Depression and Suicide: Two perspectives

The Mind-Brain connection I am very interested in the potential integration of neuroscience and psychoanalytic thought. One potential example came to mind with a patient quite recently. She was referring to the well-known phenomenon that depressed individuals are more likely to attempt suicide as they emerge from an episode. This has always been seen as a kind of physiologic consequence of the increasing energy level experienced by the depressed patient as the mood lifts. An analytic view might be somewhat different. Edward Nersessian M.D. in a recent paper has made the intriguing suggestion that depression itself can be seen as a defense. Often enough, people unconsciously keep themselves depressed because they feel too guilty about events in the past to allow themselves any optimism about their life. The psychic trade-off is something like: “I’ll close myself off to the world and partake of none of its joys if I can spare myself my intolerable rage and guilt”,  literally a case of choosing your poison. Now if the person begins to recover through medication or therapy, these old “harpies” return and in their fury, can drive a patient to pay the ultimate price for mental peace. This view supplies the “inner perspective” to the outwardly observed phenomena and alerts us as therapists to be especially wary of the effects of unconscious guilt on an impulsive depressed individual.

 

Travesty and a call to arms?

We are all perforce political animals; what happens in political life affects us daily and never more so in a climate of post financial crash frugality and an increasing reliance upon mega business to drive the American economy. For most of my life, I as a psychiatrist and psychoanalyst, have tried to avoid public political stances largely out of the value I place on analytic neutrality and the way in which such public stances could negatively impact my work with patients of different political persuasions.
This brief note is a break from that tradition. The last time I felt impelled to make such a commentary was a time when Congress was busy trying to prevent the use of so-called antipsychotics, and major tranquilizers in nursing home populations. In doing so, it was responding to a pleasant myth: e.g. that the use of such agents was perpetrated by uncaring, unempathic coldhearted doctors and staff upon helpless “victims”. It is always so nice when the situation can be neatly divided into good versus bad, the abuser versus the abused. Of course this view was as dangerous as it was ill-conceived. No one will argue that such medicines were given in ways that were not optimal or not given with enough care. This was most notable in the state hospital populations where such administration produced, over many years, significant tardive dyskinesia. On the other hand, I think no one who ever spent any time in nursing homes and who has seen the effects of significant Alzheimer’s related agitation and dysphoria could doubt the essential value of these agents over any other pharmacologic choice. I am grateful that my voice at that time was helpful in forestalling that dangerous legislative trend.
Now, is another time when action is required. Unfortunately, our “enemy” is an entity far more powerful; an enemy which perhaps exerts more control over our government than any other: the health insurance industry. Each of us must be aware of an increasing trend in insurance company practices of late to demand “peer review” as a method to beat down our therapeutic interventions to once a week treatment. This is not a blip on the curve; this is a concerted effort on the part of the insurance companies to make once-a-week psychotherapy the standard for all mental health care.

A recent article in the New York Times, entitled “LACKING RULES, INSURERS BALK AT PAYING FOR INTENSIVE PSYCHIATRIC CARE” spells out insurers aims in this regard. Already I would, as a psychoanalyst and a dynamic psychotherapist, “balk” at having anybody label a two or three session a week psychotherapy “intensive” psychiatric care. The concern is especially heightened in the setting of the Affordable Care Act being rolled out as it is likely that the federal government will be even less likely to intervene in an effort to establish safeguards for psychiatric care while they need the cooperation of insurance companies to institute this larger health initiative.

Recently I had one such “peer review” myself and in the aftermath of that review, which was predetermined in its outcome, I was given an explanation for the negative determination. In it, United Behavioral Health states that it is their policy “the use of multiple weekly therapy sessions typically is limited to acute exacerbations of illness, or in the context of a clinically urgent situation.” They went on to say that since my patient had a good job and was not acutely suicidal, once a week treatment is sufficient.
Before the typical counterattack by insurers and critics of our field is raised, namely that seeing a patient frequently is “a luxury” or is done for the financial benefit of the practitioner, I would make the following comments: my financial life, along with many in my field, has been adversely affected significantly by my decision to study psychoanalysis and to obtain training in intensive dynamic psychotherapy. I and countless others, have undergone long and extremely expensive educational endeavors because it takes great training and skill to do what we do and because, in my judgment, we have learned that this process is in fact the best way to address mental anguish and the dreadful repetitions of neurotic conflict that are inevitable without their elucidation. Further, it is not the practitioners of this modality who have principally suffered as a result of insurance decisions. Much larger sacrifices are made by patients who struggle to see us more frequently and who face the daunting reality that often more than 50% of their fee must be paid by themselves anyway. Insurers play with the numbers of so-called “prevailing rates” in the community to drive fees to arbitrary low levels and then with deductibles and paying only percentage of the remaining fee leave the patient to bear the bulk of treatment costs. From clinical experience of my colleagues, I have learned that patients are quite ready to accept significant financial burdens to be in treatment and often take second jobs or work overtime in order to have this important therapeutic experience.

Why are multiple sessions so important? The short answer is transference.
Therapeutically, whether or not there is unanimity on all aspects theory, those trained in analytic psychotherapy and in psychoanalysis are united in appreciating the fundamental power of analysis of transference which can only occur in the setting of a significant emotionally meaningful relationship. There can be no investigation of the conflicted past and no possibility of real mutagenesis without transference and its clear appearance in connection with the therapist. Further there is no question that multiple sessions, when feasible and tolerated by the patient, offer the strongest opportunity for the emergence of powerful transference trends which can be both apperceive intellectually and emotionally apprehended by the patient in a meaningful way.

To interfere with this process, or to limit it so drastically to once a week treatment is nothing less than forcing us as doctors to treat with watered down penicillin enough to offer the illusion of care. The insurance companies would authorize just enough to keep people extent but not enough to get them fully well.
It is worth pointing out that good treatment doesn’t simply result in one individual patient feeling better or living a better life. What we, as psychotherapists do, is like throwing a stone in the pond; the ripples of increased self-understanding extend through the patient far out into other peoples’ lives. Marriages go better, child rearing is improved, the ability to fulfill one’s dream and to work successfully with others in the workplace all are dramatically affected. It has been clearly demonstrated that good dynamic psychotherapy provides all kinds of benefits to the surround and to the social matrix as a whole.

Unfortunately, I see no one in the political or social field with the muscle, conviction, dedication or knowledge to resist this potential plowing under of our field and our therapeutic power to assist our distressed clients. And whereas universal health coverage is a fine idea, efforts to balance the books and reap financial reward on the backs of our clients by defunding coverage to treatments of more than once weekly is inhuman and constitutes a retreat from what we have learned in treating mental illness for over 100 years.
I would urge all friends of dynamic psychotherapy and psychoanalysis to write to their respective congressmen and to pressure legislative leaders on this important matter. I would also wonder if a social media campaign could be initiated to express our intense objection to this dangerous accelerating trend.

What can be said of the naked manifest dream?

 

A clinical experience the other day led me to revisit a long-standing psychoanalytic controversy.

One of my patients told me that she had remembered a small piece of a dream. She is in termination phase and is only reluctantly appreciating the profound changes that have occurred as a result of the analysis. The session was filled with negative thoughts. Nothing had changed, she was depressed and feeling hopeless etc. In the last third of the hour, she reports a dream which goes as follows: I dreamt I was in my home and I suddenly discovered an attic, like an extra space I never knew existed. Later she added: It was big…you could stand up in it. In her brief associations, she mentioned that the attic in her home was actually more a crawl space not somewhere where one could stand.

The reported dream in psychoanalysis is called the “manifest dream.”  Freud’s initial theory of mind concluded that the bizarreness of dreams is a consequence of the effects of disguise and censorship combined with need to represent conflict in pictures. Freud was adamant that to understand a dream, one had to follow the extensive associations a patient provided to each small piece of dream material. He insisted only then could the latent dream thoughts be revealed. The dream itself was nothing more than a reworked defensively packaged amalgam, a piece of “bric a brac”.  Over the years many psychoanalysts have questioned this point of view and felt the “manifest content” to be replete with meaning as a creation on its own. Using Freud’s famous “Irma dream”, some notably Eric Erickson, have attempted to demonstrate that many of the key conflicts could be demonstrated in the manifest dream material itself without extensive associations.

Theoretically I adhere very much to Freud, but for many years, I have felt that the manifest content does have a unique value.  The “manifest dream” (that which is reported to the therapist) is an exquisite “compromise formation”; like all mental products, the result of the interplay of wishes to reveal and to disguise, instinct and defense. However, as the state of sleep (and associated motor paralysis) requires less strenuous censorship, the resulting dream is very frequently, a revealing self-portrait; a partly involuntary representation of the state of the ego itself.

In my view, the structure of the dream space, the metaphorical symbolic structure and the “action” of the manifest dream does correlate well to the flexibility, competence, confidence of that individual in solving his problems in his awake state, in other words the state of his ego.

To return to the problem at hand, the patient is in termination phase. This means that part of her wants to go on with her life and part of her wants to stay with me. On the surface, we hear how everything is terrible, nothing despite our work has changed and life is hopeless. BUT she dreams and reports to me of “suddenly finding ‘more room’. In the setting of termination and her reluctance to appreciate that our goodbye is approaching, she fights with me about her progress yet her dream reveals in the manifest content her expanding inner world. With few associations, the analyst can be fairly clear that she is experiencing growth. I am aware that it is always a possibility, as some analysts might point out, that this could be a dream of “compliance” and that she is trying to be a “good girl” in her dream life but the timing of the dream, the surrounding contrary material makes me more convinced of its veracity.

As I listen, I have a few more associations of my own which I “tuck away”. The attic is a place where one puts discarded “old things”. The attic could represent a place where secret/sexual things go one while kids hide from parental authority. Does her discovery of an “attic” indicate more of a willingness to address early childhood sexual wishes and will more of the patient’s past be revealed as she explores her “attic” in the remaining sessions?

The “house” dream symbol beautifully represents herself, her body with the “attic” at the apex (head) but it is also a universal symbol of mother. This individual, who felt clearly emotionally suppressed by her “mother” may now be aware of being able to “stand up” to her as an adult and, in the transference, to “stand up” to me. That the attic was “discovered” suggests it was there all along (as a potential) but had been subject to repression.

My point more generally is how this snippet of a dream, without associations, can be fruitfully understood as an internal ego/self representation. Even when a dream seems particularly murky, or often when a patient is unable or unwilling to provide associations to individual dream elements, it can still prove valuable in the immediate moment as a statement about the treatment and the patient’s relationship to the work.

I would emphasize that the dream, as a result of its regressive (topographic) nature has much more to reveal, primarily about early fantasies/memories of childhood and deeper instinctual longings, the recovery of which is central  in redressing neurotic conflict. Freud, as usual,  is correct in emphasizing that patient associations are key to unearthing this richer and more subterranean material.

However, as a snap-shot of her psychic world, in the physical/spacial language of dreams, my patient is telling us that as a result of  our work, we are fulfilling Freud’s anticipated analytic outcome “Where id is, there shall ego be”.

 

Chemical Imbalance and Depression

 

Quickpoint: Sometimes humans create distinctions that in fact don’t exist. The above is a clear example. There is no logical medical or scientific difference in using either of these labels. The distinction can seem to exist for a moment only because of our inability to conceptualize the brain=mind frontier. There are two reasons for this so-called distinction to be insisted upon. The first is clearly intended to be helpful; the second is quite pernicious and both arise from the same source. It is a frequent consequence of depression that the patient feels immensely guilty and responsible for his condition. By medicalizing his condition, guilt can be reduced and the patient, feeling passively afflicted can free himself to use needed psychiatric medication.  Unfortunately that same conflation which frees the patient, can tragically be used, by the patient, family or medical community to refute the well established fact that psychoanalytic treatment can be curative and is essential for complete recovery.

 Recently I overheard a woman talking about her spouse who was, in her words, “deeply depressed”. She was saying that they had sought help from a number of psychiatrists and he had been placed on medication. Her companion asked if he was “in therapy” but she adamantly responded that they had been told his condition was a chemical imbalance and that, by implication, therapy would be of no use.

All ideas, all feelings, all movement, all memory entails the work of neurons in the brain. It is by the firing of these special cells and their interconnections that all mental activity is possible. Kill the brain, stop the firing and the person dies. Although there is much we do not know about how neuronal circuits work, medical science has been clear that one neuron communicates and “sends its message” to the next via chemicals. Between individual nerve cells there is a small space (synaptic cleft) and chemical transmitters are released from the first neuron and migrate to the second where they trigger a new neuronal “pulse”. An absence or diminution in neuronal transmitter reduces the firing of the downstream neuron in the same way that using less gas causes a car to slow or stop.

Many studies over many years have shown that depression is correlated with a depletion of these chemical triggers in the space between the neurons. All antidepressants work by altering the amount of available transmitter which in some complicated way, “charges up” the person and leads to an improvement in mood.

Drugs work and they have an important role to play for seriously depressed individuals. But of course like primitive cosmologies, saying that the problem is “decreased transmitter” or “chemical imbalance” begs the question as to why there was a decrease in the first place. Just as aspirin reduces the effects of fever in infection, the drugs improve well being but don’t address the underlying illness process.

Although there is debate on neurophysiology and mood disturbances, we know much about what causes people to become sad and further, to drop into a transmitter depleted state …e.g. depression. This understanding applies to the entire range of depressive experiences from neurotic depression to major depression or bipolar disorder. We know that the depression is a result of certain conscious or unconscious fantasies of being unloved and abandoned by a person of enormous unconscious significance and as a result, a feeling of utter hopelessness.  

 Intensive psychoanalytically informed therapeutic work to restore the core sense of value and self love is the only definitive treatment.

 

 

Negation, Disavowal, Aggression and the Death Instinct

Recently I was asked to review a collection of articles from contemporary thinkers in our field. The issues raised have important implications for our work with more impulsive and defiant individuals. The issue of aggression in human life and in the psyche remains unclear but its effects are powerful and potentially therapeutically stymieing. Given its centrality in current work I am including it on the web site for interested parties.

 

I have been asked to review On Freud’s “Negation,” one of a series of books entitled Contemporary Freud  Turning Point and Critical Issues.  In each, a seminal article by Freud is used as the reference point for contemporary clinicians and theorists to recapitulate expand or reformulate Freud’s initial ideas.  This book is edited by Mary Kay O’Neil and Salman Akhtar.

 

It is important to remember that, as the series editor Leticia Glocer Fiorini states in the opening page, this publication is a deliberate effort at “gathering psychoanalysts from different geographical regions, representing, in addition, different theoretical stances, in order to be able to show their polyphony.  She reminds us of the “extra effort” the reader must make to discriminate relations and contradictions these different analysts pose that have yet to be reconciled in any one theory of mind.

 

“Extra effort” might be a bit of an understatement.  I, as any reviewer must acknowledge at the outset, am somewhat bound by my training and clinical experience.  Many of the thinkers contributing to this volume have conceptual frameworks far removed from my own. Their ideas and concepts feel strange and uncomfortable to me whereas, to others, they may seem obvious and immediately graspable.

 

In addition, as this volume is to serve as a kind of psychoanalytic “buffet,” none of these authors are comprehensively represented.  Each article appears to represent a small sampling of the body of thought of these significant thinkers in our field.  On the negative side, the reader must thus struggle to orient himself in each presentation only to then leave the new material in abeyance as he must struggle with the next author’s conceptualizations.  On the positive side, this is a special opportunity to be exposed to the ways modern psychoanalysts from very different perspectives the world over are rethinking and elaborating psychoanalytic data, theory and technique.

 

This volume, after a brief introduction by Salmon Akhtar, begins with Sigmund Freud’s original paper and its core concepts.  Freud states that by using the signifier “no,” an individual allows for the emergence into consciousness of intellectual knowledge of the repressed while the associated affect remains repressed.  On the one hand the “no” is a defense but, by allowing repressed information into consciousness, it greatly enriches thought and allows for greater understanding.  The capacity to relate has another important benefit: negation is critically related to the formation of judgment:  judgment of both quality (difference) and existence (reality testing).  These developments are central to the formation and functioning of the pleasure ego.  The goodness or badness, the “quality” of things initially leads to an early decision as to whether the ego wants it “inside” or “outside.”  This polarity Freud states corresponds to “the opposition of the two groups of instincts which we have supposed to exist. Affirmation — as a substitute for uniting — belongs to Eros; negation — the successor to expulsion — belongs to the instinct of destruction.”  As the ego struggles against unpleasure it is forced to seek satisfaction in the “real” world.  Thus existence of a thing entails not a finding, but a  refinding of the satisfying object as it exists in the external world.

 

We, as analysts, are familiar with the “No” as part of a structured defense such as reaction formation but negation and the full spectrum of denial and disavowal is particularly relevant where a surfeit of aggression and destructiveness exists as in borderline conditions and psychosis.  It is this greater, more global and more destructive aspect of negation, in general, with holds these authors’ attention.

 

It would behoove any reader of On Freud’s “Negation” to start with the epilogue written by Mary Kay O’Neil.  This overview is extremely helpful to appreciate the various contributors and their different areas of interest.  I could not hope to duplicate her efforts at summarizing the perspectives of each individual thinker and can only offer the briefest of descriptions of some of the contents of this dense work.  I hope that in doing so I can in some way prepare the reader for what lies in store.

 

The volume begins with an article by Bonnie Litowitz whose training is in psycholinguistics.  She reviews the developmental sequence from motor negation (spitting out or waving away) through refusal and the development of the semantic ‘no” at fifteen months.  She demonstrates how negation deepens thought by its potential to propagate multiple meanings e.g. “the swan is not black … it is not the swan that is black … it is not the case that the swan is black” (page 24).  But in addition, the development of the semantic “no” also represents the earliest of object relations (Spitz) and the beginning of a dialogue (with parental figures) which will result in the increasing clarification and differentiation of opinions and attitudes between the self and others.  As Litowitz says “Language is acquired in the context of caretaker-child interactions.”  The older rejection, spitting out models in Litowitz’s opinion coexist with later more discriminatory models of negation.  Rather than simply being superseded they can at times be active and detectable in clinical material of patients.

 

In general, most of the authors in this collection focus on the broad “work of the negative” (Green) in patients where the effects of the negative and the operation of a Death instinct is profound.  These are patients for whom classical psychoanalytic models seem ineffective; patients with a surplus of negative behaviors: unstable ego structures, severe pathological masochism, intense “acting out,” primitive psycho-physiologic states.

 

Jorge Canestri emphasizes the difference between negation as outlined by Freud and a more severe “shattering or splintering” process of disavowal which result in a break with reality.  He demonstrates this horizontal split in the ego’s reality sense can so be profound that his patient could believe both ideas simultaneously from childhood:  “Either there was no difference between the sexes or the situation could be remedied” (page 48).

 

Brian Robertson uses the negative as an opportunity to reexamine the meaning and clinical manifestations of negative therapeutic reaction (NTR).  He wishes to restrict its use to the specific clinical situation in which it was first described: the clinical deterioration and erupting negativism seen after a piece of good analytic work which would ordinarily lead the analyst to anticipate improvement.  He underscores its relation to Freud’s idea of the operation of the death instinct, while offering an interesting supposition that NTR is a reaction to “the individual’s experience … of being possessed, invaded or mastered by the object (an unconscious transference phantasy of mother/ analyst intervening without empathy, adequate boundaries, or a real sense of the other).

 

Ilany Kagan discusses psychic holes as it pertains to denied memories/phantasies of the holocaust.  She underscores how these hidden (denied) realities in the lives of the parents can be relived and unconsciously re-experienced by their offspring.

 

Antonino Ferro in the last article explores counteracting the “negative” by using the creative potential of the analytic dyad.  He leans heavily on Bionion ideas of alpha and beta elements and the need to undergo a “transformation into creativity.”

 

 

Cesar and Sara Botella, again underscoring a kind of elemental “negative” before language and before conflict, use Freud’s ideas of the primal horde to elaborate on an Oedipus complex of the Id, a parricide that is mindless and predates the structured Oedipus of Ucs.  They argue for the need for a transformational process which via figurability allows for the successive development of the later structured Oedipus.  They are influenced heavily, as are a number of the other contributors, by the work of Andre Green (see below).

 

Joachim Danckwardt explores the negative in dreams reminding us that in Freud’s earlier formulations of the unconscious, it, like the dream, cannot render a “no.”  The dream must either link contradictory ideas as in Freud’s dream of the open air closet, transpose affects or, in the case of his patient, represent “negation” by consecutive dreams.  In the manifest content of the second dream the patient dreams of a ghostly figure which is subsequently interpreted as his analyst.  This then is the dream’s effort to “white out” the analyst following the previous day’s painful interpretation.

 

This “whiting out” is a central idea in the long and complex article by Andre Green “The work of the negative and hallucinatory activity.”  His ideas are far too complex to recapitulate here; however a thorough reading of this article could act as a good introduction to this important current contributor to psychoanalytic theory.  Green starts by revisiting the phenomenon of negative hallucination and states that it demands explanation of two different categories:  the former, hallucination, and its relation to perception, dreams, and unconscious representation, and the latter, the “negative” as it relates to more clearly recognized phenomena of splitting, repression and negation.  He states that the need to deny an undesirable, intolerable perception can lead to a negative hallucination which does not attack the preconscious representation but acts by disavowing the perceived object itself.  Green references Cotard syndrome in which deeply depressed individuals claim they have no internal organs.  Many of Green’s ideas are extremely difficult to understand, highly theoretical and require reading and rereading multiple times.

 

I found of great interest Green’s reexamination of the development of the pleasure ego.  He points out, as analysts have previously done, that the pleasure ego is a necessary structure for development but indicates that its existence is less a development than an achievement.  The early pleasure ego (and its ties to the development of judgment and reality testing) and hallucinatory wish fulfillment are dependent on the mnemic trace/ experience/perception of satisfaction.  Hallucination, postulated to be the infant’s earliest way of dealing with frustration and deprivation, in actuality, requires a back drop of satisfactions at the hands of the earliest caretaker in order to create the satisfactions secondarily hallucinated.  Clearly grossly aberrant caretaking then can be expected to alter the quality of the satisfaction or accentuate the negative.

 

The work of the negative is seen as especially strong in those patients who demonstrate “pregenital fixation … the fragility … of  the ego’s defenses which are both rigid and in danger of breaking down … the prevalence of splitting …the fore-closure of symbolic formation, absence of capacity for representation … object relations marked by an intolerance of separation” (page 131).  The classic psychoanalytic model links neurotic repression acting on preconscious word-representations of unallowed satisfactions which themselves are tied to unconscious wordless memories of satisfactions/phanatsies in the Ucs.  But this model already presupposes a level of organization which is belied by the facts of perversion, psychosomatosis, negative hallucination, and psychosis.  Here repression can act directly, more in the form of disavowal to “erase” (“white-out”) whole segments of perception, and can interfere with memory of analytic work or even words spoken in analytic sessions.  Such intense anxiety occurs that such a patient, in Dr. Green’s words, “will be overwhelmed if the object (analyst) is no longer there … and [even when there] … is threatened by a kind of hallucinatory (negative) realization … which affects the quality of the transference … the return of the repressed [is seen as] a fulfilling actualization.  The connotation of restitutive repetition is not recognized in the transference which seems to unfold with the atmosphere of a trauma is in full swing.” The analysis then “is more a question of a return of a psychic event needing to be exhausted.

 

Jorgen Luis Maldonado expounds on the negative as it pertains to the analyst-analysand relationship particularly in narcissistic patients. Such a patient is one who in his damaged state, identifies with the phallus which is seen as having absolute value. The therapeutic relationship and the analyst himself are seen intrinsically as threatening his defensive phantasies of perfection and elicit an effort to destroy. “The patient asks the analyst for help, but….this overt request is transformed into something different which consists in emphatically denying the existence of the object (page 188)” The result is a trench warfare in which the analysand attempts to demolish and destroy the analyst and his understanding.

 

 

These articles are, for the most part, quite theoretical. Often these theories deal with mental events that are beyond and before language. I have some doubt as to how much we can meaningfully conceptualize about a world that is without or before words. To my mind, Winnicott’s ability to use elliptical poetic forms to describe primitive and disturbed mental states seems somehow particularly fitting and useful. And finally our work as psychoanalysts is more poetry than science, more heart than philosophy.

 

As different as these authors are it would appear that they all sense something is missing (negated?)  from our understanding of our more afflicted patients. An examination of negation in all its forms (the death instinct?) and the significant ways this process interferes with an accommodation to reality and the capacity to grow is clearly needed.  This volume should stir the reader’s interest and imagination and will hopefully lead to even more fruitful understanding of Freud and psychoanalysis as it is practiced today.

 

The Dream Screen/Isakower Phenomena and “self-cutting”.

Recently I posted some thoughts about the peculiar symptom of self-cutting. I indicated that the solution of self-cutting lay with the “skin” being the special sense organ that first mediates between an “interior” and an “exterior”. As such it plays a central role for the baby in his gradual discovery of an “outside” including the discovery of need fulfilling objects which ultimately leads on to the discovery of the “other” (mother).

Recently I came across some very similar ideas in a paper by Bertram Lewin “Reconsideration o the Dream Screen”. From the central idea that dreams are wish-fulfilling and serve to prolong and protect sleep, Dr. Lewin had suggested, via a series of clinical observations, that the dream is projected (as in dream screen) by the sleeping infant onto the white curved surface of the (phantasized) or real breast of the mother as the baby sleeps in her arms. The “screen” reported frequently in adult dreams is curved and often blank akin to the breast itself.  In the paper referenced above, he adds his observations to those of Otto Isakower and the so-called “Isakower Phenomena”. This was a hypnagogic  experience of a doughy, rough, dry crumpled feeling in the mouth,  poorly localized, which represented the experience of being partly crushed by the feeding breast as it looms overly large in front of the nursing child. I will quote: “The distinctions between different regions of the body is blurred, as well as the distinction between the mouth and the skin and between the inside and outside of the body”.

The early satisfactions of the nursing situation with mother is central to the successful development of the pleasure-unpleasure ego and ultimately the core core optimism of the individual. A bad mother-baby interaction can, in my judgment, frequently result in the chronic negativism, depression and demoralization most self-cutters experience. It would then be most natural, for such an individual, at times of great stress, to attack the one sense organ that maintains in unconscious memory traces its distant connection between himself and “mother” namely the skin.

 

 

 

Defense as Form or Style

Be alert for defensive operations which attack meaning and thus undermine the process of the psychotherapy

I was supervising a young social worker the other day. This is someone not without experience; she ostensibly felt comfortable working with her male patient and in fact felt the work seemed to be progressing well. The woman began recounting last week’s session. I was listening to the material but to my mind it all felt scattered and completely confusing. One subject followed another without rhyme or reason. If one of those proverbial monkeys had been set a typewriter he could have produced a session with more structure. I could think of nothing to say to her that would be helpful but, as I was struggling, I heard the social worker reporting that she had said to her patient “so if I were to summarize what you have said …” It was only at that moment that I realized there was no way to do so and moreover this was precisely the most striking feature of the session. The patient was seemingly unconscious of his rambling; more striking yet was that this was true of the therapist. Rather than appreciating her confusion and possible irritation that the session going nowhere, she felt it was up to her to create a meaning and present it to the patient.

There are certainly sessions which can meander and sometimes the material can feel “stuck” or repetitive, but every session, like every thought, has a trajectory which is normally fairly transparent. This was not such a situation; in fact it was the opposite, where material was offered with the preconscious intent of generating confusion. The patient defended himself from unpleasant ideas and affects by presenting material in such a manner that it remained incomprehensible to the therapist and thus to himself as well.

I teach a course on psychotherapy in which one of my pet visual metaphors is that of sitting in an easy chair to help young therapists perhaps almost bodily conceptualize how it would be best to conduct a psychotherapy hour. I use this as a kind of optimal zero point and then can underscore that when one is pushed out of one’s “easy chair” something is at work from the side of either patient or analyst that requires the analyst’s attention. The nature of the affective/ideational disturbance can run the gamut from sexual excitement, to boredom, to fear/anxiety, to irritation or rage.

In the above sequence the therapist’s discomfort only came into focus as I explored my own. I struggled in my “easy chair” unable to figure out what was being expressed. At first I felt awkward and unsure…”after all, I thought, ‘I am the supervisor supposed to know.’ But then I realized how I was unconsciously repeating/identifying with the anxiety the therapist felt rather than asking myself: why is the material so confusing and what is the need to summarize anything? The patient had been creating a confused mess which was left for the therapist to unscramble. Why and wherefore remained to be determined.

All this is fairly straightforward and yet long analyses or psychotherapies offer the opportunity for subtle and insidious defensive styles to be accepted as a “given” and thus they are no longer subjected to our usual demands that they too must be analyzed.

I would say this is particularly true with the expanding scope of our work. Many patients now treated suffer from profound and very early trauma which leaves its mark not just in terms of overt symptoms but on developmental synthetic and symbolic thinking itself.

It was noted with some irony many years ago that patients could sound very crazy early on in treatment and then gradually seem increasingly normal. This change may be in part a product of the progress of the treatment but, perhaps more, reflects the gradual accommodation of the therapist to the patient’s mental landscape.

It is critical that some of these “styles” which we unconsciously accept as “given” be analyzed to move the treatment forward, to improve (or develop) self-reflection and to allow for the consolidation of ego structure.

It is not uncommon for patients to paint themselves as inept or incapable and well meaning therapists can easily be tricked into doing the “heavy lifting” in an effort to provide help and demonstrate the value of the treatment. But it is critical to remember that many of these patients are actively unconsciously interested in rendering the treatment ineffective and the therapist impotent. Their gratification often is greatest (on the surface) at being treated as impaired or broken and thusly deserving of special care and attention.

Patients require that we, as therapists and analysts, hold a vision of what they can become and keep that vision safe and alive in the way we work. We expect that adults who are cognitively capable can examine their own mental products and can render meaningful explanations as to the ideas and affects they experience, if not right away then soon after treatment begins. Any deviation from that expectation, however subtly arranged by the patient, will cause a treatment and progress to founder. The therapist in the above example was encouraged in the following session to say something like: “Usually I can follow your train of thought but last week it seemed especially confusing. What are your thoughts about this/” Then the “style” comes back into the treatment and its defensive aspect can be profitably addressed.

 

Skin as ‘Mother’

In our role as analysts/therapists, we often face behaviors that defy simple explanation. That they can appear regularly in certain kinds of patients can lull us into thinking that we understand phenomena that remain puzzling and intriguing theoretically. I am thinking specifically of the frequent practice of self-cutting that occurs with borderline and other more impulsive patients. When asked about this behavior many of these patients offer a similar explanation: namely that seeing the blood causes a diminution in anxiety and that pain, which we would think might be present, is not experienced in the moment at all. Certainly there is an obvious connection to the extreme masochism these patients exhibit; but the peculiar choice of self-punishment requires further explanation. The general focus on “skin eroticism” has certainly been discussed and would fit nicely with sado-masochistic expressions that combine sexual excitement with sadistic punishment. It is my view that there is a close relationship between “mother” and the skin itself. In its grossest manner, skin is the first boundary; it is also the way “mother” as she begins to emerge from part-object is appreciated both as a giver of pleasure (soothing/stroking) and pain (rough handling/being left cold or wet). These early defining interactions with the first object make the skin in some sense, where mother can be found and further, where mother can be attacked. In our more symptomatic patients, who have had extraordinarily frustrating relationships with their mother, cutting must also be thought of as a way of expressing the less overt sadism of our patients who can do no more than impotently slash at the earliest remnants of that often very problematic relationship. I would be interested if there are other clinical situations that may support this supposition.