DIRECTORS' COLUMN

By Seth Warren, PhD

Going Deep

Full fathom five thy father lies;

Of his bones are coral made;

Those are pearls that were his eyes:

Nothing of him that doth fade,

But doth suffer a sea-change

Into something rich and strange...

-W. Shakespeare, The Tempest ("Ariel's Song")

I would like to share a fascinating and surprising moment I experienced recently, in which psychoanalytic work made an entirely unexpected cameo appearance. First, however, I want to take a detour through a few psychoanalytic reflections on the meanings of water, both universal and personal.

Water has always had rich psychoanalytic connotations. In our work we refer to "surface" and "depth," our treatments are described as "depth-oriented," and the psychology of the unconscious has long been called "Depth Psychology." The contents of water are concealed from our conscious eyes, but we intuit the energy and forces below, sometimes in our thoughtful reflection and in our dreams, breaking the surface to encounter them.

All life comes from the sea, "she" is mother to us all, and each of us came into existence first as aquatic beings, in the silent sea of our own mother's wombs. Many world rituals of rebirth and regeneration involve water. We are baptized in water, born again; we cast our sins into the sea, water so vast - its infinite aspect mirroring God's - that they disappear there and we are clean once again. Water has always symbolized transformation, a substance remarkably available to us in three different states. Water is connected with change, there are dissolving processes, rusting, crystalizing processes, currents, waves and, always, the depths.

My earliest dream/memory is of fish, golden and beautiful, in a pond in no recognizable context. All throughout my life, even up to the present, I have had vivid dreams of an underwater world, seeing objects through water from above, and of oddly beautiful and alien creatures there, evocative, shimmering, and enigmatic, perhaps representing unconscious elements, simultaneously strange and familiar, sometimes inspiring fear or awe.

On a more conscious level, I have many happy memories involving the water. My father teaching me to swim, and his taking me as a small boy into the ocean at Rockaway Beach; many childhood summer vacations in Wellfleet, snorkeling in the ponds, and bodysurfing at the ocean beaches there; beachcombing with my children when they were small, finding magical watery creatures and treasures.

But when I learned to scuba dive about 12 years ago, I was finally able to break the surface and enter the dream-world beneath the sea, to experience the phantasmagorical landscapes and strange fauna of that underwater world, floating dreamily in very often quite warm and crystal clear blue water. Once again, sensations perhaps reminiscent of origins, the salty womb, the source of all living things, the Great Mother. Remember Freud's description of states of mystical union as the "oceanic feeling"?

It is because of my interest in scuba diving that I stumbled onto Bernie Chowdhury's book, "The Last Dive," a narrative that tells the story of a well-known father-son pair of adventurous technical divers who ultimately died in the course of collecting artifacts and trying to identify the wreck of a very deep sunken U-Boat off the eastern seaboard. Chowdhury, himself an accomplished technical diver, describes in his book the development and history of technical diving by sport divers using SCUBA gear. "Technical diving" is something entirely different from tropical scuba diving over shallow and colorful reefs, maybe a bit like Himalayan mountaineering in comparison to, say, a spring hike in New England. It involves a great deal of equipment and training, great depths, lengthy decompression schedules, complex gas mixtures, and the management of serious objective risks and hazards in conditions not suitable for recreational divers. All of which I could enjoy from the safety and comfort of my reading chair!

In his book, Chowdhury describes an incident in which he almost dies, surfacing from a deep shipwreck in an emergency without spending the requisite time at various depths "decompressing," and so suffered a serious life-threatening episode of the "bends." It is a terribly painful condition that can cause serious damage to multiple organ systems including the nervous system, and may leave a person permanently injured even if they survive. Chowdhury was evacuated by helicopter to a specialized "recompression" treatment medical where he received many days of intensive treatment that saved his life, though he was told he could never dive again. Chowdhury goes on to describe the lengthy and difficult process of rehabilitation from his injuries and his gradual return to scuba diving.

But it was at this point in his book that something quite remarkable happened. Thinking about his three year-old son, and wife, and how he nearly left them behind, Chowdhury makes a decision to re-evaluate his relationship to diving. He realizes that he needs to better understand his own motivations and his choices, some of which he recognizes contributed to the mistakes he made leading to his near-fatal incident.

And, so he consults with... a psychoanalyst. I kid you not. An academic sociologist, to be precise, also a scuba diver, who had obtained psychoanalytic training. In New Jersey, no less! Chowdhury describes the process of coming to understand the idea of unconscious motivations, and he is determined to learn more about that inaccessible side of himself - the side below the surface - so that he might not again take an unnecessary chance, or make a decision lacking in self-awareness, and leave his family behind. "According to Dr. Hunt's training and beliefs, unconscious recollections, notions, and emotions affect what we think, what we say, and how we act. Unresolved conflicts from earlier life experiences may be hidden in the unconscious and influence behavior, which is especially important to people such as divers, who engage in high-risk activities" (p. 220).

As a psychoanalytic reader, I was stunned, completely unprepared for this turn. It was just so unexpected and delightful; to read about this man's search for self-understanding in the course of his growth as someone working on the adventurous edge of what is humanly possibly.

And I was pleased, needless to say, that someone out in the "real world" recognized the pragmatic value of what we have to offer as psychoanalytic practitioners and found his way to psychoanalytic consultation. It was the most unusual plug for our business I have seen in a while! This diver, used to penetrating otherworldly depths in the sea, recognized the "alien" otherness of his own psychic depths, and how they might affect his choices and his life.

We psychoanalytic workers are all divers in this sense, finding our way in sometimes difficult and murky water, sometimes water of startlingly beautiful clarity, looking for what is unseen and hidden in ourselves and our patients. We deal in the alien familiarity of the unconscious every day, the otherworldly parts of ourselves and others, crossing barriers, moving between states, marking transformations and discovering psychic landscapes "rich and strange."

1 Chowdhury, B. (2000), The last dive: A father and son's fatal descent into the ocean's depths. Harper Collins, NY.

This article was reprinted with permission from the New Jersey Psychological Association.  The original article appears in their publication, The New Jersey Psychologist, Volume 59, Number 1, Spring 2009. Special thanks to Thomas Johnson, LCSW, EdD.

There are few topics that strike more fear in the heart of a psychologist, particularly a psychologist in private practice, than stories about colleagues who've become ill and are forced to take a leave from their practice, even for a time-limited recuperation. Anxieties abound about financial catastrophe, about loss of opportunities, and about compromise of professional identity and reputation. Despite the natural wish to avoid this topic, much needs to be said about the impact of this experience on our work. In particular, the potential for ethical complexity in this situation needs to be addressed, not only from the perspective of the people we serve, but also from the psychologist facing the crisis.

Until the past twenty years or so, there were few accounts of the impact of illness in a therapist on the process of treatment (Dattner, 1989; Halpert, 1982). For example, Freud suffered intensely from jaw and oral cancer for the last 16 years of life and underwent 33 painful surgeries (Edmundson, 2007; Halpert, 1982; Schwartz, 1990). Yet there is no mention of the effect of this experience on his clinical work in any of his writing. We are left with the image of a heroic caregiver who stoically continues to analyze in the face of pain and death. We still hear many stories of clinicians who "bite the bullet" and work in the face of pain, discomfort, and even death. In truth, many of us are devoted to the people we serve and worry about leaving them in the lurch when we become ill. But there are also other important emotional processes at play here that drive an ill psychologist to keep working: the fear of lost income; the fear that no one will ever again refer to an ill psychologist once the word gets out; the loss of privacy in dealing with illness in one's own idiosyncratic way if illness is acknowledged and disclosed; and the belief that recovery will go better if a sense of usefulness and power is ensured. But there are other stories that have to be recognized too: of patients who only discover that their therapist has been suffering from serious heart disease upon notification of the therapist's death (and, at times, with terrible irony, these are patients with histories of traumatic loss); of patients becoming terribly destabilized when they arrive for an appointment and discover at one fell swoop that their psychologist is wearing a wig and that she is undergoing chemotherapy; of patients whose inquiries about the apparent poor health of their psychologist are met with denial or mystification. There is much clinical complexity with regard to these scenarios, and no unilateral clinical truth to endorse, but a discussion of the ethical complexities that emerge when a psychologist becomes ill is an important dimension of this situation to examine. Three ethical issues seem to be the most salient in this situation: Informed Consent; Competence; and Provision for Continuity of Services.  

Informed Consent

     According to the Ethical Principles of Psychologists and Code of Conduct 2002 (APA, 2002), psychologists are obliged to provide information to therapy patients about "the nature and anticipated course" of the treatment "as early as is feasible in the therapeutic relationship" (Standard 10.01). We can extrapolate from this principle to consider the ethical aspects of the issue of whether or not an ill psychologist should disclose information about their illness to a patient. There is a diversity of opinion about this from a clinical perspective. Some address the psychologist-centered perspective of whether or not an ill psychologist is owed privacy and self-protection in meeting the demands of their situation (Barbanel, 1989). Others contend that disclosure of this kind of information burdens the patient and interferes with their treatment, particularly if one aspires to create an atmosphere of neutrality, and that ill therapists are too much in the grip of countertransferential strain to sort out effectively which patients would be helped versus harmed by this kind of disclosure (Abend, 1990). Some psychoanalytic writers advocate taking a case-by-case approach in deciding whom to tell (Dewald, 1990). There are others who feel that this kind of disclosure is inevitable given that the therapist's illness will invariably come to color the work (Pizer, 1997), and others who feel that intentional disclosure offers many benefits to patients including appreciation of their abilities to reciprocate empathic and reparative intentions (Hoffman, 2000). I believe that a psychologist's work is always affected in known and unknown ways when they are ill. Disclosure allows for direct interpersonal negotiation and intrapsychic exploration of the effects of that variable; however, there are some patients who prefer that this kind of material is not overtly discussed, and we have to be flexible about how we work.

Competence

     In the Competence section of the Ethical Principles, Standard 2.06 (Personal Problems and Conflicts), indicates that psychologists should restrict their activities in areas in which personal problems will compromise their competence; and that they obtain consultation when they become aware of problems that may interfere with their work performance. Similarly, in the General Principles, under the Principle of Beneficence and Nonmaleficence, there is specific call for psychologists to remain aware of the impact of their own mental and physical health on their capacity to help.

     The ability of psychologists who are physically ill to be competent professionals, in general, is obviously not in question. Amy Lichtblau Morrison (1990, 1997), a clinician who maintained a practice while living with metastatic breast cancer for 10 years, wrote compellingly of the many ways in which her experience enriched her attunement to her patients and sharpened her acumen in helping patients struggle with unresolved separations and loss. Ann-Louise Schlessinger Silver (1990), a psychiatrist at Chestnut Lodge who struggled with cancer, and Irwin Hoffman (2000), a Relational analyst who underwent coronary bypass surgery, also write about the possibilities for interpersonal and intrapsychic transformation in patients who deal directly with the implications of the serious illness of their therapists.   However, all of these clinicians had regular consultation available to them.

     There are so many opportunities for bias and blind spots when a working psychologist is contending with illness because the experience is so potentially overwhelming. Psychoanalytic writers suggest that we all have the inclination to regress under the strain of illness, and defenses such as denial and omnipotence, and problematic affects like shame, guilt, and envy can shape our work (Halpert, 1982). When patients know of the psychologist's illness, their potential responses -anger, terror, indifference, flight-can also tax an already overwhelmed clinician. Supervision and consultation are invaluable in trying to respond in ways that take both the clinical needs of the patient and the personal needs of the psychologist into consideration.

Provision for Continuity of Services

     The ethics code requires us to make plans for patient care and transfer of services in the event of possibilities we all dread: withdrawal from practice due to illness, sudden disability, or death (Standard 3.12, Interruption of Psychological Services; Standard 6.02, Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work; Standard 10.09, Interruption of Therapy).

     Professional wills offer a means for addressing these possibilities. They offer plans and instructions for taking care of patients; provide information on the location of important files and professional resources; and designate colleagues to take over in the event of one's disability or death. There are a number of resources for creating professional wills (De Angelis, 2008; Pope & Vasquez, 2005).

     The reports of therapists who have worked with patients whose previous therapists died over the course of treatment offer some useful perspectives on patient care (Ziman-Tobin, 1989). These writers recommend that a "Bridge Therapist" be designated who makes contact with the therapist's patients when the therapist dies, offers them crisis sessions, and helps them find another therapist should they choose this.

     All of these issues are complicated and delicate for everyone concerned. The availability of a Colleague Assistance Program and of professional consultation can help to make a painful and sometimes lonely professional situation less isolating and overwhelming.

References

Abend, S.M. (1990). Serious illness in the analyst: Countertransference considerations. In H.J Schwartz & A.S. Silver (Eds.), Illness in the analyst: Implications for the treatment relationship (pp.99-113). New York: International Universities Press.

American Psychological Association (2002). Ethical Principles for Psychologists. Washington, D.C. Available on line www.apa.org/ethics.

Barbanel, L. (1989). Introduction to The Death of the Psychoanalyst (Panel Presentation). Contemporary Psych., 25(3), 412-419.

Dattner, R. (1989). On the death of the analyst: A review. Contemporary Psychoanalysis, 25(3), 419-427.

DeAngelis, T. (2008). How to prepare for the unexpected. Monitor on Psychology, 39(6), 50-52.

Dewald, P.A. (1990). Serious illness in the analyst: Transference, countertransference, and reality responses-and further reflections. In H.J. Schwartz & A.S. Silver (Eds.), llness in the analyst: Implications for the treatment relationship (pp.75-98), New York: International Universities Press.

Edmundson, M. (2007). The death of Sigmund Freud: The legacy of his last days. New York: Bloomsbury USA.

Halpert, E. (1982). When the analyst is chronically ill or dying. Psychoanalytic Quarterly, 51, 372-389.

Hoffman. I. Z. (2000). At death's door: Therapists and patients as agents. Psychoanalytic Dialogues, 10(6), 823-846.

Morrison, A. L. (1997). Ten years of doing psychotherapy while living with a life-threatening illness: Self -disclosure and other ramifications.

Psychoanalytic Dialogues, 7, 225-241,

Pizer, B. (1997). When the analyst is ill: Dimensions of self-disclosure. Psychoanalytic Quarterly, 66, 450-469.

Pope, K.S. & Vasquez, M. J. T. (2005). How to survive and thrive as a therapist. Washington D.C.: American Psych. Association.

Schwartz, H.J. (1990). Illness in the doctor: Implications for the psychoanalytic process. In H.J. Schwartz & A. S. Silver (Eds.), Illness in the analyst: Implications for the treatment relationship (pp. 115-149), New York: International Universities Press.    

Silver, A. S. (1990). Resuming the work with a life-threatening illness - and further  reflections. In H.J. Schwartz & A. S. Silver (Eds.), Illness in the analyst: Implications for the treatment relationship (pp.151-176), New York: International Universities Press.

Ziman-Tobin, P. (1989). Consultation as a bridging function. Contemporary Psychoanalysis, 25(3), 432-438.

Meet Our Faculty: Richard Reichbart, PhD

I have been asked to write something personal about myself as a faculty member of CPPNJ, and so I will try to tell the somewhat wandering story of how I came to be a psychoanalyst. I do so with trepidation, for although our very profession began with an act of self-revelation in the Interpretation of Dreams, we have since been taught a "blank screen" way of speaking about ourselves (supposedly so our patients do not know too much of us) which I sometimes think borders on self-abnegation, but which is generally the approved way of doing things.

I have practiced in Ridgewood for 25 years. Whenever a psychoanalytic patient graces me with her narrative, I marvel at the adventures that brought me here.

I was raised when quite young in a small town (less than 800 people in the winter) in the high Adirondacks, where my grandfather, a country doctor, and my grandmother, a country dentist - both originally from Riga, Latvia -- lived and practiced and to which I frequently returned in the summers. For my elementary and high school years, I lived in Manhattan. Perhaps it was this dichotomy between city and country, perhaps it was my experience of a black maid when I was a child, or perhaps it was the decidedly liberal leanings of my parents -- but regardless, I always have been fascinated by different cultures and their formative effect upon people and always moved by a sense of justice for people in general.

But I did not begin with any particular interest in psychology much less psychoanalysis. In fact, although intellectual and knowledgeable, my parents thought psychoanalysis was not a profession to pursue. As a young adult, my interests were varied - at one point medicine, then art and creative writing and anthropology. After graduation from Yale College, I ended up at the University of California at Berkeley in playwriting, and became involved in and arrested in the Free Speech Movement in late 1964. From there, with some detours, I went down south where for one long summer I was on the staff of the Southern Christian Leadership Council, Martin Luther King's organization, and in charge of civil rights workers in Peach County, Georgia. I lived and worked in a small southern town, Fort Valley, for part of that time: an experience which to this day has influenced me greatly.  

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By Harlene Goldschmidt, PhD

Antonio Damasio's recent book, Self Comes to Mind: Constructing the Conscious Brain (2010), inspired three members of the Neuro-Psychoanalysis reading group to prepare a review essay of it for The Psychoanalytic Quarterly. With the guidance and experience of Martin Silverman and Debi Roelke, we set out to summarize and critique a cutting edge book that addresses the role of emotions in generating the evolution of the human consciousness. Most of the books selected for our reading group have been written by psychotherapists who have acquired advanced knowledge of neuroscience. Damasio's book, however, was written by a neurologist rather than by a therapist. That he comes to some of the same time-honored views that are held by psychodynamic psychotherapists is validating and gratifying. His main point is that feelings are integral to human consciousness and shape our human psychological experience. Without feelings there would be no consciousness.

After some back and forth discussion, we decided to title our review essay "Sentio Ergo Cogito"- "I feel, therefore I think." This is a reference, in part, to an earlier book by Damasio, Decartes' Error: Emotion, Reason, and the Human Brain (1994). As his titles suggest, Damasio sees continuity in self, mind, emotion, and body rather than subscribing to a false mind/body dichotomy. He takes issue in both books with the historical neglect of emotion as an essential focus of neurological research.

For the inquiring psychoanalyst, Self Comes to Mind offers certain neurological parallels to Freud's division of the mind into Id, Ego, and Super-Ego. Damasio describes an Id-like, drive-based, somatic Protoself, operating in the brain stem and primitive cortex, that generates emotions which are expressed outside of psychological representation, and an Ego-like, somato-psychic Core Self, that observes and appraises the world around and within us, and even more importantly, studies our interaction with that world in order to decide what succeeds more or less successfully and what does not. As the complexity of memory and experience builds, a truly psychological Autobiographical Self emerges that examines past and current functioning and mediates anticipation and planning for the future. The activity of this over-arching agency is reminiscent of Freud's concept of a Super-Ego. Damasio also provides a neurological basis for Freud's emphasis on defense and on the importance of conflict among different components of the psyche. He states, for example, that: "Increased cognitive demands have made the interplay between the cortex and the brain stem a bit rough and brutal, or to put it in kinder words, they have made the access to the wellspring of feeling more difficult (p.251)."

Authors like Antonio Damasio are helping to build bridges between psychoanalytic therapists and the researchers who yearn for a fuller understanding of the neurological basis of our conscious and unconscious, mental and emotional functioning. Damasio deserves credit for being quite accessible, clear, and comprehensive as he presents the extremely complex information that is contained in his books. The reader of his books is rewarded by obtaining a deeper understanding of feeling, thinking, and the emergence of self within the context of our multi-factorial neurological, emotional, and bodily dimensions.

Daniel Hill, PhD

CPPNJ hosted Daniel Hill, PhD from PsyBC for Part 2 of his presentation on "Attachment Theory and Affect Regulation-Treatment Applications" on Saturday, March 16, 2013 at Fairleigh Dickinson University. Dr. Hill focused on the period of human development between 10 and 18 months. He described the evolution of primary affect during this time-emphasizing the right brain with its limbic system as coming on line through the caregiver's nonverbal communication of affect. He gave a treatment parallel describing attunement as the way a therapist is with a patient. He stated that the therapist's ability to be attuned to affect is especially useful when the patient's affect is dissociated and needs the therapist to pick it up and amplify it.

According to Professor Hill, the primary function of the early attachment figure is to regulate the infant. Since the survival of the infant requires that he/she adapt to the emotional style of the caregiver, the attachment relationship shapes the regulation of primary affect in the developing child. Managing the affect of shame can be seen as the central regulatory problem faced by the infant. Dr. Hill described shame as the wish to hide and indicated that it results in a state of metabolic collapse in which the heart rate drops precipitously-the freeze response.

Dr. Hill described right brain processes as forming a "gestalt". In contrast, he noted that the left brain, which comes on board at around age 2, processes information in a linear fashion and leaves out context. He concludes that treatment needs to encompass   both right and left brain activity. This is especially the case with a relational approach. As we engage our patients, we help them explore their own minds and the minds of others. This requires that we help to regulate the patient nonverbally by keeping ourselves regulated.

As a metaphor for the relationship between right and left brain activity which is well integrated, or not-- Professor Hill recommended a book by Iain McGilchrist entitled The Master and his Emissary. It tells the story of the "divided brain and the making of the Western world."

Dr. Hill credited Allen Schore with the formulation of Modern Attachment Theory. Schore speaks of the "relational unconscious" and states of "bodymind" (comparable to "self states"), which are more or less integrated depending on the basic attachment patterns that have emerged. Insecure attachment patterns are correlated with disorders of affect regulation and lead to negative expectations in life.

Specifically, the narcissistic character disorders are linked with both preoccupied and avoidant attachment patterns.   "Uninhibited" narcissism shows itself in hyperaroused dissociation and the search for mirroring, while "inhibited" narcissism presents with hypoaroused dissociation and the withholding of attention. Both are considered to be the "structured insecure"- because they have a strategy for maintaining safety with a caregiver, whereas the individuals who display "disorganized attachment" have coping mechanisms are that are unstructured and chaotic. Borderline personality disorder has been linked to disorganized attachment.

As time ran out, Dr. Hill invited further questions and was quickly surrounded by a group of enthusiastic participants. Perhaps there will be more to come...

By Ruth Lijtmaer, PhD 

Nina Williams, PsyD

On March 10, Nina Williams, PsyD, faculty member at CPPNJ and an innovator in sex education for nearly twenty years, presented a thought provoking workshop based on the trilogy of books and their focus on the erotic and emotional experiences of dominance and submission.  Unlike the secrecy surrounding the popularity of previous books on the subject, these books have become part of the cultural mainstream.

Dr. Williams started the talk indicating how these series are being described as "mommy porn." However, in her research she found that 90% of the readers are females of all ages.  This series became a "best seller" before it was published as it started on-line. It also stayed on the "best sellers" list for a year. In terms of technology, the search "50 Shades of Grey" got 81 million hits. These books also increased sales for sex shops. At that point in the presentation, Dr. Williams showed an amusing Amazon commercial for Mother's Day in which mothers were reading the book and "got caught" doing it.  Dr. Williams indicated that BDSM (bondage, dominance, submission and masochism) and sadomasochism) are topics implicit in the books.

Dr. Williams raised some questions throughout her presentation that were discussed with audience participation. The first question concerned why the books were so popular.  She explained that Fifty Shades of Grey (FSOG) was originally on-line fan fiction of the popular series Twilight.  She compared the books with romance novels, noting that readership of romance novels was almost as large as consumption of on-line pornography. 
 
The second question was: What do women in particular like about the book? The audience described a range of responses from  enjoying the book's depiction of an evolving relationship, to appreciating the sexual exploration for its erotic potential to the popularity indicating a growing comfort with the public acknowledgement of private matters.  Some in the audience indicated how difficult it to admit that they liked the books for fear of exposure and embarrassment while younger commenters didn't regard the content as particularly lewd because they had longer access to a wider range of sexual content via the internet, Dr. Williams also mentioned two contrasting viewpoints:  (1) As women have more power in the outside world, they have tired of their independence and long to surrender  and (2) As woman have more power, it becomes safer for women to explore sexual submission because they no longer need to fear gender inequality.

The third question followed on this reasoning:  As gender equality increases and more trust between man and woman develops, are we destined to become more kinkier?  One unknown is the reason many men resist reading this book, despite its potential for describing "what women want."

Dr. Williams summarized the on-line BDSM community's concern that the relationship depicted in FSOG, which practitioners describe as unhealthy, will mislead the public about these practices.  BDSM conventions of  clear verbal negotiations of limits are not followed in the books.  One member of the audience brought up the topic of domestic violence and how she had mixed feelings about recommending the books to her abused female patients because the hero of the novel behaves dangerously.

The last point was directed to us as psychoanalysts and clinicians.   Referring to Dimen's argument that psychoanalysis either domesticates or demonizes perversion, Dr. Williams pointed out while the topic matter of the books may shock some readers, the outcome of the story is that the sadomasochistic desires of Christian Grey are ultimately dominated by Anastasia Steele, who wins him over to a traditional version of committed love.

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