Fittedness and Implicit Relational Knowing: What is Mutative

In co-creating fittedness, the therapist and the patient implicitly move toward a shared intention. In a beautiful explicit, concrete example, a colleague shared how she and a pre-teen, female patient were drawing a story together on a large whiteboard [an example of the therapist joining or following the patient]. After awhile, the young patient became embarrassed and moved away from the shared task, but then, looking over her shoulder and seeing the therapist still drawing, the patient returned to the whiteboard for some finishing touches [an example of the patient joining the therapist]. That is, the two moved closer and closer toward a shared intention. Moving toward a greater ‘fittedness’ leads to an increased coherence within the dyad, which, in turn, expands implicit relational knowing.

Expanding implicit relational knowing widens the possibilities of how to behave with one another and enriches the repertoire of relational patterns. Likewise, flexibility increases, as does the hope for spontaneity. This is mutative. This is change. Change opens the way to insight, when, after comfortability with a new way of being with an other, one notices that and how things are different.

This is to say that change precedes insight, not follows it.

The Boston Change Process Study Group [BCPSG] has turned psychoanalytic thinking on its head in another way with their explication of how relational patterning is primary and the foundation of psychological life, while conflict and defense are secondary. They cite attachment patterns at age twelve months (seen in the Strange Situation) as evidence for the presence of conflicts and defenses based on relational experiences (because the infant has already apprehended what to expect from the caregiver). For example: an infant with avoidant attachment has learned it cannot count on the caregiver to soothe it when distressed and so appears to have little affect [defensive] while seeking objects to soothe itself; or, conflict is evident in disorganized attachment where the infant reaches for its mother while simultaneously backing away from her.

Change in Psychotherapy: A Unifying Paradigm. (2010). The Boston Change Process Study Group. New York: Norton.

Continuing Case Continues? and disruptions, and continuity of sense of self

There was today in class a lot of confusion on the instructor’s part. Even if we get past the limitations imposed by differing accents, by the teleconferencing connection, and by this instructor’s hearing impairments, there remains that the instructor could not sort out when the presenter was talking about what occurred in the session explicitly between patient and therapist and what was being related from the presenter’s mind as hypotheses and as background information about the patient and the treatment for the class to know. [To this instructor’s relief, the instructor was not the only one confused about ‘what is going on around here’ in the class.]  So we decided to discuss together what was going on. [Unfortunately, the presenter was not able to get through the session she had looked forward to presenting; a melancholy choice: choose one, lose the other.]

By addressing in class the process instead of content, we were able to glean some useful ideas.

Quoting one classmate, we could ask: What belongs to whom? Whose ‘language’ is spoken? (whose desire? [a topic of the earlier course]) and Who am I?, all of which might relate to the patient, the patient vis a vis her parents, the therapeutic dyad, and to the class. This same classmate noted that the disruptions might be related to the session (as well as to the presentation), specifically to the possible dissociated self states of the patient coming into the session, threatening continuity of self and of session. Another classmate noted a possible dilemma between fusion and individuality for the patient, that is, the patient experiences an attachment as having to lose the self or part of the self if she is to maintain a connection. (The presenter confirmed this with an example from the session). There is also the Adult Attachment Interview research which found an incoherent narrative is indicative of insecure attachment, which the patient here certainly experienced with her intrusive mother. Lastly, the instructor’s repeated attempts to clarify what the presenter was saying caused not only too many  interruptions (discontinuity) but also had the presenter feeling scrutinized just as the patient had felt so micromanaged by her mother.

All this by way of saying what the reader already knows: process is as important, maybe more so, as content; class process may reveal valuable information about the patient’s inner life; parallel process exists; instructors need to be more mindful of how her desire affects the presenter’s; and much more.

Holding in mind: Dreams in Continuing Case

So our therapist, having recently dreamed about her patient (see post of 11-28-18), opens the door for reciprocity and inquires about the patient’s dreams, particularly dreams about the therapist. The patient, red-faced, shares a previously unshared dream from three months earlier:

I am in a session with you and I come toward you to kiss you. As I get closer, you turn into my mother. I don’t stop but go ahead and kiss you. Suddenly I am my room in my childhood home and you have turned into my father. The scene changes again and I am at my mother’s childhood home and I am kissing a man.

The patient says she woke up from this dream very upset, more upset than from any remembered dream. The patient asks why therapist made this inquiry. The therapist makes the decision to share her dream with her patient. She makes this decision based on ideas about co-creation and from Philip Bromberg’s idea that the therapist’s thoughts, feelings, dreams, about the patient are the purview, the property, of both the patient and the therapist.

This patient’s [maternal] grandmother, now dead six months, had been safe haven for the patient, protecting the patient from the wrath of the parents. As the therapist is describing to her patient the patient’s grandmother as found in the therapist’s dream, the therapist recalls that this grandmother’s brother, the patient’s maternal great uncle, had been eschewed by the family for his political views and activities. While literally dead, this great uncle was also ‘dead to’ the family as they never spoke of him.

Saving associations to the patient’s own dream for a later time, the therapist asks the patient what it was like for the patient to hear of the therapist’s dream. The patients says it had been a tough week for she had been considering when would be the right moment to come out to her parents; and she had run into her father in public that week while with her female lover. Also, the patient and her mother had had their first, in a very long time, serious conversation, all jokes aside, over coffee that week, and her mother had cried. The patient had not overreacted with her mother and she notes that the mother had to choose between living in a faraway town with her husband or staying with her own mother. Choose one, lose the other.

The therapist notes aloud to the patient a connection: the patient believes she, too, must choose between her parents and her girlfriend (and her Self as a lesbian). Furthermore, there will be the feared additional loss of the therapist, for the patient believes therapy can end after she reaches her last goal of coming out to her parents. The therapist shares her own feelings and dilemma: the pride she has for her patient; the therapist’s own loss when the patient leaves. The patient asks for homework [housekeeping; see post of 11-28-18].

The beauty of this session is the ongoing deepening of the relationship between the patient and therapist. The patient had already been growing (mustering her courage to come out, being able to converse with her mother without overly reacting), and one wonders if the patient implicitly experienced and made use of the therapist holding the patient in the therapist’s mind, made explicit by the therapist sharing her dream of the patient.

A therapist's dream about her patient; Continuing Case continues

A therapist has a dream about her patient:

I was waiting for her to come to the session but the therapy room was in my home. Before she came I was trying to make my bed because my stuff was all around and I can see it is my childhood bedroom, the one I used to share with my brother. There are two beds and I am trying to make my own. I have a conversation with my mother, telling her not to interrupt us. My mother says she is not sure whether she will or not. I am setting boundaries with my mother, saying, “No, you won’t!” My patient is coming with her mother and her grandmother. There is a table between us, my patient sitting next to me; on the other side of the table is her mother and grandmother. All the time I am thinking there is no father [here], only the mother and the grandmother. It is as if I am counseling parents, as if my patient is not an adult and I am talking to two parents about a child. At the end of the session the patient asks me for a prescription to protect her from having to do [house]work [for her mother]. I say, “Okay, [names patient], I could write this for you but then it would mean you have depression or withdrawal [can’t handle work because you are withdrawn]. You can’t handle the job, otherwise I can’t prescribe what you are asking at this point.” The patient’s mother says, “She would not have to ask for this prescription if she would have sexual relations with a man.” We [patient and therapist] looked at each other and laughed.

The Continuing Case class noted that the burden of the load of [house]work in the treatment had been mostly on the therapist’s shoulders, where there had been a noticeable asymmetry. The therapist reminds the class how in a recent, previous session the patient had mentioned she now felt more “equality” between herself and the therapist [see post on 11-8-18]. The patient had been able to say ‘no’ to her mother but was, as yet, unable to tell her parents that she is a lesbian. In fact, the patient’s last goal in therapy is to come out to her parents, after which she can terminate the treatment. In the dream, it is the therapist who stands up to her own mother. In the dream, the patient is requesting the therapist’s “prescription” perhaps like an alibi or excuse to not have to do -- in the parents’ eyes --  the work of a woman, that is, not have to marry a man. Perhaps the therapist in the dream is saying that, should the patient succeed at circumventing the parental demands for heterosexuality by coming out to them, then, were the patient to be also depressed and withdrawn, the therapist would have an excuse to keep the patient in treatment.

It seems that the therapist’s dream about her patient condenses the patient’s difficulties while also resonating with the therapist-as-daughter issues. The patient’s mother, upon falling in love with the father, had had to leave her own mother and move far away. In parallel, the patient expects to be abandoned by her own parents should she choose to openly love [a woman]. To be forced to love a man in order to maintain ties with her parents would cause depression and withdrawal in the patient. The therapist dreams a way for the patient to stay in relationship with the therapist and the treatment, though not a perfect solution. These themes, fresh in the therapist’s mind, may now be revisited and reconfigured together in future sessions.

Misogyny in psychoanalysis

    Never was the contrast between classical and contemporary psychoanalysis more stark than in the chapter chosen for a beginning course in technique* by CAPA (China American Psychoanalytic Association). The chapter --- (#2) “Assessments, Indications and Formulation” ---  appears in Long-Term Psychoanalytic Psychotherapy, Third Edition (2017) by the renowned psychiatrist and psychoanalyst Glenn O. Gabbard, MD where he formulates the case of a 38 year-old woman “to explain the patient’s clinical picture.” 
The patient presented with depression and the beginning of a new, troubled, heterosexual relationship. Her mother ”had never really been able to take care of her because her mother was emotionally unstable and upset all the time.” Her father was an alcoholic and a womanizer who would comment on the patient’s looks, and the patient was contemptuous of him. The parents divorced when she was 12 years old. The patient had been using alcohol from a young age and had intercourse at age 13 years with a man who bought her alcohol. Subsequently she began using illicit drugs. She described herself as “highly ‘promiscuous’” and said she is addicted to alcohol and sex.

    Gabbard makes a lot of the woman’s sexualness and seductiveness, in her dress and in her attitude toward her male therapist.  In his formulation, his “psychological hypothesis” is: “Ms. A grew up in a tumultuous childhood situation where she felt neglected by her mother, so she attempted to get love and admiration from her father by attending to her appearance and sexualizing their relationship.” Even if we decide to ignore the patient’s contempt for her father--- and his behavior toward her and others--- and surmise that a part of her, of course, is longing to be loved and recognized by him, nowhere does Gabbard mention in his formulation her rape at age 13. Instead, there appears to be an implicit blaming of her.

    Other than “a tumultuous childhood situation where she felt neglected by her mother” Gabbard does not find the history of this rape significant enough to include in his formulation. He does not include anywhere in his formulation anything about insecure attachment or the dissociation and incoherence that result when a mother could not attune, regulate or protect the patient as a little girl, all of which likely contributed to the patient’s inability to understand the intentions of others in a self protecting way. That the patient seeks recognition and tenderness seemed to have been confused [Ferenczi] by Gabbard, as seen in his emphasis on ‘sexual’ behavior. Would a clinician not wonder if her “promiscuity” were not an enactment of her childhood sexual traumas [plural, as I imagine more than one]. Gabbard's formulation at best indicates he is wedded to drive and Oedipal theory and at worst intimates that the child unconsciously orchestrated her own rape as a consenting [as if the age of consent in an equitable and civil society were 13] seducer of men; and why? because she longed for her father's attention. And what about her mother’s attention in this formulation?

Are we still living in this kind of world?

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

Lauren Levine and the Film "Room"

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

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

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

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

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

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

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

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

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

Vote for Health, Mental and Physical

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

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

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

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

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

Continuing Case Conference, continued

Power Games [TBIPS’ Continuing Case seminar] Part II

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

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

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

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

Attunement and Shame  [TBIPS’ Continuing Case] Part III

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

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

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

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

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

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

Upon learning of this patient’s rageful breaking up of the girlfriend’s property as a result of their breakup, the therapist tries to explicitly link the patient’s violent reaction to the patient’s college interest in the anarchy group and to her mother’s abandonment. This ‘interpretation’ enrages the patient, “Stop playing power games with me with your irrelevant pseudo-interpretations!”

 

[What is an interpretation, different from clarification, confrontation, musing aloud? One participant in class notes it is a way to find meaning, to explicate meaning; it is a hypothesis. Another participant, recalling the traditional idea of ‘making the unconscious conscious’ says it is a way to bestow insight, to bring the intention into awareness. Some contemporary theorists say change in experience and behavior precedes insight. See example below.]

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

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

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