Teicholz is Terrific!

Convergences In Psychoanalytic Theories
Noting the far reaching impact of constant and immediate mutual influence (as documented in infant research) on the therapeutic endeavor, Judith Teicholz, Ed.D., urged clinicians in a most collegial, small discussion group (hosted by the Tampa Bay Psychoanalytic Society, Inc. on March 6, 2010) to consider the humbling discovery that we impact patients more than we imagined and at a pace greater than imagined. This occurs outside of conscious awareness, and it is from this constant mutual influence that the structure of the self emerges. Beebe’s infant research films show that it is steady, attuned responsiveness that is ideal, and also what is continually disrupted and repaired. Being in a relationship with someone-- who is genuinely trying, over and over and over, to understand you, while simultaneously creating a new and evolving narrative -- is at the heart of therapy. In comparing theoretical positions, Teicholz recommended that our theoretical intentions be held in tension with openness to the patient’s experience.

“An Improvisational Attitude”
In her morning presentation Teicholz discussed the dialectic between safety/ trust, play, and self. Winnicott wrote that only in play can an individual be creative, and, furthermore, only creativity allows the emergence (‘discovery’ was his word) of the Self. Teicholz sees spontaneous play between patient and analyst as a royal road to self and other. Collaboration is a unique expression of an intersubjective field, belonging neither to one or the other alone, but a third created, and it requires both participants to be open to the self and to the other. Teicholz, too, sees (dyadic) play as a creative process, and necessary for a cohesive sense of self. Improvisation, a form of play, as with actors, requires taking what the other puts forth and using it, and that an improvisational attitude engenders play. The cue from an other, within relentless, bi-directional , mutual regulation, can go to places undreamed of by its initiator. Empathy too requires imagination, and Teicholz says empathy signals a willingness to play. Mutual empathy builds a relational bond, and both feel safer. Likewise, safety co-created facilitates the space for play.

Play and improvisation, then, are growth promoting. Improvisation, with its spontaneity and make believe [unquestioned as per Winnicott], in therapy is the impromptu (unplanned and unintended) provision of whatever is needed at a given moment. This is not a gratification of instinctual drive, but a necessary provision to enhance the cohesion of self and other, and to facilitate the psychoanalytic process. Improvisation is a subjective form of engagement which can open a third position in a dyadic stalemate (Ringstrom). The back and forth play in service of the patient, while strengthening the dyadic bond, expands the sense of self and one’s consciousness, creating new meanings and and facilitating growth, joy, interest, and curiosity.

Tronick writes that the human mind strives toward coherence and complexity. Two or more together create complexity, and coherence emerges when complex meanings come into place (as within the therapeutic dyad). Tronick says that to create new meaning, one must give up (or reconfigure) the old [or, maybe, hold old and new in tension?] and accept the chaos of the dyadic expansion, including via play, of the self. Teicholz adds that improvisation moves us toward the goal of creating new meanings and greater complexity, thereby enhancing cohesion of the self.

Sometimes improvisation includes mimicry in an exaggerated form, as when the mother echoes the baby’s movements, voice, or state, but in a slightly altered form, creating both the experience of being understood as well as of otherness (Fonagy et al). Because humans have the capacity to continually adapt to significant others, improvisation can dislodge (violate expectations: Lachmann) entrenched experience. But play alone is not mutative; it must be relevant, affectively salient, and occur within a ‘good enough’ dyadic experience, where one, and the other, is known in a new light. Play can reorganize experience [relational paradigms, emotional convictions, organizing principles] and enlarge the repertoire. Tropp et al write that the goal of therapy is to produce change powerful enough in one context to produce alterations in other contexts. While insight might lead to behavioral change, Lyons-Ruth and Tropp note the reverse is also true, that altering behavior [through, e.g., implicit relational knowing and through improvisation] can lead to insight.

“Dancing on the Edge”—the Forward and Trailing Edge
As if her earlier presentation were not replete enough with beautiful clinical examples, Teicholz spent the afternoon in a small group setting discussing in detail a clinical example to illustrate how important it is for the therapist to hear the patient’s point of view and to somehow make sense of it in order to understand what the patient is trying to do. The forward edge (Kohut, Tolpin) or leading edge is a striving toward cohesion and health or psychic growth, and in the transference the patient looks to the analyst for what is missing. Tolpin called the forward edge ‘the repetition compulsion of health.’ The trailing edge, on the other hand, speaks to the regressive pull of instinctual life, of what is repetitive and defensive.

While Freud may have emphasized what was pathological (trailing) about defenses, Kohut reminded us what is purposeful (forward) and protective about them. While all behaviors, including within transference-countertransference dyads, have an element of the forward and trailing, it is sometimes difficult to recognize the forward edge. Deeply hidden are the tentative outgrowths of hope for relational experience. For example, while verbal attacks on the analyst may also include a defense against intimacy, they paradoxically invite engagement. When the analyst survives (Winnicott) attacks, that is, neither retaliates nor withdraws, but keeps alive interest in the patient’s experience (a kind of ‘primary maternal preoccupation’), the forward edge of the hope for shared connection and attachment is illuminated. In the search within the dyad for the forward edge, it is incumbent upon the analyst to place the patient’s painful experience in the context of the analyst’s failure (wearing the attributions-Lichtenberg). When the analyst evokes both the here and now, and the past, increased recognition by the patient of the delineation of inner and outer, new and old, may result.

A remarkable day
was spent with Judith Teicholz, Ed.D. Not since Carla Leone visited Tampa in March 2009 has a speaker’s explicit talk been so in consonant with her/his demeanor. What was communicated implicitly by Teicholz did not contradict her papers. She demonstrated in attitude and behavior exactly what was meant by her words. How very important this is when we consider implicit relational knowing and how so much is communicated without words. [In fact, what I often think “creepy” about a person is when the implicit and explicit do not ‘match up’ (Upshaw).] Just as ongoing mutual influence transcends any particular theory, so Teicholz is transcendent in her integration. No wonder, with her ability to synthesize and utilize, as called for by the moment, varying theoretical positions, Teicholz’ has been the perfect choice to pull things together at the end of large conferences.

Lycia Alexander-Guerra, MD

On therapeutic action - From emotional availability to psychoanalytic compassion.

In addition to Orange’s (1995) initial view of empathy as emotional availability, Lachmann’s discourse on empathy (February 13th, Tampa) also brought to mind this treasure she gave us in 2006: an elaboration of emotional availability as psychoanalytic compassion. Although it is best to study this essay in its entirety, for brevity I will review here only the section on ‘Compassion as Emotional Understanding’. In footnote 4, Orange explains: “I think of empathy as a larger capacity to understand another's emotional experience from within an intersubjective field (Orange, 1995). Compassion, in my view, is that part of empathy that makes me willing and able to descend into and to explore the Dantean realms of suffering with the other.” Deriving from the Latin patior (to suffer, undergo), patient, as a designation, is not pejorative, for “a patient is one who suffers, one who bears what feels unbearable. Compassion, then, is a suffering with, a bearing together.”

Orange notes that the capacity to share the suffering of another “can gradually restore the shattered, alien-feeling, frozen, lost, dehumanized other a sense of belonging to the human community,” and therefore, along with others, Orange “would restore the concept [of compassion] itself to a central role in the “therapeutic action” discourse. In this paper, however, she focuses “on the attitude and capacity that the analyst brings to the psychoanalytic engagement.”

Not technique, and even less a rule of technique, compassion is, instead, both process and attitude. As process, compassion approximates Gadamer’s (1975) dialogic process of “undergoing the situation with the other” and arriving at an understanding, which is something Orange (1995) elucidates as emotional understanding. “Together we make sense of the patient's emotional predicament within the relational system that we experience together, and gradually this shared world changes by means of a personal reorganization of experience (of both participants)” (emphasis added).

Something that, at times, may not seem gentle or nice, and may occasionally even challenge, contradict, or introduce alternative perspectives, “[a] compassionate attitude... enables hitherto unknown and impossible forms of experiencing. Implicit and explicit forms of participation in the patient’s suffering create a world of compassion that introduces new experiential possibilities” (emphasis added). Ah, therapeutic action, how analysis cures, rendered less elusive, less mysterious!

But that is not all. “This participation, however, is a way of being-with, not a formula for doing psychoanalysis. Where there was indifference, humiliation, rejection, shattering loss, and the like, compassionate psychoanalytic understanding does not simply replace or heal by intentionally providing new experience. Instead, when the analyst treats a person as endlessly worth understanding and his or her suffering as worth feeling-together, this attitude of compassion implicitly affirms the human worth of the patient. Instead of being preoccupied with the question of the patient's recognition of the analyst as a subject, the psychoanalytic relationship accords to the patient, often for the first time, the dignity of being treated as the subject of one's own experience (the reciprocity may come later).”

And what about interpretation? “Because of their previous experience in life and in treatment, patients most often come to us expecting to be classified, judged, treated with rigidity, or exploited. If, however, we are not too intent on naming pathologies and defenses or with being right, but instead relentlessly seek to understand and accompany the sufferer, an implicitly interpretive system emerges. For me, close and compassionate listening is itself an important form of interpretation, dissolving the interpretation-gratification duality, and fully deserves to be considered psychoanalytic. It says to the analysand: "You are worth hearing and understanding." ” (emphasis added).

Orange then adds detail. “This listening involves attention to the ways the patient's experiential world has created suffering for the patient as well as for others in the patient's life. Without leaving the patient's side or becoming judgmental, we can understand how one could come to be so hurtful to oneself and to others. We can understand the simultaneous two-sided experience, so often dissociated, of being both hurt and hurtful. Recognizing context and complexity [the two preceding sections of the essay] prevents reduction and judgmental attitudes and enables compassionate understanding. ”

To make the concept of psychoanalytic compassion more complete, Orange offers the notion of accompanying the other. “In recent years I have become more aware of the importance of simple accompanying that some would contrast with proper "analytic" work and might disparage as "supportive" psychotherapy. Whether my patient suffers from an incurable, painful, and debilitating disease or from terminal cancer or lost a family member in the World Trade Center tragedy, I must not look for ways to see my patient as causing or even contributing to her own suffering; if I did so, I would be joining those who tell her just to accept it or get over it. There is no way to fix the situation or to "cure" the patient, so I must accept my own powerlessness to help. I must simply stay close to her experience, sorrowing and grieving and raging with my patient, even if this means that my practice feels very heavy to me. Even when the story is very complex -and it always is - a willingness to walk together into the deepest circles of the patient's experiential hell characterizes the attitude of compassion ... that the process of psychoanalytic compassion requires.”

Orange summarizes this way: “The interpretive gesture of reaching out to embrace the patient in a sustained, even relentless, struggle to find an understanding is what I mean by psychoanalytic compassion...[it is] an implicitly interpretive process of giving lived meaning and dignity to a shattered person's life by enabling integration of the pain as opposed to dissociation or fragmentation. A compassionate attitude says to every patient: your suffering is human suffering, and when the bell tolls for you, it also tolls for me.”

Orange, D. (1995), Emotional Understanding: Studies in Psychoanalytic Epistemology. New York: Guilford Press.
Orange, D. (2006), For Whom the Bell Tolls-Context, Complexity, and Compassion in Psychoanalysis. International Journal of Psychoanalytic Self Psychology, 1 (1):5-21.
Gadamer, H. (1975), Truth and Method. New York: Crossroads, 1991.

Ernesto Vasquez, MD
February 17, 2010.

[Donna Orange will speak in Tampa April, 2011]

Working with Patients who have Survived Childhood Sexual Abuse

Today, in Winter Park, FL, I had the pleasure of discussing with the Florida Organization for Relational Studies (FORS), an affiliate of The American Psychological Association’s Psychoanalytic Division (Division 39) the Davies and Frawley (1994) text Treating Adult Survivors of Childhood Sexual Abuse. After laying the biological groundwork for dissociation:
Hormones triggered by stress impair hippocampal functioning, while neurotransmitter (NE) stimulates the amygdala. Generally speaking, the amygdala is responsible for procedural (behavior you can do without thinking, like riding a bike) memory, perceptional-sensory/body memories (like when the hair on the back of your neck stands up when you sense danger, even before you have a conscious recognition of danger), and emotional memory. The hippocampus is responsible for episodic (event) memory, for explicit, semantic (symbolically encoding, giving words to) memories, and for contextualizing events with their emotional significance.

When implicit, perceptual, affective memory is enhanced, but not linked to the event (such as childhood abuse), we have fragmented affective states without a link to their causes. And we have episodic memory of a moment (e.g. a flash of the abuser’s face) without link to its emotional significance or meaning. That these memories are not linguistically encoded has a huge impact on therapy which has traditionally relied on words and narrative. As a result, trauma in childhood impairs organization of memories.

Abuse is also an attack on subjectivity. Consequently, Intersubjectivity as a developmental achievement (the capacity to recognize the subjectivity of the other as well as the self) [subjectivity defined as the sense of self as a subject with an independent agency and desire] is impaired. Because therapy is an invitation to consider meaning from one’s own point of view, inviting a patient to hold forth her own reality can produce anxiety and panic. When the abuse was denied or invalidated by caretakers, the child’s sense of reality (reality testing) is also impaired.
To survive, a child must preserve the needed ties to caregivers and so takes upon herself (introjects) the sense of badness of the abuser, leading to decreased Self esteem and sense of self. The child maintains an illusion of control (‘if I caused it, then if I change it; if I can change the situation, then I am not helpless).
Without sound reality testing and the ability to trust her perceptions, adult survivors cannot adequately obtain gratification nor avoid danger. They tend to subjugate their reality to that of an Other, including complying with therapists’ interpretations. Not being recognized, comforted and protected, the isolation is profound. The world is seen as unsafe, and others, as betrayers.
There is also an impaired capacity to self regulate, such that any arousal is experience as hyperarousal. Therapy, inviting feeling, and intimacy, can lead to hyperarousal. To self soothe a survivor may engage in dangerous or self-abusive behavior to feel the subsequent calm (facilitated by the release of endogenous opioids) and to feel in control (turning passive into active), as well as attacking the abuser-introject, serving, at the same time, to attack the treatment and the therapist’s ability to contain and help.
The therapist can imagine out loud (symbolize in words) what the behaviors might be telling us.

“Behaviors have meaning. They tell us things that have yet to be put in words. When you miss sessions or come late or come high I think about how this unpredictability and instability is what you experienced when your parents could lash out for no reason or when they could not get up to get you to school. Since I am left confused, disappointed, and resentful about the interruption of our work here together, I can only imagine that you too might likely have felt these things (and more) at the hands of your parents. Maybe your lateness and missing sessions is your hope to help me see what it was like for you as a child.” [Note: in this way you highlight the behaviors without blaming. In fact, part of you is grateful to be getting the message. You also let the pt know that one can have negative feelings and still be invested in the relationship and the work. This kind of disclosure does not reveal personal content like where you went over the weekend or how many children you have. It reveals personal feeling states and thoughts about what is going on between the two of you, revelations that model the naming of feelings, their connection to events, and that having feelings does not self or other or the relationship.]

Or the therapist can make empathy-filled interpretations:

“It makes sense that, with the unpredictability of childhood events, you want to be the one who says when the pain starts or stops.”

Before traumatic experiences can be remembered, they must be reenacted. Through projective identification various roles in relational paradigms will be reenacted in complementary, simultaneous, ever-shifting, and overlapping fashion, like hot potatoes passing freely between patient and therapist. Davies and Frawley explicate many permutations of the Neglecting Adult -Neglected child; Abusing Adult -Abused child; idealized and omnipotent Rescuer-Entitled/needy child; and the Seducing Adult-Seduced child, all eight roles, representations of the patient’s child and adult selves, and of her object representations.
Sometimes the pt, unconsciously identified with the uninvolved parent, is the cold, rejecting, unavailable one, silent and withholding, disdainful, preoccupied, bored, hostile. The therapist, as the complementary neglected child, may feel compelled to try harder to reach the patient. When the therapist is reenacting the indifferent adult, her neutral ‘blank screen” may parallel the indifference and denial of the non-protecting parent.
When the patient is reenacting identification with her abuser, she may attack the therapist, the therapeutic frame, or engage in self-abuse. Privileging the love (attachment to the abuser), pain and terror around which the abusive behavior is organized may be easier for pt to engage.

“We all prefer to feel in control, even powerful, rather than feel so painfully vulnerable and helpless. Because I sometimes feel helpless to meet your demands, I wonder if these demands aren’t the additional communication to me that you really want me to know what it felt like to have your father make such controlling, angry demands on you. Also, all children wish to be loved by their parents, even abusing, out of control parents. Maybe if you can be like him sometimes, that allows you to feel a connection to him, and then it is not so sad to feel you never were close to your father.”

Or about the self abuse:

“I understand that this way you feel you are the one in control of the pain-- when it starts, when it stops-- just as your father had been when you were a child.”

As therapists, we are already drawn to the role of rescuer. The pressure to heroically save the abused plaintive child must be made explicit. To attempt re-parenting can interfere with mourning the lost childhood and the loss of the idealized parent. Instead the pt’s adult-self must be allowed to mourn. The therapist must accept that there will be constant tension between symbolic gratifications, frustrations, and interpretations.

“It may seem to you that the only way I can be with you is to be in the same geographic place, that it is not enough that I hold you in my mind or that you hold me in your mind. As much as we both might want to have dinner… together, to do so would have me feeling like your intrusive and inappropriate (father) and then you would begin to doubt the safety we are beginning to forge here.“

Thx needs to recognize pt as sexual subject, without the threat of action.

“Sometimes children learn that the only way anyone seems to pay attention to them is when something flirtatious or teasing is going on.”

“It is only natural that describing sexual activities is, however unwelcome, arousing. I am concerned on the one hand that you may feel rejected if I do not respond in kind to your overtures, but, on the other, am concerned that you may feel responsible for my arousal, the way you did about your father’s, and that would cause you to worry even more that you are dangerously seductive.”

Davies and Frawley use a Treatment Model of: Containment (of hyperarousal); Recovery, Disclosure, Elaboration (of trauma experiences); Symbolization and Encoding (putting into words, making explicxit); Integration (Contextualization); and Internalizing New Object Relationships. Taking for granted first co-creating a safe place, I like mnemonic devices, so I call it the four I’s: Identification (Recovery); Interpretation (putting into words); Integration; and healing as Internalization (of new relational paradigms).
In creating a safe space, the therapist must be comfortable with protracted chaotic reenactments and must maintain the frame, including the stopping and starting on time, and the patient respecting the therapist’s privacy, sleep, vacation. To foster safety, effects on both the therapist and pt of the daunting and protracted reenactments, must be discussed along with how to better negotiate tenacity for the therapeutic work and relationship. This includes inviting the patient to tell the therapist what the therapist does, or does not do, which leads to the therapist or the therapy being [inadvertently] experienced as re-traumatizing. Reality testing can be strengthened by asking what aspects of therapist’s behavior led pt to arrive at her conclusion. Treatment must be a MUTUAL process. The working alliance includes awareness of therapist’s contributions to the relationship. Two-person psychology means the therapist’s behavior is under scrutiny. If not part of the negotiation, then the one-sidedness parallels the abuser’s abrogation of responsibility. It is in negotiation, about the difference in how therapist and patient experience their relationship and each other, that the absence in childhood of toleration of difference is highlighted.
The therapist must ask herself: Can I tolerate the demands, survive the psychological assaults, complaints and invectives, participate in reenactments, work with the dissociated child-selves? Do I get angry when pt brings up… ? Am I reluctant to fully experience myself as a bad object? Am I un-comfortable with my own aggression and helplessness?

Discrepancies in therapist’s and patient’s experience create the potential for managing contradiction and the opportunity for strengthening the pt’s reality testing. To explore these discrepancies requires collaborative inquiry. It is the process, including validating (considering patient’s reality as something to be considered), not the content that is useful. The experience to agree, or disagree, without concomitant loss of integrity on either’s part, leads to mutual recognition, and to an increased subjectivity. It’s a paradox: one needs subjectivity to negotiate well, and negotiation develops/enhances subjectivity.
Empathic immersion and affective attunement foster capacity for self regulation; and diminish self doubt, and affective instability. Containment paves the way for recovery, disclosure and elaboration. As reality testing is strengthened and confidence in her memory increases, memories will emerge.
When you contain, listen and accept (believe), you change the original traumatic experience of isolation and despair and bring about a new object relations configuration, a change in internal structure. These MUST be repeatedly enacted.
Being curious about the meaning of the behavior helps the patient be curious about its meaning.

“This behavior is trying to tell us something, give us clues to something. You are telling us so emphatically through action, over and over again, it is as if you’ve had the experience of no one hearing or believing you.”

“You must have been very distressed, fearing being abandoned by me if you let us both know how angry you were at me. The cutting, by stimulating release of your body’s natural painkillers (opioids), temporarily relieves your fear and helps you feel in control.” [This type of empathic comment makes explicit the meaning of the behavior without passing judgment.]

In Tx: Ask questions and make interpretations to help make CS the roles being enacted.

“I have a theory about this recent cutting behavior, would you like to hear it? When I would not accommodate a change in appointment time I was the abuser who did not care about you, but cared only about herself. This understandably would make anyone angry. We have already discussed that you are uncomfortable with being angry at anyone, and prefer to be angry at yourself, take anger out on yourself. Could that be what was happening here, when after our last session you cut yourself? “

But the dangerous concreteness of self abuse can lead to the therapist’s dilemma which needs to be actively stated:

“I am concerned that should I under react and not step in to hospitalize you, then you could seriously, even fatally endanger yourself, but, on the other hand, I am concerned that if I over react and arrange to Baker act you, I become like your mother who never heard the meaning behind your crying and who got angrier at you and sent you away when you needed her help the most. So you and I together have to figure out what kind of danger you are in right now and what needs to be done about it.”

Replacing a the sadomasochistic struggle with collaborative effort may take years of active interpretation and repetition, containment and self soothing.

All the self states need to participate in treatment. “Neutrality” now comes to stand for the therapist’s capacity to keep fluid these ever changing re-enactments. Here neutrality means equidistance from all the multiple selves that are patient and therapist. Working through, for patients with dissociation, means integrating episodic memories with their dissociated emotional and cognitive significance, as well as integrating dissociated self and object representations.
It is from mis-attunement and correction, rupture and repair, from failing but surviving, that recognition and mutual respect arise. The child-self, previously existing only in the context of the abusive internalized object relationship, now can be integrated into the whole personality and child-like creativity and spontaneity are there to be expressed without fear of fragmentation of the self or without fear that disappointment will devastate. Integration of self and object representations is an aspect of healing, and it is heralded by mourning. Both the child and adult selves have struggled to come to terms with the horrific, deadening realities: That the abuse occurred; that childhood was destroyed and is never to be reclaimed. The pateint has come to terms with the finality and irreversibility of loss.
Treatment is a negotiation between two people each of whom requires a mutual recognition of difference, and allowing for each person to impact and influence the other. New object relationships accept both loving and hating identifications. Acceptance changes intrapsychic and interpersonal reality. Patient has seen that her own hate does not destroy the other and that the therapist’s anger is not accompanied by the attempt to destroy the pt. The experience in treatment to agree, or disagree, without loss of integrity on either’s part, leads to mutual recognition, and an increased subjectivity.
Healthy, mature self-organization is an amalgam of widely varying self- and object representations, each unique in its affect and ideational content, some even contradictory but no longer mutually exclusive. Internalization of new object relationships now allow for different self-states to have mutual understanding, respect, and affection (adult/child) for each other. There is increased tolerance and empathy. Now the child-self confers on the adult survivor increased vitality, passion-without-shame, play, fantasy, creativity, imagination, and ambition. The increased capacity to tolerate contradiction, love and anger, in self and others, and intersubjective experience, leads to an increased capacity for intimacy (exploring interiority of another and allowing an Other in) (both sexual and non-sexual).
Healing, like treatment, is an ongoing process, an ongoing dialogue between self states. It is not a finished product. Because treatment is co-created, no two therapists will have traveled the same path with a given patient. The acceptance of defeat without dissolution, failure, but survival, exists. Now there is a philosophical expansion of a profound appreciation for life, and for connection with an Other.

Trust, Contextualization, and Trauma: Documenting Holocaust Experiences of Homosexuals

Film: Paragraph 175

By William Spell
presented November 8, 2009 at the Film Series: Fear of Difference: The Diversity of Holocaust Experiences, Tampa, FL

Our presence here together unites us for a living tribute to the courageous Holocaust survivors of the documentary Paragraph 175 as well as all survivors of genocidal trauma. The seven remarkably articulate elders emerge from these interviews with a seemingly impossible grace and eloquence, putting words to unbearable experience.

I am also in awe of this achievement by the director-producers, Rob Epstein and Jeffrey Friedman, their partner in production, Michael Ehrenzweig and their many talented collaborators, who with the inspiring guidance of Klaus Muller, have set a sensitive stage and created a trusting rapport with each survivor.….for their voices to be heard and their beautiful faces to be seen with a clarifying light.

Dr. Doris Brothers, in her paper, Trust, Uncertainty and Therapeutic Alliance in Trauma-Centered Treatment suggests that “trauma does not reside in a specific event alone, but rather in the meanings of that event for the individual involved.” And she places “the focus of treatment on the trustworthiness of the relational engagement of analyst and patient.”

We see from the beginning of this project, a resistance and ongoing crisis of trust when Klaus telephones to confirm a meeting, Karl Gorath answers, “Not today” and later in person, Karl agrees to the session.

.....Pierre Seele, arriving at the train station feeling sick, not wanting to proceed, feeling hostile toward Klaus and offended by his black leather jacket, not wanting to shake hands with a German and paranoid about Klaus’ intentions.

Heinz F. speaks for the first time with another person about his 8 ¼ years in the concentration camps of Dachau, Mauthausen and Buchenwald, confined for being a homosexual. He fears using his surname for the film and initially requests that his face be seen in an anonymous silhouette of dark shadow.

From listening to the director’s added commentary on the DVD, I learned that Heinz F. upon viewing the monitor and seeing how dark his image appeared, decided that he wanted his face to be seen, since at age 93 he felt that he hadn’t much time left for the rest of his life.

There was a survivor living in Poland who ultimately declined being interviewed on film because he was battling with the fear of being publicly exposed as a homosexual.

Another German man who was castrated by the Nazis, had given consent to participate when, on the day of his filming, someone helping with the production told his landlady that he was going to be interviewed. When he found out that she knew this, he became very upset and refused to continue and Klaus spent a lot of time calming and comforting him.

The directors discuss their experience of a troubling ambivalence as they respectfully engaged Albrecht Becker, arrested for his homosexuality by the Nazis. Albrecht explains the alarming indifference and passivity of many German citizens to their widespread, word-of-mouth knowledge of the death camps.

Michael Ehrenzweig affirms that without Klaus having established relationships of safety and trust with the film’s subjects over a period of years, this ground breaking documentary would not have been possible.

Dr. Lycia Alexander-Guerra, in her presentation for the Tampa Bay Institute for Psychoanalytic Studies’ Trauma Workshop Series, discussed how, physiologically, traumatic memories are dissociated, de-contextualized from each other, and unlinked to words. In referencing the work of Dr. Jody Messler Davies and Dr. Gail Frawley, she discussed how re-enactments of experiences which lack words can become an opportunity for the therapist to lend words and help construct meanings with the survivor of previously unspeakable traumas.

Klaus encourages Heinz Dormer’s painstaking, verbal descriptions of “the singing forest”. There are haunting silences between Heinz Dormer’s words, the palpable “goosebumps” and his powerful gaze, contained by Klaus.

After approaching the abyss again, I was relieved to hear Heinz find his open-ended meanings, in his words: “inhuman” “beyond human comprehension” “inexplicable” “and much remains untold”.

Heinz F. and Klaus offered words freely and tenderly to one another. Heinz F., often tearfully sobbing, spoke of his shame. “It’s all about patiently carrying one’s burden”. When asked if there was anyone he could have spoken with, he insisted, “Never!” “Nobody wanted to hear about it” “If you would just mention one of those words…..Leave me alone with this stuff---it’s over now and done with”.

Dr. Sam Gerson's paper, When the Third is Dead: Memory, Mourning, and Witnessing in the Aftermath of the Holocaust is in press: International Journal of Psychoanalysis, 2010.

Paragraph 175 remained a law until 1968 in East Germany and 1969 in West Germany. Homosexuals continued to be classified as criminals. Heinz Dormer was re-arrested during the 1950s and 1960s.

Dr. Bruce Reis emphasizes that in the treatment of massive trauma the language of narration cannot translate away the raw pain of traumatic exposure. He recommends the work of Dr. Sue Grand in being a witness to trauma, illuminating silence and rendering it audible.

Dr. Ghislaine Boulanger represents therapeutic recognition as "when clinicians resonate to situations in their patient’s lives with which they can identify only too well; locating parallel experiences and feeling states in themselves. This often unacknowledged resonance between the patient’s and analyst’s experience signals a level of acceptance and understanding that can be transformative and promote analytic reflection.
However, when resonating to a familiar affect state is not possible, clinicians must be prepared to serve as containers and witnesses to terrifying and alienating experiences without losing their connection to the survivor. Inevitably, that connection is sometimes lost as the clinician struggles against his or her own tendency to dissociate in the face of horror."

Our hearts today contain these passages of love, hope, faith and devastating loss.

Annette Eick recounts the story of the miraculous “love letter” that saved her life, surviving only with her brother as her entire family perished in the camps.

Gad Beck remembering trying desperately to rescue and flee with his young lover, Manfred Lewin, who felt compelled to stay with and take care of his sick family, soon to go to their deaths in a camp. As Gad describes the moments of agony when he and Manfred were separated for the last time, he says, “I couldn’t think but I knew something was forever broken.”

Pierre Seele frantically beseeching Klaus, “Do you think I can talk about that?” “This is too much for my nerves, Klaus! I can’t do this anymore! I am ashamed for humanity.”

In the director’s commentary, Michael Ehrenzweig shares a story of the transformative power of Paragraph 175, the documentary.

Immediately following the film’s premiere showing in Berlin, Michael quickly joined Gad Beck and Pierre Seele in the audience and walked them slowly down the aisle to the stage, both men on each of his arms, as the fully packed theater gave them a standing ovation with thunderous applause.

Later that night Gad and Pierre sat at a café table nearby, holding hands and receiving the loving recognition and warm attention of many who had just seen their film. As a result, both men were inspired to subsequently travel extensively, speaking publicly and seeking official acknowledgement for their case and advocating support for other survivors. This reminds me of Dr. Adrienne Harris’ description of analytic process as “the shared labor of relational mourning.”

I feel this humbling work of art is an archive for all of humanity with the potential to inspire honesty and compassion for the understanding of massive traumatic experience and a caring acceptance of women desiring women and men desiring men.

-- Will Spell

References:

Alexander-Guerra, M.D., Lycia (2009). http://tbips.blogspot.com/2009/02/healing-through-witnessing.html

Boulanger, Ph.D., Ghislaine (2008). "Witnesses to Reality: Working Psychodynamically with Survivors of Terror." Psychoanalytic Dialogues, 18:638-657.

Brothers, Ph.D., Doris (2008). http://blogs.confer.uk.com/0809trauma/the-lead-paper.html

Gerson, Ph.D., Samuel (2010). "When The Third is Dead: Memory, Mourning, and Witnessing in the Aftermath of the Holocaust." IN PRESS: International Journal of Psychoanalysis.

Harris, Ph.D., Adrienne (2005). "Gender as Soft Assembly." Hillsdale, NJ: The Analytic Press.

Reis, Ph.D., Bruce E. (2000). "A Review of the Reproduction of Evil: A Clinical and Cultural Perspective: Sue Grand. Hillsdale, NJ: The Analytic Press, 2000. xvi + 167 pp." Contemporary Psychoanalysis, 36:730-734.

What are the curative factors in recovery from mental illness?

Link to a very interesting article in the Washington Post on Feb. 10, by Charles Barber, a mental health worker at Yale:

http://www.washingtonpost.com/wp-dyn/content/article/2008/02/08/AR2008020803272.html?hpid=opinionsbox1

Barber describes his own journey to recovery from an incapacitating mental condition, and draws some observations from his own experience and from research into the conditions that facilitate recovery. He speaks against the "medical model" of attempting to alleviate symptoms through the use of drugs, and instead focuses on the healing effects of "social context." He notes that outcomes from even such severe mental illnesses as schizophrenia are better in developing countries, where "patients get more support from family and society." His is an argument against pharmacotherapy and "therapist as expert," and instead, an argument for immersion in a supportive social mileau.

Barber does not use the language of self psychology or relational analytic theory but, using these schools of thought as lenses, what he says becomes readily explainable. A self psychologist would recognize all of the curative factors Barber lists as sustaining selfobject relationships that lead to restoration of cohesion to the disequilibrated self. What Barber describes as curative is the restoration of the "selfobject mileau."

Near the end of his article, Barber states that "Listening to patients [the curative factor] cuts against the establishment grain." Here, he speaks of what Kohut and others have termed "empathic immersion" in the patient's experiential world. (Cf. also Donna Orange et al.)

How would other schools of psychoanalytic thought explain what Barber describes in his article? Post your thoughts, reactions, and other musings on how best to explain the important observations about what constitute the curative factors that Barber describes.

Note that Barber has a newly-published book in which he elaborates on these ideas.