Saturday, October 27, 2012

Film: we are all connected

Like Avatar, whose message was ‘we are all connected’ (to nature, to our ancestors) and which included corporate greed destroying anyone/anything in its path, Cloud Atlas gives the same syrupy, but not untrue, message, but it does so in a more interesting and bloody way, jumping through time and Oscar-worthy make-up artistry to, like Soylent Green, let us know just how carnivorous greed can be. In an intersubjective age of psychoanalysis, where neurobiological research demonstrates that experience affects our chemistry and anatomy (and, even our genes) and that our thoughts affect the thoughts of others, add to these the recognition of the intergenerational transmission of trauma (my mother’s dissociation becomes my own), we certainly are connected, to each other and through time. But why does the film audience require this to be made so Dr. Phil explicit as if putting it into symbols (whether words or images) will have as powerful an effect as procedural learning? Even the visual images, whether Pappy taking his granddaughter’s hand or two people making love, are symbols here, as if film lacks the capacity to teach implicitly. Not that I wasn’t entertained by Cloud Atlas—who doesn’t love Tom Hanks and Halle Berry? – it’s just that I find being hit over the head with the message tiresome. I prefer the unfolding of an experience, the development of relationship as it occurs through time,as in an analysis or in life.

The Perks of being a Wallflower allowed for this, and so to me it was more ‘real’ not because it used few special effects and stuck to fantasy only as it is experienced in the human psyche of the film character, but because it never screamed “Look at me, I am intergenerational trauma!” It never repeated “We are all connected!” but instead demonstrated it through the healing powers of friendship and friendship's connection. The latter movie may be nominated for less Oscars, but it is far more satisfying as a vehicle to demonstrate the message. 

Monday, October 22, 2012

Poem and forbearance

Months ago in The New Yorker magazine (May 14, 2012, p.78 to be exact) I read a poem: Audiology by Sean O’Brien.  The phrase:

the held breath
Of forbearance

struck me at the time as somehow apropos of the psychoanalytic process. Some patients furrow their brows, some exhale in exasperation. They give the impression of forbearing as I contemplate their implicit message to rethink where I fell off track. I suppose therapists, too, at times exhibit forbearance, but I was particularly grateful for that of my patients.

I have copied an excerpt from the poem in which this phrase is embedded because the poem to me is thrilling:

I hear an elevator sweating in New Orleans
Water folding back on black in tanks deep under Carthage,
Unfracked oil in Lancashire
And what you are thinking. It’s the truth—
There goes your silent count to ten, the held breath
Of forbearance, all the language not yet spoken
Or unspeakable, the dark side of the page.

This poem was brought to mind last week when the Relational Study Group of the Tampa Bay Institute for Psychoanalytic Studies, Inc had the pleasure of discussing a paper by Holly Levenkron along with its commentaries by Bromberg and Renik. I particularly found Renik’s comments enlightening and comforting. In his abstract, Renik wrote that he "agree[d] with her view that a successful analytic process is a negotiation between analyst and patient. [He added: However, I question Levenkron's idea that the analyst must loosen her hold on her own subjectivity in order for the negotiation to proceed. An analyst cannot and need not diminish her subjectivity. Rather, what is required for clinical analytic work to unfold is that the analyst include the patient within the analyst's subjectivity—or, in other words, that the analyst come to love the patient.” But this is to discuss another time, unless I contemplate that part of the reason we love our patients is for their forbearance.]

Renik closes with, and this is the comforting part: “We do well to remember, though, that so-called errors are part of every successful treatment. In clinical analysis, it is not the analyst's job to be right all the time; the analyst's job is to facilitate a productive learning process for the patient.” Somehow our so-called errors and our patients’ forbearance seemed to me connected. 

  Renik, O. (2006). Discussion of Holly Levenkron's “Love (and Hate) With the Proper Stranger... Psychoanal. Inq., 26:233-238. 

Saturday, October 13, 2012

A Fascination with Fairbairn

In teaching Relational theory at the Tampa Bay Institute for Psychoanalytic Studies, Inc, we find we often go back to its origins in British Middle School’s Object Relations theory. What a gem is the 1958 paper of the Scottish psychiatrist/psychoanalyst W. (Ronald) D. Fairbairn. Of note, and embraced by contemporary relational clinicians today, are some of his avant garde ideas:

Fairbairn spoke to the importance of what today we refer to as intersubjectivity and included the analyst’s subjectivity in what is observed:

the subjective aspects of the phenomena studied are as much part of the phenomena as the objective aspects, and are actually more important; and the subjective aspects can only be understood in terms (p.376) of the subjective experience of the psychologist himself.' (p.377)

Negotiation (“the personal interests of both parties”) as well as the need for authentic disclosure about the needs of the analyst are discussed by Fairbairn:

It would appear to be an elementary requirement that in a therapeutic situation the restrictions of the therapeutic method employed should be imposed primarily in the interests of the patient. This does not mean, however, that the interests of the analyst should be ignored. Indeed, the greater the importance attached to the actual relationship existing between the patient and the analyst as persons, the greater the justification for recognizing the personal interests of both parties to the relationship. At the same time, if it is felt necessary to impose restrictions in the interests of the analyst, this fact should be explicitly acknowledged.(p.378)

He goes on to discuss how relationship, including analytic attitude, importantly influences outcome:

interpretation is not enough; … the relationship existing between the patient and the analyst in the psycho-analytical situation serves purposes additional to that of providing a setting for the interpretation of transference phenomena (p. 377)

… the actual relationship existing between the patient and the analyst as persons must be regarded as in itself constituting a therapeutic factor of prime importance. The existence of such a personal relationship in outer reality not only serves the function of providing a means of correcting the distorted relationships which prevail in inner reality and influence the reactions of the patient to outer objects, but provides the patient with an opportunity, denied to him in childhood, to undergo a process of emotional development in the setting of an actual relationship with a reliable and beneficent parental figure. (p. 377)

In my own opinion, the really decisive factor is the relationship of the patient to the analyst, and it is upon this relationship that the other factors … depend not only for their effectiveness, but for their very existence… not just the relationship involved in the transference, but the total relationship existing between the patient and the analyst as persons… not just the relationship involved in the transference, but the total relationship existing between the patient and the analyst as persons. (p.379)

it is necessary for the patient's relationship with the analyst to undergo a process of development in terms of which a relationship based on transference becomes replaced by a realistic relationship between two persons in the outer world. (p. 381)
If the relationship is to change, then the analyst needs to change.

Even Systems Theory can see that Fairbairn intends a ‘perturbation’ to the rigidity of the intrapsychic life effected by the relationship’s capacity to open up transitional space:

A real relationship with an external object is a relationship in an open system (p. 381)  and

the central importance of the relationship between patient and analyst as a means of effecting a breach in the closed system of internal reality (p.385)

As for the couch? what a heretic—or perhaps Fairbairn already intuited that microexpressions as communication (right brain to right brain) allowed additional and greater access to the interiority and meaning of being human:

…I have come to entertain doubts regarding the validity of the requirement that the patient shall lie on a couch with the analyst out of view.(p.378)               
Something Fairbairn alludes to as of
a very high defensive value for the analyst (p.378)

Over a half century later, Fairbairn continues to speak to contemporary analysts.

Fairbairn, W.D. (1958). On the Nature and Aims of Psycho-Analytical Treatment. Int. J. Psycho-Anal., 39:374-385.

Monday, October 8, 2012

Do you speak 'Bionese'?

Bion’s ideas resonate for me with Zen and other metaphysical ideas about being and ways of being, but they are, in their descriptions, too often over burdened with jargon. Those who embrace and write about Bionian theory (e.g. Grotstein) can make it unnecessarily more difficult to comprehend when they continue to use Bionian jargon. I personally prefer how Ogden illuminates Bion (see below). While I may be fluent enough in alpha and beta and L, H, K, O, and their impediments (or negatives), and decades ago I may even have excelled in theoretical calculus, I nonetheless find jargon in a conference setting obfuscating instead of elucidating. It is as if a secret language has been learned by some and is expected all should have learned it or be excluded.

On Saturday, Oct 6, 2012 at the local Tampa Bay Psychoanalytic Society Speaker Program Meeting Walton Ehrhardt. EdD from New Orleans did make some of Bion’s principles more accessible. These were my favorites from the day:
1.       Thinking is driven by the human need to know the truth.
I do not necessarily cotton to the idea that there is a the  truth, as truth is varied and contextual to each therapeutic relationship, but I accept the inclination.  
2.       It requires two minds to think disturbing thoughts.
I especially like this idea, as it applies so well to the therapeutic dyad. What one finds untenable to bear alone may be shared, made bearable, with another.
3.       The capacity for thinking is developed in order to come to terms with thoughts derived from disturbing emotional experience.
A little broad reaching, but certainly one of the motivators for thought. And thought, symbolized in language, can help one “contain” disturbing experience. Ehrhardt emphasized that for Bion thought and emotion are inextricably intertwined. I think there exist ineffable experiences that are sometimes  not traumatic.

I longed for Ehrhardt to metabolize terms such as container, reverie, alpha function, beta, and K and re-present them to us in usable form so that the attendees might make use of them and more easily dialogue.

Ehrhardt did elaborate three of many types of projective Identification, all of which are, of course, are about relationship. [I was unsure what Ehrhardt intended to illustrate clinically with these]:
1.       Projective Identification as communication: the content of words, thoughts, ideas, dreams-- both waking and sleep dreams [Bion believed we were always dreaming] --projected, then introjected by the recipient, and, if a good fit, a relationship ensues.
2.       Evacuative type:  The unconscious wish to rid oneself of unacceptable parts, so these unwanted aspects of the self are projected on the other. The other accepts the projections whether through identifying or despising them.
3.       Through Control and Possession of the Object: when the other is treated as an object, related to not as a subject but as function, or a good or bad part-self or -object representing otherness.

Here is what Ogden says about it:
        The idea that there is something therapeutic about the therapist's containment of the patient's projective identifications is based upon an interpersonal conception of psychological growth: one learns from … another person on the basis of interactions in which the projector ultimately takes back … an aspect of himself that has been integrated and slightly modified by the recipient. (Ogden, 1982, p. 40)
[Ogden refers here to the alpha function]

Bion’s basic assumptions about groups were also thrown in:
1.       Dependence: group members behave passively as if the leader = parent; then resent, undermine, finally  topple the leader; then begin again choosing a new leader;
2.       Pairing: the group expects something new to be produced as if met only for a reproductive or sexual purpose.  Two group members or two subgroups do the work; others watch, relieved they do not have to work, and await the product of the ‘couple’  (a messiah, a rescuer of the group, a savior).
3.       Fight or flight: The group may be bonded by aggression (gangs, teams) or in flight (late arrivals, stories that occupy all’s attention, or avoidance of personal involvement of one’s emotional being).
What I found most fascinating was contemplating Bion’s idea that intrapsychically we are all made up of ‘groups’ which can behave according to these same  basic assumptions.

Still the struggling as a group to apprehend some of these concepts was invigorating, and taught empathy for those who were not fluent in ‘Bionese.’

Friday, October 5, 2012

Shame and The Grandiose Self

The Tampa Bay Institute for Psychoanalytic Studies, Inc emphasizes an analytic attitude as much as any other parameter of the frame. An important component of the analytic attitude is striving to avoid shaming or humiliating a patient, and so we devote an entire course to shame. This past week, the second year class in its Developmental Issues course, Narcissism and Development of Shame Throughout the Life Cycle, read Broucek’s 1982 paper on Shame and its Relationship to Early Narcissistic Developments. I found this paper most interesting, not the least because it supplemented my own psychoanalytic training which had been from a very traditional ego psychology point of view.

Traditionally shame had been seen as a relationship one has to one’s ego ideal or vis a vis one’s parental/societal expectations, shame a consequence of not living up to them. The traditional view took into account the development of the capacity to have self consciousness, such as a child considering itself in the mirror at about 18-24 months, as a necessary prerequisite for shame. Broucek, relying on the ideas of Tomkins (1963) recounts that shame arises “in the wake of disrupted or negatively attenuated interest, excitement or joy…activated on the neurophysiological level by a decrease in the density of neural firing.” This places shame at a much earlier age, as early as when an infant, able to distinguish its mother’s face from a stranger’s, “is disappointed in his excited expectation.” An infant in an “acute distress state associated with the inability to influence, predict, or comprehend an event which the infant expected” experiences not only shame but a disruption of its sense of self. (As an aside, ‘optimal’ shame may facilitate individuation, excessive shame may impede it.)

Broucek also diverges from the classical idea of shame as a reaction formation, stating that “In some cases it may be more accurate to view exhibitionistic trends as reaction formations to shame rather than the reverse.” He goes on to elaborate the grandiose self -- something which Kohut viewed as part of the normal self and ego ideal and needed to be, through mirroring, integrated into the Self, and Kernberg viewed as pathological, to be interpreted for its aggressive (manipulative) components. Broucek, calling to mind Bach’s later 1998 on being a subject or an object, posits that the “egotistical narcissist” privileges the grandiose self, denying the actual self, and is “unabashedly self-aggrandizing and is utterly shameless” while the “dissociative” narcissist denies the grandiose self.

Clinically, therapists often find the entitled, easily slighted, egotistical narcissist more difficult. The class waged dialogue on setting protective boundaries for oneself when the raging patient hurls an onslaught of denigration our way. Some suggested meeting, in a controlled manner, the patient’s hostility with our own. My preference for the best boundary is to ‘survive,’ neither withdrawing nor retaliating (ala Winnicott; and I think survival fails on Kernberg’s part with his proscriptive contracts. It is survival which bounds the omnipotent grandiosity of a patient who expects her/his vitriol to destroy us. Kohut might agree that it is only when the grandiose self is no longer dissociated through fear of its omnipotence which allows it to be integrated and then its energies used to facilitate the growth and creative activity of the self.

Monday, October 1, 2012

Learning with Bion

This Saturday, Oct 6, 2012, Walton Ehrhardt, EdD will present to the Tampa Bay Psychoanalytic Society, Inc “Learning with Bion,” a timely presentation both because Bion has influenced contemporary intersubjective theorists, and because some find the writings of Bion inaccessible. As many others find his work inspiring and illuminating, it behooves us to better understand what we can learn from Bion. Wilfred Bion spent his early years in India and his experiences as a tank commander in World War I profoundly shaped his approach to psychoanalysis. It is suggested that his way of going on living after an experience with death in war speaks profoundly to clinicians practicing in our contemporary world of trauma and dissociation.

Long fascinated with Bion’s admonition to approach the analytic hour without “memory or desire” I mused on what might be meant by such an exhortation. This phrase may intimate technique but it seems to me to be more likely to do with something greatly emphasized at the Tampa Bay Institute for Psychoanalytic Studies, Inc., that is, an analytic attitude. Bion exhorts a particular quality of mind. An “ ‘act of faith’ ” [not the K system, but the O system], an open receptivity to the unknown, which both facilitates becoming instead of knowing [O preceding K], and respects the unique personality of the analyst. [Bion says of O: “the void, the formless infinite…the perfect blank” and “the ultimate reality… the thing-in-itself.” Gerhardt refers to Bion's "O is the unknowable and ineffable which is felt as emotional truth and which we can only ever approximate. In treatment, O is turned into K and partially grasped to the extent it can represent connection between the self and the other; it is a knowing; it is not knowledge. K does not lead to O because experience precedes thought. -K is the experience that impedes or reverses the experience of understanding as it unfolds in the intersubjective expereintial field or as it unfolds in the intrapsychic dialogue."] The felt emotional truth of who we are seeks recognition in experience, not merely cognitive understanding and words, yet we also approach, in part, O in the clinical situation to the extent it is transformed into K. Unlike Freud, who wrote that, like archeologists, we can carefully dig up through reconstruction (based on theory) the repressed event or memory as an existing entity of the past, Bion recognized that uncertainty permeates the analytic process as it unfolds unpredictably from the unique combination of analyst and patient experience. There is no existing truth to be revealed but rather a moving toward an as yet unrealized truth co-created in a moment between two intimately entwined psyches.

Bion is probably best known for his ideas about containment and reverie. We cannot discuss containment without discussing “alpha function,” the function of the primary caretaker to receive projected unwanted or overwhelming infant affects and process/modify these otherwise overwhelming experiences and return them to the infant in a palatable form. It develops the infant’s capacity for self regulation; is a part of mutual regulation; and ‘gives’ meaning to experience. [Bion did not necessarily describe how the ‘container’ function takes into account the subjectivity of the mother/therapist. More contemporary analysts might take umbrage with the idea that one person can be merely an object to receive projections, and remind us that the subjectivity of the receiver likewise influences what is received as well as what was projected, adding that projective identification tends to over emphasize the idea of therapist as container.]   In being a 'container,' the therapist takes in thoughts or feelings untenable to the patient, and then represents them in a modified fashion so as to make them more usable (acceptable; less omnipotently destructive, easier to identify with; etc). This is done, in part, by holding the patient in one’s mind, as mother does with infant, via memory and reverie.

Thomas Ogden expounds on the dream-like process Bion has called reverie by discussing its absence:
"… the pressure on an infant to behave in a manner congruent with the mother's pathology, and the ever-present threat that if the infant fails to comply, he would cease to exist for the mother. This threat is the muscle behind the demand for compliance: "If you are not what I need you to be, you don't exist for me." Or in other language, "I can see in you only what I put there. If I don't see that, I see nothing"

Reverie, then, is the state of mind of the mother (or the analyst) which allows her to serve as a container to her infant, allows her to imagine herself in the infant’s ‘shoes’ and discern his needs. The feeding, holding, and soothing of her infant are her ‘interpretations’ of his experience and need. The Object Relations' idea of projective identifciation along with Bion's containment may come into play with our ability to 'wear the attributions' [ala Lichtenberg] a patient deems for us. To do this requires of us a capacity to feel our way into our patients' shoes and discern their hunger (longing), disappointment in and fear of us, and their demands for recognition and mutuality. Reverie aids our ability to feel our way into the other. It informs the analytic attitude, and eventually and hopefully, engenders, through experience, these shared capacities in our patients.

Bion, W.R. (1962) Learning form Experience. Oxford, UK: Jason Aronson
Bion, W.R. (1970) Attention and interpretation. London: Tavistock. In Seven Servants (1977) New York: Jason Aronson.
Gerson, S. (2004) The Relational Unconscious: A Core Element of Intersubjectivity, Thirdness, and Clinical Process. Psychoanal Q., 73:63-98.
Ogden, T.( 1992) The dialectically constituted/decentred subject of psychoanalysis. I: The Freudian subject. Int. J. Psychoanal., 73:517-526.

Friday, September 28, 2012

Poem: A Therapist's Morning

The young man grows up
With a father, chronically disparaging, disappointed
In his son.
The father, a ne’er do well.
‘Who is he to criticize me?’
The boy wonders.
The boy learns to hide himself:
“We don’t have to tell your father’
‘No need to stir things up’
Says his mother.
At school he invents a life,
Invents pot, invents sex
To be cool, to be accepted.
No one sees him.
Like Eleanor Rigby
He puts on face
He keeps in a jar by the door.
No one sees him. Who is he?

Do we seek recognition here?
Will I be seen?
Will someone like me?

A young woman grows up
One of far too many siblings.
‘Suck it up!’ says her father.
‘Pray’ says her mother.
Over the years their lack
Of inclination
To see her
Begins to wear her away.
Their insistence on boxing
Her into their religion or
You are no longer our daughter
Pulverizes her
Dust now.
Only exhaustion remains
The stone of resentment
Long placed atop her
Disappointed longings.

Do we seek recognition here?
Will I be seen?
Will someone like me?

Monday, September 24, 2012

uncertainty, compassion, chaos: early morning ramblings

The Self Psychology Study Group of the Tampa Bay Institute for Psychoanalytic Studies, Inc recently read C.B. Levin’s 2006 paper “That's Not Analytic”: Theory Pressure and ‘Chaotic Possibilities’ in Psychoanalytic Training. It saddened me that she endured from her supervisors “the constricting pressure to conform” from their authoritarian, dismissive comments about her creative and spontaneous work, but also inspired me that she wrote such an illuminating and interesting paper about her experience. If American ego psychology privileges as psychoanalytic free association and interpretations of conflict, resistance and transference, and eschews as unanalytic, and merely supportive, the participation in co-creating and negotiating the analytic process, then the possibility for change by analysand and analyst alike is greatly constrained.

It is hard to be on “the edge of chaos” as a patient, a therapist, a person trying to make her or his way in the world. As therapists we try to open our hearts to the unknowable, the uncertain, the unpredictable. For some, the need to be certain, to stand on unshifting conviction about what is right or true becomes a life or death struggle, whether to prevent annihilation of the self, the soul, or one’s physical existence.

Sometimes, the more one’s certainty is attacked the more one might dig one’s heels into the presumed safety of the rigidity of certainty of creed, dogma, or ideological beliefs. White Jim Crow southerners feared the loss of the self (defined by their straw man superiority over ‘coloreds’); fanatical Muslims, also often poor and uneducated, take to the streets on the edge of a deadly chaos in protest against the ill-conceived, so-called film The Innocence of Muslims, and people are killed.

In the U.S. we ask ourselves: Where does freedom of expression cross the line to become intent to incite violence? When does free speech become agitprop? How do we reconcile poor taste and ill humor with freedom of expression? Certainly Terry Jones, the Florida preacher, voiced intent to provoke fanatical Muslims in hopes to reveal Muslims as gone astray from the nonviolence of Mohammed, just as Jim Crow southerners went astray from the teachings of Jesus. The dangers of dogma in the consulting room are less drastic, while perhaps more insidious.

In the psychoanalytic world, being rule-bound allows little room for possibilities foreign to one’s circumscribed world, a world made impermeable by the rigidity of dogma, seemingly protecting one from uncertainty, but also from the chaotic possibility of making something new and changing the self and other in the process. A patient accuses me of never being able understanding her trauma, tortured in a war ravaged country experiencing ethnic cleansing, atrocities I can barely imagine much less bare to listen to. I cling to a belief that, in being a witness, in feeling compassion, in listening attentively, I diminish her isolation and honor her suffering. But what if my belief keeps her pain from truly penetrating my weltanschauung? This work is rife with uncertainty, as it must be. I liked Levin’s modus operandi of “opening up a space for honest inquiry” and revealing as “unanalytic certainty of knowing a priori what is analytic.” And so we press on.

Levin, C.B. (2006). “That's Not Analytic”: Theory Pressure and “Chaotic Possibilities’... Psychoanal. Inq., 26:767-783.

Thursday, September 20, 2012

Shame, Aloneness, and Winnicott

More than theory or technique here at the Tampa Bay Institute for Psychoanalytic Studies (T-BIPS), we again and again emphasize the analytic attitude. Of great importance to this attitude is the avoidance of shaming our patients. Because disappointed longings often induce shame in the one who is disappointed (I am too greedy, I am too needy, It must be that I am so unlovable/so unworthy that I do not deserve what I long for) it becomes incumbent upon the analyst to strive toward being ever mindful of the reaction of our patients to any of our communications.

A very interesting discussion about Winnicott ensued last evening in the second year course Development of Shame taught here at TBIPS. We were reading about Being and so read Winnicott’s Capacity to be Alone and Playing: Creative activity and the search for the self. Candidates and students claimed to enjoy the discussion so much and to find it so illuminating that we toyed with the idea of writing a handbook, a kind of Winnicott for Dummies. We were especially taken with delineating the capacity to be alone with the capacity to be alone-in-the-presence-of-the-other.

The capacity to be alone results from the infant’s repeated experience with having its needs met in a timely fashion. Consequently, the infant has the expectation that what is needed will be forthcoming. Hunger and loneliness, then, are bearable because of the infant’s faith that these will eventually be resolved. An infant without this faith will be overwhelmed by the expectation of unrelenting hunger (or pain or loneliness). An adult without this capacity may strive to avoid unbearable feelings of want (overeat, become addicted to behaviors or substances, incessantly need to be in the company of others).

The capacity to be alone-in-the-presence-of-the-other is an even more sophisticated developmental achievement, also wrought from experience with caregivers. Does the caregiver allow the toddler to explore the world without undue intrusion and impingement? The capacity to be alone-in-the-presence-of-the-other is also linked to creativity and spontaneity, to very aliveness, if you will. Creativity in early childhood is fostered when the caregiver provides objects for exploration (pots, pans, blocks, etc) but does not insist on how these objects be explored (as opposed to uwanted intrusions like No, don’t line the blocks up like that, stack them like this). The caregiver, in the background, enjoys, sometimes even participates in, the child’s play. The child is given psychological space to enjoy the world and her/himself in the world but is not abandoned to the world. The caregiver in the background is ready to step in when needed.

Ideally, both adults in a partnership have developed the capacity be alone-in-the-presence-of-the-other, and then come together for mutual enjoyment, sharing, recognition, comfort and reciprocity. Adults who have not developed the capacity be alone-in-the-presence-of-the-other may constantly demand attention from the other, be jealous and resentful of time the other devotes to hobbies, work and friends, may feel chronically dissatisfied, and devitalized, may distort themselves to garner attention from others.

Most clinically apropos: how does the therapist give the patient enough space to allow for exploration, creativity and play in the therapeutic situation and still be in the background awaiting use should s/he be needed? This tricky tightrope is a huge challenge for the analyst. Winnicott intended to provide enough space for Ms X to allow her to spontaneously develop her own way in the world, but, as a few in the class noticed through Ms X’s repeated complaints, Winnicott failed to be sufficiently at the ready for joining with Ms X when she needed him to be more present. How does a therapist know when to give space and when to join in? It is not easy, but I think our patients tell us, by their words, tone, breathing, posture, facial expressions, etc, moment by moment, where we need to be if we can pay attention and learn to walk a very thin line, juggling on a tightrope.

Monday, August 13, 2012

Birthday noted

I thought it fitting in this election year, when freedom of choice and rights to healthcare for women in the USA are again under attack, to note the birth date of Lucy Stone, born on this date in 1818. An American abolitionist and suffragette, she inspired Susan B Anthony, after Anthony heard her speak, to take up the cause for a woman’s right to vote. Women were granted the right to vote on August 18, 1920 by the 19th Amendment to the Constitution. Stone had been dead 27 years.

I often wonder what makes us so afraid of the liberty of others, what affront to our sense of self will occur should difference be allowed, let alone embraced. When I decided to switch from Family Practice to Psychiatry, and then become a psychoanalyst, a friend from high school thought I was making a politically incorrect decision for she erroneously thought mental health professionals unduly influence others to accept the status quo, to learn to live within a reality of constraint and even oppression, particularly for women, for example, to accept an unhappy marriage. Far from this type of acceptance or submission, in my view psychoanalysis helps people see a larger range of possibility. One female patient, in an unhappy marriage for over a decade, through analysis found the courage to imagine a life on her own without her abusive husband.

Lucy Stone advocated not just for the rights of woman to vote, but for the rights of women to divorce, to retain property and childrearing responsibilities after divorce, and, married herself, was the first American woman known to retain her own name after marriage. In other words, like psychoanalysts, she advocated for all people, including female persons, to live up to an panoply of potential based on inner resources and not on chromosomes.

Thursday, August 9, 2012

Ah. Yes.

Ah. Yes.

The best love letter I ever received was one word. Back in the days when people actually put pen to paper, and between the salutation “Dear Lycia” and the “Love, …” was scrawled in large, very large, letters, the single word, “YES.” It answered no asked question and therefore answered every possible question, evincing an openness to infinite possibility.

In an Angels and Airways song, Lifeline, the refrain goes:
"We all make mistakes.
Here's your Lifeline.
If you want it I want to."

But it sounds to me like singer Tom DeLonge is really singing:
We all make mistakes.
Here's all I’ve learned.
If you want, I want to.
For me, If you want, I want to, is ‘yes,’ where ‘yes’ is the giving oneself over to the other (or to the experience) in a leap of faith, the leap of faith required to open oneself to the experience of the other in the therapeutic dyad.

I am reminded of the 1981 paper by Michael Eigen The Area of Faith in Winnicott, Lacan and Bion. (IJPsa., 62:413-433) [see also blog post of 2-14-09]: “For Winnicott, … creativity permeates psychic life and is involved in the very birth of self and other...” and, “Winnicott assumes life is primarily creative and in infancy this creativity unfolds …” Eigen elaborates Winnicott’s infant: “while the infant is living through creative experiencing, he neither holds on to anything, nor withholds himself.”[italics added, to emphasize the 'yes' of it] …“The true self feeling involves a sense of all out [italics added] personal aliveness …This connects with Bion's insistence that truth is necessary for wholeness and emotional growth….For Winnicott, the true self feeling is essentially undefensive...” [italics added].

Even Bob Hicok’s Confessions of a Nature Lover celebrates the ‘yes’ when he ends his poem:

"...that’s why we say
of real estate, location, location,
location, and of speech,
locution, locution, locution,
and of love, yes, yes, yes,
I am on my knees, will you have me,

Monday, August 6, 2012

The Runaway Bunny  by Margaret Wise Brown, pictures by Clement Hurd

Difficult patients are difficult for their chronically intermittent, sometimes seemingly relentless, attacks on the work and on the therapist’s competence: “This isn’t working;” “Nothing has changed;” “Analysis is useless;” and, more pointedly, “You don’t care about me;” “You only care about the money;” “You don’t know what you’re doing;” “You suck!” Commonly, there are also frequent threats to quit analysis, often expressed with the threat of suicide.

To keep my balance and to survive (neither withdraw nor retaliate, in the Winnicottian sense), that is to persevere without thinking: “Here we go again;” “Who needs this anyway?”; or “Good riddance,” I recall the delightful children's book, The Runaway Bunny (1942) by Margaret Wise Brown, probably better known for her Goodnight Moon.

The Runaway Bunny is a felicitous analogy for working with patients who want us to believe that we are unimportant to them. The runaway bunny

              said to his mother, “I am running away.”
              “If you run away,” said his mother, “I will run after you.” …

              “If you run after me,” said the little bunny,
              “I will become a fish in a trout stream
               And I will swim away from you.”

              “If you become a fish in a trout stream,” said the mother,
              “I will become a fisherman and I will fish for you.”

              “If you become a fisherman,” said the little bunny,
              “I will become a rock on the mountain, high above you.”

              “If you become a rock on the mountain, high above me,”
              said his mother, “I will become a mountain climber,
              and I will climb to where you are.”

And so on for a crocus in a hidden garden, a bird flying away, a sailboat sailing away, his mother always finds a way to stay in connection with her little bunny.

                   “Shucks,” said the bunny, “I might just as well
                   stay where I am and be your little bunny.”

I can imagine this gives reassurance to an adventurous or angry, small child, that her/his mother will always come for it. With this on my mind, I hold the faith of commitment to the relationship and to the work.

Perhaps this attitude is implicitly conveyed, a balm of certitude for a patient who has experienced unpredictable or abandoning parents. Perhaps it is explicitly conveyed, “I will be here tomorrow at the appointed time.” Either way, it is my job, I think, to remain steadfast and keep faith when the patient conveys, with an onslaught of doubt and vituperation, her/his hopelessness, anger, or disappointment in me and in the work. A candidate asked, when I convey this attitude in class, if I were a masochist, or a saint. Neither, and I referred the candidate to Ghent’s 1990 paper on Masochism, Submission, Surrender.

Recently, after unrelenting, expressed hopelessness, a patient  said to me, “I think I am doomed with or without you -- but I’d rather be doomed with you.” And after a few wiped tears, he added, “You’re the person I want to be doomed with,” and smiled.

Tuesday, July 24, 2012

Tragic De-realization

Having experienced a long bout of what is called "derealization" after recovering from a serious drug overdose, I have developed a theory of the bizarre behavior exhibited by the perpetrator of the Aurora, Colorado Massacre. When you are in a state of derealization, everything seems like a figment of your imagination, not "real," like the way things used to be. You may think you are in an elaborate dream, purgatory, the afterlife, or merely inside your head depending on your beliefs.

Holmes' actions are consistent with someone who experienced a psychotic break and entered a prolonged state of derealization. Why would Holmes booby trap his house with the intention of killing any law enforcement who entered, then tell the same law enforcement that his house was booby trapped? Why the palpable look of remorse on his face in the courtroom? How can someone spend weeks planning out a mass murder, carry it out, and then suddenly feel remorse? This would be bizarre if one did not consider the concept of derealization. When Holmes carried out the act, something snapped him back to reality and his psychotic break of derealization ended. In this light Holmes, too, is a victim, and we should do what we can to further our understanding of the state of derealization. If

this theory turns out to be correct, we must then ask: should a person in a state of derealization be held responsible for his actions? The remedy would seem to be increasing public awareness of derealization, and vastly improving the quantity, quality, and accessibility of available mental healthcare, as well as de-stigmatizing mental illness and increasing awareness of it so as to encourage people to seek help before terrible things happen.

By Tim LaDuca

Monday, June 11, 2012

Art: an antidote to sports?

June 9, 2012

Ukraine hosts the Euro 2012 Football championship this year, and its local club has given 3000 tickets to its hardcore fans, the Ultras, who ignominiously boast “…no dark skin, no blacks, no slant eyes in our section of the stadium…” This racism causes me to wonder what ‘doer-done to’ relational template in childhood was internalized by these “hooligans” who seems to have a penchant for the side of the doer.

Perhaps an antidote for the “Ultras” is the contemporary art exhibition dOCUMENTA which runs for 100 days every five years in Kassel, Germany. Today begins dOCUMENTA 13 and this year’s, reflecting globalization, includes exhibits in Kabul and Banff. Artistic director Carolyn Christov-Bakargiev says that dOCUMENTA (13) Collapse and Recovery “looks at moments of trauma, at turning points, accidents, catastrophes, crises, events that mark moments when the world changes.”

Some of the art this lustrum comes from war zones. American artist Michael Rakowitz, who worked in Afghanistan, features the poignant tablets carved from stone by Bamiyan masons -- Bamiyan, where the Taliban blew up, in March 2001, two of the world's artistic treasures: two giant, 1400 year old Buddhas carved from a cliff in central Afghanistan. “Both Kabul and Kassel have witnessed destruction through war and the need for physical reconstruction and mental retrieval, becoming stages where our present is represented or transcended.” Nalini Malani displays a work of carouseling shadows which highlight the oppression of women in India. A Pakistani refugee herself, her art additionally depicts the politics of the Partition and its cost of hundreds of thousands of lives. She also illustrates the essay The Morality of Refusal by Arjun Appadurai reflecting on Ghandi’s non-violent political practices. William Kentridge, the South African anti-apartheid artist is featured for the third time.

Wednesday, May 30, 2012

Book Review Psychotherapy Lives Intersecting

Long before any theoretical contributions from various schools of psychoanalysis are introduced to first year candidates at the Tampa Bay Institute for Psychoanalytic Studies, the majority of the first year course, Introduction to Psychoanalytic Concepts I,  discusses with candidates how to be with patients. How fortuitous that I have recently come across the immensely readable (and highly autobiographical) primer by Louis Breger, Psychotherapy Lives Intersecting (2012; Transaction Publishers, New Brunswick, NJ) which adds the perspective of former patients, what they found helpful and unhelpful in their treatments, to the pearls gleaned from his vast experience as a psychoanalyst. Breger aims his book at people considering therapy, but therapists, too, will greatly benefit from this jargon free exposition. What is unique about this book is that the many clinical vignettes are enriched by reflections from patients about their own psychoanalytic journeys, something the reader may find courageous.

Elizabeth (pp. ix) writes, 'Throughout the therapy experience with you, I always felt like a person in a relationship, rather than a person to be understood by you, and then explained back to me…you communicated an utter lack of judgment, an acceptance of the aspects of my life about which I was most embarrassed, and modeled that Not Knowing was okay'. Another patient, Bernie, (pp. 29) “singles out catharsis, having a safe person to talk with, and insights-in that order-as the helpful factors of his therapy.” Breger says of his own analysis, “…it was the relationship itself—being accepted, listened to in a noncritical manner, understood, appreciated, even liked—after revealing what I felt were my most shameful and guilt-ridden secrets—that was most helpful." Breger listened closely, was not dogmatic, and did not dictate rules.

Just as research shows that the person of the analyst is more important than her/his theoretical orientation, Breger recognizes that relationship is as important, maybe more so, as interpretation and insight. Breger also sees the benefit of ‘fit’ between analyst and analysand, including whether the therapist likes and identifies with the patient. Instead of illustrating how to behave as an analyst, Breger writes about an analytic attitude. Breger muses on anonymity, authenticity (about being human), self disclosure (must [also] be for the benefit of the patient), and analyzability. But Psychotherapy Lives Intersecting is as much about Breger’s personal journey as an analyst as it is about how his patients viewed their treatment. The neophyte will benefit greatly from this disclosure. His “straightforward approach” to writing and to his patients is refreshing. As a traditionally trained analyst who also found a relational home in contemporary theories, I found it wonderful to immerse myself in a book where I found like mindedness.

Monday, May 14, 2012

Covert Ops and Psychoanalysis? Who Knew

While I advocate in analytic treatments for openness and authenticity, I was surprised that Henry A Crumpton, whose book The Art of Intelligence: Lessons from a Life in the CIA's Clandestine Service which came out today, stated some things that good spies have in common with therapists, namely "an intense intellectual curiosity; willingness to deal with ambivalent situations [by which I took he meant ambiguity]; and a certain degree of creativity." Part of me shudders. Still, I like to see our work as therapists as one of collaboration, where both parties strive, by the very nature of their relationship, toward a common purpose, not enemies except in moments of rupture, not out to deceive the other except in protection of the sense of self coupled with a longing to be known and understood. Therapy is a tricky business, no precious metals to be acquired, no missile heads to be dismantled, no foreign dignitaries to be protected, but sometimes a sense of life or death for a particular self state or relationship, an urgency to find one another in the tumult of the outside world, and a hope that we each will sleep more peacefully tonight.

Sunday, May 13, 2012

MOTHERHOOD May 2012 Mother’s Day

Winnicott said that the good enough mother never asks the infant to answer of itself the question about the transitional object ‘did I find it or did I create it?’ I also think the good enough mother welcomes and enjoys her infant, sharing the joy of its developing experiences, accepting and loving it, most times, just for its being born, and making quick repair when she doesn’t. But the greatest gift a mother gives her child is her own genuine happiness, a consequence of her own subjectivity and interests, her own feeling of being loved and accepted in the world. This gift gives children the license to be happy themselves, permission for their own subjectivity, hope for the future (of aging), as well as infuses them with the belief that they are enjoyed, welcomed, and contribute to parental happiness. Jessica Benjamin noted that the subjectivity of the analyst also relieves the patient of having to feel responsible for the analyst’s ‘happiness.’ A Happy Mother’s Day to all the moms out there.

Tuesday, May 8, 2012

Maurice Sendak Beloved Children's Illustrator and Author Dies

Maurice Sendak, acclaimed children’s book illustrator and author, died today a few weeks shy of his 84th birthday. His most famous book Where the Wild Things Are, a Caldecott Medal winner, is also beloved to psychoanalysts because it lends itself beautifully to metaphors about the unconscious life and about therapy. We pledge to open ourselves to the scary and the wild in our patients and in our selves, and to go with them to places where others are not allowed or fear to tread. His illustrations of monsters are personal to Sendak (not griffins or gorillas) derived from his childhood experiences with all his Jewish relatives with “big warts and hairs growing out of their noses,” adults who “treated them in silly fashion” as kids constrained in best clothes awaiting dinner and having to “listen to their tedious conversation” as well as having been told he and his siblings had gotten big or fat and they would “eat us up.” The monsters tell Max: Please don’t go, we’ll eat you up, we love you so. [Sendak lamented that book signings unwittingly turned him into a strange monster to the children shoved at him to autograph (write in their books, an action forbidden to them) and whom they imagined wanted to take, keep, as well as defile their favorite book. Sendak said, “A child was a creature without power, …pocket money or escape routes of any kind.” He detested Peter Pan because he could not conceive that any child would want to remain a child, powerless. He thought “all kids would like to have control” And Max, the king of all wild things, was lonely and wanted to be where someone loved him best of all. Max not afraid of the montsters and so child readers likewise were not afraid. Sendak’s own fears included the vacuum cleaner and The Invisible Man, a movie which he credited for his lifelong insomnia. He found “terrifying” the unraveled bandages (of head) exposing nothing there. Big events in his childhood were “being sick” and “being expected to die” (discussed in front of children by his parents) which “pervaded my soul apparently.” In the days before antibiotics and vaccines, Sendak spent lot of time, sick, in bed with childhood illnesses. When sick, before TV, Sendak spent a lot of time looking out windows, happy memories which appeared in his books. His father left Eastern Europe before the Holocaust but all father’s relatives perished there and father grief stricken all Sendak’s life. In the Night Kitchen was banned in some libraries across the USA because its protagonist Mickey appears nude. Sendak said of this that he was “not out to cause a scandal”… “I assumed everyone knew little boys had that.” Outside Over There is about sibling rivalry and responsibility; Ida is left to babysit her baby sister, who is kidnapped by goblins, and Ida must come to terms with her ambivalent feelings as she goes on a magical adventure to rescue her sister. Among other awards, Sendak also received a Newbery Award for his illustration of Isaac Bashevis Singer’s children’s story Zlateh the Goat. Sendak’s family moved a lot due to money problems growing up in Brooklyn. He also wrote a book about homelessness We Are All in the Dumps with Jack and Guy: Two Nursery Rhymes with Pictures.

Sunday, April 29, 2012

A Contemporary Look at Conflict

I am always delighted when I read how contemporary relational thinkers reconfigure century old tenets in psychoanalysis. Adrienne Harris does just that with conflict in her 2005 paper Conflict in Relational Treatments (PsaQ 74:267-293). Though finding her paper somewhat confounding, the TBIPS Relational Study Group delightedly discussed the elaborations of conflicts in human experience which Harris considers. She elaborates on conflicts between the needs of self and others (interpersonal conflicts), between two unconsciouses (intersubjective conflicts), and conflicts between self states, in addition to the traditionally understood conflicts between wishes and between wishes and their prohibitions. Along with conflicts between ego-id-superego, additional intrapsychic conflicts exist between the multiple selves of one person and the multiple unconsciouses found within these multiple selves. Disavowed or dissociated parts of self may then never come into the treatment with the selves states of a particular analyst. Conflicts for the analyst, too, include the conflict between sticking to the rules of training and being spontaneous; the conflict of desiring the imposition on the patient of the normative and the hope for the patient to have freedom from these constraints. Speech, too, provides for conflict, for example, between what is said and how it is said, between content and tone/prosody, or content and intention. For both participants there is the pull between the wish to change and the wish to stay the same. There are the interpersonal and intersubjective conflicts between analyst’s and analysand’s agendas, both overt and covert, and also those between the unconscious(es) of the analysand and the analyst. Consider then the multiplicity of the analyst’s selves and those of the analysand in their innumerable combinations! I often think that the analyst must juggle a huge number of balls in the air-- while walking a tightrope. Harris made me consider adding to that number.

Friday, April 20, 2012

The Limits of Desire

In the Development course of First Year at the Tampa Bay Institute for Psychoanalytic Studies, the paper Aggression and Sexuality in Relation to Toddler Attachment: Implications for the Caregiving System by Alicia F. Lieberman (1996, Infant Mental Health Journal, 17(3) 276-292) was recently discussed. I recommend this paper for its elegant vignettes which readily illustrate how parents might enhance a child’s sense of self and self worth by their responses to a toddler’s aggressive or sexual strivings. But it is its applicability to the psychoanalytic situation that cause me to quote from what Lieberman describes as the outcome of well or poorly handled responses.

She writes that when negative feelings are generated in the attachment relationship around sexuality or aggression, there occurs

a constriction in the areas of experience where the child can rely
trustingly on the attachment figure’s emotional availability …
Attachment loses some of its richness and range because certain
domains of experience must be kept secret from the parent for the sake of not risking rebuke and disapproval.

And its corollary:

When aggression and sexuality are appropriately accepted, modulated, and socialized by the attachment figures, in contrast, there is an expansion in the range of affect that becomes permissible to experience and to share. Toddlers acquire a visceral [procedural] sense of pleasure in who they are and how they are made when their parents cherish and celebrate their body and its accomplishments…when appropriate limits are being set that allow the child to learn what is permissible and what is not in a clear and nonpunitive manner.

Certainly, the analyst hopes to invite in to the consulting room the broadest range of affective experience and to eschew rebuke and disapproval for what a patient brings. We want our patients to cherish and celebrate a broad range of self experience. Likewise in the psychoanalytic situation it is incumbent upon the therapist to remain emotionally available to analysands even when they bring potentially unwelcome strivings, to remain emotionally available by empathizing with and remaining sensitive to the patient’s strivings, keeping open the elaboration of wishes and desires without unduly frightening a patient and without foreclosing the transitional space for play by reifying or concretizing patient’s wishes through action. Keeping the elaboration of desire alive while holding sensitively to the limits of its permissibility is a very difficult balance, reminding me of what a medical school, surgery mentor used to say when things got unpredictable and potentially dangerous on the operating table, “We’re in tiger country now.”

Monday, April 16, 2012


I recently began musing on happiness when invited by David Burton, a local, independent, documentary filmmaker to be interviewed on this very subject for his present film project. I thought about how the human brain is wired for moments of happiness; it releases happiness chemicals during certain experiences such as love or orgasm or a runner’s high. The more experiences our brains have with happiness, the greater our faith that we can expect future happiness to be forthcoming. As such, I recommend we practice some joyfulness every day.

Because as infants and toddlers we require attachment for our very survival, each of us as children constructs what we believe will maintain that attachment bond. As such, children will comply with parental demands to themselves be the parent to the parent, or to be the container of all bad feelings or behaviors, to achieve in sports or academia, and so on. Even with good enough parenting, eventually well-fed and well-loved infants who have delighted in playful interchanges with caregivers learn as toddlers that their caregivers are no longer under the child’s omnipotent control, a loss compensated, ala Benjamin, by the joy of two separate minds coming together, because they choose to, to share one thing, e.g. the child’s wonder at a dandelion. Later when we are aware that we are finite, mortal, and alone in the universe, this meeting of the minds bridges the gulf of existential isolation, and momentarily we are joyful.

Happiness, or at least contentment, comes with satisfaction of certain innate strivings of human beings, five that Lichtenberg beautifully delineated: physical needs (food, safety, shelter); needs for creativity, exploration, and play; for sensual and sexual pleasures; for attachment and affiliation; need to defend against or escape adversity as well as to assert ourselves. Happiness is co-created in the context of relationships. When we have had the experience of being welcomed and enjoyed, then our parents’ joy infuses us. We learn joy and to enjoy ourselves, as well as others. Happiness comes more easily to those who have been welcomed and enjoyed. And when we despair, it is easier to keep the faith that happiness will eventually be coming around again.

I remembered a psychiatry resident from a few years ago whom I was to supervise. She came to me, terrified about the prospect of doing psychotherapy without sufficient training, and I asked her what she thought most people want. After a few moments she answered, profound in its simplicity, "love and acceptance." That is, then, I told her, exactly what we must learn as psychotherapists to weave into the treatment relationship.

I advocate, then, for love and acceptance in the psychoanalytic situation, welcoming and enjoying our patients, even their darkest self states, such as anger, despair, envy, and murderous rage, self states of which they are ashamed and may disavow, but being welcomed into the treatment room can find voice, and, ideally, can find dialogue with one another. The psychoanalytic experience of love and acceptance coaxes forth shamed and disavowed self states, invites in play and creativity, and a communion between self states, mine and the other’s, in a panoply of possibility. When I experience myself with another, intimately, fully, authentically, there is happiness.

Wednesday, April 11, 2012

Female Sexual Development and Fathers

The Tampa Bay Institute for Psychoanalytic Studies, Inc's first year class has been reading Freud’s ideas on female sexual development in the Development course. Because in each class we try to offer a dialogue between antipodal points of view, as a preview to the readings in today’s class I thought I might comment on Jessica Benjamin’s 1991 paper Father and Daughter: Identification with Difference — A Contribution to Gender Heterodoxy.

It seems Freud could not conceive that small children wanted it all, to be and to have all, but instead thought both male and female children only wanted the penis. Likewise, Freud did not conceive that 'normal' children might have homoerotic longings but instead only heterosexual ones: when little boys longed for attention, affection, love from their fathers, they must be feminized (the negative oedipal complex) and likewise little girls attached in an active way to their mothers must be like little men, be little men, just like little boys who want their mothers in a heterosexual way. While Freud postulated that the fear of losing his penis catapulted the little boy out of the oedipal phase, he posited that little girls enter the oedipal stage from their castrated state, turning to the father in search of a penis (or its psychic equivalent, a baby).

Benjamin revisits and reconfigures penis envy of little girls and places it not at the cusp of the oedipal configuration but instead squarely in the pre-oedipal period, noting that pre-oedipal girls turn to the rapprochement father, not yet an object of erotic love, but instead as an object of identification. The father, the penis, the phallus all stand for independent agency, subjectivity. Little girls, as do little boys, use the glamorous, exciting out-in-the-world-father as an idealization of subjectivity, a role model, a subject with agency, will, and desire. It is identification with this father as subject, separate from and independent of mother, that allows for children of both sexes to individuate from mother. Benjamin further expects that the latency age girl who wishes to be buddy to her father seeks to consolidate her identification with an independent subject. Rather than seeing this behavior as a masculine protest (Freud), Benjamin notes that it further consolidates a feminine identity.

Benjamin proposes that thwarted identificatory love may also explain girls’ fantasies in Freud’s A Child is Being Beaten. Thwarted identificatory love may lead a woman to privilege desire of a man over her own desire, whereas welcomed identificatory love, Benjamin writes, may sow the seeds for later erotic, mutual heterosexual love rather than being complicated by submissive, even masochistic, behavior towards men.

Sunday, April 8, 2012

Easter Sunday musings on Resurrection

For Christians, Easter Sunday is the holiest and most joyous holiday, the day they believe that Jesus Christ rose from the dead. While their believe insubstantiates the triumph over death, psychoanalysts engage instead in the metaphorical (re)vitalization of their analytic partners who often come to analysis with the complaint of feeling empty, dead inside. In feeling their suffering I sometimes wonder to myself, ‘where was the parent with the gleam in her/his eye to enjoy this self as baby, infusing the self with joy and enlivening it via connection with a mutually attuned other?’ Is analysis some kind of ‘corrective emotional experience’ in which there is a way that together we can find a moment of connection that enlivens us both? Before we were isolated, separate, and hopeless, and then, in an unexpected and miraculous moment we meet, are fleetingly connected. Is this connection (perhaps more protracted for the faithful) not what a god promises its supplicant?

Because we can never know the suffering of others, I am reminded of Roger Rosenblatt in Kayak Morning quoting Philo’s admonition “Be kind for everyone you meet is carrying a great burden.” This resonates for analysts who recognize that all of us, like Christians who walk in Jerusalem the Via Dolorosa (translated as the way or road of suffering) to commemorate Jesus’ carrying the cross to his death , walk through the world in suffering, suffering both made worse and caused by isolation from others.

Tuesday, March 20, 2012

Intergenerational Transmission of Trauma

Doris Brothers, author of The Shattered Self, spoke in Tampa March 10, 2012 on trauma,and briefly alluded to intergenerational transmission of trauma. I would like to elaborate on some of the neurobiological mechanisms that might illuminate how intergenerational transmission of trauma occurs. To that end, I utilize Alan Schore’s Advances in Neuropsychoanalysis, Attachment Theory, and Trauma Research: Implications for Self Psychology.(2002). Psychoanal. Inq., 22:433-484.

As we are aware from infant research and neurobiology, an infant requires the presence of an attuned other for its optimal development and to optimally organize its experience. Winnicott said there is no such thing as a baby, that is, there is a mutual (interdependence) influence (regulation) between infant and mother in which the two function as a unit, including unconscious communications that serve to develop the brain of the infant. [This bulwarks the relational theories which take psychoanalysis from a one-person (intrapsychic) to a two person (intersubjective) psychology.] The 'good enough' caregiver helps the infant maintain its homeostatic equilibrium and facilitates the emerging self. Instead of the Cartesian mind-body duality (or of self from the environment) regulation of physiological functions builds the brain (the mind, the self) in particular ways.

A mother who may herself utilize dissociation as a result of her own childhood trauma, or due to depression, may be unavailable to regulate her infant. The 'good enough' caregiver helps the immature (as yet unformed neuronal connections, and unmyelinated peripheral nerves) infant regulate through her gaze, soothing voice, etc). Ruptures in regulation affect the infant’s homeostasis, and negatively affect attachment. They may even threaten the infant’s survival. Additionally, the infant is unable to acquire experience for self regulation and restoration of its equilibrium. In an attempt to restore homeostasis, the infant must divert energy away from needed growth, development, and learning (sometimes leading to failure to thrive, to lower IQ, and lower socio-emotional learning). Because brain growth is experience-dependent, experience with dysregulation negatively impacts the developing brain, the self, and the sense of self in relation with others, particularly during the brain’s growth spurt in the first three years of life. It can lead to later psychopathology, e.g. affect dysregulation commonly found in certain psychiatric disorders.

The right hemisphere, larger in the first two years, and, more than the left, processes and stores early infant experiences. Resonant attachment experiences involve “synchronized and ordered directed flows of energy” in the primary caregiver’s brain and the infant’s brain. The right hemisphere, more than the left, also has extensive connections with the limbic system. The limbic system is the emotional processing center which helps to guide emotional expression and behavior and organize new, procedural learning. The right brain is central to “integrating and assigning emotional-motivational significance to cognitive impressions” and “the association of emotion with ideas.” The right brain, with its connections to the right prefrontal cortex, allows the sense of self continuous through time. The right hemisphere, with its bodily connections, analyzes signals from the body, and helps regulate appropriate survival mechanisms, through the autonomic nervous system (ANS)which, in turn, help maintain a cohesive sense of self.

An infant responds to traumatic chronic misattunement by hyperarousal or by dissociation. When attuned response is not forthcoming, a distressed infant initially increases its attempts (e.g. by crying) to engage the mother. Should this fail, the infant, hopeless to effect the other, conserves energy, and seems to implode, go limp, itself dissociate, becoming helpless. The ANS lends a physiological explanation for hyperarousal and subsequent hypoarousal. The sympathetic and parasympathetic systems work to maintain homeostasis. The sympathetic ANS prepares the body for fight-flight (increased heart rate, increase blood flow to the skeletal muscles, etc); and the parasympathetic, responding to elevations in stress-induced cortisol, is energy-conserving (going quiet, staring off in space, and becoming limp).

As Winnicott noted, “ If maternal care is not good enough, then the infant does not really come into existence, since there is no continuity in being; instead, the personality becomes built on the basis of reactions to environmental impingement.”
We know that dissociation affects one’s sense of subjectivity. A mother, or grandmother, who has suffered herself with unresolved trauma conveys her terror and dissociation to her infant via infant matching of the mother’s right corticolimbic firing patterns, inadvertently transmitting to the next generation her, or her mother’s, experience of trauma. Mother’s “regulatory strategy of dissociation is inscribed into the infant's right brain implict-procedural memory system.”

Maltreatment in childhood, then, is a growth-inhibiting environment for the developing brain and results in “structural defects of cortical-subcortical circuits of the right brain, the locus of the corporeal-emotional self.” “[D]issociation is associated with a deficiency of the right brain” and “early relational trauma is particularly expressed in right hemisphere deficits”. The untoward consequences include disorders in attachments, regulation of affect, and subjectivity and sense of self, with threats to going-on-being.

Monday, March 12, 2012

Reducing Uncertainty

Doris Brothers spoke to the Tampa Bay Psychoanalytic Society, Inc on March 10, 2012 on uncertainty and trauma. Brothers notes that people are motivated to reduce uncertainty--despite there is no certainty in the world-- by simplifying experience, accomplished by dissociation. We think, feel, fantasize, and make decisions, all regulatory processes created to have a sense that we will go-on- being [WInnicott]…until trauma shatters this sense.

Brothers defines trauma as that which threatens our going-on-being, threatens us with the fear of annihilation. Trauma threatens us with uncertainty. While her formulations about trauma are ongoing, she says a few ideas about trauma persist for her:

1. Trauma is relational, that is, trauma always has a relational meaning.

2. We always make restorative efforts, however faulty, that give us a sense of certainty that we will go-on-being, and that the relational surround will be there so we can go-on-being. We restore ourselves by clinging to convictions (certainties), from which we cannot be dissuaded.

3. Trauma goes hand in hand with dissociation. Brothers says dissociation is a restorative effort to reduce uncertainty by simplifying that which is complex. For example, while others purport that feelings are often too intense to be born, Brothers says it is the range of feelings, often contradictory, that we cannot bear. (As a colleague noted, perhaps all defenses, and all symptoms, are restorative attempts.) I agree with Brothers that therapists need to respect symptoms, which Brothers says allow for safety and certainty that otherwise would not exist. Therapists ought not seek to take away prematurely what is necessary to the patient to stave off terror of annihilation.

4. Shame is an inevitable companion of trauma.
On a note of self disclosure, such as therapists admitting to failures of empathy brought to our attention by our patients, Brothers notes an implicit ‘Ah, you notice my humanity, it may be safe to show me yours.’

Brothers also spoke of trauma as having a before, during, and aftermath, and what’s more, the before can have occurred before conception, as in intergenerational transmission of trauma. As Winnicott noted in The theory of the parent–infant relationship (1960, NY, IUP) “If maternal care is not good enough, then the infant does not really come into existence, since there is no continuity in being…” Winnicott (1958, IJP: The capacity to be alone) also noted that when a mother is depressed or dissociated (perhaps from her own past trauma or that of her mother’s) and unable to provide mutual regulation of experience, the infant, in matching its mother’s state, is devoid of subjectivity at a time critical in development. An infant who has extreme fluctuations in subjectivity, a traumatically dissociated infant, experiences discontinuity and threats to its going-on-being.

Friday, March 9, 2012

Poem: Witness

Having read the previous post (also found in the TBIPS Spring 2010 Newsletter) on Winnicott and the comment " ... to recognize that we all need, at times, the presence of the effected other to come into being", David Baker, PhD recently wrote this poem (after a party) with a thought to the analytic encounter:

I know you’ll know what I’m talking about.
You’ve walked out of the house
Into the yard
In the middle of your own party
And looked back through the living room window to see
The outlines of your friends
As they laughed and danced and drank
And you wondered
Among other things
If they knew you were missing
From your own party.
Wondered if they knew you were out there watching them,
If they would look back at you through the window,
Maybe set down their drink and ponder you
As you ponder them.
In the air just above you
Thoughts rise to meet theirs and from that ether is born
a knowing of each other.
It’s hard to know each other at a party.
We play at it, we like a party.
We like to see and be seen,
We like to be known,
Like to be missed.
But the almost-collisions of human-to-human
Never really allows for the deeper knowing.
It’s the depths we crave
Within ourselves and in others.
We need witnesses to our life, in order to really have our lives.
Perhaps that is why you walked outside,
Looked back,
Delighted in them.
In those few moments you were witness to their lives,
Held them, loved them into the eternity of your own memory.
How fortunate they were.
How they may never know about the gift you gave
By stepping out and away
To hold them closer than you ever could
Had you stayed in the room
Politely listening to their laments over real estate.

David Baker

Friday, March 2, 2012

Using Winnicott, Part II

In Playing and Reality (1971) Chapter 4: Creative Activity and the Search for the Self, Winnicott hopes to illustrate how, if the analyst would sometimes just get out of the way, the patient will come into a sense of self in her/his “search for the self.” In his clinical example, Case In Illustration (pp. 56-64), he allows a three hour session with a patient because she needs a lot of time to come into being, as it were. He believes he is allowing the patient freedom from his intrusions, impingements, derailments, [and cleverness] by his protracted silence. [Indeed, the patient may have felt Winnicott to have been palpably present by his demeanor, benevolent attitude, ability to hold her in his mind, etc., but the reader does not have this benefit.]

Upon rereading this case with the first year class at the Tampa Bay Institute for Psychoanalytic Studies, Inc, I was struck by the patient’s many attempts to feel Winnicott more significantly engaged with her. She says: “I’m loathe to come into this room…I feel of no consequence.” Winnicott adds that she cites “Odd details of my dealing with her, implying that she is of no consequence.” She states “I don’t matter.”

When the patient eventually speaks of positive feelings and activities, Winnicott takes this as evidence of her be[com]ing real as if this naturally unfolded by her creative play, alone in the presence of the other. What Winnicott does not acknowledge here is that this ‘positiveness of being’ followed both his interpretation (indicating he understood how withering and deadening it is when there is no one to give back to her her experience; no mutuality, as it were) and his responsiveness that she drink up the milk he had made available there for his patients.

Having reported more of her feelings and activities, she then asks, “Where are you? Why am I alone so?...Why don’t I matter anymore?” And, after talking about her birthday experiences, the patient says, “I feel as if I have wasted this session. I feel as though I came to meet somebody and they didn’t come.” [Here I think the patient is talking about Winnicott’s absence, as he tries to stay out of her way, from being in the space with her.] Winnicott speaks, reflects back, and the patient says, “I get a feeling sometimes that I was born.” [I take this as further confirmation that it is Winnicott’s participation which enlivens the patient.] Winnicott reflects for her what she may have always felt: that others were not glad that she was born, that they did not enjoy her. She confirms this with: “what is so awful is existence that is negatived” [negated]. She continues and asks [hopefully], “…is there a little soul waiting to pop into a body?”

Winnicott emphasizes, from the patient’s dream: “I might find a me—get in touch with a me,” that the patient is “trying to show you me” for the first two hours of the session. Winnicott writes: “The searching can come only from desultory formless functioning, or perhaps from rudimentary playing, as if in a neutral zone.” Yet I could not help noticing that the patient was only enlivened, came into being, when Winnicott spoke to her in such a way as to communicate his understanding of her, thereby giving her evidence of his having been listening attentively, and had done so because she was significant to him. Perhaps his patient felt his silence as an indication that she was insignificant to him.

In class, I was equally struck by one first year student who could so adeptly feel her way into Winnicott’s position, illuminating to the class a different point of view from mine, and imagine that his patient, having perhaps had demanding, intrusive parents, who forced compliance of her being to theirs (that she please them, say what they wanted to hear), would very much need an analyst who stayed out of the way, letting the patient say what she wanted, or say nothing at all, indicating she would not have to please the analyst. [Still, I thought, when Winnicott was pleased to let the patient give an interpretation that he would have made himself, that the patient was indeed saying something she thought he might want to hear, and doing so perhaps to keep him engaged with her.]

Had Winnicott lived today, would he now drop the ‘the’ of “the self” and characterize self as a more fluid, emerging entity? More importantly, would he have transformed his theory to view interaction through a slightly more contemporary lens, a lens which recognizes the need for all of us, including patients, to be seen, to have an effect, to feel significant to someone, even to one’s analyst, to recognize that we all need, at times, the presence of an effected other to come into being? Or would silence, as an indictor of respect for the patient's creativity and being alone in the presence of the other, still loom so large with a patient so desperate to feel significant to her analyst?

Tuesday, February 28, 2012

Using Winnicott, Part I

I find no writer more felicitous to read than Winnicott. Immensely prolific, it is as if he is speaking to me spontaneously about things about which he is passionate. He is relatively jargon free, and he relatively rarely refers to other authors. His many ideas are original and profound. My favorite two Winnicottian concepts, because I find them so clinically useful, are survival and transitional space.

In The Use of the Object... (1971, Playing and Reality) Winnicott refers to the necessity of the mother surviving (that is, neither retaliating nor withdrawing) the attacks of the infant if the infant is to see her as an external subject outside his omnipotent control, thereby allowing the infant both a capacity for concern as well as a mitigation of guilt about his aggression. Likewise, in the psychoanalytic situation, the analyst surviving the analysand’s attacks (of the analyst, of the process, and of hope itself) is necessary.

In Transitional Objects and Trsansitional Phenomena (1951) Winnicott notes that a good enough mother never falls to one side of the question of whether the infant created the transitional object or found it external to himself. So, too, he intimates that the good enough analyst does not close the transitional space by imposing the analyst’s reality on the creations and observations of the patient. It is into this transitional space that play is sometimes invited, a play with words, though much like the squiggle game, to imagine together what if.., what would it be like if… and sometimes to enjoy wistfully together what has come into being through pretend.

My great admiration for Winnicott and the enormity of usefulness I have derived from his ideas made my criticism of Chap 4: Playing: Creative Activity and the Search for the Self in Playing and Reality (1971) when re-reading it with students in the TBIPS Development Course, a bit of a surprise to me. I will post next time on the use the class made of his Case Illustration.

Friday, February 24, 2012

Deconstructing what we read

Nothing pleases an instructor more than when students learn to read and think critically. How pleased was I then when the first year class at TBIPS was able to take the clinical vignette from an assigned journal article, deconstruct the reported interaction, and come up with additional points of view.

In the assigned artice, the author began with some background: a young woman of a withdrawn, depressed mother and a hostile, accusatory father was described as being opaque to others, unable to be vulnerable and emotionally intimate with others, operating from a paranoid-schizoid position, distrustful of men, found it difficult to bond with women, and experienced interpretations as intrusive and insulting. The analyst complained that his attempts at empathy were rebuffed.

Then followed from the author/analyst a brief portion of process notes:

The patient was indignant about a male colleague who had made advances; the male analyst responded by giving an explanation for the colleague’s behavior. [The class easily recognized the analyst as defending the other’s, not the patient’s, point of view, in essence an attack on the patient’s reality. ] The patient responds derisively, accusing the male analyst of being like all those other men who think they can say or do anything with women.

The patient continues, talking about being professionally excluded by an Old Boys’ Club at work. The analyst, attempting empathy, lands on interpreting her feeling alone, without female colleagues. The patient says she thinks the analyst really think she is a bitch and she accuses her analyst of phony empathy. [The analyst does not consider here his own contribution to his patient’s rebuff, that perhaps the patient perceives accurately what is in her analyst’s heart. The analyst, after all, had only moments before attacked her point of view.]

The patient then complains about her very bad day and asks her analyst if he has ever had such a day. The analyst asks for her thoughts. [Here the analyst is the opaque one, being with his patient exactly what he, in his description of her, accused her of being, and he is likewise being unknown to her, just as her depressed mother had been. Is this an enactment?, the class asks.] The patient then insults the analyst, accusing him of being uncaring and, as a man, without compassion.

Vignettes from the literature and from our own clinical experiences are often used in classes to improve our skills. And where the medium is the message, we deconstruct who we are alongside what we say and think, leaning in the direction of hope, empathic attunement, and opening the third space. Next time I will post on how the Intro. class used Winnicott.

Sunday, February 19, 2012

Useful Relational Intersubjective Inferences

Having recently attended a conference where the speaker read a paper which leaned heavily toward inferring, from the psychoanalytic situation, particularly the narrative, infantile drives and fantasies, I was much relieved to find myself once again in the Tampa Bay Institute’s Study Groups and classes discussing inferences from infant research and attachment theory. Specifically discussed was the 1999 paper The Two-Person Unconscious: Intersubjective Dialogue, Enactive Relational Representation, and the Emergence of New Forms of Relational Organization by Karlen Lyons-Ruth.

Lyons-Ruth reminds us that meaning systems are organized by more than the symbolic (words and images): “meaning systems are organized to include implicit or procedural forms of knowing.” As such, a primary engine of change is “new enactive ‘procedures for being with’ [which] destabilize existing enactive organization…” Moreover, “procedural forms of representation are not infantile” for “development does not proceed only or primarily by moving from procedural coding to symbolic coding.” She states that “‘internalization’ is occurring at a presymbolic level...[thus] representation [is] not of words or images, but …of enactive relational procedures…”

One such procedure is parent-infant dialogue and, when flexible and collaborative “is about getting to know another’s mind…” A coherent, open dialogue requires openness of the parent, not in the form of “unmonitored parental self-disclosure, but by parental ‘openness’ to the state of mind of the child...” [And] “intersubjective recognition in development requires close attention to the child’s initiatives in interaction…” Likewise, the parent seeks “active negotiation and repairing of miscues, misunderstandings, and conflicts of interest;” It is from these ideas of Lyons-Ruth and others that clinicians infer the importance in the analyst-analysand dialogue the need for flexible and collaborative openness to the state of mind of the other, with attention to initiatives of the other, and a responsibility to seek repair of ruptures.

Tuesday, February 14, 2012

Valentine's Day Musings

"When the satisfaction or the security of another person becomes as significant to one as is one's own satisfaction or security, then the state of love exists" (Sullivan, 1940)

“Such mutuality, however, seems clearly an ideal, not a normative practice. No matter how mature and healthy, all love relationships are characterized by periodic retreats from mutuality to self-absorption and demands for unconditional sensitivity and acceptance.” (Mitchell, 1984)

Among its other important components, I still contend that the analytic relationship is one of love. And as Mitchell notes, and Benjamin reminds us, it is almost impossibly difficult to hold for long the tension between mutual recognition and negation of the other; instead we are always falling to one side (usually negation). This realization of how easily we fall, I think, is in sharp contrast to Orange and Levinas putting the (suffering) other above ourselves, making psychoanalysis, with this impossible ideal, once again the impossible profession. I think that love might just be in the striving, not the success, to recognize the other.