Tragic De-realization

Having experienced a long bout of what is called "derealization" after recovering from a serious drug overdose, I have developed a theory of the bizarre behavior exhibited by the perpetrator of the Aurora, Colorado Massacre. When you are in a state of derealization, everything seems like a figment of your imagination, not "real," like the way things used to be. You may think you are in an elaborate dream, purgatory, the afterlife, or merely inside your head depending on your beliefs.

Holmes' actions are consistent with someone who experienced a psychotic break and entered a prolonged state of derealization. Why would Holmes booby trap his house with the intention of killing any law enforcement who entered, then tell the same law enforcement that his house was booby trapped? Why the palpable look of remorse on his face in the courtroom? How can someone spend weeks planning out a mass murder, carry it out, and then suddenly feel remorse? This would be bizarre if one did not consider the concept of derealization. When Holmes carried out the act, something snapped him back to reality and his psychotic break of derealization ended. In this light Holmes, too, is a victim, and we should do what we can to further our understanding of the state of derealization. If

this theory turns out to be correct, we must then ask: should a person in a state of derealization be held responsible for his actions? The remedy would seem to be increasing public awareness of derealization, and vastly improving the quantity, quality, and accessibility of available mental healthcare, as well as de-stigmatizing mental illness and increasing awareness of it so as to encourage people to seek help before terrible things happen.



By Tim LaDuca

Art: an antidote to sports?

June 9, 2012


Ukraine hosts the Euro 2012 Football championship this year, and its local club has given 3000 tickets to its hardcore fans, the Ultras, who ignominiously boast “…no dark skin, no blacks, no slant eyes in our section of the stadium…” This racism causes me to wonder what ‘doer-done to’ relational template in childhood was internalized by these “hooligans” who seems to have a penchant for the side of the doer.

Perhaps an antidote for the “Ultras” is the contemporary art exhibition dOCUMENTA which runs for 100 days every five years in Kassel, Germany. Today begins dOCUMENTA 13 and this year’s, reflecting globalization, includes exhibits in Kabul and Banff. Artistic director Carolyn Christov-Bakargiev says that dOCUMENTA (13) Collapse and Recovery “looks at moments of trauma, at turning points, accidents, catastrophes, crises, events that mark moments when the world changes.”

Some of the art this lustrum comes from war zones. American artist Michael Rakowitz, who worked in Afghanistan, features the poignant tablets carved from stone by Bamiyan masons -- Bamiyan, where the Taliban blew up, in March 2001, two of the world's artistic treasures: two giant, 1400 year old Buddhas carved from a cliff in central Afghanistan. “Both Kabul and Kassel have witnessed destruction through war and the need for physical reconstruction and mental retrieval, becoming stages where our present is represented or transcended.” Nalini Malani displays a work of carouseling shadows which highlight the oppression of women in India. A Pakistani refugee herself, her art additionally depicts the politics of the Partition and its cost of hundreds of thousands of lives. She also illustrates the essay The Morality of Refusal by Arjun Appadurai reflecting on Ghandi’s non-violent political practices. William Kentridge, the South African anti-apartheid artist is featured for the third time.

Book Review Psychotherapy Lives Intersecting

Long before any theoretical contributions from various schools of psychoanalysis are introduced to first year candidates at the Tampa Bay Institute for Psychoanalytic Studies, the majority of the first year course, Introduction to Psychoanalytic Concepts I,  discusses with candidates how to be with patients. How fortuitous that I have recently come across the immensely readable (and highly autobiographical) primer by Louis Breger, Psychotherapy Lives Intersecting (2012; Transaction Publishers, New Brunswick, NJ) which adds the perspective of former patients, what they found helpful and unhelpful in their treatments, to the pearls gleaned from his vast experience as a psychoanalyst. Breger aims his book at people considering therapy, but therapists, too, will greatly benefit from this jargon free exposition. What is unique about this book is that the many clinical vignettes are enriched by reflections from patients about their own psychoanalytic journeys, something the reader may find courageous.



Elizabeth (pp. ix) writes, 'Throughout the therapy experience with you, I always felt like a person in a relationship, rather than a person to be understood by you, and then explained back to me…you communicated an utter lack of judgment, an acceptance of the aspects of my life about which I was most embarrassed, and modeled that Not Knowing was okay'. Another patient, Bernie, (pp. 29) “singles out catharsis, having a safe person to talk with, and insights-in that order-as the helpful factors of his therapy.” Breger says of his own analysis, “…it was the relationship itself—being accepted, listened to in a noncritical manner, understood, appreciated, even liked—after revealing what I felt were my most shameful and guilt-ridden secrets—that was most helpful." Breger listened closely, was not dogmatic, and did not dictate rules.



Just as research shows that the person of the analyst is more important than her/his theoretical orientation, Breger recognizes that relationship is as important, maybe more so, as interpretation and insight. Breger also sees the benefit of ‘fit’ between analyst and analysand, including whether the therapist likes and identifies with the patient. Instead of illustrating how to behave as an analyst, Breger writes about an analytic attitude. Breger muses on anonymity, authenticity (about being human), self disclosure (must [also] be for the benefit of the patient), and analyzability. But Psychotherapy Lives Intersecting is as much about Breger’s personal journey as an analyst as it is about how his patients viewed their treatment. The neophyte will benefit greatly from this disclosure. His “straightforward approach” to writing and to his patients is refreshing. As a traditionally trained analyst who also found a relational home in contemporary theories, I found it wonderful to immerse myself in a book where I found like mindedness.

Covert Ops and Psychoanalysis? Who Knew

While I advocate in analytic treatments for openness and authenticity, I was surprised that Henry A Crumpton, whose book The Art of Intelligence: Lessons from a Life in the CIA's Clandestine Service which came out today, stated some things that good spies have in common with therapists, namely "an intense intellectual curiosity; willingness to deal with ambivalent situations [by which I took he meant ambiguity]; and a certain degree of creativity." Part of me shudders. Still, I like to see our work as therapists as one of collaboration, where both parties strive, by the very nature of their relationship, toward a common purpose, not enemies except in moments of rupture, not out to deceive the other except in protection of the sense of self coupled with a longing to be known and understood. Therapy is a tricky business, no precious metals to be acquired, no missile heads to be dismantled, no foreign dignitaries to be protected, but sometimes a sense of life or death for a particular self state or relationship, an urgency to find one another in the tumult of the outside world, and a hope that we each will sleep more peacefully tonight.

MOTHERHOOD May 2012 Mother’s Day

Winnicott said that the good enough mother never asks the infant to answer of itself the question about the transitional object ‘did I find it or did I create it?’ I also think the good enough mother welcomes and enjoys her infant, sharing the joy of its developing experiences, accepting and loving it, most times, just for its being born, and making quick repair when she doesn’t. But the greatest gift a mother gives her child is her own genuine happiness, a consequence of her own subjectivity and interests, her own feeling of being loved and accepted in the world. This gift gives children the license to be happy themselves, permission for their own subjectivity, hope for the future (of aging), as well as infuses them with the belief that they are enjoyed, welcomed, and contribute to parental happiness. Jessica Benjamin noted that the subjectivity of the analyst also relieves the patient of having to feel responsible for the analyst’s ‘happiness.’ A Happy Mother’s Day to all the moms out there.

Maurice Sendak Beloved Children's Illustrator and Author Dies

Maurice Sendak, acclaimed children’s book illustrator and author, died today a few weeks shy of his 84th birthday. His most famous book Where the Wild Things Are, a Caldecott Medal winner, is also beloved to psychoanalysts because it lends itself beautifully to metaphors about the unconscious life and about therapy. We pledge to open ourselves to the scary and the wild in our patients and in our selves, and to go with them to places where others are not allowed or fear to tread. His illustrations of monsters are personal to Sendak (not griffins or gorillas) derived from his childhood experiences with all his Jewish relatives with “big warts and hairs growing out of their noses,” adults who “treated them in silly fashion” as kids constrained in best clothes awaiting dinner and having to “listen to their tedious conversation” as well as having been told he and his siblings had gotten big or fat and they would “eat us up.” The monsters tell Max: Please don’t go, we’ll eat you up, we love you so. [Sendak lamented that book signings unwittingly turned him into a strange monster to the children shoved at him to autograph (write in their books, an action forbidden to them) and whom they imagined wanted to take, keep, as well as defile their favorite book. Sendak said, “A child was a creature without power, …pocket money or escape routes of any kind.” He detested Peter Pan because he could not conceive that any child would want to remain a child, powerless. He thought “all kids would like to have control” And Max, the king of all wild things, was lonely and wanted to be where someone loved him best of all. Max not afraid of the montsters and so child readers likewise were not afraid. Sendak’s own fears included the vacuum cleaner and The Invisible Man, a movie which he credited for his lifelong insomnia. He found “terrifying” the unraveled bandages (of head) exposing nothing there. Big events in his childhood were “being sick” and “being expected to die” (discussed in front of children by his parents) which “pervaded my soul apparently.” In the days before antibiotics and vaccines, Sendak spent lot of time, sick, in bed with childhood illnesses. When sick, before TV, Sendak spent a lot of time looking out windows, happy memories which appeared in his books. His father left Eastern Europe before the Holocaust but all father’s relatives perished there and father grief stricken all Sendak’s life. In the Night Kitchen was banned in some libraries across the USA because its protagonist Mickey appears nude. Sendak said of this that he was “not out to cause a scandal”… “I assumed everyone knew little boys had that.” Outside Over There is about sibling rivalry and responsibility; Ida is left to babysit her baby sister, who is kidnapped by goblins, and Ida must come to terms with her ambivalent feelings as she goes on a magical adventure to rescue her sister. Among other awards, Sendak also received a Newbery Award for his illustration of Isaac Bashevis Singer’s children’s story Zlateh the Goat. Sendak’s family moved a lot due to money problems growing up in Brooklyn. He also wrote a book about homelessness We Are All in the Dumps with Jack and Guy: Two Nursery Rhymes with Pictures.

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.”

Happiness

I recently began musing on happiness when invited by David Burton, a local, independent, documentary filmmaker to be interviewed on this very subject for his present film project. I thought about how the human brain is wired for moments of happiness; it releases happiness chemicals during certain experiences such as love or orgasm or a runner’s high. The more experiences our brains have with happiness, the greater our faith that we can expect future happiness to be forthcoming. As such, I recommend we practice some joyfulness every day.

Because as infants and toddlers we require attachment for our very survival, each of us as children constructs what we believe will maintain that attachment bond. As such, children will comply with parental demands to themselves be the parent to the parent, or to be the container of all bad feelings or behaviors, to achieve in sports or academia, and so on. Even with good enough parenting, eventually well-fed and well-loved infants who have delighted in playful interchanges with caregivers learn as toddlers that their caregivers are no longer under the child’s omnipotent control, a loss compensated, ala Benjamin, by the joy of two separate minds coming together, because they choose to, to share one thing, e.g. the child’s wonder at a dandelion. Later when we are aware that we are finite, mortal, and alone in the universe, this meeting of the minds bridges the gulf of existential isolation, and momentarily we are joyful.

Happiness, or at least contentment, comes with satisfaction of certain innate strivings of human beings, five that Lichtenberg beautifully delineated: physical needs (food, safety, shelter); needs for creativity, exploration, and play; for sensual and sexual pleasures; for attachment and affiliation; need to defend against or escape adversity as well as to assert ourselves. Happiness is co-created in the context of relationships. When we have had the experience of being welcomed and enjoyed, then our parents’ joy infuses us. We learn joy and to enjoy ourselves, as well as others. Happiness comes more easily to those who have been welcomed and enjoyed. And when we despair, it is easier to keep the faith that happiness will eventually be coming around again.

I remembered a psychiatry resident from a few years ago whom I was to supervise. She came to me, terrified about the prospect of doing psychotherapy without sufficient training, and I asked her what she thought most people want. After a few moments she answered, profound in its simplicity, "love and acceptance." That is, then, I told her, exactly what we must learn as psychotherapists to weave into the treatment relationship.

I advocate, then, for love and acceptance in the psychoanalytic situation, welcoming and enjoying our patients, even their darkest self states, such as anger, despair, envy, and murderous rage, self states of which they are ashamed and may disavow, but being welcomed into the treatment room can find voice, and, ideally, can find dialogue with one another. The psychoanalytic experience of love and acceptance coaxes forth shamed and disavowed self states, invites in play and creativity, and a communion between self states, mine and the other’s, in a panoply of possibility. When I experience myself with another, intimately, fully, authentically, there is happiness.

Female Sexual Development and Fathers

The Tampa Bay Institute for Psychoanalytic Studies, Inc's first year class has been reading Freud’s ideas on female sexual development in the Development course. Because in each class we try to offer a dialogue between antipodal points of view, as a preview to the readings in today’s class I thought I might comment on Jessica Benjamin’s 1991 paper Father and Daughter: Identification with Difference — A Contribution to Gender Heterodoxy.

It seems Freud could not conceive that small children wanted it all, to be and to have all, but instead thought both male and female children only wanted the penis. Likewise, Freud did not conceive that 'normal' children might have homoerotic longings but instead only heterosexual ones: when little boys longed for attention, affection, love from their fathers, they must be feminized (the negative oedipal complex) and likewise little girls attached in an active way to their mothers must be like little men, be little men, just like little boys who want their mothers in a heterosexual way. While Freud postulated that the fear of losing his penis catapulted the little boy out of the oedipal phase, he posited that little girls enter the oedipal stage from their castrated state, turning to the father in search of a penis (or its psychic equivalent, a baby).

Benjamin revisits and reconfigures penis envy of little girls and places it not at the cusp of the oedipal configuration but instead squarely in the pre-oedipal period, noting that pre-oedipal girls turn to the rapprochement father, not yet an object of erotic love, but instead as an object of identification. The father, the penis, the phallus all stand for independent agency, subjectivity. Little girls, as do little boys, use the glamorous, exciting out-in-the-world-father as an idealization of subjectivity, a role model, a subject with agency, will, and desire. It is identification with this father as subject, separate from and independent of mother, that allows for children of both sexes to individuate from mother. Benjamin further expects that the latency age girl who wishes to be buddy to her father seeks to consolidate her identification with an independent subject. Rather than seeing this behavior as a masculine protest (Freud), Benjamin notes that it further consolidates a feminine identity.

Benjamin proposes that thwarted identificatory love may also explain girls’ fantasies in Freud’s A Child is Being Beaten. Thwarted identificatory love may lead a woman to privilege desire of a man over her own desire, whereas welcomed identificatory love, Benjamin writes, may sow the seeds for later erotic, mutual heterosexual love rather than being complicated by submissive, even masochistic, behavior towards men.