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.

PS: to reach me directly and so that I might have your email address you may contact me at

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 …
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.’