Wednesday, February 27, 2019

Polarities, Attachment and Personality Development

Blatt's & Levy's paper provides a broad theoretical matrix concerning the contribution of attachment theory, psychoanalysis and developmental research to personality development, as well as provides a basis for the conceptualization of psychopathology. They also elaborate a fuller developmental perspective in understanding the insecure attachment patterns as they pertain to the psychoanalytic view of mental representations and to Bowlby’s Internal Working Models. Additionally, the authors focus on integrating the multiple polarities that exist in attachment patterns, especially that of separation [autonomy] (avoidant attachment and introjective processes)  vs. attachment [connection/relationship] (preoccupied and interpersonal processes), and internal workings models (cognitive vs. developmental), mental representations and psychoanalysis (drives - object-representations).

Specifically, a clinical and research overview is given to demonstrate the polarity concerning the development of personality. Blatt et al suggest as fundamental dimensions in personality development  relatedness and self-sufficiency; Freud (1930) the urge toward happiness (egoistic) and the urge toward union (altruistic); Loewald (1962) separation and union; Balint (1959) connectedness (ocnophilic tendency) and self-sufficiency (philobatic tendency), Shor and Sanville (1978) intimacy and autonomy; Adler (1951) discussed the balance between social interest and self-perfection; Rank (1929) both self-and-other-directedness; while Horney (1945,1950) defined personality organization as either moving toward, moving against or away from interpersonal contact.  Other non-psychoanalytic personality theorists such as Angyal (1941,1951) discussed surrender and autonomy as two basic personality dispositions. Similarly,  Angyal, Bacan (1966) defined communion and agency; McAdams (1980,1985) and others described themes of intimacy and themes of power; Wiggins (1991), agency and communion. Spiegel & Spiegel (1978) noted two basic forces in nature- fusion and fission, integration and differentiation. Most theorists consider relatedness and self-definition as two independent processes, while others consider them as antagonistic or contradictory forces.

The authors -- in accordance with Erikson's epigenetic model of psychosocial development -- propose a dialectic, synergistic interaction between self and others and conceptualized personality development as involving two fundamental parallel developmental lines, the anaclitic or relatedness line and the introjective or self-definitional line. Based on these two lines, they define two distinctly different configurations of psychopathology. The first are the anaclitic psychopathologies which  primarily use avoidant defences and involve preoccupation with interpersonal relations, and the second, the introjective pathologies, are primarily concerned with establishing and maintaining a viable sense of self and tend to use counteractive defences.
Several studies have shown that anxious-resistant attachment is associated with an anaclitic/dependent type of depression, while avoidant attachment with an introjective/self-critical type of depression.

[Accordingly, the authors describe two subtypes of Avoidant attachment: the dismissive avoidant and the fearful avoidant, with the latter having more differentiated, complex mental representations and thus are considered to be developmentally more mature; and two types of Ambivalent-resistant: the compulsive care-seeking and the compulsive care-giving.] The disorganized style of attachment is based on Hesse & Main's research. They associated this type with the parental unresolved fear, defining two types of children's behavioral responses: the controlling punitive and the controlling-caregiving.  Lyons-Ruth also distinguishes two subtypes of Disorganized attachment resulting from two types of parental behavior: Disorganized Approach have mothers who are helpless-withdrawn [frightened], and Disorganized Avoidant have negative-intrusive hostile [frightening] mothers. There was a history of early trauma in these mothers, physical abuse or witnessing violence in D-Avoid mothers, and sexual abuse or parental loss in D-Approach mothers.

Lastly, Blatt and colleagues -- incorporating psychoanalytic theory, the cognitive developmental perspective of Piaget and Werner, and cognitive-affective components of mental representations for the self and other -- developed scales (The Early Memories Test, the Objects Representation Scale for Dreams, and others) for assessing the development and impairment of self and object representations. Their main goal was to examine the content and structure of mental representations (internal working models) in different types of attachment patterns, concluding that different developmental levels can be identified in the representations of individuals within each type of insecure attachment which offer explanations about the relationship of attachment classifications to various types of psychopathology.

-Ageliki Tsikli, Candidate, TBIPS

Blatt, S.J. and Levy, K.N. (2003). Attachment Theory, Psychoanalysis, Personality Development, and Psychopathology. Psychoanal. Inq., 23(1):102-150

Tuesday, February 26, 2019

Utilizing Attachment Theory with Adult Patients: Disorganized-Unresolved

Toddlers classified by the Strange Situation [Ainsworth] as having a disorganized attachment pattern [Main] usually had caregivers classified as unresolved on the Adult Attachment Interview [Main]. The unresolved caregiver can appear to the infant frightened or frightening, with dissociation as a hallmark of their own unresolved trauma. The trauma may be event trauma (war, separation, abuse) or relational trauma (chronic misattuenement, humiliation, or emotional abandonment). Persons with PTSD, dissociative disorders, and personality disorders with dysregulation of affect all could suffer from unresolved traumas.

Trauma unresolved can be ‘frozen’ in time and unpredictably experienced as if occurring in the present moment. It causes discontinuities in memory because overwhelming affect at the time of the trauma caused the amygdala to ramp up emotional, sensory, procedural memory storage but decreased the activity of the hippocampus, vitiating the hippocampus’ ability to give context and language (event memory) to the trauma. Without words and context the trauma remains inaccessible in the treatment situation except through its procedural and affective expression via enactments between the patient and the therapist.

The treatment situation offers a safe, reliable, intersubjective (i.e. respecting the agency of both participants) context -- different from experience with early, unreliable caregivers -- in which ruptures can be repaired and trauma can eventually be resolved. Mentalization, a necessary step away from psychic equivalence and on the road to developing intersubjectivity, is fostered by sharing -- always with the aim to protect the patient from shame, injury, intrusion -- the contents of the therapist’s mind.

Wallin, D.J. (2007) Attachment in Psychotherapy Chapter 14. (Guilford Press, NY)

Tuesday, February 19, 2019

Utilizing Attachment Theory with Adult Patients: Ambivalent-Resistant/Preoccupied

While dismissing patients avoid feelings and avoid closeness with others, the preoccupied patient is driven by fear of abandonment and seeks closeness by any means.  Toddlers classified as ambivalent-resistant in their attachment styles learned that attachment figures are too preoccupied to be consistently available and responsive to the child’s needs for e.g. regulation of distress. Consequently, the child learned to be overly demonstrative about distress in order to receive much needed attention. Unfortunately for the patient, this pattern often includes low self-esteem and difficulty trusting others. Likewise, they may be helpless and demanding, and range from appearing histrionic to borderline.

When working with preoccupied patients, the preoccupied therapist may have the urge to rescue the helpless preoccupied patient [identifying with the need] or to abandon the angry, demanding one [another enactment]. Preoccupied therapists with their own abandonment fears may be unduly hurt or angry with devaluing patients, finding it difficult to ‘survive’ [Winnicott] when working with patients to whom they seem unimportant; They may feel the dismissing patient’s devaluing complaints are justified and, thus, avoid -- out of shame-- exploring the relational pattern being enacted. (Or the preoccupied therapist may feel uncomfortable with the dismissing patient’s idealization such that the therapist might prematurely disabuse the patient of this idea without first discussing the function this idealizing behavior served for the patient.)

The preoccupied patient is in need of a therapist who is consistently emotionally available and responsive, a therapist who does not mistake the patient -- seemingly readily in touch with feelings -- with a patient who is confidently able to manage those feelings. Therapists must not dissociate their own fears of abandonment and anger if they are to see the distrust and fear of abandonment that may underlie the patient’s compliance. Instead, the preoccupied therapist might use her empathy and own  feelings to create with the patient a now manageable experiencing of relationship and feelings.

Wallin, D.J. (2007) Attachment in Psychotherapy Chapter 13. (Guilford Press, NY)

Monday, February 18, 2019

Utilizing Attachment Theory with Adult Patients: Avoidant--Dismissing

A toddler classified as avoidant --who learned s/he could not turn to attachment figure(s) in times of distress -- can grow up to be avoidant of genuine intimacy and dismissing of feelings in self and others. Such adults in the clinical situation often overvalue self-sufficiency and can appear obsessive (control others and fear being controlled), alexithymic, schizoid, or narcissistic. It is hard for them to expect help from the therapist and, depending on which self-state is present, may keep their distance by being angry, or by idealizing or devaluing the therapist, or by being controlling.

Therapists, too, bring their own attachment styles to the clinical situation. A dismissing therapist may collude with a dismissing patient in avoiding affect. Or such a therapist may seem cold and distant, or may be controlling. The therapist may also collude with the dismissing patient’s idealization of the therapist (the patient having the need to feel special with a special therapist, and the therapist enjoying too much the patient’s admiration without questioning the patient’s perception that the therapist needs to be “propped up.”) Power struggles with dismissing patients bring up issues of submission or of being controlling, with their respective feelings of resentment  or guilt in the therapist. With preoccupied patients, dismissing therapists may find the demands for closeness and the emotional displays too unwelcome.

We know that avoidant toddlers seem unaffected by the departure of their mothers, but actually have increased galvanic skin response, heart rates and cortisol levels. One therapist reported that she thought her patient, a divorced accountant, had no feelings or attachment toward her, but his smart watch --which kept track of his heart rate and said ‘Good job!’ after his daily work outs-- would say ‘Good job!’ at the end of sessions [patient’s heart had been racing in session though his affect had appeared stable], a reminder to follow evidence of affect as communicated bodily.

Likewise,  sharing our own affective participation with our patients can help them “integrate their own dissociated feelings.”[p. 212] Wallin advocates a balance of empathy and “confrontation” with dismissing patients. He defines ‘confrontation’ as our “deliberate or spontaneous expression of our subjective experience of what it’s like to be on the receiving end of the patient’s communication.” [p. 213]

Wallin, D.J. (2007) Attachment in Psychotherapy Chapter 12. (Guilford Press, NY)

Thursday, February 14, 2019

Relational really resonates

A candidate at the Tampa Bay Institute for Psychoanalytic Studies, a contemporary institute which emphasizes relational and interpersonal ideas, recently attended a conference on shame in another major city. The presenters were mostly classical/Freudian analysts. A case session was presented and discussed. The TBIPS candidate was flabbergasted to hear how others thought about the female patient, and he felt very isolated when all the attendees seemed to agree with what they were hearing from the discussants. The candidate had learned to listen in a different way from Freudian analysts. He was thinking about attachment, a second year course taught here at TBIPS in which he is currently enrolled.

This particular female patient had been separated at birth for many days due to a postpartum illness in the mother. On reunion, the mother did not believe the baby returned to her was her baby. Then, due to a death in the family and other catastrophes, the girl was separated from her parents again for three years.

In the session presented, the female patient came late and then asked for some water. The Freudian analysts all commented that she was a very aggressive patient. When the patient asked the therapist ‘what do you want me to talk about?’ the discussants reiterated what a very aggressive patient she was, ‘trying to control everything.’ The analyst remained silent and the patient began to talk about things in her life and the discussants complained that she was spewing ‘useless’ information, information of no value or importance in attempt to ‘disorient’ and confuse her therapist. They complained that she did not talk about her trauma and so did not allow them to give interpretations that would ‘create space’ inside of her.

The TBIPS candidate was bewildered by the comments, for the patient had, to him, been saying very meaningful things. She had been talking about her school days when she had always felt forgotten by others, for example, her name being left off the class rosters such that she had not even been assigned to a classroom teacher. The candidate felt the patient was talking about the trauma, about having been ‘forgotten’ by her own parents, left out of/ absent from their minds, if you will.
The candidate, feeling the patient had been unduly re-traumatized, felt he had to speak up and add a different point of view  to that of drive theory and aggression. He thought that, just as the the patient had been raised in a family where her feelings had no value for her family, so, too, had the analysts been seeing her words as valueless, and the therapist had been feeling ‘useless’ to ply the wares of the classical analytic trade, interpretation. The candidate wanted to think with the attendees about the need to establish between therapist and patient -- a patient with attachment traumas -- a secure attachment, a safe space from which to explore one’s inner life.  

The candidate had been disappointed by the conference. It had seemed unimaginative, lacking in curiosity and narrow in its scope, failing to take into account infant-caregiver research and attachment theory. I was sorry for the candidate’s suffering through that seminar but inordinately proud of his broadened perspective, as if TBIPS courses had ‘created space,’ opened up something inside of him.

Wednesday, February 6, 2019

IMHO and Film: Roma

I don’t think of a movie as ‘good’ based on my enjoyment of it. (My enjoyment does not mean it a good movie. I might enjoy a romantic comedy even while finding it predictable.)  A ‘good’ movie, for me, is intelligent or provocative or beautiful or juxtaposes disparate elements such that I think about something in a new way. I like literary elements -- foreshadowing or metaphor -- to be subtle. Sometimes I don’t mind being hit over the head with something if it is in spoof (such as the cartoon-blood scenes in Tarantino’s Kill Bill). I like to be gripped, engrossed, feel the delight or the suspense or the tension. I like to be surprised.

This is not a year with a lot to choose from. Not like 2017 which had Three Billboards, Shape of Water, Get Out, Lady Bird, Mudbound, and more excellent films. Even so, I do not understand how A Star is Born was so copiously nominated. The only interesting note in that film was -- after having previously heard Bradley Cooper say in an interview that he wanted his character to have Sam Elliot’s voice and so practiced using Elliot’s voice --- Cooper’s singer Jackson Maine telling his older brother Bobby (played by Elliott) that it was Bobby’s voice he’d always wanted.

With Roma (2018, written and directed by Alfonso Cuarón) -- nominated by Academy for Best Picture, having already won Golden Globes for Best Director and Best Foreign Film-- I did not know what to expect, and I liked that. While I was uncertain why Cuarón lingered on certain scenes for as long as he did -- I did not always get their significance, even in retrospect-- still I found the images compellingly lulling. The opening scene of soapy water repeatedly being sloshed across bricks set me up to expect redemption or a cleansing of some sort. But none came. So I imagined it meant that Cleo (Yalitza Aparicio Martínez, nominated for Best Actress -- as is her female employee, played by Marina de Tavira) was the one to wash away all the shit (the brick walkway was continually littered with dog shit) which in her quiet, soulful way, I guess she did. As the camera takes in more we see the brick floor is a courtyard which, as we watch Cleo walk with her bucket through it, we note numerous caged birds. Will she turn out to be a caged bird? Later, I pondered the metaphor of the broken vessel, spilling pulque (a disgusting -- IMO-- , viscous, fermented --alcoholic--beverage made from maguey/agave juice): was the unwanted fetus’ male progenitor’s seman the pulque? was its spilling a protection of the developing fetus whose pregnant mother should be avoiding alcohol?

The juxtaposition of disparate elements: Cleo is the servant, an Indigenous, quiet, brown, young woman from Oaxaca (wah-ha-ca) working for a white, Mexican family with four children. She is both a caged woman and the one who is most at peace, most free if you will, with her calm strength, her courage. She is the only one of many able to hold the yoga pose, the tree with closed eyes. And she saves her wards from drowning. Bearing with equanimity-- all traumas in the film are born thus, as if matter-of-fact, daily life-- an earthquake, a fire, an abandonment, and a death (for which -- with use of magical thinking/psychic reality -- she feels guilty, until bathed in the love of her employers.)
This film portrays class/race disparity: the servants who are brown and the middle class whites who employ them. There is also a feminist element: a mother abandoned by her physician husband and receives no child support for their four children; a pregnant, young woman whose boyfriend disappears upon learning of the pregnancy; Her obstetrician reassures her this is not uncommon.

I was completely engrossed by the quiet, plodding Roma -- a Ravel’s “Bolero” that never get louder -- wondering what would happen next. I was delighted by it being a ‘period piece’ set in Mexico City in 1970-71 and shot in black and white. Cuarón was ten years old in 1971 and the film is purported to be semi-autobiographical. ‘Roma’ refers to the district in which he grew up, Colonia Roma, filmed, in part, of the street where he grew up. Cuarón includes the June 10, 1971 Corpus Christi massacre in the plot as nonchalantly as all the other events. His equanimity I found fascinating. [Perhaps as a boy he had felt secure attachments and safety while the world outside swirled about.]

Cuarón also directed and co-wrote Y Tu Mamá También (2001), Children of Men (2006) and Gravity (2013), and directed Harry Potter and the Prisoner of Azkaban (2004). He is the first Latin American director to win the Academy Award for Best Director (for Gravity).

Sunday, February 3, 2019

Daniel Shaw on Traumatic Narcissism

Daniel Shaw advocated for transparency and demystification when speaking to the Tampa Bay Psychoanalytic Society, on Saturday, February 2, 2019, about traumatic narcissism. He noted patients can benefit from both psychoeducation about the therapeutic process and from understanding of how negating, narcissistic parents can make both separation and connection unsafe-- engendering a disorganized attachment, Mary Main’s ‘fright without a solution.’  Likewise, patients can benefit from understanding something about the analyst’s mind. One part of psychoeducation includes how narcissists disavow and project their own shame and dependency needs, then degrade the other (child, follower) in order to uphold their own delusions of superiority and grandiosity.

Shaw, himself a cult survivor, became interested in how sociopathic, malignantly narcissistic leaders fashion their abusive, exploitative relationships with their followers. He came to recognize that families, workplaces, houses of worship, and politics can also function like cults, where a charismatic leader denigrates others to preserve the delusion of omnipotence. The traumatizing narcissist grooms others to believe that they are the ones who desire what it is that the traumatizing narcissist is desiring. The relationship of the traumatizing narcissist is subjugation, and it is maintained through shame and fear. Sometimes patients may want to subjugate themselves to an idealized, ‘omnipotent’ therapist, while a therapist may prefer to negotiate power and authority. In moving toward transparency, the therapist may eschew defensive opacity and not be the silent, still faced analyst of old who turned the patient’s complaints back on the patient.

The negating, narcissistic parent calls the child ‘selfish, weak, immoral’ for having needs. Only the narcissistic parent’s needs are valid. They do not apologize or admit wrong doing. There is no recognition of the child’s subjectivity. Abandonment is a looming threat. The child may then grow up to disown her/his childhood rather than feel its shame (as Eugene O’Neill did ). To survive, the child  may also externalize their shame and dependency, later becoming traumatizers themselves; or they may internalize the ‘badness’ [Fairbairn] and remain objectified and subjugated in subsequent relationships. Just as the child was ‘gaslighted’ by the parents who denied their cruelty, so, later, the rejected, betrayed part of self may give way to the traumatizer part of the self which attacks and blames the self (‘It’s your own fault.’) or others (who can never do enough to compensate for what has been done to the child self). In therapy, these multiple, disparate parts may be encouraged to be in conversation with one another, so that disavowed shame might be openly mitigated and defensive grandiosity might be tamed.