(Bolstered by Soren Kirkegaard’s lament that “ours is a paltry age because it lacks passion,” Dr. Alan Karbelnig writes this regular column to provoke thoughtful reaction from his colleagues. He practices psychoanalytic psychotherapy and forensic psychology in South Pasadena.)

In some unknown but dramatic way, I must have felt vulnerable the day I was suddenly crushed by counter-transference. I was obsessing about a new sports coat I’d just bought at Barney’s. It has Cashmere in it. I’ve never had a coat with Cashmere in it. I purposefully donned the jacket, and even a flashy orange tie, in preparation for the meeting with a new patient. The referral source told me he was an authoritarian, successful physician who had strayed in his relationship with his wife and strained the trust of his partners.

Just as I feared, the man proved to be “Mr. Perfection” himself. Aged around 40, 6’4” tall, sun-tanned and muscular, highly-educated and even better-compensated, articulate and charming—he was a perfect male specimen. And he was wearing a sports coat five times more expensive and ten times better-looking than mine. Worse, just as I prepared to hide behind my well-rehearsed professional role, Mr. Perfection hands me my signed informed consent form, downloaded from my website. He had attached a check for $1000 so he could “buy a number of sessions in advance.”

Reflexively I accepted the check and, in my best pre-adolescent voice, squeaked out my standard line, “Tell me something of what brings you and I’ll tell you about me and how I work.” He proffered various confessions, but they sounded more like conquests than failures. He showed little guilt or shame about his ethical breaches, and no anxiety or depression.

The first half hour was unbearable. I was drowning in feelings of inadequacy the likes of which I hadn’t felt for 45 years. I was in recess in elementary school, skinny and sickly. I was small weak unintelligent out of shape ignorant and even poor. He was so good-looking that I wondered if I was having homosexual longings. It wasn’t clear who was the patient and who the doctor.

Then, slowly, a few ideas broke loose from the swarm of self-doubt. He was no psychopath, but he clearly demonstrated that concept of externalization so popular in academic psychology these days. Rather than look inward at his intra-psychic dramas, he enacted them in the outside world. He was seeking my help because of problematic ethics, I told him, not because of mental pain. He admitted that, like a slight aching in a distant limb, he could feel guilt at the pain he’d caused his wife and partners only minimally. And even that discomfort was absorbed by the externalizing behavior of consulting me: he was seeking help, after all; he was actively solving the problem.

As we talked my gaze fell upon the informed consent form lying on my ottoman with the check neatly clipped onto it. Because he had paid for a number of sessions in advance, I suddenly realized that I was in truth indebted to him. He had turned the tables on me. Classic for those who externalize rather than internalize: he had projected the entirety of his vulnerability into me.

Adrenaline rushed through my system, and strength returned to my muscles (well, kind of). The dynamics suddenly became clear! Mr. Perfection here, just another wounded human being like all of us, had managed brilliantly to transform his internal emotional world entirely into external action. He had left no small number of burning wrecks in his past in the form of ill-informed patients, envious colleagues, cheated wives, and wounded children.  We had some serious work to do, and now I was finally engaged in it with him.

Counter-transference is always an interpersonal process, with your fault lines intersecting with your patient’s. Identifying these subtle reactive feelings ideally helps guide your work. But sometimes these feelings transport you to shadowy spaces long forgotten. My brilliant Mr. Perfection, with his dulcet voice and smooth rhetoric, carried me right back to painful elementary school years.  That Barney’s sports coat really was absurdly overpriced – all that Cashmere for protection against nothing.

The End

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Confusions of Freedom

April 20, 2009

(Bolstered by Soren Kirkegaard’s lament that “ours is a paltry age because it lacks passion,” Dr. Alan Karbelnig writes this regular column to provoke thoughtful reaction from his SGVPA colleagues. He has been a member of SGVPA since 1988, and served as its president in the early 1990s; he has chaired the SGVPA Ethics Committee for 14 years. Alan is a Training and Supervising psychoanalyst at the New Center for Psychoanalysis and the Newport Psychoanalytic Institute. He practices psychoanalytic psychotherapy and forensic psychology in South Pasadena.)

Although it may sound idealistic or even grandiose, the heart of our work as psychotherapists lies in enhancing freedom. More specifically, it lies in expanding freedom of choice. We help liberate persons from self-deception, from tyrannical internal dramas, or even from painful academic, occupational, or interpersonal situations.

The unfortunate name for our endeavor, “psycho-therapy,” implies a discrete entity, the “psyche,” for which a specific intervention, the “therapy,” is provided. This grossly distorts the truth of the matter. The psyche, unlike any other entity to which “treatment” is applied, arises only partially from the biological substrate; it also emerges from such non-material factors as early social relations, culture, language, and socio-economic status. Therefore, ethics and politics, and therefore ideas like freedom, lie at the core of the psyche. Comparing “therapy” for the psyche to “therapy” for muscle pain is patently absurd. The variables affecting the psyche approach the infinite; biological systems clearly predominate in the case of a strained muscle.

Whether patients are highly regressed or extremely mature, we psychologists strive to increase their autonomy. In cases of acutely distressed psychotic persons, for example, we tend to be more active, focusing on reducing distress and improving coping capacity. We might even work on basic activities of living and medication compliance. But we are still striving to increase their autonomy. With highly functional persons, the “problems” for which they seek assistance, whether depression, anxiety, substance abuse, or whatever, also cause restrictions in freedom. While we are of course working to reduce their pain, we are also helping them to freely be themselves, to get out of their own way, and to take actions like improving friendships, obtaining exercise, seeking spiritual solace – all intended to improve the quality and meaning of their lives. We build autonomy and thus greater freedom of choice.

This focus on freedom creates paradoxical problems for psychotherapists as licensed professionals. Due to the laws governing the practice of psychology, and to our society’s litigation-proneness, excessive responsibility falls on psychologists. For example, in accordance with the Tarasoff precedent, we psychologists must protect potential victims of violence. Since the Goldstein v. Ewing case, we must also now consider not only information from patients, but what we learn from patients’ friends or families. We risk being sued or imprisoned if we fail to do so. We have become agents of the state.

Or consider, more benignly, psychologists whose outgoing voice mail messages instruct callers to phone 911 in case of medical emergency. These messages insult the callers, and treat them as if they have no autonomy. They incessantly remind them of what an average two-year old knows: Call 911 or go to an emergency room if you are acutely ill!

These conflicts between the autonomy-enhancing role of psychologists, and the protection of society as a whole, require ongoing and serious consideration. Psychologists have been mandated reporters of child abuse since the 1970’s – another way they serve as agents of the state. But this is not without other societal consequences. Many child abusers, pedophiles, and others who prey on vulnerable children now avoid seeking help from psychotherapists. They view us, correctly, as informants. State legislators now contemplate making domestic violence a mandated reportable event. Where will it stop? Will we be required to summon the police the next time adolescents advise us they are smoking Marijuana?

This dilemma was brilliantly addressed centuries ago by the motto of the French revolution: Liberty, Equality, and Fraternity. Be all that you can be (liberty), be considerate of others as you do so (equality), and remember that we are all in this together (fraternity). In applying our method of enhancing personal freedom, we psychotherapists will always be emphasizing liberty for individuals, within their particular social context. Certainly we do our work in a broader societal context but, in the final analysis, our loyalty lies to the agency of the person, not of the state.

(Bolstered by Soren Kirkegaard’s lament that “ours is a paltry age because it lacks passion,” Dr. Alan Karbelnig writes this regular column to provoke thoughtful reaction from his SGVPA colleagues. He has been a member of SGVPA since 1988, and served as its president in the early 1990s; he has chaired the SGVPA Ethics Committee for 14 years. Alan is a Training and Supervising psychoanalyst at the New Center for Psychoanalysis and the Newport Psychoanalytic Institute. He practices psychoanalytic psychotherapy and forensic psychology in South Pasadena.)

As if finding true individuality weren’t difficult enough, Derrida, Foucault, and other post-modernists make discovery of the “real you” near-impossible. They suggest that individuality cannot exist free from the influence of the “other.” The search for individuality, however intense, requires an equally passionate understanding of what French psychoanalyst Jacques Lacan terms the “Big Other” – a subtle set of rules, encoded in language, encoded in the culture, that influences how we view self and other. The Big Other manifests like an over-riding internal object, similar to the Freudian superego, but bigger, more diffuse, more subtle, and more a function of culture.

In the world of object relations, the concept of a “dynamic structure” speaks to the same phenomenon, but on a smaller scale. W.R.D. Fairbairn, the Scottish psychoanalyst who proposed this unique idea, believed that representations of self are always linked with representations of other. If we feel proud of our work after a particular psychotherapy session, “internal objects” applaud while parts of our “egos” or selves experience a feeling of success. The concept of the dynamic structure was a key development in the history of psychoanalysis, but does not go far enough because it ignores culture.

The Big Other incorporates culture, or even God, and affects us in any number of positive or negative ways. For example, the Big Other beckons unknowingly when someone reaches out to shake our hand, and we reach out ours in return. The Big Other lies behind any number of ethical behaviors, from making coffee for our suitemates to calling them when patients appear in the waiting room at the wrong time. Derrida considers God to be the “transcendent signifier” or the ultimate “Big Other.” If we resist our impulse to murder our suitemate, we are likely responding to an injunction, as Derrida would say, from the Big Other.

Now the Big Other also influences behavior in less positive ways. It motivates us to purchase unneeded items because of a shared cultural belief that we’ll feel more fulfilled after doing so. It may cause us to feel irresistibly drawn to eat at a new restaurant, or see a particular movie, just because we’ve heard “critics” or friends rave about them. (Critics themselves, who are nothing more than other individuals, serve a powerful if absurd Big Other function).

But the presence of the Big Other may be way more subtle and unpredictable. At a recent holiday open-house, a colleague whom I’ll call Jonah found himself talking to a female of easy wit and sparkle. Despite his staunch commitment to marital rectitude – he is, as some would say, very married – he was irresistibly, passionately, dangerously drawn to this enchanting woman who was not his wife. But suddenly Jonah crashed to earth. Not because he recovered his sense of propriety or moral equilibrium. No. The encounter terminated when the future love of the rest of his life announced that she was building a second home in Boston – a city Jonah despises with mythic, pathological loathing. He clings to this deranged repugnance for a city that’s no more or less hateful than any other city or town. Here the Big Other manifests as Boston, and in an immense way. Reeling with alienation, Jonah abandoned his ex-future-wife and headed for the wine table (which promised yet another Big Other experience).

The Big Other will always exist, in one form or another, and will always play a major role in our behavior. Individuality can only be found nested within it. But interior “Bostons” can also be stifling (even though, ironically, Jonah’s Boston may have saved his marriage!). Such versions of Big Others inhibit us, create anxiety, confusion, ambivalence. They block the path towards authenticity; they prevent us from heeding the Greek poet Pindar’s injunction to “be who we are.” We must keep searching for individuality anyway. After all, no one from the ancient Greeks to those French postmodern guys ever said this crazy search for self was for the faint of heart.

Obsessive Ruminations #4

(Bolstered by Soren Kirkegaard’s lament that “ours is a paltry age because it lacks passion,” Dr. Alan Karbelnig writes this regular column to provoke thoughtful reaction from his SGVPA colleagues. He has been a member of SGVPA since 1988, and served as its president in the early 1990s; he has chaired the SGVPA Ethics Committee for 14 years. Alan is a Training and Supervising psychoanalyst at the New Center for Psychoanalysis and the Newport Psychoanalytic Institute. He practices psychoanalytic psychotherapy and forensic psychology in South Pasadena.)

As they enter the consulting room for their first meeting with a person, psychotherapists should feel terrified. They enter the room with, well, nothing. They carry no technical devices. Unlike physicians, who have any number of tools from blood pressure cuffs to electrocardiographic machines, psychotherapists have only themselves. Unlike attorneys, who take notes, refer to legal authorities, and compose official documents, psychotherapists offer only ideas and emotional responses. They present in an exposed state; they carry only their inherited or learned psycho-biology and their knowledge of whomever of the various theorists they have found the most influential.

This nakedness notwithstanding, persons seeking the services of psychotherapists arrive with expectations, even demands. They complain of stale marriages, paralyzed employment situations, or painful emotional states. They request solutions and relief. They insist their psychotherapists take action. This combination of demand, on the one hand, and lack of technology, on the other, creates unease if not abject anxiety in psychotherapists – particularly in the early stages of their work.

How do they then cope with such vulnerability? Some psychotherapists take refuge in dogmatic theoretical approaches. For example, if they have the conviction that all psychopathology results from pent-up aggression and envy, they will view problems exclusively through this lens. If they believe that failures of empathy are the cornerstones of psychological difficulties, they will conclude that emotional troubles result solely from interpersonal deprivation. And so on.

At the other end of a continuum, some psychotherapists eschew theory, and practice some variety of “rent-a-friend.” As one colleague put it, somewhat crassly, psychotherapy is “a love affair without the affair.” Perhaps these psychotherapists are helpful, but they run serious risk of violating the patient, crossing boundaries, or otherwise failing to adhere to the fiduciary aspect of the psychotherapeutic contract. “Patients” are paying a fee for a service, and if only love and friendship are provided, their “sessions” smack of a variant of prostitution.

Striving to find the “middle zone” between these two extremes, psychotherapists face incredible complexity and uncertainty. Even within the confines of the psychoanalytic model, for example, wide variance in theory exists. Different theorists hold that psychopathology results from deficits in maternal care, from intra-psychic conflicts, from unresolved Oedipal complexes, from pent-up aggression and envy, from repressed sexual urges, from existential concerns like fear of death, or from primitive mental states characterized by excessive splitting and projective identification.

Ideally, all these variants should not be causes of anxiety but embraced as part of the beauty and fullness of human experience that psychotherapy uniquely mediate. Psychotherapists do face incredible ambiguity. They should feel awed and humble. They err if they are too rigid in theory; they err if they are too loose. They must struggle to find their way between these two extremes – all the while keeping an open a mind.

But keeping an open mind is anything but easy, particularly when feeling uncomfortable. G. K. Chesterson once wrote that “an open mind is like an open mouth, it looks for something hard to bite into.” Psychotherapists must avoid biting into anything hard. In his recent book called The Black Swan, Nassim Taleb describes theory as “like medicine (or government): often useless, sometimes necessary, always self-serving, and on occasion lethal.” He suggested that theory “be used with care, moderation, and close adult supervision.”

Hopefully, psychotherapists cherish the mystery of the persons who sit before them. Hopefully, they strive to understand what they speak, feel, or display, and then respond in a unique fashion. And as they navigate through the clouds on their lonely journey towards helping others, they can ultimately rely only on this: Their own sense of integrity.

Obsessive Ruminations #1

(Dr. Alan Karbelnig, who quietly slipped into his 50s last year and lost all decorum in the process, writes this regular column to provoke reaction from his SGVPA colleagues. Bolstered by Soren Kirkegaard’s lament that “ours is a paltry age because it lacks passion,” Alan strives to avoid the pablum that characterizes most professional newsletters, and instead strives to serve up more zesty reading. Regarding his professional career, Alan is a long time member of the SGVPA, having served as president in the early 1990s; he has chaired the SGVPA Ethics Committee for the last decade. He practices clinical psychology, psychoanalysis, and forensic psychology in South Pasadena.)

I recently had lunch with two of my illustrious SGVPA colleagues who, in the course of discussing their clinical work, used words such as “attachment,” “affective attunement,” “activation,” and “dysregulation” repeatedly. I understood what they meant. They were describing the phenomena of being close to other persons, of resonating with them, of becoming excited, and of feeling overwhelmed. After lunch I returned to the office perturbed. My fellow practitioners know these words trouble me. Maybe they use them with more vigor when I’m around to demonstrate their attachment or attunement to me. Maybe they want to get me activated. But this time I just felt like shouting. I offer this rant for the SGVPA newsletter instead.

In the middle part of the last century, the psychoanalytic lexicon was rife with earlier versions of these words. Had you dined with psychoanalysts in, say, 1955, you would have heard about patients’ cathexis to their analysts, or about their ego weaknesses, or about the corruption of their superegos. If the patients were particularly emotional, perhaps you would have heard them described as overwhelmed by Id impulses that had perforated their repression barriers, over-riding proper ego functioning.

I suppose such language may suffice for communication between professionals, and therefore I should not be so dysregulated by it. But as Thomas Szasz used to say, we psychotherapists need to be careful not to literalize our metaphors. These interesting words – then and now – are chock-full of mechanistic, post-Enlightenment ideology. Used without caution – and this is the danger Szasz alludes to—these terms can violate sanctity of the human subjects who engage us in our consulting rooms. No disrespect to the Age of Reason, but our patients are not motorized contrivances we can deconstruct with a Newtonian calculus. They exist as real, fleshy, sentient human beings experiencing a near-infinite range of sensations, thoughts, feelings, and images, all of which swirl around in inter-relationship with one another, never to be reduced to finite categories. These persons demand to be received in all of their complexity and fullness

Attachment, a horrible word, sounds like a button, or a snap, or a piece of Velcro. What if, instead of affective attunement, we think about being present, as completely as possible, to the being of the person meeting with us? Attunement sounds like a melody produced by a mouth harp, or an mp3 file. Perhaps we could just strive to “be” ourselves instead of being attuned. Perhaps we could flow with others’ words, thoughts, fantasies, images, and feelings. The same holds true for “activation” or “dysregulation,” terms suggesting that a hose attached to your cooling system has come loose. These “technical” phrases are too constrictive as well as too robotic to describe the complexities of the human experience

Samuel Johnson once said that all professions are conspiracies against the public, and I suppose these automaton-like words represent part of the conspiracy of professional psychology. We take the intense richness of human experience and reduce it to a few scientific-sounding categories. That way we can design studies, pretending that we work in a branch of the natural sciences. We can imagine a human person reduced to a set of internal regulatory mechanisms that we can then “treat” according to certain algorithms that emerge from our studies. We can simply ignore the impossible richness of the living subject who will forever lie beyond our categories.

I am of course just as guilty as many of my colleagues. Since I also do some psychological assessment, perhaps I don’t notice my own use of terms such as “behavioral control,” “affect modulation,” or one of my favorites from the Rorschach, “a tendency to abuse fantasy.” I obviously like the phrase “obsessive ruminations,” which of course is also the title of this column, but maybe “ranting” would be more precise, especially if followed by an exclamation point!

So we should persist in our conspiracy, as we must, but since the real human experience is the focus of our profession, I think it would behoove all of us to remember that metaphor is metaphor, and that people live in a real experiential world of language and imagery and feeling. I enjoyed lunch with my distinguished SGVPA peers. I certainly came away feeling peeved, but neither activated nor dysregulated.