TBIPS' TRAUMA WORKSHOP SERIES, Part I: Dissociation

Dissociation: Dis-order of Subjectivity.

Dis-aggregation; and Dis-connection
De-personalization; De-realization; and De-contextualization

The most provocative part of any presentation is, for me, the clinical, which, in addition to who says (left-brain) what to whom, includes relationship, the implicit, and, a lot of right-brain knowing, and not-knowing. For ethical reasons, I can only marginally report on who says what to whom. Still, discussing ideas, not a particular case, excitedly lights up the curious brain.

On October 25, 2008 Richard A. Chefetz, MD, from New Directions in Psychoanalysis at the Washington Psychoanalytic Foundation, and the Advanced Psychoanalytic Training of the Washington School of Psychiatry opened the Trauma Series Workshop of the Tampa Bay Institute for Psychoanalytic Studies, Inc with a paper on Dissociation. Chefetz used Bucci's definition of dissociation: the unlinking of normally associated elements of experience that nonetheless remain unconsciously, implicitly, bound and related. This unlinking is facilitated by failure of the brain to formulate referential connections between different elements of experience, the failure to provide the context necessary to [more]accurately interpret experience.

While dissociation is part of normal mental function, e.g. highway hypnosis, or the fact that the brain selectively allows little, at any one time, into conscious awareness, when the right (amygdala) brain is overwhelmed with emotion, the left brain (Broca's area) is hypoperfused such that the experience cannot be linked to potentially helpful narrative. In fact, during intense emotion, e.g. intense fright, one can be rendered literally speechless (a fact that can be used didactically-cognitively to vitiate the guilt of a survivor who could not protest at the time of the abuse and victimization). Right brain hyperactivity can intensify vulnerability and aggravate trauma by denying it symbolization through narrative. (Likewise, when the left brain is busy, we tend to notice less our painful feelings and bodily sensations.)


Trauma is an experience that changes one's world view, one's self view, one's subjectivity (a person's interpretation of thoughts, feelings, and sensations). The dissociative process protects the self from trauma, from, e.g. the disparate elements of both loving and fearing the unpredictable caretaker. But its fallout includes severely limiting one's affective capacity and it creates incoherence, coherence being necessary for self regulation.

Isolated affect, an attempt at regulation, is dissociation that maintains attachment. A child accommodates to prevent the needed caretaker's withdrawal. Security, i.e. sameness -what is predictable, coherent, familiar- is sought, even if it is painful, creates deadness, or requires the disappearance of the self. Chefetz notes that a therapist, by being helpful, can cause a shift in a patient's self state, from child to adult, but then, the adult, believing only children need (and get) help, paradoxically, goes into a panic.

Dissociative Identity ("multiple personality") Disorder challenges the therapist's idea of a unified, cohesive self. We are likewise challenged to tolerate our own varying self states, and our capacity, as well as the patient's, for anger, rage, sadism, collusion. Can we, for example, explore with the patient her/his request for physical closeness and sexual contact, its meaning, its potential betrayal if acted upon, and can we be trusted to set and maintain appropriate boundaries? Will we deny this capacity in ourselves and insist on being the 'rescuer,' or withdraw, or lose all awareness of the ways we are sadistic?

Chefetz reminds us to be be curious and open about what we are feeling in a given moment, and to remain 'experience near.' I will, on January 10, 2009 in Part II of the Trauma Workshop Series, talk more about dissociation, both in the therapist and patient, how to navigate and how to use it, as well as about how to recognize, after the fact, enactments and their usefulness, when working with adults who have survived severe physical and childhood sexual abuse.

Lew Aron, PhD in Tampa

Lew Aron visits Orlando-Tampa and shares with us his talk on

"Rethinking Psychotherapy and Psychoanalysis: What Does Feminism Have to Do With It?"

Lew Aron, PhD, a great, modern, psychoanalytic thinker and orator, visited Tampa on Saturday October 18, 2008 to share his critique on the historical evolution of psychoanalytic thinking, and on the contribution made to it by postmodern, deconstructive feminism. As we know from our clinical work, some beliefs have to be 'broken' to allow putting them back together in a new configuration. Never had I seen attendees at a Tampa Bay Psychoanalytic Society Scientific Meeting so abuzz with excitement as they embraced the iconoclastic thoughts put forth by Dr. Aron. Some of his points are as follows:

Aron urges that to understand the concept one must understand its context. When an author, Freud, for example, writes: whom is to be convinced by the paper, with whom is it in dialogue, with what is the author struggling?

After discussing how psychoanalysis today is in trouble (the aging out of analysts of the American Psychoanalytic Association, the paucity of candidates in training, the ever declining number of analytic patients), Dr. Aron notes how analysts can not even agree on the definition of what analysis is, nor on whom might benefit from it. There is an argument about the number of sessions per week, about sitting up or recumbency, about how much supportive work means it is no longer an analysis. Aron sees some of the arguments in history to be about economics and prestige.

Freud never differentiated between psychoanalysis and psychotherapy, but he did eschew hypnosis and suggestion, the latter having brought down his illustrious contemporary Charcot. Psychoanalysis has been so doctrinaire as to try to fit the patient to the theory/technique, instead of vice versa. Franz Alexander advocated for this flexibility and was summarily extricated from mainstream American psychoanalysis, accused of blurring the distinction between psychoanalysis and psychotherapy, and of ignoring psychoanalytic parameters (Eissler).

European emigrant analysts coming to the U.S. before WWII could afford more flexibility. But those who fled the Nazis, losing home, livelihood, family, may have recreated in the U.S. what had been lost, and so may have clung tenaciously to doctrine. Gill defined psychoanalysis as a therapy that when conducted by a neutral [as if exists] analyst leads to the unfolding (i.e. intrapsychic) regressive transference neurosis to be resolved by interpretation alone, or mostly.

Interpretation has been privileged as an active masculine penetration of the passive female unconscious (an idea which backs imperialism, colonialism, racism, homophobia, misogyny; and allows for conquering the inner world and beating down resistance, as one attendee noted). Likewise, autonomy has trumped dependency. Hartman and Rapaport argued for ego autonomy, i.e. analysis led to structural change; if take this parameter away, then one would rob patients of the ability to do for themselves. After all, successful outcome is measured by a patient's ability to continue in self-analysis, having internalized the analytic process and the analyst. Yet Wallerstein's 1954 study at Menniger "54 Lives in Treatment" showed the relationship to be mutative. (Kernberg, who ran the study, has noted that the main contribution of psychoanalysis to the world is psychoanalytic psychotherapy. [One attendee modified this to: it is psychoanalytic thinking that is its greatest contribution].) The implication: if psychoanalysis deals with the inner world and autonomy, then psychotherapy deals with behavioral change and transference cure.

Apparently, analysts have privileged autonomy, in part, because analysts like to be left alone! (Smith's study on the ideal patient). Autonomy is valued (but then how have a healthy dependent relationship, such as marriage?), and dependency feminized.

Freud's theories arose contemporaneously with the rise of antisemitism in Vienna. Freud feared people would say his ideas applied only to Jews. Rabbinical Jews idealized the studious, passive man, but, in a culture which conflated circumcision with castration, Germanic men did not want to be seen as passive and effeminate. Aron purports that when Freud said that the bedrock of psychoanalysis is the repudiation of femininity, Freud had to repudiate his culture's belief that Jewish men were feminine, passive, castrated. Using Greek mythology to bulwark his position, Freud advocated the opposite: a kind of 'I, like all men, am not passive, castrated or feminine (or homo erotically attracted to Fliess, nor willing to be so with Ferenczi) but, instead, I am Oedipus, aggressive, willing to murder (even my own father), attracted sexually only to women (even my own mother).' (Freud, if he believed it, he believed it to be universal.)

An important insertion: Freud never denied that sexual abuse occurred prevalently. He only denied that it was the etiology of hysterical neurosis. (Himself hysterical, he would be indicting his father.)

Freud had to defend this binary opposition between active/passive; male/female; (Goy/Jew) to save his science (psychoanalysis) and save himself. Historical acceptance of falling to one side of the polarity, this binary configuring, leaves no room for a third and the tension held between two polarities. Aron encourages us to refrain from investing in binaries, and encourages, instead, their deconstruction.

Accordingly, Aron cautions against the erroneous conflation of intensity of training with the intensity of treatment. Different from most of his contemporaries, Aron finds it a mistake to separate psychoanalytic and psychotherapy training. Instead, he recommends that candidates receive didactics and supervision, but that candidates learn for themselves the difference frequency (really the meaning of a particular frequency--loved, enslaved, dependent, special--to a particular patient) and intensity make for their patients, some seen on the couch, some in a chair. Most radically, he recommends that candidates choose their own therapy.

There seem to be only two things analysts agree upon: that there is an Unconscious (though not on what it is or how it works) and it is important to scrutinize the therapeutic relationship (though not on how or when). Aron quotes (L. Friedman) "monstrous" [like a gryphon or chimera?] to describe psychoanalysis. It does not fit one category well, not solely science, art, medicine, psychology, literature, cinema, quixotic, or cost-benefit soundness). Our fore thinkers were rebels, misfits, radicals, and reformists, living in a particular relationship to authority. Psychoanalysis has moved from the Golden Age of consensus, to pluralism.

[It's been a long, and temporally short, road.]

Healing Haunted Lives: Trauma Workshop Series

Recognizing and Treating

Dissociative Adaptations

to Trauma in Adults

Richard A. Chefetz, M.D

Saturday, October 25, 2008

9:00am - 4:30 pm

Crisis Center of Tampa Bay

One Crisis Center Plaza, Tampa, Florida

(Exit Bearss Avenue WEST, off I-275)

This is an introductory program geared to provide clinicians with a theoretical framework that uses common sense language to describe dissociative processes and their vicissitudes.

Using selected videotapes from the clinical setting, Dr. Chefetz brings the participant into the consultation room to educate about the intensity of the affective disarray and the profound nature of shifts in subjectivity that regularly intrude upon the consciousness of persons with complex dissociative disorders. Dissociative processes are part and parcel of mental life, not just a production of severe trauma. This seminar will help participants learn to identify dissociative processes in both patient and therapist as a routine, but usually un-noticed, part of subjective experience.

Healing Haunted Lives: Trauma Workshop Series

4-part Trauma Series Workshop begins on October 25, 2008, starting off with Dr. Richard Chefetz who will elaborate on dissociation. The series will end on March 7, 2009 with Dr. Ghislaine Boulanger discussing herlongstanding work with Vietnam Veterans as well as more recent work with those intimately affected by the events of 9/11. Discounted registration will be available for attendance of the complete series.

Early Registration Discounts through 10/19!

Contact tampabaypsa@aol.com to register or call (813) 908 - 5080

Program

Recognizing and Treating Dissociative Adaptations to Trauma in Adults

• What really happens in dissociation? (Video)
  
• Attachment, Dissociative Process, and Psychotherapy
  
• Transference/Countertransference
• Enactment and Dissociation (Case presentation and discussion)
  
• Working with Intense Shame (Brief Case and Video)
  
• Affect and Dissociation: The Golden Thread

Richard Chefetz, M.D.

Faculty, Institute of Contemporary Psychotherapy & Psychoanalysis, Washington School of Psychiatry, Modern Perspective inPsychoanalysis and New Directions in Psychoanalysis/Washington Center for Psychoanalysis; Distinguished Visiting Lecturer at theWilliam Alanson White Institute, NYC; past-president International Society for the Study of Trauma and Dissociation

Peggy Hutson on "Unconscious Gender Messages in Adult Men and Women and their Effects on Self, Feelings, and Actions"

On Saturday, September 13, 2008 the Tampa Bay Psychoanalytic Society hosted their friend and colleague from Miami's Florida Psychoanalytic Institute and Society, Peggy Hutson, M.D. who has written extensively on Shame.

It is the discrepancy between one's self representations [who one thinks one is] and one's ego ideals [what one hopes to be] that leads to shame, she notes, deeply influencing self esteem and one's ability to have needs met. When self esteem diminishes, so does one's capacity for empathy. Ego ideals, housed in the superego, but separate from the "superego proper" (concerned with prohibition of drives), exercises a "need satisfying agency" (Freud) for good feelings about the self. One set of ego ideals is about gender. Some of these ideals are conscious, many are early introjections. Some are helpful, some hurtful, some considered the norm even when they are limiting.

Shame (as) Conflict was described. One difficulty that may arise, from a history of success leading to rejection by the envious, narcissistic primary object, is for one to feel shame when they do not succeed, but threatened with loss of safety and security (attachment) when they do. Also, when one envies an other: there may first be experienced a diminution of one's self esteem, with the signal affect of shame, followed by one coveting for oneself what the other has. One may then become adaptively ambitious. Or, without such an adaptation, envy may lead to aggression.

Dr Hutson notes that shame can be manifest in a variety of ways: as haughtiness or arrogance, snobbery, or over achieving, as denigration or envy. When the need for safety and security is threatened, one can react with rage. She distinguishes this threat from the threat to the cohesion of self. Early losses of safety and security, hearkening back to early separation difficulties, may, when present day experience threatens to repeat such a loss, lead to panic attacks. Severe anxiety can then lead to loss of cohesiveness.

When working with shame, Dr. Hutson employs analysis of the superego and of defense, such as projection, by using close process monitoring ( ala Paul Gray, based on Freud's psychic determinism). An example might be when a patient's criticism of and anger at another is immediately swept away by complaints of guilt (as a defense against the anger). Dr. Hutson also works with reruns/templates (transference) with the goal of achieving "transmuting internalizations."

While Dr. Hutson's talk on shame was appreciated, and she did note that gender ideals are "man-made," I personally was hoping to hear more about gender. Gender itself is a construct. Muriel Dimen (In Psychoanalytic Dialogues 1(3): 335-352) writes that gender has at its core "difference, not essence, the relationship between masculinity and femininity as culturally conceived, interpersonally negotiated, and intrapsychically experienced." A dialogue about gender would be welcomed by me at the Tampa Bay Psychoanalytic Society.

Key words: shame, shame conflict, gender, Peggy Hutson, Muriel Dimen

9-11 and musings on trauma

Last Friday morning on National Public Radio's Story Corps, a life was truly celebrated through listening. A mom interviewed her son who had been a kindergartner on 9-11 and whose grandfather, her father, had died in the World Trade Center. This boy related with great equanimity good memories of his grandfather, such as pretend sword fighting as Peter Pan and Captain Hook. When his mother asked what he remembered about that day, 9-11, his voice became tearful as he recalled her distress. His mother asked about the trouble he had for awhile about falling asleep and how he had managed that. He said he had held on to his stuffed animal and thought of his grandfather as still alive.

I found this recording on NPR particularly moving both because of 9-11, and because I work with so many people who have experienced trauma. It illustrated both the importance of the emotional connection to the mother in cuing and helping a child navigate loss as well as the importance of transitional objects, whether toys or thoughts. Trauma for children is not simply the loss of a loving other, though this is sufficiently devastating, but can sometimes mean the literal, not just psychic, annihilation of self. The concomitant grief of the parent must include a model of surviving as well as allow for the maintaining of a stable enough connection between parent and child. It was wonderful of this mom to provide the space for grieving and for remembering together with her child.

Though not evident in the radio vignette, trauma is often accompanied by dissociation. In children it is used (particularly when it is the parent who has inflicted the trauma) to maintain the tie to the loved and much needed parent. In adults, dissociation can help to split off otherwise overwhelming affect (emotions). For the therapist, working with the many compartmentalized self representations of a patient who has experienced long term trauma takes a particular willingness to utilize (once they are discerned) projective identifications, to wear the attributes the patient lends us, and to participate in the reenactments that help bring to light the disavowed parts that must one day be owned.

As this work sometimes necessitates consultation, colleagues from the Tampa Bay Institute for Psychoanlytic Studies decided to invite a special kind of dialogue about Trauma to our town. A 4-part Trauma Series Workshop here begins on October 25, 2008, starting off with Dr. Richard Chefetz who will elaborate on dissociation. This Series ends on March 7, 2009 with Dr. Ghislaine Boulanger talking about her longstanding work with Viet Nam Veterans as well as more recent work with those intimately affected by 9-11.

This now fateful anniversary always casts a somber shadow on my mood. I try to use it to recall the thoughts on that Tuesday, not the least of which is the reminder to try to cherish and respect those I love; to reevaluate, daily, choices about what (and who) is meaningful in my life; and to take some comfort in the fact that the work we do helps ameliorate somewhat some of the all too prevalent traumas.

Living by One's Convictions

I was impressed yesterday to learn that Gov. Palin has a five month old son with Down's Syndrome. Many an expectant mom would have made a different choice. My heart also goes out to Bristol Palin who is an expectant mom at age seventeen. I agree with the Governor's announcement that this is a difficult choice requiring lots of support. Today a young woman, still a child herself really, will need to contain an infant's raging, teach subjectivity to a toddler, and, later, help with homework perhaps alongside her own studies, and frankly discuss sex with her teen. I am so happy that just eighty-eight years ago women who had reached majority age were granted choice, to vote.

In February 2008 on this blog I reviewed the film "Juno" and asked the presumptous question of how an otherwise educated teen could find herself in the predicament of being unwantedly pregnant. I will not presume to ask such a question now, as the decision belies the wanting. (Many decades ago when I was a teen, the belief was that only "good" girls got pregnant because they were not planning to have sex, and so were unprepared---recognizing birth control is not 100%).

In our consulting rooms with our therapy patients, nothing is off limits to discuss. This, unfortunately, is not so in the personal forum nor the political arena. Not all teenage girls have a supportive, educated, or well to do family. Regardless, there are those girls who may not want to carry a pregnancy to full term. Palin, of course, wishes to over turn Roe v. Wade, and so lives by her convictions. I applaud those who do. In a world troubled by people and countries who find it hard to recognize the center of subjectivity inherent in each other's experiences, I do not, however, expect others to live as well by my convictions. Having daughters myself, I am for freedom of choice, for them, their bodies, and their dreams.

Cormac McCarthy's The Road

by Lycia ALexander-Guerra, MD

A road, a journey, the myriad of metaphors for life or life experiences, and for an analyst, a metaphor for the experience of psychoanalysis itself. But the 2007 Pulitzer Prize winning novel The Road by Cormac McCarthy [who also won the National Book Award for All the Pretty Horses, (1992)], a book of "gratitude" dedicated to his young son John Francis, is almost too much to bear. I recall writing the film review, based on another of McCarthy's novels, No Country for Old Man, and alluding to psychoanalysis as no country for the faint of heart. The opening page of The Road had me reevaluating thinking myself of pretty strong constitution. McCarthy writes "the frailty of everything revealed at last."

I thought the novel might be describing the metaphoric annihilation of a severely depressed person, an existential angst par excellence of aloneness in a cruel world. The father in The Road says "if only my heart were a stone." And he recognizes that "he could not enkindle in the heart of the child what was ashes in his own." The Road is profoundly sad, but, unlike depression, beautiful. Tenderness and sacrifice evident in a yellow toy truck or a half packet of cocoa. Frighteningly, aliveness seemed to interrupt the relentless deadness only in passages that described a kind of kill-or-be-killed mentality, and a spark of love or tenderness almost too much to bear. I thought of patients who cut themselves.

There is a kind of 'be here now' to their lives, whether vigilant for marauders or a swim in a mountain pool. There is no past, and no place to be. The compelling reality is the search for food and for shoes.

The terse sentences, the paucity of dialogue, the bleakness, all reminded me of Hemingway, but, in The Road, even with the man sometimes dreaming of "aching blue" sky, or of his bride, or of flowering woods, there is no room here to entertain illusion, as Jake (The Sun Also Rises) thought Brett might, evident in his question to her, the book's last line: "Isn't it pretty to think so?" The Road has not a chapter, not a name (except Papa; and a name used as a lie); with almost every thing barren, sometimes not even a completed sentence, not an apostrophe, save one, for contractions, the daylight, grudging, the sun, indifferent. Corpses grimace, and the mummied dead are everywhere.

The boy is (understandably) frightened, alot. Perhaps the most heartbreaking of all is the recognition of what children in this (our) world always bear. The father, exhausted, irritable, tells his son, "You are not the one who has to worry about everything." The boy replies, "Yes, I am. I am the one."

Though the environs in The Road stand in stark contrast to descriptions of nature's lushness in McCarthy's The Orchard Keeper, I was nonetheless reminded by The Road of the journey of Inman, in Charles Frasier's Cold Mountain, on his intrepid trek, plodding through starvation, murdering marauders, and cold. But in The Road the man and his son trek through a nuclear winter of total destruction. If there is parallel devastation for Inman, it was what he thought became of goodness within himself, whereas the boy in The Road still carries the "fire" within, and his father believes this enough to keep them both alive against all odds for as long as necessary. Sometimes the analyst carries the belief inside, enough to propel analyst and analysand through the devastation. Sometimes it is the analysand who is responsible.

Perhaps in the last line of her NY Times review (Sep 25, 2006) of The Road, Janet Maslin said it best: "'The Road' offers nothing in the way of escape or comfort. But its fearless wisdom is more indelible than reassurance could ever be." Another Janet, Janet Malcom, might have written that about psychoanalysis, had she read The Road before writing The Impossible Profession.

key words: psychoanalytic literary criticism, Cormac McCarthy

Links to the blog posts about David Brooks's article and Empathy in Children have now been added to the posts.

The links to the articles in the blog posts about the David Brooks article, and empathy in young children, have now been added to the posts.

Edward H. Stein

Has David Brooks become a relationalist?

Has David Brooks, the usually-conservative New York Times columnist, become a relationalist or a contestualist?

http://www.nytimes.com/2008/08/12/opinion/12brooks.html

Edward H. Stein

New Study Shows Children Ages 7-12 Are Hard-Wired for Empathy

A new study by two University of Chicago students has demonstrated that children ages 7 t0 12 years are hard-wired for empathy. Their MRI studies demonstrating their findings, with graphics MRI images, are at the above link. Their studies demonstrated that the areas of the brain associated with moral reasoning are activated when the children see pain inflicted upon others. These are similar to findings that have previously been demonstrated in adults.

http://chronicle.uchicago.edu/080814/empathy.shtml

Edward H. Stein