A Contemporary Look at Conflict

I am always delighted when I read how contemporary relational thinkers reconfigure century old tenets in psychoanalysis. Adrienne Harris does just that with conflict in her 2005 paper Conflict in Relational Treatments (PsaQ 74:267-293). Though finding her paper somewhat confounding, the TBIPS Relational Study Group delightedly discussed the elaborations of conflicts in human experience which Harris considers. She elaborates on conflicts between the needs of self and others (interpersonal conflicts), between two unconsciouses (intersubjective conflicts), and conflicts between self states, in addition to the traditionally understood conflicts between wishes and between wishes and their prohibitions. Along with conflicts between ego-id-superego, additional intrapsychic conflicts exist between the multiple selves of one person and the multiple unconsciouses found within these multiple selves. Disavowed or dissociated parts of self may then never come into the treatment with the selves states of a particular analyst. Conflicts for the analyst, too, include the conflict between sticking to the rules of training and being spontaneous; the conflict of desiring the imposition on the patient of the normative and the hope for the patient to have freedom from these constraints. Speech, too, provides for conflict, for example, between what is said and how it is said, between content and tone/prosody, or content and intention. For both participants there is the pull between the wish to change and the wish to stay the same. There are the interpersonal and intersubjective conflicts between analyst’s and analysand’s agendas, both overt and covert, and also those between the unconscious(es) of the analysand and the analyst. Consider then the multiplicity of the analyst’s selves and those of the analysand in their innumerable combinations! I often think that the analyst must juggle a huge number of balls in the air-- while walking a tightrope. Harris made me consider adding to that number.

The Limits of Desire

In the Development course of First Year at the Tampa Bay Institute for Psychoanalytic Studies, the paper Aggression and Sexuality in Relation to Toddler Attachment: Implications for the Caregiving System by Alicia F. Lieberman (1996, Infant Mental Health Journal, 17(3) 276-292) was recently discussed. I recommend this paper for its elegant vignettes which readily illustrate how parents might enhance a child’s sense of self and self worth by their responses to a toddler’s aggressive or sexual strivings. But it is its applicability to the psychoanalytic situation that cause me to quote from what Lieberman describes as the outcome of well or poorly handled responses.

She writes that when negative feelings are generated in the attachment relationship around sexuality or aggression, there occurs

a constriction in the areas of experience where the child can rely
trustingly on the attachment figure’s emotional availability …
Attachment loses some of its richness and range because certain
domains of experience must be kept secret from the parent for the sake of not risking rebuke and disapproval.

And its corollary:

When aggression and sexuality are appropriately accepted, modulated, and socialized by the attachment figures, in contrast, there is an expansion in the range of affect that becomes permissible to experience and to share. Toddlers acquire a visceral [procedural] sense of pleasure in who they are and how they are made when their parents cherish and celebrate their body and its accomplishments…when appropriate limits are being set that allow the child to learn what is permissible and what is not in a clear and nonpunitive manner.

Certainly, the analyst hopes to invite in to the consulting room the broadest range of affective experience and to eschew rebuke and disapproval for what a patient brings. We want our patients to cherish and celebrate a broad range of self experience. Likewise in the psychoanalytic situation it is incumbent upon the therapist to remain emotionally available to analysands even when they bring potentially unwelcome strivings, to remain emotionally available by empathizing with and remaining sensitive to the patient’s strivings, keeping open the elaboration of wishes and desires without unduly frightening a patient and without foreclosing the transitional space for play by reifying or concretizing patient’s wishes through action. Keeping the elaboration of desire alive while holding sensitively to the limits of its permissibility is a very difficult balance, reminding me of what a medical school, surgery mentor used to say when things got unpredictable and potentially dangerous on the operating table, “We’re in tiger country now.”

Deconstructing what we read

Nothing pleases an instructor more than when students learn to read and think critically. How pleased was I then when the first year class at TBIPS was able to take the clinical vignette from an assigned journal article, deconstruct the reported interaction, and come up with additional points of view.

In the assigned artice, the author began with some background: a young woman of a withdrawn, depressed mother and a hostile, accusatory father was described as being opaque to others, unable to be vulnerable and emotionally intimate with others, operating from a paranoid-schizoid position, distrustful of men, found it difficult to bond with women, and experienced interpretations as intrusive and insulting. The analyst complained that his attempts at empathy were rebuffed.

Then followed from the author/analyst a brief portion of process notes:

The patient was indignant about a male colleague who had made advances; the male analyst responded by giving an explanation for the colleague’s behavior. [The class easily recognized the analyst as defending the other’s, not the patient’s, point of view, in essence an attack on the patient’s reality. ] The patient responds derisively, accusing the male analyst of being like all those other men who think they can say or do anything with women.

The patient continues, talking about being professionally excluded by an Old Boys’ Club at work. The analyst, attempting empathy, lands on interpreting her feeling alone, without female colleagues. The patient says she thinks the analyst really think she is a bitch and she accuses her analyst of phony empathy. [The analyst does not consider here his own contribution to his patient’s rebuff, that perhaps the patient perceives accurately what is in her analyst’s heart. The analyst, after all, had only moments before attacked her point of view.]

The patient then complains about her very bad day and asks her analyst if he has ever had such a day. The analyst asks for her thoughts. [Here the analyst is the opaque one, being with his patient exactly what he, in his description of her, accused her of being, and he is likewise being unknown to her, just as her depressed mother had been. Is this an enactment?, the class asks.] The patient then insults the analyst, accusing him of being uncaring and, as a man, without compassion.

Vignettes from the literature and from our own clinical experiences are often used in classes to improve our skills. And where the medium is the message, we deconstruct who we are alongside what we say and think, leaning in the direction of hope, empathic attunement, and opening the third space. Next time I will post on how the Intro. class used Winnicott.

Shaddock Shares Systems Theory Approach to Couples

The Tampa Bay Institute for Psychoanalytic Studies, Inc (TBIPS) was delighted to have as guest lecturer on October 19, 2011 David Shaddock, author of Contexts and Connections: an interubjective systems approach to couples therapy, apply systems theory to his work with couples. Intersubjective Systems theory recognizes that people are inherently connected. Moment to moment an individual’s psychological life is embedded in relational context. One advantage of a Systems approach is that everything is inherently contextual, everything potentially important. Likewise, the therapist does not have to be the one who knows (everything), as the goal instead is to bring about a shift in the dynamic system. The therapist asks herself in the moment ‘What triggered this shift?’

Shaddock says that a Systems approach, with its tenet that the whole is more than the sum of its parts, is optimistic, for systems can rearrange unpredictably after perturbation. Phase shifts are always possible. Perturb the system and the chance that it will reorganize itself in a new way becomes possible. Systems theory recognizes that the self is organized and reorganized spontaneously, not predictably predetermined. The therapist ‘catches’ these phase shifts. The couples therapist can, by making explicit a shift in the system, empower a couple with the experience that it does not take much to induce change. For example, when an angry couple suddenly softens because of something implicit, Shaddock will, to bring it under conscious control of the couple, point out the shift (e.g. ‘What just happened here? Your face just softened with concern and then your wife became calmer.’)

The therapist may view the couple through the frames of the repetitive selfobject dimension (ala Stolorow ), and the self/interactive regulation of affect dimension (ala infant research). In the former, one member of the couple may, in the therapy situation, have her/his worst fears confirmed. Couples therapist Carla Leone will watch the faces of each member of the couple to discern any hint of this retraumatization. The therapist can then intervene to shift from the repetitive pole to the more hopeful, regulatory one.

Recognizing two important ways to organize the world: defensively, and engaged toward relatedness, the therapist focuses on ‘toward relatedness.’ Couples therapists want both members of the couple to feel understood. (This decreases defensiveness, engenders hope, and increases the chance that each feels safer to state which needs each would like met.) A history, taken in front of the other partner, helps both the therapist to elucidate for herself a partner’s repetitive pole, and invites a new relational dynamic between the couple (by allowing the other partner to witness that it is historical factors, not the witnessing partner, which trigger fearful responses) and this may lead to a reparation of empathy.

In the affect regulatory dimension, each partner sometimes needs attunement from the other (interactive regulation) and sometimes needs time apart or alone for self regulation. Problems arise when there is a mismatch between how much a partner prefers one type of regulation. Because how we regulate and organize ourselves becomes who we are, the mismatch can suddenly shift to a ‘do or die’ level when denial of a preference threatens the self and feels like annihilation. Shaddock will make the shift explicit (e.g. Five seconds ago you were just talking about who does the dishes and now we are talking about divorce. How do we understand such a shift?).

Shaddock’s presentation was so illuminating that we look eagerly forward to his return to TBIPS in January 2012 to lecture again in our Couples Treatment course.

Self and Relational Psychologies Face-off

Soon after Labor Day each year, The Tampa Bay Institute for Psychoanalytic Studies, Inc (T-BIPS) recommences its two (Self and Relational) Study Groups. On Friday, September 16, the TBIPS Self Psychology Study Group read the 2005 paper by Israeli analyst David G. Kitron The Unacknowledged Knowledge and the Need for a Sanity-Confirming Selfobject. It made for a lively discussion about whether or not an analyst could actually “temporarily” or “partially” “suspend his or her own subjective experience.” Self psychologists and the Stolorow et al Intersubjectivists tend to intimate that we can. Relational Intersubjectivists claim this is not possible.

No doubt that our profession aims at being helpful to our patients, which means being toward a focus, even with our own subjective experience, on the patient’s experience. Kitron aptly commends Ghent’s (1990) surrender over submission. He also reminds us that survivors of childhood trauma have had their reality-testing attacked, what he calls a failure of a sanity confirming self object. I applaud when he writes, “It is the therapist’s duty…to search for any mistake he might have made.” Not to do so would attack again the patient’s reality-testing (gas lighting) and re-traumatize. The analyst’s mistake, if denied by the analyst, becomes part of the “unacknowledged knowledge.”

Where Kitron and Relational thinkers may diverge is when does the therapist deem that “a side-by-side coexistence of two subjectivities is gradually made possible.” Kitron says “the therapist has to ‘step aside’ and suspend his subjectivity temporarily” until the patient has developed the capacity for intersubjectivity [mentalization, Fonagy would contend, is a component of this capacity]. I tend from the very beginning to lean toward the “hold in tension” philosophy. What I mean is that I do not want to obfuscate the part of the patient that is inevitably aware of my subjectivity [as even psychotic patients are] even while, because the patient has had the repeated experience of attack on her/his reality testing, the patient finds any other’s subjectivity unwelcome, even noxious or traumatic. To “suspend” my subjectivity might then be a mere reversal of where one “dominates and paralyzes the other.” I try, then, to hold my subjectivity in tension with the need of the patient to have her/his subjectivity exalted.

The Monkey and the Fish

As the Tampa Bay Institute for Psychoanalytic Studies, Inc, a contemporary training program, gears up for classes to begin September 21, 2011, I often muse about how to convey to candidates and students an open attitude toward patients, an attitude which often includes ‘letting go’ of the bastion of [pejorative, accusatory] interpretation in its attempt to rid patients of “defenses” as if we are the authority on what is best for a patient.

My colleague, Horacio Arias, and I have, more than once, discussed the idea, captured beautifully in his pithy statement ‘there is no such thing as pathology,’ that patients have established their ways of being in the world (whether nuanced and called symptoms, defenses, transference, organizing principles, RIGS, relational paradigms, etc) for very good reason, and, as such, we therapists best be respectful of the necessary purposes these serve to maintain the psyche’s functioning, however precarious or constraining that functioning may be (or seem to us). Rushing in to interpret may not be at all fortuitous, and may create a less safe –and inadvertently humiliating-- psychoanalytic space, or even result in bringing down a house of cards.

To bulwark my patience, I remind myself of a little story told on Mt. Gorongosa in central Mozambique about white colonists and modern philanthropists who thought they knew what is best for the local African people. It is the story of The Monkey and the Fish and it goes like this:

A monkey was walking beside a river one day and notices a fish in the water. The monkey thinks to itself, “Oh, no! That poor animal will drown! I must do something.” The monkey scoops up the fish and the fish begins flailing in the monkey’s hands. The monkey says to itself, “Look how happy I have made it. It leaps for joy.” The fish dies, and the monkey thinks, “If only I had gotten here sooner, I might have saved its life.”

I try to remember to not be the monkey in this story when I am tempted to think I know what is best for my patients to do, like when I think they should give up drug use, leave a battering spouse, or stop being so stubborn.

Finding our analytic way

As TBIPS concludes its academic year, candidates continue to grapple with what are the therapeutic aims of treatment and what brings about change. This grappling is a never ending negotiation between therapist and patient, and therapist with her/his own professional identity.

Sandy Shapiro [see Sept 12, 2010 post]said that patients will let us know what they need. Sometimes people come with unspoken but profoundly human motivations communicated in the action of relationship. Therapists, relying both on the unique patient’s needs, and a background of understanding of human needs in general, are able to provide experiences which have been heretofore lacking [deficit model] for the patient. E.g., if a patient grew up discounted and ignored, the analytic situation offers an opportunity for a different experience and a reconfiguring of the way a patient sees her/himself in the world.

The biological striving to pass on genetic material for the survival of the species is accompanied by many postulated psychological motivations. Freud’s theory of motivation postulated the discharge of the accumulated energy from instinctual drives. Winnicott saw creativity and play as essential aspects of the true self. Kohut advocated the development and maintenance of a cohesive self. Bach saw as important the integration of a “sense of wholeness and aliveness” which included developing one’s own awareness and subjectivity, as well as learning to see oneself as one among many, with a place in the world. Maroda notes that people, to develop a full interpersonal repertoire as both subject and object, need to have their affective communications responded to, held, and returned in modified form [ala Bion]. Spezzano writes that human beings are motivated to share their conscious selves, regardless of other unconscious motivations, and that we can only know ourselves in light of how others know us.

If people require a sense of agency, including capacity for self and mutual regulation of affective states, and a sense of the subjective self in the context of relatedness and recognition by (and identification with) others as subjects in their own right, then isn’t it helpful to patients for therapists to include in their analytic attitudes the capacity to sometimes regulate dysregulated affect, the articulation of being affected by the subject of the patient, as well as the capacity to play, and an open-hearted acceptance of a patient as s/he is now while also holding in mind the future, changed patient? If a patient was made to feel helpless and hopeless about affecting others, the analytic relationship is a place where the analyst, when moved, does not necessarily keep a blank face or remain silent. If a patient endured trauma in isolation, s/he now has a companion who knows her/his suffering. Each candidate strives to hone her/his personal identity and style while trying to meet each patient’s unique needs. It is a formidable task, and a joyful one.

Projective Identification

Recently, at TBIPS’ Relational Study Group, a paper we were discussing brought up projective identification, a concept that has baffled clinicians for decades. I would like to share my thoughts on projective identification. When Melanie Klein coined the term, it was to describe an intrapsychic phenomenon: how the unwanted parts of the self (often aggression or helplessness) were projected into the other, and were then seen as under the control of the self, and, consequently, so too was the other seen as under the control of the self. Note that s/he who did the projecting was also doing the identifying with the unwanted part.

Projective identification became redefined as a phenomenon between two people: what was projected by the self was identified with by the other such that the other began to behave commensurate with the projection. E.g. a patient projects sadistic impulses into the therapist and the therapist inadvertently becomes sadistic, or feels sadistic. The self could behave in such a way as to make the other feel what it felt like to be the one doing the projecting. Projective identification, then, began to include the countertransferential use of the projection giving the therapist information about the patient’s experience.

Even when projective identification is seen as emanating from the paranoid position, it nonetheless is an attempt to communicate how one is feeling, as well as a wish to be understood. Because patients are sometimes bereft that the therapist will ever know what it feels like for the patient to experience such rage or helplessness or envy or despair, they are nonetheless sometimes fortunate enough to utilize projective identification to help move the therapist’s understanding along. Otherwise, patients might feel untenably isolated and unconnected to us. Despite how uncomfortable (causing the therapist to disparage the defense and pathologize the projecting patient) it may be to be in the throws of the experience, if not bound by the projection, the therapist might sometimes have the wherewithal to inquire whether the patient has somehow managed to come upon a way to aid the therapist to better know what the patient’s experience felt like by inadvertently helping the therapist to feel that way too.

Since its original definition was conceived within a one-person psychology, contemporary Relational theorists, if they use the term at all, have further redefined projective identification. Relational theory questions the unidirectionality of projective identification. It does not conceive the projection to originate entirely from the patient’s psyche but instead recognizes how unlikely the therapist would be to ‘identify’ with a ‘projection’ were it not to resonate with something already within the experience of the therapist. The therapist, too, contributes to what is projected in addition to resonating with the projection.

I like to say that it is one thing to wear the attributions of a patient and explore what, for both the patient and oneself, it would be like to do so, but it is something else to be what the patient attributes to us. I suggest to less experienced colleagues that we be brave about discussing patients’ (e.g. aggressive) feelings toward us. When patients have ‘split’ us into the bad or hateful object, it sometimes helps restore personal equanimity to consider how and why it became necessary for the patient to operate, at this moment, from the paranoid position. Harder is to consider how we might have inadvertently contributed to this shift.

Frame

In the Fall of 2011 TBIPS will offer to both first year and third year classes a practical course on helping the analyst negotiate with patients the analytic frame. We will ask what distinguishes psychoanalysis and psychoanalytic psychotherapy from what a good friend or a loving family member can provide. What makes psychoanalysis and psychoanalytically oriented psychotherapy so special a relationship? Does the psychoanalytic attitude [see Jan 3, 2011 post] really allow the patient a freedom of self unlike any other relationship? Can the relationship really allow for the safe exploration of automatic ways of being with another in the world?

Analyst and patient together negotiate the frame or rules on which the two will come to rely. The analyst is punctual [lest the patient unnecessarily be made to feel like ‘chopped liver’] and alert [lest the patient unnecessarily be made to feel unable to garner the attention of important others], ready to be interested and self-reflective. And when the analyst is not punctual or interested and alert, the analyst must open her/his failings to the patient for exploration. The frame will describe when and how often the sessions will occur, the analyst’s availability between sessions, the fees, times, etc. including how many weeks or months the analyst is out of the office (conferences, vacation, etc). The frame includes the psychoanalytic attitude with its asymmetrical focus on what is in the best interest of the patient and with the safety of the patient’s psyche foremost. Safety is fostered when analysts do not judge, when we do not question with implicit incredulity or veiled contempt [both which can inadvertently humiliate a patient]; when we are attentive to changes in the patient’s (and our) self states, tone or prosody of speech, autonomic responses, or other indications that we may need to ‘slow down’.

Safety is also facilitated by our reliability, punctuality, earnestness in the experience, by our listening, processing, and considering what we have seen, heard, felt, and experienced. Maintaining the frame will, at times, help communicate safety. At other times, the frame must be flexible enough to allow for negotiation, and for enactments [sometimes patients seek to break the frame, not as resistance but as an attempt to reach us]. Because psychoanalysis (or psychoanalytic psychotherapy) is a dialogue within a frame, and with a reciprocity of sorts, and because it includes the multiple unconsciouses of both participants, both patient and analyst will emerge changed in some way.

More about Listening

How we organize what we hear and observe is influenced by our own subjectivity, our experiences, and our theories. Because no theory holds the ‘truth,’ we must hold our theories lightly, recognizing that each person’s reality is perspectival, and recognizing that the meaning of the material need not be fit into the procrustean bed of a theory. As I listen and muse on what is going on in the therapeutic dyad, I often think I am like a juggler, with many plates in the air at once. I must simultaneously consider whether or not I hear at this moment a familiar sigh or theme from the patient; whether or not the present narrative or relational paradigm harkens back to the patient’s childhood events; what, if any, are the transference counter-transference implications; what happened in this past moment or last session or over the months or years of analysis that contributed to this coming up or happening now; and so on; all the while being open to the unknown and to surprise in a free floating reverie with evenly hovering attention!

Listening is dialectical (you can never stand in the same river twice), which means patient and therapist influence each other and neither is ever the same again. Listening is intersubjective, containing within it both the listening and the being listened to. Listening allows space for creativity (Winnicott) and for the, as yet, unformulated and unspoken. It is a gift we give our patients, interested in every word and gesture. It is a gift our patients give us, along with the privilege of their trust. When we listen, we do not seek to confront or contradict the patient, though we may sparingly ask for clarification. Many people have never experienced such genuine attentiveness from another.

As communication is both explicit (with words and common gestures) and implicit (perhaps what Freud referred to as unconscious to unconscious communication) we must listen as well with our perceptions and unconscious perceptions. We attend to the texture of feeling and gestural communication and not just to words or content or to conscious understanding and insight. We become comfortable, not impatient, with silences when the patient may need to be with some caring other without the pressure to produce or perform. Each therapist will have a unique interest in this or that part of a story, evoking a resonance with something in the therapist’s personal history. Each therapist must find her/his own way of expressing, in a way contributory towards patient growth, what has meaningfully affected us.

'Listening'

Living an examined life (Socrates) requires a penchant for a balancing act. In the treatment process, there is always the need to balance orders of experience: the intrapsychic with the interpersonal; the analyst’s subjectivity and experience with the patient’s; the past, present and future; moving toward or away from a closer approximation of the ‘truth’; and so on. Tension needs to be held between dichotomies with an attitude of not ‘either-or’ but ‘both’. While psychoanalysis has traditionally long privileged left brain (explicit, verbal), growing evidence seats the unconscious in the right brain which is emotional-affective, bodily based, relational, and implicit. So another balancing act includes ‘listening’ not only to patients’ words, but to implicit communication.

Right brain information processing is so rapid as to be is non-conscious. It is ultra-rapidly integrative of emotion, affect, facial expression, auditory prosodic, gestural, and other relational data. The right brain is the seat of implicit memory, but interfaces with the left hemisphere, where explicit, verbal communication originates. The brain develops in a way such that self and mutual regulation go on at the non-conscious, implicit level. Schore states that 60% of communication is non-verbal (facial expression, gesture, tone, prosody, pitch, inflection, etc) and recommends that analysis consider affect-laden experience, even dissociated affects. This requires not only understanding language, but understanding implicit process as well.

Freud advocated for the fullest possible acquaintance with the unconscious mind through free association, which presupposes psychic determinism and contiguity, by the patient, and through careful and trained listening by the therapist. Attentive listening is paradoxically balanced with evenly hovering attention and reverie (Ogden), a listening with the third ear. During the evaluative process we let the patient talk freely without too much interruption or direction, but probably ask lots of questions at that time. Subsequent sessions can afford the patient a more direct role in the process while the therapist listens for not merely content but for shifts in the content and affect of the patient; waxing and waning attunement on our own part; shifts in the patient’s and our own self states; initial comments of the hour; developmental issues; character style; relational patterns; transference references; fantasies; etc. Standing in the spaces between so many avenues of inquiry and interest can seem daunting, or meditative, depending on our comfort with uncertainty.

The Person of the Patient

Patients come to us for many reasons, often associated with symptoms such as anger problems, loneliness, insomnia, lack of interest in sex, depressed or anxious mood, repetition of unpleasant situations, or general unhappiness. Some come hopeful, some without hope. Some are motivated to decrease psychological suffering; some seek increased self awareness. Some are coerced by others to show up; some are desperate for any relief we might offer. Some may ask for advice, yet might benefit more from figuring out what has prevented them from taking advice they have already heard. It is the therapist’s job to ‘feel’ our way into their moccasins. By doing so, and by listening openly, if nothing else we decrease their isolation by sharing in their experience. To this we might add engendering hope.

When patients seem to us to ‘fail’ to make an effort, to change, to accept responsibility, or to let us ‘fix' them, we may feel angry, helpless, incompetent. There will be things about patients that will challenge our capacity to engage them whole-heartedly. They may smell, be combative and oppositional, or they may be supercilious and insulting. They may scare us or make us feel incompetent or helpless with their self injurious behavior or their threats, or with their too slow progress. They may whine or chronically come late or not show up at all. They may be too clingy, call us too frequently between sessions, or behave as if what we say and do has no effect at all on them. They may delay or withhold payment. We do neither patients nor ourselves any favor by pretending that patients don’t get under our skin.

It is also the job of the therapist to collaborate with patients to understand the perfect sense that their constraining, obnoxious, or even harmful behaviors make in light of their histories. These behaviors were the best possible solution at the time, usually in childhood, of their inception. A child is without experience, perspective, cognitive maturity, or, sometimes, without any aid or advocate. And because these behaviors may hold a fragile self together, patients and their behaviors are to be respected, and to be changed only with great caution.

Review of "Gaslighting, the Double Whammy, Interrogation, and other Methods of Covert Control in Psychotherapy and Analysis" by Theo Dorpat (1996).

As a layperson I found Gaslighting... by Theo L. Dorpat a true gift. Through it I learned that the psychoanalytic process could be a useful and trustworthy tool in the treatment of mental illness. Before I read Gaslighting..., I harbored a great distrust for psychoanalysis and psychotherapy in general. Gaslighting... taught me it is not these great institutions that matter, but the individual persons who populate them and their kindness*.

It is hard to get across the impact this book has had without quoting it extensively, which I shall do. It has a very high signal-to-noise ratio. By that I mean it is jam packed with facts and truths, and I would recommend it for that alone.

Gaslighting... is a book about "covert methods of interpersonal control" both inside and outside of the therapeutic framework. It's not just about covert abuse in psychoanalysis but the role of covert abuse in the genesis of mental illness. This dual framework is what makes the book so amazing. Hopefully the first three sentences will peak the readers interest:

It has been said that fish don't know they swim in water until they are out of the water. Similarly, most people do not know about the subtle and covert types of interpersonal control, domination, and abuse they are exposed to all of their lives in their families, at their schools, or in their workplace. Not until they have experienced relationships that are more caring, respectful, and nonmanipulative are they able to recognize how much they have been covertly manipulated, controlled, and abused by others. (1)

Aptly covered is the concept of "projective identification", Dorpat's definition:

In projective identification, the subject first unconsciously projects unwanted aspects of themselves onto another person and pressures the object to contain, as it were, the subject's disavowed affects and contents. (6)

This is a primary form of gaslighting, which I assert, is unfortunately used quite commonly on children unwittingly by their parents becoming the source of many, in Dorpat's words, "pathogenic beliefs" often seen by clinicians.

Dorpat covers many covert methods of interpersonal control in the therapeutic situation including the aforementioned projective identification, a form of gaslighting which "...is an attempt to impair or destroy an individual's confidence in his or her psychic abilities". (7) Also covered are questioning, "defense interpretation", confrontations, interrupting or overlapping communication, and abrupt change of topic all which can lead to a "fragmenting [of] the patient's experience" (11).

I want to emphasize that although this book emphasizes the therapeutic framework, it also recognizes the covert methods that are endemic in society.

Dorpat wastes no time with a brief, simple but scathing critique of behavioral therapy and it's use of rewards and punishment, noting that "Humans have used rewards and punishment as effective means of training and attaining social control over others... for millions of years" (22), concluding that behavioral therapy is merely a means of getting patients to "act normal"(23). [In the interest of revealing my own bias, I would add that CBT is even more insidious with the "C" merely a proxy for brainwashing.]

Dorpat includes numerous, rich case studies to explore the dynamics of psychoanalysis. By studying where psychoanalysis goes wrong he manages to show its immense worth by saving the baby from the bathwater. He discusses a patient's reaction to attacks on the patient's judgements and perceptions noting the patient's "self-esteem fell as his confidence in his reality-testing and mental functions was markedly lowered." (36)

Dorpat skillfully portrays the use of questioning (quite simply, asking questions) as a method of control. In a vignette he reaches a beautiful conclusion of what a patient tries to communicate about the author's use of questioning: "Don't worry about not immediately knowing something about me. Your questions are pushing me away!" (54) Dorpat takes a very hard line on questioning, stating that it is only useful "in situations where the therapist is uncertain about the meaning of something said by the patient...". (71)

Gaslighting... shows some ways psychoanalysis can be counter-productive and the meat of this book illustrates in great detail, through vignettes, the disastrous results of covert interpersonal control in therapy. I fast-forward to the beautiful conclusions of this book. Extensively paraphrasing Wiess et al. (1986) Dorpat agrees:

Psychopathology stems from unconscious pathogenic beliefs of dangers if the patient were to pursue certain important goals. Unconscious pathogenic beliefs are irrational and they involve feelings of guilt, shame and anxiety. These are mainly formed in childhood out of traumatic relationships with parents and others... Patients are powerfully motivated to disconfirm these beliefs because they are maladaptive and grim, and they produce much mental pain. (238)

This is pure gold. Other conclusions are: to avoid the use of stereotyped psychoanalytic approaches (226); to recognize the importance of the nature of the analyst's interaction with the patient (231); and the importance of evaluating patient's responses to interventions by the analyst (247).

Much of my admiration for this book is due to the fact that it is very extensively sourced (a quality with which it shares in common the Pulitzer Prize winning "Denial of Death", Becker (1972)), drawing on works from A-Z including Hienz Kohut, Robert Langs, Joe Weiss, DW Winnicott, Eric Fromm, Bob Stolorow, and more than 100 others.


Gaslighting... is a great starting point for anyone interested in covert abuse, mental illness, psychoanalysis, and how power is unconsciously communicated in American society. I'll end with the books cogent epigraph:

For those who stubbornly seek freedom, there can be no more urgent task than to come to understand the mechanisms and practices of indoctrination. These are easy to perceive in the totalitarian ocieties, much less so in the system of "brainwashing under freedom" to which we are subjected and which we all too often serve as willing or unwitting instruments. Noam Chomsky, 1987


* Dorpat's kindness and caring is unconsciously woven though every page of the book.


Tim LaDuca
Wednesday, March 16, 2011

Safety and a Flexible Frame

Early in my medical training I recognized that a large majority of patients sought medical help for behavioral (overeating, excess alcohol, lack of exercise) and other psychological (anxiety, depression, psychosomatic illness) problems. I gave up Family Practice in favor of Psychiatry, but early in psychiatric residency training I entertained the notion that accurate diagnosis and appropriate medication-- while perhaps dampening psychosis, vegetative symptoms, and autonomic responses-- may not fix a bad marriage, undo past trauma, or feed the soul. The rare psychoanalytic supervisor seemed to have a deeper grasp on the exigencies of being human. But what is so special about the psychoanalytically oriented psychotherapeutic relationship? why psychotherapy; why psychoanalytic training; what distinguishes therapy from a good friend or a loving family member?

In addition to an analytic attitude (Jan 3, 2011), psychoanalysis (and psychoanalytically oriented psychotherapy) allows the patient a freedom of self unlike any other relationship. It allows for the safe exploration of automatic ways of being with another. Together therapist and patient negotiate the frame, or rules, on which the two will come to rely, such as punctuality, alertness, and a readiness to be interested and self-reflective. When we as therapists fail to be punctual or alert or ready, we must open our failings to the patient for exploration. The frame includes the psychoanalytic attitude with its asymmetrical focus on what is in the best interest of the patient and with the safety of the patient’s psyche foremost. Safety is fostered when we do not judge or incredulously question in a way that humiliates; when we are attentive to changes in the patient’s (and our) self states, tone or prosody of speech, autonomic responses, or other indications that we may need to ‘slow down’.

Likewise our reliability, punctuality, earnestness in the experience, our listening, processing, and considering what we have seen, heard, felt, and experienced also facilitate safety. Maintaining the frame will, at times, help communicate safety. Sometimes the patient seeks to break the frame, not as resistance but as an attempt to reach us, particularly if we hide behind a role. At other times, the frame must be flexible enough to allow for negotiation, and for reenactments. Because psychoanalytic psychotherapy is a dialogue within a frame-- with a reciprocity of sorts-- and because it includes the multiple unconsciouses of both participants, both patient and therapist will emerge changed in some way.

Subjectivity, self-disclosure, and an ideal

It is now well articulated that our own subjectivity greatly influences, both explicitly and implicitly, the work co-created by us and our patients. Whereas Freud thought abstinence, neutrality, and anonymity were part of the ideal stance, contemporary thinkers know these to be not only impossible but sometimes unhelpful, even detrimental, to the therapeutic process. Aron (1991), and Hoffman(1983) write that the patient's experience of the analyst's subjectivity needs to be made conscious, that is, it is sometimes okay to ask patients what they notice about us and our reactions, perhaps particularly when we have feelings we hope we have kept hidden from the patient. Patient reaction to our subjectivity is only one aspect of the transference, but was, traditionally, a neglected area of exploration. (Remember that what patients notice about us may also be defended against by patients.) Just as patients can not entirely know themselves, neither are we the authority on the accuracy of our patients' perceptions of us. Patients learn about themselves from us, so we, too, learn, often uncomfortably, about ourselves from patients. Bion thought that the more real the analyst, the more the analyst can be in tune with the patient’s reality.

Still we strive to be careful not to impinge on the psychoanalytic process by excessive self-revelation. I like to think that self disclosure pertains to allowing into the process what is going on with me in the therapeutic relationship, not about what goes on with me in my private life. Semrad quipped that psychotherapy is a mess trying to help a bigger mess, his way, I think, of saying that you do not have to be a perfect person to be a good therapist. Because self-revelation by the therapist is ongoing and inevitable, we (through our deportment, dress, attitude, etc) cannot help but to reveal our imperfections. They may impinge upon the patient less when we find in our personal lives gratification in love, work, and play, separate from what gratification we un/consciously hope for from patients.

When considering our own subjectivity (point of view, beliefs, opinions, goals, desires, etc.), we might examine our own motivations for having chosen the mental health profession as well as our fantasies about how we might help others, and ourselves, by having so chosen. Philosophically, do we have hope for ourselves (and do we hope to facilitate hope in others) for a life experienced with fullness and passion, for both joys and sorrows, and to experience life, not in isolation, but in authentic connection with others? Is ardor for life a personal value? An ideal stance then might better be suited by being open and curious, and brave toward newness, uncertainty, and psychological intimacy.


Aron, L. (1991). The Patient's Experience of the Analyst's Subjectivity. Psychoanal. Dial., 1:29-51
Hoffman, I.Z. (1983). The Patient as Interpreter of the Analyst's Experience. Contemp. Psychoanal., 19:389-422.

The Psychotherapeutic Relationship

The therapeutic process is not only about what is intrapsychic (the content of the mind, and the unconscious); it is also an interactive, bidirectional, and co-created engagement between therapist and patient. Regardless of any particular theories one utilizes, fostering from the very outset a mutually respectful relationship with the patient is paramount. Understanding diagnoses will not be helpful if the patient does not come back. To that end, the patient must, from the beginning, implicitly understand that you are trustworthy, respectful, and caring. Sometimes it is helpful to acknowledge with open inquiry the interpersonal experience. Collusion with patients’ illusions, without inquiry, may serve to increase the patient’s anxiety, hopelessness, and self-alienation.

Hoffman (1983) and Aron (1991) recognize that, while the relationship is mutual (both make contributions and affect one another), it is also asymmetrical. Relationships, including those between therapist and patient, are constituted by mutual regulation. We affect and are affected by each other, and, when this is not the case, one or both can feel ineffectual, unrecognized, even helpless. We aspire to mutual recognition. While we want the patient to journey her or his own path, we do not aspire to foster an autonomy that threatens the patient with isolation. When we do not demand pathological accommodation, or when we offer being alone in the presence of the other, it may be the patient’s first, or a rare, experience of autonomy without risk of loss of connection.

In seeking to connect with us, patients may probe beneath our professional façade. Do not mistake striving to know the therapist as [only] hostile or as [only] resistance. Consider the wish for connection and a longing to have an authentic effect on others. Sometimes patient silence is hostile as when the patient is too furious to speak or is withholding. Sometimes an experience or memory has no words. But sometimes it reflects a wish to be accepted as one is, without having to perform or produce. It is okay to admit that you do not know what the silence is about but would like to know, and likewise, it is okay to sit in silence, intimating your willingness to wait. I remember Hermann Hesse’s Siddhartha: I can think, I can wait, I can fast. Sometimes the therapist must be so willing, too.

Aron, L. (1991). The Patient's Experience of the Analyst's Subjectivity. Psychoanal. Dial., 1:29-51
Hoffman, I.Z. (1983). The Patient as Interpreter of the Analyst's Experience. Contemp. Psychoanal., 19:389-422.

Psychoanalytic Training Changed My Life, Really

Psychoanalytic training in the USA requires experience as an analysand, in addition to the clinical training as an analyst being supervised by more experienced analysts, as well as the didactic courses. Embarking on the journey to become a psychoanalyst required for me a radical shift from my medical training. As a physician and psychiatrist, I learned to be a diagnostician, pharmacologist, and advice-giver. Being a psychoanalyst requires a different perspective. Modifying the medical ‘fix it’ model, I had to emphasize collaboration with, instead of imparting knowledge to or directing, a patient. Symptoms and complaints take on additional communication about symbolic meaning and relationship. (Experience in interpreting poetry, literature, and film for their many levels of symbolic meaning gave me a good start for thinking about the many levels of connotative meaning, beyond the denotative, of a patient’s narrative.)

There are many theories about what is helpful to psychoanalytic psychotherapy patients. Theories of psychoanalysis and psychoanalytic psychotherapy have evolved for more than a century since Freud first introduced his ideas, and they continue to evolve, so we hold onto theories lightly. We still utilize some of the traditional Freudian principles, e.g. one of the cornerstones of psychoanalysis remains the acknowledgement of the Unconscious (or Unconsciouses) , though defining it, and ideas about accessing it, have undergone modification. The other aspect agreed upon is that the relationship is important.

While there is some research about what is mutative, it is relatively sparse. Various schools of psychoanalysis privilege different aspects. Structural/Ego analysts, for example, might aim to foster the more frequent use of more mature, adaptive defenses, or to ‘discover’, with the patient, unconscious conflict. Object Relations analysts might strive to keep pace with what part –object is manifest in the patient or analyst at any moment and to help the patient integrate her/his sense of self/others. Relational analysts might utilize what is going on within the therapeutic dyad to co-construct a narrative that helps patients connect more with themselves and with others. Self psychology recognizes the importance of empathy and attunement, and of the analyst serving as a selfobject experience for the patient so that the arrested psyche can recommence its development. The Intersubjective School might stress mutual recognition that fosters reciprocity and greater interpersonal satisfaction.

All authors and clinicians have their own biases about theories. From difference we enrich our repertoire and experience. Supervision and peer supervision is invaluable, as is sharing the conversational ‘space’ and embracing difference of opinions. While reading papers and texts may initially aid confidence, nothing can substitute for experience. Not only did psychoanalytic training improve my capacity to be open to and understand patients, benefitting treatment outcomes, but it allowed the building of a full and satisfying practice. One of the aspects of practicing psychoanalysis which makes it so delightful to me is that, if we are open to the present moment, we get better and better at it, day by day, minute by minute.

Oscar Countdown: The King's Speech

In a film about one man’s struggle to find his voice and about the talented (and intersubjective) speech therapist who helps him to do so, we find the contemporary analytic attitude of the psychotherapeutic consulting room. In The King’s Speech, Colin Firth as “Bertie”/Prince Albert/King George VI and Geoffrey Rush as the failed actor/speech therapist Lionel Logue enter into a relationship whose endeavor can succeed only through mutual recognition, no easy task for a patient who is used to subjects of the Crown, not those who would be subjects of independent action, desire, and will. Not only does Logue insist on recognition and otherness, he also balances compassion for Bertie’s plight. Logue asks about earliest memories, discusses the Prince’s childhood and understands his anger and humiliation. Whether sharing fears or shouting obscenities, Logue allows for play, spontaneity, and creativity, opening the space to where Bertie’s speech is stutter-free.

Just as we set aside the transgressions, and sometimes heinous crimes, of our patients in order to be useful to them and to experience the world from their perspective, so we need, in The King’s Speech, to set aside historical context. The Monarch King George VI stood for an Empire which subjugated nations while colonizing one quarter of the planet, and Prime Minister Chamberlain, in a failed appeasement, conceded to Hitler in the Munich Pact. Then we can watch, with immense enjoyment, this sometimes humorous, sometimes emotional, historical film about one individual’s struggle to reach his potential. The King’s Speech, directed by Tom Hooper, is the frontrunner for the Oscars, having garnered twelve nominations, including Best Picture, Best Actor, Best Supporting Actor, Best Director, and Best Supporting Actress for Helena Bonham Carter as the supportive wife Queen Elizabeth, the mother of Elizabeth (II) and Margaret.

Experience Near

On Saturday afternoon, January 15, 2011, Alan Kindler held an interactive workshop at Memorial Hospital with the Tampa Bay Psychoanalytic Society, Inc on staying close to what the patient was experiencing and reporting. [This was a lot harder than one would think, especially for experienced clinicians who may have found it hard to divest themselves from their theories and interpretations and simply reflect back what was heard instead of adding our own speculations.]

In an attempt to have workshop participants practice getting closer to the patient’s experience, Kindler used video clips of actors playing patients and asked audience participants to use empathic observation to access the specific feelings and experience (and the relationship between the two) of ‘patients’, and to make tentative (open to objections and corrections by the patient) responses to their subjective feelings in the context of what the ‘patients’ were relating. Kindler recommended really knowing the details of conscious experience before moving to the unconscious, fully aware that which details come to the foreground of the therapist’s attention are contingent upon the subjectivity of the therapist. Experience-near data, the details of the patient’s experience, passes by so quickly that much is missed in the listening.

Kindler used the following definition of empathy: a mode of observation and listening in which the therapist strives to apprehend the patient’s subjective experience, as reported by the patient in the present about the past. Empathic understanding is the recognition of the details of the patient’s experience at any moment within its context. Empathic understanding requires attention to detail and a life time of practice. [E.Vasquez noted that understanding may be the core of therapeutic action. W.Player noted that empathic understanding might be oxymoronic, since attunement is more implicit than cognitive, to which Kindler suggested empathic resonance.]

Kindler described the components of subjective experience, where affect is central and contextualized, which may include thoughts, fantasies, acts, intentions, memories, images, assumptions, and beliefs. Because affects are central components of the patient’s subjective experience, their accurate recognition is the essential first step. Kindler suggested that clinicians hone the nuanced language of affect to find the right word to help the patient give a name to the affective experience.

An Analytic Attitude

As I come off a three week break from facilitating classes at the Tampa Bay Institute for Psychoanalytic Studies, Inc., I think again about how experienced psychoanalytic clinicians might share an analytic attitude with students, avid to experience a deeper relationship and understanding with those who seek them out for help. While an analytic attitude comes with inclination and experience, fostered by training and our own analyses, and while there is no agreement on theory, analysts share the common attitude of endeavoring to understand the intrapsychic and interpersonal life of the patient, to hold the needs of the patient within a frame, and to foster the growth and development of the patient toward a more meaningful and enriched, diverse life. We behave ethically. We behave with restraint. We work to be aware of the influence we have on patients by being self-reflective. We bear, sometimes with our patients, sometimes alone, unbearable affects, tensions, paradox, and uncertainty.

Perhaps I would benefit most from a New Year's resolution to give up control, to 'let go.' Most people, including therapists, particularly those with medical training, have the urge to assert control and avoid vulnerabilities and insufficiencies. Giving up the illusion of control, however scary, and being open to the experience of therapy and its co-creativity, allows transformative possibilities, and leads us and our patients away from self-alienation. Control does not constitute nor uplift the self.

A psychoanalytic attitude is the openness to experience the emotional ‘truth’ of the other’s, as well as our own, subjectivity. It is an ardent experiencing, appreciating experience in its own right, alongside insight, toward the true self; to value not only knowing but being toward the true self. This philosophical attitude decenters insight’s privileged place and makes room for relationship and for being with. Decreasing the patient’s isolation can lessen suffering. Psychotherapy is a sacred experience, under-taken, like faith, with one’s whole being, giving oneself over to the possibility of being in communion, if only rarely and momentarily, with another. Each member of the dyad ideally participates with openness and intensity as we make meaning of ourselves and our lives through revelation and through impact on each other.

Bion advocated an openness to the patient within the bounds of our ethics, always mustering up our respect, decency, and wisdom. When analyzing, open inquiry is preferable to knowledge. Bion advised that we approach each session ‘without memory or desire,’ that we be open to the new possibilities co-created when the therapist does not insist on knowing or on helping, but instead leaves space for a path that is always evolving, unpredictable and unique. When we, with an open heart, do not expect patients to give up their troubles, another serendipitous effect may include the lessening of those very symptoms.

I ask myself, "Can I recognize without flinching another’s subjectivity, or, when I inevitably flinch, can I acknowledge with the patient my discomfort in a way that negotiates a new closeness with, and understanding of, the patient? Can I model that there is no thing too untenable to hear, or to bear feeling, in the company of another? Can I survive the untenable without retaliation (withdrawal, humiliation, breaches of empathy) and hold in tension (not ‘either/or’ but ‘both’) uncertainty with knowing?"

Lycia Alexander-Guerra, MD