Alan Rickman in Seminar - The Reluctant Psychoanalyst Goes to a Convention and A Play

Sometimes the world falls into place in a way that defies explanation – synchronicity or kismet or fate or whatever it is that lines things up and makes them right acts to create a syzygy that can’t be ignored.  Tonight that happened.  The plenary address at the convention I am attending was by Judith Chused and was titled the “Psychoanalyst’s Narcissism” and the thesis was that the narcissism of the analyst (always abundantly on display at conventions of analysts) is not just off-putting and even destructive, but also can be – because it includes a desire to be helpful and a wish to avoid being vulnerable – one of the therapeutic elements that we bring to the table.  Of course this can cut both ways, but generally we think of narcissism as something to be vanquished rather than as something that is our ally.  So it was an interesting talk; provocative, but in a subtle way.  A talk that was applicable to me and to my work, novel, but not strangely new or different.  Perhaps like the best of new ideas, one that seems so sensible that we feel we must have thought it to be the case all along.

Then, we went to the Theater.  We stood in line to get half price tickets and chose to see “Seminar”, mostly because Alan Rickman stars in it and we like the way he plays wry, self-satisfied characters.  Well, this character was a bit over the top in that department.  Not just wry and self-satisfied, but a full blown narcissist who, at least initially, appears to be totally insensitive and destructive.  Cast as a teacher of a seminar of four young writers living in New York; instead of teaching them, he belittles, berates and attacks them – not their writing, but they, themselves as people.  He attacks them directly in the case of three characters, calling one dull, the second a whore, and the third a pussy; in the case of the fourth he even more insidiously attacks her by sleeping with her – something that she believes will help her writing career.  These attacks turn out to enact the very thing that Chused was describing, though I think in an idealized way that conveys some truth, but also in an exaggerated fashion that includes some dangerous elements of fiction and wish fulfillment.

Narcissism is essential to parenting, teaching, editing, and to therapy.  Narcissism is a complicated term that has been defined in a variety of ways.  For the moment, let’s think about the aspect that is central to parenting.  At birth, our children, little lumps of living breathing flesh, evoke tremendous feelings of love.  Part of that – a big part of it – is because this little lump is our creation – more than that, a part of us.  We love the child the way that we love our own bodies – the way that we love our own ideas  - they belong to us.  As the child grows and develops their own identity and becomes the person that they will be – a person who is influenced by our genes and our relationship – they also become a person more and more certain that they themselves own.  Indeed, many of the conflicts between parents and children revolve around this very issue – who is it that is in charge of my life?  To a lesser per cent perhaps than in parenting, we identify – more than that, psychologically “own”, the people with whom we work.

The positive aspects of “owning “ our patients includes wanting to protect them, wanting our work to be effective – it will reflect back on us if it is not - and not wanting to hurt our patients – indeed wanting to protect them more broadly, including from ourselves.  This is balanced by the danger of not recognizing that our children/patients/students/etc. are actually doing the work that will lead to the changes that they (and we) desire as a result of treatment.  Further, it is their actions (not ours) that are ultimately going to be the ones that carry them to a place – a place where they no longer need us in the way that is very gratifying to us that they do now.  We can get derailed from that process in a thousand ways; including by becoming caught up in and believing in our own power to manipulate, change, and to achieve through them what, at its worst, we have not been able to achieve ourselves. 

In the play, Alan Rickman’s character is a writer who, the seminar members discover, was drummed out of publishing when he was accused of plagiarism.  Rickman’s character himself later clarifies that he was accused of plagiarizing by a student he has slept with who feels rejected by him.  This led him to have to give up writing – and to move into editing.  He is now an editor who wields some power.  His challenge to the dull writer leads her to make up a first person account that is not her own, but of a person that she imagines.  The seminar leader notes the value of this writing and gets her a job interviewing people to ghost-write stories for them.  He lines up an interview with a Hollywood producer for the writer he has dubbed a whore – and this clearly is consistent with the career aspirations and abilities of the writer – and he saves the writer years of work discovering that this is his calling.  He also finds an appropriate slot for the person he is sleeping with. 

The fourth writer, the “pussy”, is the one whom he sees as having the ability to become a really good writer and with whom he most closely identifies.  He offers to edit this man’s writing and to mentor him through the process of publishing so that the man does not crash and burn the way that the seminar leader did.  The writer is skeptical and worries that Rickman's character does not actually have the chops to help him.  He shows up, unannounced, at the seminar leader’s apartment (discovering that the seminar leader is now sleeping with the other female member of the group).  While the seminar leader is tending to his private life, the writer reads something the Rickman character has written, becomes convinced that the leader is, indeed, a good writer and can help him and decides to work with him.

We leave this feel good play cheering for the narcissist whose apparently destructive intentions have had a positive impact on those who have been in his care.  This experience is part of the experience of the child/patient/student who successfully concludes a relationship with a truly caring other, one who is mildly distracted by their own agendas in the ways that all good enough parents/therapist/teachers are, but not so much that they harm the child/patient/student.  But it is not clear to me that this narcissist really was concerned about his students.   While sleeping with the first might be construed as consistent with an expressed desire on her part, sleeping with the second seems to me to make it clear that he is really much more interested in his own agenda with no regard for those of the others.  More to the point, the Rickman character is not willing to put his own writing out there.  He has not done what he will ask his protégé to do – publish the work and let other’s attack it or love it in whatever way they will. 

While we want to rewrite history to have our past demons become angels in disguise (or, perhaps, more to the point, we want to justify our demonic actions by pointing to the positive outcomes that occur in spite of our malevolent intentions), I think this sort of thinking clouds our narrative.  This editor/teacher is not benignly, but malignantly narcissistic – meaning that his own need for self satisfaction and acknowledgement will not be achieved through his own actions, including by having an impact on others that frees them to engage the world more fully as themselves, but he will achieve his satisfaction through claiming the actions of others as his own, while being able, simultaneously, to distance himself from them by ascribing the negative/disliked/disowned to them.

Chused’s position was that our narcissistic investment can, despite the dangers, be our ally as we work to help those who are dependent on us.  I think the play suggests that we can allow our narcissism more license than I believe is warranted.  In so far as narcissism is our ally, it is a dangerous one because its heady perfume can lead us into dangerous, indeed damaging waters – waters where we are tempted to justify ourselves out of all measure to what is actually taking place.  Generative narcissism requires; and this is almost oxymoronic, self-disavowal.  We must be prepared to give our investment in our dependents up in order that they may become whomsoever they will be, and take satisfaction, not in their accomplishments, but in our own – including the accomplishment of letting them go.

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Monet's Water Lilies - The Reluctant Psychoanalyst Goes to a Museum

On Saturday, February 4, a travelling exhibit of Monet's paintings of Giverny, France, opened at an Art Museum near me.   It is a small exhibit, four water lilies, two paintings of the Japanese bridge in Monet's garden, three paintings of wisteria, and three landscapes; so only a dozen paintings in all.  And they are, as my son pooh-poohed ahead of time, only paint on canvas.  When we see thousands of images daily, why should we devote time to these particular ones?  Despite his reservations, my wife and I dragged him to the exhibit.

As a psychologist and psychoanalyst, I am interested in the arts and curious about how and what artists are communicating to us.  I spend much of my day, as I'm sure you do, trying to communicate with others - usually verbally or in writing.  Much of that time is spent communicating facts: what happened on a particular occasion, or what needs to be done in the future.  But I believe there may also be a deeper level to even the most everyday communication.  There may be a wish to be understood - to be heard - to have someone else know and share in our experience.  If that is the case, I think we rarely acknowledge it.

Monet's primary stated intent was to convey his emotional experience more directly.  And his medium was, indeed, just paint on canvas.  Up close, that paint looks, especially in the water lilies, like crayons childishly applied to paper by a kindergartner.  As we move back from the canvas, a magical transformation occurs.  The seemingly random and even clashing colors dissolve into a shimmering, three dimensional space, and the lilies are floating on water - water that is reflecting the colors of the sky and the trees in the background, and the flat canvas is transformed into a three dimensional window into Monet's France, but also, I think, into his mind.

We are wowed by his technical command: his ability to transform those seemingly random squiggles into something beautiful, but that serves to deepen our experience of awe at the beauty of the painting itself which, in turn, helps us appreciate the awe that I think Monet felt as he was looking at something he found profoundly inspiring: nature itself.  We are invited, for just a few moments, to reflect on something that was central to Monet's experience: Wonder at the aesthetics of the world around us.  That something as simple as water lilies floating on a pond could open up inside of us an experience as profound as his paintings do is truly miraculous.  Further, that he is able to share that miracle - so that we, a hundred years later and on a different continent, can experience something of what he felt - is a miracle, too.

 We are bombarded by thousands of images daily.  They cry for our attention.  We see nature, whether it is the grass growing through the cracks in the sidewalk, or the clouds scudding across the sky, as we hustle back and forth in our very busy lives.  Spending a few minutes with a few squiggles of paint on canvas can help remind us that there is, indeed, beauty all around us and that we are gifted to be able to experience and to communicate it.

I, obviously, was taken with the water lilies.  My son preferred the wisteria - ironically he liked the flat quality of the squiggles and could imagine them as a top down view of islands with sandy beaches in the midst of a sea.   My wife preferred the landscapes - something about the motion of the wind blown trees that Monet was able to capture.   I also like being able to talk about the experiences we were having, in hushed tones, as we walked around the small gallery that contained the paintings.

My son invited me to a different three D experience – Star Wars episode I rereleased with the new technology.  The effects were disappointing to both of us.  We agreed that the trailers, of movies made as 3D movies to begin with, better exploited the medium.  The movie itself, though not as gripping as episode IV or VI, continues to engage, and to offer insight into George Lucas’s vision of the world.  The vision he presents is much more complex than what can be conveyed by Monet’s water lilies.   He also has those thousands of images and surround sound, not to mention a narrative thread or three, to convey them. 

Regardless of the differences, one thing that unites the experiences is the communication of affective states.  Monet communicates a kind of serene calm, a sense of wonder that, in the case of the landscapes, has a frothier edge – it feels a bit like you might get blown away at any moment.  Even the water lilies, along with their wonder, bring a certain smell to mind, one that reeks a bit of damp and decay.  Lucas’s emotions are more powerful, more riveting, and they inspire awe not quietly, but with powerful and immediate attentional demands that leave us satiated and exhausted by the end.  They are also, ironically perhaps, more difficult to discuss.

Going to a museum or watching a film can give the illusion that connecting with another person can take place quickly.  We might spend 5 minutes looking at a painting if we are quite taken by it.  Star Wars, at 2 hours and 11 minutes, seems long for a movie.  An analysis, something that involves meeting for an hour 4 or 5 times a week oftentimes for years seems incredibly long by comparison.  Two things, though, mitigate that length in my mind.  First, emotion is being conveyed throughout the analysis.  Second, neither the painting nor the movie – though they can be seen in relatively little time – are the work of a moment.  Monet had to develop his techniques – indeed plant his garden – and then work on each individual canvas for a considerable period of time.  Lucas worked on writing and then filming each episode, with the help of many, many people over the course of years.  We dip into that experience, perhaps as an analyst dips into the life of her or his analysand, and because of the craft and the ways that it touches who it is that we are, we are able to connect with it relatively quickly.

Analysis can be seen, then, as practicing the craft of communicating what we are feeling.  We practice this with our analyst, but while we are doing that, we are also practicing it with ourselves.  We are learning to hear ourselves, to feel ourselves, to appreciate the incredible graphics that we produce in our dreams on a nightly basis (and frequently discard – completely forgetting them by morning).  As we do this, hopefully we become more confident in our abilities to articulate what we have to say.  We become more practiced in the art, using the medium of conversation and all that goes along with that, of expressing ourselves, as Monet did with his paintbrush.

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Jo Nesbø ‘s The Redbreast - The Reluctant Psychoanalyst Reads a Thriller:

Jo Nesbø is a Norwegian writer of detective tales and other books.  His alcoholic and otherwise dissolute Harry Hole is the hero of a series of books with The Redbreast as the third in an ever expanding (currently nine or twelve) book series (.http://en.wikipedia.org/wiki/Jo_Nesbø).  Before describing the book, I must comment on the name.  Hole (pronounced Hul – luh in Norwegian) means “hill” and is a common last name based on families who live in “holes” – farms nestled in the hills of Norway.  The Editors or translator apparently chose to transliterate rather than translate the last name, creating an unnecessary, in my opinion, adolescent double entendre not intended by the author.  Be that as it may, our hero turned out to be the focus of interest for me.

Harry is a police detective, and he spends the book tracking down a serial murderer.  The central mystery of the book is the motivation of this murderer – and an ancillary murderer who wanders into the plot (this second murderer’s motivation will certainly be the focus of speculation in the next book or three).  But Harry’s motivational system captures my attention in part because he reminds me of a friend of mine, a friend who died last spring of cancer.  Both Harry and this friend, one of the people whom I have been closest to in my life, are mysteries to me.

Harry drinks a lot.  He goes on binges and, when he is drinking he disappears – from work, from his social life – holing up in his apartment, leaving only to sit alone at the bar.  At least some of these benders are in response to one trauma or another.  At these times, he does not reach out to others.  In between, when he is sober, he is sincere, hardworking and takes direction well from others.  On the other hand, he is not the brightest bulb in the box, and, though very connected to those he cares about (who are generally female), he avoids socializing with his peers like the plague. 

OK, now that I’ve described him, Harry Hole does not sound much like my friend Armando.  They both drank, but Armando invited others to drink with him.  In fact, one of the things that was difficult about the relationship were the number of times that I felt compelled to stay up all night to keep him company.  Armando was also brilliant.  And he was a consummate collector of people.  He knew and enjoyed people of all stripes.  We used to go together into dorms late at night and turn out the hallway light to see whose room lit up under the door, knock on the door, introduce ourselves, invite ourselves in, and chat for an hour or so – get to know the person.  Armando truly enjoyed these excursions and the people that we met.  He was also a fierce and loyal friend, keeping up with people from various parts of his life.  When one of his best friends married his first wife, he not only remained fast friends with him, he deeply and terribly mourned him when he died.  In fact, Armando lost a lot of friends.  Close friends.  And each time that he lost one it hurt him terribly.

Perhaps this is a place where Harry and Armando intersect.  They both cared deeply about people.  But also, I think, people cared about them deeply.  Sometimes it seemed that others cared more for Armando than he cared for himself.  Besides his drinking and smoking, he just couldn’t bring himself to keep his apartment clean.  When he somehow got a rather nice looking car, a week later he managed to run into something and he never fixed the banged up right front corner.  A friend of ours commented that he just couldn’t have nice things.

I think that Armando and Harry are also jaded.  They don’t believe in the goodness of others.  Or they are skeptical.  This trait makes sense in a cop, but Armando was a high school math teacher.  He was thoroughly skeptical by nature, not by profession.  And there was something about that skepticism that hooked – if not others – it certainly hooked me. 

Armando’s father killed himself when Armando was about 16.  It is certainly easy to hang his skepticism on that hook, but I think it predated his father’s death, though from his talking about his father, I think his father’s skepticism also predated his death.  His father was a steel worker.  He was also a professional wrestler.  Or more accurately, he was a professional loser – beaten by the Anglo with the golden hair every time – derided by the angry mob as the bad guy – maybe the guy who was taking away their jobs in the mill – but also as the guy who couldn’t compete with their hero.  And Armando carried some of the bitterness that his father must have taken from being hired to be the hated and vanquished intruder.

Armando got a rare and deadly form of blood cancer.  He was able to make an autologous donation of his own bone marrow and to go through the bone marrow transplant and to have that successfully take.   He went through the treatment very much on his own; relying on his twenty something year old son to care for him as he was limited in his ability to care for himself.  For a considerable period of time, he wore a neck brace as his bones had become so brittle that he broke them just by turning his head.  I talked to him last about a year ago and he was doing well.  The transplant had taken and he was producing his own blood.  He was warm and it felt good to talk with him – something that was not always the case.  Sometimes his cynicism was hard to bear – especially when he directed it at me.

Then, a couple of months after our last phone call, when I was thinking it was time to talk to him again, I got a call from his second wife – from whom he was divorced but with whom he was very close.  She told me he had died.  She let me know that he had a relapse.  He had not told many people.  She said that he was afraid to tell them for fear that they would feel that he had let them down.

We never got to say good-bye.  His funeral was quick – he wanted a green funeral – and I did not fly across the country, pulling myself away from my clients and my University work, to get there.   I miss him.  I miss him like a sore tooth.  He kept me honest.  And perhaps that is how he and Harry are alike.  They both keep to a trail.  They don’t get distracted, even though they take side trips.  Their appraisal of a situation and of a person is honest.  They aren’t polite.  They don’t pretend.  And they are clear sighted.  All virtues.  In fact, they are virtues in an analyst.  They are all also virtues that are difficult to live with.  They are especially difficult to live with if you are a friend.  If you are an imperfect friend, a flawed friend, Armando was not afraid to let you know that; and apparently it was difficult for him to live with his virtues himself.  His self-criticism kept us from being able to say good-bye.  It kept me from being able to let him know, once last time that I loved him.

I also think that, in the end, I was angry with Armando.  He always did things his way and on his clock and you could adjust or be damned.  His death was that way as well.  Perhaps I didn’t travel across the country not only because of the ties holding me here, but also to have the last word, the last laugh, to not, finally be, once again, a pawn in whatever game it was that Armando was playing.  I know that sounds small and petty, and I hope that this tiny anger resides inside a bigger one – the anger that my friend has left me.  The wish to deny that he is gone.  I know that both of those are there, but I think less noble angers are as well.  I think I always felt that – next to Armando’s great and terrible integrity – a gritty and sometimes mean integrity that overshadowed niceties, that my own integrity failed – and perhaps one last act of defiance was a way of trying to preserve something of myself when someone so important to me had failed.      

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Psychoanalysis and Research - The Reluctant Psychoanalyst Goes to a Convention

There are a couple of challenges in writing this blog that occur regardless of the object I review, whether book, movie, or experience.  One is trying to boil down a very complex subject into a summary that can be evocative to someone who is familiar to the work or quickly enough sketch the work without restating it – necessarily losing the richness of the work.  The second is that I can only use one nugget or maybe two from the vast array of psychoanalytic insights that are available – and it is not like these nuggets are sitting on a shelf and I pull them down in some kind of organized fashion – there are a variety of analytic perspectives that seem relevant to most of the works, and I choose to write from the one(s) that seems most compelling at the moment.

This parallels the dilemma of describing a particular person – for instance in a diagnostic report – and a psychotherapy.  This morning I was at a professional meeting and was discussing the work of a research group that I belong to.  The research group listens to tape recorded analyses and rates both the patient – how well he or she is doing at the beginning of the treatment and then at the end – and the process of the treatment – what are the therapist and client doing across the course of the treatment?  This process, intended to allow us to quantify what it is that we do in analysis, necessarily boils down the richness of the interaction into values on various scales.  At its worse, “My mother screamed at me as a child,” becomes a value of 3 on a scale from 0 to 4 on “Patient takes a developmental perspective in the hour.”  It also becomes a value of 9 (N/A) on the scale measuring the use of dreams in the hour.

The presentation this morning involved assessing the process of a particular psychotherapy from many, many different perspectives.  The process was evaluated from the perspective of what kinds of psychoanalytic techniques were used by the analyst, from the perspective of the warmth of the analyst, from the perspective of the defensiveness of the patient, from the perspective of the accuracy of the analyst’s interpretation, etc., etc.  What I found to be intriguing is that each of these perspectives was telling a similar tale: that in the analysis the analyst and patient worked well together from the beginning, worked best in the middle of the treatment, and the treatment did not work so well in the last eight sessions of the treatment. 

The process of studying the psychoanalysis involved dividing the psychoanalytic hours up into groups – the first 8 sessions, the 8 sessions after six weeks of treatment, the 8 sessions at one year, at two years and then the last 8 sessions as five separate groups.  Each of these groups of hours was further divided into portions of hours.  Researchers listened to each hour and rated them from a variety of perspectives, rating the hour on a number of different scales each of which was based on a particular theory about what was curative in analysis.  Each of the sets of scales told roughly the same story.   The analyst offered better interventions from the perspective of EACH theory in the fourth and fifth group of sessions, and the patient responded best during that segment of the treatment.

 Now, if the research had been from any one of the various perspectives, the conclusion would have been: THIS PARTICULAR THEORY IS SUPPORTED.  Having multiple perspectives complicates, clouds, or perhaps clarifies just how complex psychotherapy – and I think human interactions in general – are.  In the words of Alice’s Queen of Hearts, who has been quoted before in psychotherapy research, “All are winners and all should receive prizes!”  One way of thinking of this is that intervening effectively on one level or from one perspective – in this case, from the perspective of the analyst’s, that he was helping the patient understand what is taking place between himself and the analysand – helps the patient and therapist work well together on other levels – in this case working through the conflicts that the patient feels, and helping the patient to resolve core conflicts in relationships outside the therapy.  Furthermore, being good at intervening in one way, in this case by again understanding what is taking place between the analyst and the therapist, is also related to changes in other dimensions of the functioning of the analyst – he or she becomes more authentic in his or her interactions, he or she becomes more emotionally immediate, and he or she more closely follows, on a moment to moment basis, what the patient is saying. 

Engagement in psychoanalysis, on the part of both the analyst and patient, is then a complicated process that involves many aspects of the self and many technical and theoretical perspectives that come together in the hour, but that are separated out in both our theoretical perspectives and also in our research.  In fact, in a debate later in the day about why science does not have a bigger impact on psychoanalysis than it does, the process of research was described – one that involves finding very simple variables that can be isolated and compared so that a causal relationship between them can be established.  I think in the same way, theoretical writing about psychoanalysis requires a certain consistency – and therefore a certain simplicity – that clinical work – the engagement of the analyst and the analysand can neither afford nor be confined by.  And yet we need guidance as we work.  And so we move back and forth between the richness of all that is going on in the moment of a therapeutic interaction, and what we can make of it, whether theoretically, empirically, or just in terms of a thought that we can have at this moment, and though other thoughts are trying to crowd in, we only have room to entertain this particular thought and we need, for a moment, to ignore the others.

Also that day, I went to a discussion of a case – a case with an impasse in it.  What was interesting about the conversation about the case is that two seemingly mutually exclusive threads emerged.  One was the breadth of reactions that the members of the group had to the case material that was presented.  Each analyst in the room that spoke, and there were about twenty of them, had a unique perspective on the case.  At the same time, there was a shared view of the case, and each of these disparate observations contributed to an overarching view that partook of each of the different perspectives, and that seemed to pull them together into a narrative that each of these disparate views both contributed to and that reflected some aspect of it.

One of the things that happens in an impasse is that both the analyst’s and the analysand’s ability to think creatively, abstractly and associatively – wondering about the richness of what is taking place – the many things that are in fact occurring – collapses.  And, instead, the analyst and the analysand have a difference – one that can only be resolved by this action or that action and that is what HAS to take place.  The role of theory – and ideally the role of research – in psychoanalysis, is to help us work with our patients who come to us in part because of the points in their lives where they cannot think of another way to solve a problem – another way to conceptualize some particular moment.  What we offer are both additional ways to think (which research and theory help us with) but also that being open to other ways of thinking is not only scary, but enlivening and useful. 

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Sleep Apnea - The Reluctant Psychoanalyst Gets Treatment (Cont.)

I posted some time ago about having been tentatively diagnosed with sleep apnea.  Since then I have: been to a dentist specializing in sleep appliances; seen a sleep physician; had a “sleep study” where I spent the night at a clinic with electrodes attached to my head; met with the sleep physician again; had another sleep study while using a CPAP machine; returned to the sleep dentist and had an appliance made; and dealt with the insurance industry.  What a nightmare!  Not so much the individual components (though the nights spent in the sleep clinic were among the worse night’s sleep I have ever had), but the amount of time that it has taken to have a treatment, the frustration of continuing to sleep poorly while knowing that a solution might be achievable, the out-of-pocket costs, and, ironically, the lack of dreams have all been part of the nightmare.

When I last posted, the diagnosis was still a hypothesis.  I was referred to the dental sleep specialist.  He evaluated me, had me fill out a brief self-report form and took X-Rays of my neck.  He explained that my symptoms were consistent with sleep apnea.  He further explained that the difficulty that leads to apnea is part of the paradoxical nature of sleep.  We need to relax our muscles in order to be able to sleep.  The danger, of course, is that if some muscles relax, our throats collapse and we can’t breathe.  This occurs with greater frequency as we gain weight and as we age – also something about my being tall contributes to the difficulty in maintaining the opening.  When the opening collapses, we panic, awaken in a fright with our adrenaline charging, and aren’t able to quickly get back to sleep.

Despite a presumptive diagnosis, the Dentist ordered a sleep study in order to definitively establish the diagnosis.  This required waiting for an intake meeting with the sleep physician, who explained what the sleep study would entail, then waiting for an opening at the sleep lab.  (Two months into the process, my secretary was concerned about her sleep, made a same day appointment to be evaluated at a different center and was in the sleep center for a study within two days, and then had the subsequent sleep study with the CPAP a week later – apparently different places work at different paces!) 

The folks at the sleep lab were very pleasant.  They applied electrodes to my scalp and to my legs, a band to measure respiration, and then had me sleep under video surveillance in a hotel bed.  A week or two later, the results showed that I had awakened from apnea events 15 times in the night, which suggested that I had a mild sleep apnea.  Consistent with my experience, I awoke from the last event about 4 am and did not return to sleep until it was time to wake at 6.  When I met with the physician again, he explained that this meant that I was not getting into the deep sleep that included REM and dreams and therefore was not dreaming at the usual rate.  By this time, school had been up and running again, I was anxious again, and I was not dreaming again – and his machines were supporting what I knew. 

The sleep doc recommended that I be fitted for a CPAP machine in addition to or perhaps in place of the dental appliance, so I scheduled for another sleep study, this time with the CPAP machine on.   When I went back for this, I was less than pleased.  The CPAP keeps the airways open by forcing air in through the mouth and nose.  Because I breathe through my mouth as well as my nose, I was fitted with a mask that covered most of my lower face – I looked like a WWII fighter pilot except that the mask was plastic instead of leather.  Sleeping with the machine on was like sleeping with your head sticking out the window of a car going down the road at about 60 miles an hour.  This was not a pleasant experience for me.  The sleep doc said that I would get used to it over time and claimed a higher success rate than for dental appliances.  The dentist stated that many could not tolerate the CPAP.  Ultimately, it took so long for the insurance to OK the CPAP that the dental appliance had already been made, and I decided to try that out before taking on the CPAP, paying for it, and wondering whether I would be able to tolerate it.

The dental appliance works by forcing the lower jaw forward in sleep and, in the process, moving the tongue forward.  This creates a larger breathing space at the back of the mouth – dramatically so.  In fact, when the appliance was put in place, I could feel how much easier it was to breathe while I was awake, something that seemed surprising to me.  The reluctant wife noticed immediately that I was not snoring and she has been able to dispose of the earplugs she has been using to protect her own sleep.  And especially immediately after starting to use the device, I was bombarded with dreams.  Likely this is related to something called REM rebound.  When we deprive laboratory animals of REM sleep for a night or two (Rats relax when they go into REM sleep so we can prevent REM by having them sleep on a very small island in water.  When they fall asleep, they roll off the island, get wet and wake up).  After having been deprived of REM, animals spend much more time in REM on subsequent nights, seemingly making up for lost time. 

My sleep pattern, in the weeks since getting the appliance, has changed dramatically.  I am dreaming again!  This means that I am waking up from those dreams – so there are unresolved issues that I can’t quite paper over in my sleep – but I am, by and large, able to get back to sleep after awakening – I think about the dream, perhaps analyze it, perhaps I pick up the thread of it and fall back asleep in it.  This doesn’t always work.  A couple of nights I have awakened and not been able to get back to sleep for a couple of hours, but this generally happens earlier in the night – at 1 or 2 – not at 4.  And the dream that awakened me has generally been disturbing – lately I’ve been dreaming, in whatever coded or not so coded fashion, about the state of my career and how dreary it is.  And this, combined with a laundry list of things that I must remember to do, can keep me up for some time.

I don’t know yet know over the long haul, how this will work out, but it seems to be a good start.  My jaw is a bit sore after having been forced into a new position and it has been very expensive.  I think more expensive than it needs to have been.  My regular dentist was appalled at what I was charged for the sleep device.  I think I will shop around next time (I saw one advertised on TV that was probably a glorified mouth guard for  $9.50), but this was also a lesson in what desperation will do to our willingness to pay for treatment.  The longer the treatment dragged out, the more I seemed willing to pay as I became more and more frustrated by not being able to do something basic to a psychoanalyst’s functioning – to sleep – and even more centrally - to dream.

To access a narrative description of other posts on this site, link here.   For a subject based index, link here.

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I.H. Paul's Letters to Simon - The Reluctant Psychoanalyst Reads a Professional Classic

Recently there was a meeting at my institute between various faculty members and a group of young, enthusiastic psychiatric residents and psychology graduate students.  The topic was: How should the students learn about psychoanalytic approaches to treating clients/patients?  We thought about various things that had worked in the past: analysts presenting their cases or teaching classes about basic psychoanalytic concepts, but when someone suggested a book club, the energy in the room picked up.  And then, as we discussed various books that we could read, it was clear that there was a special place in the hearts of the analysts for a book by I.H. Paul (1973): Letters to Simon.

Letters to Simon is modeled after C.S. Lewis’ Screwtape Letters.  Lewis was writing to Christians – warning them as it were – by presenting a series of letters from a wise and avuncular devil to a neophyte who was just learning the craft of temptation (I have posted about an imaginary meeting between Lewis and Freud here).  Paul writes to his – presumably imaginary - nephew, Simon, a neophyte therapist just learning the craft.  In Paul’s book we do not read the correspondence of the student – we know about it only from the references to it in the master's letters. 

We were all excited to recommend Letters to Simon, it held an important position in each of our development and, as the leader of the resident group characterized it, we seemed so attached that she did not recommend asking to borrow our texts – we valued them that highly.  That was true, but we also were somewhat concerned about how well the book had held up.  It was written at a different moment in the development of psychoanalytic theory.  It was a time when psychoanalysis was in vogue – and a time that predated some important developments in both psychoanalytic theory and technique.  So when we agreed to read the book together, it was with some trepidation and some anticipation that I picked it up.

Simon’s letters were still warm and clearly written.  They do, indeed, have a time bound perspective – but from that perspective they clearly articulate good psychoanalytic technique and provide an articulate rationale for that technique.  Simon’s perspective is that the intent of Psychotherapy (he referred to his particular perspective by this handle, though I think it describes the dominant, middle of the road psychoanalytic thought at the time he was writing) is to increase the autonomy of the client/patient.  To this end, the job of the therapist is to be as unintrusive as possible – to assiduously avoid suggestion – and, instead, to offer interpretive help when that is available, and silence when it isn’t.  This creates a picture of the analyst that is still dominant in New Yorker cartoons – a silent, all knowing, but somewhat stilted, formal and unavailable therapist isolated behind a couch offering pronouncements.

The book is longer and denser than I remembered it.  Despite its informal tone and format, there is quite a bit of challenging material between its covers.  It also failed the primary test that I have for technique-based texts: it did not evoke any current patients that I am treating.  So it was with some trepidation that I approached the book club.  I spent time, somewhat defensively, preparing to help them understand why this book was so important to the development of the analysts in the group, to explain how we have developed since then, and to promise to look for books that were more current and likely to be more relevant to their experience.

So, imagine my surprise when the group – a small group, it met during the holidays, maybe that has something to do with it – was very excited about the text.  They found it to be a reassuring, avuncular voice just as we had a generation earlier.  They were taken by the model and appreciative of it.  As neophyte therapists, they found it very useful to have a clearly articulated model – a handbook, as it were, of what it is that they are to do in the therapy session.

I now realized why the book had failed my test of a good technique article - the focus is not on clients/patients and their experience, but on the experience of the analyst/therapist.   While I found that distracting, these novice therapists found it helpful to have a clearly articulated set of rules, just as the analysts with whom we had met earlier had found it orienting.  But, these rules were not the current rules of engagement.  They work best with a very narrow range of clients – really the most healthy ones – and they lead to certain limits in treatment outcome – clients/therapists become more comfortable with their inner worlds, but they can also become too autonomous – taken with themselves, they have trouble relating well to others.

So, now concerned about the opposite end of the spectrum, I took the position that, while the students clearly were finding the book helpful, its position was not the only one – and was not a particularly current one, and I maintained that they ought to think about what this technique, as articulated would promote – autonomy (as advertised) – but what might be lost in pursuing this – a sense of the relationship between the therapist and client and the ways in which articulating that relationship – being more real and present with the client/therapist – could lead to therapeutic outcomes that would influence more than just the capacity of the client/patient to be comfortable with their own thoughts, but also to move towards being more comfortable being in relationship with others while also being connected with their own thoughts.

The students, for their part, ended up comparing two of their teachers and the conflicting approaches that these teachers offered – one represented, more or less, by the book, and the other represented, more or less by my corrective.  This led to a conversation about the tension between the two positions, the virtues of both, but also the limits and concerns associated with each.  Hopefully I was able to inhabit an avuncular space that helped these novice therapists continue the process of developing the skills that are part of this complex but also very human art.  And next month we will read something much more contemporary – Wearing my Tutu to Analysis and other stories...

To access a narrative description of other posts on this site, link here.
   For a subject based index, link here.

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Henrietta Lacks, HeLa Cells and Experimentation - The Reluctant Psychoanalyst Reads Nonfiction

Henrietta Lacks was an African American woman born in 1920 in Maryland.  She died in 1951 and likely would not be someone about whom we would ever know anything except that the cervical cancer cells that would eventually kill her were taken from her when she was a patient at Johns Hopkins University Medical Center.  They were cultured and they not only lived outside her body, but they multiplied rapidly, proving hugely useful to the study of cells and pathology all over the world.  Rebecca Skloot recreated Henrietta’s life in her recent book The Immortal Life of Henrietta Lacks.

The book is the result of a collaborative relationship with Researchers, but mostly it is the result of a collaborative relationship with Henrietta’s four surviving children, her husband, and other members of her family.  In significant part, it is the story of the relationship Rebecca Skloot developed with Deborah Lacks, and, perhaps more impressively, with Deborah’s brother Zakariyya in order to tell this story.  Deborah and Zakariyya are children of a woman who died very early in their life.  They were raised in part by their father, who was very poor, but also by, in Zakariyya’s case, a wicked aunt who locked him in the basement when he was “bad” and beat him with an electrical cord.  Neither of them is well educated, and both are very angry that their mother was taken from them – at times they believe that Hopkins killed their mother - and both harbor beliefs that Skloot is working for Johns Hopkins and is trying to exploit them further – a belief that is supported by the actions of the staff at Hopkins who have, for instance, taken blood from the family in order to study their genes without explaining that this is what they are doing. 

Skloot begins the book by stating in the preface that she wants to keep the language usage of the family – and others in the book – when they are speaking.  This helps her descriptions come to life, but so does the patience that she shows in getting to know the family, working with them to help them understand what her mother’s cells are from a scientific perspective, and in terms of what they have done for science, and to understand what the now adult children’s perspective on their mother’s cells are and how they believe them to be imbued with characteristics that are related to the person that their mother was.  This allows for what feels to me like a very sensitive articulation of the people that Deborah and Zakariyya are, bearing in mind the limits that a white person, no matter how compassionate, will run into in exploring the mind of an African American in the South (see my blog on The Help) – with the further complication of being a representative of the dominant culture that has medically exploited the family. 

Despite – or maybe because of Skloot’s sensitive portrayal, I found myself thankful that Deborah died before the publication of the book.  She would have been, from the description in the book, a person that would be very hard to feel compassion for.  In my mind’s eye, Deborah appears on a talk show or in a news clip.  She is hard, angry, and speaking with very poor grammar.  Even having read the book, I have a hard time embracing her – accepting her – doing much of anything but cringing as she talks.  Who she presents on the outside prevents me from appreciating who she is and, I think, feeling that she deserves, for instance, any compensation for what was taken from her mother. 

Knowing someone from the inside out – and being able to describe them from that perspective – while also knowing them as they come across and being able to appreciate that and the power that their presentation has – is a very psychoanalytic means of engagement.  Which raises the question, who is this for?  In this family, whose mother’s cells were taken without her permission, cells that started a whole industry that has earned many people very good lives and brought considerable wealth to some; this family who has endured interviews and articles that have portrayed them in a variety of ways; this family who is now being interviewed by a journalist who, it turns out, will profit from a very successful book and support the publishing industry, what is the proper and just compensation they should receive?

The answers of the family members themselves vary.  Deborah wants recognition for her mother.  She wants the scientific community to know the person who produced these famous and useful cells.  I think the book accomplishes this.  All of the family members are aware of the irony that the cells have made tremendous health interventions possible – from polio vaccines to treatments for cancer – treatments that they cannot afford.  The book does not change this situation.  Zakariyya, and many of the men in the family, want money.  But Zakariyya is visibly softened, and clearly and very movingly appreciates, the pictures of his mother’s cells that a scientist gives to the family.  Seeing the cells through a microscope and learning about them are, at least through Skloot’s and our eyes, moments of epiphany for Deborah and Zakariyya.  Skloot, herself, sets up a scholarship fund for the children in the family from part of the royalties from the book.  This is money, but with strings attached.

What compensation should our patients receive for the treatment that we provide?  This may sound like a funny way of putting it, but we are “practicing”.  We are learning from our patients as they are learning from themselves and from us.  We are looking into their psyches just as other scientists look into the cells of the patients that they treat.  We, like those scientists, and like the author, need to be compensated to be able to provide the service that we do.  The service that we provide is to help articulate the narrative that has brought the people that each of us serve to the point where they are when we engage with them.  The position of the courts has been that what we take from that and apply to our next patient or, in the case of the book, how we use what we have come to learn about the family and the experiences that they have had, are ours to use as we will to forward the good of human beings and to profit from.  Our patients take, when the treatment is successful, greater insight, a more cogent narrative, and skills to navigate life’s insults a little more gracefully.  They may also be relieved of some measure of pain and inner turmoil.  But, they are not free of the events that led them to seek treatment.  They do not get the concrete compensation that something like money would represent.

Dr. Karl Menninger used to ask whether it was ethical to charge for empathy.  Some have responded that empathy is not paid for, our time is.  Skloot, I think, deserves compensation for her time and expertise.  But that comes from the perspective of a fellow professional.  Our system of compensation has always placed minimal value on the raw materials of wealth and poorly compensated those who unearth or concretely produce them.  Instead, we have placed value on those who organize, understand, and develop the raw materials.  I have certainly pursued the ability to do that, not as a means towards wealth, but I am certainly glad that our system of rewards fits with my predilection towards production.  I am also thankful that I have had the means to achieve the opportunity to make those kinds of productions.  Skloot offers the family support in making the transition to becoming that kind of member of society.  I will be curious to see what comes of that.

To access a narrative description of other posts on this site, link here.   For a subject based index, link here.

For other posts looking at Race in America see: James Cone's The Cross and the Lynching Tree, and applied to a Rock Musical, Dorothy Holmes presents to the 2016 Psychoanalytic Convention, 2017 Convention Aktar, Powell and Trump, hearing Ta-Nehisi Coates talk, Black Lives Matter,  John Lewis' March, Get Out, Green Book and Blackkklansman, Americanah, The Help, Selma, August Wilson's Fences, Hamilton! on screen, Da 5 Bloods, The Black Panther, and Ta-Nehisi Coates' Between the World and Me.

To subscribe to posts (which occur 2-3 times per month), if you are on a computer, hit the X button on the upper right of this screen and, on the subsequent screen, hover your cursor over the black line in the upper right area and choose the pop out box that says subscribe and then enter the information.  I'm sorry but I don't currently know how you can subscribe from a mobile device - hopefully you have a computer as well...