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In the assigned artice, the author began with some background: a young woman of a withdrawn, depressed mother and a hostile, accusatory father was described as being opaque to others, unable to be vulnerable and emotionally intimate with others,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.

Sunday, February 5, 2012

Is Addiction Inherited?

This past week the media (National Public Radio, BBC World News, for example) picked up a story from Science that addiction might be hereditary, based on a study out of Cambridge, UK, of 50 pairs of siblings, where one sibling had a cocaine addiction and the other did not, yet both had similar changes in the brain (in areas of impulse control). The conclusion that these similar brain changes indicate inherited traits may overlook the discovery that experience changes brain anatomy, chemistry, and function. As such, it might be equally plausible to conclude that siblings were similarly exposed to parents who were unavailable, misattuned, or abusive in ways that caused the brain to develop as seen in the touted study.

In the TBIPS course on Repetitive Painful States, in which a portion of the course is devoted to addiction, we consider the possibility that addictive behavior (whether substance abuse or self injurious such as cutting) is a way to manage untenable beliefs and affects. Having gone unrecognized and misunderstood, or worse, as often is the case, having had one’s reality attacked and one’s spirit nearly extinguished, a child is often without the opportunity to learn to regulate one’s impulses. Does this not affect the developing brain? [This is not to say that the myriad possible ways a child's brain might develop is not constrained by genetics.]

We go even further in class, presupposing that new experience in relationship with the analyst, repeated and protracted, also begins to change brain anatomy and function, encoding experience in such a way that impulse control is gradually developed, not by prohibition of behaviors, but by the shared experience of accepting a patient’s reality, bearing painful affects together, and reconfiguring belief systems about the self and the self with others. Differing with most treatment modalities for addiction, I expect that it would be a further misunderstanding of an analytic patient to base treatment on the contingency of abstinence while the patient has yet to have help with painful affects and untenable beliefs.

Thursday, February 2, 2012

Mitchell's Developmental Tilt

This semester the TBIPS first year class is reading Mitchell’s Object Relations Theories and the Developmental Tilt. In it, Mitchell asks (doubts) whether so many diverse theories can go under one theory called Object Relations. But, more importantly, he notes that many Object Relations theorists maintain allegiance to the Freudian drive-conflict model (whose sine qua non of neurosis according to Freud is the Oedipus complex) by simply placing relational issues developmentally earlier than the oedipal stage. He asks, is Object Relations just an extension of drive theory? Or is it altogether new, substituting drive discharge as motivation and the structural theory (ego, id, superego) of mind with object-seeking as motivation and with relational configurations, “relations with others, past and present, real and imaginary” (mental representations of part/whole objects, in Object Relational terminology, and how they interact with each other) as the makeup of the mind?

Mitchell sees assimilation of Object Relations theory into drive theory as mixing apples and oranges. He says that assimilating Object Relations, through what he calls the” developmental tilt,” into drive theory risks designating lifelong needs of relationship as pathology:

“these innovations have been introduced into psychoanalytic theory via the developmental tilt; consequently, the dynamic issues they depict tend to get characterized as infantile, pre-oedipal, immature, and their persistence in later life is often regarded as a residue of infantilism, rather than as an expression of human relational needs extending throughout the life cycle.”

Mitchell believes contrivances such as regarding “relational issues as prior to drive issues”, were required by ego psychologists (who privilege drive and defense, ie the structural conflict model) in order to assimilate Object Relations. Mitchell does not conceive that relational issues “emerge sequentially over the course of early infancy, becoming progressively resolved” but says they instead persist throughout life.

Furthermore, the developmental tilt risks, Mitchell contends, infantilizing patients by casting the analytic relationship in an infant-mother dyad:

“…instead of conceptualizing these dimensions of the analytic relationship as providing the patient with a richer, more complex, more adult kind of intimacy that his previous psychopathology allowed him to experience, the developmental tilt leads to a view of these dimensions essentially as developmental remediations…”

Consequently, spontaneous gestures as evidence of new relationship (such as Balint’s somersaulting patient) are viewed not as a ‘forward edge’ [Tolpin], but as a regression to the old and are pathologized: their “evidence later in life is regarded as a regressive residue of very early disturbance.” When Object Relations theory is “positioned via classical theory” through the developmental tilt, psychoanalytic “interaction is collapsed into mother-infant terms.” Similarly “the need for tenderness throughout life”… is collapsed “into the infant's need for tenderness from the mother … depicted as regressive, unresolved residues from earliest childhood” [and] “depicted as [the] …only developmental forum in which such needs make sense.”

Mitchell agrees with contemporary theorists on the importance of the real relationship, as well as of what is new:

“the analytic relationship has been understood as more and more of a real and new relationship than previously. For Freud, the relationship with the analyst was a re-creation of past relationships, a new version struck from the original "stereotype plate" (Freud, 1912). The here-and-now relationship was crucial, but as a replication, as a vehicle for the recovery of memories, the filling in of amnesias, which cured the patient. Contemporary views of the analytic relationship tend to put more emphasis on what is new in the analytic relationship. The past is still important, but as a vehicle for understanding the meaning of the present relationship with the analyst, and it is in the working through of that relationship that cure resides.”

I find I agree with Mitchell’s ideas, especially the need for relationship and tenderness being lifelong (just as Kohut posited a lifelong requirement for self object experiences) and can dust off my previously long constrained (anonymous, abstinent) self to participate with my patients in the therapeutic endeavor toward new experience co-creating new ‘templates [Herzog].’

Mitchell, S.A. (1984). Object Relations Theories and the Developmental Tilt. Contemp. Psychoanal., 20:473-499.