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.