Mentally ill or mentally handicapped? A longitudinal study of severe learning disorder

SUMMARY

In the course of some eighteen months of psychoanalytic psychotherapy, a young woman of twenty-seven once deemed braindamaged at the age of seven years, has shown herself capable of sustaining once weekly psychotherapy. Against all expectations she has taken responsibility for her own attendance, travelling by public transport alone to her sessions. She has also taken initiatives in relation to finding work for herself.

Psychotherapy has disclosed a significant component of autism in the personality which is resorted to regularly and which seems to drag the patient into a passive acceptance of half-life which she tries not to mind. In the course of her sessions the patient has come to take more notice of her predicament and to mind more about the dissatisfactions which she experiences.

The case presented here is considered to have the characteristics of a particular group of adolescents. These are often described as “just slow” and are brought for psychiatric or psychological attention by desperate parents urgently concerned about the working future of their children.

These are individuals of whom the original definition of mental handicap contained in the Mental Health Act 1913 “a state of arrested or incomplete development of mind” would seem to offer as honest, appropriate and meaningful an assessment as the formal I.Q. score introduced in 1959. Unlike the latter, it is an assessment based on a concept of mental development. Assessment by I.Q. score has led to emphasis on training to compensate for the supposed loss of functioning and also to notions like “training for development” and “education from birth”.

In the case described here it was the abandonment of training aims and approaches which produced a dramatic improvement in the well-being of the patient and her family. Treatment is now fostering the potential in this woman to bring her own mind into action and to support in her, her own wish for personal development.     

The development of a dream from concrete realization to symbolic story

This paper is based on material from an analysis with a girl who was four years old at the time she started analysis. I relate how we worked with her feeling of vacillating, between invading and being invaded by the object, and how she was finally able to let go of her omnipotent control to a higher degree than before. Inspired by Hanna Segal and Donald Winnicott, I trace our progress from; (1) a denial of separation; (2) the analysand establishes a certain sense of separation by creating her own “space”. Through splitting and projective identification, she rids herself of feeling dependent and helpless, feelings that she cannot bear to acknowledge. The analyst receives, contains and names these feelings; to a stage where (3) the relationship established through the agency of projective identification is dissolved, and makes way for an ability to experience dependence as well as a recognition of the analyst as a separate person whom the analysand needs and can use.     

A Comparative Assessment of an Analysis of Envy: Commentary on Paper by Julie Gerhardt

This discussion is introduced with emphasis on the need for comparative psychoanalytic studies in our pluralistic psychoanalytic world and describes an approach to such an endeavor. A very brief comment on the extensive literature review is followed by a more detailed focus on the “analysis of envy,” which gradually changed into the analysis of the patient, as a person. The discussant's “empathic entry” into the analyst's mode of listening and responding was simultaneously also applied to the patient's experience, to see how well patient and analyst communicated with each other and whether or not the patient indicated that she felt understood or not. When she did not feel understood, the patient signaled this with an intensification of her envy into furious “envy attacks.” The analyst's “decoding interpretations” implied that the patient was causing her own problems and should not feel the way she did. The analyst discovered this later herself. Her discoveries in the fourth year of the analysis yielded notable changes both in her approach and in the patient's progress. Ultimately, the analyst allowed her subjectivity to enter the analysis and became better amalgamated with her chosen theory, leading to the changes in a progressively more fruitful analysis.     

Attention and Narration to Micro-Moment Registrations of Embodied Dialogue in the Clinical Interaction: How Are We Doing?

ABSTRACT

This article offers a comparison between two different strategies for clinical attention. The author compares his lens shaped by a musical metaphor of “polyrhythmic patterning” on embodied registrations which he describes as “fluidity” in contrast to a lens of structures or categories of experience. He then contrasts this lens to that offered by Lewis which she describes with the metaphor of an “imaginary camera” with which she creates “snapshots” as representations of unbearable (and often unformulated) trauma shaped by the patient's narrative and her own trauma history. Acknowledging the exquisite connection between analyst and patient, the author uses 2 clinical moments to further illustrate the benefits of each metaphoric lens for possible analytic work.     

Who,What, When,Where, How,and Mostly Why?

SUMMARY

The death of a client by suicide was very emotionally destabilizing to this therapist. She worked hard to distance herself personally from the pain at first and at the same time she found herself overfocused on the “psychological autopsy.” She had difficulty accepting new clients and wanted to withdraw from a meaningful appointment to a state advisory committee. Only when she was able to identify with the client's pain and realize how that pain touched her own history of loss was she able to grieve productively. She realized that gender was relevant in her identification with the victim and in sorting out each of their histories of loss.     

“Crunches,” “(K)nots,” and Double Binds—When What Isn't Happening Is the Most Important Thing: Commentary on Paper by Barbara Pizer

This discussion compares Pizer's concept of “relational (k)nots” with “crunches” and double bind impasses. It argues that all of these constructs capture what happens when conventional analytic method—the exploration, elucidation, and interpretation of transference—fails to work. In this context a “last-ditch effort” emerges, a necessary crisis of treatment. The situation is a plea that something must occur “now or never” or the “charade of therapy is over.” This plea is extraordinarily challenging since it embodies contradictory elements wherein the patient's very call for involvement with the analyst is embedded in a process that obfuscates their connection. Notably this sets the stage for the “damned if one ‘gets it’ and damned if one doesn't” experience that is a part of the paradox of recognition/mis-recognition that befuddles many analyses.

Extrication from such impasses requires the analyst's recognition that she is colluding in a kind of avoidance or distraction from recognizing their disconnection. Her second act involves meta-communication about their process. That is how their “relational knot” both binds them together while negating their connection. While this observation may be necessary it is recognized as insufficient on its own. Thus her third move out of the impasse requires her to enter into a state of improvisation. That is, to use some part of herself that must surrender from the one-up one-down impasse position of “either your version of reality or mine.” Instead, she must cultivate through her action a third way in which both she and her patient can think about their impasse and do something about it, including something different from what either one might have imagined before.     

Did You Say He Has a Hitler Mustache?: Analytic Vulnerability and Destabilization in the Face of Trauma

This paper looks at analytic vulnerability and destabilization through a detailed clinical example. There are different ways in which we may be vulnerable with our patients. In this paper I describe the raw and sudden vulnerability of allowing ourselves to be in a place of not knowing when both patient and analyst are unable “to see.” I describe an experience in which I lose my ability “to see,” both literally and metaphorically, while in session with a patient who is unable “to see” because she has dissociated her experience of loss and her experience of a sense of danger when in the presence of her stepfather. I link this clinical experience to the patient’s dissociated feelings and to my history of intergenerational trauma as well to current cultural violence and hate.     

Incognito or not? the patient's subjective experience of the analyst's private life

This paper examines the meaning for the patient of the analyst's personal life and personality which are ostensibly banished from the consulting room. The therapist has a not‐always‐so‐secret “secret life”; that the patient is supposed to “not know”; about. Yet, more or less unconscious perceptions, impressions, and fantasies about extratherapeutic aspects of the analyst are omnipresent and significantly color the psychoanalytic enterprise.

Moreover the analyst as a person generally plays a critical and underacknowledged role in the patient's experience of the endeavor. Constructing multiple overlapping images of the analyst and of the analytic relationship, the patient discovers himself or herself in the matrix of these relationships with various images of the analytic other. The analysand is motivated to make sense of the analyst as wholly as possible, the better to place into context the analyst's interventions. The patient's resulting view of the analyst's subjective experience acts as a lens that filters and subtly alters the meaning of the analyst's communications.

I illustrate these points by relating my work with a patient whose dreams uncannily picked up on a (consciously) unknown aspect of my private life—my having a handicapped son. The treatment thereafter centered on the patient's identification with my child (as someone “disabled") and on the meaning of her having dreamt something so personal about her therapist.     

Bodies in Dialogue: Empathic Connectedness in the Realm of the Unspeakable

ABSTRACT

This article joins in contemporary psychoanalysis’ ever-expanding conversation about the “something more” than spoken language that has long been privileged in our profession. Specifically, the notion is explored that infant research’s conceptualization of mind as dialogic in origin—that we are prewired from birth to participate in nonverbal, affective communication—is consistent with the position that an embodied, dialogic, co-created, empathic connectedness can evolve with severely traumatized, frozen patients whose experience is not just unformulated but unspeakable. This is illustrated with an in-depth account of a challenging therapeutic journey with a highly intelligent man whose social relatedness hid a world of frozen grief and terror of violation. It was only when the therapist could connect with trauma-generated aspects of herself that had remained frozen, could she find an empathic way of being-with and ultimately understanding her patient’s wordless, frozen world.     

Emotional Communication and the Unconscious in the Analytic Setting

ABSTRACT

One type of unconscious communication is conceptualized as a form of emotional communication, the channel of communication that conveys information about a person’s emotional state through the nonsymbolic expression of feelings and is experienced as feeling in the receiver. Some of the analyst’s feelings are attuned responses to the patient’s unconscious communications; others are disjunctive and related only to the analyst’s unconscious. Attuned feelings can be identified by their congruence—similarities, consistencies, and analogies—with the patient’s verbal material, which reveals the meaning that the analyst’s feeling has within the patient’s subjectivity. Attuned feelings also have a meaning within the analyst’s subjectivity. Two cases are discussed, one in which the analyst experiences the patient’s unconscious communication within the symbolism of one of her own childhood memories. The other illustrates the risk of confusing disjunctive feelings emanating from the analyst’s own unconscious with unconscious communication from the patient.     

Identifications Annealed,Adhesive and Political: Commentary on Paper by Nina Farhi

Farhi's fascinating paper pays tribute to and extends those segments of Milner's clinical work that Milner hesitated to theorize explicitly herself. Seeking to understand the latter, I trace psychoanalytic politics in general and the history of Milner's relationships with Winnicott, Klein, and Riviere in particular to explore how her dutiful compliance to the rigid taxonomy of psychoanalytic power of her time bore on the trajectory of her becoming an analyst with a mind of her own. It is in accounting for how she struggled to disentangle herself from that web, that we discover how Milner was able to creatively refashion her work with her patient Susan, a process by which Susan was greatly impacted.

Following the trail of Farhi's ideas around this process and considering her thoughts around their psychic meanings for both analyst and patient, I explore their clinical implications. I focus on the transferential iterations of these dynamics to consider Farhi's suggestion that an annealed bond needs to be established in the treatment of patients who have, early in life, failed to develop annealed identifications. This opens up questions around how such bonds can malignantly colonize the analyst's mind and psychic reality, raises questions of self-care in the analyst and contributes to prognostically anticipating certain sets of enactments in the course of long-term psychoanalyses.     

How a Kleinian Analysis Also Tells a Relational and Intersubjective Story Commentary on Paper by Meira Likierman

Dr. Likierman narrates her case in ways that differ dramatically from the usual discourse of relational analysts, and she frames her work with constructs that derive primarily from contemporary Kleinian theory. Yet I believe that if we listen closely to her clinical material, we can see how she and her patient live out a deeply relational/intersubjective process—intersubjective in both Stolorow, Brandchaft, and Atwood's (1987) broad sense and Benjamin's (1995) more developmental point of view.

I suggest is that there is real mutuality in their relationship, a reciprocal, unconscious, taking in of the mind and role of the other—a mutual change in which, paradoxically, both parties seem more real and, more deeply than ever, to express themselves. Ultimately, I think we can see that analyst and patient have “enacted” a slightly subversive, yet vital, mutual dance into and through precisely the paradoxes that Likierman recognizes as “forbidden” territory in the therapeutic relationship.     

Discussion of Presentation by Joseph Newirth

Discussing Joseph Newirth's case from a modern Freudian perspective, I explore possible sources of the patient's degraded view of herself, her ambivalent feelings toward men, and her fears of sexuality. I also discuss the course of the treatment, noting that both the patient's progress and the core of her resistance centers on her complex relationship with her analyst. This has been the source of healing and of avoidance of her inner world of imagination and fantasy. I further suggest that active confrontation of the patient's defensive use of her relationship with her analyst would enhance the substantial gains that she has already made.     

Frieda fromm-reichmann,loneliness and deafness

Abstract

This paper explores the rôle that Fromm-Reichmann's parents' adult-onset severe familial deafness may have played in the development of Fromm-Reichmann's career choice and of her charismatic style. She, too, became deaf. Her final paper, “Loneliness” is perhaps her most emotionally evocative work. Perhaps her own increasingly severe experience of loneliness motivated her writing on this theme. Just as she expected self-honesty from her Chestnut Lodge colleagues, this paper demonstrates that she held herself to this same standard. The author urges the deaf community to seek out the newly deaf and to encourage their learning to sign, thus ameliorating the newly deaf individual's loneliness.     

Enactment as Unconscious Communication

ABSTRACT

I explore the way in which unconscious primitive and nonsymbolic experience is communicated to the analyst’s unconscious through enactment. As the analyst receives the projections unconsciously, she is encouraged to enact aspects of the patient’s internal world. The analytic work then is through the understanding of these subtle and ubiquitous enactments. I value the work of understanding enactments as a rich and subtle pathway into the deepest levels of the patient’s unconscious. I explore the nature of this work and illustrate my point with clinical examples.     

Witch-mother is which? The potential role of the analyst in facilitating authentic motherhood

Abstract

This paper explores challenges in the treatment of women suffering from disturbances in maternal identification. A review of the psychoanalytic and developmental literature focuses on the frequent finding of early-onset mother–daughter relational disturbance involving maternal narcissistic fragility and exaggerated dependency needs, intergenerational trauma, and related psychopathology including mutual affect dysregulation. A case example of a young woman with a severe anxiety disorder is presented and discussed to illustrate the challenges to the traditional psychoanalytic technique. This patient avoided pregnancy into her late thirties and entered analysis with feelings of inauthenticity, characterological masochism, and a “secret mission” to unmask the witch recurring in her dreams. Through an elaborate working-through of negative maternal transference, the analyst and patient saw through the birth of the patient’s authentic self, a new approach to her career, her relationships with men, and her anticipation of the birth of a child by the sixth year of treatment. The author posits that psychoanalytic technique benefits from contemporary, attachment, and trauma research that supports the analyst’s playing a more active role in approaching, co-regulating, tolerating, and integrating avoided affects and memory traces that are associated with early-onset relational disturbances worsened by the effects of violence, maltreatment, and loss.     

A Response to the Contributors

Abstract

In my “response to the contributors” I emphasize that I was moved to write my book in response to the question “Why are so many well-trained colleagues, young and old, having so much difficulty developing satisfying analytic practices?” To answer that question I proposed to explore my experience successfully developing and maintaining an analytic practice.

In attempting to answer the question I inadvertently stumbled upon a revolutionary (with a “small r”) answer to the problem. I discovered, in my attitudes and in my way of working in a consultation and the early phase of an analytic collaboration, a new “concrete puzzle solution” to the problem of how to help a prospective, often reluctant collaborator give analysis a “try.”

My book emphasizes my view that courses on “analyzability” and differential diagnosis are based on psychiatric rather than psychoanalytic diagnostic schema and may interfere with candidates' ability to learn how to create analytic patients.

Since I was a candidate, courses on analyzability have always seemed to me to resemble an exclusive club, deciding whom to exclude and whom to admit, rather than a procedure based on sound clinical experience. Analytic experience has demonstrated that it is not possible in a consultation to predict accurately the outcome of an analysis. To make matters worse, it is probable that an analyst whose mind is focused on the task of evaluating a prospective analysand contributes to creating an environment in which certain patients are experienced as sicker than they might otherwise be.

In spite of the fact that it is not possible in a consultation to predict accurately the outcome of an analysis, many experienced “senior” analysts believe an analyst can and should be evaluative and selective. In their discussions of the subject, they focus primarily on characteristics of the patient rather than the match.

In my book I emphasize that in a consultation there are advantages in focusing on the patient's responses to the idea of engaging in a trial of analysis. The issue of the match and the particular time in their lives are significant from my perspective. The analyst's gender, age, personality, and related state of mind may be as important in effecting the outcome of a trial as any feature of the patient's mind.

My book shifts the emphasis of the focus of inquiry in a consultation from the patient to the analytic couple. It offers a different way of teaching candidates to work with prospective collaborators.     

Developing a Psychoanalytic Practice

Abstract

This paper examines two methods of developing a psychoanalytic practice. The first is an “internal” approach that helps a patient make the transition from therapy to analysis with the same analyst. This may be accomplished by attenuating the patient's unconscious fears of analysis as a facilitator of an anticipated regressive loss of control and as a reactivator of feared desires and impulses. Increased motivation for analysis may also result from a therapy that leads the patient to an awareness that an ongoing level of distress is internal, together with the experience of a deepened therapy and of the analyst as safe and potentially providing relief. The second method of developing an analytic practice is an “external” approach that provides others, such as analytic, mental health, medical, and academic colleagues, an experience of the analyst as person and some idea of the type of work he or she does.