Psychoanalytic workshops at our institute follow a familiar pattern. There is a formal lecture on Friday night by a distinguished psychoanalyst; in this case, Peter Goldberg flew in from San Francisco to talk with us. Then there is a case presentation - and this takes various forms - on Saturday morning. In this workshop, a candidate - a psychoanalyst in training, presented her work to Peter. The institute as a whole - faculty, candidates and students in other programs - listen to the conversation between the presenter and the distinguished analyst, adding their questions, comments and presence. I have reported on other presentations at our institute in the past, including by Anton Kris and Andrea Celenza.
Dr. Goldberg's presentation style was disarming. He hemmed and hawed - he is originally from South Africa, earned his Ph.D. at the Wright Institute of UC Berkeley - and has ended up in the Bay Area, where he currently is head of faculty at the San Francisco Institute - as he recounted a history of psychoanalysis, one that is familiar to each of us, essentially recounting the first fifty years of a one person psychology and noting the shift from that to the two person, object relational into intersubjective perspective starting in the 1950s. This seemed so flat footed (I think he was actually getting the temperature of the room and warming up to us as we warmed up to him) that I was caught by surprise at the profundity of his content, especially as it seemed on the surface to be as rehashed and old as his history.
Dr. Goldberg proposed a four fold set of styles of personality functioning - styles, he claims, that each of us engage in. These styles are not intended to be universal - and, because they are each characterized by a defensive function, they are each pathological - but to varying degrees. And while we may each spend time in each of them, many of us spend more time in one or the other.
The first style is a neurotic style and this is characterized by the defense of repression. This style requires a personality structure that allows us to have a stable sense of ourselves that we defend by repressing - by pushing down and covering up and hiding - aspects of ourselves that are inconsistent with our dominant view of ourselves. This characteristic style of functioning is the one that the one person psychology of Freud was intended to treat. This treatment was, of course, characterized by teaching/facilitating/supporting the patient as he or she begins more and more freely associating - with free association being the one directive - and the goal of treatment. Goldberg proposes that this makes sense. The repressed material is symbolically represented in dreams and symptoms - products of the patient's (of our) mind - and that mind, while having a repressive barrier is one entity.
The second style is a borderline style that is based on splitting. By splitting, Goldberg means projecting unwanted aspects of oneself onto others - thus cleansing oneself of ownership of the bad thoughts and imagining them - thus thinking them -not as one's own, but rather as the product of someone else. While there is pathology here, Goldberg points out that there is also the potential for health. Projections are also hypotheses about what is going on inside of others - fantasies about what others are thinking. By discovering what those people are actually thinking, we learn to revise our fantasies - to have versions of the other person's mind that more and more closely mirror who they actually are. Also by having others "double" us, which he sees as being a more sophisticated version of mirroring that is supported by Daniel Stern's understanding of cross modal integration - we learn what we ourselves are thinking - and build the kinds of psychological structures that lead to being able to function neurotically.
Treatment of individuals who are engaged in splitting - and Goldberg is including a broad range of pathologies under this heading including narcissistic pathologies - does not rely primarily on helping the person freely associate to connect with the disavowed aspects of themselves - because these are not primarily represented symbolically - but concretely - as fantasies, frequently of what another person is thinking and feeling. The thought is that others are not trustworthy for a variety of reasons, but that I myself am completely trustworthy - I have a persona that is not divided but perfectly and seamlessly constructed. We feel this way, for instance, when we are in the midst of righteous indignation and just plain angry that others have done us wrong. So the treatment is an interpersonal one - one in which I interact with you in a laboratory - we engage in an "as if" relationship and we try to understand what each of us is thinking and feeling at a particular time. The treatment is not one where I offer interpretations of how you are symbolizing what is going on inside of you, but one in which I try, with your help to understand what you are thinking and feeling, meaning what your fantasies are about me and others, and to help you re-own the disavowed fantasies as your own rather than as things that are simply going on out in the world.
The third class of defenses, then, is dissociation. This is a characteristic mode of functioning that involves having no association between the self that is currently functioning and the "true" self. While this is characteristic of trauma, Goldberg is not referring primarily to trauma based dissociation, but to more garden varieties of this. Donald Winnicott, a British Pediatrician who became an analyst and wrote just as we were beginning to see psychoanalysis as a two person point of view, wrote about a self state he called the "false self". Goldberg doesn't like the term, but it clarifies that people can be in a dissociated state and be functioning perfectly competently socially. They construct a self - usually one that is hyper sensitive to and hyper aware of the needs of others, but one that is not all that tuned in - and frequently not tuned in at all to one's own needs.
Again, the treatment for this is completely different than the treatment for neurosis and, for that matter, for splitting. In this way of greeting the world, we have no fantasy - no narrative of ourselves - not even one that we disavow. In the case presentation the next day - a case of severe early trauma - Goldberg clarified that when we are in unsafe waters, we learn how to not articulate the very normal, everyday yearnings that we have - things like wishes to move through time and space - to eat and drink - to express pleasure of dismay - because these can be used against us. We learn, then, to ignore - or to hypnotically suppress them - and instead to focus on what the environment wants from us and to provide that. Here, just being with the patient, including and especially when they are in a dissociated space, noting, for instance, that having nothing to say may be safer than saying anything - and that when they have nothing to say that is likely evidence that they are not thinking - that there is no psychological functioning going on at that moment.
The most extreme example of lack of psychological functioning, then, is the fourth state that Goldberg calls adhesion. In this state, he maintains, we have no psychological functioning occurring. We are conscious only of our physical limits - of where we rub up against the world. We frankly didn't talk about this state so, while my descriptions above likely include distortions - the following examples are my own and may be completely off. In the normal spectrum, I think this might be the experience of being in a meditative state where we are intentionally being conscious only of our physical state. It might also be like being on a roller coaster, where the intensity of an experience is all that we are aware of. I'm guessing that Goldberg intends this to be descriptive of a psychotic state. He did not talk about a treatment associated with it, but I think that it is safe to say that an associative treatment does not make sense. There is nothing to associate to. That said, simply being with the other is a means of forming the most basic relational association, one that the they can build towards.
As I said at the beginning of the essay, there appears to be little here that is new. On the other hand, I found the lecture and the clinical interaction to be enthralling and novel in part as a result of its simplicity - as if Goldberg were using what we already know to carve nature at the joints - and in part because of something else - the idea that these states, described and most easily understood as separate, can exist in each of us.
The power of the first part, that nature is being carved at the joints by these states, is that we need to do different kinds of treatments with different kinds of patients as analysts. When we are treating neurotics - or people functioning neurotically - we need to help them follow their associations - and to interpret their repressive defenses, including resistance - and transference based resistances. When we are treating borderlines - or people functioning in a splitting mode - we need to teach them how to relate, both to themselves, through doubling, and to others, by helping them re-own projected aspects of themselves. And, with folks who are in a dissociative mode, we need to help them appreciate the fears that they have of asserting themselves, create a safe(r) space in which they can explore that, and also help them build a cohesive, coherent narrative of their lives. With adherents, or in those moments when we are simply present, I think we need to be present to others.
The rub here, is the caveat that we are never with neurotics, borderlines, dissociatives, or adherents - we are, at any moment, with a person who might be in any of these states. So, from a clinical standpoint, we have to be flexible. From a research standpoint, we have to be careful. No particular intervention is called for, even with a particular patient, all of the time. We have to think about that in ways that I will articulate soon in another post. But from a theoretical - or as we analysts call it - a metapsychological perspective - this wreaks havoc.
How are we able to have such completely different ways of organizing ourselves? How do these organizational structures co-exist? What signals the shifts between them? Ok, let's start at the end. The shifts between states have been well documented. Terms like regression describe losing the ability to maintain a more mature level of functioning and reverting to a more primitive means of functioning. How is it that we can have such completely different modes of functioning within ourselves and retain a sense of personal integrity and a coherent life narrative? Of course this becomes more and more difficulty the more time we spend in the dissociative/adherent end of the pool, but I can call up, for instance, moments of rage - some on the basketball court and a few, unfortunately, with my children - and I know that in those moments I was not myself - and simultaneously me. I am suddenly beginning to sound like a French Psychoanalyst - perhaps I should quit while I am ahead.
I think, though, in closing, that accurately describing the human condition - especially when that is done simply and clearly as Peter Goldberg has done - creates awe and wonder at the complexity of who it is that we are and how it is that we function. Talks like Dr. Goldberg's lead me to appreciate being a psychoanalyst, even if I embrace that part of my identity reluctantly.
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Addendum: This post is one that I rushed to finish - there is a certain half life to some material, and the material from this workshop slipped through my fingers particularly quickly. I think this was partly because the material was simultaneously so familiar and so novel. I think, by the time I got this down, more of the familiar and less of the novel had slipped back into place, so my apologies if this post is not as exciting as the workshop was for me.
Why was it so exciting? I think one measure of the quality of clinical paper or a workshop is the ways in which they help me think about - or think in new ways about - my current cases. This workshop helped me reconceptualize a number of cases in what I hope will prove to be useful ways. It also helped me think differently about myself. Thinking about myself as being, at various moments, paralyzed about moving forward - not able to do that psychologically because I am in a dissociated state - seems to ring true in ways that beating myself up for not doing something because I am conflicted about it doesn't seem to help - or even seem accurate. If I allow that I have times where I am not a psychological being - just as there are times when an infant or a toddler can't be reasoned with - but that I also have times where I can work things out - just as an infant or toddler is, at other times, extremely present - both rings true and might be useful in ways that I haven't yet had a chance to try out on myself or others...
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