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?] http://tbips.blogspot.com/2018/11/misogyny-in-psychoanalysis.html
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. http://tbips.blogspot.com/2018/11/the-forward-edge-and-co-created-opening_8.html
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 hen 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.] http://tbips.blogspot.com/2018/11/continuing-case-conference-continued.html
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.]
American writer Richard Ford, who has recently written Between Them -- the memoir of his parents’ (Parker and Edna) life and love-- shared with PBS Newshour’s IMHO (In My Humble Opinion) on May 19, 2017 some of the reasons one writes a memoir:
“To render testimony
To bear witness
To make sense of a recollected life...
Substantiate ourselves to ourselves…
To utter what must not be erased…”
and because “I missed them” and some longings are “acted upon even long after it might be
supposed that enough time has passed for longing to subside.”
Furthermore, “Age is a winnowing process and sometimes what gets sifted out as we seek to know the important consequence of lives are the actual lives themselves.” About his parents’ lives, he recognized that though “as most parents are, [they were] all but unnoticeable in the world’s disinterested eye,” they were of importance to him because of the love and relationship they shared with him. [I am reminded of the iconic play “Our Town” (1938) by Thornton Wilder where the ordinary town of Grover’s Corners and the ordinary lives of its citizens are made extraordinary by the relationships people share.] He said of them: “Being their son seemed a privilege, and almost mysteriously, they opened for me a world of immense possibility.”
Perhaps in response to the current political climate, he added, “In a world cloaked in supposition and opinion and misdirection and often in outright untruth, things do actually happen. My parents’ lives did take place.”
Some of Ford's reasons for writing this memoir speak to our work (witnessing, remembering and making sense, even instantiating authentic beings through actual experience). When we listen with reverence and love to the stories of the lives of our patients, we validate the importance of their memories, their feelings and their lives. For as Ford noted from Saint Augustine ‘Memory is a faculty of the soul.’ http://tbips.blogspot.com/2017/08/more-about-narrative-or-narrating-ones.html
A lot has been written in contemporary psychoanalysis about the need to free ourselves from strict theory and technique in favor of the process of the moment to moment experience of two people intimately engaged in the collaborative construction of relationship and of meaning, primarily for the patient’s benefit. I was pleasantly struck to find the same ideas about uncertainty, spontaneity, surprise, and surrender in the process of one author’s writing.
Listen to what George Saunders, author of the critically acclaimed and New York Times best-selling novel Lincoln in the Bardo (2017), tells Jeffrey Brown on the Newshour Bookshelf (March 28, 2017) about the process of writing: “The holiest state is to be a little confused by what you are doing and you are guided by the energy that the story is actually giving you as it is revised. That’s kind of tricky because it means you have to abandon your ideas about organization or thematics and really submit [surrender] to the story… and hopefully it will result in some new mode of beauty.”
I thought it aptly put. (He is a wordsmith after all.)
By the way, Saunders additionally said in the same interview that he was inspired by Lincoln who had somehow been able to “transform... sorrow into a kind of expanding empathy for everybody” and whose “response to fear or hardship was expansiveness instead of shrinkage.” Were that we all were so heroic. http://tbips.blogspot.com/2017/08/more-on-storytelling-narrative-and-on.html
Emily Esfahani Smith, author of “The Power of Meaning” reported in a PBS Newshour IMHO (In my humble opinion) segment on Mar 10, 2017 that psychologists have counterintuitively concluded that the chasing after happiness can leave people unhappy and lonely. It is instead the search for meaning and trying to figure out how to make our lives count which bring happiness. She cites the epic of Gilgamesh, one of the oldest known literary works (Mesopotamian, ~ 2500 BC), and sees in it the hero’s search for how to live knowing that he will die. Smith says his quest remains urgent.
Social scientists say meaning is found when we connect and contribute to something beyond ourselves, such as to family, work, nature, or god. Smith cites three conditions found in people who say they have meaningful lives: 1) They believe their lives matter; 2) They have a sense of purpose; and 3) They think their lives are coherent and make sense. Storytelling itself gives meaning, she says, and offers clarity.
I am reminded of the work we psychoanalysts do, a connection which brings personal meaning to our lives, but also affords to our clients both a search for meaning and an attempt at a coherent story. We know that a coherent narrative in Mary Main’s Adult Attachment Interview predicts secure attachment. We know, too, that an important job in parenting is to convey to a child that she or he matters, has a right to exist, and is connected to something bigger (the family). Tomorrow, were he alive today, would be my father’s 96th birthday. I wanted to give a grateful shout out to my father for having always conveyed meaning to our lives by his love and dedication to his family (he was a great listener and storyteller himself) and to his work (he was a writer who showed joy and meaning could exist in one’s professional life), and by seeing his joy burgeon as he aged (through his interaction with his grandchildren).
Meaning through connection and narrative? Our profession was made for it. http://tbips.blogspot.com/2017/08/the-search-for-happiness-i-mean-meaning.html
Bion conceived of the analyst as a ‘container’ of projected parts of the other-- as mother is for infant-- particularly of intense, negative affects. The extruded parts and affects of the other are what is ‘contained.’ Analyst (as with mother) is not merely a receptive container, but a welcoming and validating one, and, moreover, accepts and modifies them (a part of the alpha function), but does not necessarily interpret them. The ‘container’ ideally dampens these overwhelming affects so that they are eventually amenable to regulation and self-reflection.
Thus, through projective identification (projection and response to what is projected) the analyst has come to know unwanted affects and painful relational patterns, and furthermore attempts to ‘digest’ them and re-present them in a more ‘palatable’ form. We might note the similarity to making use, after the fact, of enactments which bring to light nonconsciously encoded patterns of ‘how to be” in relationship-- except that enactments are made use of by both analyst and patient who intersubjectively process shared experience and co-create any meaning making. An example might be mutual recognition containing aggression because complementarity is no longer at work.
Spezzano adds a felicitous element to Bion’s ambiguous term ‘container’ when he intimates it is: to be held in the mind and meaning system of the other as a protection against psychic homelessness, meaninglessness and chaos. Putting parts of the self in the other may then be an attempt to create holding of the self in the analyst’s mind. In the analyst’s mind, there can be an increased opportunity to co-create context for them, and an increased capacity to safely play with these projected parts, as was the case with a young man-- an avid user of ‘spice’ or K2, but no longer a user of heroin -- who let me feel all the sadness, himself long indifferent (numb) to the pain experienced by the little boy whose mother had left him and his father when he was but six years old (he never saw her again). Tears could stream down his face when I described the plight of an abandoned six year old, but that boy’s sadness was not his own. Through approaching the loss and confusion of a child through the little boy I held in mind, my patient could begin to approach what might have been his own experience. http://tbips.blogspot.com/search?q=Container+Function
Clinicians just starting out often worry about saying the ‘right’ thing to a patient. I often tell supervisees that people come to us not for answers, and not necessarily for words, but for “something more,” such as a longing to be recognized, to have someone take an interest in their inner lives. As humans, we usually have an interest in others, and as therapists, a deep interest in others and in their inner lives. We have a desire to know more, and we make an effort not to impinge with our curiosity, to have a benevolent curiosity if you will. So far so good.
People also come to us needing to be held in mind. Just as caregivers grow the brains of their infants by gazing at them, by enjoying them, by remembering and imagining what it was like to be such a baby with an inner life and with experiences, so the holding a patient in mind (even outside of the session) comes to us as we reflect on and imagine the past, present, and future experiences of our patients. The caregivers’ interest grows the baby’s inner life: the baby experiences itself as ‘I am interesting. I am important. I have a right to be here. I exist.’
Sometimes our patients need such things from us: to be held in mind, to be enjoyed, to hold our interest, to have their feelings “marked” (in the same direction of the affect, without being identical). These experiences are part of “implicit relational knowing” and do not require words to effect reconfigurations in brain anatomy and brain chemistry.
Sometimes our most sorrowful of patients have missed out on some necessary pre-verbal experiences: of being gazed at, nursed, rocked, sung to, of being held in the caregiver’s arms, and being held in mind. Ogden called this very important fundamental stage of sensory experience the autistic-contiguous position. It is the foundation or sensory ‘floor’ upon which subsequent experience is integrated and organized.
I recall a 15 year old boy with a horrible history of abandonment, neglect and physical and sexual abuse, often in foster care, who was court ordered to see me after punching his father. (His father had called the police.) The boy arrived for the first appointment very angry. He crossed his arms, declared emphatically that he was not going to talk to me, and promptly fell asleep on the couch for the entire session.
Perhaps I had the autistic-contiguous position in mind. Perhaps I was thinking about this boy’s childhood (some of it previously revealed to me by his father when the father had made the appointment) and thus was imagining that this boy had probably never been held in the mind of a caregiver, never been held in a caregiver’s arms and been rocked and sung to, never had consistent opportunities for mutual regulation of distressing affects. But, whatever the 'reason,' I began to sing him a lullaby as he slept there immobile. When the session was over, he lept off the couch. He returned the following week and each week thereafter, and talked and told me his sorrows. (He even hoped to continue long past the six months ordered by the court.)
Ogden, TH. (1989) The Primitive Edge of Experience. Northvale, NJ: Jason Aronson. http://tbips.blogspot.com/2017/07/lullaby.html
Internalization alludes to aspects of the other, including those projected, which can become part of the self, encoded experientially and procedurally in the brain, as do interactions or way of interacting with the other. What the other feels about the self, what is implicitly communicated, also becomes part of the sense of self, whether positive or negative feelings. It is the feeling (affect) more than the action that is encoded. Whether the self can come to expect soothing or neglect is also internalized. This procedural knowledge is carried forth into later life.
Black girls age 5-9 years are seen as older than their years, called ‘adultification,’ according to a recently published study by Jamilia J Blake, PhD, Associate Professor of Educational Psychology at Texas A&M University and Rebecca Epstein, Executive Director of Georgetown Law’s Center on Poverty and Inequality. Blake and Epstein found that black girls are seen by the school and juvenile justice systems as more adult and less innocent than their white peers. They are perceived as needing less protection and less comfort and nurturing, and were found to be punished more harshly than white peers, e.g. five times more likely than white girls and twice as likely as white boys to be suspended from school. Teachers were more likely to call the police on black girls and prosecutors less likely to drop cases against them than white girls. While a previous study by a separate research team [Perry] had shown a similar ‘adultification’ of black boys from about age ten years, black girls showed a higher disportionate rate of disciplinary action than even black boys, thought due to ‘gender transgressions’ (violating norms of femininity).
What adults project onto children affects the way children see themselves. So, what happens when children are seen as less innocent and more adult like (whether ‘adultified’ or parentified)? are punished more harshly? and given less nurturing? Do they grow up perceiving themselves to be ‘bad’ and unworthy of their longings for [inter]dependency, comfort, and help? Do they feel undeserving of tender caring and instead are the caregivers, or, worse, so bereft of receiving care that their subsequent and understandable resentment and anger lead to lashing out, even becoming the delinquents others expected all along? http://tbips.blogspot.com/2017/07/black-girl-interrupted-black-girls.html
Because Adrienne Harris so eloquently discussed intergenerational transmission of trauma on March 18, 2017 at the Tampa Bay Psychoanalytic Society [see 3-21-2017 post], I thought I might share a bit of what Bruce Bradfield’s wrote on the subject:
“[P]sychic trauma...attempts to make meaning out of a phenomenon that resists knowing. … [D]issociation [i]s a primarily relational process, which keeps traumatic experience
unformulated and ambiguously signified in both the mother and her child. … [It is] a defense against intolerably painful affective states,which manifests in the mother’s intrapsychic experience, and in the relationship between mother and child…[T]rauma [is]...an experience that overwhelms the individual with inassimilable affects.
“[E]lements of parental traumatic experience are passed on to their children …and… subsequent generations. …[D]issociation is a consequence of a disruption of the parent’s caregiving capacity. [The parent’s] disrupted capacity to be emotionally attuned to the child ...[and] may impact on the child’s expectations[.]... [W]hat may be dissociated are not only the emotions associated with the parent’s trauma, but also the child’s need for relationship with the parent. …[T]rauma [is] communicated through patterns of relationship. … [C]hildhood interpersonal trauma has implications for the development of a particular disruption in lived experience [going on being], affecting attachment relationships directly. [There is] a relation between attachment style and posttraumatic responses.
“[A]ttunement within the relationship between mother and child facilitates the development of a capacity to integrate and contain painful emotions. … [D]issociation [is] an experience of disruption of the... capacity to integrate painful affective experiences. [D]issociation [is] manifest in future interpersonal relationships. …[and] reflects the incommunicability of traumatic histories, with trauma being held in familial and individual narratives as something unformulated and nameless.”
Bradfield, B. (2011). The Dissociation of Lived Experience: A Relational Psychoanalytic Analysis of the Intergenerational Transmission of Trauma. Int. J. Psychoanal. Self Psychol., 6:531-550. […] http://tbips.blogspot.com/2017/03/dissociation-as-hallmark-of-trauma.html
We may go into this helping profession with fantasies of being all knowing, all powerful (to change others), and, especially, all loving. Our ambitions to change, help, or fix our patients collide with the reality that patients have symptoms and behaviors that sometimes must remain if the patient is to feel safe and unfragmented. Not discerning the purposes served by these necessary symptoms, our ambitions can fail and we feel helpless, incompetent, unseen, and useless. Thus, we may become angry with patients, as if they are incorrigible or recalcitrant. We may resent them for rebuffing our overtures to be helpful. We may become ashamed of our failure and of our negative feelings, as if good therapists don’t get angry, good therapists don’t resent their patients.
Therapists can feel shame when talking about fees as if accusations of being greedy, uncaring, or sadistic hits too close to home. Therapists can feel shame about bodily infirmities such as when hearing loss, urinary urgency, gastrointestinal upset and other uncontrollable bodily changes are present. They can feel shame asking for referrals from more successful colleagues, or when litigation or completed suicide stigmatizes their practices.
If our expectations of ourselves are unrealistic and our assessment of ourselves harsh, we may respond to our mistakes with shame despite knowing that mistakes are inevitable, are useful learning opportunities, and can reveal heretofore unrecognized dynamics within and between patients and ourselves. Part of our shame can be resonating with our patients’ shame (e.g. projective identification) and thereby help us empathize with our patients’ experience. Owning up to our mistakes with our patients models survival of our own humiliation and may lead to more authenticity in the therapeutic relationship. Our patients’ forgiveness through repaired or continued trust can mitigate our sense of failure and shame.
Patients can experience a lessening of their shame in therapy when they find acceptance and empathy from therapists upon revealing what was once thought unspeakable, but when the therapists’ shame remains unrevealed, where do they find relief? Supervision with a nurturing and accepting, experienced colleague may help the therapist transform a grandiose ideal self into a more realistic expectation of one’s role as the therapist. Supervisors can remind us that patients value our dependability, our empathy, our trustworthiness, our ability to provide a safe space more than insight and perfection.
Weber.R.L. & Gans, J.S. (2003) The Group Therapist’s Shame: A Much Undiscussed Topic, International Journal of Group Psychotherapy, 53:4, 395-416. http://tbips.blogspot.com/2017/03/the-analysts-shame.html
An elegant, little paper from 1990 by Phyllis W Meadow, simply titled “Treatment Beginnings,” shows the author’s perspicacity about contemporary psychoanalytic ideas. She encourages the therapist to consider “[w]hat quantity of stimulation will help the patient to be in the room with me and to talk.” [‘Quantity of stimulation’ is what is noted in infant research re: regulation: up or down, to engage or sooth, respectively, the infant.] She writes, “the initial phase of treatment is… creating an environment in which the patient can give up his resistances to talking in the presence of the analyst.” Contemporary analysts might substitute for “give up his resistances...” the words ‘feel safe and participate in building a relationship,’ but the author’s meaning is clear: “Creating the relationship that will be therapeutic is the primary task of the analyst…” It is the analyst who bears the lionshare to create the safe space and to keep the process alive. (Winnicott described the good-enough mother who adapts the environment to the infant’s needs.) Meadow’s ideas about awareness of the patient’s “patterns for making contact” speak to a utilization by the analyst of relational paradigms. In fact, she states explicitly, “change takes place within the doctor-patient relationship.”
I am particularly fond of her stating that “The projector does not need a contradictory perception…” because I think it speaks to the idea that the patient first needs us to join with him, to welcome his perspective [and only later, when intersubjectivity is accessible to the patient, introduce our otherness.] Recently a patient accused me of being “vindictive and treacherous” which I could not initially wrap my head around until the patient added that she believed I was plotting with another patient to kill her. Owning that all of us have murderous impulses, I then could understand my treachery. Wearing her attributions, instead of contradicting them [Note: if I had contradicted them even silently, with right-brain to right-brain knowing she would have felt my opposition] had the effect of calming her fright. She was calmed somewhat perhaps because I was not contradicting her, not challenging her beliefs, not murdering her agency, if you will. Later, much later, in moments of mentalization (a necessary component of intersubjectivity), we were able to consider her ‘assumptions’ as thoughts, without a psychic equivalence.
Another lovely pearl was Meadow’s “Even the simplest mode of interpretation, confrontation, pointing out a patient’s behavior or explaining its effects, even this leaves the patient feeling criticized or attacked…” [and shamed, like a specimen under a microscope, less than fully human;
All interpretations in the classical sense, ‘you did this --- because of that ---’ may serve to humiliate and criticize.] Meadow notes that such confrontations “may intensify self-doubts.” Don’t many of our patients already come to us with a history of having their hard-wired capacity for reading the intentions of others vitiated by parents who scolded, ‘You don’t mean that!’ or ‘You don’t feel that way.’? When analysts want patients to question assumptions and erroneous beliefs, we hope to find a way for the exploration to be a collaborated effort which includes the patient’s curiosity and not just our own ambitions. Meadow wrote, "More important than progress is the ability to resonate with a patient..."
Meadow, PW (1990)Treatment Beginnings. Mod. Psa. 15: 3-10. http://tbips.blogspot.com/2017/10/meadows-treatment-beginnings.html
Bromberg writes that dissociation is both a structure and a process; it can be pathological--in its extreme, DID: Dissociative Identity Disorder, formerly known as Multiple Personality Disorder-- defensive, or normative, the latter occurring ubiquitously and a part of everyday life, such as putting aside our maternal selves while performing open-heart surgery or when we drive home with no memory of how we got from point A to point B.
When we think of dissociation as sequelae to attachment (relational) trauma, or to traumatic events, we consider overwhelming affect-- unmitigated, unshared, unsoothed-- that threatens to disrupt one’s sense of ‘going on being’ or continuity of self. Bromberg writes:
In order to preserve the attachment connection and protect mental stability, the mind triggers a survival solution, dissociation, that allows the person to bypass the mentally disorganizing struggle to self-reflect without hope of relieving the pain and fear caused by destabilization of selfhood.
Often patients have complained that they would feel ‘weak’ or ‘too dependent’ if they expressed their need for comfort (for shared affect) from an important other. Bromberg reminds of us the double shame inherent in the psychoanalytic process: the shame that comes from both seeking solace and from the belief that their needs are illegitimate, unreal to the other, and thus that the patients themselves are unreal and risk losing the attachment bond. He reminds us that, if the analyst does not recognize the patient’s desire to communicate to us the dissociated parts of the patient’s self, then the patient will continue to feel her needs are illegitimate and undeserving of solace.
Bromberg, P (2011) The Shadow of the Tsunami. Ch. 2. Routledge, New York & London. http://tbips.blogspot.com/2017/10/dissociation.html
We often hear that certain things, such as cocaine addiction or violent behavior, are inherited. Then there is the fascinating idea of epigenetics which, reminiscent of Lamarck, indicates that behavior can change genetic expression and can then be passed down in the genes. What seems to go under-emphasized outside psychological psychoanalytic circles is the intergenerational transmission of trauma, particularly relational (attachment) trauma. Schore puts intergenerational transmission of trauma like this: “...the infant is matching the rhythmic structures of the mother’s dysregulated arousal states.”
While two excellent, long-term studies have shown that violent behavior needs both the genetic vulnerability and the environmental exposure to violence in the home (the latter which is also a relational trauma, the relational trauma of a parent not seeing the child’s feelings, not regulating the child’s feelings, etc), why is it not also likely that drug addiction is not simply a genetic vulnerability but also a way of regulating one’s emotions? The addicted parent could not be sufficiently present to recognize, attune and regulate the child’s emotions and thus that child grows up with its own dysregulation, perhaps later likewise finding some soothing from substances. This dysregulation is not simply genetic. It is an intergenerational transmission of trauma, just like with a child who is sexually abused and unprotected and un-comforted, maybe even un-validated in her experience and pain, who grows up and becomes unable to protect her own child from sexual abuse.
A parent’s dissociated states from unbearable affect can create a dissociation in her infant (and disorganized attachment). The infant is then at risk for “a lack of integration of sensorimotor experiences, reactions, and functions” as seen in the common sequelae of somatic disorders (such as pelvic pain, fibromyalgia, migraines) resulting from childhood sexual abuse. Does one then say that sexual abuse of children is inherited? Not usually. Perhaps other behaviors, such as substance abuse, and even anxiety and depression, show up in the next generation and the generation after that because a parent who is not present (drunk, dissociated, anxious, or depressed) transmits these same self states to the infant, right brain to right brain. http://tbips.blogspot.com/2017/10/intergenerational-transmission-of-trauma.html
What we learn first stays with us the longest.
In beginning a new cycle of first year courses this semester, TBIPS, in its Intro to Psa Concepts I, starts with a contemporary point of view. Asking candidates and students to think about what are some possible components of a psychoanalytic process, someone includes ‘transference.’ We have read for today’s class a paper by Lew Aron and one by Irwin Hoffman.
A psychoanalytic candidate expresses scepticism about the relational concept of mutual influence in the transference: ‘Doesn’t the patient bring things in her head that have been there before she ever met you?’ Of course the patient brings things that had nothing to do with the therapist, but what emergeswith the therapist is constitutive of being with the therapist. The candidate gives an example: ‘I open the door to a first time patient and she says, “your building smells.” How could that not have come from her alone?’ I am curious. The candidate says this particular patient had had a traumatic past and had been physically disfigured-- her face, her gait-- in a fire. I inquire: what was his experience at the moment he opened the door to this patient whose face had been thus scarred. The candidate said that the film The Exorcist had come to his mind, her face horrifying, terrible.
Since microexpressions can be non-consciously communicated, right brain to right brain, and since horror can look like disgust, and disgust akin to bad smells, was it possible that this new patient recognized her new therapist’s look of disgust and her right brain registered it as ‘something stinks around here’? Maybe. The patient did not return after the initial consultation. What might have happened had the therapist spoken aloud to the trauma this patient endured as evident from her facial scars and, more important, had inquired about what it was like to see the initial shock of them on his face?
The class is inordinately grateful for this candidate’s example which helped us illustrate a more contemporary view-- that of mutual influence-- of transference. His example speaks to the readings:
From Aron:
“The analytic situation is constituted by the mutual regulation of communication between patient and analyst in which both patient and analyst affect and are affected by each other. The relationship is mutual but asymmetrical.”
“the patient’s experience of the analyst’s subjectivity needs to be made conscious”
“It is often useful to ask patients directly what they have noticed about the analyst, what they think the analyst is feeling or doing, what they think is going on in the analyst, or with what conflict they feel the analyst is struggling.”
“The exploration of the patient's experience of the analyst’s subjectivity represents only one aspect of the analysis of transference.”
From Hoffman:
“For Langs what is wrong with the classical position is that it overestimates the prevalence of relatively pure, uncontaminated transference.”
“the implications of the patient's ability to interpret the analyst's manifest behavior as betraying latent countertransference.”
Aron, L. (1991). The Patient's Experience of the Analyst's Subjectivity. Psychoanal. Dial., 1(1):29-51.
Hoffman, I.Z. (1983). The Patient as Interpreter of the Analyst's Experience. Contemp. Psychoanal., 19:389-422. http://tbips.blogspot.com/2017/09/when-transference-stinks.html
One of the benefits of membership in the Tampa Bay Psychoanalytic Society is participating in its monthly discussion group. This year the group is reading Philip Bromberg's Awakening the Dreamer. In the Introduction, Bromberg reprises Standing in the Spaces: "Self-states are what the mind comprises. Dissociation is what the mind does. The relationship between self-states and dissociation is what the mind is."
Bromberg sees dissociation as normative in the structure of the mind, but also as a process by which psychological survival is preserved in the face of overwhelming threat to self-continuity. When parents disallow aspects of a child's self, these aspects are dissociated by the child in order to maintain the needed tie to the parent. As the child grows into adulthood, his sense of self includes "'his parents' child'"-- that is, he continues to dissociate these aspects. Unlike repression that disavows content which causes conflict, dissociation disavows parts of the self. Bromberg claims that this disavowal of parts of the self impairs intersubjectivity such that the self is "largely unable to see himself through the eyes of an other."
Psychoanalysis, writes Bromberg, includes an act of recognition (different from understanding) of the patient's disavowed self-states, states accessible within the intersubjective field through enactment. Repeated experience with recognition [and the welcoming in] of these disavowed self-states increases their accessibility. Once accessible, these self-states are available to symbolization and self-reflection, and to conflict [the stuff addressed by traditional psychoanalysis].
In contrast, self-states that are not recognized by the analyst thwart the patient's desire for recognition and acknowledgement, and lead to shame. "..[B]ecause it is not forthcoming, [it] supports the reality of their needs being illegitimate." But "when the therapist is able to relate to each aspect...[t]his linking of self-states increases a person's sense of wholeness..." allowing one to live a fuller life. http://tbips.blogspot.com/2016/09/dissociation-and-trauma.html
Home is the place where, when you have to go there,
They have to take you in - Robert Frost
We long for the certainty of unquestioned acceptance and welcome, a feeling of home, the place where we belong, but then come to “the realization that one’s longing for home can never be met.” Brothers and Lewis (2012) expand the idea of homesickness— in self-psychology language—as “a longing to recover (or gain for the first time) a sense of certainty that the selfobject experiences upon which selfhood depends are unquestionably available.”
What do we do when we are confronted with the painful realization that we can never go home again, if home indeed ever was? What do we do when confronted with “this painful sense of unfulfilled and unfulfillable longing for home”? Brothers and Lewis intimate that a compensatory ‘home’ can be created by patient and analyst when they come to know one another in predictable, reliable ways and by building together a shared unique language. “In a healing analytic relationship…patient and analyst develop a shared language—partly verbal, partly nonverbal—by means of which excruciating experiences of sameness and difference become bearable.” [Here, sameness speaks to the need for twinship (see post of August 28, 2016), belonging as one does when ‘at home,’ and “the need to experience difference…to experience oneself as unique, special…”] Treatment additionally offers the opportunity for mourning what was lost, what one never had, and/or what one can never have.
Familiarity and belonging allow for the creation of meaning. But the sense of certainty and of familiarity are shattered by trauma. Trauma, in turn, can lead toexile “when trauma brings with it a desperate need to experience the clarity of difference.”
While Brothers and Lewis utilize the John Cheever quote ‘Fifty percent of people in the world are homesick all the time’ , their points about longing for what never was are also aptly illustrated in the Cheever short story Reunion (1962) where the son, meeting his father with heightened anticipation after years of estrangement, comes to the painful realization over lunch that he will never have the relationship with his father that he had always longed for; his longings for connection will remain unfulfilled; his efforts futile. Many of the works of Cheever speak to a kind of nostalgia or ‘homesickness’ for lost culture and community experienced in the isolating and alienating suburbs. There is a deep pathos in Cheever’s works. So, too, in ours.
Brothers, D., Lewis, J., (2012) Homesickness, Exile, and the Self-Psychological Language of Homecoming. International J. Psychoanalytic Self Psychol. 7:180-195
Cheever, J., (1978) The Stories of John Cheever, New York: Alfred A. Knopf; story originally appeared in The New Yorker magazine, October 27, 1962. http://tbips.blogspot.com/2016/09/homesickness-and-cheever.html
What better describes our need for sameness and difference, and for belonging, than this beautiful poem offered as an elaboration of yesterday’s post on Twinship.
Poem: Human Family by Maya Angelou
I note the obvious differences
in the human family.
Some of us are serious,
some thrive on comedy.
Some declare their lives are lived
as true profundity,
and others claim they really live
the real reality.
The variety of our skin tones
can confuse, bemuse, delight,
brown and pink and beige and purple,
tan and blue and white.
I’ve sailed upon the seven seas
and stopped in every land,
I’ve seen the wonders of the world
not yet one common man.
I know ten thousand women
called Jane and Mary Jane,
but I’ve not seen any two
who really were the same.
Mirror twins are different
although their features jibe,
and lovers think quite different thoughts
while lying side by side.
We love and lose in China,
we weep on England's moors,
we laugh and moan in Guinea,
and thrive on Spanish shores.
We seek success in Finland,
are born and die in Maine.
In minor ways we differ,
in major ways the same.
I note the obvious differences
between each sort and type.
But we are more alike, my friends,
than we are unalike.
We are more alike, my friends,
than we are unalike.
We are more alike, my friends,
than we are unalike. http://tbips.blogspot.com/2016/08/poem-human-family-by-maya-angelou.html
Most psychoanalysts are familiar with Kohut’s mirroring and idealizing transferences. Togashi and Kottler (2012) write about the twinship transference and note Kohut’s “transformation from the psychology of the self to the psychology of being human” and from “the disorder of the self to… trauma-centered psychoanalysis.” They enumerate the many faces of twinship:
(1) between merger and mirroring. Kohut originally conceived of the mirror transference in three forms: merger, twinship, and the narrowed mirror transference, their differences “based on the degree to which an individual” sees others as an extension of themselves or as a separate person.
(2) as a process of mutual finding. This does not mean “recognizing…the other’s subjectivity” but rather that “two participants…regulate a sense of sameness and difference in their effort to match…their subjectivity” such as when the analyst finds aspects of herself and not-herself in her patient and the patient, likewise, can find aspects of himself and not-himself in his analyst, this mutual finding process, essential to the twinship experience.
(3) as a sense of belonging. Later (1984), Kohut distinguished twinship from mirroring to a sense of belonging. Here twinship speaks to [authors quoting White and Weiner] ‘a similarity in interests and talents, along with the sense of being understood by someone like yourself” and [quoting Basch] ‘the need to belong and feel accepted by one’s cohort.’ [BTW, in this same volume, VanDerHyde writes a lovely paper on the importance of twinship, stating the need to belong precedes the need for mirroring or idealizing]
(4) passing talents and skills to the next generation. Togashi and Kottler write: “For Kohut, an individual’s efforts to educate others is often based on her yearning for a person who[m] she can experience as essentially alike, or for a person in whom she can find herself.” The parent sees herself in the child and, reciprocally, the child sees himself in the parent. The child sees himself as the welcomed “successor” as the parent is “creating and finding oneself in the next generation.”
(5) as silent communication. Twinship allows each “to share the feeling of connection without verbal communication –as with mother and infant; lovers; or analyst and patient—and to share in a “regulatory process to match (and not-match) one another.”
(6) feeling human among other human beings. Kohut noted the necessity to feel human among other human beings. Narcissistic parents can treat the child as an extension of themselves or as a non-human thing, the latter causing the child to experience himself as non-human among non-humans.
(7) in trauma. The authors cite Stolorow: “a need for twinship is a reaction to psychological trauma” [IMO, the authors decline to temper this statement by adding that we are hard-wired for a social network (a tribe), as well as that we can find joy in being understood and this not simply as secondary to trauma] and Brothers, noting that trauma destroys certainty and meaning. [and that we need relationship to restore the latter.]
Please see the next post for a poem by Angelou which beautifully illustrates humans’ need for a human family, same and different, but belonging. http://tbips.blogspot.com/2016/08/twinship.html
Tonight on the PBS NewsHour was aired an interview with German filmmaker Werner Herzog (Grizzly Man; The Cave of Forgotten Dreams) whose latest film, the documentary Lo and Behold: Reveries of the Connected World was released today. He asks “What makes us human? How do we communicate?” Herzog, like myself, does not have a cell phone as a matter of culture. Like me, he wants to be involved with the person across the table with whom he shares a meal and not be available to everyone else all the time.
It is a danger if we teach our children, for example: when preoccupied with our cell phones, that they are uninteresting and unimportant. A parent, chronically disinterested in the experiences of a child, may seriously impede the development of that child’s ‘voice.’ Many years ago, when my younger daughter was in preschool, I observed a sad scene.
Another parent and I drove into the parking lot at the same time. She was on her cell phone. We parked alongside one another. We walked the sidewalk together, into the building together, down the hall, and out the door to the playground area. She was still on her cell phone. I dropped to my knees when I saw my daughter and opened my arms. My daughter ran into them. The other parent did not say ‘hi’ to the little boy she had come for, but took his hand and the four of us retraced our steps. My daughter is telling me of her morning experiences as I buckle her into her car seat. The woman next to me is still on her phone. Her son is silent.
What or who is it that is so compelling on the other end of a cell phone that is worth making the person right beside us feel second best?
One of the salubrious pleasures of the quiet consulting room is the intense attention paid to one another as we struggle to navigate intimacy in the here and now. http://tbips.blogspot.com/2016/08/the-pleasures-and-perils-of-technology.html
Edward Tronick in his talk “The Dyadic Expansion of Consciousness Model of Psychoanalytic Change” noted that there are many “something more”(s) going on between two people in a dyad and that the state between the two contains more information than either has for one’s self. This information can be apprehended by either and used to make meaning. Tronick further noted that one needs to feel secure [At the body level this refers to wholeness, safety, boundedness] if one is to be flexible, creative, and able to engage in relationship with others. Conversely, insecurity impairs meaning making, self regulation, and can lead to rigidity, dissociation, defensiveness, etc. as the patient holds on to the organizing patterns he already has.
Information may come at the bodily level, for example, through synchrony of respiratory sinus rhythms by parasympathetic regulation, particularly when each has protracted experience of the other, through ‘matching’ of tone, prosody, etc, as well as emotional matching and shared meaning at the symbolic (linguistic) level. Meaning making occurs bodily, emotionally, and symbolically and one system can bring to light (and help regulate)another.
His comments reminded me of a patient who complained that his “true self” was being “crushed” by the phoniness displayed by friends and family members and induced in him a likewise inauthenticity. I inquired where he felt this sensation of ‘being crushed’ in his body for as he reiterated his complaint I had the image of a baby’s face smashed into its mother’s breast while nursing. He replied that it was his face, like a mask smothering him. When I shared my image aloud, he though it “weird” but was willing, when invited, to consider (or play) with the image I introduced. He came up with a heretofore unrecalled memory of his father musing aloud when the patient cried that “Indians” blew into the face of their crying infants to get them to stop crying, by way of “suffocating” them. [The patient had oft complained of not being able to breathe, not catch his breath fully, since childhood, and of having no one, not even the family doctor, understand his complaint.]
This vignette came to mind as Tronick spoke because it illustrated to me to one particular moment where my patient and I had access to information between us that neither of us might have had access to alone. It was in exploration of the bodily component that the memory was activated and put into words. http://tbips.blogspot.com/2015/07/making-meaning-dyadically.html
A supervisee, praised in her respective psychoanalytic training program for her “calmness and stability,” asked me recently how she could keep herself stable when faced with her very unstable patient whose instability, lamented the supervisee, she could feel inside herself as if her patient were “pushing” her. The therapist complained that she could feel herself “influenced” by her patient’s self states. Her patient was continually running away from the chaos of her own world and now the therapist-supervisee wanted to run away from this patient. A professional therapist, the supervisee claimed, can keep herself stable, work deeply and slowly, and could “stay there” in the room with her patient.
I was pleased to know that the therapist I supervised had the capacity to be influenced by her patient. Now we had to find a safe and comfortable enough way for the therapist to share with her patient that her patient was no longer alone in the chaos. And what a good job the patient was doing communicating her own internal states. [Is this what projective identification is?] If the therapist, too, could feel the chaos, and if the therapist could both survive the chaos and not be shamed by her lack of stability, what might these mean for the patient? That the patient was no longer alone? That it is okay to make mistakes? The supervisee further lamented that when she managed to feel calm and stable with this challenging patient, it was at the cost of feeling “dead” inside, feeling “serious: and unable to “interact” with her patient. The therapist found that paying attention to her own body sensations relieved her some of the deadness. The supervisee asked how she could be both alive and stable with this patient.
That is the big question, isn’t it? Bromberg, in On Knowing One’s Patient Inside Out (1991), wrote about how very difficult it is to be both participant and observer [Sullivan]. I have often wondered how one can hold the patient’s hand and jump into the abyss with the patient, and still hang on to the rim. It must take Herculean strength, and personal mettle. I know I failed gravely at least one patient.
Is the deadness the therapist feels inside not also, at least partially, a joining with a self state of the patient’s? Could the patient’s chaos be a way to protect herself from such deadness? Had the therapist stumbled upon something that the patient had dissociated in attempt for the patient to save herself from deadness? The supervisee asked why I, the supervisor, in multiple venues we had shared, was always so alive. That got me to thinking about from what deadness inside myself did I wish to run? Was avoidance of such deadness what made it impossible for me to truly leap into the abyss with my patient(s) and could it have simultaneously caused me to let go of my observer stance? The supervisee worried that, were she to enter the self states of her patients, they would either not make progress in therapy or they would leave treatment altogether for they would lose hope. I surmise that, should we make friends with our dissociated self states, neither destroyed not shamed, that might open a path for hope. http://tbips.blogspot.com/2015/06/having-fallen-into-abyss-myself.html
An erotic transference can stir up anxiety in the analyst. I recently had opportunity to view a teaching film in which a male analyst is asked by a female client whether or not he is attracted to her.
She begins the session modeling her new dress. The analyst says she must be going somewhere [after]. She sits and looks glum. The analyst asks her ‘what’s the matter?’ She says she had felt so foolish because she had gotten “no response” from him upon revealing in their previous session that she had a “crush” on the analyst. He disagrees that she should feel foolish [attacking her point of view/ the validity of her experience] and she reiterates that she indeed felt foolish. Again he disagrees and tells her that her revelation took courage. The client again complains that the analyst had said nothing about how he felt about her. The analyst gives an explanation about the asymmetry of the therapeutic relationship.The client persists in saying she felt stupid because the analyst did not speak to his feelings about her. He empathizes with her difficulty [saying nothing about his own]. He does state a dilemma: if he tells her he is not attracted to her she will be devastated and feel more like the fool; If he says he is attracted to her, the atmosphere will shift and she will feel less safe to say what she feels [He apparently does not consider the possibility that his honesty might model and engender further honesty from her]. The client stated again [third or fourth time, by now] that she still wanted to know if he finds her attractive.The analyst complains that what he is saying is being ignored. The client persists, “Am I attractive?” and the analyst complains he is being steamrolled in the way that her previous boyfriends have complained she tried to control them and dismissed their POV. The client persists, wanting an answer to the question asked at the beginning of the session. The analyst [in an attempt to force mentalization, I think] accuses the client of not caring what he feels. The client says the analyst is being “stubborn” by not answering “a simple question.” The analyst says the client does not want him to be her therapist. She denies this and becomes tearful as she complains that he will not do what she wants. The analyst seizes this opportunity to tell her she wants to control men. The client acquiesces [or has insight?] and says she does not know why [controlling men] is so important to her. The analyst tells her that she fantasizes if she can control men then they won’t leave her. Hanging her head, moving her tongue side to side pressing the insides of her cheeks, she says she can see that. The analyst adds that her father, asserting his independence, left her and her mom, so the client repeats the same thing over and over not getting the outcome she wants [you know, the definition of stupidity]. The client says she sees, but does not like it.
If an analyst’s anxiety can be measured by how much he/she talks and/or intellectualizes, the audience was certainly privy to the anxiety of this analyst in the video who talked significantly more than his patient did and who intellectualized with her instead of speaking to the affective relationship in the room. The audience was divided in their response, some seeing the analyst as deflecting, using ‘neutrality’ and abstinence and accusation [interpretation] as a shield; some seeing the analyst as handling the transference perfectly appropriately and using interpretation to impart insight. In this situation, I, too, have been made anxious. It is difficult for the analyst to stay empathically immersed (as Geist was able to in his 2009 paper on mutually constructed boundaries) when faced with confusion about the best way to proceed. How do we validate the client’s POV and still have a differing one conveyed? How do we speak to the emotions in the room present in both therapist and client and still keep open the potential space [instead of foreclosing space by reifying through action]? Certainly I have failed multiple times in this regard. What is missing in the therapeutic relationship in the consulting room that the client, or analyst, is willing to throw it over in favor of something else? How do client and therapist alike speak to and mourn what cannot be, and still remain in relationship? Analysis, in addition to everything else it is, after all, is also simply 'two people in a relationship.' http://tbips.blogspot.com/2015/04/conference-on-countertransference-and.html
Bromberg, who has written cogently on the patient’s need to stay the same (not give up a part of himself or lose a sense of who he is) while changing, cautions the analyst against attempts to alleviate a patient’s depression without first respecting that depression is not merely an affective state but is also who the patient is: “For many people [depression] is a self-state with its own narrative, its own memory configuration, its own perceptual reality, and its own style of relatedness to others.” Because the patient has a need to preserve the self and self meaning, he cannot easily allow the analyst to destroy a part of his personal reality as if it is meaningless.
By giving in to a patient’s demands in an effort to relieve him of his depression the analyst attacks the patient’s self and speaks to the analyst’s incapacity to bear with him his suffering. Gratification of patient’s needs (in attempts, for example, to relieve depression) can become “a form of misrecognition, …evidence to the patient that the analyst is unable or unwilling to authentically ‘live with’ the patient’s state of mind.” While “patients in general need soul-searching emotional openness from their analysts” the analyst’s inauthenticity makes it difficult for her to give the patient what is actually needed—genuine mutuality— and so the patient understandably responds by pushing the analyst “to the edge” in the hope of helping her change into someone more capable of genuine mutuality.
Bromberg, P.M. (1994). “Speak! That I May See You”: Some Reflections on Dissociation, Reality, and Psychoanalytic Listening. Psychoanal. Dial., 4:517-547. http://tbips.blogspot.com/2015/01/depression-is-us.html
Because we all seek to maintain [or create anew] a sense of individual meaning, Lafarge writes that disruption of our sense of self can lead to the wish for revenge, “a ubiquitous response to narcissistic injury.” Revenge “serves to represent and manage rage and to restore the disrupted sense of self [and restore the] internalized imaging audience [the other].” Narcissistic injury is a disruption to meaning and self value and to the story of one’s experience. In efforts to reestablish meaning and to construct a story, as well as create a witness to one’s story, the avenger uses anger and revenge to consolidate early experiences (a time when the “imagining parent” [like Bion] helped construct the infant’s mind with meaning and with its representations of self and others). Communicating experience and constructing its story is also present in the revenge. It is a way of being seen and heard and helps maintain the tie to the lost, imagining parent. Thus, revenge can ward off object loss [Searles] and hatred can be an early form of object constancy. “Giving up the wish for revenge requires the avenger to recognize the rage and helplessness that are warded off…[and] involves acknowledgement of a transient disruption of self experience” that they accompany.
Lansky tells us that shame gives rise to rage as a strategy to protect one’s sense of self from the awareness of helplessness, abandonment, betrayal. Sometimes, clinically, it is easier to analyze the visible rage and resentment than its underlying shame, but it is the detailed exploration of shame that sheds light on its unbearableness. When one’s sense of self is chronically disrupted from the betrayal by needed and beloved others, attachment is at risk. All future attachment is at risk, for who wants to be duped again, subject to humiliation and shame? The disrupted self, in valiant efforts to reconstitute a self representation that can be lived with, may need to withdraw and isolate, project, omnipotently control, split, or retaliate. The latter, as revenge, can seemingly restore a sense of power and effectiveness as well as protect against awareness of vulnerability. Revenge also protects against the uncertainty of forgiveness. Only awareness of loss and its mourning can circumvent the need to humiliate the other, leading to forgiveness both of self and other.
LaFarge, L. (2006). The wish for revenge. Psychoanal. Quart., LXXV, pp. 447-475.
Lansky, M.R. (2007). Unbearable Shame, Splitting, and Forgiveness in the Resolution of Vengefulness. J. Amer. Psychoanal. Assn., 55:571-593. http://tbips.blogspot.com/2014/12/revenge-and-forgiveness.html
Unlike Kohut, who believed in a unitary self and thought health was an increased cohesiveness in one’s sense of self, Bromberg says that we all exist in a multiplicity of self states, each with its own memory, experience, and unconscious. “Health is not integration. Health is the ability to stand in the spaces between realities without losing any of them.” (p.186), that is, it is simultaneous awareness of these many discrete selves. The sense of a unitary self, writes Bromberg, is an adaptive illusion. Dissociation of certain self states, with their untenable affects (such as shame) occurs in all of us, often in response to the traumas of misattunement, misrecognition, or attacks on our reality. Bromberg recommends that analysts learn to see the validity of a patient’s psychic reality alongside their own, careful not to claim ownership of arbiter of reality. In this capacity to see both realities, space is made to construct consensual meaning. Their relationship is continually renegotiated.
Sometimes the only way to access dissociated experience is through enactments which can painfully draw the analyst into the early object relations of the patient. Sometimes these enactments additionally allow the patient to see his impact on the analyst. Enactments are
…an example of what Levi (1971) called “a powerful though perverted attempt at a self cure” (p.184). It involves a need to be known in the only way possible – intersubjectively—that is different from the old and fixed patterning of self-other interactions, a version of the situation that led to the original need for dissociation. (p.172)
For a patient in analysis to look into his own nature with perceptiveness, and to utilize creatively what is being enacted, there must exist a simultaneous opportunity for the patient to look into the analyst’s nature with an equivalent sense of freedom and security. (p.176)
In the clinical situation, those patients with the most dissociation, often called personality disorders, cannot resonate with interpretations which address conflict because, until contradictory self states are in simultaneous awareness, the contradiction/conflict cannot be 'seen' by the patient. Because psychic reality varies by self state, an issue already explored in one self state may come up again later in another self state. As one candidate noted to herself as her patient spoke, "Didn't we already go over this!" In this 'Groundhog Day' phenomenon, and the going over and over the same ground, is what I like to call 'the joy of Sisyphus,' and the candidate asks, "So where's the joy?"
From STANDING IN THE SPACES: Essays on Clinical Process, Trauma, and Dissociation (1998). Psychology Press. New York, London; Chap. 12, Shadow and Substance. http://tbips.blogspot.com/2014/11/dissociation-and-enactments.html
If Freud said our personal ideologies are our “private religion” (convictions with unfaltering ritualization of behavior, repetition compulsion, if you will), Shaw adds that our private religions spring from our attachment story for we are all subjugated by our internal objects. Shaw defines traumatic narcissism as the need to defend against dependency, for dependency is intolerably shameful and humiliating, and must be disavowed. Instead, dependency and neediness is seen in the other for the traumatic narcissist has everything within the self and needs no one. Traumatic narcissism is a relational dynamic requiring both the narcissist and its object to be subjugated. The easiest target is its child.
While all parents may sometimes attack the reality of their children, self aggrandize the child’s accomplishments, and have hope that the child will make up for their own failures, the traumatic narcissist can never admit fallibility, can never apologize, and continually attempts to control and erase the subjectivity of their children. This is the cumulative relational trauma. The traumatic narcissist despises the child’s neediness, yet, paradoxically, any attempts by the child towards independence and agency are punished (by withdrawal or retaliation) for the narcissist requires the child to be the container for shameful neediness, Bateson’s classic double bind. This child, shamed for its dependence (and what is a child but dependent?), made to feel selfish and greedy, recognizing that only the attachment figure’s needs are deemed valid, grows up to identify with the hated, but much needed, aggressor, an intergenerational transmission of traumatic narcissism.
Objectification of the child by the traumatic narcissist is an absence of recognition, or a presence of negation. In analytic love, the therapist envisions the potential that cannot be realized, much like the good enough parent sees what the child can become. The children of traumatic narcissists, when they become our patients, demand not only that we recognize their trauma, but that we recognize our own disavowed traumatic narcissism! What a dangerously fraught journey for both patient and analyst as we struggle together toward freedom from the tyranny of our inner objects. http://tbips.blogspot.com/2014/11/daniel-shaw-on-traumatic-narcissism.html
As we know, trauma increases blood flow to the amygdala while decreasing perfusion to the hippocampus with the effect that procedural, emotional and sensory memory take place without the benefit of symbolization in language and without contextualization (one physiological explanation for dissociation). This phenomenon informs how clinicians can work with experience that has no words. The narrative approach assumes that symbolization is already present. Trauma, including the trauma of chronic misattunement, can cause chronic autonomic nervous system activation (affecting respiration, heart rate, perspiration, muscle tension, etc) with its emphasis on sensory not symbolic representation.
Bucci proposed a multiple code theory of emotional processing, three systems of emotional schema: the subsymbolic (perceptual, sensory), symbolic imagery – both non-verbal— and the symbolic (verbal). These three systems are separate, but through the relational attunement and secure attachment with caregivers, who use their own emotional and cognitive schema to help children name, accept and regulate their emotional states, connections between the three are forged. In somatization, subsymbolic somatic schema are activated but are dissociated, never linked, or have lost their link to symbolic representations.
Taylor contrasts conversion disorder with somatization disorders. In the former, symbolization is intact and emotions are represented, and symptoms are the result of repressed (by an active ego), conflictual fantasies. On the other hand, somatization, writes Taylor, lacks underlying fantasies, and emotions are poorly representable, sometimes called alexithymia. (The ego is made helpless by dissociation.) Two different therapeutic aims ensue. For conversion symptoms, Freud made conscious the unconscious conflict through interpretation, but with somatization symptoms, says Bucci, what is required is a strengthening of connections between the subsymbolic and symbolic.
Gottlieb gives a nice history of the way different psychoanalysts have conceived of psychosomatic symptoms. They argue causality, meaning, and treatment. Students might enjoy contrasting Janet, Freud and MacDougall, as well as distinguishing la pensee operatoire from alexithymia. Many agree that somatization involves dissociation. Where does a child turn when the very people who are to help regulate distressing feelings are also their source? Hopefully, we will, in class, add from our clinical experience the relational intersubjective component of psychosomatic disorders, with the understanding that caregivers powerfully affect one’s ability to symbolize, mentalize, and see the other as an equal center of subjectivity.
Gottlieb, R. (2003). Psychosomatic medicine: the divergent legacies of Freud and Janet. J. Amer. Psa. Assoc., 51:857-881.
Taylor, G. (2003). Somatization and conversion: distinct or overlapping constructs? J Amer Acad Psa, 31:487-508. http://tbips.blogspot.com/2014/09/somatization-and-subsymbolic.html
Winnicott and Knox both speak to the infant’s developing sense of self and both are relational in the import for this ascribed to the environment. Winnicott wrote that only in play, being creative, can the individual discover [become] the self. Being creative is not about products of the body or mind, but rather a feature of total living. Play, for Winnicott, meant living in the potential space [sometimes called transitional space or the third], “an area that is intermediate between the inner reality of the individual and the shared reality of the world that is external…” Winnicott exhorts the therapist to create an environment which allows for this third space in which to play. The good enough therapist provides repeated experiences that allow the patient to trust as well as enters into the arena of play with the patient.
While Winnicott recommends refraining from getting in the patient’s way to self discovery, for example, by the therapist being more interested in being clever, the one who knows or makes sense of, than in following the patient’s formlessness, his example seems to belie that his patient came alive from her formlessness (and his restraint from interpretation). Instead, she seems to complain repeatedly that she did not matter to him and only became enlivened after he actually shared the contents of his mind with her. [The mother develops her baby’s mind, and co-creates meaning,by having him in her mind, and by engaging the infant in reciprocal turn-taking.] It was when Winnicott reflects back, nearly two hours later, his patient’s experience to her does her experience take on meaning for her. [It befuddles me how Kohut failed to cite Winnicott when writing about mirroring.]
Knox writes that the infant’s sense of self first comes in to being by the meaning attributed to its actions by its mother. A child internalizes [develops its sense of self through] its mother’s attributions, positive or negative. Negative attributions, internalized, then, can generate a sense of a deficient self, with its concomitant shame. To bulwark a diminished self, grandiosity and narcissism may be self-protective as the child struggles to remain alive emotionally.
Knox, J. (2011). Dissociation and shame: shadow aspects of multiplicity. J. Anal. Psychol., 56:341-347.
Winnicott, D.W. (1956). D.W. Winnicott, Playing and Reality, London: Tavistock, Chapter 4. Playing: creative activity and the search for the self. http://tbips.blogspot.com/2014/09/developing-sense-of-self.html
The body remembers. Early traumatic experience, whether occurring before the hippocampus comes ‘on-line’ or dissociated from symbolism by decreased blood flow to the otherwise functioning hippocampus, is procedurally ‘learned’ and stored by affect and perceptual senses. Chronic thigh pain may be the only link to the pain of childhood sexual abuse, the smell of a particular cologne and its consequent headaches the only connection to herald long ago parental tirades. We feel. We panic. We don’t remember the events. It may take countless hours of psychotherapy before integration and words allow voice to be given to those early threats to sense of self.
In Theaters of the Body (1989) Joyce MacDougall writes that psychosomatic illness results from the body reacting to a psychological threat as though it were a physical threat due to lack of awareness of our emotional states when being threatened, so seeking psychological treatment is very tricky for both patient and therapist. While one may wish to be free of psychological (and psychosomatic) symptoms, we must remember that these symptoms have been, since childhood, a best possible attempt at bearing the unbearable. Our patients wish and fear the giving up of these symptoms for these symptoms helped (in earlier times) with psychic survival. They may also be the only clues we have to early traumas.
Kradin, from a Jungian perspective, provides an introduction to the psychosomatic illnesses. He states that the psychosomatic symptom is “a symbolic communication by the suffering self to caregivers…a cry for help in hope that someone will respond, and a method of repelling others as an expression of unconscious dread.” Early caregivers regulate infant distress and give meaning to infants’ bodily sensations. The failure of symbol formation in people suffering with psychosomatic disorders speaks, in part, to the inadequate regulation between mother and infant. Kradin highlights (from Noyes) the anxious maladaptive attachment style where (from Driver) etiology of at least one disorder, CFS, is speculated to include “inadequately internalized maternal reflective function, affect dysregulation, and diminished psyche-soma [Winnicott] differentiation.” Other events often found in the histories of patients with psychosomatic disorders are “a parent with physical illness, a history of family secrets, and childhood maltreatment” including emotional abuse. Kradin reminds therapists that our aim is treatment of the disordered self and not symptom reduction. “[S]ymptoms are ‘real’, whatever their cause” and “healing begins only once caregivers have disabused themselves of the notion that patients are responsible for their disease.”
Kradin, R.L. (2011). Psychosomatic Disorders: The Canalization of Mind into Matter. J. Anal. Psychol., 56:37-55. http://tbips.blogspot.com/2014/09/psychosoma-intro.html
I call your attention to the Pulitzer-prize winning journalist and best-selling author Ron Suskind ’s latest book, a memoir, Life, Animated, A Story of Sidekicks, Heroes, and Autism because the remarkable journey of his family to find their way to connect with their son Owen reminds me of some of the very best we strive for in the psychothera-peutic relationship. Owen, as present in 1/3 of the cases of the millions of children with autism, has regressive autism, that is, he appeared to develop normally but then began, in his case before his third birthday, to lose speech and social skills. Owen, without necessarily comprehending, memorized the entire scripts of the Disney films that he for so long and continued to watch, and he could do all the characters’ voices, too. Initially, the Suskinds discouraged as non-productive Owen’s perseverative obsession with Disney animated characters. But in their attempt to look for a way into the psychological life of their son, cut off from the rest of the family, they decided to use what Owen presented to them as the key to make their way in, and his entire family became proficient in Disney voices. Suskind would even recommend dancing in front of the TV screen if need be.
I take this as good advice, jumping into the rabbit hole as it were, with some of our most unreachable patients, even those with psychosis, instead of trying to make them conform to our ideas of how to communicate a narrative; to use what is presented and find within its inexplicable vehicle some nidus around which together to build meaning [meaning, after all, arises from within connection]; To bend the frame as needed, dance in front of the screen, if there exists any hope to reach the unreachable. In other words, welcome in, welcome in, with an attitude of ‘If you want, I want to,’ for without connection, there is a deadness to our being together.
To animate both their lives, Suskind and his wife, and their older son Walt, decided to go where Owen was. What they previously had thought was a prison for Owen has become a pathway to communication between them. Remembering from the Lion King’s ‘Remember who you are,’ Suskind asks Owen, ‘Who are you, Owen?’ and Owen, remembering, too, replies, ‘Your son.’ http://tbips.blogspot.com/2014/07/dead-or-alive.html
The local psychoanalytic professional society offers every year a discussion group as part of its extension division. This year, the readings will all come from Philip Bromberg’s 1998 book Standing in the Spaces, Essays on Clinical Process, Trauma, and Dissociation. In its introduction, and addressing the psychoanalytic process, Bromberg grapples with the human ability to allow “continuity and change to occur simultaneously.” He posits that the self is not unitary but that the mind is a “configuration of shifting, nonlinear states of consciousness in an ongoing dialectic with the necessary illusion of unitary selfhood.”
Bromberg emphasizes the role of dissociation—a result of trauma— as equally significant and more powerful than repression and conflict, in shaping the psyche. Psychoanalysis builds a bridge between dissociated (not-me) self states of the mind and thus, transforming it, allows for “the experience of intrapsychic conflict.” It enhances “a patient’s capacity to feel like one self while being many.” Dissociation, both normative and pathological, exist in both participants and the patient and analyst purposefully confront and engage each other’s (and their own) multiplicities and nonlinear realities as they organize their relationship.
In moments of intense affective arousal, when parents are unable to reflect upon a child’s mind, both staying in the appropriate affective experience with the child and bringing the parent’s new perspective to bear, the child may be “traumatically impaired in his ability to cognitively process his own emotionally charged mental states…and thus own them as ‘me’.” Bromberg continues, “[P]sychological trauma can broadly be defined as the precipitous disruption of self-continuity through invalidation of the internalized self-other patterns of meaning that constitute the experience of ‘me-ness’.” This threat to self is experienced as annihilation anxiety. Dissociation protects the sense of self continuity by keeping at bay traumatic disruption. Unfortunately, safety of this trauma based personality requires one to be at the ever ready for disaster such that one can never feel safe even when one is.
One poignant example of dissociation exists in the schizoid patient whose dissociation, Bromberg writes, is “so rigidly stable…that is tends to be noted only when it collapses.” To protect itself from annihilation anxiety, the schizoid personality prevents spontaneity by keeping a boundary between the inner and outer world such that things remain predictable and controllable. “The struggle to find words that address the gap that separates us is the most potentially powerful bridge between the patient’s dissociated self-states…Once the words are found and negotiated between us, they then become part of the patient’s growing ability to symbolize and express in language what he has had no voice to say.” http://tbips.blogspot.com/2014/07/dissociation-and-building-bridge.html
The negotiation between analyst and potential analysand, says Wilson, includes facilitating an unending process of “mutual adaptation” toward “a ‘thought community.’” He writes, “A thought community works to bring into existence new objects, or so modifies old objects that they appear in a new way…” I surmise that, here, there may be an interpenetration of subjectivities, a ‘hive mind’ where, as Freud noted, one’s unconscious speaks to the unconscious of another. Both patient and analyst participate in many thought communities at a given time, and the analyst facilitates the awareness of the tensions that exist between them as they approximate a closer and closer shared reality and come to terms with differences. One such difference might include the fury at the not good-enough mother clashing with the new found and mitigating recognition that mother had also been deprived as a child. It is the perturbations that make for fruitful moments of negotiation.
Tensions as well exist between differing theories held by the analyst. While theories may serve to ‘hold’ the analyst in times of inevitable uncertainty, adherence to theory may also generate tensions. To which theories we adhere is multifactorially, and unconsciously, determined. Wilson notes the pressure “to adhere and yet not to adhere...” to our theories. Both patient and analyst must adapt not only to each other but to their shared or disparate theories. Wilson expects that analysis will take on a stability “constituted by more than the individual inputs of analysis and patient” [the analytic third], and that the analyst will move “from the realm of precepts to the realm of understanding” and both participants will move toward “understanding how to understand” as they develop together an analytic space where the work of analysis can be fruitfully done.
Wilson, A. (2004). Analytic preparation: The creation of an analytic climate with patients not yet in analysis …
J. Amer. Psychoanal. Assn., 52:1041-1073.
Bohm reminds us that we are, as we listen to patients, influenced by our theories and training; and while theories may help us organize and make sense of what we hear, we must be careful not to fit the patient into the Procrustean bed of our theories, but instead be open to surprise and learning anew. We must tolerate uncertainty and accept that we cannot always know what is going on in every moment of the therapeutic encounter. I am reminded of a visit to Tampa in Sept 2010 from Sandor Shapiro [see post 9-12-10] when he noted that theory helps mitigate the analyst’s anxiety and not to underestimate the value of lessening the analyst’s anxiety! Bohm suggests we “work with mixtures of exploring and applying attitudes” and he favors “more pluralistic thought systems.”
Meissner, while accepting as fact objectivity and neutrality, nonetheless reminds us to listen at “multiple levels of discourse simultaneously.” He writes, “The analyst listens not merely to the words…but also to the tone, pace, affective coloring, nuances of expression, and … other behavioral factors…” and he believes (re: reading the patient) that “there is no reading at all without a previously accepted framework.”
Ideas about listening analytically are on my mind not just because they are being discussed by candidates and students in the introductory series, but also because attorneys, among others, have recently inquired about how psychoanalytic listening differs from that done by a psychiatrist. I can’t help but think that my psychiatry training taught me to listen from a statistical point of view with the aim of fitting what I heard into columns A and B of a Chinese menu of diagnoses, whereas my psychoanalytic training thought me to listen from the unique and singular POV of one patient’s experience, to listen for not just what the patient says, but for what s/he intends, and even to read between the lines for intentions that the patient may not yet be aware that s/he has. All the while we cannot be completely sure of the other's subjectivity, except, as candidate Dimitris Tsiakos, points out, we are the while participating (co-creating) our subjectivities. If you don't mind the mixed metaphor, it is a tough nut to juggle so many balls in the air simultaneously. http://tbips.blogspot.com/2013/11/listening.html
For Winnicott, aggression is the infant’s natural exuberance and assertion, its motor activity, a ruthlessness without the intention of destruction, and it fuels creativity and the self’s coming into being (becoming alive, having a sense of self). Aggressiveness, as such, is part of who the infant is, a necessary part—and by implication, should be a welcomed part if the infant is to come into being without dissociating or distorting part of himself as a Not-me [Bromberg’s dissociated not-me]. Freud and Klein saw aggression as innate, as part and parcel of the death instinct. Winnicott sees destruction, infant ruthlessness, not as essentially hostile, but rather as a necessary part of the developmental struggle, much like Phyllis Greenacre’s analogy of a chick ‘hatching’ -breaking out of its shell.Winnicott disagreed with Klein (and Freud) about the innateness of aggression (the kind with hostility) , seeing hostile aggression instead as a natural consequence of frustration, and, as such, its intensity and fate dependent on the environment’s ability to adapt to the infant’s needs without creating undue frustration. With this understanding of the consequence and interplay of the infant’s aggression with the environment of objects, Winnicott provides us with the relational aspect. He recognizes that an infant’s development isalways in relation to its mother (there is no such thing as a baby) and that a reliable relationship is essential to healthy development. Afterall, it was the mother’s reliable response to the needs of the infant which allowed him in the first place the illusion of a sense of omnipotence.
The sense of self coming into being is central to Winnicott. Because the infant’s sense of self comes into being in relation to its mother, and because her attitude–including the contents of her mind—toward her infantand his aggression greatly impact his sense of self, it is imperative that the mother [and the analyst] accept and allow for expression of his aggression, and survive it, so that aggression can be integrated into his whole self, the Me, so he can become, so he can become whole. The mental health and contents of the mother’s mind are as important, maybe more so, to the infant’s development as is the intrapsychic life of the baby that Klein and Freud so privileged.
The analyst’s attitude, likewise, becomes important in her interactions with her patient and his aggression. Aggression, for Winnicott, is what facilitates a creative life, a life lived by a spontaneous and authentic self. If the mother grossly impinges on the baby’s sense of self and his becoming, she disrupts his continuity of being,his going on being. If the analyst derails the patient, she too impinges. Because I include Winnicott’s theory of aggression as aiding the creative potential in becoming the self, as well as in separating the self (Me) from the other (Not-me), I do not theoretically want to dispense with the patient's aggression, even though in reality at times it is very difficult to both bear and survive. http://tbips.blogspot.com/2013/10/yes-to-aggression.html
While Poland uses traditional language and clings to the idea that insight via interpretation is what is mutative, he nonetheless recognizes the power of the implicit and procedural and its consequent necessity for the analytic attitude to be open, even to explore the analyst’s self. He grapples with this by delineating the “declarative interpretation” (content) and the” procedural interpretive attitude” (process). More than once, Poland notes that psychoanalysis is defined by its belief in the unconscious with its wellspring of hidden motivation and meaning. An interpretation, he writes, must include something new in understanding or experience. His emphasis on exploring new understandings might seem to privilege content over process except that Poland is writing about an interpretive attitude (part of process) which he deems necessary for change to occur. –Poland speaks to process when he “wondered about what was unfolding between us” [p.820]—The interpretive attitude includes caring curiosity, and inquiry, exploration, and revelation, all working toward bulwarking the premise that there is always more to be learned.
What Poland calls the interpretive attitude I might call the implicit welcoming we offer our patients to hear whatever the patient brings, to bear it, to think about it, and, in heights of inspiration, articulate new meaning. I disagree with Poland that experience can always eventually be put into words or even that putting experience into words is a necessary component for change to occur. Sometimes, the procedural experience of openness, without interpretation, is sufficient.
More than the willingness to explore and interpret, an analytic attitude includes behaving ethically. Allphin says that qualities of an analytic attitude strive to:
hold the needs of the patient as the priority;
[be] devoted to the growth and development of the patient;
be conscious of their impact on patients;
presumably…avoid suggestion. [author’s italics];
act humanely;
[and]deal with ambiguity and paradox.
Allphin alludes to the necessity in training of offering a place for the neophyte analyst to discuss the most shameful of fears and feared transgressions, just as we offer to our patients. Inviting in the shadowed side of our patients and ourselves allows for greater recognition. Referring to Buber’s I-Thou relationship and its concomitant absence of projections onto the other, Allphin writes “The self cannot be whole if parts of it are unknown.” A good enough analyst is not free of flaws but rather is willing to own responsibility and make those flaws which affect the analytic relationship part of the negotiation as both participants strive toward mutual recognition.
As an aside, the issue of confidentiality and “duty to warn” will be discussed by Barry Cohen, Esquire on November 16, 2013 at the Tampa Law Center where we will discuss the none to rare clash between what is legally required and what is therapeutic.
Allphin,(2005). An ethical attitude in the analytic relationship. Journal of Analytical Psychology, 50:451-468 http://tbips.blogspot.com/2013/10/teaching-openness-and-ethics-in.html
Poland, W.S. (2002). The Interpretive Attitude. J. Amer. Psychoanal. Assn., 50:807-826.
According to Natterson, love, or the actualization of love, is the aim of the psychoanalytic treatment process where love is defined as “the desire to recognize” and “the caring interest in the patient’s subjectivity.” In an atmosphere and context of the mutual care giving of the therapeutic encounter, dependency and individuation are negotiated between patient and analyst. Lachmann and Beebe, though they do not call it love, offer a manifestation of mutual care giving in the therapeutic process where self- and mutual- regulation are enhanced. Lachmann rightly notes that it is the analyst’s responsibility to match posture, prosody, intensity, gaze, or attune to the patient’s self state, but Natterson, I think, would see this attempt at matching and attunement as an act of love. When, I wonder aloud for candidates, do we see evidence of care giving from the analysand to the analyst?
Candidate Dimitris Tsiakos writes this about Natterson’s paper:
The question of how the therapeutic experience unleashes the potential for love and thus leads to actualization of self may be answered in the following way. The patient comes to therapy for help with a particular problem, but also the patient is bringing as subtext his or her unique version of a universal aim, namely, the achievement of love. Correspondingly, the therapist's desire to help improve the patient's life is an unstated but fundamental wish to give love. But what is the fate of the therapist? The therapist leads a complex life outside the therapeutic chamber, of course, and after a successful therapeutic experience has ended, the therapist, like the patient, brings his or her gains of love and self to the other areas of intersubjective relatedness, including the other therapeutic projects in which he or she participates. Love from others, love for others, and love for self all increase in essential simultaneity.
The two papers are a point of view about relationship in the analytic setting. At TBIPS we talk about the subjectivity of both participants and think about their relationship before we ever start talking about the contributions of the great, historical minds of Freud, Ferenczi, Klein, Winnicott, Sullivan, Kohut, Mitchell, Bromberg, and others, on formal theory and technique.
Lachmann, F.M., Beebe, B. (1996). Chapter 7 The Contribution of Self- and Mutual Regulation to Therapeutic Action: A Case Illustration. Progress in Self Psychology, 12:123-140.
Natterson, J.M. (2003). Love in Psychotherapy. Psa. Psychol., 20:509-521. http://tbips.blogspot.com/2013/10/discussing-relationship-in.html
2013-2014 Film Series “Children and Trauma” kicks off on Sept 29 with The 400 Blows
According to philosopher Janoff-Balman (1992) parents are charged with instilling 3 basic assumptions in their beloved children: 1) that the world is benevolent; 2) that the world is meaningful, and 3) that the self is worthwhile. Psychoanalyst Eric Erikson noted that infancy, if the baby’s needs are attended to in a timely and good enough fashion, is the time a child learns a sense of basic trust, and that this early attunement is the most fundamental prerequisite of mental vitality. This sense of basic trust developed from the loving care children receive from their caregivers enables them to be content with themselves, with relationships, and with the world, and contributes to these three basic assumptions, that the world is benevolent, the world has meaning, and I am worthwhile; I have a right to be here. By providing for the child’s basic physical and emotional needs, parents contribute to the child’s sense of self and self worth.
Traumatic life events impact our basic assumptions, our sense of trust, and our self esteem. Chronic neglect and disregard or mis-attunement and misrecognition are considered traumatic for they assault the child’s assumptions about the world and the self in the world. The self, necessary to sustain relationships with others, is undermined as is the belief that there is meaning to human experience. The child’s faith in the natural or divine order of things is violated, which can lead to a state of existential crisis. Children thus injured must then work hard to find divertissement from their existential anxiety, their sense of meaningless and sense of worthlessness. Their ability to participate in Society in a way that brings joy and allows them to share themselves with the world is vitiated. Without love, acceptance, being enjoyed, and engaging in mutual recognition—all which give meaning to life-- a child is at risk for cynicism and alienation; a child might feel unlovable, unacceptable, incapable of joy, and feel he does not deserve a place in the world.
Director Francois Truffaut like Doinel was an unwanted child. His mother gave him up to his grandparents for the first years of his life. He found solace and meaning in cinema. The famous final shot of the 400 blows is the face of Antione Doinel, a restless boy who seems to beseech the audience with questions like’ where do I belong?’ and ‘what do I do now?’
More than theory or technique here at the Tampa Bay Institute for Psychoanalytic Studies (T-BIPS), we again and again emphasize the analytic attitude. Of great importance to this attitude is the avoidance of shaming our patients. Because disappointed longings often induce shame in the one who is disappointed (I am too greedy, I am too needy, It must be that I am so unlovable/so unworthy that I do not deserve what I long for) it becomes incumbent upon the analyst to strive toward being ever mindful of the reaction of our patients to any of our communications.
A very interesting discussion about Winnicott ensued last evening in the second year course Development of Shame taught here at TBIPS. We were reading about Being and so read Winnicott’s Capacity to be Alone and Playing: Creative activity and the search for the self. Candidates and students claimed to enjoy the discussion so much and to find it so illuminating that we toyed with the idea of writing a handbook, a kind of Winnicott for Dummies. We were especially taken with delineating the capacity to be alone with the capacity to be alone-in-the-presence-of-the-other.
The capacity to be alone results from the infant’s repeated experience with having its needs met in a timely fashion. Consequently, the infant has the expectation that what is needed will be forthcoming. Hunger and loneliness, then, are bearable because of the infant’s faith that these will eventually be resolved. An infant without this faith will be overwhelmed by the expectation of unrelenting hunger (or pain or loneliness). An adult without this capacity may strive to avoid unbearable feelings of want (overeat, become addicted to behaviors or substances, incessantly need to be in the company of others).
The capacity to be alone-in-the-presence-of-the-other is an even more sophisticated developmental achievement, also wrought from experience with caregivers. Does the caregiver allow the toddler to explore the world without undue intrusion and impingement? The capacity to be alone-in-the-presence-of-the-other is also linked to creativity and spontaneity, to very aliveness, if you will. Creativity in early childhood is fostered when the caregiver provides objects for exploration (pots, pans, blocks, etc) but does not insist on how these objects be explored (as opposed to uwanted intrusions like No, don’t line the blocks up like that, stack them like this). The caregiver, in the background, enjoys, sometimes even participates in, the child’s play. The child is given psychological space to enjoy the world and her/himself in the world but is not abandoned to the world. The caregiver in the background is ready to step in when needed.
Ideally, both adults in a partnership have developed the capacity be alone-in-the-presence-of-the-other, and then come together for mutual enjoyment, sharing, recognition, comfort and reciprocity. Adults who have not developed the capacity be alone-in-the-presence-of-the-other may constantly demand attention from the other, be jealous and resentful of time the other devotes to hobbies, work and friends, may feel chronically dissatisfied, and devitalized, may distort themselves to garner attention from others.
Most clinically apropos: how does the therapist give the patient enough space to allow for exploration, creativity and play in the therapeutic situation and still be in the background awaiting use should s/he be needed? This tricky tightrope is a huge challenge for the analyst. Winnicott intended to provide enough space for Ms X to allow her to spontaneously develop her own way in the world, but, as a few in the class noticed through Ms X’s repeated complaints, Winnicott failed to be sufficiently at the ready for joining with Ms X when she needed him to be more present. How does a therapist know when to give space and when to join in? It is not easy, but I think our patients tell us, by their words, tone, breathing, posture, facial expressions, etc, moment by moment, where we need to be if we can pay attention and learn to walk a very thin line, juggling on a tightrope. http://tbips.blogspot.com/2012/09/shame-aloneness-and-winnicott.html
The Runaway Bunny by Margaret Wise Brown, pictures by Clement Hurd
Difficult patients are difficult for their chronically intermittent, sometimes seemingly relentless, attacks on the work and on the therapist’s competence: “This isn’t working;” “Nothing has changed;” “Analysis is useless;” and, more pointedly, “You don’t care about me;” “You only care about the money;” “You don’t know what you’re doing;” “You suck!” Commonly, there are also frequent threats to quit analysis, often expressed with the threat of suicide.
To keep my balance and to survive (neither withdraw nor retaliate, in the Winnicottian sense), that is to persevere without thinking: “Here we go again;” “Who needs this anyway?”; or “Good riddance,” I recall the delightful children's book, The Runaway Bunny (1942) by Margaret Wise Brown, probably better known for her Goodnight Moon.
The Runaway Bunny is a felicitous analogy for working with patients who want us to believe that we are unimportant to them. The runaway bunny
said to his mother, “I am running away.”
“If you run away,” said his mother, “I will run after you.” …
“If you run after me,” said the little bunny,
“I will become a fish in a trout stream
And I will swim away from you.”
“If you become a fish in a trout stream,” said the mother,
“I will become a fisherman and I will fish for you.”
“If you become a fisherman,” said the little bunny,
“I will become a rock on the mountain, high above you.”
“If you become a rock on the mountain, high above me,”
said his mother, “I will become a mountain climber,
and I will climb to where you are.”
And so on for a crocus in a hidden garden, a bird flying away, a sailboat sailing away, his mother always finds a way to stay in connection with her little bunny.
“Shucks,” said the bunny, “I might just as well
stay where I am and be your little bunny.”
I can imagine this gives reassurance to an adventurous or angry, small child, that her/his mother will always come for it. With this on my mind, I hold the faith of commitment to the relationship and to the work.
Perhaps this attitude is implicitly conveyed, a balm of certitude for a patient who has experienced unpredictable or abandoning parents. Perhaps it is explicitly conveyed, “I will be here tomorrow at the appointed time.” Either way, it is my job, I think, to remain steadfast and keep faith when the patient conveys, with an onslaught of doubt and vituperation, her/his hopelessness, anger, or disappointment in me and in the work. A candidate asked, when I convey this attitude in class, if I were a masochist, or a saint. Neither, and I referred the candidate to Ghent’s 1990 paper on Masochism, Submission, Surrender.
Recently, after unrelenting, expressed hopelessness, a patient said to me, “I think I am doomed with or without you -- but I’d rather be doomed with you.” And after a few wiped tears, he added, “You’re the person I want to be doomed with,” and smiled. http://tbips.blogspot.com/2012/
I recently began musing on happiness when invited by David Burton, a local, independent, documentary filmmaker to be interviewed on this very subject for his present film project. I thought about how the human brain is wired for moments of happiness; it releases happiness chemicals during certain experiences such as love or orgasm or a runner’s high. The more experiences our brains have with happiness, the greater our faith that we can expect future happiness to be forthcoming. As such, I recommend we practice some joyfulness every day.
Because as infants and toddlers we require attachment for our very survival, each of us as children constructs what we believe will maintain that attachment bond. As such, children will comply with parental demands to themselves be the parent to the parent, or to be the container of all bad feelings or behaviors, to achieve in sports or academia, and so on. Even with good enough parenting, eventually well-fed and well-loved infants who have delighted in playful interchanges with caregivers learn as toddlers that their caregivers are no longer under the child’s omnipotent control, a loss compensated, ala Benjamin, by the joy of two separate minds coming together, because they choose to, to share one thing, e.g. the child’s wonder at a dandelion. Later when we are aware that we are finite, mortal, and alone in the universe, this meeting of the minds bridges the gulf of existential isolation, and momentarily we are joyful.
Happiness, or at least contentment, comes with satisfaction of certain innate strivings of human beings, five that Lichtenberg beautifully delineated: physical needs (food, safety, shelter); needs for creativity, exploration, and play; for sensual and sexual pleasures; for attachment and affiliation; need to defend against or escape adversity as well as to assert ourselves. Happiness is co-created in the context of relationships. When we have had the experience of being welcomed and enjoyed, then our parents’ joy infuses us. We learn joy and to enjoy ourselves, as well as others. Happiness comes more easily to those who have been welcomed and enjoyed. And when we despair, it is easier to keep the faith that happiness will eventually be coming around again.
I remembered a psychiatry resident from a few years ago whom I was to supervise. She came to me, terrified about the prospect of doing psychotherapy without sufficient training, and I asked her what she thought most people want. After a few moments she answered, profound in its simplicity, "love and acceptance." That is, then, I told her, exactly what we must learn as psychotherapists to weave into the treatment relationship.
I advocate, then, for love and acceptance in the psychoanalytic situation, welcoming and enjoying our patients, even their darkest self states, such as anger, despair, envy, and murderous rage, self states of which they are ashamed and may disavow, but being welcomed into the treatment room can find voice, and, ideally, can find dialogue with one another. The psychoanalytic experience of love and acceptance coaxes forth shamed and disavowed self states, invites in play and creativity, and a communion between self states, mine and the other’s, in a panoply of possibility. When I experience myself with another, intimately, fully, authentically, there is happiness. http://tbips.blogspot.com/2012/04/happiness.html
Intergenerational Transmission of TraumaDoris Brothers, author of The Shattered Self, spoke in Tampa March 10, 2012 on trauma,and briefly alluded to intergenerational transmission of trauma. I would like to elaborate on some of the neurobiological mechanisms that might illuminate how intergenerational transmission of trauma occurs. To that end, I utilize Alan Schore’s Advances in Neuropsychoanalysis, Attachment Theory, and Trauma Research: Implications for Self Psychology.(2002). Psychoanal. Inq., 22:433-484.
As we are aware from infant research and neurobiology, an infant requires the presence of an attuned other for its optimal development and to optimally organize its experience. Winnicott said there is no such thing as a baby, that is, there is a mutual (interdependence) influence (regulation) between infant and mother in which the two function as a unit, including unconscious communications that serve to develop the brain of the infant. [This bulwarks the relational theories which take psychoanalysis from a one-person (intrapsychic) to a two person (intersubjective) psychology.] The 'good enough' caregiver helps the infant maintain its homeostatic equilibrium and facilitates the emerging self. Instead of the Cartesian mind-body duality (or of self from the environment) regulation of physiological functions builds the brain (the mind, the self) in particular ways.
A mother who may herself utilize dissociation as a result of her own childhood trauma, or due to depression, may be unavailable to regulate her infant. The 'good enough' caregiver helps the immature (as yet unformed neuronal connections, and unmyelinated peripheral nerves) infant regulate through her gaze, soothing voice, etc). Ruptures in regulation affect the infant’s homeostasis, and negatively affect attachment. They may even threaten the infant’s survival. Additionally, the infant is unable to acquire experience for self regulation and restoration of its equilibrium. In an attempt to restore homeostasis, the infant must divert energy away from needed growth, development, and learning (sometimes leading to failure to thrive, to lower IQ, and lower socio-emotional learning). Because brain growth is experience-dependent, experience with dysregulation negatively impacts the developing brain, the self, and the sense of self in relation with others, particularly during the brain’s growth spurt in the first three years of life. It can lead to later psychopathology, e.g. affect dysregulation commonly found in certain psychiatric disorders.
The right hemisphere, larger in the first two years, and, more than the left, processes and stores early infant experiences. Resonant attachment experiences involve “synchronized and ordered directed flows of energy” in the primary caregiver’s brain and the infant’s brain. The right hemisphere, more than the left, also has extensive connections with the limbic system. The limbic system is the emotional processing center which helps to guide emotional expression and behavior and organize new, procedural learning. The right brain is central to “integrating and assigning emotional-motivational significance to cognitive impressions” and “the association of emotion with ideas.” The right brain, with its connections to the right prefrontal cortex, allows the sense of self continuous through time. The right hemisphere, with its bodily connections, analyzes signals from the body, and helps regulate appropriate survival mechanisms, through the autonomic nervous system (ANS)which, in turn, help maintain a cohesive sense of self.
An infant responds to traumatic chronic misattunement by hyperarousal or by dissociation. When attuned response is not forthcoming, a distressed infant initially increases its attempts (e.g. by crying) to engage the mother. Should this fail, the infant, hopeless to effect the other, conserves energy, and seems to implode, go limp, itself dissociate, becoming helpless. The ANS lends a physiological explanation for hyperarousal and subsequent hypoarousal. The sympathetic and parasympathetic systems work to maintain homeostasis. The sympathetic ANS prepares the body for fight-flight (increased heart rate, increase blood flow to the skeletal muscles, etc); and the parasympathetic, responding to elevations in stress-induced cortisol, is energy-conserving (going quiet, staring off in space, and becoming limp).
As Winnicott noted, “ If maternal care is not good enough, then the infant does not really come into existence, since there is no continuity in being; instead, the personality becomes built on the basis of reactions to environmental impingement.”
We know that dissociation affects one’s sense of subjectivity. A mother, or grandmother, who has suffered herself with unresolved trauma conveys her terror and dissociation to her infant via infant matching of the mother’s right corticolimbic firing patterns, inadvertently transmitting to the next generation her, or her mother’s, experience of trauma. Mother’s “regulatory strategy of dissociation is inscribed into the infant's right brain implict-procedural memory system.”
Maltreatment in childhood, then, is a growth-inhibiting environment for the developing brain and results in “structural defects of cortical-subcortical circuits of the right brain, the locus of the corporeal-emotional self.” “[D]issociation is associated with a deficiency of the right brain” and “early relational trauma is particularly expressed in right hemisphere deficits”. The untoward consequences include disorders in attachments, regulation of affect, and subjectivity and sense of self, with threats to going-on-being. http://tbips.blogspot.com/2012/03/intergenerational-transmission-of.html
Having recently attended a conference where the speaker read a paper which leaned heavily toward inferring, from the psychoanalytic situation, particularly the narrative, infantile drives and fantasies, I was much relieved to find myself once again in the Tampa Bay Institute’s Study Groups and classes discussing inferences from infant research and attachment theory. Specifically discussed was the 1999 paper The Two-Person Unconscious: Intersubjective Dialogue, Enactive Relational Representation, and the Emergence of New Forms of Relational Organization by Karlen Lyons-Ruth.
Lyons-Ruth reminds us that meaning systems are organized by more than the symbolic (words and images): “meaning systems are organized to include implicit or procedural forms of knowing.” As such, a primary engine of change is “new enactive ‘procedures for being with’ [which] destabilize existing enactive organization…” Moreover, “procedural forms of representation are not infantile” for “development does not proceed only or primarily by moving from procedural coding to symbolic coding.” She states that “‘internalization’ is occurring at a presymbolic level...[thus] representation [is] not of words or images, but …of enactive relational procedures…”
One such procedure is parent-infant dialogue and, when flexible and collaborative “is about getting to know another’s mind…” A coherent, open dialogue requires openness of the parent, not in the form of “unmonitored parental self-disclosure, but by parental ‘openness’ to the state of mind of the child...” [And] “intersubjective recognition in development requires close attention to the child’s initiatives in interaction…” Likewise, the parent seeks “active negotiation and repairing of miscues, misunderstandings, and conflicts of interest;” It is from these ideas of Lyons-Ruth and others that clinicians infer the importance in the analyst-analysand dialogue the need for flexible and collaborative openness to the state of mind of the other, with attention to initiatives of the other, and a responsibility to seek repair of ruptures. http://tbips.blogspot.com/2012/02/useful-relational-intersubjective.html
"When the satisfaction or the security of another person becomes as significant to one as is one's own satisfaction or security, then the state of love exists" (Sullivan, 1940)
“Such mutuality, however, seems clearly an ideal, not a normative practice. No matter how mature and healthy, all love relationships are characterized by periodic retreats from mutuality to self-absorption and demands for unconditional sensitivity and acceptance.” (Mitchell, 1984)
Among its other important components, I still contend that the analytic relationship is one of love. And as Mitchell notes, and Benjamin reminds us, it is almost impossibly difficult to hold for long the tension between mutual recognition and negation of the other; instead we are always falling to one side (usually negation). This realization of how easily we fall, I think, is in sharp contrast to Orange and Levinas putting the (suffering) other above ourselves, making psychoanalysis, with this impossible ideal, once again the impossible profession. I think that love might just be in the striving, not the success, to recognize the other. http://tbips.blogspot.com/2012/02/valentines-day-musings.html
POSTED FRIDAY, DECEMBER 16, 2011-Steven Graham PhD
Last month at our Tampa Bay Psychoanalytic Society, Inc meeting, I found myself literally jolted by a concept. Many of our speakers have left indelible ideas and memories within me, but this notion explored on a November Saturday morning struck me as profound and clear and pervasive. Dr. Shelley Doctors elucidated the psychological process called "pathological accommodation," in which a person, likely from infancy onward, learns essentially to erase him- or herself in order to have a relationship with an important other. In other words, a child grows up knowing that in order to maintain a relationship with a caregiver, he or she must deny longings, feelings, and opinions that reside authentically within: "I will accommodate to you, my mother, so that I can have a relationship with you and thereby survive, but I do so at the cost of my very self and its development. I will do this because to be rejected by you, I fear, will be the very end of me. So, this is my choice, the lesser of two evils, between having no self and having nothing at all."
The Impact of Pathological Accommodation
It was not the idea of pathological accommodation per se that rocked me, but rather, the developmental course that this may take in one's life. Authors Brandchaft, Doctors, and Sorter1 describe these possible trajectories:
The child may attempt to preserve and protect this core of individualized vitality at the expense of object ties by determined non-conformism or rebellion. That is a path of isolation and ultimate estrangement. Alternatively, the child may abandon or fatally compromise his central strivings in order to maintain indispensable ties. That is the path of submission. Or the child may oscillate
between these two . . . Depression becomes the dominant affect in a person whom such a conflict has become chronic and internalized. It signals the loss of hope where no synthesis can be found between intimate connectedness with important others and the pursuit of a program of individualized selfhood. (p. 56)
It is deep within this quandary where I see many precious people. Those who disconnect relationally may do so because they have come to the conclusion that the price tag surrounding personal connections, especially intimate ones, is simply too high: it requires a submission of self-ness, authentic personhood. Those who remain in unhappy intimate situations may do so because they have concluded that it is better to have a relationship that is smothering and controlling (or abusive), than to disconnect from it and risk alienation or worse. And the third group: those who cannot be at peace in isolation or stultifying relationship. These try one approach until the pain of their current dynamic overwhelms them and then they flee---either into nonconformity in a brave attempt to find and hold onto their own voice, or into a painful intimacy in an attempt to feel less alien, less disconnected from.
Perhaps as you read about this process, you might identify with it, if only to some degree; perhaps you have noticed themes in your life not altogether different than the process of pathological accommodation. Coming to a point in life where you dare to believe that you can indeed have relationships that are mutual and reciprocal, that do not require a forfeiture of self, is not only a life-changing moment, but a life-giving one.
Steve Graham, PhD
1. Brandchaft, B., Doctors, S., & Sorter, D. (2010), Toward an Emancipatory Psychoanalysis: Brandchaft's Intersubjective Vision. London: Routledge. http://tbips.blogspot.com/2011/12/pathological-accommodation.html
Mental health includes a sense of agency and of the subjective self in the context of relatedness and recognition by, and identification with, a subject (m)other/therapist who is a subject in her own right. Spezzano writes that human beings are motivated to share their conscious selves, regardless of other unconscious motivations, and that we can only know ourselves in light of how others know us.
Alongside the biological imperative to pass on genetic material for the survival of the species are many postulated psychological motivations. Freud’s theory of motivation was discharge of instinctual drives. Winnicott saw creativity and play as essential aspects of the true self. Bowlby and subsequent attachment theorists write about the need for safety and security. Ghent might have added “surrender.” Bach sees it as important to integrate a “sense of wholeness and aliveness” which included developing one’s own awareness and subjectivity, and learning to see oneself as one among many, with a place in the world. Maroda notes that people, to develop a full interpersonal repertoire as both subject and object, need to have their affective communications responded to, held, and returned in modified form (ala Bion).
Understanding of development is an important backdrop for the therapist when listening to and experiencing our patients. Therapy contributes to enhanced development, perhaps by recommencement of truncated development through a safe, empathic, good enough environment which facilitates reorganization of patterns of experience, as well as that co-constructing shared meaning can enhance self regulation. http://tbips.blogspot.com/2011/04/motivation-and-development.html
POSTED MONDAY, APRIL 11, 2011-Lycia Alexander-Guerra MD
How we organize what we hear and observe is influenced by our own subjectivity, our experiences, and our theories. Because no theory holds the ‘truth,’ we must hold our theories lightly, recognizing that each person’s reality is perspectival, and recognizing that the meaning of the material need not be fit into the procrustean bed of a theory. As I listen and muse on what is going on in the therapeutic dyad, I often think I am like a juggler, with many plates in the air at once. I must simultaneously consider whether or not I hear at this moment a familiar sigh or theme from the patient; whether or not the present narrative or relational paradigm harkens back to the patient’s childhood events; what, if any, are the transference counter-transference implications; what happened in this past moment or last session or over the months or years of analysis that contributed to this coming up or happening now; and so on; all the while being open to the unknown and to surprise in a free floating reverie with evenly hovering attention!
Listening is dialectical (you can never stand in the same river twice), which means patient and therapist influence each other and neither is ever the same again. Listening is intersubjective, containing within it both the listening and the being listened to. Listening allows space for creativity (Winnicott) and for the, as yet, unformulated and unspoken. It is a gift we give our patients, interested in every word and gesture. It is a gift our patients give us, along with the privilege of their trust. When we listen, we do not seek to confront or contradict the patient, though we may sparingly ask for clarification. Many people have never experienced such genuine attentiveness from another.
As communication is both explicit (with words and common gestures) and implicit (perhaps what Freud referred to as unconscious to unconscious communication) we must listen as well with our perceptions and unconscious perceptions. We attend to the texture of feeling and gestural communication and not just to words or content or to conscious understanding and insight. We become comfortable, not impatient, with silences when the patient may need to be with some caring other without the pressure to produce or perform. Each therapist will have a unique interest in this or that part of a story, evoking a resonance with something in the therapist’s personal history. Each therapist must find her/his own way of expressing, in a way contributory towards patient growth, what has meaningfully affected us. http://tbips.blogspot.com/2011/04/more-about-listening.html
Living an examined life (Socrates) requires a penchant for a balancing act. In the treatment process, there is always the need to balance orders of experience: the intrapsychic with the interpersonal; the analyst’s subjectivity and experience with the patient’s; the past, present and future; moving toward or away from a closer approximation of the ‘truth’; and so on. Tension needs to be held between dichotomies with an attitude of not ‘either-or’ but ‘both’. While psychoanalysis has traditionally long privileged left brain (explicit, verbal), growing evidence seats the unconscious in the right brain which is emotional-affective, bodily based, relational, and implicit. So another balancing act includes ‘listening’ not only to patients’ words, but to implicit communication.
Right brain information processing is so rapid as to be is non-conscious. It is ultra-rapidly integrative of emotion, affect, facial expression, auditory prosodic, gestural, and other relational data. The right brain is the seat of implicit memory, but interfaces with the left hemisphere, where explicit, verbal communication originates. The brain develops in a way such that self and mutual regulation go on at the non-conscious, implicit level. Schore states that 60% of communication is non-verbal (facial expression, gesture, tone, prosody, pitch, inflection, etc) and recommends that analysis consider affect-laden experience, even dissociated affects. This requires not only understanding language, but understanding implicit process as well.
Freud advocated for the fullest possible acquaintance with the unconscious mind through free association, which presupposes psychic determinism and contiguity, by the patient, and through careful and trained listening by the therapist. Attentive listening is paradoxically balanced with evenly hovering attention and reverie (Ogden), a listening with the third ear. During the evaluative process we let the patient talk freely without too much interruption or direction, but probably ask lots of questions at that time. Subsequent sessions can afford the patient a more direct role in the process while the therapist listens for not merely content but for shifts in the content and affect of the patient; waxing and waning attunement on our own part; shifts in the patient’s and our own self states; initial comments of the hour; developmental issues; character style; relational patterns; transference references; fantasies; etc. Standing in the spaces between so many avenues of inquiry and interest can seem daunting, or meditative, depending on our comfort with uncertainty. http://tbips.blogspot.com/2011/03/listening.html
If Unconscious is in the Right Brain, why is analysis in the Left Brain?
There is something extremely puzzling to me. My hope is that, through discourse, I can come to better understand this question about analysis in the left brain (verbal, symbolization via language, logic-of sequence, explicit, etc) when growing evidence seats the Unconscious in the right brain (nonverbal, emotional-affective, bodily-based, relational, implicit). This 'crisis of faith' (really, of emphasis, or privileging of what is mutative) was triggered by my attendance at the American Psychological Association, Division 39 (psychoanalytic) over the weekend in NYC. Though I attended over 30 hours of presentations and discussions, I was most 'blown away' by the 50 minute lecture of Allan N. Schore, Ph.D. [of UCLA, author of "Affect Regulation and the Origin of the Self" and "Affect Regulation and the Reparation of the Self"] on April 12, 2008 entitled, "The Paradigm Shift: the Right Brain and the Relational Unconscious."
Schore is a neuropsychologist, so he talked about the brain. The most ancient part, the brainstem, oversees the automomic nervous system (think "automatic:" breathing and heart rate, fight-flight responses, etc), arousal, and pain. It interfaces with the limbic system (the seat of our emotions and libidinal and aggressive motivations), which, in turn, interfaces with the Right hemisphere. The right brain is bodily based, nonverbal, ultra-rapidly integrative of emotion, affect, facial expression, auditory prosodic, gestural, and other relational data, and is so rapid that this information processing is truly unconscious! It is the seat of implicit memory. In turn, the right brain interfaces with the left hemisphere, where explicit, verbal communication originates.
Early interactions between infant and caretaker regulate affect and self. The primary care-giver regulates the infant's bodily-based, affective arousal (the mind is not separate from the body). The infant brain actually develops according to relational, two-person, intersubjective experience! As most regulation is going on at the unconscious level, Schore recommends that analysis focus on recovery of affect-laden infantile experience, even dissociated affects.
As Schore states that 60% of communication is non-verbal (facial expression, posture, gestures, tone, prosody, pitch, inflection, etc), it makes one question how did psychoanalysis come to privilege left brain (explicit, verbal) communication? Because it is easier to quantify and understand consciously? [Some, including Lew Aron, who will visit us in Tampa October 17, 2008, and Jessica Benjamin theorize that the repudiation of feminity - designated as that which is relational and right brain, while language is designated masculine (think Lacan) - had something to do with the eschewing of right brain communication.]
I have to rethink how I will define psychoanalysis. Will my definition remain left brain lop-sided, privileging the revealing of the unconscious through reading between the (verbal) lines, or will I have to learn to value and make use of right brain communications? And am I doing that unconsciously already, unconscious to unconscious? Can this use of right brain unconscious even be taught or is it dependent on the infantile development of my own brain? Something besides insight from interpretation must be mutable, too, but how do we define it, learn it, understand it? Let me know what you think. I am grateful to Schore for giving me a basis to understand the clinical value of the elegant and painstaking research of Beebe and Lachmann on speech patterns and facial expression of the analyst. My children are grateful for any information that helps me pay more attention to tone.
http://tbips.blogspot.com/2008/04/if-unconscious-is-in-right-brain-why-is.html