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.

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