Wednesday, December 17, 2014

novel Blindness; blind to recognition, containment, acceptance?

In Blindness— the 1995 novel by the Portuguese (1998) Nobel laureate for literature Jose Saramago— an epidemic of “white blindness” mysteriously renders all people, save one, blind, and chaos and cruelty ensue. Written without much punctuation the reader must, much like a therapist trying to make sense of the patient’s narrative, discern who is speaking to whom and about what. Blindness teems with allusions to our metaphorical blindness, such as people “behave as if they were afraid of getting to know each other.”  Saramago speaks to the sanctity of reciprocity: “I have no right to look if the others cannot see me,” and to the wrath – “some will hate you for seeing” –  of being the one who sees what all others are blind to (or disavow, like a parent who attacks the seeing child’s reality). There are moments of tenderness, such as when two blind lovers reunite: “how did they recognize each other…love, which people say is blind, also has a voice of its own,” and moments of despair when one’s true self goes unrecognized: “what good would it do her beautiful bright eyes…if there is no one to see them.”

Because all, save one, are blind, there can be no witness, yet some manage to find affective sharing when the blight can “convert strangers into companions in misfortune.” Despair overtakes many in this dark novel for “what meaning do tears have when the world has lost all meaning.” Even the one who is spared this affliction is incredulous to what becomes of those around her: “what shocked her was her disappointment, she had unwittingly believed that…her neighbors would be blind in their eyes, but not in their understanding.”

If blindness is, in part, the blindness to the need of the other, then I am reminded of Stuart Pizer’s 2014 paper The Analyst’s Generous Involvement: Recognition and the “Tension of Tenderness” which eloquently joins with and departs from Emmanuel Levinas’ idea of putting the suffering other above oneself. If one is to lean towards another’s need, one must first see (recognize) the need. Pizer takes Sullivan’s concept of the ‘tension of tenderness’: “the analyst’s recognition of a need or an affect state in the patient evokes an internal tug constituting the analyst’s need to provide for what has been recognized.” He writes, “An instinctual tug toward tenderness, or a spirit of generosity, in response to a recognized state of need in the Other is an inherent feature of our functioning attachment system.”

But how does a blind person see the Levinasian strange, transcendent, unfathomable ‘face’ of the other? Pizer sees generosity as instinctual, but expects Levinas to “reject instinct in favor of a subjectivity open to interruption, surrender, and awakening by an encounter with the Other.” Pizer continues, [we are] “wired to seek community, relational embeddedness, or ‘we-ness.’” Generosity sometimes requires of the analyst, per Corpt, an “unsettling re-evaluation and openness to amending any and all aspects of analytic practice in light of the patient’s forward edge strivings.” Pizer learned from his grandfather the healing power of the affectively resonant, witnessing presence of someone who recognized his need, and accepted him just as he was. Saramago notes its opposite, “Blindness is also this, to live in a world where all hope is gone.” That is, no hope of being seen, recognized, contained and accepted.

Pizer, S. (2014). The Analyst’s Generous Involvement: Recognition and the “Tension of Tenderness”. Psychoanal. Dial., 24:1-13.

Tuesday, December 9, 2014

Whose responsibility, anyway?

The task of the analyst is to help the patient learn about himself (discover the many facets of himself, if you will), not to impose on the patient the necessity to prove the analyst’s pre-learned theories about human behavior. The analyst, then, has no corner on ‘truth’ and cannot privilege her perspective over that of the patient’s psychic reality. Instead, both analyst and patient struggle to negotiate a working relationship toward discovery. Faltering, fumbling, rupturing, both then strive to upright and repair what has been lost in the relationship. No matter how both analyst and analysand are implicated in the co-creation of the transference, countertransference, or resistance, whatever the patient does is always in the service of trying to heal himself. The patient tests the analyst for trustworthiness, commitment, and circumspection. Make no mistake, that whatever the outcome—whether impasse, acquiescence, failure to improve, getting worse, or stopping treatment – it is always the analyst’s responsibility. The analyst  welcomes in, then must contain what has been welcomed. The analyst’s failure to monitor interactions between patient and analyst, to recognize and correct misattunements, can have dire consequences. While both take responsibility for the discourse, any failure lies on the shoulders of the analyst alone.

Tuesday, December 2, 2014

Revenge and Forgiveness

Because we all seek to maintain [or create anew] a sense of individual meaning, Lafarge writes that disruption of our sense of self can lead to the wish for revenge, “a ubiquitous response to narcissistic injury.” Revenge “serves to represent and manage rage and to restore the disrupted sense of self [and restore the] internalized imaging audience [the other].” Narcissistic injury is a disruption to meaning and self value and to the story of one’s experience. In efforts to reestablish meaning and to construct a story, as well as create a witness to one’s story, the avenger uses anger and revenge to consolidate early experiences (a time when the “imagining parent” [like Bion] helped construct the infant’s mind with meaning and with its representations of self and others). Communicating experience and constructing its story is also present in the revenge. It is a way of being seen and heard and helps maintain the tie to the lost, imagining parent. Thus, revenge can ward off object loss [Searles] and hatred can be an early form of object constancy. “Giving up the wish for revenge requires the avenger to recognize the rage and helplessness that are warded off…[and] involves acknowledgement of a transient disruption of self experience” that they accompany.

Lansky tells us that shame gives rise to rage as a strategy to protect one’s sense of self from the awareness of helplessness, abandonment, betrayal. Sometimes, clinically, it is easier to analyze the visible rage and resentment than its underlying shame, but it is the detailed exploration of shame that sheds light on its unbearableness. When one’s sense of self is chronically disrupted from the betrayal by needed and beloved others, attachment is at risk. All future attachment is at risk, for who wants to be duped again, subject to humiliation and shame? The disrupted self, in valiant efforts to reconstitute a self representation that can be lived with, may need to withdraw and isolate, project, omnipotently control, split, or retaliate. The latter, as revenge, can seemingly restore a sense of power and effectiveness as well as protect against awareness of vulnerability. Revenge also protects against the uncertainty of forgiveness. Only awareness of loss and its mourning can circumvent the need to humiliate the other, leading to forgiveness both of self and other.

LaFarge, L. (2006). The wish for revenge. Psychoanal. Quart., LXXV, pp. 447-475.

Wednesday, November 26, 2014

Ferguson and Thanksgiving

In the wake of Ferguson, MO’s Grand Jury decision not to indict a white police officer’s killing of a black teenager, residents expressed their concerns. Whether police brutality or self defense, black young men are in danger, aggravated by lack of accountability on too many sides. One mother tearfully asked, “What am I to tell my son when he grows up?...You try to have hope.” Another woman tearfully expressed a more universal need, “We just hope for one time that our lives will matter; that somebody will see that our lives are valuable.” This latter plea speaks to the human motivation to be seen, to be recognized for who we are and still be accepted.

As we gather around the Thanksgiving table with our families of origin and the families we have made, may we take a break from seeing what we expect and, instead, look anew from an other’s point of view, accepting her or him just the way they are, and, hopefully, being accepted in return. What might we be thankful for? That in the best of relationships we are loved, warts and all.

Wishing a Happy Thanksgiving to you and yours.

Thursday, November 20, 2014

Dissociation and Enactment

Unlike Kohut, who believed in a unitary self and thought health was an increased cohesiveness in one’s sense of self, Bromberg says that we all exist in a multiplicity of self states, each with its own memory, experience, and unconscious. “Health is not integration. Health is the ability to stand in the spaces between realities without losing any of them.” (p.186), that is, it is simultaneous awareness of these many discrete selves.  The sense of a unitary self, writes Bromberg, is an adaptive illusion. Dissociation of certain self states, with their untenable affects (such as shame) occurs in all of us, often in response to the traumas of misattunement, misrecognition, or attacks on our reality. Bromberg recommends that analysts learn to see the validity of a patient’s psychic reality alongside their own, careful not to claim ownership of arbiter of reality. In this capacity to see both realities, space is made to construct consensual meaning. Their relationship is continually renegotiated.

Sometimes the only way to access dissociated experience is through enactments which can painfully draw the analyst into the early object relations of the patient. Sometimes these enactments additionally allow the patient to see his impact on the analyst. Enactments are

…an example of what Levi (1971) called “a powerful though perverted attempt at a self cure” (p.184). It involves a need to be known in the only way possible – intersubjectively—that is different from the old and fixed patterning of self-other interactions, a version of the situation that led to the original need for dissociation. (p.172)

For a patient in analysis to look into his own nature with perceptiveness, and to utilize creatively what is being enacted, there must exist a simultaneous opportunity for the patient to look into the analyst’s nature with an equivalent sense of freedom and security. (p.176)

In the clinical situation, those patients with the most dissociation, often called personality disorders, cannot resonate with interpretations which address conflict because, until contradictory self states are in simultaneous awareness, the contradiction/conflict cannot be 'seen' by the patient. Because psychic reality varies by self state, an issue already explored in one self state may come up again later in another self state. As one candidate noted to herself as her patient spoke, "Didn't we already go over this!" In this 'Groundhog Day' phenomenon, and the going over and over the same ground, is what I like to call 'the joy of Sisyphus,' and the candidate asks, "So where's the joy?"

From STANDING IN THE SPACES: Essays on Clinical Process, Trauma, and Dissociation (1998). Psychology Press. New York, London; Chap. 12, Shadow and Substance.

Tuesday, November 18, 2014

Envy as refused desire

Gerhardt’s rich paper on the intersubjective contribution of envy elucidates the part played by the mother’s (and analyst’s) failure to identify with the infant (later, analysand). Unlike Klein who saw envy as primary and related to aggression and the death instinct, Gerhardt frames envy in terms of refused desire. She sees envy as secondary to thwarting of this wish to be at one with the object, to both have and be the object, to matter to the object, as when the mother refuses to accept desire from the child as well as fails to help the child feel desired by her. The failure of the mother to adapt to the needs of the infant and her failure to see the infant’s demands for recognition as legitimate, renders her unable as well to experience maternal identification with the infant’s (secondary) envy. When the analyst (or mother) dissociates her own disavowed envy, dependence, and shame, she cannot identify with the patient’s split off self-states, and is less able to contain and transform them for the patient’s use. Gerhardt’s patient felt contained when Gerhardt invites and sustains a kind of one-ness, in part, through the analyst’s mutual identification with her patient, rendering horrible affects less terrifying.

Gerhardt writes that envy results when the “normal identificatory processes have gone awry,” and quotes Benjamin: “when desire to identify goes unanswered, envy takes its place.” [I think of penis envy and father’s rejection –or mother’s prohibition— of the female child’s identification with the father.] Envy, for Gerhardt, is an attempt at “denial of difference” and “repudiation of dependency” in response to the mother’s failure to identify with and manage the infant’s expelled and intolerable states, in particular those in which the infant (later, analysand) feels abject and defective, full of shame.  Envy, then, is also secondary to shame. Gerhardt also invokes Bion’s “protesting the separation between knower-known” [which calls to mind the humiliation engendered in the patient when the analyst insists on being the only ‘knower’ in the dyad]. [As an aside, she reminds us that Bion had noted that the mother’s failure to contain the infant’s fear evokes in the infant “nameless dread.”]

Oelsner takes the classic object relations approach, taking umbrage with Gerhardt seeing aggression and envy as secondary, and recommends the repeated analysis of aggression. He reminds us that Bion conceived of envy as an attack on linking. Envy destroys otherness by denying, through projective identification, recognition of separateness. Ornstein, on the other hand, as a self psychologist, agrees with Gerhardt that envy is secondary (this time, to empathic failure of participation of the analyst’s subjectivity and rejection of patient’s efforts) and sees Gerhardt’s eventual capacity to empathize with her patient— by giving up her “decoding interpretations” (experienced by the patient as “counter-attacks”) and by recognizing her part in thwarting the patient’s desires. Ornstein recommends seeing what transpired between them not as an attack by patient on analyst, but as a forward edge in terms of being able to make a demand of the analyst that the patient could not make as a child on her mother.

Gerhardt, J. (2009). The Roots of Envy: The Unaesthetic Experience of the Tantalized/ Dispossessed Self. Psa. Dial., 19:267-293
Oelsner, R. (2009). One Envy or Many?: Commentary on Paper by Julie Gerhardt. Psa. Dial., 19:297-308.
Ornstein, P.H. (2009). A Comparative Assessment of an Analysis of Envy: Commentary on Paper by Julie Gerhardt. Psa. Dial., 19:309-317

Saturday, November 15, 2014

Daniel Shaw on Traumatic Narcissism

If Freud said our personal ideologies are our “private religion” (convictions with unfaltering ritualization of behavior, repetition compulsion, if you will), Shaw adds that our private religions spring from our attachment story for we are all subjugated by our internal objects.  Shaw defines traumatic narcissism as the need to defend against dependency, for dependency is intolerably shameful and humiliating, and must be disavowed. Instead, dependency and neediness is seen in the other for the traumatic narcissist has everything within the self and needs no one. Traumatic narcissism is a relational dynamic requiring both the narcissist and its object to be subjugated. The easiest target is its child.

While all parents may sometimes attack the reality of their children, self aggrandize the child’s accomplishments, and have hope that the child will make up for their own failures, the traumatic narcissist can never admit fallibility, can never apologize, and continually  attempts to control and erase the subjectivity of their children. This is the cumulative relational trauma. The traumatic narcissist despises the child’s neediness, yet, paradoxically, any attempts by the child towards independence and agency are punished (by withdrawal or retaliation) for the narcissist requires the child to be the container for shameful neediness, Bateson’s classic double bind. This child, shamed for its dependence (and what is a child but dependent?), made to feel selfish and greedy, recognizing that only the attachment figure’s  needs are deemed valid, grows up to identify with the hated, but much needed, aggressor, an intergenerational transmission of traumatic narcissism.

Objectification of the child by the traumatic narcissist  is an absence of recognition, or a presence of negation. In analytic love, the therapist envisions the potential that cannot be realized, much like the good enough parent sees what the child can become. The children of traumatic narcissists, when they become our patients, demand not only that we recognize their trauma, but that we recognize our own disavowed traumatic narcissism! What a dangerously fraught journey for both patient and analyst as we struggle together toward freedom from the tyranny of our inner objects.

Tuesday, November 4, 2014

Lansky on Shame

Lansky delineates shame and guilt for us, and refers to the classical literature to make his points. He describes shame as resulting from failure to live up to one’s aspirations (ego ideal) and it signals fears of loss of relationship or separation and/or fears of exposure with concomitant humiliation. Weakness, defectiveness, vulnerability are all words patients might use to describe their shame. When shame is triggered, it may result in impulsive action, such as the intimidation of others (e.g. domestic violence) or compulsive binging, as one tries to regain control over one’s disorganizing sense of weakness. Guilt, on the other hand, results from failure to live up to superego expectations and can be used to defend against shame, for it gives a sense of action (some committed transgression) rather than the helplessness or powerlessness which evoke shame.

Shame is a hidden affect (there is shame in being ashamed), but Lansky says that it is not the affect itself which is hidden, but the consequences (social annihilation) of the affect. His idea alludes to the relational nature of shame, though when shame is consequent to failure to live up to one’s ego ideal it does not necessarily involve the other. Freud had previously noted that neurotic symptoms were an attempt to hide from awareness that which would evoke painful affect, as are defenses. (Not until 1926, in Inhibitions, Symptoms, and Anxiety, did Freud made explicit his signal theory of affect.)

Freud relegated shame to conflicts around toilet training, but Erickson spoke closer to the problem in his stage Autonomy v. Shame and Doubt, which is contemporaneous with Freud’s anal stage. Freud places guilt, and fear of retaliation (by castration), in the oedipal phase, whose heir, as you may recall, is the superego. Klein puts shame in the paranoid-schizoid position when, in addition to fear of attack and destruction, the expectation of one’s vulnerability being exploited by others with the intent to humiliate exists. Klein places guilt in the depressive position, which for her precedes the oedipal phase, when the infant becomes aware of the injury it inflicts on the mother. Kohut “divorced the notion of shame from any notion of conflict”, but Lansky opines that had Kohut linked ‘fragmentation anxiety’  in terms of its failure to live up to an ego ideal of maintenance of self image and self respect, Kohut might not have been so ostracized by the classical psychoanalysis of his day.  

My favorite nod to shame comes from Tomkins; He proposed that shame results from an interruption of joy. [How felicitous is that to remind us to meet our children’s joy with our own!] Many of the patients I see have indeed experienced the failure of their ‘love affair with the world’ to be met with attuned parental joy. Analysts, too, are called upon to meet our patients in the same direction affectively, though somewhat modified and without the disorganizing intensity, if lucky.

What Lansky might have elaborated more is the analyst’s shame, a powerful impetus to our dissociation, as when the struggle of our patients with their helplessness, their humiliation, and fears, trigger our own. He does note that “the shame of others makes us feel about ourselves what we do not like to feel: vulnerable, weak, powerless, dependent, contingent, disconnected, and valueless” and that “the emerging shame of the other stirs up our own difficulty bearing shame, our helplessness, and our anxiety that we may prove defective and fail in our professional roles because we, in facing the patient's incipient experience of shame, will be found to have nothing effective to offer.”

Lansky, M.R. (2005). Hidden Shame. J. Amer. Psychoanal. Assn., 53:865-890.

Tomkins, S. 1963 Affect, Imagery, Consciousness. Vol. II The Negative Affects New York: Springer.

Monday, October 27, 2014

Group Process 2

Additional important lessons for individual therapists to be taken from participation (procedural learning; 'the medium is the message') and understanding of group process as demonstrated by Roth on Oct 25, 2014 include:

1. The assignment (or acquisition) of authority (power).
The group facilitator often asked permission of the group and individuals to make comments on certain behaviors, e.g. pairing, before actually making said comments. He also, on occasion, made it clear that these were his point of view and open to review by the group with the possibility of a different outcome.

2. The use of data that was present and available for all to make use of.
The facilitator skillfully used exact words and phrases from group participants to call events of individuals to the entire group's attention, always reminding the group that one member may have been designated by the whole group to hold or contain something for the entire group (e.g. loss, trauma, sadness, aggression). Unfortunately, for some, this method was too exposing, felt to be too personal, and, therefore, narcissistically injurious, something the individual therapist strives to avoid but inevitably finds her/himself inflicting. Since injury is inevitable, what is valuable is the reparation. Reparation cannot occur if admitting injury is further humiliation. Likewise, the disappearance of the consultant, like the end of a session, feels, to some, being 'kicked to the curb' and we have no next session with the facilitator. The group will have to make use of the consultant through object constancy.

Sunday, October 26, 2014

Group Process

Many psychoanalysts eschew group therapy, but yesterday the Tampa Bay Psychoanalytic Society, Inc had an experiential look at group processes provided by its guest 'speaker' Jeffrey Roth, MD. Based on Wilfred Bion’s basic assumptions about groups, as taught in the U.S. by the A.K. Rice Institute for the Study of Social Systems, we had firsthand experience with the impact about how our behavior and unconscious processes organize experience intrapsychically, interpersonally and en masse.

Bion posited three basic assumptions for group behavior:
1)      Fight/flight, where the group hostilely engages authority
2)      Dependency, where the group does nothing but expect that the all powerful authority will provide for everything, and
3)      Pairing, where the group deems authority as incapable of providing what is needed and so two in the group are ‘elected’ as the pair who will now make provision of group needs.
A fourth group, the work group which functions to accomplish tasks, is often thwarted by these three basic assumptions, while paradoxically illuminating (through consultation) what the work group needs to address.

How did our use of group process help us in our work as individual therapists? We procedurally learned that everything that emerges (data) is useful and has meaning, contributing to the richness of the dyadic interaction, if the therapist welcomes it in, and can make use of it, instead of being bored as if nothing ‘deep’ is being related. All data signals what would like to be taken in or pushed away. Groups function around ‘BART’,  boundaries, authority, roles, and tasks. How these four entities are negotiated by the group are experienced, studied, elucidated, and may be transformative. While the group experience is transformative, and may continue to be so, old roles and skill sets (leader, scapegoat, etc) remain available. We are made up of multiple selves, after all.  

Sunday, October 19, 2014

Horror Film: The Orphanage, viewed and discussed 10-19-14

The Orphanage (2007), directed by Juan Antonio Bayona,  is about the unconscious, inadvertent, intergenerational transmission of trauma and it was deftly discussed today by Adriana Novoa, PhD at the Return of the Repressed Film Series.  She notes that most horror films place what is horrifying ‘outside’ or into the ‘Other’, but that this film places the horror inside the characters, and inside the audience through its emotionally resonating themes.

Laura (Belen Rueda), her husband Carlos and their adopted, seven year-old son Simon (Roger Princep) move to Laura’s childhood orphanage which she hopes to restore and reopen to care for five more children. Simon does not understand his mother’s need to take in more children. He has been told neither that he is adopted nor that he is HIV positive, but is understandably angry when he overhears this. When Laura and Carlos host a festive garden party for potential wards,  Simon disappears. Laura begins to suspect that the orphanage is haunted. Consulting a medium (Geraldine Chaplin), she learns that a number of orphans had been poisoned there. Perhaps Laura repressed any knowledge of Tomas who had drowned, a few days after Laura is adopted, as the result of a cruel prank played on him by the other orphans. These culpable children disappeared soon after.  

The audience can speculate that Laura’s dissociation of her early traumas (loss of childhood playmates, for example) made it difficult for her to recognize the losses Simon experiences. Her refusal (out of terror) to recognize her own son behind the mask, as well as his anger at her ‘lies’, lead to his unfortunate demise. His final attempts to communicate himself to her (through banging from the cellar where he is trapped) fail just as his previous communications about his discoveries of Tomas’ anguished world fail to get Laura’s understanding. Her misrecognition of Simon’s world is fatal. Laura’s unconscious wish to restore the lost (murdered) five children by caring for an additional five differently-abled children is thwarted. Likewise her unconscious knowledge of the accidental death of Tomas is recreated, poignantly, in Simon’s accidental death. Only in Neverland, in death, can the lost children be reunited with Wendy, now grown. Nowhere is the return of the repressed more dangerous.

Wednesday, October 15, 2014

The Developing Self and Origins of Shame

 Knox gives us a neurobiological explanation for the origins of shame. Should the mother register disgust for her infant or her infant’s agency, the infant’s sense of self and of agency is linked –through the insula (where mirror neurons may activate disgust) and the midline structures (where the sense of self is thought to be encoded) –with shame. A mother who cannot tolerate her infant’s distress may cause the infant to procedurally learn to hide pain in order to protect the attachment. This may result in a fear of love or Fairbairn’s schizoid personality, where shame has been linked to relationship.

A sensitively attuned mother is less likely to be disgusted by her infant and his needs. Winnicott speaks of the primary maternal preoccupation as a necessary requisite to allow for development of sufficient attunement of mother for baby. In doing so, we can infer that, he advocates for safeguarding the necessary space for the pregnant woman and new mother to acquire the necessary sensitivity to the needs of her infant. Should there be a failure to attune to the infant’s needs, the infant is in danger of a disruption of going on being, and of annihilation anxiety. Winnicott notes that in the early days of life, it is the mother who must identify with the baby, and not vive versa.

Lycia Alexander-Guerra
Tampa, FL

“…the need for the therapist to facilitate a process of disruption and repair (Beebe & Lachman 2002) in which the patient has an opportunity to correct the therapist's misattunements (Benjamin 2009)”  
I give an example from today’s session.
The client, in 8th year of therapy with me, tried to correct my misattunement saying that I had to listen [to]her need more, that is, she did not need my mirroring, but rather my opinion different [from] hers. While explaining that to me I asked her what she was experiencing my mind focused on. She replied, “I know you listen to me [with] so [much] concentration that I get love and affection.” Then gradually she started crying. After a little [while], I asked, ‘What was the correlation with your tears?’ She told me, “I asked for your opinion different [from] mine [and] you give me a different focus on me, compared to the not being focused [on by] my parents. How can I be so arrogant?”

 I think that was an example of disruption and repair where a part of herself was correcting me, paying attention to a self state I was ignoring, while another self state of hers was being repaired but was partially ignored by her!

 “What the mother does well is not in any way apprehended by the infant at this stage. This is a fact according to my thesis. Her failures are not felt as maternal failures, but they act as threats to personal self-existence”
I am not sure I agree with such a thesis. Although there is limited consciousness or self to perceive the mother as good enough, or bad enough, I think there is sufficient attachment-based relational need that is encoded preverbally via the body. If the mother attunes well or not well with the baby’s attachment needs, regulation/dysregulation is experienced via the body.
Stavros Charlambides
Athens, Greece

Knox, J. (2011). Dissociation and shame: shadow aspects of multiplicity. J. Anal. Psychol., 56:341-347.

Winnicott, D. (1956). Primary maternal preoccupation. In: Collected Papers, Through Pediatrics to Psychoanalysis. NY:Basic Books.

Thursday, October 2, 2014

More on Winnicott’s The capacity to be alone

I like, as always, the poetic rhythm Winnicott offers to the reader! As I was reading Winnicott’s The capacity to be alone, I questioned whether the author was trying to make explicit a narcissistic developmental issue or a schizoid developmental trauma? In my view, the latter was more likely.

The capacity to be alone is presented as a prerequisite of the capacity to be alone with your self. While he goes very deep in helping us understanding the issue I think the paper misses addressing the other side of the coin, that is, the capacity not only to be with your self but also the capacity to be without the other. This is in my view different from the former one. I did not see something written in the paper regarding dissociative phenomena, especially about those clients who are caught in between, partially being able to stay alone, and, simultaneously, stay without the other.

These clients can stay in silent moments in treatment for a while and give a glance to the analyst. They can stay partially alone in the presence of the analyst but cannot stay equally alone without his presence (that is evident via the glance). Many times as well these clients are alone psychically in the presence of the analyst: they are involved with the discussion but you sense their body is frozen (not in excitement attachment). This is an indication, I think, that they can be partially alone in the presence of the analyst, and with themselves, but not alone without him .

Winnicott, D. (1958). The capacity to be alone. Int.J.Psa., 39:416-420.

Stavros Charalambides
Athens, Greece

Wednesday, October 1, 2014

On Play and the Capacity to be Alone

[Winnicott writes]
·       The capacity to be alone is a highly sophisticated phenomenon and has many contributory factors. It is closely related to emotional maturity
·       Ego-relatedness refers to the relationship between two people, one of whom at any rate is alone; perhaps both are alone, yet the presence of each is important to the other
·       Gradually, the ego-supportive environment is introjected and built into the individual's personality, so that there comes about a capacity actually to be alone.
·       If the patient cannot play, then something needs to be done to enable the patient to become able to play, after which psychotherapy may begin. The reason why playing is essential is that it is in playing that the patient is being creative.
·       There is no need for the therapist to organize chaos all the time. Sometimes that behaviour covers and substitutes a real need for rest and empathic listening.

For example I have a patient deeply emotionally detached [who] tries to understand how to handle relationships. For that reason I proposed [to] him to join a group and indeed he accepted. He is in the group for 3 months and now he feels angry with other members because they talk and they do not allow time and space for him and others. When I asked him (in individual session) what do you want from others when they see that you are not talking? He replied "to give space to my silence. I do not want [them] to tell me anything but I need [them] to respect my silence and accompany me in that. I want to stay all in silence for some minutes in order to feel what I feel, to touch the depth of my sorrow that I cannot otherwise demonstrate."

At the previous session I "played", as Winnicot says, with him. I showed him a video from the web. In that video a man was seeing a woman from a distance and then tried to reach her by walking [across] a street. A car hit him, some glass from a window broke [and reached the woman]. However, they did not reach each other. The message was that all of that was only in the man’s fantasy. While my client was watching the video he cried and I did not ask him anything except one comment, "It seems that you at least reached out to something." So I was company, a silent company to his noisy loneliness.

Winnicott, D. (1958). The capacity to be alone. Int.J.Psa., 39:416-420.
Winnicott, D.W. (1956). D.W. Winnicott, Playing and Reality, London: Tavistock, Chap. 4  Playing: creative activity and the search for the self. 

Dimitrios Tsiakos, 
Athens, Greece

Tuesday, September 30, 2014

Somatization and the subsymbolic

As we know, trauma increases blood flow to the amygdala while decreasing perfusion to the hippocampus with the effect that procedural, emotional and sensory memory take place without the benefit of symbolization in language and without contextualization (one physiological explanation for dissociation). This phenomenon informs how clinicians can work with experience that has no words. The narrative approach assumes that symbolization is already present. Trauma, including the trauma of chronic misattunement, can cause chronic autonomic nervous system activation (affecting respiration, heart rate, perspiration, muscle tension, etc) with its emphasis on sensory not symbolic representation.

Bucci proposed a multiple code theory of emotional processing, three systems of emotional schema: the subsymbolic (perceptual, sensory), symbolic imagery – both non-verbal— and the symbolic (verbal).  These three systems are separate, but through the relational attunement and secure attachment with caregivers, who use their own emotional and cognitive schema to help children name, accept and regulate their emotional states, connections between the three are forged. In somatization, subsymbolic somatic schema are activated but are dissociated, never linked, or have lost their link to symbolic representations.

Taylor contrasts conversion disorder with somatization disorders. In the former, symbolization is intact and emotions are represented, and symptoms are the result of repressed (by an active ego), conflictual fantasies. On the other hand, somatization, writes Taylor, lacks underlying fantasies, and emotions are poorly representable, sometimes called alexithymia. (The ego is made helpless by dissociation.) Two different therapeutic aims ensue. For conversion symptoms, Freud made conscious the unconscious conflict through interpretation, but with somatization symptoms, says Bucci, what is required is a strengthening of connections between the subsymbolic and symbolic.

Gottlieb gives a nice history of the way different psychoanalysts have conceived of psychosomatic symptoms. They argue causality, meaning, and treatment. Students might enjoy contrasting Janet, Freud and MacDougall, as well as distinguishing la pensee operatoire from alexithymia. Many agree that somatization involves dissociation. Where does a child turn when the very people who are to help regulate distressing feelings are also their source? Hopefully, we will, in class, add from our clinical experience the relational intersubjective component of psychosomatic disorders, with the understanding that caregivers powerfully affect one’s ability to symbolize, mentalize, and see the other as an equal center of subjectivity.

Gottlieb, R. (2003). Psychosomatic medicine: the divergent legacies of Freud and Janet. J. Amer. Psa. Assoc., 51:857-881.

Taylor, G. (2003). Somatization and conversion: distinct or overlapping constructs? J Amer Acad Psa, 31:487-508.

Monday, September 29, 2014

Developing sense of self

Winnicott and Knox both speak to the infant’s developing sense of self and both are relational in the import for this ascribed to the environment.  Winnicott wrote that only in play, being creative, can the individual discover [become] the self. Being creative is not about products of the body or mind, but rather a feature of total living. Play, for Winnicott, meant living in the potential space [sometimes called transitional space or the third], “an area that is intermediate between the inner reality of the individual and the shared reality of the world that is external…” Winnicott exhorts the therapist to create an environment which allows for this third space in which to play. The good enough therapist provides repeated experiences that allow the patient to trust as well as enters into the arena of play with the patient.

While Winnicott recommends refraining from getting in the patient’s way to self discovery, for example, by the therapist being more interested in being clever, the one who knows or makes sense of, than in following the patient’s formlessness, his example seems to belie that his patient came alive from her formlessness (and his restraint from interpretation). Instead, she seems to complain repeatedly that she did not matter to him and only became enlivened after he actually shared the contents of his mind with her. [The mother develops her baby’s mind, and co-creates meaning,by having him in her mind, and by engaging the infant in reciprocal turn-taking.] It was when Winnicott reflects back, nearly two hours later, his patient’s experience to her does her experience take on meaning for her. [It befuddles me how Kohut failed to cite Winnicott when writing about mirroring.]

Knox writes that the infant’s sense of self first comes in to being by the meaning attributed to its actions by its mother.  A child internalizes [develops its sense of self through] its mother’s attributions, positive or negative. Negative attributions, internalized, then, can generate a sense of a deficient self, with its concomitant shame. To bulwark a diminished self, grandiosity and narcissism may be self-protective as the child struggles to remain alive emotionally.

Knox, J. (2011). Dissociation and shame: shadow aspects of multiplicity. J. Anal. Psychol., 56:341-347.
Winnicott, D.W. (1956). D.W. Winnicott, Playing and Reality, London: Tavistock, Chapter 4. Playing: creative activity and the search for the self.  


Wednesday, September 24, 2014

the politics of inclusion

Two wonderful things happened this week in NYC:

Today The United Nations Security Council resolved unanimously to stem the flow of foreign terrorist fighters across borders, allowing Secretary General Ban Ki-Moon, in his address to the Council, to note how “enemies of faith…brutalize women and girls” and “target and slaughter minorities.”    He also said, “Eliminating terrorism requires international solidarity …[W]e must also tackle the underlying conditions…The biggest threat to terrorists is not the power of missiles. It is the politics of inclusion…and respect for human rights…Missiles may kill terrorists, but good governance kills terrorism…societies… free from suffering, oppression and occupation.”

And Melinda Gates highlighted the pressing need for gender equality (e.g. in education and health) around the world. [Despite the gender inequality unaddressed] in the Civil Rights movement, the tenet that ‘no one is free until we are all free’  still rings true, and women and girls have waited a long time for equality. Perhaps the wait is approaching closer its end.

Monday, September 22, 2014

Horror Film: The Ring, viewed and discussed 9-21-14

Scott Ferguson, PhD, Film Professor at USF, spoke to the “pleasure” of horror films—indulging viscerally, sensually-perceptually, and affectively in the “abject”— and about the pleasures and horrors of media. Evoking Marshall McLuhan, he noted that egalitarian access to information media destabilized roles and place, frightening some, while simultaneously allowing new freedoms for connections. How are we to negotiate being with one another in these new ways, all the while uncertain, our privacy threatened? There are ethical challenges to consider [and only Aidan pauses to ask about how our choices affect others].

Ferguson asked us to consider how a film engages the cultural moment, socially and historically, not merely to think psychologically about relationships and characters, but to additionally think about how these are also conditioned by electronic media. The winged shape of a ‘samara’ seed enables the wind to carry it farther away from the parent tree. Thus estranged from its origins, Samara – adopted, then killed, then killer— speaks to the futility of recapturing the nuclear family, if one ever existed.

Symbols in this film confound the viewer, first suggested, then disconfirmed, offered, then undermined. There is the ring left by a coffee cup or that formed by the mouth of the well, Samara’s tomb, and, of course, the fatal telephone ring. A ring can symbolize wholeness, closure, where beginning and end meet, but in this film there is no resolution. A lighthouse which is meant to give protective warning, leads to more danger. The island isolates and connects. Where medium is viewed as conduit, agency, means, The Ring depicts multi-media: telephones, boats, water.

Much was made of reproduction, whether the copying of the VHS tape or human procreation, both leading, in this film, to a deadly end. One audience member asked why do humans seek to procreate, particularly when children are so disruptive to their parents’ lives. Anna kills her adopted daughter Samara.  Thinking about the relational context depicted in the film, how are the children allowed to develop and then engage the world? Neither Samara nor Aidan were wanted by their fathers, Richard and Noah, respectively. Despite the exterior trappings of a normal home, there was no space for Samara to be herself. Samara was a child wanting to be heard, calling out to be saved. Her adoptive parents constrained her, not just in the barn, but in every way.  Samara’s agency frightened her parents. She had to produce herself, come in to being herself. Parents who disempower their children, dehumanize them, creating monsters.

The audience also appreciated the cinematography, comparing its chaotic black and white scenes to Picasso’s Cuernavaca, the isolation of the island buildings to Hopper, and the grayish-greenish imagery to our surreal nightmares. At other scenes, color was hyper-saturated, like neon invading our senses.

So many perspectives brought together, what a rich discussion followed the viewing of The Ring yesterday!

Saturday, September 20, 2014

TBIPS 2014-15 Film Series “Return of the Repressed” (horror films)

The 2014-15 Film Series “Return of the Repressed” (horror films) opens Sunday, September 21, with The Ring (2002), directed by Gore Verbinski, and discussed by USF Film Professor Scott Ferguson, PhD, and myself.  The Film Series is a collaboration between the Tampa Bay Institute for Psychoanalytic Studies and  the Tampa Bay Psychoanalytic Society.  I am no fan of horror films, but I will discuss at the film’s showing how The Ring, [as does Case 39, to be shown on Feb. 15, 2015] exemplifies our fear of our children.  Scott, I think, will be discussing our fear of technology.

Because an infant’s sense of self first comes in to being by the meaning attributed to its actions by its mother, a child is vulnerable to its mother’s negative attributions. If she sees his hunger as greedy, or his natural exuberance as evil, the infant senses her disapproval and rejection. [I once heard a mother attribute her infant son’s fists to his wish to assault her. The ‘fists’ of a baby are consequent of the grasp reflex, with which all healthy infants are born--perhaps left over from our more furry ancestors clinging to their mothers’ backs.] These negative attributions are internalized and are thought to become part of one’s sense of self (in the cortical and subcortical midline systems via connections to the insula.  Mirror neurons in the insula are triggered when one observes disgust on another’s face. )

When mothers are unable to regulate their own distress, the distress of their infants becomes unmanageable.  Depressed mothers ‘shut down,’ turn away, or ‘close’ their faces to their infants. [We are told in The Ring, that Anna was unable to carry her own biological child and was institutionalized.]
Mothers who eschew their children’s strivings convey that the child’s agency is unacceptable. Should a parent’s repressed or dissociated (disavowed) fears and impulses be unconsciously projected onto their children, the child becomes ashamed of himself, his impulses, and his agency. He sees himself as bad, destructive, unlovable.  [Perhaps Samara is living out what her adoptive parents saw in her, that which was disavowed in themselves.]

We hope that local readers will join us Sunday, Sept 21 at 2pm. Here is the entire series roster:

the 2014-2015 Film Series
Horror films: “Return of the Repressed”

Psychoanalysis is interested in art, such as film, because it assumes two levels of meaning, one manifest, the other hidden. It is the latter unconscious meaning which resonates with the viewer. Horror films, in particular, express the Freudian motivations (drives), and the fear of aggression and libido, which are often communicated in symbols. Some say it is these unconscious motivations, threatening to become manifest, which terrorize us, including the fear of the discovery of the unknown, whether it be the monster lurking in the shadows or in the unconscious. What contemporary analysts understand to be more horrific, though, is loss of connection and meaning, when one finds oneself utterly devoid of embeddedness and place.

DATE:             Sundays, monthly (see specific dates below)
TIME:              200pm-500pm
LOCATION:      Auditorium, 13919 Carrollwood Village Run, Tampa, Florida 33618
CHARGE:         $2 donation (includes popcorn and soda)
Informal and convivial afternoon viewing, then discussing, a film. Facilitators for each film discussion include an academician (film, humanities) and a psychoanalytic psychotherapy clinician.
Other films this year:       

September 21, 2014     The Ring         
Scott Ferguson                      Academic Discussant 
Lycia Alexander-Guerra      Clinical Discussant
October 19, 2014          The Orphanage    
Adriana Novoa             Academic Discussant        
Robert Porter                Clinical Discussant

November 16, 2014      Night of the Living Dead  
Amy Rust                        Academic Discussant
Kathryn Lamson            Clinical Discussant

January 25, 2015           The Sixth Sense    
Kersuze Simeon-Jones     Academic Discussant    
Michael Poff                      Clinical Discussant
February 15, 2015         Case 39                 
Silvio Gaggio                     Academic Discussant                  
David Baker                       Clinical Discussant

March 8, 2015                Cronocrimenes     
Heike Scharm                    Academic Discussant       
Horacio Arias                     Clinical Discussant

April 19, 2015                 Frankenstein        
Margit Grieb                     Academic Discussant         
Sheldon Wykell                  Clinical Discussant

May 17, 2015                 The Innocents       
Eve Hershberger             Academic Discussant      
Linda Berkowitz              Clinical Discussant

Tuesday, September 16, 2014

Psychosoma Intro

The body remembers. Early traumatic experience, whether occurring before the hippocampus comes ‘on-line’ or dissociated from symbolism by decreased blood flow to the otherwise functioning hippocampus, is procedurally ‘learned’ and stored by affect and perceptual senses. Chronic thigh pain may be the only link to the pain of childhood sexual abuse, the smell of a particular cologne and its consequent headaches the only connection to herald long ago parental tirades.  We feel. We panic. We don’t remember the events. It may take countless hours of psychotherapy before integration and words allow voice to be given to those early threats to sense of self.

In Theaters of the Body (1989) Joyce MacDougall writes that psychosomatic illness results from the body reacting to a psychological threat as though it were a physical threat due to lack of awareness of our emotional states when being threatened, so seeking psychological treatment is very tricky for both patient and therapist. While one may wish to be free of psychological (and psychosomatic) symptoms, we must remember that these symptoms have been, since childhood, a best possible attempt at bearing the unbearable. Our patients wish and fear the giving up of these symptoms for these symptoms helped (in earlier times) with psychic survival. They may also be the only clues we have to early traumas.

Kradin, from a Jungian perspective, provides an introduction to the psychosomatic illnesses. He states that the psychosomatic symptom is “a symbolic communication by the suffering self to caregivers…a cry for help in hope that someone will respond, and a method of repelling others as an expression of unconscious dread.” Early caregivers regulate infant distress and give meaning to infants’ bodily sensations. The failure of symbol formation in people suffering with psychosomatic disorders speaks, in part, to the inadequate regulation between mother and infant. Kradin highlights (from Noyes) the anxious maladaptive attachment style where (from Driver) etiology of at least one disorder, CFS, is speculated to include “inadequately internalized maternal reflective function, affect dysregulation, and diminished psyche-soma [Winnicott] differentiation.” Other events often found in the histories of patients with psychosomatic disorders are “a parent with physical illness, a history of family secrets, and childhood maltreatment” including emotional abuse. Kradin reminds therapists that our aim is treatment of the disordered self and not symptom reduction. “[S]ymptoms are ‘real’, whatever their cause” and “healing begins only once caregivers have disabused themselves of the notion that patients are responsible for their disease.”

Kradin, R.L. (2011). Psychosomatic Disorders: The Canalization of Mind into Matter. J. Anal. Psychol., 56:37-55.

Monday, September 15, 2014

Comments on Auerbach and Bach, Narcissicism and Shame (2)

1.       For Auerbach a narcissistic individual, in contrast, the self is experienced as cohesive and vital at the cost of the object's becoming fragmented and lifeless,and vice versa. That is why one who has capacity for self-love can love others,and why narcissistic individuals are profoundly invested in others but only insofar as others are mirroring them or are capable of being idealized. Terms like part object, selfobject, and transitional object express the narcissistic patient's representational and relational difficulties.

2.   Auerabach using a Piagetian framework according to Bach, states that narcissistic patients have difficulty in establishing equilibrium between subjective awareness (i.e., the immediate, nonreflective immersion in the experience of self as a center of thought, feeling, and action) and objective self-awareness (i.e., the awareness of self, including thoughts, experiences, feelings, actions, etc., as an object among other objects and a self among other selves).

3.  Auerbach states that shame is a core issue in the effort to understand narcissism. "that shame is an ineluctable consequence of objective self-awareness, and that objective self-awareness, the eye turned inward to discover in the midst of interest or enjoyment hidden faults and defects, is the core of shame.

4.  Shame emerges, in this second perspective, as the mediating term in the dialectic of subjective and objective self-awareness but at the same time is also at the core of the resistance to psychoanalytic psychotherapy and psychoanalysis by containing a desire not to be exposed.

5. Psychological health, adequate self-esteem, involves not an absence of shame but a capacity to tolerate the shame that inheres in individuality. In other words, shame ensures that selfhood, no matter how well established, always remains a locus of conflict.

6. Bach notes, provide alternative but illuminating developmental perspectives on this narcissistic dilemma, and suggest that narcissistic disturbance involves not so much a misallocation of libido as a problem in the representation of objects and object relations.

7. Subjective awareness, as I call it, is a state in which we are totally into ourselves and our feelings while the rest of the world is in the background—that is, a Romantic or Dionysian state of mind.

8. For Bach we are all both Dionysians and Apollonians, Romantics and Classicists, but one difference lies in our preferred mode of being and also in our abilities to make the transition or oscillate back and forth, flexibly and appropriately, between these two states.

9.  For Bach there are 2 types of narcissism: the inflated sadistic type who presents with open grandiosity and an unconscious sense of worthlessness and the deflated masochistic type who presents with open feelings of worthlessness and an unconscious sense of grandiosity. The inflated type with open grandiosity exists primarily in a state of subjectivity, concerned only with himself and unable to be objective about his aspirations, but unconsciously he feels worthless and self-critical. The deflated type with open feelings of worthlessness exists primarily in a state of objective self-
awareness, masochistically denigrating and criticizing himself as if he were some hostile outside observer, but unconsciously he may feel quite special or grandiose.

10. But, what occurs as the child matures is not just better regulated and more appropriate oscillations between subjectivity and objectivity or between self and other but rather a more complex synthesis, a blending and interpenetration of the two in the transitional area so that they are no longer simply dichotomous.

Dimtrios Tsiakos
Athens, Greece
Candidate, TBIPS

Sunday, September 14, 2014

Narcissism and Shame (1)

It was fortuitous to have had John Auerbach, PhD in Tampa yesterday speaking at the local (Tampa Bay) Psychoanalytic Society, for the Institute begins its Fall Semester this week and we are reading on Wednesday, in the Narcissism and Shame course, a review by Auerbach. Speaking to Bach’s ideas on the subject, Auerbach highlights the disruption of reflective self-awareness in those with narcissistic disturbances.

Bach tells us that the grandiose, inflated narcissist exists in a state of subjectivity (increased subjective awareness, ‘it’s all about me’), with the sense of worthlessness in the background. Subjective self-awareness alternates with objective self awareness in which the narcissist denigrates the self, feeling deflated and worthless. Auerbach notes the paradox of these two states of reflective self-awareness: “subjective awareness increases the sense of aliveness but decreases objective knowledge of self, and objective self-awareness, by increasing knowledge of one’s place (and smallness) in the world, decreases self esteem.” This very paradox is what causes in the narcissist fragmentation of the sense of self.  Interpretation (of, for example, the difficulty) is experienced “as an attack upon the self, a narcissistic injury.” Instead, the transitional space between objective and subjective can be utilized to develop and maintain self cohesion.

Self reflection is the ability to view oneself as if looking on (objectively) from the outside. Bach notes two states of self awareness: subjective and objective, and how difficult it is to move easily between them if early caregivers did not help regulate the transition between them smoothly enough to prevent abrupt shifts in autonomic and limbic systems’ firing. Auerbach, too, in his review of Nathanson’s The Many Faces of Shame, tells us that sudden interruption of excitement or joy can induce shame, the hallmark affect of narcissism, and Auerbach writes, “shame is the ineluctable consequence of objective self awareness…”  And isn’t that what psychoanalytic therapy partly endeavors to do, to increase objective self-awareness, all the while inadvertently engendering shame? This semester, we endeavor to discuss how to minimize shame in our patients and ourselves as we struggle to become.

Auerbach, J.S. (1990). Narcissism: Reflections on Others' Images of an Elusive Concept. Psychoanal. Psychol., 7:545-564.

Bach, S. (1998).Two Ways of Being. Psychoanal. Dial., 8:657-673.

Thursday, August 7, 2014

Remembrance of my father

If he had lived a few years more, my father would be 93 years old today.  He was a newspaperman for his home town paper for half a century, in the days when that was a profession in which facts were just that, and judiciously weighed. He also wrote opinions: the op-ed page, a column, and book reviews. It would be no exaggeration to say I grew up in a home with 10,000 books. No one questioned his word or his character. He seemed to know everything. The older kids in the neighborhood came to him to settle their disputes. My older daughter, in her eulogy of him, said, “Grandpa was Google before there was Google.”   I remember one time from when I was very small he loaded up the family station wagon with my brother and me and a bunch of boys from the neighborhood and drove us to the local drive-in movies. A boy said, “Mr. Alexander, we can all hide in the back, under the blankets, so you don’t have to pay for everybody.” But my father, of course, paid for every child. That is one of my earliest memories and it shaped my idea of my father. It also taught me something about honesty and integrity. As analysts, we strive daily toward honesty, a heady ambition. Though dead, he remains a role model.
My father had a remarkable capacity to recite poetry off the top of his head. This was one of his favorites, from his childhood:

"If" by: Rudyard Kipling

If you can keep your head when all about you
Are losing theirs and blaming it on you;
If you can trust yourself when all men doubt you,
But make allowance for their doubting too;
If you can wait and not be tired by waiting,
Or being lied about, don't deal in lies,
Or being hated, don't give way to hating,
And yet don't look too good, nor talk too wise:
If you can dream ‑‑ and not make dreams your master;
If you can think ‑‑ and not make thoughts your aim;
If you can meet with Triumph and Disaster
And treat those two imposters just the same;
If you can bear to hear the truth you've spoken
Twisted by knaves to make a trap for fools,
Or watch the things you gave your life to, broken,
And stoop and build 'em up with worn‑out tools;
If you can make one heap of all your winnings
And risk it on one turn of pitch‑and‑toss,
And lose, and start again at your beginnings
And never breathe a word about your loss;
If you can force your heart and nerve and sinew
To serve your turn long after they are gone,
And so hold on when there is nothing in you
Except the Will which says to them: "Hold on!"
If you can talk with crowds and keep your virtue,
Or walk with kings ‑‑ nor lose the common touch,
If neither foes nor loving friends can hurt you,
If all men count with you, but none too much;
If you can fill the unforgiving minute
With sixty seconds' worth of distance run ‑‑
Yours is the Earth and everything that's in it,
And ‑‑ which is more ‑‑ you'll be a Man, my son!

Wednesday, July 30, 2014

Dead or Alive?

I call your attention to the Pulitzer-prize winning  journalist and best-selling author Ron Suskind ’s  latest book, a memoir,  Life, Animated, A Story of Sidekicks, Heroes, and Autism  because the remarkable journey of his family to find their way to connect with their son Owen reminds me of some of the very best we strive for in the  psychothera-peutic relationship.  Owen, as present in 1/3 of the cases of the millions of children with autism, has regressive autism, that is, he appeared to develop normally but then began, in his case before his third birthday, to lose speech and social skills. Owen, without necessarily comprehending, memorized the entire scripts of the Disney films that he for so long and continued to watch, and he could do all the characters’ voices, too. Initially, the Suskinds discouraged as non-productive Owen’s perseverative obsession with Disney animated characters. But in their attempt to look for a way into the psychological life of their son, cut off from the rest of the family, they decided to use what Owen presented to them as the key to make their way in, and his entire family became proficient in Disney voices. Suskind would even recommend dancing in front of the TV screen if need be.

I take this as good advice, jumping into the rabbit hole as it were, with some of our most unreachable patients, even those with psychosis, instead of trying to make them conform to our ideas of how to communicate a narrative; to use what is presented and find within its inexplicable vehicle some nidus around which together to build meaning [meaning, after all, arises from within connection]; To bend the frame as needed, dance in front of the screen, if there exists any hope to reach the unreachable. In other words, welcome in, welcome in, with an attitude of ‘If you want, I want to,’  for without connection, there is a deadness to our being together.

To animate both their lives, Suskind and his wife, and their older son Walt, decided to go where Owen was. What they previously had thought was a prison for Owen has become a pathway to communication between them. Remembering from the Lion King’s ‘Remember who you are,’ Suskind asks Owen, ‘Who are you, Owen?’ and Owen, remembering, too, replies, ‘Your son.’  

Sunday, July 27, 2014

Dissociation and building a bridge

The local psychoanalytic professional society offers every year a discussion group as part of its extension division. This year, the readings will all come from Philip Bromberg’s 1998 book Standing in the Spaces, Essays on Clinical Process, Trauma, and Dissociation. In its introduction, and addressing the psychoanalytic process, Bromberg grapples with the human ability to allow “continuity and change to occur simultaneously.” He posits that the self is not unitary but that the mind is a “configuration of shifting, nonlinear states of consciousness in an ongoing dialectic with the necessary illusion of unitary selfhood.”  

Bromberg emphasizes the role of dissociation—a result of trauma— as equally significant and more powerful than repression and conflict, in shaping the psyche.  Psychoanalysis builds a bridge between dissociated (not-me) self states of the mind and thus, transforming it, allows for “the experience of intrapsychic conflict.” It enhances “a patient’s capacity to feel like one self while being many.” Dissociation, both normative and pathological, exist in both participants and the patient and analyst purposefully confront and engage each other’s (and their own) multiplicities and nonlinear realities as they organize their relationship.

In moments of intense affective arousal, when parents are unable to reflect upon a child’s mind, both staying in the appropriate affective experience with the child and bringing the parent’s new perspective to bear, the child may be “traumatically impaired in his ability to cognitively process his own emotionally charged mental states…and thus own them as ‘me’.” Bromberg continues, “[P]sychological trauma can broadly be defined as the precipitous disruption of self-continuity through invalidation of the internalized self-other patterns of meaning that constitute the experience of ‘me-ness’.” This threat to self is experienced as annihilation anxiety. Dissociation protects the sense of self continuity by keeping at bay traumatic disruption. Unfortunately, safety of this trauma based personality requires one to be at the ever ready for disaster such that one can never feel safe even when one is.

One poignant example of dissociation exists in the schizoid patient whose dissociation, Bromberg writes, is “so rigidly stable…that is tends to be noted only when it collapses.” To protect itself from annihilation anxiety, the schizoid personality prevents spontaneity by keeping a boundary between the inner and outer world such that things remain predictable and controllable. “The struggle to find words that address the gap that separates us is the most potentially powerful bridge between the patient’s dissociated self-states…Once the words are found and negotiated between us, they then become part of the patient’s growing ability to symbolize and express in language what he has had no voice to say.”

Sunday, July 20, 2014

Becoming a Subject

It is the subject who desires. Bromberg [blog post July 6, 2014] already alluded to anorexia as renunciation, or inability to own, desire. Developing a cohesive sense of self, or subjectivity, requires in infancy and childhood attunement which serves to regulate physiological and affective experience. Affect, once regulated, can be integrated with experience (as episodic memory) such that accumulation of memory gives a continuity over time and the experience of a sense of self. Subjectivity also includes agency, which begins with that of an infant able to engage the caregiver in cooing repartee or the toddler who can command the shared delight of a caregiver when a presented (shared) dust bunny or acorn.  Benjamin notes it is the shared joy, the toddler at discovery, the mother at the toddler’s joy, not the presented thing itself, that brings communion.

As Winnicott knew and Kennedy notes: reality [and meaning] arise out of shared interaction between two subjects, that is, socially constructed, neither already present nor individually created, but of both. Nietzsche, too, posited that the subject is not given, but invented, added up. Society as well arises then from the result of subjective meaning. Meaning, co-created with the caregiver (having a place in a relational world), gives one a sense of having the right to be here in the world, and be here as a welcomed subject. At the same time, there is the dilemma, what Husserl called “the paradox of human subjectivity” because we are both subjects (with desire) for the world and objects (of desire) in the world.

Bromberg, like Hume, denies a singular subject or self, but instead sees us made up of a collection of self states, variably integrated, or “a collection of different perceptions.” Kennedy describes a kind of thinking “which takes account of a fleeting and ambiguous nature of our subjective life as it exists in relation to a world of other subjects, and which cannot be tied down to the centralised and solitary ego.”  Kennedy, evoking Benjamin, “points to the need to use a model of the mind that incorporates both positions [intrapsychic and intersubjective] without privileging either.

Kennedy tells us that Kojeve noted Hegel’s introduction of the desiring subject, distinct from the knowing subject, for Kojeve

emphasised that the person who contemplates and is absorbed by what he contemplates, that is the ‘knowing subject’, only finds a particular kind of knowledge, knowledge of the object. To find the subject, desire is needed; the desiring subject is the human subject. As explored by Kojeve, what is essentially human about desire is that the subject desires not just an object, not even the body, but the other's desire. One desires the other's desire. The movement between the subject and the other in a constant search for recognition of their desires constitutes human reality. Desire is the essential element reaching beyond the individual subject to the other subject. These descriptions seem to capture an important element of the psychoanalytic relationship, in which the subject's desires, or wishes, dreams and fantasies are the material on which analyst and patient work.

Kennedy writes that “With the analyst not being directly available, the analytic setting sets in motion a complex search for the human subject.” This got my colleagues and I arguing about the use of the couch and whether the analyst out of sight promotes the subjectivity of the patient, as if in order to be a subject, the other must be an object— which, to my mind, is anti-Hegelian (Hegel notes that the subject must be recognized by an equal other in order to be a fully experienced subject). Kennedy notes that we must own desire of the other as object, and that being a subject also entails the capacity to take up different positions without become frozen or fixed in any. Our welcoming in varying self states of the patient, then, can confound the patient who, himself, finds these dissociated parts unwelcome (and vice versa for the analyst). Included in the patient’s (or our) disavowal is the difficulty of allowing the other to make an impact.

Moreover, intersubjectivity, adds Kennedy,   

refers not only to the sharing of experiences but also to issues of meaning surrounding these relations, the nature of the orientation to the other, how one understands the other and is affected by the other and the place of human desire, as well as the nature of the social world.

Kennedy’s  paper is rich in contemporary ideas, but I wondered in his clinical material— where he writes that Mrs. A could not find her own subjectivity— if her complaints did not also include that she could not find her analyst’s (as had been the case with her mother’s) subjectivity either.

Kennedy, R. (2000). Becoming A Subject: Some Theoretical And Clinical Issues. Int. J. PsychoAnal., 81:875-892.