Sunday, April 29, 2012

Anton Kris on Learning and Unlearning - The Reluctant Psychoanalyst Goes to a Seminar

Friday night Anton “Tony” Kris came to town to talk about psychoanalysis.  Dr. Kris is an interesting person for a number of reasons, not least of which is that his mother was Marilyn Monroe’s second analyst – who referred her to Ralph Greenson, her final, controversial analyst who became overly involved in Marilyn's life – and death.  But Tony was here to talk about something else – the learning and unlearning that is necessarily a part of becoming a psychoanalyst.

There is much to unlearn in becoming a psychoanalyst.  The analytic interaction is a weird one.  You, as a helping person, sit behind a couch and relatively silently listen as someone talks about what comes to mind.  You generally try to help them explore the depths of their feelings – despair, fear, pain – without trying to talk them out of them, or to tell them that things will be better – perfectly natural human responses that we have overlearned, especially if we are helping professionals.  Instead of reassuring our patients, we try to help them understand the roots of these dark, difficult feeling states, offering hypotheses about what has lead to them as a means of helping them becoming freer – less bound by the past, and also by the fear of having these states jump up unbidden when they talk or think about or run into something that threatens to expose them.

So, to become analysts, we have to unlearn responses that are so powerfully learned that they seem reflexive.  And, while Dr. Kris wanted us to appreciate this, he really wanted us to appreciate that we also have to unlearn what we have come to know – to inherit – from our psychoanalytic fathers and mothers.  We have to discard the foundations of our psychoanalytic knowledge because they are, in a word, wrong.  He gave seven examples of foundational assertions that Freud and his followers made that we have learned that we must discard.  These included: Specifics about the early growth and development of the human psyche and how that is tied to erogenous zones – the oral, anal and phallic; the idea that it is sex and/or food that we want, not attachment; ideas about women’s psychological functioning; etc. (Another thing that we may have to give up is the idea of gender being binary and immutable).

He maintained that this unlearning is very difficult for a number of reasons, not the least of which is that we have learned them from people we revere in the context of intense relationships.  Psychoanalytic training includes three parts:  Classroom work reading texts with teachers; clinical supervision with analysts; and a personal analysis of the analyst by a senior analyst that lasts for years.  Each of these sources get stamped on us – on our analytic identity – in ways that we understand and in ways that we don’t.  Each of these people – our teachers, supervisors and analysts – was formed, in turn, by their own teachers, supervisors, and analysts.  And they were wrong.  They were also right in some very important ways.  They helped us tremendously.  Our teachers helped us understand difficult texts and master concepts that guide the work we do; our supervisors helped us understand our patients and how to helpfully , if counterintuitively , intervene; and our analysts helped us not only with sorting out our own lives, but by modeling how to do an analysis – both well and poorly. 

Dr. Kris gave an example from his own experience of having visited upon one of his analysands a poor interpretation that came directly from his own first analyst.  With the help of a sensitive and careful supervisor, he was able not only to see that this had happened, but to discover a fruitful way of intervening.  And he proposed that this is the general model for unlearning – to observe, together with another person, the ways in which what we have done has not been useful.  Indeed, this is the model for analysis itself.

The upshot of all this was that we should be altering our curricula.  We should not be teaching what Freud wrote, and then teaching our current theory as edits upon that (which is what we do) because it is not true.  We believe that the mind, the psychoanalytic process; indeed being human, are fundamentally different than what Freud believed them to be.  So we should teach what we know now – all the while knowing that it will be superseded – knowing that it is wrong – knowing that it will have to be unlearned by those we are teaching.  And yet we teach this foundation – this new place on which we stand – as the starting point.  We also need to teach what Freud said – and what he believed.  We need to help our students learn to decode, to decipher, to unearth the roots of what we believe and to understand how earlier folks have gotten us to the point where we currently stand.

Tony made an interesting comment – that we don’t know enough about unlearning.  I think that, in his model, our learning is intimately tied to relationships.  Cognitive psychologists have long distinguished between episodic learning – what happened today – from semantic learning – the learning of facts and figures.  They believe that there are two separate systems for these two types of learning.  Perhaps because of the method of learning – psychoanalysts are home-schooled if you will – these types of learning overlap in ways that are powerful – we learn to function as our analytic parents did, something that helps us overcome the powerful identifications with our birth parents – but this has its own costs as well – we can become complacent in our execution and understanding of psychoanalysis.  We can quit trying to learn from other fields or from new voices within our own field.

The work of an analyst, just like the work of a teacher, a parent or a change agent of any sort, is difficult because we have to confront the status quo – to acknowledge it and its benefits, but to propose an alternative that, we believe, will work better.  This requires that we have our feet firmly planted in the place that we want to help people to move to – even in a process as open ended and unsure of a destination as analysis itself.  We need to be open to ambiguity, to paradox, and to our own shortcomings and blind spots, while advocating for a method of exploration and some fundamental building blocks of that method.  We are, in the words of the philosophers, forever in a state of becoming.

The tool that we use to move the process forward is to offer a new alliance, a new relationship, that can serve as a way station towards achieving a new foundation, a new mode of operating, that will serve our clients better.  This involves a continuous chain of attachment to new figures at the cost of giving up some of the deeply held, but on some levels false attachments to older figures.  We are forever connecting in new relationships and mourning the loss of old connections if we are continuing to grown and change.  We are also preserving aspects of those old relationships, necessarily.  They are the bedrock on which the foundation is built.  Tony expressed concern that, when that bedrock is flawed by trauma - by unprocessable aspects of the relationship - he feared that we may not be able to give up that initial, flawed identification - that we may not be able to separate from original connections that were too damaged themselves.

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Saturday, April 21, 2012

The Hunger Games- The Reluctant Psychoanalyst Goes to a Popular Movie

My son and stepdaughter have both read the first two of the three Hunger Games books.  Last night my stepdaughter who had already seen the movie was sick on a night the family had planned to go to the movies.  So my son and I went to see The Hunger Games.  I knew from the commercials and from what the kids had said that this would be a bloody and – if this distinction can be made – violent odyssey.  I anticipated that it would be grim and that I might find myself hating the ways in which I would be drawn into a post apocalyptic spectacle.  Instead I found it to be a delightful, if as bloody as advertised, coming of age movie that rang truer to my current personal experience than I would have expected.

The premise of the movie is that two children are chosen from each of twelve districts to represent those districts in an annual reality show akin to Survivor – except that here those who don't survive do, in fact, die, - frequently killed by the other "players" who are armed with weapons to murder each other.  The premise had been aired in  commercials that gave the impression that there was a sado-masochistic relationship between an all-powerful elite and a destitute and disabled set of underlings.  And yes, this movie does explore that, but it equips the underlings – not with masochistic tendencies (OK, some of them have those), but with skills and more importantly virtues that contrast with the morally vacuous standing – and just simple cunning – of the tyrants. 

This, then, is a story of good versus evil, but with a twist.  One of the good guys wants to “win”, not by surviving, but by retaining his integrity, by not letting the bad guys alter his essential approach to living.  His partner – and it is complicated but also necessary to have partners in a fight to the death – cannot retain her integrity if she or they are to survive.

On a much less life and death scale, I feel like I have been fighting the institutional hierarchy to wrest from them the necessary resources to have my program survive.  Simultaneously, and in ways that are apparently unrelated, the President has decreed that employees of the institution will no longer have birth control covered by our health insurance.  In both cases I feel firmly on the higher moral ground (and there is more than a little irony there) and thoroughly outgunned.  And the struggle to use what weapons I have available to me – including allying myself with entities that do not have my interests in mind, dovetails more neatly than I had imagined into the plot of the movie.

On the analytic front, I have been reading the works of Donald Winnicott.  He was a British Physician, originally trained as a pediatrician, who used his insights about kids and parents to help psychoanalysts learn how to set up the treatment space as a play space – an idea first introduced by Freud (since writing this I have learned that Freud's space was actually a little more like a battleground than a playground).  But Winnicott clarified in an essay about location of cultural space that the play space is a space that is intermediate between the external, outside space of action – the behaviorally determined space of reacting to a world that evokes behaviors – and the cerebrally determined internal space of the mind – a space that pulls us to withdraw into its infinitely compelling dreams, fantasies, and constructions. 

Winnicott’s position is that we need to find a space to play – a space to engage both behaviors and fantasies – to engage simultaneously with ourselves and with others – in order to integrate ourselves and to discover who it is that we are.  He proposes neither that the unexamined life is not worth living, nor its opposite, that the unlived life is not worth examining, but a dialectical fusion of these ideas – that the well lived life involves engaging both our private, internal, vulnerable selves and our external, active, powerful selves in a stimulating, fun, engaging middle ground where we play, feel, and touch each other while also remaining connected with those aspects of ourselves that can’t be seen touched or felt by others.

The intersection, then, of the movie with my world is just such an interstitial space.  It allows me to imagine my vulnerable self - the one that is beset by the administration - endowed with powers - to shoot an arrow, to run fast and hide, to retain my integrity, that will allow me not just to best the other lower level administrators that I am pitted against, but to expose the corruption of the higher administration.  My sense from the excitement of both my son and stepdaughter about this movie is that it is connecting with a similar space for them – it may mirror for them the struggles that they have against oppressive others like their parents or school authorities, or whoever it is that would tell them to march to the beat of an external drummer while they are feeling within themselves their own pulse and there own pace, which in turn is what the movie is portraying being enacted by the protagonists, each in his or her own way.

The Hunger Games’ Chief oppressor uses the games to maintain dominance and is very aware of the potential for the games to empower those he enslaves.  The victor from years past from our hero's district, now dissolute perhaps from guilt, who is an assigned mentor and who responds to the capacities of this year’s crop of a boy and a girl "tribute" from his district (the participants in the games) becomes transformed and genuinely supports them as he gains hope that they will actually win.  The two star crossed tributes – he who has the luxury to love wholeheartedly and thereby to retain his integrity, she who has greater obligations that necessitate compromise (compromise that, because of the politics of power, my son assures me will lead to unimaginably more awful consequences than any victory could ensure – but he has read the second book…); each of the principle characters is playing with the intersection of their internal world with the world that they encounter.  And each achieves a particular outcome with its own consequences.

My issues of supply have not yet been resolved.  I have lost some of my dignity, if not my integrity, already in what looks like it will become a prolonged battle.  We will see whether one can retain integrity and win the battle, despite what the Hunger Games proposes.  We will also see how the birth control issue gets resolved.  Our President, and his bishop, are attempting to enforce on us what the church has been unable to enforce on their own parishioners.  If those who are most educated and most devout are most likely to use contraception within the church, I think the bishop and my President – who I believe has lost credibility as a Jesuit by trying to impose health benefits that do not include birth control on faculty and staff who come from many faith traditions – will not win the war with this faculty.  But again, the Hunger Games, at least through two volumes, would suggest otherwise. 

I will ask my son and stepdaughter to get to work on the third volume while I continue tilting at the windmills of academe…

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Monday, April 9, 2012

American Pastoral - The Reluctant Psychoanalyst Reads a Pulltzer Prize Winning Classic

Philip Roth’s Pulitzer Prize winning novel American Pastoral is a great and very emotionally difficult read.  Roth uses his alter ego, Nathan Zuckerman, to get the story going (and actually to tell the ending at the beginning – the frustrating, explosive ending of the book that left so little resolved became manageable for me only when I realized that the resolution of the story had already been offered – in the first twenty five pages or so when I was still trying to get oriented), but he abandons Zuckerman (thankfully – the man is an overly introspective and bitter guy) to take on the task of telling, in the first person, the story of Seymour “Swede” Levov – rhymes with love - a blond haired, blue eyed jewish grandson of immigrants who is gifted athletically, revered by his peers; and who chooses to walk away from professional baseball to take over the family’s glove making factory in Newark.  He does not take over the family’s ethnic identity, however.  He moves out to Old Rimrock, New Jersey – a bastion of WASPs in a pastoral setting, where he lives in a two hundred year old home, marries Miss New Jersey 1949, and settles into a bucolic existence.

In his seventies, Swede asks to meet with Zuckerman, the writer, to have the writer help him tell his father’s story – a story of disappointment.  But the meeting never gets to the heart of the matter.  Swede is too stoic, too surfacy, and has had too much of the perfect life for the writer to find a way in.  He can’t connect with the deeper parts of Swede, and is bored as he tries to stay on the surface with him.  Zuckerman then goes to a high school reunion, where we meets up with his old buddy, Swede’s younger, very competitive brother, gets from him the skeleton of the story of their father’s disappointment, and learns that Swede has died of the prostate cancer he thought he had beaten.  Zuckerman then becomes Swede, telling the story of his life in the first person, and revealing layer after layer of emotional complexity beneath the apparently calm exterior of this fantastically gifted and stoical man.  As he does this, he reveals the beating that Swede has taken- the work to become the factory manager and owner, to steer the factory through the race riots, and the devastation of having his family implode (I won’t go into detail here to avoid spoiling too much for those who have not yet read it).

This book works on many, many levels and, while the psychological nitty gritty is certainly one of them, I would like to set my sights on a different vista.  I think this book is a description of America itself; the America of the last half of the twentieth century, with all of its earlier history coming to bear on a time of transition and tumult.  It is the story of a country of boundless opportunity, without great self reflection, that is, as Swede is depicted on one of his weekly five mile walks back from the country store, in love with life – imagining itself as Swede does to be Johnny Appleseed, sowing a future pregnant with bounty.  This great, beautiful country, filled with immigrants who transcend their heritage to become, like Swede, the iconic golden child, but also filled with those who fail: the African Americans, children of slaves, toiling in factories and living in squalid cities, and the WASPs who, like the country gentlemen down the road, have lost their sense of purpose along with their moral sensibilities.  And America, a ship of state, containing all and sundry, not mixed but held together, sailing blissfully forward, founders on the socio-cultural upheaval of the sixties and seventies: the race riots, the war and the objections to it; Deep Throat the movie, and deep throat the source that together reveal the seamier, perverse, pornographic underside of this great horizonless place and the cinematic vision - the Hollywood version that is the result of heavy censorship - can no longer be maintained.

Now, when I write in that experience distant way this book must seem like it must be as stilted, preachy, and sweeping as my paragraph has been.  Nothing could be further from the truth.  Yes, there are great truths revealed.  Yes, the culture is described, but this occurs in the particulars; particulars that are fascinating, and each sentence impelled me to read the next.  I was drawn, in horror and fascination, to know more about the ways that Swede, the person that he was, that he wanted to be, was to be thwarted by all that piled up around him; drawn in by a perfect storm that kept brewing and brewing, a storm that leads to the final scene in the book when a group of characters come into Swede’s home together intent, without knowing it, on destroying him. 

And yet, we know from the beginning, he survives.  He doesn’t just survive, he goes on to thrive.  He lives a life of dignity despite the deluge.  Just as America “recovered” from Watergate – somewhat more cynical, somewhat more wary, but still, underneath it all, still hopelessly optimistic and ready to move forward – to take on new challenges as if the old wounds had healed, when in fact they are still carried within us, alive, cutting at us, but not derailing us.  But also, at least in the person of Swede, the wounds seem unavailable, hidden beneath a placid surface with a happy ending, and therefore there seems to be nothing much to talk about; nothing much to tell.  Swede starts out as the kind of person that we might despise – and do despise in the beginning  – the kind of person we envy, but also pity – the person who does not know himself, until Zuckerman helps us know him – until we read, enthralled, about all that lies within him.

About a year and half ago, my reluctant wife and I went to the Mohammed Ali museum in Louisville.  It is a remarkable museum in many ways, not least of which is that, unlike some museums devoted to a person – notably many of our presidential museums – it does not completely sugar coat the story.  It tells of the characteristics of the man, both good and bad, that make him who he is.  And he was The Greatest not because he had no flaws, but because he used himself as an instrument fully – in ways that worked well and some that didn’t.  The Swede, like Ali, like America itself, is a great and wonderful character not because he is good at everything – that is the surface.  He becomes a great and wonderful character as we appreciate the complexity, the difficulty, the joys, but also the turmoil that is involved in becoming fully instrumental.  And he is remarkably American in that he ends up moving on, continuing to live, even joyfully, despite all that has happened, and without much introspection or awareness of all the turmoil, all the complexity, all the contradictions, that lie within him. 

He wants to tell Zuckerman, but ultimately can't.  He keeps the secret.  But Zuckerman comes to know him anyway.  He inhabits him and opens him up.  He knows what must lie beneath the surface, even if the particulars are wrong.  He knows how he has been torn, even if Swede can't acknowledge it himself.  We admire those around us who have come through, like our country, relatively unscathed, even if we know, for both the country and the individuals that there have been great and terrible costs.  And we truly admire them when we look at those costs, share them and their pain, and balance them against the good that has been done and, in a more balanced way, know what it is that we are seeing.

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Telephone Treatment - The Reluctant Psychoanalyst Earns Continuing Education Credit

A couple of weeks ago I went to a Mandatory Continuing Education workshop.  Now, I didn’t have to go to this particular workshop – it is mandatory that I receive 20 hours of continuing education every two years, and three of those hours have to be in the area of ethics in order to maintain my license in psychology.  This workshop offered the needed ethical credit, and it was on an area that has been of great interest to me: Provision of psychological treatment via phone and the internet.

I have wandered into providing service via phone and email as many of my peers have done, a little bit at a time, reading as I go along, but also finding that the literature on treating at a distance is evolving, just as my practice is.  That said, I have always provided psychological services at a distance.  My very first training in the field was when I was in High School and I was a volunteer at a community mental health agency and I was trained on a suicide hotline.  I don’t think I fielded a crisis call during that stint, but I certainly fielded many during my next paraprofessional tour of duty in a halfway house for runaway teenagers when I was evaluating, after college and before graduate school, whether this really was the profession for me.

As a psychologist in training, then as a psychologist in practice, I fielded many calls – from clients asking about entering treatment to calls from established clients in crisis.  I have always felt comfortable using the phone.  It creates a particular kind of intimacy – a closeness and a safety – the safety of not being in another’s presence, that seemed to be actually quite psychoanalytic in nature.  If the couch is intended, in part, to relieve both analyst and analysand of being concerned with the other’s facial expression, if it is further intended to help the analysand construct the analyst as he or she will, doesn’t the phone do that to even greater levels?

So, when an analysand proposed meeting by phone during a period of travel, it seemed to make sense to me to try it and to see how it went.  And the answer, in so far as such things can be answered, seemed to be a mixed bag.  In some ways, there was that increased sense of intimacy – there was a sense of closeness.  On the other hand, I did not always know where we were meeting and sometimes that didn’t seem to be well thought out by the analysand and we needed to work on setting up appropriate places to meet.  More importantly, there was an interaction between what was talked about and whether we were talking in person or on the phone.  And it seemed like there were times when the analysand chose to set up the meeting by phone – for instance when there was particularly difficult material to discuss – as if being in the same room to talk about it would make it more difficult to address.  We were able to talk about this part of the process and to discover that it sometimes seemed to be the case that our difficult meetings were not consciously planned by phone but seemed instead to “work themselves out” in relation to unconscious motives.

I was fascinated by the interaction of the phone and motivations and talked with some of my peers who had been or were doing some of their own analyses by phone because they were commuting for training.  They resonated with the experience of my analysand and I and I briefly considered doing some research to investigate how the work of various analyst/analysand pairs was affected by including the phone as a means of doing the work.  I did not complete this project, but did some reading about the burgeoning field of telephone analysis and telephone psychotherapy more generally, so it was with some interest that I attended this workshop.

The workshop was led by the executive director of our state board of psychology and a member of the state psychological association who specializes in the use of technology in the practice of psychology (I consider both of them friends of mine).  After reviewing the evolution of phone, email, and other electronic communication use in psychological practice, the presenters noted that laws have not kept up with the spread of communication devices as a therapeutic modality.  They reviewed new laws that our state has put in place to protect the consumer of psychological practice – in particular, anyone treating someone who is currently in our state (whether they reside here or not) can only be treated by someone who is licensed in this state.   The intention of the law is to protect residents of the state from being harmed by someone practicing somewhere else and the citizen of our state having no recourse in case of malpractice.  The effect of this on the group was a little different, however.

The group, all practicing psychologists, began to fear that they would soon be breaking the law if they were to talk with their patients who were travelling in other states – or if the patient moved to another state and they continued to meet by phone.  As the person sitting next to me noted, the room began to be dominated by a powerful emotion: fear.  We all became psychologists for many reasons – but, I think especially when we were younger and more idealistic, foremost among those was the wish to help others.  From this perspective, a license to practice psychology was a means to do good.  It was like a driver’s license to a sixteen year old, an emblem of freedom – but in the case of the psychologist’s license, it is the freedom to provide useful and needed treatment.  Now, of course, it is and was also a means to a livelihood.  We anticipated that we would be able to charge for our services or be hired by an agency to provide them and this would become our livelihood.

In the group at the workshop (and I count myself in that group) it was the latter motivation that was dominant – and the resulting emotion – fear that our livelihood would be taken away – came to dominate our experience and our conversation.  We were consumed by the fear that we would do something wrong – illegal – and lost sight of the telephone and the internet as a means to more broadly do good works.  We were afraid that we would break the law – and also disdainful of the “counselors” that were called up on people’s smartphones who stood ready to provide counseling at rates that would be charged to a credit card by the minute.  While I share some skepticism about how useful that therapy “by the minute” might be, I must acknowledge that this may be a way of delivering service that is more in step with our current culture than I am comfortable admitting.  While it takes McTherapy to a whole new level, could it be that this is an entry point to the mental health field, a field that can be notoriously difficult for “consumers” to navigate?  Could reasonable referrals be made from such a means of being available?  While I am skeptical, I also wonder about the possibilities.  And more importantly, I am concerned that, once we have created a safe way of doing things, that we become closed to new and innovative means of addressing mental health needs.

When Freud shifted from applying mild electric currents to his patients’ numb arms and legs to asking them to tell him what came to their minds about their symptoms, this was a revolutionary shift in our approach to treating conversion disorders.  We now have very powerful treatments – and thus also the means of inflicting harm.  We need to protect our patients, but we also have an obligation to figure out ways of delivering the services that we offer to those who need them in ways that will work best for them.  It will be interesting to see how we move into this brave new world – and how we will balance our fears for our citizens and our fears for our livelihoods with our concerns for our citizens’ best interests and with using our license to work for those interests.    

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What is Porn? A Psychoanalytic Reaction.

I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description ["...