Wednesday, March 21, 2018

Disclosure

Sandra Buechler spoke on March 17, 2018 at the Tampa Bay Psychoanalytic Society’s Speaker Program meeting.

An interesting paper (1993) of hers talks about the analyst’s emotions and whether, and when, to share them with the patient. Some of the benefits which may be gleaned by sharing the analyst’s feelings about the patient include:

they may evoke from the patient additional, illuminating data;
they may allow the patient to feel he or she has an impact;
they may de-mystify the interaction;
they may communicate the analyst’s dedication to the analytic process;
they may be taken as expressing a sense of caring, even if they are negative emotions;
they may generate new experiences: new emotions, and that emotions can be explored;
they may convey that the analyst can survive [Winnicott: survival];
they convey respect, acknowledging the patient’s responsibility for her/his impact on the analyst;
they may relieve the analyst of interference from unexpressed negative feelings;
they may acquaint the patient with her/his potential for affective interchanges;
they may acquaint the patient with the joy of mutual regulation rather than control imposed by the other;
they may allow the patient to vicariously experience forbidden affects which the analyst carries for both;
They may communicate to the patient the therapist's involvement;
the patient may be better able to explore intolerable feelings with an emotionally responsive person;
[and may foster authenticity and intersubjectivity, of which emotions are a part]

Buechler, S (1993). Clinical Applications of an Interpersonal View of the Emotions Contemporary Psychoanalysis, 29:219-236

Monday, March 19, 2018

Poetry and Psychoanalysis

It was the pleasure of the Tampa Bay Psychoanalytic Society to host on March 17, 2018 Sandra Beuchler, PhD at its monthly Speaker Program Meeting. In the intimate setting at 8:15 am of a 'Conversation with the Speaker'  Buechler shared "Poems that Inspire Clinical Work." She opened with an excerpt from "The Four Quartets," specifically "East Coker," by T.S. Elliott which eloquently captures the psychoanalytic process with its shared struggles:

Trying to learn to use words, and every attempt 
Is a wholly new start, and a different kind of failure
Because one has only learnt to get the better of words
For the thing one no longer has to say, or the way in which
One is no longer disposed to say it. And so each venture
Is a new beginning, a raid on the inarticulate
With shabby equipment always deteriorating
In the general mess of imprecision of feeling,
Undisciplined squads of emotion.

Wednesday, March 14, 2018

Relational ideas, a smattering

First year courses at TBIPS have finally reached their emphasis on theoretical contributions from relational authors and so I am pleased to present a few concepts that have so informed our way of being in relation to our patients. They include the paradigmatic shifts from intrapsychic to interpersonal and intersubjective, from one-person to two-person, from drive-conflict model to relational [Mitchell], and from a unified self to a multiplicity of selves (in health, held together by a sense of continuity, cohesion, and coherence) [Bromberg]. Also important has been the shift from the analyst as objective authority [Sullivan] and all-knowing blank screen to flawed subject inevitably implicated in the relational dyad [Levenson] and a co-creator of the patient's transference. The mind, the self emerges from the matrix of social relationships.

Relationships and their 'internalization' are primary motivators [Bowlby] and are the organizers of psychic life. Early experiences are encoded in the brain in such a way as to become the 'default' way of being with others. Until subsequent experiences (including psychoanalytic therapy) over time reconfigure neuronal dendritic branchings, we may reenact either side of earliest complementary ways of being. Infant research [Beebe and Lachmann] gifts us with three salient principles: ongoing affect regulation, timely and consistent repair of ruptures, and shared moments of heightened affect. Schore concludes that attachment is affect regulation. Schore also notes another major paradigm shift: from left brain (interpretation, insight, explicit,) to right brain (emotional, perceptive, procedural) where dissociated self states [Bromberg] are brought to the conversation through their enactment and what was once unformulated [Donnel Stern] and implicit can then be made explicit.

In the therapeutic space of the analytic third [Winnicott, Benjamin, Ogden], greater than the sum of its two participants, spontaneity, play, and co-creativity can take place. Negotiation of differing agendas from each participant foster an intersubjective [Benjamin] way of being together as each member of the dyad contributes her/his respective perspectival reality. Uncertainty, fluidity, and unpredictability are lived as analysts no longer take cover behind dogmatic theories and technique. This fluidity includes contributions from feminism, queer theory, gender studies, linguistics, social constructivism, and Hegelian dialectics as we let go of linear dynamics.

Friday, March 9, 2018

A View from the Other Side of the Couch

A Gift of Cuban Oregano
Psychotherapy is hard. I do not mean that it is hard because a patient must relive painful and often times repressed childhood memories. We all know that this is hard.
No, what I mean is that it is hard being a patient. Fulfilling the role of patient is hard.  Managing the emotional investment required to “co-create” an effective therapeutic relationship is taxing and, frankly, scary.  My role as a patient is to allow myself to form a potentially one-sided emotional bond with a person I don’t even know. I don’t really know who this person is that I am trusting with my most intimate thoughts and deepest fears.   I have to form an intense emotional bond with a person who, when it comes right down to it, is only there because I pay her. I don’t know who she is. I don’t know where she goes after work, I don’t know where she lives, I’ve never been to her house, I’ve never met her husband or kids, I’ve never talked to her outside her office.   And yet I trust her implicitly. I have to. How else is therapy possible unless you don’t throw caution to the wind, close your eyes, and blindly jump? And so I have. But this is emotionally challenging. It is hard. It can be draining.
The challenge is to honor the trust.  It is a challenge because it is a trust that can’t be tested and reaffirmed in ways that trust in other relationships can be.  I can’t call her up to see if she wants to chat. I can’t drop by her house for a visit. I can’t ask her to meet for coffee. I can’t do the things that in a normal relationship would be incremental tests of whether my emotional investment is reciprocated.  I have to trust. And to keep the therapy vital, I have to honor that trust.
This is the odd thing about a therapeutic relationship.  A patient (i.e., me) has to demonstrate his respect and caring and love for his therapist by not doing the things that you would do in any other kind of relationship.  In most relationships care is demonstrated by doing; in a therapeutic relationship it is demonstrated by not doing.  Herein lies the stress.  I am bursting with care and love for my therapist, but I can’t demonstrate it.  At best, I show respect by staying within the confines of the boundaries that therapeutic technique and professional ethics require.  Most demonstrations of caring are therefore somewhat invisible. I show up on time, I don’t cancel appointments, I pay my bill. In short, I demonstrate my caring by being a good patient.
But this is unsatisfying.  In all the great relationships in art and literature, none are based on such mundane demonstrations of affection.  Romeo and Juliet did not sacrifice themselves on the altar of arriving at scheduled appointments on time. Elizabeth Barrett Browning did not count paying bills on time amongst the ways she loved thee.  Pythias did not demonstrate his friendship with Damon by staying away.
Ultimately, patients have the need to offer tangible demonstrations.  Giving gifts is one way of doing this. But what kinds of gifts are appropriate for a therapeutic relationship?  Even deciding this can be stressful. I would like to give my therapist something to show my affection, but I want to show my respect by staying within the boundaries.  It can’t be too expensive or too romantic or too intimate or too anything. So what kind of gift is right for the relationship without it being so trivial it’s meaningless?
I decided on a small plant.
I have been growing a Cuban oregano plant on the window sill in my kitchen for a number of years.   When it grows too big for the little pot it’s growing in, I snip off the overhanging vine and stick the cutting into another pot.  In this way, I have come to have multiple pots crowding my window sill. It occurred to me that maybe one of these plants would be an OK gift.  It seemed appropriate. It was by no means an expensive gift. The little terracotta pot probably cost less than a few dollars, the Cuban oregano was propagated from a plant I already had and which I had an excess of.  From a purely economic perspective it didn’t seem valuable enough that it would create any uncomfortable expectation of reciprocity. It just seemed like a nice little gift. She has other plants in her office and it seemed like it would fit in.  Plus, it had the added benefit of being something that I had cared for and nurtured rather than some cheap gift I bought off the shelf. Whether she would perceive it or not, it had meaning to me.
But because it had meaning for me, I hesitated.  I deliberated on whether it really was appropriate and whether it was honoring the trust, or whether she would in fact see that it had meaning to me and therefore see it as an attempt to push boundaries.  Maybe, I feared, she would see it as an attempt to make the therapeutic relationship into something else. I worried that it would put her in the awkward situation of having to reject my gift and then having to work to put the relationship back on track.  I was worried about the emotional stress she would be forced to endure if this were the case. Consequently, I didn’t give her the Cuban oregano and simply took on the emotional stress of wanting to give it to her, but not doing so. I absorbed the stress and I fretted.
Finally, though, I decided to go ahead take the risk.  I reasoned that we—my therapist and I—have weathered “ruptures” in our therapeutic relationship before and have come out of them with an even stronger therapeutic alliance.  So even if the gift turned out to be inappropriate, it would be something we would discuss together and work through. It would simply be another therapeutic opportunity. In fact, I reasoned, to hold back now would not be honoring the trust.  Thinking about giving the gift was causing me emotional distress and emotional distress is precisely what therapy is all about. At this point, therefore, I was therapeutically obligated to take the gift to her. So I did.
She loved it.  She took it for exactly what it was—a gift of little economic value, but immense symbolic value.  It was a gift that symbolized my wish to express an emotion while simultaneously doing so without violating the boundaries of therapy.  With embarrassing clarity, she told me that she saw it is a part of me that I have left in her care to nurture and grow. I was pleased.
No, I was relieved. In fact, I was so relieved that she did not reject the gift that I failed to understand that she really did like it.  It took a number of days before it sunk in that she actually liked it and I had to wait until our next session to confirm that I had understood correctly.  Then it took a couple of more sessions to understand why I didn’t understand that she liked the gift. In the end, it was a therapeutic opportunity after all.  I gained insight into my anxieties, our therapeutic relationship, and my relationship to that relationship.
I’m not sure this has made being a patient any easier, though. I still want to honor the trust, I still want her to know I care, I still want to stay within the boundaries of a therapeutic relationship, and I still struggle to maintain the balance between these goals.  It can be a difficult emotional balance. I wonder if therapists know how difficult it is to be a patient. I wonder if my therapist knows. I wonder if I should tell her. I wonder if I should let her read this essay. I wonder how she would interpret it. What if she takes it the wrong way?
Psychotherapy is hard.

-Tom Ford

Friday, March 2, 2018

Film: Lady Bird

(spoiler alerts contained within this post)


Greta Gerwig’s (Frances Ha, To Rome with Love) directorial debut is captivating. Stephen Colbert, according to Entertainment magazine, presented Gerwig with the Golden Globe for Best Motion Picture in a comedy or musical, and called it “heartbreaking” and “heart opening.” Autobiographical in nature, it is a realistic coming of age story with painful, though probably not unusual, experiences of finding out your first love is gay, or losing your virginity to a guy who doesn’t really care about you, or discovering the longed for popular crowd is not all that appealing after all. (the


Most painful for me to watch is Ladybird (Saoirse Ronan)’s relationship with her mother (Laurie Metcalf, TV series Roseanne, Nora in A Doll’s House) and to be reminded of the terrible things parents say to their children: “You don’t think of anyone but yourself!” [We see daily in our offices the results of such disregard by parents of their children.] Metcalf plays a psychiatric nurse -- a professional choice which perhaps saved her from becoming “an abusive alcoholic” as her own mother was -- who repeatedly puts Ladybird down, yet she also alters her prom dress, rescues a homeless teen, shares in the joy of her colleagues’ parenthoods, and speaks in a frank manner answering questions about sex. [The contradictory experience of one’s mother and one’s ambivalence must be excruciatingly confusing for a child.]


Illustrating a dilemma common to both therapist and patient (that of accepting the other --or self-- just the way one is, while also holding out hope for a ‘better’ other/ self) Metcalf says, “I just want you to be the very best version of yourself that you can be.” And Ronan retorts, both in defiance and fear, “What if this is the best version?” Others describe Metcalf’s character as “fiercely loving” but I just saw her as mean, though understandable, mean as a result of her worries and frustrations.


Last year, another semi-autobiographical coming of age story, Moonlight, deservedly won the Oscar for Best Picture.  Saoirse Ronan (Brooklyn, Atonement) won Golden Globe for Best Actress in comedy or musical for her performance in Ladybird, playing the truculent teenager. [Ronan is 23 in real life -- so not so distant a past to conjure, whereas Jamie Lee Curtis in Freaky Friday or Tom Hanks in Big had to dig deeper to recall]. There are funny, Catholic school memories such as the admonishment by a nun separating boys and girls on the dance floor: “Six inches for the Holy Spirit,” inadvertently conjuring up the fabled average length of a penis while trying to keep the dancers chaste.

Ladybird’s dad (Tracy Letts), oblivious at the breakfast table, struggles with his own depression after having been laid off, but can be tender, bringing a candled cupcake to awaken Ladybird on her birthday. This film deals with delicate issues, secrets and their consequent shame, be it the stigma of depression in Father Levine or fear of the reactions of others should a gay teen come out of the closet. I recommend this film without reservation, but still think Three Billboards (Post Dec 12, 2017) deserves the Oscar, [with Lady Bird awarded Bronze, losing maybe by seven hundredths of a second].

After leaving the theater, I felt sad that mothers speak to their daughters that way, and also thought, in my professional experience, that -- the one unrealistic portion of the film, IMO-- daughters do not express gratitude so quickly or so easily. My older daughter loved this film -- it speaks to her generation -- and she thinks it should win Best Picture, but, I remember, she also forgave me my shortcomings very quickly.


Monday, February 26, 2018

Film: The Shape of Water

Reportedly inspired by Creature from the Black Lagoon, with the wish that 
this time the monster gets the girl, Guillermo del Toro said The Shape of Water (2017) is "a movie in love with love and in love with cinema... [it is] a musical, a thriller, a comedy." Co-written with Vanessa Taylor and directed by del Toro and nominated for Best Picture it rivals Three 
Billboards for its original screenplay. Not so dark as Pan’s Labyrinth, but a 
fairytale nonetheless, this, like many fairytales, is a heterosex-ual love story, set not in Spain following its Civil War but in Baltimore during the Cold War when the USA was in a space race with Russia. The soundtrack, like the amphibious creature, is magical. It transports you, sometimes deliriously, from scene to scene with a smile.


While a twist on Disney’s Little Mermaid-it is the male creature who lives in the water, and the female is mute- still, it is the woman who must follow the male creature to his world. In this love story, love is about recognition. Elisa-who is mute-(Sally Hawkins) says about the creature (Doug Jones): “When he looks at me he doesn’t know how I am incomplete. He sees me as I am.” del Toro said that "Stories help us heal." This story is also about the magic of love to heal. del Toro said 
"When we admit love exists and is the most powerful force in the universe...it's like water and it has no shape until it takes it.


del Toro and Taylor speak to the sexual harassment of womenin low paying jobs, and of people without a voice, and paint their villain as sadistic. But we know that ordinary men need not be so wholly villainous to want their women silent. The co-writers also give a nod to the homophobia and racism of 1962 but we know that these heinous creatures still exist today. del Toro wants lines that have been drawn in the sand to be erased: "The other has always been us."

If the nominees for Best Picture were Olympic speed racing, this would lose to Three Billboards by only four hundreths of a second.

Wednesday, February 21, 2018

Why attachment theory

Schore writes that affect regulation is attachment, attachment is affect regulation. To create a secure attachment in the treatment relationship requires mutual regulation of affect. Regulation of affect is mostly a right brain to right brain experience, that is, it is done not through words but through a way of being (procedure, perception, affect) with another. It requires a willingness to ‘mark’ in the same affective trajectory, though not match with the same intensity, the emotional experience of the patient. We thus must be emotionally present. It is recommended that therapists be welcoming, accepting, open to the patient’s experience, and emotionally present (authentic).  A secure attachment includes trust, safety, and authenticity. From a secure base, one can explore novel, even scary, experience. Consider, of course, that a secure attachment in one self state may be insecure in a different self state.

It may be useful to know that Ainsworth described, in her Strange Situation research, three attachment patterns (one secure, and two insecure: avoidant and resistant-ambivalent-anxious) detailing the responses of 12 month olds upon being separated from mother with attempts to be comforted by the returning parent and by a stranger. Main described a fourth attachment pattern, another insecure one, called disorganized attachment. Main also devised the Adult Attachment Interview (AAI) which asks the adult to describe her or his relationship with her or his own parental figures. It is the coherence of the narrative, and not the content, which deems a secure attachment in childhood. It turns out that the AAI predicts what type of attachment the infant of that adult will have! Secure attachment on the AAI predicts a secure attachment in the Strange Situation. A dismissive style on the AAI predicts an avoidantly attached infant in the Strange Situation while a preoccupied parent predicts a resistant-ambivalent infant.

More important, perhaps, than knowing attachment styles as per the Strange Situation and the Adult Attachment Interview, is recognizing patterns of how-to-be-with-another. Like any ‘non-conscious’ experience (i.e., procedural, perceptual, emotional experience), right brain phenomena may be better accessed by non-verbal right brain to right brain communications. These right brain interactions are the “something more” that Stern, et al of the Boston Change Process Study Group describe. This means that interpretation and its promised subsequent insight (both left brain, verbal phenomena) may be insufficient, perhaps even unhelpful, in addressing a procedural way of being in relationship.

A note: Here in Florida (Parkland), another mass shooting took place where a 19 year old boy killed seventeen people at Douglas High School and wounded many more. My first thought upon hearing of this tragedy was not about gun safety laws and gun accessibility, though I think about those as well, but wondering about what sort of attachments this boy had had. It seems to me that one must have been somehow dehumanized in childhood in order to be capable of so dehumanizing others enough to kill them. Can dehumanizing and a deadening inside take place from an extremely dismissing, preoccupied, frightened or frightening parent? Now, high school students across Florida, and spreading to other states, are organizing protests against gun violence, reminiscent of the 1960s when college student protested against the Viet Nam War. Both are/were fighting for their lives. While gun accessibility and safety, and mental health all need to be addressed, I was wondering if another important prevention might not be teaching parents (and students from preschool onwards) how to be emotionally present with infants and one another. Perhaps if we could nip in the bud the trauma of chronic misattuenement (relational trauma) children would grow up feeling alive with others and cherishing lives.

Sunday, February 11, 2018

help with formatting?

Dear Readers:

I do not know why the past couple months that the words are cut in middle to start on next line.
My apologies.
If anyone knows how to fix, please let me know.

Apparently, though, the entire (future) post will come to your email if you enter your email address in the requested space at bottom, right hand corner.

Thanking you in advance.
Lycia

PS: to reach me directly and so that I might have your email address you may contact me at tbinstitutepsastudies@gmail.com
that's tbinstitutepsastudies@gmail.com


Smoking cigarettes, eating glass

The local Tampa Bay Psychoanalytic Society was privileged to host the author of Smoking Cigarettes, Eating Glass (2015) Annita Perez Sawyer who read excerpts from her humorous and poignant book about the perils of misdiagnosis and treatment and the iatrogenic harm they cause.
Being read to in her soft, melodious voice transported me back to childhood memories of bedtime stories read aloud by my parents, but in conjunction with the painfully disturbing content it was a disorganizing experience to have disparate elements: voice and words, juxtaposed. Perhaps that was the point, for her memoir tells of her dissociative experiences resulting from childhood trauma. Hospitalized in the 1960s with symptoms of derealization, depersonalization, and suicidal behavior desperate to communicate what was happening at home, and no understanding yet of PTSD as a result of childhood trauma, she was misdiagnosed with schizophrenia-- a diagnosis which, at the time, dictated treatment with ECT (shock treatment). Thus, Sawyer’s memoir makes a plea to clinicians to see, not symptoms or diagnosis, but the individual. Sawyer writes that the admitting psychiatrist during her first hospitalization at the age of seventeen had read aloud her diary to her as evidence of her need to be hospitalized. Her memoir states this intrusive authority had been “defiling what might have been mine but now was his” -- prescient of the much later recognition of her childhood incestuous sexual abuse.

Also welcome in this memoir is more anecdotal evidence of relationship over technique: despite having been hospitalized in the heyday of classical Freudian psychoanalysis, it was not neutrality, abstinence or anonymity, nor interpretation and insight which jump-started her recovery. Instead it was her (eighth) psychiatric resident who had the courage to see her as a person, and to be authentic, spontaneous--he laughed at her puns-- as well as attempt to understood that her disruptive and self destructive behavior was a communication of her history of childhood trauma.

This resident’s supervisor was Harold Searles who -- as Philip Bromberg now so elegantly elaborates -- shared his feelings evoked by Sawyer (the patient) with her. He noted that Annita as a patient was so innocent, so frightened like a fawn and so shy, that he felt like a dirty old man, and that bad feeling about himself had made him want to kill himself, just as the Sawyer herself had also been suicidal. Later, as a clinician, she decided this had been a kind of projective identification. She felt Searles had made contact [with her guilt], and she felt her [heretofore helpless] self able to have an effect on others.

Tuesday, February 6, 2018

Some mutual regulation

The traditional psychoanalytic opinion that insight leads to change has been challenged of late by contemporary writers who think behavioral change precedes insight. It is as if the latter are saying: First one has the procedural, non-conscious (right brain) experience (not a cognitive thought or realization) of a new way to be with an other -- such as trusting someone for a moment or feeling someone is proud of me-- and the subsequent encoding in the brain of this new experience has a calming effect, which in turn allows for blood flow to the left brain where symbolization, explicit thought, (insight) takes place. In writing about the film Three Billboards Outside Ebbing, Missouri, (Post on 12-12-17) I quoted Chief Willoughby opining that love leads to calm and calm, to thought. Felicitously a clinical example from a supervisee presented itself.

A supervisee asked me to help her think about shifting self states in a patient of hers who was often fidgety and affectively dysregulated. What was going on with her patient who one week had been sobbing and angry about a break-up and felt so awful that the patient was going to run out of the room before the session was over, and, in the next session, the patient was calm and even offered an insight about her dating habits? In the first session the therapist had invited her patient to stay with the therapist and sit together in her distress, which the patient was able to do. How did the patient return in a calm state, able to sit with stretches of relative silence?

I was reminded of how affective regulation contributes to a secure attachment and how a secure attachment leads to calm. If Chief Willoughby knows anything, calm leads to insight. While love calms, I also see where calm, in attachment parlance, leads to love. The patient, soothed by the therapist in the first session, returned more securely attached, more able to trust, and to feel love for the therapist, all unspoken. The supervisee said that she had felt love for her patient in that second session. Ah! Mutual regulation. The mother calms the distressed baby and feels competent, useful, meaningful to the baby, and she feels love for her baby, just as the calmed baby feels important to the mother, and they share meaning and joy in their soothed state.

Monday, January 29, 2018

Play and Creativity

Playing and Reality. Ch. 4 Playing: Creative Activity and the Search for the Self


Here Winnicott reminds us of the analytic third, the potential space where play and creativity can emerge. Play is formless, aimless, unorganized nonsense, without sense, not about accomplishment, production, or denial of chaos. Play is about being or, rather, about becoming. Creativity is about becoming the self. Prescient about neuroscientific discoveries and the importance of the right brain over the left, Winnicott writes “...explanation is ineffectual. The person we are trying to help needs a new experience…” so he hangs back from intruding by interpretation.


Winnicott stands squarely in the relational field when he writes “a description of the emotional development of the individual cannot be made entirely in terms of the individual, but ... the behaviour of the environment is part of the individual’s own personal development…” But Winnicott, in his zeal to let his patient “discover” herself and make her own interpretations, seems to forget that meaning is made within a relational context, that we become and come to know who we are through interaction with others. In his example of a session as a case illustration, Winnicott seems to abandon a relational stance when he refrains from sharing himself and his thoughts with his patient for the purpose of allowing her to find herself without interference. 

My enormous appreciation of Winnicott flags only with this clinical example. Winnicott seems to believe the new experience for the patient is his not demanding anything of her, not demanding she comply to his expectations. And while I believe this to be true, it is not sufficient for his patient repeatedly complains, in the context of his silence, that she feels ‘of no consequence’ and has ‘a desperate feeling of not mattering.’ She complains further, ‘I haven’t yet really made contact with you at all today.’  and ‘...was I talking to myself?’ Winnicott behaves as if this is all a consequence of her traumatically unrecognizing childhood and does not seem to locate himself in a re-traumatizing experience. She only becomes enlivened in response to his eventually speaking. I posit that it is not what Winnicott says, but that he speaks, interacts, reflects (mirrors), making a shared meaning. Two things, then, seem to be necessary: both the freedom to become ourselves from within us (Winnicott) and the need to have our becoming selves reflected back by a participatory subjectivity recognizing our own (Hegel).

Wednesday, January 24, 2018

The Analyst's Hate

We see in Winnicott’s 1949 paper on hate a resonance with Bromberg’s contemporary ideas on sharing feelings we have about our patients with our patients. Bromberg writes about dissociation, both normal and pathological, in both patient and analyst and recommends the analyst work hard to bring dissociated feelings to the conversation.
The analyst must be prepared to bear strain without expecting the patient to know anything about what he is doing, perhaps over a long period of time. To do this he must be easily aware of his own fear and hate. ...Eventually, he ought to be able to tell his patient what he has been through on the patient's behalf …
And:
The analyst's hate is ordinarily latent and is easily kept latent. In analysis of psychotics the analyst is under greater strain to keep his hate latent, and he can only do this by being thoroughly aware of it. Now I want to add that in certain stages of certain analyses the analyst's hate is actually sought by the patient, and what is then needed is hate that is objective. If the patient seeks objective or justified hate he must be able to reach it…[for authenticity, to trust his own gut feelings, his own reality]

Winnicott, a pediatrician before becoming a psychoanalyst, was already aware of what more recent infant research has shown, and what Kohut later explicated and emphasized:
There is a vast difference between those patients who have had satisfactory early experiences which can be discovered in the transference, and those whose very early experiences have been so deficient or distorted that the analyst has to be the first in the patient's life to supply certain environmental essentials.

Winnicott was also aware of how psychic equivalence operated (as in Klein’s paranoid-schizoid position)  :
For the neurotic the couch and warmth and comfort can be symbolical of the mother's love; for the psychotic it would be more true to say that these things are the analyst's physical expression of love. The couch is the analyst's lap or womb, and the warmth is the live warmth of the analyst's body.

[Note that when, in this paper, Winnicott uses the term ‘psychotic’ he refers to Borderline personality structure; Also note that objectivity is no longer considered desirable -- even were it possible, but Winnicott may be indicating that the analyst stay in or, rather, eventually recover an analytic attitude that keeps the patient’s needs primary.]

Winnicott, D.W. (1949). Hate in the Counter-Transference. Int. J. Psycho-Anal., 30:69-74.

Wednesday, January 17, 2018

Klein’s Contributions: Paranoid-Schizoid and Depressive Positions

Klein posited that the paranoid-schizoid position develops first in infancy and operates when one is unable to hold in tension contradictory (unintegrated) parts of a whole but instead has to split (hence, schiz) good and bad parts from one another in order to protect the good object from destruction by hostile feelings directed at the bad parts of the object. Along with splitting, projective identification, and idealization operate in this position. When the infant projects bad parts of itself into the object, the object becomes -- in (ph)fantasy [as well as in reality should the projection resonate in the therapist and cause the therapist to, for example, make sadistic interpretations] --  persecutory (hence, paranoia). Thinking here is psychic equivalence where the thought = the thing, the thought is believed to be real and to exist also externally, as when believing that thinking or speaking makes it so. Moreover, in this position there is no mentalization, and the infant or patient believes everyone thinks as he does. When our patients experience us (or themselves) as all bad or all good they have temporarily dissociated the others parts of us (or themselves) that make up our whole selves.

With further development, the infant is able to integrate disparate aspects of the object into a whole (allowing now for ambivalence). The bad parts of the object, once railed against, are now recognized as belonging to the same object who is beloved, good, and on whom the infant depends. The infant feels remorse for its ‘attacks’ on this whole object and feels a capacity for concern (Winnicott). No longer operating at this position with projective identification, the fantasized omnipotent control of the object is lost. The infant feels guilt for its previous attacks, and recognizes its separateness from the object (a nascent intersubjectivity as mentalization begins to develop), with the loss of control over object, and guilt, leading to depressive feelings.

Klein preferred ‘position’ to ‘stage’ because she recognized that either could appear as defensively needed and was not usurped by a subsequent developmental achievement. Her concept of ‘positions’ dovetails nicely with the contemporary idea of multiple self states, for any can move into the foreground or background at any time, that is, it is not in a linear developmental sequence where one position (or experience or self state) is left behind once another is achieved, but rather all are encoded in the brain and can be triggered to ‘appear’ under the right circumstance.

I am uncertain if Klein explains the development from paranoid-schizoid to depressive position. Was it a natural consequence of maturity? Winnicott explains this development via the mother’s survival.  Of clinical use might be the question: just how do therapists allow in the depressive position when the patient is operating from the paranoid-schizoid position? When a child says to the mother “I hate you!,” the good enough mother might say “I see that you are so angry at this moment that you hate me but I also remember that there are others times that you also love me.”  [Were the mother to say “Don’t say that!” or “You don’t mean that/feel that way!,” the child may learn that all her feelings are not welcome and she must relegate certain feelings to the ‘not-me’ experience, and that she might not even be able to trust her own feelings.] Were a patient to see us only as part object, as when a patient of mine called me a ‘c--t,’ how do we remember that the patient also, in other moments, values our contributions to the work? [It may be true that I am a ‘c--t’ but that is not the entirety of who I am]. Such an attack on the therapist requires us to recover our own experience of the other as a whole object.  

Wednesday, January 10, 2018

Klein's Contributions: Projective Identification

In the TBIPS course, Intro to Psychoanalytic Concepts I, we have come -- after months of discussing an analytic attitude and ways to be in the clinical situation -- to the historical contributions of major psychoanalytic theorists. For a few weeks we discussed Freud and Ego Psychology and today began looking at Object Relations, especially Klein’s projective identification and the paranoid-schizoid and depressive positions. One informative paper is Spillius’ 1992 Clinical Experience of Projective Identification.

Spillius describes Klein’s idea that in projective identification the patient extrudes parts or characteristics of the self and, in phantasy, places them in the other, and -- beyond simple projection -- operates as if these extruded parts are under the control of the self. Bion elaborates Klein by noting the communicative part: that through projective identification the analyst has the opportunity to feel what the patient feels or to feel what the patient wants the analyst to feel. Joseph adds that through projective identification the analyst is ‘nudged’ to behave the way the patient expects. One candidate contributed Ogden’s elaboration that the analyst owns the projection. [The class aptly noted that, while relational is on its horizon, the Spillius paper has not quite made it to intersubjectivity, for it does not much describe the analyst’s contribution to triggering the patient’s use of projective identification.]

The candidates posed to one another fascinating questions regarding the analyst’s struggles to determine what or how much comes from the patient and what or how much from the analyst:  Doesn’t the projection have to resonate somewhere within the analyst? What if the projection is ego dystonic? Many analysts are trained to see the projection as an entirely intrapsychic phenomenon rather than struggling to accept it as intersubjective in some way. Can ‘wearing the attributions’ ascribed by the patient sometimes be defensive on the analyst’s part, as when the analyst wants to avoid confrontation or wants to show superiority by being able to accept the attribution? One pointed resonance is when the projection, which narrows the analyst’s experience by requiring the analyst to behave in a certain way as to meet the patient’s expectations, triggers childhood experience of parental expectations which restricted the child’s burgeoning self. It was also noted how ‘blind spots’ likewise can narrow the experience of the analyst by, for example, attenuating the ability to self reflect.

One very fascinating part of the discussion was a clinical example provided by a candidate: A patient continually praised the therapy and its gains yet the analyst kept thinking the patient was about to leave treatment. This idea greatly narrowed the analyst for she could think of nothing else when with the patient. Because the candidate-analyst was going through a difficult period of being very tired and feeling insecure, as well, about her abilities, and because she worried her difficulties would also chase off other patients, she considered that her idea this patient was about to leave her was all her fault! That is, that the idea came solely from herself. With supervision, and with her own capacity to struggle with the question ‘what comes from whom?’, the analyst overcame her immobilization and her fears of embarrassment should the patient say ‘That is your problem, not mine!’ (or fears the patient would feel misattunement) and shared with her patient that she had the thought he would leave despite all his accolades about therapy.  She put herself in the position to own something very shameful should it not also belong to the patient. As it turned out, as one might expect, it enlarged the opportunity to see how both had co-created what was happening between them [Bromberg notes that the analyst’s feelings about the patient are not the sole property of the analyst]. The analyst did not say to the patient ‘This is yours!’ nor could she allow that ‘This is solely mine’ and from the struggle, instead, negotiated with the patient, ‘what comes from whom.’