Wednesday, November 14, 2018

Misogyny in psychoanalysis

    Never was the contrast between classical and contemporary psychoanalysis more stark than in the chapter chosen for a beginning course in technique* by CAPA (China American Psychoanalytic Association). The chapter --- (#2) “Assessments, Indications and Formulation” ---  appears in Long-Term Psychoanalytic Psychotherapy, Third Edition (2017) by the renowned psychiatrist and psychoanalyst Glenn O. Gabbard, MD where he formulates the case of a 38 year-old woman “to explain the patient’s clinical picture.” 
The patient presented with depression and the beginning of a new, troubled, heterosexual relationship. Her mother ”had never really been able to take care of her because her mother was emotionally unstable and upset all the time.” Her father was an alcoholic and a womanizer who would comment on the patient’s looks, and the patient was contemptuous of him. The parents divorced when she was 12 years old. The patient had been using alcohol from a young age and had intercourse at age 13 years with a man who bought her alcohol. Subsequently she began using illicit drugs. She described herself as “highly ‘promiscuous’” and said she is addicted to alcohol and sex.
    Gabbard makes a lot of the woman’s sexualness and seductiveness, in her dress and in her attitude toward her male therapist.  In his formulation, his “psychological hypothesis” is: “Ms. A grew up in a tumultuous childhood situation where she felt neglected by her mother, so she attempted to get love and admiration from her father by attending to her appearance and sexualizing their relationship.” Even if we decide to ignore the patient’s contempt for her father--- and his behavior toward her and others--- and surmise that a part of her, of course, is longing to be loved and recognized by him, nowhere does Gabbard mention in his formulation her rape at age 13. Instead, there appears to be an implicit blaming of her.
    Other than “a tumultuous childhood situation where she felt neglected by her mother” Gabbard does not find the history of this rape significant enough to include in his formulation. He does not include anywhere in his formulation anything about insecure attachment or the dissociation and incoherence that result when a mother could not attune, regulate or protect the patient as a little girl, all of which likely contributed to the patient’s inability to understand the intentions of others in a self protecting way. That the patient seeks recognition and tenderness seemed to have been confused [Ferenczi] by Gabbard, as seen in his emphasis on ‘sexual’ behavior. Would a clinician not wonder if her “promiscuity” were not an enactment of her childhood sexual traumas [plural, as I imagine more than one]. Gabbard's formulation at best indicates he is wedded to drive and Oedipal theory and at worst intimates that the child unconsciously orchestrated her own rape as a consenting [as if the age of consent in an equitable and civil society were 13] seducer of men; and why? because she longed for her father's attention. And what about her mother’s attention in this formulation?
Are we still living in this kind of world?

* [does ‘Technique’ imply we apply one set of actions to all patients?]

Monday, November 12, 2018

Lauren Levine and the Film "Room"

Discussing on the morning of Nov 10, 2018 the Film Room in her presentation about mutual vulnerability at the Tampa Bay Psychoanalytic Society’s monthly speaker meeting, Lauren Levine, PhD noted how the protagonist (ironically named Joy), abducted and held captive and raped for seven years, must both stay enlivened for her five year old son Jack while also surviving her own deadening suffering. But how does one bear unspeakable trauma and stay enlivened when stuck in “the endless now,” Levine asks.

Listening, witnessing, taking in our patients’ narratives about their trauma gives voice, Levine says, to unfreeze time for them. But “therapists are penetrated by shards of the patient’s trauma,” resonating with the therapist’s own past. As Levine notes from Harris’ paper You Must Remember This: “the inevitable presence in the analyst of wounds that must serve as tools” (2009), it follows then we are thus also called upon to be mindful of our own self-care. In the discussion that followed a profound and amazing thing happened: The attendees enacted self-care by revealing their own horrific past traumas to a receptive, witnessing audience, a room full of clinicians.

Returning to the film Room, I had been struck by the lack of articles (a, the) when characters spoke about ‘room’ or ‘rug’ or ‘skylight.’ In Levine’s afternoon presentation titled ”The Faraway Nearby”  a possible meaning for this dawned on me. In using the writings of Rebecca Solnit - stories are geography and anchor us to place-- Levine helped me see that using articles would have made the place, the room which imprisoned Joy and Jack, too present, too real, thwarting Joy’s need to keep from their psyches the horrific thing happening in the now.

Thursday, November 8, 2018

The Forward Edge (and a co-created opening of the therapeutic space)

Marian Tolpin encouraged us to consider the forward edge, that is, the striving for growth, which is often obfuscated by what appears to be only ill-conceived and regressive behavior on the part of our patients. An illustration of a forward edge, which only became evident one year later, was discussed in this week’s continuing case seminar. About three years into treatment, a patient and a therapist were having a difficult time understanding one another at the beginning of a session. Silence punctuated this difficulty and the patient abruptly left the session.

In the subsequent session, and another session later, the therapist wished to explore what had happened. However, the patient would not elaborate on what had happened. A year later, after the patient had missed the previous session, the therapist brought that abrupt leaving of the session again up to the patient. The patient wondered aloud if treatment were even helping and, then, this time addressing her abrupt departure from that session a year earlier, the patient shared how significant that leaving had been to her: after that event, the patient had become able to tell her intrusive mother ‘no.’

The class surmised that the patient, able to exercise her own agency, leave the therapist and have the therapist survive, had been a new experience for the patient which allowed her to ‘leave’ her mother’s point of view without fear that her mother would die. (The mother had often said that the patient’s words, object choice, and actions might kill her father or her mother.) Interestingly, the therapist’s own mother had died previous to that session of misunderstanding, something the therapist shared in a subsequent session. The patient’s ability to leave that session had not been merely an inability to tolerate a different, temporarily less attuned therapist, but had been the forward edge toward autonomy and independent agency, scaffolded by the therapist’s ability to survive the leaving.

Why was the patient now, a year later, willing to discuss with the therapist about that day? The class had some ideas. This patient had refrained from telling her mother any new ideas or events in her life until these were firmly established in her own experience lest the mother usurp, destroy, or self aggrandize what the patient brought to the mother. The patient had now firmly established the ability to say ‘no’ to her mother as well as had increased trust that the therapist would not usurp this new power.

What was the therapist’s contribution to facilitating this long awaited discussion? It turns out that the therapist had also brought up -- prior to the patient having shared the positive impact of that year ago session -- empathy or attunement to the patient’s little girl ‘lost’ self, and the therapist had brought up the idea of power games (patient puts down her girlfriend, patient’s mother puts down patient) between the therapist and patient: did patient feel put down by therapist’s power games [see post of 11-1-18] in the previous session, to which the patient replied that she now felt more equality between herself and her therapist. It was after making explicit this equality that the patient was about to share with the therapist how the therapy has been helpful.

Monday, November 5, 2018

Vote for Health, Mental and Physical

Childhood experiences become neurochemical as well as can affect gene expression. Stress, via, e.g., cortisol production, affects brain and other body chemicals, and triggers readiness for fight, flight or freeze reactions through the vagus nerve --Cranial Nerve X -- which travels to the heart, blood vessels, lungs, and other vital organs via its sympathetic and parasympathetic branches. [The vagus nerve, really a pair of them, is the longest nerve of the autonomic --  ‘automatic’ -- nervous system.] Children who experience protracted stress (domestic violence, physical and sexual abuse, death or separation form a needed caregiver, chronic misattunement, etc) trigger these fight-flight-freeze reactions and ‘prime’ or ‘kindle’ the vagus to react more and more quickly as the child ages. Chronic stress affects the development of the hormone receptors in the brain, causing a problem with the stress regulation system. Stress also impairs the immune system leading to problems like infections and cancers, and stress elevates the inflammation response causing greater risk for all kinds of physical diseases (cardiovascular via C-reactive protein, autoimmune, chronic pain, etc)  

Kids who grow up with violence, neglect, unpredictability and uncertainty recreate in the classroom this way of being with others and bully or get bullied. They are often [mis]diagnosed with attention deficit disorder, oppositional defiant disorder, bipolar disorder when all they are doing is trying to survive the overwhelming chaos of adverse childhood experiences (ACE). They are affectively dysregulated -- for their parents could not participate in mutual regulation-- with insecure attachments and later will be diagnosed with personality disorders such as avoidant or borderline.

Adult children of childhood trauma and ACE are more likely to suffer with anxiety disorders like Panic disorder, PTSD, and Generalized anxiety, as well as with mood disorders such as depression. But they are also more likely to suffer with obesity, cardiovascular disease, and cancer. Faulty stress regulation may cause overreaction when confronted with stressful situations, or under-reaction, not recognizing risky situations.

Adverse childhood experiences (ACE) have been studied retrospectively from data collected by Kaiser Permanente in California and prospectively in Dunedin, New Zealand with an n (sample size) of a thousand. What was found is that children with a history of 4 or more ACE grew up to have greater risks for mental and physical disorders, including, but not limited to, depression, anxiety, suicide, cardiovascular disease, cancer, and substance abuse.

If we spend all kinds of money to prevent and treat cancer and heart disease, etc, why don’t we get serious about prevention and start by supporting mothers (and fathers) in such a way as to solve homelessness, food insecurity, domestic and gang violence, childhood sexual abuse, insecure attachment, and the many other adverse childhood experiences? Early trauma produces lasting changes in the brain and the body. Social problems as it turns out are neuro-chemical. So, when we vote in the USA on Nov 6th, 2018, we might think to vote for health, mental and physical health and for programs that diminish ACE.

Friday, November 2, 2018

Continuing Case Conference, continued

Power Games [TBIPS’ Continuing Case seminar] Part II

The patient accuses her therapist of playing “power games” [See post of Nov 1, 2018] in response to a connection the therapist tries to make between the patient’s acting out (destroying property) and feeling abandoned by her mother. The therapist also sees the behavior as an enactment for, when the patient was abandoned repeatedly by grievance misattunement on her mother’s part, the patient felt destructive violence had been done to her, her sense of self, her going on being. -- [When bad things happen to us, we feel ashamed, as if it were our fault.]

When the therapist makes a repair, and remains serious, the patient apologizes and looks ashamed. The therapist, reflecting later on the session, wonders if the shame had not been co-created, for the therapist had felt a need to regain control of the session. Perhaps the therapist had been too controlling, lending validity to the patient’s complaints about power games.

The therapist notes her and her patient’s strong tendency to have to be right. The therapist recalls that the patient had once said that her friends accused her (the patient) of playing power games. The patient is very articulate in being able to ‘put down’ the therapist when she feels the therapist is engaging in mind games. One classmate notes how the patient’s mother plays power games with the patient, but implicitly. This may have caused the patient to be more intolerant, or perhaps frightened by, covert power games. The patient prefers fighting outright.

When the therapist tries to ‘control’ the session, induce or prematurely introduce ideas, or has expectations that the patient should see things the therapist’s way, the patient may experience implicit violence. The patient’s behavior may bring this to the fore with her explicit action. Because the patient experiences herself to need the therapist more than the therapist needs the patient -- the therapist has many patients; the patient only one therapist-- the patient may not only feel shame but feel knuckled under to the therapist’s superior power play.

Attunement and Shame  [TBIPS’ Continuing Case] Part III

The patient relates a dramatic reaction to her rejection by her girlfriend. The therapist says, “It must have been so painful, I can’t imagine how painful.” The patient goes silent. The therapist inquires about how the patient experienced the comment, for the patient seemed to become defensive. [In the past, the patient had said when friends sympathized with her: “I can’t stand it. I want to be strong.”] The patient replies with derision, “You are professional; you do your job well.”

[Did the patient experience the therapist as disingenuous? Is sympathy too alien to the patient for her to assimilate it? Did it make the patient feel weak instead of ‘strong’ and serve to humiliate her further? What do we in class miss in tone and in other implicit communication when hearing case notes?]

The class discusses. Not only does failure to attune to one’s needs engender shame [I am not deserving of having my needs met. I am greedy. I am needy. I am not important. I am nothing.] but sympathy for the patient’s suffering may also inadvertently cause shame.  What if the patient experiences attunement as pity? Pity would devalue her, make her feel ‘less than.’ [Something happened to the patient but did not happen to the more fortunate and better-positioned therapist.]

Thursday, November 1, 2018

Change precedes insight [example from TBIPS Continuing Case Conference/Course] Part I

A therapist makes an ‘interpretation’ which is summarily rejected by the patient.

The patient’s girlfriend has broken up with the patient and the patient takes a baseball bat to her girlfriend’s living room. (Some history: In high school the patient’s parents had disapproved of her homosexuality and immediately sent the patient to a different school upon learning the patient had a girlfriend. In college, the patient had belonged to an anarchist group which occasionally destroyed the property of capitalist institutions. The patient experienced her mother as abandoning and misattuned.)

Upon learning of this patient’s rageful breaking up of the girlfriend’s property as a result of their breakup, the therapist tries to explicitly link the patient’s violent reaction to the patient’s college interest in the anarchy group and to her mother’s abandonment. This ‘interpretation’ enrages the patient, “Stop playing power games with me with your irrelevant pseudo-interpretations!”
[What is an interpretation, different from clarification, confrontation, musing aloud? One participant in class notes it is a way to find meaning, to explicate meaning; it is a hypothesis. Another participant, recalling the traditional idea of ‘making the unconscious conscious’ says it is a way to bestow insight, to bring the intention into awareness. Some contemporary theorists say change in experience and behavior precedes insight. See example below.]

The therapist recognizes her misstep and ‘back pedals’ [Mitchell] saying that maybe she misstated or gave her idea too much weight or maybe was wrong entirely. The patient calms [an example of mutual regulation, see Part II in next post] and becomes her usual, joking self, but the therapist remains serious. The patient then looked ashamed and apologized [for being frivolous or cavalier]. However, the patient subsequently expresses a wish that her own mother would take her seriously, for her mother is always blithe and one cannot have a serious conversation with the mother.

How did the therapist ‘decide’ not to join the patient in her more jocular tone? It was not a conscious decision but the therapist did have previous knowledge that the mother could not take the patient seriously. The therapist’s ‘failure’ to join in with the patient’s jocular state of mind turned out to be a fortuitous, intuitive response because, in providing a different experience-- a different way of being-- with the patient, the patient recognized the longing to be ‘seriously’ connected to [recognized by] her mother.

One class participant wonders if perhaps looking ashamed had really been looking surprised, taken off guard by this peculiar/alien experience, or even looking relieved to be finally taken seriously. The felicitous outcome was that the patient was now aware of something hitherto unformualted; now she knew what it was she wanted. [Here is the example of a change in experience being followed by the insight.]

Thursday, October 25, 2018

Women and Picasso

Pablo Picasso (Oct 25, 1881 - Apr 8, 1973) is probably the most famous painter of the 20th Century.  His diverse styles in his paintings, drawings, sculptures, and ceramics exteriorized his relationships and changed, like his houses, with the women who inspired him. His art chronicled these women and his life.  He was born in Malaga, Andalusia Spain the first child of Don José Ruiz y Blasco, an art instructor, and María Picasso y López. The family moved to Barcelona after the death of his sister when he was seven years old. Later he would deconstruct the female form to abstraction. He would have two wives, but many mistresses, and he both adored and abused women.

Picasso at age sixteen moved to Madrid to study, 
then at nineteen to Paris with his friend Carlos Casagemas. 
The suicide of Casagemas in 1901 
over Picasso’s model Germaine Florentin Pichot 
began Picasso’s Blue Period (1901-1904).

La Vie. (Life)

It is said that his model Madeline 
relieved his depression, and 
inspired his Rose Period (1904-1906).


It is rumored she aborted his child.

Mother and child.

In 1904, Picasso meets Amelie Lang (Fernande Olivier)
his muse for seven years. Her likeness appears in 
Les Demoiselles d’Avignon. 
One of Picasso’s most famous 
african influenced paintings
--perhaps his first cubist painting-- 
it shocked his contemporaries 
by its style, scale and subject matter (prostitutes in a bordello), 
but it transformed modern art.

In 1907 he and Georges Braque define and proliferate 

Girl with mandolin.

Beginning an affair with Eva Gouel in 1909,
he leaves Fernande and Paris in 1912, 
joining Braque in Sorgues. 
Braque is conscripted in WW I, 
and Eva died of tuberculosis in 1915.

      I love Eva. 

Eva and Picasso.

In 1917, while designing a ballet set with friend Jean Cocteau, Picasso meets his first wife ballerina Olga Khokhlova. She introduces him to the glitterati of the day, Chanel and Stravinsky, and others. They marry in 1918, and though she refuses to divorce him, he leaves her and their son Paulo. She had been his model and muse throughout his neoclassical period. 

His family had been transformed into giants.

In 1927 he began an affair with seventeen year old Maria-Therese Walter. Happy, he brings new colors to his work. In 1930 Picasso purchases Chateau de Boisegeloup for sculpting Maria-Therese. He brought Olga there to live in 1932. Maria-Therese gives birth in 1935 to Maya (Maria de la Concepcion) named after Picasso’s dead sister.

Maria-Therese would kill herself four years after Picasso’s death.

After Maya’s birth, Picasso began an affair with photographer Dora Maar in Paris. Fascism is on the rise. The tragedies of the Spanish Civil War compel Picasso to paint his most famous bombing of Guernica in 1937. It is a black and white painting of despair. 

Dora remained his muse in the dark days of occupied Paris.Painting of Dora
                    Maar, 1938

In 1946 Picasso moves to the south of France with Francoise Gilot, an art student forty years younger than he, and is happy again. 
La Joie de Vivre.

He purchases La Galloise, and he sculpts and paints at the Factory (La Furnace). He creates ceramics at Madoura’s. Francoise gives birth to Claude in 1947, then Paloma (she is named for Picasso's work with the global peace symbol, the dove of peace) in 1949. Francoise tolerated his wife and former mistresses until she left him in 1953 (and later married American physician-researcher Jonas Salk).

Picasso met Jacqueline Roque in 1953 at the Madoura. After the death of Olga, she would become his second wife in 1961.  Picasso was 79. He portrayed Jacqueline in his work more than any other woman in his life, painting seventy portraits of her in one year. 

Picasso died April 8, 1973. They were together all total twenty years. After arranging an homage to his work, Jacqueline killed herself in 1986.

[Please forgive that I call all the women by their first names, while Picasso is denoted by his mother's name].

Tuesday, October 9, 2018

Peer supervision in continuing clinical case

A therapist is terrified that her suicidal patient, with attempts in the recent enough past, will actually end her life this time. The patient is hospitalized by family members when she attempts to kill herself at home. The therapist is relieved, but only a very little. The patient might still come back to the therapist and they might then recommence with the helplessness. The therapist feels alone. The patient might not return to the therapist’s office; Many psychiatrists and many medications have failed this patient before. Perhaps the patient holds on to the fantasy of omnipotence. I am so bad, so damaged, so ill, that no one can help me.

Perhaps the therapist is so angry at this patient for frightening her all these months and for making the therapist feel so incompetent for so long. The therapist is frightened now. The patient might kill herself; The patient might come back to treatment. Maybe the therapist has implicitly communicated ‘Don’t come back!’ as all the patient’s previous therapists may have done. Perhaps the therapist is ashamed of being angry, wishing the patient gone, hating the patient. Could this be made explicit? [Making the implicit explicit is not the same as making the unconscious conscious.] Could the therapist someday tell the patient, ‘Sometimes, when I feel incompetent to help you, I think I hate you. Sometimes you probably hate me, too, when I am so incompetent to help you. I expect our relationship will survive this hate, too.’

The patient herself might feel terribly guilty and ashamed that she hates. Hates her own children. Hates her therapist-who-is-only-trying-to-help. Mothers aren’t supposed to hate their children. But what a difficult job mothering is! How could exhaustion and tears and helplessness to live up to such expectations not engender hate sometimes? Just a little hate. Alongside love. Complicating things for the patient may be the childhood belief that her own mother didn’t love her. Afterall, her mother was dissociated and preoccupied with her own childhood trauma. A child does not know why a mother is not attentive and joyful. The child thinks, ‘Perhap it is my fault. I am unlovable. ‘Do unlovable people even deserve to live?’ she might, all grown up, question, but know ‘in her bones’ the answer: No. Complicating factors might be that the mother loved and hated her daughter (the patient), wanted her to sometimes go away.

Perhaps making hate explicit, and contained, signals to the patient that hate is felt by everybody. It is nothing to be ashamed of. We all feel it sometimes. It is nothing to be frightened of. Relationships can weather it.  Perhaps the sharing of the contents of the therapist’s mind -- ‘when I feel incompetent to help you’ -- disabuses the patient that her own mother’s hate was all the patient’s fault.

Complicating things for the therapist is the loss of a former patient by suicide while in hospital. The therapist had learned of that patient’s death during a work day. The next patient is here.* No time to grieve. The mother of that dead patient hounds the therapist with phone calls intimating blame. Can the therapist bear another suicidal patient after such a trauma? Complicating things for the therapist is the therapist’s own history in childhood of trying to save important others. I can’t leave behind my omnipotence. I can save them all. And Don’t be silly. Know my own limits. Or Let some people die. I can’t save them all.

*Again, do we make explicit to the patient what s/he may already implicitly know? The therapist is different. Is it me? Perhaps the therapist says something like, ‘You may sense that I am a bit off today. It is a personal matter. I am willing to power through if that suits you or we can reschedule. What do you think?’