Tuesday, October 9, 2018

Peer supervision in continuing clinical case

A therapist is terrified that her suicidal patient, with attempts in the recent enough past, will actually end her life this time. The patient is hospitalized by family members when she attempts to kill herself at home. The therapist is relieved, but only a very little. The patient might still come back to the therapist and they might then recommence with the helplessness. The therapist feels alone. The patient might not return to the therapist’s office; Many psychiatrists and many medications have failed this patient before. Perhaps the patient holds on to the fantasy of omnipotence. I am so bad, so damaged, so ill, that no one can help me.

Perhaps the therapist is so angry at this patient for frightening her all these months and for making the therapist feel so incompetent for so long. The therapist is frightened now. The patient might kill herself; The patient might come back to treatment. Maybe the therapist has implicitly communicated ‘Don’t come back!’ as all the patient’s previous therapists may have done. Perhaps the therapist is ashamed of being angry, wishing the patient gone, hating the patient. Could this be made explicit? [Making the implicit explicit is not the same as making the unconscious conscious.] Could the therapist someday tell the patient, ‘Sometimes, when I feel incompetent to help you, I think I hate you. Sometimes you probably hate me, too, when I am so incompetent to help you. I expect our relationship will survive this hate, too.’

The patient herself might feel terribly guilty and ashamed that she hates. Hates her own children. Hates her therapist-who-is-only-trying-to-help. Mothers aren’t supposed to hate their children. But what a difficult job mothering is! How could exhaustion and tears and helplessness to live up to such expectations not engender hate sometimes? Just a little hate. Alongside love. Complicating things for the patient may be the childhood belief that her own mother didn’t love her. Afterall, her mother was dissociated and preoccupied with her own childhood trauma. A child does not know why a mother is not attentive and joyful. The child thinks, ‘Perhap it is my fault. I am unlovable. ‘Do unlovable people even deserve to live?’ she might, all grown up, question, but know ‘in her bones’ the answer: No. Complicating factors might be that the mother loved and hated her daughter (the patient), wanted her to sometimes go away.

Perhaps making hate explicit, and contained, signals to the patient that hate is felt by everybody. It is nothing to be ashamed of. We all feel it sometimes. It is nothing to be frightened of. Relationships can weather it.  Perhaps the sharing of the contents of the therapist’s mind -- ‘when I feel incompetent to help you’ -- disabuses the patient that her own mother’s hate was all the patient’s fault.

Complicating things for the therapist is the loss of a former patient by suicide while in hospital. The therapist had learned of that patient’s death during a work day. The next patient is here.* No time to grieve. The mother of that dead patient hounds the therapist with phone calls intimating blame. Can the therapist bear another suicidal patient after such a trauma? Complicating things for the therapist is the therapist’s own history in childhood of trying to save important others. I can’t leave behind my omnipotence. I can save them all. And Don’t be silly. Know my own limits. Or Let some people die. I can’t save them all.

*Again, do we make explicit to the patient what s/he may already implicitly know? The therapist is different. Is it me? Perhaps the therapist says something like, ‘You may sense that I am a bit off today. It is a personal matter. I am willing to power through if that suits you or we can reschedule. What do you think?’

Thursday, October 4, 2018

popular poetry for young women

Today is the 26th birthday [born Oct 4, 1992] of best selling (in part, due to her use of social media) poet Rupi Kaur, whose collections include Milk and Honey (2014) and The Sun and Her Flowers (2017), which have inspired [not necessarily critics] millions of young women, if one goes by her sales.  Born in Punjab, India, and immigrating at age four years to Canada, she did not learn English until the fourth grade. After having ‘felt voiceless for so long,” she likes performing her poems with a booming mic as well as being able to put words to the complex feelings she had had no words for in childhood. She writes about womanhood,


its struggles and dreams:


… all we’ve endured
has prepared us for this
bring your hammers and fists
we have a glass ceiling to shatter


love relationships:


you ask
if we can still be friends
i explain how a honeybee
does not dream kissing
the mouth of a flower
and then settle for its leaves…


Or


...and you should see me
when my heart is broken
i don’t grieve
i shatter


Her first publication followed quite a stir she created by bringing the taboo topic of menstruation into a photo expose on Instagram. When Instagram twice removed them, she wrote "thank you Instagram for providing me with the exact response my work was created to critique." Instagram apologized. She also wrote [but in all caps], “I will not apologize for not feeding the ego and pride of misogynist society that will have my body in an underwear but not be okay with a small leak…”




Therapists may know something about:


i am vulnerable
  to falling in love with
     human beings that tear
        themselves open for me...


Happy Birthday, Rupi

Monday, October 1, 2018

Some final ideas from and thoughts on Jill Gentile’s presentations in Tampa

In emphasizing materiality, the external world, Gentile notes the limits this reality places on imagination and omnipotence. The infant, in creating the transitional object, must also surrender to its limits, the constraints of the physical world out there to be found, and to its properties. We come into being through both our imagination/dreaming and through the limits of reality. Gentile muses that President Trump, aided and abetted by people who protect him from reality, has not tempered his omnipotence and fails to surrender to both reality and the rules of law [Lacan notes that without the Real there is a collapse of space, of the third, into two-ness. As such, when cultivating a fidelity to desire one still must be held accountable, responsible for one’s desires and actions. Bion, too, says there is a ‘truth instinct’-- what Civitarese* describes as the “drive toward integration and the construction of a psychic space”-- propelling us to a transcendent dimension while still relative or accountable to reality.]


Another interesting supposition of Gentile’s was to state that psychoanalysis spends too much time thinking about the analyst’s actions (interpretation, containment, etc) and too little time facilitating the actions and agency of the patient. In her practice, she tries -- with the intent to cultivate the patient’s voice and the patient’s agency-- to re-locate the primary action with the patient. Gentile intimates that in resistance, patients subvert the analyst’s agency and, if patients can do that, they are powerful enough to effect change. She went so far as to remind us of the patient’s part in ‘resistance.’ (This led, in the afternoon, to discussion amongst the attendees about when and how to approach this with the patient so as not to sound blaming and shaming.) Also discussed was the contradiction of the analyst’s authority as part of what is ‘curative’ [ala Freud] and the deconstruction of the analyst’s authority in order to achieve a level playing field in which the patient’s voice and authority could emerge.


Gentile also noted patients’ stubborn allegiance to identities such as ‘victim’ or ‘helper’ foreclosing potential for change [consistent with Bromberg’s staying the same while changing]. Gentile warns that too much reassurance and soothing from the analyst, too much provision of selfobject experience, deprives patients of the space for necessary conflict [confrontation with otherness?]. She reminds us that ‘maternal preoccupation’ [Winnicott, the perinatal period where the mother meets the needs of and adapts to the baby] is a time where the mother puts her own subjectivity on hold. Eventually the mother’s subjectivity, her mind, provides triangular space, the third, to the mother-infant dyad.


Space allows others into the conversation. Collapsing space through complementarity of doer-done to [Benjamin] forecloses possibility for conversation, curiosity, agency, initiative, and desire.


If space (transitional, triangular--the ‘third’--, …) is required for the emergence of self, for subjectivity and agency, then what about the feminine metaphor for agency? We have the phallic metaphor for potency and power, where is that which signifies creativity and generativity for the uterus? [How men 10,000 years ago must have marveled, and envied, that women could regularly bleed (and live!) and women could bring forth, from hidden, unnamed spaces -- out of their bodies -- another living being! Did men feel so dwarfed by these feats that they compensated with tall buildings and subjugation by brute force and myths like Athena arising from the head of Zeus? When asked what men fear from women, they answer: ridicule, being laughed at. Women, when asked what they fear from men, answer: being killed. One male comedian even quipped that men fear their blind dates may be ugly while women fear their blind dates may be serial killers.] Oh, the unequal playing field.


*Civitarese, G. (2013). The Grid and the Truth Drive. Ital. Psychoanal. Annu., 7:91-114.

Friday, September 28, 2018

More ideas inspired from and by Jill Gentile

In the main presentation of the morning “Between Psychoanalysis and Democracy: On Free Speech and Feminine Law,” Gentile says psychoanalysis is a semiotic project, a process of semiotic empowerment, because the analyst opens the space for conversation on equal footing, similar to the ideals of democracy. Gentile says that both psychoanalysis and democracy appeal to truth, rebuke tyranny and exchew censorship. Psychoanalysis, with its fundamental rule to tell the truth and throw off the chains of censorship, is akin to free speech, a treasured element of democracy. One responsibility of citizenship is to have/use one’s voice, and, just as in psychoanalysis, to participate, particularly in truth telling and in proclaiming one’s desire [through voting, for example]. Both psychoanalysis and democracy have a rule of law (which demands accountability) to honor a third ‘space’ for mediation or for checks and balances.


Psychoanalytic concepts such as ‘containment, potential space, intersubjective space’ speak to the importance of seeking metaphors for ‘space’ [the gap] which Gentile says is the search for a feminine metaphor previously adumbrated by the phallic. Democracy is about creating a level playing field and thus eschews exclusion [John Dunn, the British political theorist]. Psychoanalysis, too, strives for a democratic process but it requires a democratic theory, an ‘equal under the law’ feminine metaphor. It needs to name the gap itself, signify the unspoken, and elevate it to a level playing field. Society’s failure to do so, noted Gentile, endangers democracy when the world excludes the rights of women [President Jimmy Carter]; it leads to the degradation of Mother Earth [accelerates global warming], and attacks the reproductive and proprietal rights of women’s bodies.


The most recent post [9-25-18] mentioned the girl’s impetus to seek knowledge and bend toward truth, while the boy might, instead, deny the mystery of the ‘gap.’ Gentile noted that Freud privileged the penis at the expense of reality. Denial is a breakdown of the tension between fantasy and reality, leaving boys vulnerable to being less tethered to the truth [contrast this with Freud’s idea that the male superego is superior to the female’s]. Gentile muses about the U.S. 2016 presidential campaign with its degradation of women’s bodies as well as how our current president [many have remarked, anyway] is untethered to the truth, whereas the “Me, too” movement is about free speech, especially including the bodies of those with minority status such as women. Empowerment comes with naming, with signification. The unnamed is marginalized. Signifying [vagina, uterus, clitoris, labia, vulva] animates genitals and their usefulness and desirability. Freud was aware of the gap but seemed to ignore its significance in the material bodies of women, instead attending to what was present in the bodies of boys. Yet, psychoanalysis gives voice to what was once unspoken; ‘what would it be if it had a name?’

Tuesday, September 25, 2018

Jill Gentile and the feminine 'gap'

Members of the Tampa Bay Psychoanalytic Society and attendees to its presentation were treated to Invited speaker Jill Gentile on Sept 15, 2018. In the earliest discussion of the day “Desire, Agency, and the Eternal Validity of Psychoanalysis” Gentile emphasized a change in psychoanalysis from viewing agency as the purview of an autonomous subject to that of the dialectically constituted subject, stating that agency cannot be claimed as a one person phenomenon but instead emerges within intersubjectivity. Agency is associated with initiative and intentionality and what Winnicott called the “spontaneous gesture.” 

Additionally, how we become semiotic agents, able to communicate through signs and symbols our very selves, is of great interest to Gentile. Through being held [imagistic symbols] in infancy in the mind of an other, and through naming (verbal symbols) the physical and psychological parts of ourselves (including our genitals), we are aided in the emergence of self. It made enormous sense to me when Gentile posited that the failure to freely name aloud female genitals and inner space (vagina), leaves a “void” or “gap” in discourse, and vitiates the subjectivity, therefore the agency, of women, i.e. if materiality leads to subjectivity [her interpretation of Winnicott], and material things must be named to have substance, to be substantively held in mind, then society’s inability to name and symbolize, to speak freely about the female genitalia and female inner spaces vitiates woman as substantive, vitiates her ability to participate in the conversation.

Yet, despite psychoanalysis’ “hierarchy of patriarchy,” Gentile says Freud derived the fundamental rule from his treatment of women, hysterics whose symptoms were bodily based, and as such, speaks to a feminine law based in Nature, rooted in the Lacanian Real [the feminine], not in Totem law [masculine]. She also notes that the discovery of anatomical differences does not merely lead to penis envy but, more importantly, evokes curiosity in children. The ‘gap’ [of the missing penis], she says, inspires scientific inquiry in children, leading to a quest for knowledge, truth, and a “reckoning of speech.” A child has questions and seeks answers, skeptical of parents’ inauthentic explanations. Gentile states that children seek out their own truth, [Bion’s truth telling instinct]. [My own father handled my question gracefully, filling me with pride, when he answered my curiosity at age three with ‘Girls are of modern design; They have indoor plumbing.’] When a child has something to be curious about, a desire for knowledge is kindled. She posits that this may be truer for girls who ‘get it’ and do not deny the ‘gap’ as boys do -- boys fantasize, according to Freud, that it was cut off -- foreclosing further explanation and exploration of the mystery.

Wednesday, September 19, 2018

An interesting supervision (Continuing Clinical Case course)

A thirty year-old professional woman, married to her colleague, suffers from severe postpartum depression. “Help me! I want to get better!’ is her obsessive lament to the therapist. She cries and wails to her exhausted therapist about her inability to be there as a mother to her infant and about how she only wants to die. She has, in fact, recently attempted suicide by taking a full bottle of sleeping medication. The patient threatens repeatedly to quit treatment. While her patient, like a distressed and flailing infant, sobs and screams on the couch, the therapist, too, feels helpless and incompetent. The therapist recognizes she must first soothe (regulate) this patient but continual attempts leave the therapist tired, so tired. ‘The patient is “haunting” the therapist, appearing in the therapist’s dreams. Is all this projective identification?,’ the therapist wonders.

The supervisor suggests using a soothing tone like one would use with an infant. The therapist worries the patient would respond to that with anger. Sometimes the therapist cannot stand this patient but is mostly sad for the patient and the patient’s baby. A classmate suggests that the therapist let the patient know the therapist’s limits and frustration. Yes, let her know she has an impact on you. ‘Help me find a way to soothe you.’ The patient’s own mother was devoid of affect, cutting off all feeling after devastating childhood losses of her own. Only death can make the patient’s mother feel (cry). Perhaps the patient gifts her mother an invitation to feel again should the patient effect death once again in her mother’s life. Perhaps the patient’s screaming and wailing is the only way her mother might hear her.

Winnicott noted that the perinatal time of maternal preoccupation is very risky for the new mother, requiring the maternal grandmother, husband, and/or others to protect the mother’s bonding time with the baby from impingement by real world demands. Perhaps this patient is screaming for protection, screaming for her life. Screaming to be heard. But the baby is so demanding, a bottomless pit. There is no soothing the baby just as the therapist cannot soothe the patient. Perhaps the therapist could share with the patient that the therapist’s helplessness parallels the patient’s own helplessness vis a vis her own baby’s helplessness, and, moreover, how helpless the patient herself felt as an infant to soothe her own troubled mother. A classmate soothes the therapist, reassuring the therapist that the therapist has the right to be tired, to take a break, and to recognize that the therapist is actually good-enough.

Sunday, September 16, 2018

Women's Voices

Mitski --the indie rock, Japanese-American, singer-songwriter-- explained the title of her latest [fifth] album ‘Be the Cowboy’ on The Daily Show [9/11/18]. Starkly truthful and poignant, she revealed that she feels she has to “apologize for existing” when as an Asian woman she walks into a room. She longs for the “arrogance” and “freedom” of the Clint Eastwood/ Marlboro Man [who owns the room]. Mitski sees the reception by critics of her music as “gendered” for they imagine her “as a vessel for emotion and a vehicle for music,” downplaying that she is actually “the creator” of these, autonomous and in control of her own artistic creations. Still, in writing songs for other performers, Mitski feels some songs she writes she “can’t serve with [her] own voice,” songs, she says, where her different personalities can be better expressed by others.


Jill Gentile --a feminist writer and psychoanalyst-- is interested in semiotics, the study of symbols and signs in making meaning and in communication. Gentile links subjectivity with materiality. [1] Since naming gives substance to materiality [can be grappled with and communicated], society’s and traditional psychoanalysis’ inability or unwillingness to name, speak, and allow speech regarding the female genital and inner space [vagina and uterus] vitiates a woman’s place in the discourse [and hobbles men’s experience as well].  She sees commonality between free association and the First Amendment’s freedom of speech and with the ability to name what has remained unnamed. Further, The ‘gap’ or ‘space’ in free association obscures and points to the unsignified female genital.” [2]


I recall how my younger daughter in her three year-old preschool class had corrected her male classmate: He had noticed another child’s mother nearing the end of her term of pregnancy and pointed out to all, “She has a baby in her tummy!”  My daughter hastily informed him, “It’s not in her tummy. It’s in her uterus!” I received that very day a phone call -- perhaps because it was a preschool based in a church -- about ‘the word’ my daughter had used in class. My reply was, “isn’t it wonderful!” [That was decades ago but to this day some parents fail to teach their children that only girls and women have a special muscle the uterus for growing a baby. I wonder, had that little boy been imagining that he, too -- if babies are grown in ‘tummies’ -- could one day be so generative?]


[1] Gentile, J. (2007). Wrestling With Matter: Origins of Intersubjectivity. Psychoanal Q., 76(2):547-582.
[2] Gentile, J. (2015). On Having No Thoughts: Freedom and Feminine Space. Psychoanal. Perspect., 12(3):227-251.

Wednesday, March 21, 2018

Disclosure

Sandra Buechler spoke on March 17, 2018 at the Tampa Bay Psychoanalytic Society’s Speaker Program meeting.

An interesting paper (1993) of hers talks about the analyst’s emotions and whether, and when, to share them with the patient. Some of the benefits which may be gleaned by sharing the analyst’s feelings about the patient include:

they may evoke from the patient additional, illuminating data;
they may allow the patient to feel he or she has an impact;
they may de-mystify the interaction;
they may communicate the analyst’s dedication to the analytic process;
they may be taken as expressing a sense of caring, even if they are negative emotions;
they may generate new experiences: new emotions, and that emotions can be explored;
they may convey that the analyst can survive [Winnicott: survival];
they convey respect, acknowledging the patient’s responsibility for her/his impact on the analyst;
they may relieve the analyst of interference from unexpressed negative feelings;
they may acquaint the patient with her/his potential for affective interchanges;
they may acquaint the patient with the joy of mutual regulation rather than control imposed by the other;
they may allow the patient to vicariously experience forbidden affects which the analyst carries for both;
They may communicate to the patient the therapist's involvement;
the patient may be better able to explore intolerable feelings with an emotionally responsive person;
[and may foster authenticity and intersubjectivity, of which emotions are a part]

Buechler, S (1993). Clinical Applications of an Interpersonal View of the Emotions Contemporary Psychoanalysis, 29:219-236

Monday, March 19, 2018

Poetry and Psychoanalysis

It was the pleasure of the Tampa Bay Psychoanalytic Society to host on March 17, 2018 Sandra Beuchler, PhD at its monthly Speaker Program Meeting. In the intimate setting at 8:15 am of a 'Conversation with the Speaker'  Buechler shared "Poems that Inspire Clinical Work." She opened with an excerpt from "The Four Quartets," specifically "East Coker," by T.S. Elliott which eloquently captures the psychoanalytic process with its shared struggles:

Trying to learn to use words, and every attempt 
Is a wholly new start, and a different kind of failure
Because one has only learnt to get the better of words
For the thing one no longer has to say, or the way in which
One is no longer disposed to say it. And so each venture
Is a new beginning, a raid on the inarticulate
With shabby equipment always deteriorating
In the general mess of imprecision of feeling,
Undisciplined squads of emotion.

Wednesday, March 14, 2018

Relational ideas, a smattering

First year courses at TBIPS have finally reached their emphasis on theoretical contributions from relational authors and so I am pleased to present a few concepts that have so informed our way of being in relation to our patients. They include the paradigmatic shifts from intrapsychic to interpersonal and intersubjective, from one-person to two-person, from drive-conflict model to relational [Mitchell], and from a unified self to a multiplicity of selves (in health, held together by a sense of continuity, cohesion, and coherence) [Bromberg]. Also important has been the shift from the analyst as objective authority [Sullivan] and all-knowing blank screen to flawed subject inevitably implicated in the relational dyad [Levenson] and a co-creator of the patient's transference. The mind, the self emerges from the matrix of social relationships.

Relationships and their 'internalization' are primary motivators [Bowlby] and are the organizers of psychic life. Early experiences are encoded in the brain in such a way as to become the 'default' way of being with others. Until subsequent experiences (including psychoanalytic therapy) over time reconfigure neuronal dendritic branchings, we may reenact either side of earliest complementary ways of being. Infant research [Beebe and Lachmann] gifts us with three salient principles: ongoing affect regulation, timely and consistent repair of ruptures, and shared moments of heightened affect. Schore concludes that attachment is affect regulation. Schore also notes another major paradigm shift: from left brain (interpretation, insight, explicit,) to right brain (emotional, perceptive, procedural) where dissociated self states [Bromberg] are brought to the conversation through their enactment and what was once unformulated [Donnel Stern] and implicit can then be made explicit.

In the therapeutic space of the analytic third [Winnicott, Benjamin, Ogden], greater than the sum of its two participants, spontaneity, play, and co-creativity can take place. Negotiation of differing agendas from each participant foster an intersubjective [Benjamin] way of being together as each member of the dyad contributes her/his respective perspectival reality. Uncertainty, fluidity, and unpredictability are lived as analysts no longer take cover behind dogmatic theories and technique. This fluidity includes contributions from feminism, queer theory, gender studies, linguistics, social constructivism, and Hegelian dialectics as we let go of linear dynamics.