Friday, October 27, 2017

Meadow's "Treatment Beginnings"

An elegant, little paper from 1990 by Phyllis W Meadow, simply titled “Treatment Beginnings,” shows the author’s perspicacity about contemporary psychoanalytic ideas. She encourages the therapist to consider “[w]hat quantity of stimulation will help the patient to be in the room with me and to talk.” [‘Quantity of stimulation’ is what is noted in infant research re: regulation: up or down, to engage or sooth, respectively, the  infant.] She writes, “the initial phase of treatment is… creating an environment in which the patient can give up his resistances to talking in the presence of the analyst.” Contemporary analysts might substitute for “give up his resistances...” the words ‘feel safe and participate in building a relationship,’  but the author’s meaning is clear: “Creating the relationship that will be therapeutic is the primary task of the analyst…”  It is the analyst who bears the lionshare to create the safe space and to keep the process alive. (Winnicott described the good-enough mother who adapts the environment to the infant’s needs.) Meadow’s ideas about awareness of the patient’s “patterns for making contact” speak to a utilization by the analyst of relational paradigms. In fact, she states explicitly, “change takes place within the doctor-patient relationship.”

I am particularly fond of her stating that “The projector does not need a contradictory perception…” because I think it speaks to the idea that the patient first needs us to join with him, to welcome his perspective [and only later, when intersubjectivity is accessible to the patient, introduce our otherness.]  Recently a patient accused me of being “vindictive and treacherous” which I could not initially wrap my head around until the patient added that she believed I was plotting with another patient to kill her. Owning that all of us have murderous impulses, I then could understand my treachery. Wearing her attributions, instead of contradicting them [Note: if I had contradicted them even silently, with right-brain to right-brain knowing she would have felt my opposition] had the effect of calming her fright. She was calmed somewhat perhaps because I was not contradicting her, not challenging her beliefs, not murdering her agency, if you will. Later, much later, in moments of mentalization (a necessary component of intersubjectivity), we were able to consider her ‘assumptions’ as thoughts, without a psychic equivalence.

Another lovely pearl was Meadow’s “Even the simplest mode of interpretation, confrontation, pointing out a patient’s behavior or explaining its effects, even this leaves the patient feeling criticized or attacked…” [and shamed, like a specimen under a microscope, less than fully human;
All interpretations in the classical sense, ‘you did this ---  because of that ---’ may serve to humiliate and criticize.] Meadow notes that such confrontations “may intensify self-doubts.” Don’t many of our patients already come to us with a history of having their hard-wired capacity for reading the intentions of others vitiated by parents who scolded, ‘You don’t mean that!’ or ‘You don’t feel that way.’? When analysts want patients to question assumptions and erroneous beliefs, we hope to find a way for the exploration to be a collaborated effort which includes the patient’s curiosity and not just our own ambitions. Meadow wrote, "More important than progress is the ability to resonate with a patient..."

Meadow, PW (1990)Treatment Beginnings. Mod. Psa. 15: 3-10.

Monday, October 23, 2017

Group Process

On Oct 21, 2017 Jeffrey Roth provided to the Tampa Bay Psychoanalytic Society an organizational group process consultation [akin to Tavistock groups]. Here were some of the things to be gleaned:

Groups are fertile ground for primary process. [By this, Roth meant sexuality and aggression, seeming less interested in attachment and affiliation.] Just as in individual treatment, there is the stated task and the “covert task” [explicit and implicit]. All that transpires is “data” [fair game, in this case]. There are no ‘as-ifs’--psychic reality is the reality of the group. Differing narratives are not destructive, but combined toward greater understanding. Individual members are ‘elected’ by the group to hold certain characteristics and affects [projections; projective identification] such as the inept one, the angry one, etc. This leaves the one doing the projecting bereft of being able to utilize that characteristic or feeling. What one member says about another is a disguise for what the speaker feels about her/himself. One question is to reflect on whether a projection serves to make the group more or less functional. Ideally, a well-functioning group is one which works to own its projected parts.

References by the leader to any individual is really a reference to the role that individual is playing on the group’s behalf. Issues of boundaries and autonomy come up. The leader speaks to the process of the group, removing the target off any one member. By questioning a member’s complaints of, for example, not having a voice or not wanting to be unkind, the leader challenges the abdication of agency by the complaining member. [Tavistock groups can serve to train leaders, facilitating recognition of what one is ‘made of’ and examining impediments to agency.] “False stupidity” [disavowal] or false muteness may serve an individual by hiding competitive strivings, avoiding risk of rejection, avoiding shame for competitive strivings or from rejection. The leader would amplify the implicit voice, eg. complaining someone was ‘long-winded’ might be interpreted as meaning a “wind-bag” and wanting to say, “Shut the F--- Up!” The leader added that, by the way, a windbag can fill the sails of another(‘s sadness, e.g.).

The group leader seeks “authorization” from the group or a member to make an interpretation about what is going on in the group. Roth would often say “pause” to stop the group and invite it to reflect. If leader does not stop to point out what is happening, then the leader is colluding. The leader does not assume to understand what any member or the group but instead offers hypotheses. He encourages each member to check out their hypotheses with other members. A leader who criticizes is not functioning well in the leader role. When asking questions, the leader reiterates that one is free to answer or not answer. “Experiments” are proposed, e.g. asking one member to speak in the voice of another member’s voice or role. The leader encourages the group to celebrate when an individual is willing to share her/his pain in service of the work of the group.

Friday, October 20, 2017


Bromberg writes that dissociation is both a structure and a process; it can be pathological--in its extreme, DID: Dissociative Identity Disorder, formerly known as Multiple Personality Disorder-- defensive, or normative, the latter occurring ubiquitously and a part of everyday life, such as putting aside our maternal selves while performing open-heart surgery or when we drive home with no memory of how we got from point A to point B.

When we think of dissociation as sequelae to attachment (relational) trauma, or to traumatic events, we consider overwhelming affect-- unmitigated, unshared, unsoothed-- that threatens to disrupt one’s sense of ‘going on being’ or continuity of self. Bromberg writes:

In order to preserve the attachment connection and protect mental stability, the mind triggers a survival solution, dissociation, that allows the person to bypass the mentally disorganizing struggle to self-reflect without hope of relieving the pain and fear caused by destabilization of selfhood.

Often patients have complained that they would feel ‘weak’ or ‘too dependent’ if they expressed their need for comfort (for shared affect) from an important other. Bromberg reminds of us the double shame inherent in the psychoanalytic process: the shame that comes from both seeking solace and from the belief that their needs are illegitimate, unreal to the other, and thus that the patients themselves are unreal and risk losing the attachment bond. He reminds us that, if the analyst does not recognize the patient’s desire to communicate to us the dissociated parts of the patient’s self, then the patient will continue to feel her needs are illegitimate and undeserving of solace.

Bromberg, P (2011) The Shadow of the Tsunami. Ch. 2. Routledge, New York & London.

Wednesday, October 11, 2017

A Dream, about Agency?

or what the Continuing Case course participants make of a dream.

A man in his mid thirties, a successful professional in a helping profession, has been working on trying to change about himself his ‘passivity” and there has come to light a hint of his resentment about having had to be so passive all his life, passive viz a viz his parents, and his parents viz a viz his grandparents. In an earlier session he had shared how ‘coming out’ years before to his mother about his homosexuality had sent her --two hours later-- to the hospital. The man brings to his male, heterosexual, therapist the following dream:

              I am at the funeral of my parents and I don’t feel connected to the loss of them,
              and I am worried that others will see that I am not sad, that I am disconnected
              from loss. My ex-boyfriend and my cousin are also at the funeral and the priest
              will not allow my cousin, because she is female, to sit with me, because women
              must sit separately from the men. I get the priest to allow my cousin to sit by me.

The patient then begins to talk about how, if his parents were dead, what he would do with all the money, items, and property he would inherit. He would sell what did not fit or what was a burden and keep only what was precious to him. Perhaps, with all the money, he would not have to work anymore.

One candidate noted in this dream the patient’s previous theme of exposure: others would know his thoughts and deficiencies, and the patient would feel shame. Funerals are about death, but this patient has felt enlivened by the therapy.

This dream could be what Kohut might consider a self-state dream, heralding a change in the patient’s capacity to be active: he asserts himself and gets the priest to allow his cousin to sit by him.

Does the priest represent his father? His strict grandfather who made the father acquiesce? The patient is able to get this traditional priest to make an exception for him. Does the patient feel, though, that he must emotionally kill off his parents if he is to be able to assert himself? Or must kill them off if he is to be with his own feminine selves (sit with his female cousin)? Or does the dream also speak to his fear of loss of relationship if he were to assert himself and, also, if he were to be with his feminine self? Is it a forward edge to be able to assert himself, free himself from his parents? Ideally, would we not wish intersubjectivity for him (to be himself while in relationship with others, that is, to have both agency and negotiated relationships)? And what about the oedipal aspect of a male authority figure keeping him away from the female relative?

A rich and lively discussion for the presenting candidate to add to his experience with the patient and this dream.

Wednesday, October 4, 2017

“Mirror in the sky, what is love?”*

In discussing an analytic attitude with beginning trainees, I find analytic love and hate must be included. Analytic love is not to be confused with romantic love or parent-child love. As part of analytic love, I advocate for a welcoming attitude. Natterson elaborates 'what is love.' While not  having repeatedly made explicit throughout his paper -- to remind the reader what he means by love -- Natterson nonetheless defines it early on (p.510), relying on Hegel and Honneth: “love is a relationship of mutual recognition.” [I love that definition!] Another excellent ‘definition’ appears towards the end of the paper (p.520), this time from his patient: taking in and honoring the patient’s experience. [welcoming, if you will]

Recognition of our subjectivity, by a parent able to hold us in mind (Bion/Winnicott) and able to survive (Winnicott) our attacks, begins in infancy. Intersubjectivity, an always precariously held position, will inevitably fall to the side of treating the other as an object (called ‘negation’ by Benjamin), and we must continually right ourselves back to subject-to-subject relating. Doing so is an act of love. Despite love, there will be moments [or days] when intersubjectivity will fail and will cause the parent, lover, friend, or analyst to treat the other subject as an object: ‘You must do what I say, must meet my needs, you must sacrifice your Self in order to stay in relationship to me.’ What gives analytic love the edge is the analyst’s continued striving to be attuned to the patient’s response to us, be self-reflective, admit our contribution to ruptures, and make timely repair, that is, to re-establish intersubjectivity.

I must add that Natterson’s paper fell short for me on two counts. One was his continued use of terms like ‘individuation’ or ‘fusion.’ Dan Stern and later infant research tell us we are born individuated, not fused, not symbiotic. It is when our early subjectivity goes unrecognized (and we are treated like an object instead of a subject) that we have the experience of being usurped by the other. I doubt anyone wishes for fusion except as a way to maintain a threatened relational tie (or, momentarily, in love-making). Merger, fusion, lack of individuation are indicators of failure of recognition of subjectivity.

The other way this paper fell short for me was Natterson’s mention of the “Oedipal guilt” in his patient without including the reality of her childhood sexual abuse and its complications to the Oedipal configuration. I do not disagree that children often have a wish to marry the opposite sex parent, especially heterosexual children. It  seems to me that children who endure childhood sexual abuse require reconciliation and restitution to find a way back, as his patient did, to a loving relationship to her abusive father.

I am grateful to Natterson for providing a paper on analytic love and recognition of subjectivity.

Natterson, J.M. (2003). Love in Psychotherapy. Psychoanal. Psychol., 20(3):509-521.

*Landslide-Stevie Nicks

Sunday, October 1, 2017

Intergenerational Transmission of Trauma

We often hear that certain things, such as cocaine addiction or violent behavior, are inherited. Then there is the fascinating idea of epigenetics which, reminiscent of Lamarck, indicates that behavior can change genetic expression and can then be passed down in the genes. What seems to go under-emphasized outside psychological psychoanalytic circles is the intergenerational transmission of trauma, particularly relational (attachment) trauma. Schore puts intergenerational transmission of trauma like this: “...the infant is matching the rhythmic structures of the mother’s dysregulated arousal states.”

While two excellent, long-term studies have shown that violent behavior needs both the genetic vulnerability and the environmental exposure to violence in the home (the latter which is also a relational trauma, the relational trauma of a parent not seeing the child’s feelings, not regulating the child’s feelings, etc), why is it not also likely that drug addiction is not simply a genetic vulnerability but also a way of regulating one’s emotions? The addicted parent could not be sufficiently present to recognize, attune and regulate the child’s emotions and thus that child grows up with its own dysregulation, perhaps later likewise finding some soothing from substances. This dysregulation is not simply genetic. It is an intergenerational transmission of trauma, just like with a child who is sexually abused and unprotected and un-comforted, maybe even un-validated in her experience and pain, who grows up and becomes unable to protect her own child from sexual abuse.

A parent’s dissociated states from unbearable affect can create a dissociation in her infant (and disorganized attachment). The infant is then at risk for “a lack of integration of sensorimotor experiences, reactions, and functions” as seen in the common sequelae of somatic disorders (such as pelvic pain, fibromyalgia, migraines) resulting from childhood sexual abuse. Does one then say that sexual abuse of children is inherited? Not usually. Perhaps other behaviors, such as substance abuse, and even anxiety and depression, show up in the next generation and the generation after that because a parent who is not present (drunk, dissociated, anxious, or depressed) transmits these same self states to the infant, right brain to right brain.