Shame, Aloneness, and Winnicott

More than theory or technique here at the Tampa Bay Institute for Psychoanalytic Studies (T-BIPS), we again and again emphasize the analytic attitude. Of great importance to this attitude is the avoidance of shaming our patients. Because disappointed longings often induce shame in the one who is disappointed (I am too greedy, I am too needy, It must be that I am so unlovable/so unworthy that I do not deserve what I long for) it becomes incumbent upon the analyst to strive toward being ever mindful of the reaction of our patients to any of our communications.

A very interesting discussion about Winnicott ensued last evening in the second year course Development of Shame taught here at TBIPS. We were reading about Being and so read Winnicott’s Capacity to be Alone and Playing: Creative activity and the search for the self. Candidates and students claimed to enjoy the discussion so much and to find it so illuminating that we toyed with the idea of writing a handbook, a kind of Winnicott for Dummies. We were especially taken with delineating the capacity to be alone with the capacity to be alone-in-the-presence-of-the-other.


The capacity to be alone results from the infant’s repeated experience with having its needs met in a timely fashion. Consequently, the infant has the expectation that what is needed will be forthcoming. Hunger and loneliness, then, are bearable because of the infant’s faith that these will eventually be resolved. An infant without this faith will be overwhelmed by the expectation of unrelenting hunger (or pain or loneliness). An adult without this capacity may strive to avoid unbearable feelings of want (overeat, become addicted to behaviors or substances, incessantly need to be in the company of others).


The capacity to be alone-in-the-presence-of-the-other is an even more sophisticated developmental achievement, also wrought from experience with caregivers. Does the caregiver allow the toddler to explore the world without undue intrusion and impingement? The capacity to be alone-in-the-presence-of-the-other is also linked to creativity and spontaneity, to very aliveness, if you will. Creativity in early childhood is fostered when the caregiver provides objects for exploration (pots, pans, blocks, etc) but does not insist on how these objects be explored (as opposed to uwanted intrusions like No, don’t line the blocks up like that, stack them like this). The caregiver, in the background, enjoys, sometimes even participates in, the child’s play. The child is given psychological space to enjoy the world and her/himself in the world but is not abandoned to the world. The caregiver in the background is ready to step in when needed.


Ideally, both adults in a partnership have developed the capacity be alone-in-the-presence-of-the-other, and then come together for mutual enjoyment, sharing, recognition, comfort and reciprocity. Adults who have not developed the capacity be alone-in-the-presence-of-the-other may constantly demand attention from the other, be jealous and resentful of time the other devotes to hobbies, work and friends, may feel chronically dissatisfied, and devitalized, may distort themselves to garner attention from others.


Most clinically apropos: how does the therapist give the patient enough space to allow for exploration, creativity and play in the therapeutic situation and still be in the background awaiting use should s/he be needed? This tricky tightrope is a huge challenge for the analyst. Winnicott intended to provide enough space for Ms X to allow her to spontaneously develop her own way in the world, but, as a few in the class noticed through Ms X’s repeated complaints, Winnicott failed to be sufficiently at the ready for joining with Ms X when she needed him to be more present. How does a therapist know when to give space and when to join in? It is not easy, but I think our patients tell us, by their words, tone, breathing, posture, facial expressions, etc, moment by moment, where we need to be if we can pay attention and learn to walk a very thin line, juggling on a tightrope.

Birthday noted

I thought it fitting in this election year, when freedom of choice and rights to healthcare for women in the USA are again under attack, to note the birth date of Lucy Stone, born on this date in 1818. An American abolitionist and suffragette, she inspired Susan B Anthony, after Anthony heard her speak, to take up the cause for a woman’s right to vote. Women were granted the right to vote on August 18, 1920 by the 19th Amendment to the Constitution. Stone had been dead 27 years.

I often wonder what makes us so afraid of the liberty of others, what affront to our sense of self will occur should difference be allowed, let alone embraced. When I decided to switch from Family Practice to Psychiatry, and then become a psychoanalyst, a friend from high school thought I was making a politically incorrect decision for she erroneously thought mental health professionals unduly influence others to accept the status quo, to learn to live within a reality of constraint and even oppression, particularly for women, for example, to accept an unhappy marriage. Far from this type of acceptance or submission, in my view psychoanalysis helps people see a larger range of possibility. One female patient, in an unhappy marriage for over a decade, through analysis found the courage to imagine a life on her own without her abusive husband.

Lucy Stone advocated not just for the rights of woman to vote, but for the rights of women to divorce, to retain property and childrearing responsibilities after divorce, and, married herself, was the first American woman known to retain her own name after marriage. In other words, like psychoanalysts, she advocated for all people, including female persons, to live up to an panoply of potential based on inner resources and not on chromosomes.

Ah. Yes.

Ah. Yes.


The best love letter I ever received was one word. Back in the days when people actually put pen to paper, and between the salutation “Dear Lycia” and the “Love, …” was scrawled in large, very large, letters, the single word, “YES.” It answered no asked question and therefore answered every possible question, evincing an openness to infinite possibility.

In an Angels and Airways song, Lifeline, the refrain goes:
"We all make mistakes.
Here's your Lifeline.
If you want it I want to."

But it sounds to me like singer Tom DeLonge is really singing:
We all make mistakes.
Here's all I’ve learned.
If you want, I want to.
For me, If you want, I want to, is ‘yes,’ where ‘yes’ is the giving oneself over to the other (or to the experience) in a leap of faith, the leap of faith required to open oneself to the experience of the other in the therapeutic dyad.

I am reminded of the 1981 paper by Michael Eigen The Area of Faith in Winnicott, Lacan and Bion. (IJPsa., 62:413-433) [see also blog post of 2-14-09]: “For Winnicott, … creativity permeates psychic life and is involved in the very birth of self and other...” and, “Winnicott assumes life is primarily creative and in infancy this creativity unfolds …” Eigen elaborates Winnicott’s infant: “while the infant is living through creative experiencing, he neither holds on to anything, nor withholds himself.”[italics added, to emphasize the 'yes' of it] …“The true self feeling involves a sense of all out [italics added] personal aliveness …This connects with Bion's insistence that truth is necessary for wholeness and emotional growth….For Winnicott, the true self feeling is essentially undefensive...” [italics added].

Even Bob Hicok’s Confessions of a Nature Lover celebrates the ‘yes’ when he ends his poem:

"...that’s why we say
of real estate, location, location,
location, and of speech,
locution, locution, locution,
and of love, yes, yes, yes,
I am on my knees, will you have me,
world?"

The Runaway Bunny  by Margaret Wise Brown, pictures by Clement Hurd

Difficult patients are difficult for their chronically intermittent, sometimes seemingly relentless, attacks on the work and on the therapist’s competence: “This isn’t working;” “Nothing has changed;” “Analysis is useless;” and, more pointedly, “You don’t care about me;” “You only care about the money;” “You don’t know what you’re doing;” “You suck!” Commonly, there are also frequent threats to quit analysis, often expressed with the threat of suicide.

To keep my balance and to survive (neither withdraw nor retaliate, in the Winnicottian sense), that is to persevere without thinking: “Here we go again;” “Who needs this anyway?”; or “Good riddance,” I recall the delightful children's book, The Runaway Bunny (1942) by Margaret Wise Brown, probably better known for her Goodnight Moon.

The Runaway Bunny is a felicitous analogy for working with patients who want us to believe that we are unimportant to them. The runaway bunny

              said to his mother, “I am running away.”
              “If you run away,” said his mother, “I will run after you.” …

              “If you run after me,” said the little bunny,
              “I will become a fish in a trout stream
               And I will swim away from you.”

              “If you become a fish in a trout stream,” said the mother,
              “I will become a fisherman and I will fish for you.”

              “If you become a fisherman,” said the little bunny,
              “I will become a rock on the mountain, high above you.”

              “If you become a rock on the mountain, high above me,”
              said his mother, “I will become a mountain climber,
              and I will climb to where you are.”

And so on for a crocus in a hidden garden, a bird flying away, a sailboat sailing away, his mother always finds a way to stay in connection with her little bunny.

                   “Shucks,” said the bunny, “I might just as well
                   stay where I am and be your little bunny.”

I can imagine this gives reassurance to an adventurous or angry, small child, that her/his mother will always come for it. With this on my mind, I hold the faith of commitment to the relationship and to the work.

Perhaps this attitude is implicitly conveyed, a balm of certitude for a patient who has experienced unpredictable or abandoning parents. Perhaps it is explicitly conveyed, “I will be here tomorrow at the appointed time.” Either way, it is my job, I think, to remain steadfast and keep faith when the patient conveys, with an onslaught of doubt and vituperation, her/his hopelessness, anger, or disappointment in me and in the work. A candidate asked, when I convey this attitude in class, if I were a masochist, or a saint. Neither, and I referred the candidate to Ghent’s 1990 paper on Masochism, Submission, Surrender.

Recently, after unrelenting, expressed hopelessness, a patient  said to me, “I think I am doomed with or without you -- but I’d rather be doomed with you.” And after a few wiped tears, he added, “You’re the person I want to be doomed with,” and smiled.

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.