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.

Thursday, July 17, 2014

More on living authentically with death

Speaking of  existential anxiety [see post 7-12-14] and, with the knowledge of death,  living authentically, Philip Larkin renders it poignantly:


I work all day, and get half-drunk at night.   
Waking at four to soundless dark, I stare.   
In time the curtain-edges will grow light.   
Till then I see what’s really always there:   
Unresting death, a whole day nearer now,   
Making all thought impossible but how   
And where and when I shall myself die.   
Arid interrogation: yet the dread
Of dying, and being dead,
Flashes afresh to hold and horrify.

The mind blanks at the glare. Not in remorse   
—The good not done, the love not given, time   
Torn off unused—nor wretchedly because   
An only life can take so long to climb
Clear of its wrong beginnings, and may never;   
But at the total emptiness for ever,
The sure extinction that we travel to
And shall be lost in always. Not to be here,   
Not to be anywhere,
And soon; nothing more terrible, nothing more true.

This is a special way of being afraid
No trick dispels. Religion used to try,
That vast moth-eaten musical brocade
Created to pretend we never die,
And specious stuff that says No rational being
Can fear a thing it will not feel, not seeing
That this is what we fear—no sight, no sound,   
No touch or taste or smell, nothing to think with,   
Nothing to love or link with,
The anaesthetic from which none come round.

And so it stays just on the edge of vision,   
A small unfocused blur, a standing chill   
That slows each impulse down to indecision.   
Most things may never happen: this one will,   
And realisation of it rages out
In furnace-fear when we are caught without   
People or drink. Courage is no good:
It means not scaring others. Being brave   
Lets no one off the grave.
Death is no different whined at than withstood.

Slowly light strengthens, and the room takes shape.   
It stands plain as a wardrobe, what we know,   
Have always known, know that we can’t escape,   
Yet can’t accept. One side will have to go.
Meanwhile telephones crouch, getting ready to ring   
In locked-up offices, and all the uncaring
Intricate rented world begins to rouse.
The sky is white as clay, with no sun.
Work has to be done.
Postmen like doctors go from house to house.

Saturday, July 12, 2014

Guilty Man again?

Kohut wrote that modern man had moved from the Freudian 19th Century  ‘guilty man’ [conflicted about libidinal and aggressive strivings, failing to live up to ideals] to ‘tragic man’ [blocked not only in strivings toward libidinal and aggressive pleasures, but blocked in creativity, expression, and in developing a selfhood, a defective and failed self, despairing and empty]. Stolorow invokes Heidegger’s authenticity and existential guilt as coexisting with one another, where existential guilt is to be accountable for and to own what is ‘mineness’.  If anxiety discloses authentic living, then Stolorow notes, shame belies it, for in shame we do not belong to the self but to the gazing other.

Heidegger expected authentic living to evoke anxiety because authentic living would own our mortality, finitude, our “being-toward-death.” Being absorbed in everyday life keeps inevitable, impending death from awareness. Stolorow posits that death and traumatic loss have similar effects. He notes how catastrophic loss shatters the “absolutisms of everyday life” and rips the veil to reveal our finitude, and the finitude of all whom we love, plunging us into anxiety. He writes, “authentic being-toward-death is always also a being-toward-loss.”

Bob Dylan may have written that ‘he who is not busy being born is busy dying’ but Heidegger and Stolorow might contend that in life it is both, simultaneously. I hold my lover in my arms, bittersweet knowing my arms will soon be empty. Do I savor the sweetness more deeply because it will soon be gone? or do I become embittered at the meaninglessness because soon we will both be gone from existence? or both?

Stolorow writes that a relational home helps us bear and integrate the eternal grieving.

Wednesday, July 9, 2014

Because of the color of the wheat

"Come and play with me," proposed the little prince."I am so unhappy."
"I cannot play with you," the fox said. "I am not tamed."
“…What does that mean-- 'tame'?"
"It is an act too often neglected," said the fox. It means to establish ties."…"To me, you are still nothing more than a little boy who is just like a hundred thousand other little boys. And I have no need of you. And you, on your part, have no need of me. To you, I am nothing more than a fox like a hundred thousand other foxes. But if you tame me, then we shall need each other. To me, you will be unique in all the world. To you, I shall be unique in all the world...
"… if you tame me, it will be as if the sun came to shine on my life. I shall know the sound of a step that will be different from all the others. Other steps send me hurrying back underneath the ground. Yours will call me, like music, out of my burrow. And then look: you see the grain-fields down yonder? I do not eat bread. Wheat is of no use to me. The wheat fields have nothing to say to me. And that is sad. But you have hair that is the colour of gold. Think how wonderful that will be when you have tamed me! The grain, which is also golden, will bring me back the thought of you. And I shall love to listen to the wind in the wheat.."

"What must I do, to tame you?" asked the little prince.
"You must be very patient," replied the fox. "First you will sit down at a little distance from me-- like that-- in the grass. I shall look at you out of the corner of my eye, and you will say nothing. Words are the source of misunderstandings. But you will sit a little closer to me, every day..."
The next day the little prince came back.
"It would have been better to come back at the same hour," said the fox. "If, for example, you come at four o'clock in the afternoon, then at three o'clock I shall begin to be happy. I shall feel happier and happier as the hour advances. At four o'clock, I shall already be worrying and jumping about. I shall show you how happy I am! But if you come at just any time, I shall never know at what hour my heart is to be ready to greet you... One must observe the proper rites..."

So the little prince tamed the fox.

And when the hour of departure drew near--
 "Ah," said the fox, "I shall cry."
"It is your own fault," said the little prince. "I never wished you any sort of harm; but you wanted me to tame you..."
"Yes, that is so," said the fox.
"But now you are going to cry!" said the little prince.
"Yes, that is so," said the fox.
"Then it has done you no good at all!"
"It has done me good," said the fox, "because of the color of the wheat fields."

From The Little Prince (1943) by Antoine de Saint-Exupery

Sunday, July 6, 2014

Bromberg’s Multiplicity of Selves: Dissociation and Eating Disorders

When we think of multiplicity and dissociation we think of Phillip Bromberg who wrote the beautifully rendered Standing in the Spaces (1998), Awakening the Dreamer (2006) and The Shadow of the Tsunami (2011).  I deem felicitous everything he puts to pen for Bromberg weaves stories, memoir, and theory into useful relation with clinical practice. Not only does he long emphasize how trauma leads to dysregulation of affect and to dissociation (as well as an inability to contain desire), but he highlights the inevitable dissociation by all of us, including the analyst, as we continually shift our myriad self states from background to foreground. [Bromberg sees the unitary self as illusion, albeit a “developmentally necessary illusion”.] These shifts or dissociations are in response to interpersonal interactions in an almost infinite number of transitory permutations which are co-created between one self state of the patient in conjunction with one of the analyst. Treatment, then,

draws the work into a dialectic between the here and now and the there and then, allowing the mutual construction of a transitional reality in which both the patient's and the analyst's dissociated experience have an opportunity to coexist as a perceived event different enough from the patient's narrative “truth” about relationships to permit internal repair to take place and the patient's reliance on dissociation to be gradually surrendered. To be fully in the moment is to be fully allowing new (as yet unprocessed) experience to interface perceptually with episodic memory, thus optimizing its potential for integration into narrative memory and, ultimately, enriching self-narrative—the goal of any form of treatment.

Dissociation, writes Bromberg, forecloses “the possibility of holding in a single state of consciousness two incompatible modes of relating.” It is the traumatized patients who most require our affective honesty in combination with safety. How are we to be genuine regarding the effect patients have on us while simultaneously avoiding shaming them or, worse, misconstruing their intentions in order to meet our own needs?  It is through a secure attachment, with its consistently repeated safe interpersonal interactions, which allows for affect regulation. Disruptions in mutual regulation create a break in intersubjectivity in which  the patient or the analyst may— until righting oneself once again in the ability to see the other as an equal subject— disparage, blame, or judge harshly the other.

We cannot undo the trauma that has been inflicted on patients, but Bromberg notes that, instead, we can try “to cure them of what they still do to themselves (and to others) in order to cope with what was done to them in the past.” Bromberg sees most of the symptoms of eating disorders as an outcome of dissociation. It is also thought (Boris, 1986) that dysregulation of desire in infancy is linked to the dysregulation of appetite [and choice] where “[g]reed is a state that attempts to eliminate the potential for traumatic rupture in human relatedness by replacing relationship with fooda solution that is largely self-contained and thus not subject to betrayal by the ‘other’.” Anorexia is the renunciation [through dissociation] of desire, but at its core, Bromberg writes, “is a loss of faith in the reliability of human relatedness” for “Trauma creates the experience of nonreparability…” Dissociation is, then, “not just insularity but regulation.”  And the “insularity reflects the necessity to remain ready for danger at all times so it can never—as with the original traumatic experiences—arrive unanticipated.” Binging and purging, also accomplished via dissociation, are an attempt to bound the self, delineate an unfragmented edge.

 by ‘noticing,’ through the impact of forced involvement with what the patient needs to call attention to without communicative speech, the dissociated self can start to exist, and a transition begins to take place... But the success of the transition depends on the ability of the patient to destroy successfully the analyst's unilateral experience of ‘what this is “really” all about’... The problem for the analyst, of course, is that his own self-image, which is a part of all this, is also dismantled, and it is this destruction he must ‘survive,’ … [Winnicott (1969)

Bromberg, P.M. (2001). Treating Patients with Symptoms—and Symptoms with Patience: Reflections on Shame, Dissociation, and Eating Disorders. Psychoanal. Dial., 11:891-912.

Wednesday, July 2, 2014

Civil Rights Act of 1964

On this day fifty years ago, the Civil Rights Act of 1964, which outlawed discrimination based on race, sex, color, creed, and national origin, was signed into law by President Lyndon B. Johnson— less than eighteen months after John F. Kennedy called for such a law in his Civil Rights speech on June 11, 1963, a speech given on the heels of the biting police dogs and fire hoses in Birmingham that Spring. This landmark civil rights legislation outlawed racial segregation in schools and at lunch counters where I grew up. It added a richness and breadth to my school day experiences.  

It is the American dream to have the freedom for self determination, not subjugated by predetermination. Neil Altman writes: “Problems arise…when one loses the dialectical relationship between being free and being determined, when one fails to take account both of our human capacity for freedom and the ways in which that freedom is limited.” Foucault reminded us how society, its institutions and history, organizes our thinking around constructed power structures.  Damaging others through subjugation of their capacity for self determination, whether talking sex or race, ought to generate guilt. But operating in the paranoid-schizoid position we split ourselves (good me - bad me) and split others. 

Separating ourselves is antithetical to healing, whether done from within— through dissociation, disavowal, projection, and denial— or from without— through racism, misogyny, contempt for others. To address our dis-integration by these mechanisms we must first acknowledge our participation in them. Once acknowledged, a public (that is, explicit) dialogue can happen. Traumatic experience otherwise remains split off, unspoken. The Fourteenth and Nineteenth Amendments, and subsequent Civil Rights legislation, came about through dialogue, sometimes waging.

We organize ourselves not merely around drives, but more over around attachment and belonging.  When excluded and left out we feel ashamed. 

There is security in finding others like ourselves, but there is joy in finding like-mindedness amongst difference.

Happy Independence Day, USA.