Attachment theory and clinical work

A ready advocate for the importance of understanding attachment in the clinical situation, I quote from Wallin’s (2007) Attachment in Psychotherapy: 

For patients whose healthy development was derailed by the shortcomings of … formative relationships, psychotherapy may recreate an interactive matrix of attachment in which the self can potentially be healed.

...attachment research enhances our ability as therapists to generate a developmentally facilitative relationship with our patients in which we are at once reworking old experiences and co-creating new ones.

Because many of our foundational experiences occur pre-verbally and became ‘internal working models’ (Bowlby), ‘representations of interactions that have been generalized’/RIGs (Stern), or ‘implicit relational knowing’ (Lyons-Ruth), Wallin suggests that therapists aid patients in integrating implicit bodily, emotional, and procedurally enacted experience [sometimes called ‘non-conscious’ to distinguish from the dynamic unconscious] - as well as symbolic, explicit experience - by attuning to these bodily, emotional, and enacted experiences of, and with, our patients as well as to the verbal and other symbolic experience. 

Foreign Climes

I recently had the privilege of guest teaching a clinical case course, this time to fourth year students, at a psychoanalytic training program separate from my home at the Tampa Bay Institute for Psychoanalytic Studies (a relational institute with an emphasis on trauma and attachment). Surprisingly, while these students had heard of attachment -- one had even translated the BCPSG’s Change in Psychotherapy into a foreign language, they seemed to have very little interest in it. The presenter went so far as to say any talk about attachment was mere theory (metapsychology) and did not have a place in psychoanalysis where “making the unconscious conscious” was the aim of treatment. Deepening treatment meant diving into the unconscious.  (Had this other institute not yet embraced the paradigm shifts in psychoanalysis from left brain narrative/interpretation/insight to co-created right brain implicit/procedural/often nonverbal communication?) 

I was reminded of the BCPSG’s ideas that 1. experiences do not always need to be verbalized for changes in implicit relational knowing to take place, and 2. that relationship may be foundational, while conflict (the contents of the Freudian dynamic unconscious) comes secondarily out of experience in relationships (as evident in attachment patterns observed at 12 months of age in the Strange Situation). In particular, I recalled Stern’s idea that a verbal/conscious search for meaning may sometimes actually impede the deepening of experience. Had the centrality of relationship in treatment eluded the curriculum of this strange (to me) institute? I will note that, when having taught clinical case seminars to its first and second year classes, the students seemed more interested, even excited by, ideas less well known to them.

The presenter in this fourth year seminar, on the other hand, eschewed attachment research and was certain that it was the patient’s responsibility, and hers alone, (in a blaming sort of way) to choose her own life, regardless of the patient’s early experiences and regardless of the present moment and the therapeutic relationship. The analyst was to make interpretations in order to bring unconscious motivations to consciousness. The class, upon hearing the case, could observe that the patient had been deprived of both a nurturing mother and of being allowed the opportunity for identificatory love with her father, yet the class saw no place for the therapist to provide a new attachment relationship where unfinished developmental business could safely be revisited. The therapist was decidedly uncomfortable with the idea of being either for the patient. The class mostly interpreted the rocky relationship between therapist and patient as the patient’s bent toward “competitiveness” (e.g. when the patient wanted to read a book the therapist mentioned) and thought it odd that I might, in addition, see the patient’s wish to identify with, be like the therapist. (And, of course, the rocky relationship between me and the class is a parallel process which humbles me.)

When the Analyst is Sexually Aroused

Continuing with the presentation to the Tampa Bay Psychoanalytic Society by Janine de Peyer on October 5, 2019, the afternoon session was about the analyst’s sexual arousal in the therapeutic session, a rarely discussed topic among mental health professionals. The ‘erotic transference’ is commonly discussed, but not ‘erotic countertransference.’ The analyst’s anger, fear, and love all seem more mentionable; we strive to refrain from being inappropriate, seductive or exploitative with our patients. Because the therapist must not act on her sexual desire, what becomes of this natural human response? Does one disclose it to the patient (Davies) despite a cultural prohibition to do so?  What about the dangers? 

[So many questions...] Can one ‘neutralize’ her erotic attraction without becoming overly constricted? Is the maternal countertransference safer, particularly when the erotic may connote the female sterotype of submission? Is the analyst comfortable being the object of desire? Was there trauma associated with this in the analyst’s own history? (The aging female analyst, unlike her male counterpart, must grapple with becoming less and less likely to be an erotic object for the patient.) Is there a co-created avoidance of the erotic transference? Also, the analyst might consider whether she is the one in the room holding the erotic feelings for a patient who has dissociated them. Sometimes for the patient, too, the maternal transference seems safer. Perhaps the patient needs to fend off hostility, impotence or felt power. In what ways might the analyst be inhibiting the patient’s erotic transference? Can the analyst be open to self states without causing trauma? Does the analyst want the patient to titillate her? 

Some of the countertransferential behaviors noted by de Peyer when attracted to a patient included presenting one’s best self (wardrobe, posture), and feeling resentful or betrayed when the patient recounts sexual encounters. 

Holding longing in contempt, desire may mean weakness. [This author sees the erotic transference/countertransference as an opportunity for mourning the loss of what one cannot have.] One attendee noted that, were the erotic feelings in the clinical situation to remain unmentioned, they might be acted out in life outside the therapy. [I might then, ala Lewis Aron, place the dilemma of the erotic countertransference on the table letting the patient know, for example, that while I share his joy I worry I might have had undue influence.] When there is shame surrounding erotic feelings, the other may have to hold the shame. de Peyer notes that perhaps the greatest gift an analyst can give her patient is her own shame. [owning it].

Davies, J.M. (1994). Love in the Afternoon: A Relational Reconsideration of Desire and Dread in the Countertransference. Psychoanal. Dial., 4(2):153-170. […]

A Most Provocative Presentation

On Saturday, October 5, 2019, The Tampa Bay Psychoanalytic Society hosted Janine de Peyer. She elaborated three heretofore very neglected ‘countertransference’ positions. They were: when the analyst has a seemingly telepathic connection with a patient; when the analyst fears the patient; and when the analyst is erotically attracted to her patient.

Regarding ‘telepathy’: Evoking ideas from quantum physics, to quote from her 2016 paper, de Peyer says,

If particles in the quantum world communicate instantaneously with one another, jumping from one place to another without seeming to need to travel in between, would it not follow that patients’ and therapists’ minds would be capable of doing the same thing?

Is a mind a closed entity just as the brain encased in a skull? Or is the mind like particles in the universe with a connection and interconnection across time and space? When a person knows what another person is thinking, the exact word(s) -- even if the words were previously unknown -- how does one know? Is there a collective unconscious? a hive mind? Or can uncanny parallel thoughts, dreams, and actions between patient and analyst be explained by implicit relational knowing? [Implicit relational knowing not only relies on experience with the physical presence of another, perceiving microexpressions, changes in breath or smell, but these experiences are encoded in the brain to provide expectations on how to behave, even in novel situations (a ‘transference’)] And don’t mirror neurons also rely on physical presence and proximity? What about influence beyond sensory perception? How does one know of the death of a loved one thousands of miles away at the exact moment it occurs? And if humans are capable of knowing the thoughts of others across space and time, could our minds be bombarded with excess stimuli were we not to ignore this capability? Would all privacy of thought then be lost?

There was also a very interesting discussion about fearing from patients for our physical safety. Some thought the patient was trying to instill fear in the analyst. I, without attributing any malintent, prefer to think that a patient must show their own fear to the analyst, presenting it on a silver platter, when s/he evokes it in the therapist. Called an enactment, the analyst and patient together must play out the dissociated parts of the patient if the patient’s experience is to be known. The analyst, too, dissociates, of course, often out of shame (de Peyer noted that with a sexually aggressive male patient she had joined him in repudiation of the feminine by having equated ‘feminine’ with ‘victim’).  She had also dissociated her own aggression, leaving the patient to carry it, and carry it alone. Correspondingly, the patient had dissociated his own vulnerability; its recognition and ownership required by him in order to heal. 

Perhaps the most provocative (taboo) discussion came when talking about the sexual arousal of the analyst by the patient. [But I will leave that to the next post.]

de Peyer, J. (2002). Private Terrors: Sexualized Aggression and a Psychoanalyst's Fear of Her Patient. Psychoanal. Dial., 12(4):509-530.

de Peyer, J. (2016). Uncanny Communication and the Porous Mind. Psychoanal. Dial., 26(2):156-174.

Moon

The Moon was but a Chin of Gold
A Night or two ago—
And now she turns Her perfect Face
Upon the World below—

Her Forehead is of Amplest Blonde—
Her Cheek—a Beryl hewn—
Her Eye unto the Summer Dew
The likest I have known—

Her Lips of Amber never part—
But what must be the smile
Upon Her Friend she could confer
Were such Her Silver Will—

And what a privilege to be
But the remotest Star—
For Certainty She take Her Way
Beside Your Palace Door—

Her Bonnet is the Firmament—
The Universe—Her Shoe—
The Stars—the Trinkets at Her Belt—
Her Dimities—of Blue— 

Emily Dickinson

4th of July, Citizens and Immigrants

No one needs to be reminded that, after killing off its Natives, our country was built by immigrants. Sometimes we forget, though, that those groups whose arrivals preceded other groups’ have historically ‘othered’ the later arrivals, and with the added intent to bar citizenship to people different in religion or country of origin or race, despite these characteristics are protected from discrimination under the law. Asylum seekers, too, have legal protection.

On The Daily Show withTrevor Noah (Sept 27, 2018) America Ferrera (actor, author --“American Like Me,” -- activist, and director) said  “...women and people of color and all sorts of marginalized people in this country are feeling we should be able to walk into spaces with our whole selves. We shouldn’t have to strip away the pieces of us that aren’t accepted by the mainstream culture to exist and be accepted in spaces. For me that means I’m an actress, that means I’m a director,  that means I’m a producer, that means I’m an engaged citizen and I get to be all of those things no matter what room I walk into.” [I have always liked this woman, in part because her immigrant parents so admired this country that they named her after it!]

The Second paragraph of our sacred Declaration of Independence says

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. 

Fortunately, for women the liberal interpretation now includes us, but, of course, we are not all created equal. Some of us are taller or faster or smarter or more symmetrical. What is unalienable is that we are all entitled to equal treatment and protection under the law. This latter truth is often circumvented. Those with money are, as we know, treated and protected better than those without money. If USA could remedy this and have equal treatment under the law, perhaps global citizens could better be recognized as deserving of human rights, no matter their country of origin. If America wants to spread its values around the world, perhaps it should start at home.

Stonewall

Last week the American Psychoanalytic Association (APsaA) apologized for its part in formerly pathologizing homosexuality and for the “discrimination and trauma” doing so had inflicted on those who sought help from psychoanalysts. In 1991 homosexuality, under threat of an anti-discrimination lawsuit, was no longer classified as a mental disorder. The APsaA now stands against conversion therapy and supports LGBTQ civil rights.

Earlier this month NYC’s Police Commissioner apologized for the raid, fifty years ago today, on Stonewall Inn, a popular bar-nightclub for gay men and women. A riot ensued when patrons fought back by throwing bottles at police officers, and, days later, demonstrations for the civil rights of LGB Americans took place. Stonewall sparked the Gay Pride movement. President Bill Clinton was the first president to acknowledge Pride month in 2000.

Virginia Goldner said:

[I]n considering the history of gender-variant subjects, I am more struck by the trauma of stigma, which, along with the isolation of being/feeling different, and of coping with the unrelenting, embodied self-alienation of gender dysphoria, takes a far greater toll on the soul than I had initially understood. I still think it is these experiences of self-alienation, combined with an estrangement from one’s very own breathing body, that constitute the foundational trauma of gender variance.

Corbett, K. Dimen, M. Goldner, V. Harris, A. (2014). Talking Sex, Talking Gender—A Roundtable. Studies in Gender and Sexuality, 15(4):295-317.

Reading Aloud and the Third

Children’s book author and two-time Newberry medalist Kate Dicamillo [Louisana’s Way Home -- described as “a story of discovering who you are — and deciding who you want to be”] recounts a momentary event that changed her outlook forever. 

In 1972, when she was eight years old at Clermont Elementary School in Clermont, FL, her second grade teacher Mrs Boyette was reading aloud to the class from Island of the Blue Dolphins. She says [Nov 19, 2018, PBS NewsHour, IMHO],

“I am literally on the edge of my seat ...caught up in the wonder of it all. I am a kid who loves a story. But also in that second grade classroom seated not too far away from me there’s a class bully. Because I am so terrified of this boy, he does not even seem real to me, he is in my mind less a boy and more … a monster. ...and I notice that he is listening too, that he is engaged by the story too, that he, like me, is leaning forward in his seat and listening with his whole heart.  I stare at him, open-mouthed. I’m struck with the sudden knowledge that this boy that I am so afraid of is, in fact, just like me. He is a kid who likes a story. The boy must feel my eyes on him because he turns. He sees me seeing him and something miraculous happens: he smiles at me, really. And then another miracle: I, unafraid, smile back. We’re two kids smiling at each other.

“Why have I never forgotten this small moment? Why, almost 50 years later, do I still recall every detail of it? I think it’s because that moment illustrates so beautifully the power of reading out loud. Reading aloud ushers us into a third place, a safe room. It’s a room where everyone involved, the  reader and the listener, can put down their defenses and lower their guard We humans long not just for story, not just for the flow of language, but for the connection that comes when words are read aloud. That connection provides illumination. It lets us see each other. When people talk about the importance of reading aloud they almost always mean an adult reading to a child. We forget about the surly adolescent and the confused young adult, and the weary middle aged, and the lonely old. We need it too. We all need that third place, that safe room, that reading provides. We all need that chance to see each other.”

Reparation, a way towards repair

H.R. 40 seeks to establish a commission to study the effects of slavery and its subsequent racial and economic discrimination, and its physical, economic, and psychological impact on African Americans today, and then make recommendations for repair and reconcilliation. In 1989 John Conyers, (D) Rep. MI, introduce H.R. 40 (40, from 40 acres and a mule) and today it might finally have some teeth. Therapists familiar with rupture and repair might have some insights to offer the US Congress on healing. While a few presidential candidates have come out in favor of reparation, one, Marianne Williamson, is an author and activist who actually knows a few things about healing the soul of our nation evident in her ideas about poverty alleviation, peace building, women’s advocacy, and feeding the hungry, to name a few.

Therapists are well aware of how insidious and pernicious intergenerational transmission of trauma is on families across time.  Attachment research and Infant-mother research have shown that anxiety and dissociation are not merely inherited but are created from experience, that is, encoded in the brain and built within central and peripheral neuronal connections that become a default position for future experience. Huge retrospective and prospective studies have documented the physical and psychological consequences of adverse childhood experiences (ACE).

Is any trauma so heinous or span centuries as slavery did in the United States? Dehumanization of people, the calculated splitting up of families (seen recently at our southern border), the terrorization to body and sense of self (continued by Jim Crowe segregation laws, the KKK, lynchings, and today, the inequitable incarceration and shooting of black men) all create long lasting sequelae to traume. Reparations (more than eigthy billion dollars) were paid by Germany to Jewish Holocaust survivors and refugees. The USA compensated Japanese interned during World War II (Civil Liberties Act of 1988). Is there a way to recognize the early economic prosperity of America established on the backs of unpaid slave labor that can heal the soul of America?

Remembering Sidney Blatt

Yesterday (April 13, 2019) the Tampa Bay Psychoanalytic Society’s own John Auerbach, PhD gave tribute to the late psychoanalyst Sidney Blatt. Blatt put forth some interesting ideas such as that of two developmental lines, relatedness and self-definition which were linked to two types of depression, anaclitic (Greek for leaning against) and introjective depression, respectively. Those with anaclitic seemed dependent on others to love them while those with introjective were self-critical and riddled with guilt. Rather than seeing these two developmental lines as sequential, one more mature than the other -- as Blatt and other traditional psychoanalysts had originally conceived -- Blatt came to understand that relatedness (once considered infantile and hysterical personalities) and self-definition (paranoid or obsessive personalities) develop in parallel, one co-defining the other, opposites only relative to each other. Auerbach noted that, of Erickson’s eight developmental stages, only two (Trust v. mistrust and Intimacy v. isolation) were about relatedness, while the rest were about self definition (autonomy, initiative, industry, generativity, etc).

The personality develops in is a continuous dialectic between relatedness and self definition. Deficits in or over emphasis of either developmental line leads to psychopathology. These polarities of relatedness and self definition were applied by Blatt et al to attachment theory and separation, respectively, where avoidant attachment presumably correlated with introjective depression, and such patients better utilize the couch, while ambivalent-resistant were tied to anaclitic depression, and may benefit more from face to face treatment. [Consider that one patient may, in different self states, exhibit both polarities. Blatt actually posited impairment was initially greater with mixed type in-patients (they also improved more). Perhaps this is because of greater dissociation at work?]

Blatt et al integrated mental representations with Bowlby’s concept of  internal working models to better explicate insecure attachments and developed a number of research tools. The Object Relations Inventory asks the patient to describe mother, father, significant other, self, and their therapist at different points in time over the treatment. This inventory apparently allowed clinicians to measure therapeutic change in patients in the [Austin]Riggs-Yale Project study by measuring changes in the developmental organization of their mental representations of self and other. Blatt et al also developed the Differentiation-Relatedness Scale to rank where a patient, at any time in the treatment process, stood in her/his capacity to be both separate and attached, based, in part, on reflective capacity.