Sunday, April 28, 2013

Happy Birthday. Harper Lee

Today is the birthday of Nelle Harper Lee. She is 87 years old and the author of the Pulitzer Prize winning, autobiographical novel To Kill A Mockingbird (1960). Her only novel was published when she was thirty four years old.  Her story is told through the eyes of a young girl (6-9 years old) Scout Finch, who refused to be boxed into dresses and etiquette by her aunt, and who often spoke first with her fists as she righted school yard injustices. Scout understands the injustice of racism, which turns human beings into the Other, a not me.

To Kill a Mockingbird was adapted to film by Horton Foote. Gregory Peck’s Oscar winning portrayal of Atticus Finch, an American icon and moral benchmark of American integrity as the small, Alabama town lawyer who defends Tom Robinson, a black man falsely accused of raping a white woman, became the greatest film hero of the 20th century.  Lee’s older sister Alice practiced law at her father’s firm till she was 100 years old. Lee’s actual father A. C. Lee had “genuine humility” and was purported to have been, like Atticus Finch, “soft spoken, dignified, and did the right thing.” He gave Harper Lee her first typewriter, which she shared with her next door neighbor and playmate Truman Capote, depicted in her novel as Dill Harris. In the 1930’s, they were considered an odd pair in Monroeville, AL, she with her tomboyish ways, Capote leaning toward his feminine side.

Lee’s feat of writing the world through a child’s eyes and with a wisdom beyond her years has rarely been matched. Lee’s novel precedes the Civil Rights Act and for a young, white, Southern woman to write herself into the shoes of a black man was, as Oprah Winfrey noted, “pretty damn brave.”  In To Kill a Mockingbird, Atticus tells Scout, “You never really understand a person until you consider things from his point of view, …until you climb into his skin and walk around in it.”

Certainly, that is an analytic attitude. We strive to understand our patients and, to do so more fully, we must dislocate ourselves momentarily from our own point of view and “climb into the skin” of our patients. Kohut called this empathy, and in the most difficult of moments, we struggle to stay empathically immersed, moving to right ourselves again when we fail. From the patients’ singular misery, we may not seem able to fight their fight, but we hope patients know we are in their corner.

Saturday, April 27, 2013

Starting out, for the beginning therapist

I like to discuss with third year psychiatry residents starting their out-patient clinical year of psychotherapy what we hope do together with our patients.  We may strive to aid the patient in reconfiguring organized experience in order to free the patient enough to tolerate new ways of experiencing and understanding. Our job may be to provide a ‘good enough’ therapeutic space to allow the ineffable, the unremembered, or the as yet unformulated to come into being in the space co-created between therapist and patient. It goes without saying that we bring to the consulting room our respect for the other person and for their uniqueness as well as an analytic attitude which includes open inquiry. We guard as sacred the confidentiality of all that the patient entrusts to us. We provide a safe enough environment for the approximation toward an authentic self  by being open with the loving openness of the lover or parent who cannot wait to hear or see what comes next, open to the unknown, the unknowable, and to uncertainty.

Discussing with a patient what it is like to be in the room with the therapist and to be invited, even expected, to discuss feelings and fantasies, especially in the here and now moment, may be the first time the patient has ever experienced such deep, untruncated interest or experienced an opportunity to talk in such a way. The patient is assessing (unconsciously, non-consciously, and consciously) what may be addressed and what must be left unknown and unsaid, based, in part, upon the implied capacity of the therapist to tolerate, accept, and embrace the most untenable aspects of the patient’s (and therapist’s) self.

It is incumbent upon us to initiate negotiation between us and the patient about how we plan to work together. Some patients will come with the hope of realizing particular goals, some very specific: ‘I want to stop throwing things when I get angry’; some general: ‘I want to be happy.’ While you cannot guarantee an outcome, you can vow to attempt to explore (via attunement and open inquiry) and experience (through inevitable enactments) together what it is that troubles the patient.

Psychiatric therapists will struggle personally between their medical role as an authority and their responsibility to offer an authentic self to the experience. Both the struggle and the offering have therapeutic potential for therapist and patient alike and make for more meaningful and enriching use of the process.

I ask the psychiatry resident to consider: Do I have faith that earnest and authentic leaning to understand is salubrious in itself, even if I, as yet, fail to comprehend what is going on? Can I respect and empathize with this patient’s suffering, even if the problems include drug addiction, pedophilia, or some other behavior beyond my comprehension? How do I open myself to the sufferings of people with whom I have difficulty empathizing? Can I bear the patient telling her/his fears even when they intimate that I am untrustworthy or have failed to help the patient feel safe or more open? And we commiserate: it’s a tough job.

Saturday, April 20, 2013

War Photojournalist and psychoanalyst of like minds

Two years ago today, war photojournalist Tim Hetherington, who, along with journalist and co-director Sebastian Junger, was nominated for a 2011 Oscar for their 2010 documentary Restrepo about American soldiers in Afghanistan, was killed in Misrata, Libya, during the civil war, having bled to death at the age of 40 after a mortar exploded.  In recounting, on NPR’s Morning Edition on April 18, 2013, a conversation Hetherington had with his father, Junger said that Hetherington defined “rich” as having “the power to determine your future.”  This got me to thinking about what psychoanalysts strive toward, that is, facilitating people toward greater freedom to determine their emerging lives. In covering war, Junger notes a “moral awareness” in making a living telling stories about people dying, which sometimes weighed heavily. Therapists, too, have a ‘moral awareness’ that we make our livings off the suffering of others. War correspondents can comfort themselves that stories must be told, just as we therapists can. Additionally, I think, and as the brave survivors of Monday's Boston Marathon proved, running toward suffering is the best hope to relieve it.

In an interview on Wed April 17, 2013 by Daniel D'Addario in Salon, Junger said of Hetherington, “Tim …was trying to understand the human experience, … engaging people in conversations and trying to tell their story, ... trying to get the experience and connect with someone.” I think this aptly describes what relational psychotherapists do as well. Also, when Junger described his own job, “I think you definitely have a need for feeling comfortable with feeling overwhelmed and in over your head, and the challenge of that is frightening, but also very stimulating. I think there’s a feeling of specialness, like I’m doing a special job that most people don’t do…”, I recognized that I, too, feel that way about my job.

Junger, whose latest documentary Which Way is the Frontline from Here?, which includes footage shot by Hetherington, and which aired on HBO two nights ago, said of his colleague Hetherington, “ [H]e really was an astonishingly open-spirited person.” And regarding the impact of photojournalists, “He broadened the sense of what’s possible.”

Wednesday, April 17, 2013

Christianity and Psychoanalysis

Max Harris discussed, over dinner, some interesting and intersecting antipathies within religion and within psychoanalysis. He stated that the battle waging within modern Christianity is over who we are: Are we defined by what was put into us, that is, original sin, as many evangelicals believe, or is who we are in relation to God defined by a process we co-create with God, where we are ‘lured’ into a relationship with God through love?  The latter, thus, incurs upon us a certain responsibility in our moment to moment actions.

The current debates in psychoanalysis move along similar lines. There are the traditionalists who define mental life via conflicts brought into play by drives (libido and aggression), that is, by what is put inside us by virtue of being born. Contemporary analysts advocate for the inclusion, perhaps the emphasis, of the relationship between therapist and patient and its co-creation by both. Likewise, here, too, more responsibility is incurred.

The Christian god may have more in common with the Freudian analyst of objectivity and anonymity. Where they diverge from the contemporary relational analyst may be around the idea of authority.  The Christian god is omnipotent and omniscient; the contemporary analyst is fallible and dependent on the analysand for meaning making.  The Christian god reveals, mandates even, the correct path; the relational analyst walks hand in hand with uncertainty, as does the patient with the analyst.

Nonetheless, both the endeavor of psychoanalysis and that of a relationship with the Christian Jesus require a leap of faith: that we are in this together no matter what, and that an abiding love means we are accepted for who we are, no matter what, imperfections and all. And as Max, a psychoanalyst and former minister, noted, his calling was the saving of souls, just no longer through the ministry.

Monday, April 15, 2013

Neuroscience and Psychoanalytic therapy

In his talk How Understanding Some Neuroscience Can Increase Empathic Attunement on April 13, 2013, Max Harris, PhD presented to the Tampa Bay Psychoanalytic Society on ways neuroscience informs our clinical work. We now understand that mother’s right brains develop their babies’ right brains, in regulation of emotions and coordination of intentions. It is hopeful to know that psychotherapy, too, confirmed by neuroimaging, also can modify neuronal networks. This is due to the plasticity of the brain, and brought about partly through modification of dendritic branching (growth of new connections or pruning of older ones). New experiences rearrange neural networks!

Relational Trauma can come about from abuse, neglect, or chronic misattunement. Trauma, through the HPA (hypothalamic-pituitary-adrenal) axis, can decrease blood flow to the hippocampus and increase it to the amygdala, such that language and context are decoupled from  sensory and procedural memory, and dissociation can ensue. (Trauma can also turn genes on and off via methylization.)  Dissociated experience, often a result of dysregulation of affect, of the patient or the analyst may be communicated through a co-created enactment. This dyadic dissociative process can vitiate reflective function.   The therapist , using self regulation, can serve as ‘container’ (Bion) in helping to regulate patient affect.

Because there are cortical (cognition) connections to the subcortical limbic system (emotions) and limbic connections to the gut (with its chemical messengers the same as some neurotransmitters) and body via vagal nerve, Harris reminded therapists to attend to facial and bodily expressions and right brain, nonverbal  communications, including one’s own.  Mirror neurons may also be a mechanism by which we can feel our way into others’ experience. Harris enumerated three aspects of empathy:  Reflective, Affective, and Intersubjective: the thinking about experience through reflective function, mentalization and theory of mind; vicarious affective matching where one feels oneself into the experience of another; and the intersubjective, where therapist and patient negotiate experience through shared dialogue. Empathic attunement, then, relies on the social right brain, mirror neurons, the parasympathetic and enteric systems’ emotional experience, as well as on the left prefrontal cortex’s reflective function. 

Monday, April 1, 2013

Survival, then gratitude in a Thank you Poem

WInnicott wrote of survival in his 1969 The Use of an Object paper. Survival for the mother or the analyst attacked by the baby or the analysand, respectively, means neither withdrawing nor retaliating. One analysand put it this way.

Thank you for allowing to express disdain for you without taking offense, without crumbling or acting childish.
Thank you for allowing me to express contempt without making me feel wrong. 
Thank you for allowing me to express disgust without retaliating.
Thank you for allowing me to hate you without making me feel ashamed, bad. 
Thank you for allowing me to be me and not throwing a guilt trip on me for doing so.
Thank you for allowing me to grow.
Thank you for allowing me to express my feelings.
Thank you for being you.
Thank you for showing me it's ok to be imperfect.
Thank you for teaching me how to withstand forces that want to rip me apart.
I want you as a friend, not an analyst.
I want you as an analyst, not a friend.
I didn't know you could be both.
Thank you for accepting me as I am, and all the hell that comes with that.
Thank you for letting me hate you.
Thank you for no strings attached.
Thank you for no conditions. 
Thank you for no retaliation.
Thank you for love.
Thank you for your patience as I try to share my pain, find who I really am.