OUT OF MY MIND

REWEAVING HISTORY: The Aftermath of Trauma.

A couple of nights ago I looked outside my window and saw a single tower of white light rising among the Manhattan skyscrapers, reaching towards the night sky. I look for it every September. Often it comes early. That tower of light is actually made up of two beams that, in the distance, merge into one single luminous reminder of where the Twin Towers stood. It lights up every September as a memorial to those who died during the terrible events of September 11. It is a fluid and gentle memorial in contrast to the events of that day, and perhaps an easy one to miss if one does not look in that direction at the right time of night.

Every September when I see the tower of light, I revisit my own memories of September 11 and the New York that was then. This time, as I looked at the unwavering light I also caught a glimpse of a nearby giant structure emerging on its right – the Freedom Tower – a single tower of glass and steel making its way toward the sky. It has taken us eleven years to rebuild what was wiped out in 45 minutes. Eleven years to plant trees, build parks and fountains, shopping malls, museums and art galleries and the Freedom Tower. Architecturally, the landscape of downtown New York has been re-shaped, weaving within its newness memories of what now constitutes many a New Yorker’s traumatic history.

September 11 always makes me think not only of the events of that eerie and terrible day, and the ensuing war torn country we have become, but also about human resilience and how we go about repairing wounds. The events post 911 illustrate how a city and its inhabitants go about living post disaster. They illustrate how all of us get on with our daily life while holding a raw and painful reality within us.

“Time heals all wounds” the saying goes, and there is truth to this – but it does not erase the scars of experience. And on September 11, the scar of the attacks on the United States- on the Twin Towers, in Washington D.C. and Pennsylvania – the scar that marks the end of the known and the beginning of the unknown for all of us that survived, that scar twitches a little every September, eleven years after the fact. It’s twitching is triggered by the anniversary, the memorial, and yes, even the Freedom Tower in all of its architectural splendor and its badge of survival.

Psychological trauma is like that. It may recede with the passing of time, only to come back (in some personal and private form) when it is triggered by external events –in this case anniversaries and memorials. Such events are always complicated emotional happenings which strike at the core of who we were before and who we have become.

While psychotherapy helps to alleviate, understand and incorporate the effects of trauma, it cannot erase its traces. As a psychoanalyst who works with varying types of psychological trauma I see people reweave such experiences into their life and move on, forever changed- like the landscape of the city that I love. On September 11, I am always reminded that we are all survivors and united through our experience of reweaving what we knew with what we now know.

 

 

* image credit:  Grandforksherald.com

OUR INTERNAL WORLD – And how it is populated.

 

Most of us are used to thinking about our life and how it progresses from the outside. We look at what we have accomplished and done, our family, our friends, our work, our daily routines and interactions. We tend to think about our lives as made up of the events that happen to us daily, and we evaluate it on the basis of how those events have transpired. But that is not the whole story. At least not when it comes to how we go about living. There is a most important internal world, made up of our history and the relationships that we have internalized, and this is the powerhouse that runs what we actually do in our life. This internal world is made up of personal memories, significant others (and things) and the emotions and feelings related to them. It holds our relational memories. Think of it as the heating and cooling system of your house- it provides the climate for everything, yet you are rarely aware of it – unless it gets too hot or too cold!

Our inner world develops early on, and initially it is made up of sensations. Warmth, wetness, colors, sounds – physical sensations. These sensations are either uncomfortable or pleasurable. They are responded to and modulated by those who take care of us, and thus, if we have hunger pangs in our stomach and someone feeds us, we are satisfied and calm. If someone does not attend to us, then we have to manage a state of discomfort on our own. And we are not equipped to do this as infants. It is almost impossible to do this on our own when we are babes. As we grow up, these sensations are relabeled with language (hungry, sad, happy, etc.) and then relabeled again through the lens of our experiences with significant people in our lives. Thus relational memories begin to populate our internal world.

Yes, our internal landscape begins to develop at birth and is a compilation of early relationships that have left their imprint on our being. Good and not so good. Our internal world is made up of real others (our parents, caretakers, siblings, teachers, places and things etc.) and our experience of them, our emotional reactions and feelings which become the fabric of the relational memories that have been taken in. So our internal world represents our intake of interactions and relationships as they have been experienced and understood at an implicit level. In psychological parlance we refer to our internal world as populated by objects (people and things) that have had an impact on our development. These internal objects can be good, bad or mixed, eliciting feelings, emotions and memories that make us feel in those specific ways even when they are triggered by other situations and people in our life. It follows that the more internal good objects we have, the better prepared we are for the relationships in our adult life, and vice versa.  Our internal world carries our attachment code- the very chemistry that moves us in and out of our relationships and interactions in the world.

While people, and particularly caretakers, figure significantly as the major players in our internal world, we also form significant attachments to things (other objects). Thus, for some of us it may be our relationship to reading, dancing, music, the ocean, food, etc. Things or places that by nature of our interaction with them become significant objects because of the way we use them and how their use makes us feel.

Ours is an internal theater that is densely and idiosyncratically populated, its particular actors and relational configurations laying down the structure of our future perception and experience of ourselves and ourselves in interaction with others.  Our external life is largely determined by our internal life. This is why psychoanalytically informed psychotherapy takes time to understand personal history and one’s relationship to it. Connecting the dots between memories, feelings, emotions and thoughts as they are represented in our internal world and played out in our external life is often what happens in the early phases of therapy, where a relational context is laid out between patient and therapist in which personal experience can be understood anew. Once this interpersonal context has been established, the patient – therapist relationship provides the stage for our internal theater to unfold and be re-experienced. This time perhaps with the opportunity to understand, question and reconsider what our life has been about and what we would like it to be.

ARE WE THERE YET? The time it takes to change.

Why does psychotherapy take time? Why is it difficult to predetermine how long a treatment will last? Are we there yet? My patients want to know. How long till we get there? How long do I have to come to therapy for? Good questions.

It reminds me of the questions we used to ask as children, when our experience of time was nebulous and one hour or sixty miles or kilometers had very little meaning. We just knew we were going somewhere, and minutes and hours stretched long ahead of us, without any sense of when we would get there. The time depended on who was doing the driving, and how they explained it. So we asked, often to no avail, and somewhere along our travels we began to have a sense of the time that it would it take. Psychotherapy is not quite like that, for one thing there are two people doing the driving, and yet, it takes time, sometimes long stretches of time that appear just as indeterminate. This post is about the time that psychotherapy and change require, and some possibilities about why.

First, there are many variables in a psychotherapeutic relationship. There is the patient, walking in with his/her own history, experiences, relationships, memories, desires, fears, heartbreaks…life in all of its personal details and complexities. It takes time to tell one’s story, to find the words to narrate it to another, a stranger who knows nothing about us and who over time will get to know us intimately. This stranger, the therapist/analyst, and his/her own history, education, training, and perspective will interact, inquire, confront and hold the patient and their history in a manner consistent with who they are and how they have internalized their understanding of human nature. Time, as it has been lived, has had an effect on both patient and analyst.

Then there is the fact that narration, and our personal story, is not just the accumulation of words which describe what we have lived and what has happened to us. There are also all of the emotions that surround the words, locked inside of us, which lend texture and meaning to what we have to say, to what and how we have lived. The intensity of our emotional life is not easily translated into words, and thus it has to be experienced by another in the context of a relationship. The therapeutic relationship takes time to build.

Human experience develops and grows over time, each new experience lending new potential meaning(s) to what has already been lived. New experiences are  re-interpreted through the lens of old experiences, and when all goes well, integrated anew. Developmentally we are always adding on to what we have already learned, automatically integrating and  re-working information. When we encounter conflicting situations we may create new categories, or when this is not possible, hold the conflict in various self-states which may interfere with our ability to experience ourselves as unitary beings. This is often the case with traumatic experience, which tends to isolate information, feelings, and thoughts from our immediate awareness, so that integration is not possible. Instead, traumatic experience remains isolated from consciousness and returns to awareness in unexpected ways. Accessing traumatic experience takes time. It takes time to find words to address it and speak of it, time to re-experience it and let another experience it with us, and time to integrate it anew into our lives.

Furthermore, human experience is not limited to what we can recall and speak of, but is also made up of sensations, affect and emotions – what we sense and respond to implicitly- and working this out requires time. Neuroscientists believe that implicit memory powers much of what we experience, unconsciously and at the neuronal level. Take mirror neurons for example. These neurons are responsible for our ability to read and respond to another with feeling, a neuronal system that operates inter-personally and gathers data about how the other is feeling and how they are likely to respond. A colleague of mine (who is a neuroscientist) believes that it is these very neurons that are responsible for the time that the therapeutic exchange requires. I think she is on to something.

Current brain and neurological research indicates that the basis for our relational self (our interactions, emotions, thoughts and actions) is laid out in early development and is directly related to the kind of caretaking relationship we have had. Further, that early brain development provides the neurological roadmap of our personality. To my mind such research offers a potential explanation about why therapy takes time. In effect, psychotherapy creates changes at the neuronal level, causing our brain to re-wire itself in order to integrate and understand old and new experiences and behaviors. This necessarily requires time. I sometimes ask patients to think of our brain and its complex network of neurons as a highway with many exits and roads, some of which are known to us and  well traveled- our usual way of being and responding in our life. When we  become aware of other routes and begin to use other exits and other roads, they are new and unused, so with each repeated use we build stronger pathways that become known and integrated over time.

Bottom line: psychotherapy requires time because neurological structure requires time to grow and develop. It requires new experiences. And it requires an ongoing relational exchange (just as it did in early development) which addresses both previously lived experience as well as a new understanding of that experience. Knowing and understanding alone does not produce lasting change. It is our relational exchange with others that creates meaning and context, and such exchanges alter and shape our neurological structure. They literally shape and change who we are.

If you are still with me, then consider this: In psychotherapy it is the doctor-patient relationship that is the crucible for change. This occurs through dialogue, as well as through felt experience- the stuff that mirror neurons are about, the stuff that makes up implicit knowing. The relationship between patient and doctor is a reflective relationship that is based not only on what is said but how what is said feels like and is experienced by both participants.  The attunement or dis-attunement between patient and doctor provides the basis for the discovery of conflictual states, the re-living of them, and their potential reparation through new experiences that are contextualized within a relationship that allows for new possibilities of being. The time that is involved in understanding something and integrating that knowledge, has to do with the kind of relationship that is established and its ability to hold, re-interpret and re-experience what has been lived – but this time in a different way.

How much time does it take to process and understand de-stabilizing experiences which re-occur without warning and interfere with our sense of personal integrity? The reparation of the self that occurs through psychotherapy is rarely a smooth and linear process. It requires an ongoing relational negotiation that addresses the old within the new. It brings about new behavioral possibilities which challenge our brain and stir it into action.  The bridge that is built between information (what we know) and experience (how we are) in psychotherapy  requires a relationship that addresses how we experience and re-experience ourselves with another, and the opportunity to negotiate the relational nuances that were non-negotiable in the past. It is this relational link that activates neuronal integration and growth. There is no mistaking this kind of change, as it is based on a new experience and sense of oneself. It is known from the inside and reflects on the outside.

It should come as no surprise that the answer to “Are we there yet?” is  relationship based. It occurs within the context that has been built between patient and doctor, and in my experience,  when we are there  we both know it.

 

 

*Image credit: Doug Smith

TOMATOE/TOMATO/POTATOE/POTATO: On The Language We Speak.

I am interested in language in every possible sense of the word: the language we speak, as well as implicit communication-the language of emotions, the language of the body, the language of movement, the language of art. We communicate in many different ways, and as a psychoanalyst I try to pay attention to as many of those communications as possible. Then recently something happened that alerted me once again to the importance of the language we speak and the many meanings embedded in it. It reminded me of my belief that our mother tongue holds many experiences that somehow lose their intensity and feel different when they are translated into another language. Here is what happened:

An Italian friend wrote me of a dream she had the night before. She recounted the dream in English. In the dream her house was being robbed, and the thieves were breaking into some boxes that belonged to her deceased mother in law. She arrived on the scene, along with two of her friends and saw two shady men leaving the premises. She yelled at the men and her friends helped to scare them away.

As I thought about the possible meaning(s) of her dream, I remembered a colloquialism often used in Italian (rompendomi le scatole) which when translated to English literally means “breaking my boxes”. It is used when someone is annoying you or taking you to task on something, or just plain haranguing you- a somewhat vulgar way of saying to someone that they are being a pain and/or testing your patience. When I remembered this and mentioned to my friend  that “someone was breaking her boxes” we had a good laugh. It literally changed the meaning of the dream for her and led her to some discoveries about her feelings regarding her mother in law and what she had left behind in those boxes. Lucky for both of us that we spoke Italian! Without knowing this phrase and its usage I would not have been able to consider an alternate meaning to her dream and invite her to play with those possibilities.

It got me thinking about how language can be used to communicate, shut down and /or change the meaning and texture of what we actually feel, say, and how we say it. While many memories and feelings, as well as dreams are represented in symbols that are often tied to a particular language, the language we actually choose to speak about those alters our experience of them. In particular, translating something that we first experience (and symbolize) in our mother tongue to another language provides some (emotional) distance from it so as to actually influence our experience of it and the thoughts we have about it. Translation provides different symbols to lived experience. Research on this topic has found that when polyglots translate from their first language to another they make decisions that are less influenced by emotions. So there it is. Emotions are first encoded in our mother tongue. Translation provides some degree of separation between emotions and thoughts by assigning different symbols to experience. True, my Italian friend may have been able to access that phrase on her own, since she is Italian and it is her mother tongue, but she was removed from it because she was reporting the dream in English. While I read it in English, I was thinking of her at home in Italy, and my experience of her was very much grounded in her ‘Italianness’ which alerted me to what breaking boxes felt like in Italian. We were connected through our ‘Italianness’ and that triggered my associations and moved us into a mutual understanding from which to begin to consider alternate possibilities.

What are the implications for therapy? Based on my own experience with an English speaking analyst, translating from the Italian into English when necessary never seemed to me to make that much difference. Not that much but some. My analyst and I worked it out so that if I could not think of the word or words for what I was feeling or wanted to say I said it in Italian and then struggled with her on the translation. Sometimes this worked fine, others it seemed to take me off course, to distance me just enough so that I lost the feeling of it. But we managed. It was good enough. Back then, I thought that perhaps some feelings needed another language, a translator to provide some degree of separation. I still think that. Another Italian expression comes to mind: Traduttore traditore- The translator betrays. Perhaps there is always a betrayal of the original sentiment in translation.

Sitting in my analytic chair I am aware of listening and speaking differently when I work with Italian or Spanish speaking patients. I use my hands much more. My voice sounds a full octave higher. The language I speak has an effect on how I present ideas, ask questions, relate to the other, understand the context of what is being said and perhaps even how I feel about what is happening. Yes I think that language can do all that and more. I think language reaches different self-states and communicates information in self- specific ways.

In a good (enough) treatment an interpersonal language develops and unfolds, where meaning is created through the relationship between doctor and patient. That language is constructed not only through the words that are being spoken, but also through what is implicitly communicated through gesture, tone of voice, and emotional resonance. In fact, while what is being spoken may change the direction, depth, and topic of the interaction, it is what is implicit and its textural fabric in communication that adds body to spoken language and goes beyond it to reach lived experience- regardless of the language it is spoken in. And therein lies the magic of the co-constructed  language within the psychotherapeutic relationship. But that is a subject for another post. Stay tuned.

ON WORK AND LOVE – and finding a balance.

In considering what makes life distinctly human and meaningful, Freud famously wrote: “Love and work are the cornerstones of our humanness.” And indeed they are. They are the very foundation on which we build a meaningful life. Think about it, our lives revolve, hour after hour on our relationships with others, and they are organized and structured by our work. This is so whether our work and our relationships are enjoyable or not. At the end of the day we have constructed something, some meaning from interactions with others and in interacting with what we do. The balance between love and work in our lives has a direct impact on our experience of ourselves in the context of our lives.

So lets start with some thoughts about work. For many, work is simply the means of providing for oneself and earning money. Yet work serves other important functions for all of us. Regardless of the type of work that one is engaged in, work provides structure and meaning, it giving us a sense of purpose. It connects us to the larger societal group and involves us within it. Work provides a purposeful activity through which we enter the world, create new relationships and develop a sense of belonging. Furthermore, all of us have a need to use our mind, our physicality, our skill set and talent, in order to express ourselves and create something. Work is a critical activity that is vital for us in maintaining our connection to who we are and who we want to be, it is a crucial source of personal identity and self-esteem. For Freud, and many other psychoanalysts, work is analogous with the motivation to leave one’s footprint in the world and transcend our temporality.

So far so good. Work is important, and perhaps that explains some of the reasons why it can take over our lives crowding out other things. Perhaps. But all of us know that there is more to life than work, no matter how meaningful; there is also love, and our need to be in relationship with others.

I will not attempt to define love, as many poets have done that much better than I could. I will limit my comments on love to say that, as Freud highlighted, love is a motivational force for all of us. It is the glue that holds relationships together, makes us feel alive and connects us to our emotions, feelings and passions. I believe that when Freud spoke about work and love, he intended to address our motivation for being. So love, as the feeling that fuels connections with others, meaningful attachments, interpersonal negotiations, and intimacy, serves as a motivational force to impact others and help us to experience ourselves through them and with them. Much in the way that I wrote about in my post “I do I do!” see https://www.drceccoli.com/2011/02/i-do-i-do-on-relationships-and-commitment/).

Some contemporary psychoanalysts view the capacity to love and work as arising out of our early relationship to our caretakers. Specifically, as related to the way we experienced parental love as infants and children, and to the expectations that we developed (as internal representations of those relationships) regarding what being loved means. In other words, our early attachment patterns establish our experience of being loved and our ability to love others, as well as our expectations of what love feels and looks like.  It establishes how we love. This is because our neural structure is wired in during critical periods of development and in direct response to how we are cared for.

Yes, there is a link between our relationship to love and our relationship to work, and it has to do with our individual early history. And it very likely has to do with how we approach and deal with both. Bear with me here. Within a good enough caretaking environment we establish the ability to feel safe while we explore our surroundings. This is usually accomplished through our relationship to our caretakers, who allow early environmental exploration (play) while supervising us without too much interference – their presence provides the security. This allows us to develop a sense of competence and a healthy curiosity. As adults, our tendency to master the environment while moving in and out of our relationship to an attachment figure is expressed through our ability to love and work. The adult equivalent of the early phase of exploration that all children go through is work. As for love, the mature expression of love constitutes the ability to negotiate an intimacy that facilitates closeness while allowing for separateness.

Might this have anything to do with how we go about working and loving? Yes. To my mind it also has to do with whether we are able to achieve a balance of both in our lives. Love and work are indeed two important components of a meaningful life, two areas which help us to express our subjectivity and individuality in constant interaction with others. Balance is something that we all strive for, and much like a pendulum it may require swinging back and forth before it can be arrived at, and then, only to swing again.

WORDS AND INCANTATIONS – Talking Magic.

As someone who believes in the talking cure, based on words that try to capture inner experience, think it through, re-narrate it based on personal history, and share the entire process with another, in the context of a relationship, I have always thought that there is something magical about words and what we can do with them. Then, I found the following quote in Harry Potter and the Deathly Hallows:

“Words are our most inexhaustible source of magic.”

Albus Dumbledore speaking to Harry.

How incredibly true and profound.

We speak, and when we speak we initiate a potential communication, an elaboration of what we think, feel, and how we want to be known – or not, as the case may be. The magic of words lies in their ability to make us known to others, in their ability to reach beyond the semantic qualities of language and engage us with others. While there are many other ways of communicating, say through a glance, a facial grimace, a smile, a touch- words add specificity to communication. Words encapsulate thought and feeling, often linking it with memory. Words can create dialogues, moods, atmosphere, interpersonal connection- and they can also break them. Psychoanalysts often rely on words to begin building a narrative of patients’ lives, one that can be explored and understood a deux- in the context of a relationship.

Writers and poets avail themselves of this fact all the time. Think of the words of poets and authors, and their ability to transport us to foreign lands, reach our hearts, and make our imaginations run wild and access all matter of feelings within us. As someone who deals with words everyday and for many hours, I understand that words are truly magical, because they allow us to communicate inner experience, they build a bridge between our inside and the outside, and between our inside and the inside of another. Now that is magic!

Those of you who follow my posts know that I am fond of writing about the fact that words often fail us in capturing the complexity of human experience, but today’s post is on the power of words and words as a source of magic.

Words can do anything. They can soothe, caress, hurt, dictate, control, create- and therein lies their magic. In the end, words allow us to elaborate ourselves throughout our lives, whether they are spoken or written, whether they are said out loud to another or spoken quietly to ourselves. Words are a particular kind of human magic. A particular link between what is personally known and what is shared. Words build bridges; they are the blocks of interpersonal transmission, the Legos of relational contact.

We learn to think with words. Our thinking is made up of our particular and idiosyncratic vocabulary. In and of itself this is an incredible accomplishment: words label our inner experience and make it known and understandable to us, and also to others. Words organize all matter of inchoate experience for us; they literally begin our inner conversations. Our personal language is inextricably tied up to consciousness. Words bring experience into awareness, a conscious awareness. And words help us to process and understand our experience. When words fail us, so does understanding.

In treatment, words may not always be available, particularly when trauma has touched us. Then experience can be insulated in sensorial and somatic languages that have sequestered information from us because of its traumatic nature, because our psyche has not been able to hold it long enough to make sense of it and assimilate it. Such is the nature of trauma on the psyche. Such experiences often have to be re-lived and experienced with another who can help us put words to what is too painful and overwhelming to be spoken or thought. In such cases, words hold the power to heal- to bring understanding through a shared narrative that can be thought about and finally spoken.

In life, words connect us to others and to our experience of ourselves in relation to them. The words that we use and assign to someone or something carry a relational meaning, which continues to echo within us, and often within our interpersonal circle. Think about it, those who are close to us take us at our word. This is how they come to know us, and later, other non-verbal interactions fill in where words fail.

Yes, it is true that words can also fail us. When I sit with patients that are too pained and tortured to put words to their experience, I may offer my words, tentative and based on my experience of their experience, of what is being communicated through our relationship. My patients often revise my words, and so we go on to co-construct a narrative that begins to give relational meaning to what has been known to them but had remained unspoken because it lacked the words to be spoken. An incantation based on the magic of words.

THE LONG AND THE SHORT OF IT: Is therapy forever?

I had planned on writing a post on collaboration, something that has been on my mind quite a lot lately. Then, Sunday morning I woke to a New York Times article that got my blood boiling – In Therapy Forever? Enough Already (click link to view):

http://www.nytimes.com/2012/04/22/opinion/sunday/in-therapy-forever-enough-already.html?_r=1&ref=todayspaper

There are many reasons why it stirred me into action. For one, it begins with descriptions of bad therapeutic behavior, which all of us who practice therapy would agree is unconscionable- yet many things can sound that way when they are taken out of the context in which they occur. But ok, bad behavior is bad behavior and there is no excuse for it. However, the author uses such bad behavior to corroborate his idea that the longer a treatment goes on, the less helpful it is. Really?

Yes really, and this is substantiated by research which while published in scholarly journals, tells us none of the details of the population studied, its size, diagnosis, issues, treatment modality, etc. It just tells us that a whopping 88% of patients got better after one session! Imagine that. I find this insulting to both patients and therapists who spend many hours in dialogue with painful memories, behaviors and issues. One session? Not psychotherapy. Not in my book.

But here is the biggest issue I take with this psychoanalysis/ psychotherapy bashing article: it privileges the therapists’ authority over the patients’. While the author gives lip service to the notion that different therapeutic approaches work differently for different people, and at the same time suggests that there are relatively few “severe” treatment issues which would justify a longer treatment (take schizophrenia, he says, as an example!) – your ‘average’ depression or anxiety can be cured and addressed in one to ten sessions, and here is the kicker: a therapist of his ilk needs to aggressively confront the patient, give his opinion and advice as to what the patient should do, all while proposing a structured action plan for changing his or her life. We clearly have different views about what constitutes therapeutic authority. And therapeutic action. And how transformation and change come about. So here goes.

Almost 15 years ago the brilliant psychoanalyst Stephen Mitchell turned his keen eye to the issue of authority in the treatment setting  (see:  http://www.dspp.com/papers/mitchell4.htm ) attempting to clarify what psychoanalysts’ could legitimately claim expertise of. As one of the founders of Relational Psychoanalysis, Mitchell approached the psychoanalytic encounter as a complex matrix of interpersonal exchanges aimed at arriving at multiple understandings of human experience. Within such a view, psychoanalysts have an expertise in how meaning is made and arrived at, in the process of self-reflection and the ongoing organization and re-organization of experience. This is because the mind is understood as a series of self-interpretive constructions- a complex and dense theater comprised of many voices, events and relationships.

Those of us who work and think relationally, respect the fact that people need a sense of personal history and motivation to “knit their world together”. As psychoanalysts we study the way that those systems of meaning come together and are constructed- we are experts at following narratives, spotting omissions and gaps, and co-constructing such histories into useful and perhaps transforming narratives with our patients. Thus analytic authority is not based on my opinion or advice about something, but on my understanding of my patient, arrived at through numerous mutual, interpersonal exchanges which transmit experience and meaning relationally- through our subjective experiences of each other. My expertise lies in being able to sift through these experiences and put forth questions, ideas and feelings which may lead us to answers and perhaps more questions, but which are lived together through the therapeutic relationship. That is ultimately the way meaning takes shape-relationally.

Contemporary psychoanalysts believe that there is never one truth, but rather many, and in treatment, the issue is more about what becomes entrenched in our narrative(s) of ourselves as the truth. What shuts out other possible versions of truth and meaning and reduces our choices in life. What prevents further truths to be explored. Such analysts are experts at holding many versions of one ‘self’, and alternating between varying selves and self-states. Some would say that this is the art of psychotherapy.

Psychoanalysts can also claim expertise at reading and understanding affect and emotions.  In her research on psychotherapy sessions, and what is curative about the psychoanalytic encounter, Wilma Bucci (http://www.thereferentialprocess.org/theory/emotion-schemas) concludes that psychotherapists have more emotional ‘schemas’ from which they can identify emotion and work with it. The language of affect is a natural part of the therapeutic encounter, and psychoanalysts have expertise in the labeling, containing and understanding of emotions on a wide spectrum of intensity. Often, it is the language of affect that requires words to be processed and understood, and this takes place in ongoing dialogue with one another.

Perhaps the issue of authority is murkiest due to the unbalanced nature of the therapeutic relationship. Often patients’ ascribe greater authority to the therapist than they do to themselves. This is inevitable and even necessary. After all, patients’ come to us because they believe us to be experts in our field, and the analysts’ authority is built into its asymmetrical nature. Yet, if the process is to work at all, it requires a collaborative relationship, which will likely need to be negotiated through many ups and downs, and will always question directives and opinions that shut out possibilities and choices.

The very asymmetry of the psychotherapeutic relationship lends itself to abuses of power such as the one implied in the NY Times article, and presented as  “what patients need”.  Furthermore, while psychotherapists can provide a structured ‘action plan’ I have rarely found this useful except for purposes of insurance and billing, as it reduces the complexity of the clinical hour to a heuristic hypocrisy. Such is not the nature of human beings or human minds. Interpersonal situations are complex actions in which consciousness comes into being through interactions with another and/or through self-reflection on those interactions. This means that events in the patient’s mind are knowable only through an active process of composing and arranging them -which happens in relationship to another.

Acknowledging the inter-subjective nature of the psychotherapeutic situation allows us to maintain a healthy respect for the patient’s autonomy while putting forth our view and experience of them as a co-constructed ‘truth’ that can be examined together. Owning our influence in the therapeutic encounter actually protects the patient’s autonomy and actively invites their participation in self-creation. To use a dance metaphor: patients lead and we analysts follow.

This means that the psychoanalyst’s expertise lies in her understanding of what happens when her patient begins to express himself and reflect on his experience in the presence of a trained listener, within the highly structured context of the analytic situation. The psychoanalytic relationship is one of meaningful engagement in which understanding of the other emerges slowly and over time, and is embedded in the fluid, interpenetrating mix of the encounter and the ongoing impact on each other.

Years ago Mitchell portrayed the analyst as an expert in collaborative, self-authorizing self-reflection. Conducting and protecting the inquiry being one of the major features of maintaining the relationship ‘analytic’: where the analyst attends to his own internal experience and is also mindful of the bigger picture, taking on the responsibility for the navigation of the relational terrain. The context specific intimacy of the analytic relationship highlighting its difference from any other kind of relationship- the constraints that it poses making it possible to open up self-reflection, self-expression and intimacy in a way that cannot happen in other relationships in our lives.

This psychotherapeutic process necessarily takes time because it is built on a healthy respect for the complexity of human experience and the recognition that despite the fact that as psychoanalysts we are experts in many of those complexities, we do not hold the key to health nor are we the arbiters of mental health. My patients are all intelligent, articulate people with complex lives and dilemmas, varying degrees of pain and trauma, severity, crisis, etc. They come to treatment because they have thought of many possible solutions about their issues and yet still struggle. For me to think that I can somehow come up with a better solution for their lives is a total abuse of the power and trust invested in me, and a simplistic and reductionist view of what constitutes growth, transformation and the therapeutic exchange.

Articles such as Jonathan Alpert’s essay in the Sunday NY Times do patients and therapists a great disservice by implying that change can come about without addressing the very fabric of who we are and how we come to be who we are.

Perhaps this post is about collaboration after all.

PLAY IT AGAIN SAM: On the compulsion to repeat.

There is a Buddhist belief that people come into our life so that we may learn something and/or work through something that we need to resolve before we can move on.  Thus everyone in our lives is a potential teacher, involving us in a relationship with the very thing that we have to work out. I like this idea. I wonder what Freud would have done with this, whether he would have reworked it or used it to inform his concept of the repetition compulsion. Perhaps he did. What he did not know, because it was impossible to know this at the time, is that neuroscience would prove him right, at least regarding the physiology of the repetition compulsion.

The concept of the repetition compulsion has undergone a number of revisions since its initial description by Freud as related to the death instinct-a move toward self-destructive behavior that he postulated was part of our psychology. According to his initial formulation, behavior patterns acquired in childhood relationships are forgotten (residing in the unconscious) and are instead acted out and repeated later in life. Such behaviors are thus reproduced not as memories but as actions, which continue to repeat themselves in our lives.

The compulsion to repeat a particularly self destructive behavior, often within a relationship, was later seen as arising from early (traumatic) experiences which were unconsciously recreated in adult relationships in an effort to repair and master them. The idea behind this was that the individual had learned to behave in a particular interpersonal way in intimacy, and unconsciously sought out people who felt familiar, effectively recreating the emotional environs of childhood and the need to behave in a particular way. We finally have a body of neuro-scientific research that validates this idea, essentially telling us that since our brain develops in relation to our caretakers and their caregiving, both brain tissue and brain chemistry are built and driven by such early experiences. The brain structures borne within the early relational matrix filter and shape subsequent psychological development including learning, perception, and behavior.

Because of the major brain growth spurts that occur in infancy, during critical periods of development, early experiences have a particularly powerful influence over the formation of neurological structures. Not only are the elements of implicit and emotional memories laid down, but  the actual placement of neuronal synapses, as well as the calibration of neuro-transmitters. Researchers now believe that our initial experiences are embedded in the brain’s physical substrate and therefore influence subsequent experiences, feelings and perceptions as well as behavior. Early experience reverberates anew through its echo in our current life. The repetition compulsion is but one of those instances.

This explains why compulsive behavior is so difficult to shift. Why the repetitions continue. The repetition is not only an effort to master it and to get it right, to repair it. It is also a circuitous loop  that is hard wired in our brain and central nervous system. It is literally mapped out in our brain structures as a unique and personal highway of affect, relational memories and adaptive (yes, adaptive!) behavior aimed at psychic survival and homeostatic regulation at all costs- even if it means playing it again, over and over. You can think of it as a loop that has been reinforced over many years (early on), which now resonates in the present and requires the development of new skills, new behaviors and  new language in order to re-wire itself into a different brain pattern. It requires new relational experience(s) in order to grow and stimulate new brain wiring.

Whew! This is why it requires time. And practice. And a relationship that makes possible new experience out of the old. This is why all behavior change requires time and practice and a relational exchange. This is why psychotherapy requires time, commitment and hard work.

The Buddhist tale I began with is more poetic than science. More descriptive of the experiential power of being open to learning something new out of something familiar and old. It too is supported by research, for in the interaction and relationship with our “teachers”  (those others that help us to play it again) we arrive at  and experience what we must learn in order to usher in change. And this too requires the hard work of practice and  the gift of time.

 

THE BONDS THAT HOLD US: ON BLOOD AND LOVE.

This blog is collaboration. While I am writing it, it is based on something that was shared with me regarding a meaningful personal experience in psychotherapy. It was spawned from a posting on authenticity (https://www.drceccoli.com/2011/07/on-being-authentic/) in which I described the potential curative power of relationships that rely on the sharing of felt experience. This got my collaborator thinking about her experiences in treatment, and in particular, how her first treatment with a male therapist had changed her life because of his willingness to be real and to make himself known in this way. She has given me permission to share part of her story. So here it is.

Her fathers’ love provided a powerful resource that helped her to survive the trauma and pain in her early life, despite his untimely death during her adolescence. As an adult, she began treatment with a male analyst, who through his authenticity, echoed and rekindled the memory of protection and trust that she had experienced with her father. This made it possible for her to address and work on many of the difficulties in her life. Her therapist’s recognition and real attunement made her feel safe and protected. After reading my blog on authenticity, and as a Potterhead (my affectionate name for those of us that are fans of the Harry Potter books), she talked to me about this experience. She told me that she felt that her analyst had sealed the “bond of love” that her father had begun, through an authentic relationship, which provided a human context in which it was possible to revisit dark places because she felt cared for, recognized, understood and protected. She further told me that she had come to understand this through her reading of Harry Potter.

So now some explanations regarding the bond of love, which in the Potter series, is a bond that is exchanged between Lily (Harry’s mom) and Harry, when she protects him from the dark wizard (Voldermort) by standing between Harry and the powerful death spell cast by Voldermort. The spell hits Lily and kills her, and leaves a thunderbolt shaped scar on Harry’s forehead. Here is how it is described in the Harry Potter Lexicon:

The bond of blood is formed when a person sacrifices himself or herself for a family member, out of love. The sacrifice creates a lingering protection in the blood of the person who was saved. It is not activated, however, until a charm is actually cast, and it is not sealed and functioning until another member of the family accepts the saved person as his or her own.

In Harry Potter, the charm is cast when the wise wizard (Dumbledore) sends Harry to live with his aunt, and gets her to agree to care for him until he can attend the school of magic. By accepting this, it is his aunt who seals the charm, and as a result Harry is protected. The nature of this magic is that it requires two people – it requires a relationship to be activated.

It is called the bond of blood, because although Harry’s aunt has no affection for him at all, she is his family, his blood. The love part comes from Harry’s mother. The one interacts with the other. Now what does this have to do with therapy? say you. Everything. Please read on.

All of us have our family blood, both literally and figuratively. It carries not only our DNA, we could say that it also contains our history at the cellular level. Our bloodline carries on through generations, as do many of the behaviors and emotions that are learned and experienced in our early family relationships. Consciously and unconsciously. Such early interactions with our caretakers literally shape our experience of our self and our self in relationship. We now know that early relationships and interactions shape the way our brains develop and function, and that this in turn affects the way that we experience and conduct our relationships. Love, and our (early) experience of it may in fact ‘protect’ us by helping us form meaningful connections and relationships to others. By paving the way to relationality.

In psychotherapy we bring our history, and our blood bonds with us, and we share them with another through our relationship with them. If that other is attuned to the emotional communication that we bring with us, and if that other is prepared to relate to us in an authentic way, that echoes our emotional history because it provides a human context in which to articulate our experience, then magic happens: the experience of feeling known and recognized by someone who can help us repair parts of our experience because they help us to re-experience it in a new way. The therapeutic relationship has the potential to activate a protective “bond of love” through its authenticity. I share this story because it captures this most important factor of the therapeutic action. And it also captures what bonds us together – our humanity.

 

THE NUTCRACKER – On Being A Soldier Through Life.

During the recent holiday season, on my daily commute to the office, I walked by a poster of New York City Ballet’s Nutcracker, smiling at the familiar image of rosey-cheeked wooden soldiers and the memories that it elicited of my childhood. Until one morning as I walked by, it elicited something else, the image of a rigid soldier attempting to fight off potential danger. Hmm. Then I remembered that in my work I have often used the metaphor of being a soldier for the experience of having to be strong and take charge too early – for a response to the experience of developmental trauma and the need to survive it at all costs.

Truth be told, Nutcracker soldiers are sweet but a bit scary. The color in their cheeks a tad too red, their expression hard and their body posture downright rigid. The Nutcracker ballet itself is not all sugar plum fairies, it is full of frightening battles, even when they are danced. Interesting that all of this came to mind suddenly, as I looked, really looked at the images of nutcrackers on the poster. Soldiers indeed, although dressed and colored as toys to be played with. In the ballet, the Nutcracker is given as a gift to Clara, the little girl, but is swiftly taken from her by her brother and his friends who manage to break him in their rough play. Clara’s godfather, the toymaker who made the nutcracker for her, bandages the wooden soldier and provides a bed for him to rest on under the christmas tree. Clara stays with him and is awakened by a battle between the toy soldiers and an army of mice, led by their king, which her nutcracker wins (with Clara’s help) despite his injury. In the end, the nutcracker turns into a prince. I love fairy tales, and I love this ballet, but it was not until one December morning that I realized why I still love it so.

A soldier is someone who has to be armed and prepared for anything – fighting for survival in an attempt to insure that no more damage will be done. A soldier is called into duty when there is a threat to safety. How like the experience of developmental trauma and the response to it. A soldier has to be skilled in weaponry, and wear armor to protect him or her from potential danger. A soldier has to carry on in the midst of ongoing, potentially traumatic events. Soldiering through insures survival. And survival is what it is all about when it comes to trauma. Particularly developmental trauma – the kind that happens when we are young, the kind that happens within the family and at the hands of those we love. We are wired to survive and so we do, and some do by soldiering on – even when there is no longer a war to be fought. In such cases being a soldier becomes part of our character structure, part of who we experience ourselves to be. This can take many forms. We may experience ourselves as strong, capable, logical within our soldier self, and fear being weak, vulnerable and needy. Yet we are likely all of the above. The soldier-self protecting what may be most princely about us – our humanity.

I have written a number of blog posts regarding the experience of trauma (see/click   https://www.drceccoli.com/2010/08/trauma-and-dissociation/  and  https://www.drceccoli.com/2010/09/dissociation-part-one-and-three-quarters/ ), what I am attempting to describe here is a state of mind, a way of being in the world that seeks to protect a wound that continues to resonate  (often unconsciously) into adulthood and threaten the individual. A soldier self-state is necessarily brittle and rigid, much like my description of the nutcracker – a bit too much. It does not allow for the experience of vulnerability, or real connection with another, or the experiencing of deep emotions because to do so brings on potential threat to the unity of the self, and survival trumps all. The traumatized psyche exercises an eternal hyper-vigilance on itself, destroying the ability to live creatively and spontaneously because it has lost the ability to move fluidly within itself. Thus, a psychic army of one is called forth to manage threats and restore safety. A personal nutcracker if you will, complete with costume and make up.

So I return to the story of the Nutcracker, where it is Clara’s intervention, when she throws her slipper at the Mouse King as he is overtaking her wounded nutcracker, which saves the day. It allows the nutcracker to  win the battle and turn into a prince, to become human. It is through our shared humanity, and our ability to connect and rely on others, to use our relationships fully that healing takes place. In psychotherapy this constitutes the bedrock of the patient-analyst relationship.