Monday, January 31, 2011

Psychoanalytic Training Changed My Life, Really

Psychoanalytic training in the USA requires experience as an analysand, in addition to the clinical training as an analyst being supervised by more experienced analysts, as well as the didactic courses. Embarking on the journey to become a psychoanalyst required for me a radical shift from my medical training. As a physician and psychiatrist, I learned to be a diagnostician, pharmacologist, and advice-giver. Being a psychoanalyst requires a different perspective. Modifying the medical ‘fix it’ model, I had to emphasize collaboration with, instead of imparting knowledge to or directing, a patient. Symptoms and complaints take on additional communication about symbolic meaning and relationship. (Experience in interpreting poetry, literature, and film for their many levels of symbolic meaning gave me a good start for thinking about the many levels of connotative meaning, beyond the denotative, of a patient’s narrative.)

There are many theories about what is helpful to psychoanalytic psychotherapy patients. Theories of psychoanalysis and psychoanalytic psychotherapy have evolved for more than a century since Freud first introduced his ideas, and they continue to evolve, so we hold onto theories lightly. We still utilize some of the traditional Freudian principles, e.g. one of the cornerstones of psychoanalysis remains the acknowledgement of the Unconscious (or Unconsciouses) , though defining it, and ideas about accessing it, have undergone modification. The other aspect agreed upon is that the relationship is important.

While there is some research about what is mutative, it is relatively sparse. Various schools of psychoanalysis privilege different aspects. Structural/Ego analysts, for example, might aim to foster the more frequent use of more mature, adaptive defenses, or to ‘discover’, with the patient, unconscious conflict. Object Relations analysts might strive to keep pace with what part –object is manifest in the patient or analyst at any moment and to help the patient integrate her/his sense of self/others. Relational analysts might utilize what is going on within the therapeutic dyad to co-construct a narrative that helps patients connect more with themselves and with others. Self psychology recognizes the importance of empathy and attunement, and of the analyst serving as a selfobject experience for the patient so that the arrested psyche can recommence its development. The Intersubjective School might stress mutual recognition that fosters reciprocity and greater interpersonal satisfaction.

All authors and clinicians have their own biases about theories. From difference we enrich our repertoire and experience. Supervision and peer supervision is invaluable, as is sharing the conversational ‘space’ and embracing difference of opinions. While reading papers and texts may initially aid confidence, nothing can substitute for experience. Not only did psychoanalytic training improve my capacity to be open to and understand patients, benefitting treatment outcomes, but it allowed the building of a full and satisfying practice. One of the aspects of practicing psychoanalysis which makes it so delightful to me is that, if we are open to the present moment, we get better and better at it, day by day, minute by minute.

Thursday, January 27, 2011

Oscar Countdown: The King's Speech

In a film about one man’s struggle to find his voice and about the talented (and intersubjective) speech therapist who helps him to do so, we find the contemporary analytic attitude of the psychotherapeutic consulting room. In The King’s Speech, Colin Firth as “Bertie”/Prince Albert/King George VI and Geoffrey Rush as the failed actor/speech therapist Lionel Logue enter into a relationship whose endeavor can succeed only through mutual recognition, no easy task for a patient who is used to subjects of the Crown, not those who would be subjects of independent action, desire, and will. Not only does Logue insist on recognition and otherness, he also balances compassion for Bertie’s plight. Logue asks about earliest memories, discusses the Prince’s childhood and understands his anger and humiliation. Whether sharing fears or shouting obscenities, Logue allows for play, spontaneity, and creativity, opening the space to where Bertie’s speech is stutter-free.

Just as we set aside the transgressions, and sometimes heinous crimes, of our patients in order to be useful to them and to experience the world from their perspective, so we need, in The King’s Speech, to set aside historical context. The Monarch King George VI stood for an Empire which subjugated nations while colonizing one quarter of the planet, and Prime Minister Chamberlain, in a failed appeasement, conceded to Hitler in the Munich Pact. Then we can watch, with immense enjoyment, this sometimes humorous, sometimes emotional, historical film about one individual’s struggle to reach his potential. The King’s Speech, directed by Tom Hooper, is the frontrunner for the Oscars, having garnered twelve nominations, including Best Picture, Best Actor, Best Supporting Actor, Best Director, and Best Supporting Actress for Helena Bonham Carter as the supportive wife Queen Elizabeth, the mother of Elizabeth (II) and Margaret.

Sunday, January 23, 2011


Passages from Lorraine Smith Pangle’s book Aristotle and the Philosophy of Friendship, Cambridge University Press, 2003.

In friendship, Plato and Aristotle both suggest, “we can best see the true character and extent of our desire to live with others when that desire is shorn of all considerations of necessity and utility. Likewise, Aristotle assumes neither the possibility nor the impossibility of what we would call altruism, but instead offers a sustained and sympathetic exploration of what is really at work in the human heart when an individual seems to disregard his own good to pursue the good of others.”

“Aristotle does not assume that the concern for a friend is necessarily tainted by partiality; he argues that friendship can be rooted on a true assessment of the friend’s worth as a person, and as such, friendship can give us the noblest expression of our sociability.”

The naturalness of friendship (that is, the tendency toward friendship as an essential dimension of human nature), the possibility of selflessness in friendship, and the relationship of friendship to justice, are the three central themes of all major philosophical studies of friendship.
Professor Smith Pangle articulates and proposes keen insights on friendship. She presents her insights first as questions, which she then answers in the affirmative with sustainable arguments throughout her book:

"What are the roots of friendship in human nature? How central to human
happiness is loving and being loved? To what extent is the desire for
affection and friendship reducible to other causes, to our defects and
vulnerabilities and needs for things in themselves altogether extraneous
to friendship, and to what extent is friendship itself a necessary or
central component of the happiness of the healthiest human beings?

"How truly can and do human beings care for others for their own sakes and
promote the good of others as an end in itself? Do they do this at all?
Do they do it when the good of the other conflicts with their own deepest
good? Or is every apparent selfless sacrifice in fact, in some complicated
or disguised way, a pursuit of a greater good for oneself?

"To what extent can friendship answer the longing for a just community with
others that political life invariably fails to answer perfectly? And what
light does an examination of the problems of justice within friendship
shed on the problem of justice as a whole?"

In psychoanalysis and psychotherapy we can benefit much from contributions such as this one from our colleagues in philosophy.
Ernesto Vasquez, MD


Passages from Lorraine Smith Pangle’s book Aristotle and the Philosophy of Friendship, Cambridge University Press, 2003.

“Friendship was a great subject of stories and of philosophical reflection in classical antiquity”---Unshakable loyalty and mutual trust made friendship a most impressive and most appealing classical virtue. Courage is another example of what the ancients considered a virtue. The “special charm and fascination of a great friendship seem to make it at once so noble and so delightfully desirable.”

The “richness and complexity of friendship, its ability to support but also at times to undercut virtue, and the promise it holds of bringing together in one happy union so much of what is highest and so much of what is sweet in life, formed a fruitful topic of philosophical inquiry for the ancients.”

Friendships were to be cultivated and “counted on as one of life's chief good”[s]. In the Nichomachean Ethics, Aristotle wrote about friendship more extensively than about any other virtue. He also offered friendship as a “bridge between the virtues and the highest life of philosophy.” In classical Greek and Roman cultures, philosophy was not the study of abstract concepts - aesthetics, ethics, and logic. Rather, it was a form of practice, the practice of aesthetics, ethics, and logic, which fostered the most desirable way of being in the world, the most rewarding form of life, the good life. In that sense, friendship was the practice of, among other things, reciprocity, and it is here that friendship for a woman and a man can get tricky, challenging.

“The study of friendship in classical authors is in many ways a study of human love altogether”, since the Greek word for friendship “can cover all bonds of affection, from the closet erotic and familial ties, to political loyalties, humanitarian sympathies, business relationships, even love for inanimate things.” But the Greek word for friendship ”means first and foremost friendship, for it is precisely in friendships of mature and virtuous individuals that we do see human love not only at its most revealing, but at its richest and highest.”
Ernesto Vasquez, MD

Thursday, January 20, 2011

Experience Near

On Saturday afternoon, January 15, 2011, Alan Kindler held an interactive workshop at Memorial Hospital with the Tampa Bay Psychoanalytic Society, Inc on staying close to what the patient was experiencing and reporting. [This was a lot harder than one would think, especially for experienced clinicians who may have found it hard to divest themselves from their theories and interpretations and simply reflect back what was heard instead of adding our own speculations.]

In an attempt to have workshop participants practice getting closer to the patient’s experience, Kindler used video clips of actors playing patients and asked audience participants to use empathic observation to access the specific feelings and experience (and the relationship between the two) of ‘patients’, and to make tentative (open to objections and corrections by the patient) responses to their subjective feelings in the context of what the ‘patients’ were relating. Kindler recommended really knowing the details of conscious experience before moving to the unconscious, fully aware that which details come to the foreground of the therapist’s attention are contingent upon the subjectivity of the therapist. Experience-near data, the details of the patient’s experience, passes by so quickly that much is missed in the listening.

Kindler used the following definition of empathy: a mode of observation and listening in which the therapist strives to apprehend the patient’s subjective experience, as reported by the patient in the present about the past. Empathic understanding is the recognition of the details of the patient’s experience at any moment within its context. Empathic understanding requires attention to detail and a life time of practice. [E.Vasquez noted that understanding may be the core of therapeutic action. W.Player noted that empathic understanding might be oxymoronic, since attunement is more implicit than cognitive, to which Kindler suggested empathic resonance.]

Kindler described the components of subjective experience, where affect is central and contextualized, which may include thoughts, fantasies, acts, intentions, memories, images, assumptions, and beliefs. Because affects are central components of the patient’s subjective experience, their accurate recognition is the essential first step. Kindler suggested that clinicians hone the nuanced language of affect to find the right word to help the patient give a name to the affective experience.

Monday, January 17, 2011

The Mutual Influence of Child and Adult Psychoanalytic Treatment: An Examination of Differences and Similarities between Psychoanalytic Work with Chil

On January 15, 2011, Rosalind Chaplin Kindler, MFA, RDT spoke to the Tampa Bay Psychoanalytic Society, Inc on “The Mutual Influence of Child and Adult Psychoanalytic Treatment: An Examination of Differences and Similarities between Psychoanalytic Work with Children and Adults.” Kinder noted that child and adult therapy mutually influence and inform one another. Contemporary psychoanalytic theory, incorporating infant research on development and attachment, informs adult treatment with ideas about spontaneity, improvisation, and playfulness, giving language to an engagement that long existed in child treatment. [What I had previously, when working with children, called going by the seat of my pants, I can now call improvisation.]

While talking has been privileged in adult treatments, children have always used action and play. Enactments, recognized by Relational therapists as an essential part of treatment, have long been recognized as common in child treatment. The therapist articulates experience for the child, making connections between feelings and events; might be able to detoxify the event, feeling, or thought in such a way as to bring them into the treatment from dissociation.

Differences include those of volition. Children are commonly, but not exclusively, brought by someone else into therapy; adults are only sometimes coerced. Patterns and expectations may be less entrenched in children. They may be living contemporaneous trauma of misattunement and unresponsiveness in their environment and therapists are present to intervene. Authenticity is the standard with children. A greater flexibility is required of the therapist, sometimes seeing the child with the parents, sometimes alone. Parents, teachers, children may all have competing needs and agendas, while alleviating distress remains a common denominator. There is no one theory or technique for every child or family, and one must also consider one’s own proclivities.

Reminding the audience that what is psychoanalytic is how you think about the material, Kindler includes the parents in the process of child therapy. She informs parents that she, the therapist, is going to try to understand the meaning of the child’s behavior and convey that to the parent. Because pathological accommodation [Brandschaft] can compromise developmental strivings in order to maintain attachments, it is imperative that child therapists help parents develop the capacity to self reflect and to think about the unique child’s experience and developmental needs. Kindler will explain to a parent, e.g. one who complains that a child is ‘manipulative’, that children have a limited repertoire to get their needs met and ask the parent to consider both the lengths a child will go to as well as what the child hopes for. Together parent and therapist can puzzle through to try to find the meaning of the child’s behavior.

Treatment of children requires directly addressing their relational context. Without intervention, parental attitudes might impede the child’s development. Facilitating the parent’s capacity to mentalize the experience of the child is an essential part of treatment. Helping parents develop a capacity to self reflect can also help shift their few of the child. We hope to aid parents in understanding the child in a new way.

Thursday, January 13, 2011



What do you know sun of the dismal, dreary day
What can you tell me water of the parching drought
What can you say light of the swarthy chilly rain
and you wind of US branches stout
that in your gust rebound
What do you know lingering, enduring flame
of the ashes that will snuff out your reign
What can you ever know of joy, nostalgia,
in your bittersweet might and main

Ernesto Vasquez, MD
January 11, 2011

Monday, January 10, 2011

Kiss of the Spider Woman

The New Year brings ‘Oscar Fever’ when film buffs anticipate which actors and films (of 2010) will be nominated. On Sunday, January 9, 2011, at the Film Series “Developing Passions,” cosponsored by The Tampa Bay Psychoanalytic Society, Inc and The Humanities Institute at USF, I had the opportunity to revisit the 1985 film Kiss of the Spider Woman, nominated for Best Picture and Best Director and bestowing the Oscar on William Hurt for Best Actor. Kiss of the Spider Woman is set in a prison cell in South America where two men, one arrested for homosexual acts (Luis Molina/William Hurt), the other (Valentin Arregui/Raul Julia) a political prisoner, are, as clinical psychologist David Baker, PhD notes, transformed by one another. To pass the time, Luis weaves tales from old films he recalls and embellishes, tales disdained by Valentin for their bourgeois love and fascist propaganda. But in every tale Valentin imagines his wealthy, former lover Marta (Sonia Braga) as the heroine, Leni or the Spider Woman. The two men, at first so different, eventually reach a meeting of minds.

Discussant Silvio Gaggi, PhD described the use of meta-theater to highlight the characters, movies embedded in the movie, a stratification of visual images like Warhol’s Marilyn: a series of lithographs from a drawing from a photo from a negative. He noted the changing interplay of the two characters: who is the escapist, who the realist? David Baker, PhD described how film can be used to illuminate the unconscious, and how Kiss of the Spider Woman so aptly parallels the psychoanalytic situation (two people in a room together; both become observers of their lives, seeing things via the other that they might never have otherwise seen, and both are changed and grow). In Kiss of the Spider Woman, both men must step out of themselves and, more importantly, be affected-in a two person psychological process- by the other, to be transformed. Baker pointed out that beauty stems from imagination, not from linear thinking or from action, and that a sense of beauty is required for transformation. Love, he said, is an act of imagination, and imagining [the forward edge] something more for a patient moves the psychoanalytic process along.

Kiss of the Spider Woman was directed by Hector Babenco and adapted from Manuel Puig’s novel of the same name by Leonard Schrader.

Wednesday, January 5, 2011



Feeling lonely is not the same as being alone. Part of our emotional life2, the experience of loneliness emerges when certain normal relational needs3 are not being met; that is, when we lack that life-giving, reciprocal steady-attuned-responsiveness4 which is the condition for the possibility of a sense connectedness.

Human connectedness is so fundamental4 to human functioning and being that without it we fall apart psychologically and physiologically, down to the cellular level.
Physiologically, over time blood pressure climbs and gene expression5 falters. The intellect dulls; the immune system deteriorates. Ageing accelerates under the constant corrosive presence of the stress hormones. The study of this biological/psychological/social interface is dubbed nowadays social neuroscience.
Psychologically, the suffering wrought by loneliness comprises the fields of psychotherapy and psychoanalysis.

Like hunger or thirst, the experience of loneliness also serves as a survival signal that powerfully motivates6 us to seek and to try to maintain the essential nourishment we derive from meaningful human connectedness.

As a survival signal, loneliness has been a powerful evolutionary force, binding humans together not only to survive, but to pursue the good life, a life worth living.

Loneliness is a strong model for understanding and delineating the inextricability of the biological and psychological dimensions of human functioning and being, which are so irreducibly relational and complex .
Ernesto Vasquez, MD.
January 5, 2011.

Cacioppo, J. T. (2008). Loneliness. Human Nature and the Need for Human Connection. New York: W.W. Norton.
2 Orange, D. (1995). Emotional Understanding. Studies in Psychoanalytic Epistemology. New York: Guilford.
3 In Self Psychology these needs are termed selfobject needs and go together with the related notion of selfobject experience:
Kohut, H. (1984). How does Analysis Cure? Chicago, Ill: University of Chicago Press.
4 This is one of the major theoretical contributions of Intersubjective Systems Theory: Orange, Atwood, & Stolorow (1997). Working Intersubjectively. Contextualism in Psychoanalytic Practice. Hillsdale, NJ: The Analytic Press; Stolorow, Atwood, & Orange (2002). Worlds of Experience. Interweaving Philosophical and Clinical Dimensions in Psychoanalysis. New York: Basic Books.
5 Gene expression is the process by which information from a gene is used in the synthesis of a functional gene product. These products are often proteins, but in non-protein coding genes such as ribosomal RNA (rRNA) genes or transfer RNA (tRNA) genes, the product is a functional RNA.
6 The issue of motivation has been comprehensibly addressed phylogenetically and psychoanalytically by Jones, J. M. (1995). Affects as Process. An Inquiry into the Centrality of Affect in Psychological Life. Hillsdale, NJ: The Analytic Press.

Monday, January 3, 2011

An Analytic Attitude

As I come off a three week break from facilitating classes at the Tampa Bay Institute for Psychoanalytic Studies, Inc., I think again about how experienced psychoanalytic clinicians might share an analytic attitude with students, avid to experience a deeper relationship and understanding with those who seek them out for help. While an analytic attitude comes with inclination and experience, fostered by training and our own analyses, and while there is no agreement on theory, analysts share the common attitude of endeavoring to understand the intrapsychic and interpersonal life of the patient, to hold the needs of the patient within a frame, and to foster the growth and development of the patient toward a more meaningful and enriched, diverse life. We behave ethically. We behave with restraint. We work to be aware of the influence we have on patients by being self-reflective. We bear, sometimes with our patients, sometimes alone, unbearable affects, tensions, paradox, and uncertainty.

Perhaps I would benefit most from a New Year's resolution to give up control, to 'let go.' Most people, including therapists, particularly those with medical training, have the urge to assert control and avoid vulnerabilities and insufficiencies. Giving up the illusion of control, however scary, and being open to the experience of therapy and its co-creativity, allows transformative possibilities, and leads us and our patients away from self-alienation. Control does not constitute nor uplift the self.

A psychoanalytic attitude is the openness to experience the emotional ‘truth’ of the other’s, as well as our own, subjectivity. It is an ardent experiencing, appreciating experience in its own right, alongside insight, toward the true self; to value not only knowing but being toward the true self. This philosophical attitude decenters insight’s privileged place and makes room for relationship and for being with. Decreasing the patient’s isolation can lessen suffering. Psychotherapy is a sacred experience, under-taken, like faith, with one’s whole being, giving oneself over to the possibility of being in communion, if only rarely and momentarily, with another. Each member of the dyad ideally participates with openness and intensity as we make meaning of ourselves and our lives through revelation and through impact on each other.

Bion advocated an openness to the patient within the bounds of our ethics, always mustering up our respect, decency, and wisdom. When analyzing, open inquiry is preferable to knowledge. Bion advised that we approach each session ‘without memory or desire,’ that we be open to the new possibilities co-created when the therapist does not insist on knowing or on helping, but instead leaves space for a path that is always evolving, unpredictable and unique. When we, with an open heart, do not expect patients to give up their troubles, another serendipitous effect may include the lessening of those very symptoms.

I ask myself, "Can I recognize without flinching another’s subjectivity, or, when I inevitably flinch, can I acknowledge with the patient my discomfort in a way that negotiates a new closeness with, and understanding of, the patient? Can I model that there is no thing too untenable to hear, or to bear feeling, in the company of another? Can I survive the untenable without retaliation (withdrawal, humiliation, breaches of empathy) and hold in tension (not ‘either/or’ but ‘both’) uncertainty with knowing?"

Lycia Alexander-Guerra, MD