Tuesday, May 31, 2011

Psychoanalysis - On the Front Lines of the Experience of Reality

It has been my experience and observation that personal pain, unexpressed and unshared, is a root cause of much malaise and suffering in the world. To the extent this can be remedied on a personal level, people can experience more freedom and become more empathic, kind and caring individuals.

To the extent that analysands can explore there own misery and suffering, share and express their pain, psychoanalysis is a tool to provide more freedom, empathy and kindness in the world.

I believe the potential collective amount of suffering in the world is boundless. It can be limitless. It is relative and thus can always improve or decline.

Thus I see psychoanalysts on the frontlines of pushing the collective experience of life in one direction or another. It's the only school of therapy I've surveyed that gives people a chance to explore deep misery and pain.

Throughout history, we have observed enormous human tragedy inflicted on humanity by it's own participants. Hitler, for example, was a person who had intense pain buried within, unshared and unaddressed (Dorpat, 2007). We all know the incredible misery he inflicted upon mankind.

Humans alone among all species (Becker, 1971) must confront their own mortality. This painful truth had led many to run from reality and lead quiet lives of misery. Projected fear of mortality has lead to all manner of collective abuse, collective denial and maladaptive behavior on a societal level.

Just as the personal experience of reality can be profoundly changed by confronting one's own deepest fears and pain, so too can the collective experience of reality be profoundly changed.

Psychoanalysis has incredible potential for humankind. Suffering is here to stay for homo sapiens. How we express it, constructively or destructively, is entirely our collective choice. As a tool for meaningful social change, psychoanalysis is the most promising frontier for mankind. Analysts and analysands alike stand at the frontlines of our collective pain and suffering.

As a tool for fighting poverty, I think psychoanalysis may be a potent tool. As a tool for alleviating social stratification and collective alienation, psychoanalysis may be the best we can offer ourselves.

All this assumes that psychoanalysis is performed with patience, respect and kindness. No school of thought has a monopoly on these traits. It also assumes that psychoanalysis can become less of a tool of, by and for those of great means, insomuch as it is just that.

Finally, I do believe psychoanalysis has an unparalleled modern voice of kindness and reason, a light that points it in the right direction. I humbly suggest this voice is that of the late Dr. Theo L. Dorpat. It is my hope that I can send as many clinicians and patients alike straight to his works. I firmly believe Dr. Dorpat shows us all the way forward to 'a more peaceful, just, and verdant society.'

-- Tim LaDuca

Tuesday, May 24, 2011

Correction

Please note that the final line by Tim LaDuca in yesterday's post "In Your Eyes..." should read: Some of us are searching more badly than others, because that maternal gaze was not so forthcoming, the universe not so friendly.

Please go to that post to see it in its entirety.

Monday, May 23, 2011

"In your eyes", infatuation, or the spark of maternal love?

"Love...
I get so lost sometimes
Days pass
And this emptiness fills my heart
When I want to run away
I drive off in my car
But whichever way I go
I come back to the place you are
All my instincts
They return
The grand fa├žade
So soon will burn
Without a noise
Without my pride
I reach out from the inside
In your eyes
The light, the heat
In your eyes
I am complete
In your eyes
I see the doorway
To a thousand churches
In your eyes
The resolution
In your eyes
Of all the fruitless searches
Oh, I see the light and the heat
In your eyes
Oh, I want to be that complete
I want to touch the light
The heat I see in your eyes"
-- Peter Gabriel, "In Your Eyes"

Is this song not just infatuation run amok? Seeing everything we've ever wanted to see in another woman's eyes? Don't we someday realize these are the eyes of a fallible human? What woman could possibly live up to such a standard?

But let's think about this from a more primal point of view:
Does not the infant get so excited to see the "light and the heat" in his mother's eyes? Is this not what he seeks? The attention he adores, the loving gaze of his mother’s eyes? Does he not often go hungry wondering if the universe will ever answer his calls? To the infant, the mother is the universe, the mother is his universe. And what could be more amazing than to gaze into the eyes of that universe staring right back at you? Especially after a long night of hunger you have no way of knowing will ever end?

As adults, I think many of us go out in the world looking for this gaze, as it was lost or withheld from us somewhere along the way. We seek the magical maternal gaze in the eyes of a significant other. The gaze that meant all was good; hunger would end; warmth would come. The adult seeks the infant’s "catch" of what for it is permanent bliss. Some of us are searching more badly than others, because that maternal gaze was not so forthcoming, the universe not so friendly.

By Tim LaDuca




Lycia Alexander-Guerra adds:

This post is very timely for the TBIPS Relational Study Group which this week reads: You Are Requested to Close the Eyes (2004) Psa Dial, 14:349-371, in which Bruce Reis critiques the Freudian, Lacanian, and Kohutian concepts of mirroring as unidirectional and failing to take into account the intersubjective experience in which “to see is to see oneself being seen by an other.” Reis contrasts these to Winnicott’s concept of mirroring which moves beyond subject-object complementarity to “communion with otherness,” ‘a two-way process in which self-enrichment alternates with the discovery of meaning in the world of seen things.’

Freud saw the visual as psychopathology (e.g. scopophilia, exhibitionism, the over excitation of the child who views the primal scene, even the blind Oedipus). Freud’s own discomfort in being looked at may have contributed to advocating the anonymous, blank screen (opaque mirror) in addition to use of the couch. Lacan proposed that the infant was alienated from its self when first recognizing itself in totality in a mirror, and doomed to “confuse the external image of herself with the images of other subjects” (Reis). Antipodal to Lacan, is Kohut’s theory that through the visual, mirroring by the mother for an infant “seeking witness for its experienced grandeur and perfection” (Reis), the infant develops its cohesive, nuclear self. Still, the mother is experienced as an object, need fulfilling though she may be.

Reis addresses “the difference between object and other,” a salient component of relational psychoanalysis. As Benjamin notes, development is facilitated by the inclusion of the not-me inherent in intersubjectivity. Reis writes of “a relationally embedded self that recognizes itself as another for another and is obliged to acknowledge that there are other perspectives.”

From infant research, Reis tells us that interpersonal matching parses (quoting Meltzoff and Moore) ‘interactions in terms of relationships rather than particular behaviors.’ Mirror neurons not only help with imitation of actions, but understanding of them. Infant research (Stern; Beebe) also reveals “that split-second responsivity occurs in facial-visual interactions between mothers and infants. Each partner influences the other moment to moment…” and, also, “there remains an irreducible otherness to the other, a strangeness that is there from the first look….” For Winnicott and Reis, this difference in the form of the other contributes to and is constitutive of selfhood. “Seeing and being seen are inextricably bound together because, for an infant to see, it must be visible for an other.”

Friday, May 20, 2011

Finding our analytic way

As TBIPS concludes its academic year, candidates continue to grapple with what are the therapeutic aims of treatment and what brings about change. This grappling is a never ending negotiation between therapist and patient, and therapist with her/his own professional identity.

Sandy Shapiro [see Sept 12, 2010 post]said that patients will let us know what they need. Sometimes people come with unspoken but profoundly human motivations communicated in the action of relationship. Therapists, relying both on the unique patient’s needs, and a background of understanding of human needs in general, are able to provide experiences which have been heretofore lacking [deficit model] for the patient. E.g., if a patient grew up discounted and ignored, the analytic situation offers an opportunity for a different experience and a reconfiguring of the way a patient sees her/himself in the world.

The biological striving to pass on genetic material for the survival of the species is accompanied by many postulated psychological motivations. Freud’s theory of motivation postulated the discharge of the accumulated energy from instinctual drives. Winnicott saw creativity and play as essential aspects of the true self. Kohut advocated the development and maintenance of a cohesive self. Bach saw as important the integration of a “sense of wholeness and aliveness” which included developing one’s own awareness and subjectivity, as well as learning to see oneself as one among many, with a place in the world. Maroda notes that people, to develop a full interpersonal repertoire as both subject and object, need to have their affective communications responded to, held, and returned in modified form [ala Bion]. Spezzano writes that human beings are motivated to share their conscious selves, regardless of other unconscious motivations, and that we can only know ourselves in light of how others know us.

If people require a sense of agency, including capacity for self and mutual regulation of affective states, and a sense of the subjective self in the context of relatedness and recognition by (and identification with) others as subjects in their own right, then isn’t it helpful to patients for therapists to include in their analytic attitudes the capacity to sometimes regulate dysregulated affect, the articulation of being affected by the subject of the patient, as well as the capacity to play, and an open-hearted acceptance of a patient as s/he is now while also holding in mind the future, changed patient? If a patient was made to feel helpless and hopeless about affecting others, the analytic relationship is a place where the analyst, when moved, does not necessarily keep a blank face or remain silent. If a patient endured trauma in isolation, s/he now has a companion who knows her/his suffering. Each candidate strives to hone her/his personal identity and style while trying to meet each patient’s unique needs. It is a formidable task, and a joyful one.

Monday, May 16, 2011

Projective Identification

Recently, at TBIPS’ Relational Study Group, a paper we were discussing brought up projective identification, a concept that has baffled clinicians for decades. I would like to share my thoughts on projective identification. When Melanie Klein coined the term, it was to describe an intrapsychic phenomenon: how the unwanted parts of the self (often aggression or helplessness) were projected into the other, and were then seen as under the control of the self, and, consequently, so too was the other seen as under the control of the self. Note that s/he who did the projecting was also doing the identifying with the unwanted part.

Projective identification became redefined as a phenomenon between two people: what was projected by the self was identified with by the other such that the other began to behave commensurate with the projection. E.g. a patient projects sadistic impulses into the therapist and the therapist inadvertently becomes sadistic, or feels sadistic. The self could behave in such a way as to make the other feel what it felt like to be the one doing the projecting. Projective identification, then, began to include the countertransferential use of the projection giving the therapist information about the patient’s experience.

Even when projective identification is seen as emanating from the paranoid position, it nonetheless is an attempt to communicate how one is feeling, as well as a wish to be understood. Because patients are sometimes bereft that the therapist will ever know what it feels like for the patient to experience such rage or helplessness or envy or despair, they are nonetheless sometimes fortunate enough to utilize projective identification to help move the therapist’s understanding along. Otherwise, patients might feel untenably isolated and unconnected to us. Despite how uncomfortable (causing the therapist to disparage the defense and pathologize the projecting patient) it may be to be in the throws of the experience, if not bound by the projection, the therapist might sometimes have the wherewithal to inquire whether the patient has somehow managed to come upon a way to aid the therapist to better know what the patient’s experience felt like by inadvertently helping the therapist to feel that way too.

Since its original definition was conceived within a one-person psychology, contemporary Relational theorists, if they use the term at all, have further redefined projective identification. Relational theory questions the unidirectionality of projective identification. It does not conceive the projection to originate entirely from the patient’s psyche but instead recognizes how unlikely the therapist would be to ‘identify’ with a ‘projection’ were it not to resonate with something already within the experience of the therapist. The therapist, too, contributes to what is projected in addition to resonating with the projection.

I like to say that it is one thing to wear the attributions of a patient and explore what, for both the patient and oneself, it would be like to do so, but it is something else to be what the patient attributes to us. I suggest to less experienced colleagues that we be brave about discussing patients’ (e.g. aggressive) feelings toward us. When patients have ‘split’ us into the bad or hateful object, it sometimes helps restore personal equanimity to consider how and why it became necessary for the patient to operate, at this moment, from the paranoid position. Harder is to consider how we might have inadvertently contributed to this shift.

Tuesday, May 10, 2011

Frame

In the Fall of 2011 TBIPS will offer to both first year and third year classes a practical course on helping the analyst negotiate with patients the analytic frame. We will ask what distinguishes psychoanalysis and psychoanalytic psychotherapy from what a good friend or a loving family member can provide. What makes psychoanalysis and psychoanalytically oriented psychotherapy so special a relationship? Does the psychoanalytic attitude [see Jan 3, 2011 post] really allow the patient a freedom of self unlike any other relationship? Can the relationship really allow for the safe exploration of automatic ways of being with another in the world?

Analyst and patient together negotiate the frame or rules on which the two will come to rely. The analyst is punctual [lest the patient unnecessarily be made to feel like ‘chopped liver’] and alert [lest the patient unnecessarily be made to feel unable to garner the attention of important others], ready to be interested and self-reflective. And when the analyst is not punctual or interested and alert, the analyst must open her/his failings to the patient for exploration. The frame will describe when and how often the sessions will occur, the analyst’s availability between sessions, the fees, times, etc. including how many weeks or months the analyst is out of the office (conferences, vacation, etc). The frame includes the psychoanalytic attitude with its asymmetrical focus on what is in the best interest of the patient and with the safety of the patient’s psyche foremost. Safety is fostered when analysts do not judge, when we do not question with implicit incredulity or veiled contempt [both which can inadvertently humiliate a patient]; when we are attentive to changes in the patient’s (and our) self states, tone or prosody of speech, autonomic responses, or other indications that we may need to ‘slow down’.

Safety is also facilitated by our reliability, punctuality, earnestness in the experience, by our listening, processing, and considering what we have seen, heard, felt, and experienced. Maintaining the frame will, at times, help communicate safety. At other times, the frame must be flexible enough to allow for negotiation, and for enactments [sometimes patients seek to break the frame, not as resistance but as an attempt to reach us]. Because psychoanalysis (or psychoanalytic psychotherapy) is a dialogue within a frame, and with a reciprocity of sorts, and because it includes the multiple unconsciouses of both participants, both patient and analyst will emerge changed in some way.

Monday, May 2, 2011

Happy Birthday, Horacio Arias


Yesterday was the 87th birthday of Tampa Bay Institute for Psychoanalytic Studies, Inc faculty and Board member Horacio Arias, M.D. and there are two valuable lessons he indefatigably, though quietly, articulates which I wish to share.

One is his reminder about the tendency to have the paranoid schizoid position come to the fore with its penchant for part object relating, along with its corollary, which he encourages, to see others as the whole person. Having trained in South America, in Colombia, Dr. Arias is immensely familiar with Kleinian theory, and steadfastly supports the person cast as the part object villain. When local psychoanalytic politics cast one another as the bad object, Arias not only points out the paranoid dynamic afoot, but continues to see each colleague in full light. I have found his words enormously helpful as I struggle in my role as a leader in various local psychoanalytic forums to maintain connection with the varying splintering factions that plague us.

A second phrase, enormously avant garde in my opinion, often heard from Arias is, “There is no such thing as pathology.” Does Arias mean that people do not suffer with paralyzingly constrained repertoires? I don’t think so. Instead, this is an analytic attitude of his which constrains the harsh judgment therapists inadvertently have for choices made by patients. (Often condemned are drug use, staying with an abusive partner, self injury, and so on.) Arias recognizes that people, all of us, are doing the best we can, that we choose less than optimal behaviors because it is the only viable solution we can conceive at the time. For me, Arias is saying that only in a safe and welcoming environment do people dare to change. It is the therapist’s responsibility to create such an environment, which includes holding both the welcoming acceptance of who the patient is at this moment (all painful choices included) alongside the hope that one day the patient will have a greater repertoire of meaningful, enriching choices.