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.