Sunday, September 12, 2010

“Psychoanalytic Process”

On the afternoon of September 11, 2010, Sanford Shapiro, MD , referring to his paper “Psychoanalytic Process” explored what is mutative. Shapiro recalled that Ego psychology teaches that interpretation of defense leads to insight. But he reminded us that many experiences, trauma, disorganized attachments, chronic and severe lack of mentalization, may occur before language acquisition, leaving the experiences implicitly encoded but without connection to symbolization or language and, so, unavailable to interpretation. Many experiences are non-conscious (implicitly encoded) such that they never make it to consciousness. These experiences do not follow Freud’s model of the unconscious, that is, are not made up of what was once conscious but repressed.

Additionally, Shapiro has given up allegiance to an intrapsychic experience, recognizing that all experience is contextualized in an interpersonal world (Atwood, Orange, Stolorow).

Implicit relational knowing (Daniel Stern) is not conscious, and, therefore, not accessible to interpretation and insight. [must be enacted and made explicit.] Benjamin writes: what can’t be told must be shown. These automatic behaviors impact all subsequent relationships, including transference, throughout life.

Neuroscience now knows that our neurons are both plastic and their number is not fixed at birth. We know that the development of the brain is context dependent. This allows the possibility for the hope of changing neuronal dendritic branching and neuronal connections through psychoanalytic therapies. What this means is that new relational experiences offer options to automatically triggered relational patterns.

The analyst helps the patient develop reflective curiosity about automatic relational paradigms, often done by ‘perturbations’ (systems theory) which may disorganize a stable system and momentarily allow for the possibility to reconfigure experience in a new way. Patients can be very forgiving when we do not blame them for ruptures and we allow for repair.

Shapiro also spoke about pathological accommodation (Brandchaft). He noted that normal accommodation is a negotiation between two people such that neither feels the integrity of either individual has been compromised. He referred to Ghent’s paper on masochism, submission, and surrender, noting that surrender is not at one’s expense, but that submission is when one subverts one’s own integrity to someone else’s authority. Brandchaft agrees with Mahler’s individuation process (but disagrees about separation): parents must negotiate the child’s individuation so that the child remains safe and can be assertive. If negotiation does not occur, the child complies or is rebellious, and pays the price with isolation.

Clinically, says Shapiro, pathological accommodation is triggered by certain events and are signaled by subtle shifts in affect (not content). Shapiro says it is important to go back and see what happened immediately before the shift, inviting the patient‘s curiosity, and admitting a mistake was made by the analyst. Taking responsibility for the rupture is sometimes a new emotional response, and the patient may begin to experience that h/she does not have to go along or comply to stay connected. It is also important to take the shame out of any rupture, e.g reframing a motivational experience from aggression (about which one can be ashamed) to a survival mechanism or a way of regulating tension (about which one might feel good).

The empathic introspective mode helps a patient “feel mentalized by the analyst." This, in turn, helps the patient begin to get a sense of self. The patient finds her/himself in the therapist’s mind. Mentalization (Fonagy) elaborates the intersubjective capacity to know that another has a separate mind with differing contents. Stern says we are born with the capacity to be intersubjective; Benjamin sees it as a developmental achievement, created via the third.

“The Evolution of Contemporary Psychoanalysis”

On Sept 11, 2010 the Tampa Bay Psychoanalytic Society, Inc hosted Sanford Shapiro, MD referred to his paper on “The Evolution of Contemporary Psychoanalysis—A Fifty Year Perspective.” Author of Talking to Patients, a self psychological view of creative intuition and analytic discipline, (Jason Aronson) the revised edition 2008, includes implicit memory and relational psychoanalytic thinking. Referring to Victoria Hamilton’s The Analyst’s PreConscious , Shapiro noted that theory helps us stay calm in face of patient assaults and added: Do not underestimate the ability to stay calm.

Shapiro, approaches each session ‘without memory or desire’ (Bion)and asks himself: how is this patient planning to use me at this moment? He notes how patients test us. The initial test is about safety. Patients expect from us what they got from their parents (the transference test). This is sometimes evident when the patient, turning passive into active, attacks e.g. our competence. Just ‘survive’ (Winnicott); surviving (without retaliation or withdrawal) the test is passing the test. Weiss noted that analysts confirm or disconfirm patients’ beliefs; when we respond in new way, we may disconfirm their beliefs.

Using empathic introspection, we need to ask ourselves: How are the patients to feel good about themselves if we are always pointing out their shortcomings? Sometimes patients comply with our theories to avoid further hurtful interpretations.

Reenactments or enactments were classically thought to be disruptions. Donnel Stern (relational) believes they are necessary before they can be made explicit and then interpreted. Frank Lachmann (self) calls them ‘rupture and repair’ . This contemporary psychoanalytic acceptance of enactments has allowed analysts to ‘come out of the closet’ into the public forum about their private theories.

Shapiro says his theory is simply investigation, or inquiry. He tries to avoid being loyal to a theory or technique so as to allow himself to be with the other. Shapiro follows the moment to moment affective response of the patient to his interpretations to know if he is on track.

In his paper, “The Evolution of Contemporary Psychoanalysis” Shapiro states that Contemporary Psychoanalysis is a two person psychology born out of the cross-fertilization between interpersonal and self psychologies. He also juxtaposed interpersonal and relational theories against Freudian, Kleinian, Ego and Self psychologies, Intersubjective, and social constructionists.

Shapiro, a student of Sterba, interpreted Sterba’s “The Fate of the Ego in Psychoanalysis” (1934)as a pioneering relational perspective because Sterba describes dissociation as the split between observing ego and experiencing ego, the former which allies itself with the analyst’s ego. But the analyst is an active participant, not an objective observer.

Shapiro explored contributions from Winnicott, Kohut, and Intersubjectivity which he had found personally useful in his professional helping of patients. For example, seeing things from the perspective of the patient (empathy) helps the patient to feel understood, more confident, and opens up explorations with lessened shame or guilt; or focusing on the impact the analyst has on the patient before interpreting transference distortions. From relational (Mitchell) was added the focus on the patient’s impact on the analyst. Because patients can sense analysts’ reactions, sometimes acknowledging what the patient already knows in self disclosure can be useful.

Shapiro changed his view of resistance. Classically, resistance was seen as arising from instinctual wishes from within the patient. Ego psychologists interpret this resistance and other defenses. But intersubjectivists [like Benjamin] view resistance as also, in part, the patient’s fear of the therapist’s response. In a two person model, we are interested, then, in exploring as well what contribution the therapist may have made to the patient’s fear. Shapiro’s clinical example illustrated staying with the patient’s perspective instead of confronting the distortion. [He did this by what sounded like ‘wearing the attributions of the patient’ ala Lichtenberg.]

Shapiro also changed his views on motivations. Likewise, he re-examined his belief in his analytic authority and expertise and became more of a facilitator, helping others overcome obstacles to resume their growth and development. He recognized that sometimes the relationship itself, and implicit communication, is mutative, and that interpretations were not always necessary. In his technique, Shapiro draws on the empathic-introspective mode from Self Psychology and the impact the patient and he have on each other from relational theory.