the presence of conflicts and defenses based on relational experiences (because the infant has already apprehended what to expect from the caregiver). For example: an infant with avoidant attachment has learned it cannot count on the caregiver to soothe it when distressed and so appears to have little affect [defensive] while seeking objects to soothe itself; or, conflict is evident in disorganized attachment where the infant reaches for its mother while simultaneously backing away from her.

Change in Psychotherapy: A Unifying Paradigm. (2010). The Boston Change Process Study Group. New York: Norton.

Wednesday, December 5, 2018

Continuing Case Continues? and disruptions, and continuity of sense of self

There was today in class a lot of confusion on the instructor’s part. Even if we get past the limitations imposed by differing accents, by the teleconferencing connection, and by this instructor’s hearing impairments, there remains that the instructor could not sort out when the presenter was talking about what occurred in the session explicitly between patient and therapist and what was being related from the presenter’s mind as hypotheses and as background information about the patient and the treatment for the class to know. [To this instructor’s relief, the instructor was not the only one confused about ‘what is going on around here’ in the class.]  So we decided to discuss together what was going on. [Unfortunately, the presenter was not able to get through the session she had looked forward to presenting; a melancholy choice: choose one, lose the other.]

By addressing in class the process instead of content, we were able to glean some useful ideas.
Quoting one classmate, we could ask: What belongs to whom? Whose ‘language’ is spoken? (whose desire? [a topic of the earlier course]) and Who am I?, all of which might relate to the patient, the patient vis a vis her parents, the therapeutic dyad, and to the class. This same classmate noted that the disruptions might be related to the session (as well as to the presentation), specifically to the possible dissociated self states of the patient coming into the session, threatening continuity of self and of session. Another classmate noted a possible dilemma between fusion and individuality for the patient, that is, the patient experiences an attachment as having to lose the self or part of the self if she is to maintain a connection. (The presenter confirmed this with an example from the session). There is also the Adult Attachment Interview research which found an incoherent narrative is indicative of insecure attachment, which the patient here certainly experienced with her intrusive mother. Lastly, the instructor’s repeated attempts to clarify what the presenter was saying caused not only too many  interruptions (discontinuity) but also had the presenter feeling scrutinized just as the patient had felt so micromanaged by her mother.

All this by way of saying what the reader already knows: process is as important, maybe more so, as content; class process may reveal valuable information about the patient’s inner life; parallel process exists; instructors need to be more mindful of how her desire affects the presenter’s; and much more.