The Emerging Of A Psychiatrist 2022

Peter Jay Stein, MD, MA

 

1. Exposed to Freud at the age of 13, I acquired an unofficial version of a Freud text, Dream Psychology (1920), a book found in a carton of books, purchased by my parents for 25 cents, at a Saturday night auction, in the Catskills.

 

2. Freud had reportedly written and published this text as a follow-up summary for the lay public, to his earlier monumental work on dreams, published in 1900.

 

3. In this hard-covered, dusty edition, serendipitously discovered in a carton by a boy at the height of puberty (me), Freud expressed certainty about the meaning of a woman’s tilted hat, which he surmised was a disguised symbol of a penis and testes, i.e., the male genitalia (p. 118).

 

4. In Freud's sensual references, and in the sheer boldness of his penetrating interpretations, he had discovered the existence of repression and formulated its mechanism of action, this "incapacity of consciousness" (ibid, p. 59), that runs "counter-current" to concerns of which one is consciously aware, non-conscious concerns which one is compelled to deny.

 

5. Freud postulated that "the most intelligible and meaningful dreams are unrealized desires" (ibid, p. 61), as are the more obscure and intricate dreams, but where, in the latter, the conflictual desires are made unrecognizable to one's conscious awareness.

 

6. Freud discovered how to recognize the unrecognizable, the often hidden, inner struggle against one's recognizing one's own longings; and he formulated how the dreamwork serves to smooth out inconsistencies of logic, and to preserve one's self-esteem.

 

7. The brilliance of the dreamwork thus erects a masterful defensive barrier, whereby one's reality-testing is compromised, i.e., painful or unacceptable truths about the self remain undiscovered or dissociated, camouflaged within the lattices of the dynamic dream imagery.

 

8. In Studies On Hysteria (Freud, S., Breuer, J., 1895), written and published prior to The Interpretation of Dreams (Freud, S., 1900), Freud was fiercely determined to piece together these disparate clues from uncharted waters, using his singular originality and intellect, to synthesize his incisive observations into the most remarkable set of evolving theories ever imagined, in his attempts to liberate the human spirit, by identifying the uncomfortable truths of our clashing instincts.

 

9. Freud echoes this mighty battle, between the individual's repressed emotions, wishes, dreams, and longings, as they further clash with the demands of one's conscience, family, community, and culture, in Civilization and Its Discontents (1930).

 

10. Psychotherapy presumably helps the individual to recognize and reconcile such clashing issues, to find a healthy compromise solution to these often emotionally crippling, inner human conflicts, between being one's true self, versus a Self that conforms to the wishes and demands of one's conscience and of those around us.

 

11. The theme of the self-realization of desire is beautifully explored and expressed in the  Adam Phillips' book Becoming Freud - The Making of a Psychoanalyst (2014).

 

12.  a more contemporary conceptualization of  the term "neurosis", now discarded because of its lack of precision, suggests that unhappiness and anxiety originate not in the child's clashing instincts, but in his or her disguised emotions; desires for love and approval, as well as feelings of frustration and anger, must be camouflaged, in a rejecting, or dismissive, or indifferent, or hostile, or insensitive, or disapproving family environment; in other words: "...Affect replaced drives in our understanding of what contributes centrally to each individual's...unique...sense of selfhood..." (Teicholz, J.G., Psychoanalysis, Self and Context, p. 23, Jan. 2018).

 

13. A self-created, charade-like, emotional stance, the organized structures of meaning (Stolorow, et al, 1987, p. 36) initiated in infancy and early childhood, serves to preserve whatever loving bonds and feelings of safety exist within the caregiving milieu, usually a parent, to thereby avert the risks, dangers, and unsafe consequences of rejection, invalidation, denigration, humiliation, and dehumanization ('emotional retraumatization'), should the patient reveal too much of her authentic self (Stolorow, R., Atwood, G., Contexts of Being, 1992, pp. 31, 58; Orange, D., Atwood, G., Stolorow, R., Working Inter- subjectively, 1997, p. 76).

 

14. With the current understanding of human relational attachment dynamics, the concept of inborn, or 'pre-wired' instincts, in contemporary terms, are more intelligibly described as "motivational systems", i.e., a neurobiological readiness for safety and intimacy (attachment); for affiliation with others; for sensual pleasure; for playfulness and exploration; for caregiving; for physiological regulation (relief from hunger, thirst, illness, pain); and for avoidance of emotional discomfort (aversiveness) (Psychoanalysis and Motivational Systems - A New Look, Lichtenberg, J., Lachmann, F., Fosshage, J., 2010 - see p. 22, on this website).

 

15. In one's search to define personal truths, and to find clinically sound, psychotherapeutic principles, a nagging dread may persist, that one may never know enough.

 

16. A patient may present as a bewildering puzzle, each individual resembling an enigmatic foreign language, with a unique unconscious landscape.

 

17. Freud's language, translated into English, served to distance the patient from the clinician.

 

18. The usefulness of Freud's visionary metapsychology and mechanistic theoretical constructs, can feel foreign to one's immediate interpersonal experience.

 

19. The quest of a young psychiatrist is for groundedness, for  fundamental, intuitive, principles, something that would reliably guide the clinician through a therapeutic encounter.

 

20. There can be a drive to master an assortment of psychoanalytic dialects, and their technical applications.

 

21. Enigmatic, unfriendly, technical vocabularies, embedded in theories that stretch across the vast intellectual highway of the 20th century, can distance the clinician from his/her  feelings, and from his/her patients.

 

22. A technical language may seem necessary, as a means of communicating with colleagues, and objectively understanding a patient, i.e., a means of understanding dreams, conflicts, and needs, in the context of a plausible theory.

 

23. But ordinary observations of one's emotional reactions  have value, although one might fear that personal impressions would be criticized if not justified within a specific theoretical framework.

 

24. What had been deemed a proper attitude towards the patient was: to remain emotionally neutral, aloof, anonymous; to hide details of one's personal life; to not answer questions too directly, too readily, too hastily, too detailed, or too enthusiastically; to encourage the use of the couch, with minimal eye contact; to endure long silences; and to not reveal the specific manifestations of these struggles to colleagues, to therefore camouflage the content of the sessions, to avoid humiliation from self-exposure, if one's brand of relating-to-others did not coincide with an amorphous  set of professional boundaries.

 

25. Texts of Rubin and Gertrude Blanck built an edifice upon Mahler’s schemata (Blanck, R., Blanck, G., Ego Psychology, Theory and Practice, 1994, amongothers), and M. Mahler (The Psychological Birth of the Human Infant, 1975), described  the achievement of object constancy. Karen Horney’s masterpiece, Neurosis and Human Growth (Horney, K., 1950) depicts the suffering generated from self-hate, if one strays from perfection.

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26. The emergence of Self psychology and Intersubjectivity represented a sea change in the history of psychoanalytic psychology.

 

27. I was encouraged to be more “myself”, and to not defensively use my ‘expert’ role; it was suggested that: “...you don’t have to be Freud, or Walt Frasier...”.

 

28. a stance of authenticity emerged, which would best allow for the bonding of patient and therapist.

 

29. a specific "reified" theoretical framework, serves as a barrier to authentic emotional reactions.

 

30. A colleague  said: “...go with what the patient brings to the session...”, which was Bion's recommendation, to approach each session with "...neither memory nor desire..." (Mitchell & Black, Freud and Beyond, 1995, p. 108), and to thereby remain as authentic and open-minded as is reasonably possible.

 

31. the ascension of Heinz Kohut, the founder of Self psychology, (1913-1981), helped to alter the academic psychoanalytic landscape.

 

32. In his biography of Kohut (Strozier, C., Heinz Kohut, The Making of a Psychoanalyst, 2001), author Strozier writes that Kohut saw Freud only once, as Freud boarded a train, the Orient Express, headed for the safety of Paris, in June, 1938.

 

33. Kohut had gotten a glimpse of Freud through the train window, tipped his hat, and Freud graciously responded, an iconic moment for Kohut (ibid., p. 57-58). Subsequent to his emigration to the United States, Kohut became a leading authority on classical Freudian psychoanalysis, steeped in drive theory, prior to the gradual, progressive modifications in his perspective of a more subjectively oriented psychotherapeutic stance and frame of reference.

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34. Through the metamorphosis and continuing developmental evolution of his theorizing, Kohut emphasized that, with vicarious, empathic immersion into the subjectively experienced emotional life of the patient, i.e., the patient’s ‘self-experience’, the language used in clinical encounters must be the language of the patient’s subjectivity; the language of empirical science is counter-therapeutic, and serves to emotionally distance the clinician from the patient.

 

35. The concept of an allegience to the patient's subjectivity had also been emphasized for decades by the clinician, author, and teacher, Carl Rogers (1902-1987), in his client- centered approach (On Becoming a Person, 1961).

 

36. The Interpersonal School, described on page 24 of this website, with reference to the writings of Irwin Hirsch (The Interpersonal Tradition, The Origins of Psychoanalytic Subjectivity, Hirsch, I., 2015), provides further historical dimensions to the development of contemporary intersubjective concepts, illustrating how sometimes earlier ideas are independently rediscovered, but then thought to be original.

 

37. Contemporary authors and clinicians point to the 16th century genius, Rene Descartes, whose “Cartesian dualism” adversely affected the 400 year trajectory of Western science, in regards to railroading psychoanalysis and psychotherapy away from somatopsychic unity towards mind-body dualism (Stolorow, R., Atwood, G., Orange, D., Worlds of Experience, 2002, pp. 19-38).

 

38. The clinician's professional identity emerges from this messy process, in her/his  search for self-understanding.

 

39.  Patients display a sense of urgency;  they are good teachers, sincere about their painful complaints; with a sense of helplessness and personal suffering, the patient naturally desires to rely on the clinician, who can help uncover his or her strengths.

 

40. With acceptance of one's limited powers, feeling the clarity of one's boundaries, the clinician feels less tyrannized by her inner demands to “fix” problems. One tunes in to what the patient desires from the therapeutic relationship.

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41. There is a healing potential exerted on the patient by the clinician's culturally-endorsed,  'expert/authority' status.

 

42. It is the patient's capacity for idealization of the doctor that contributes to the concept of "positive transference", i.e., factors that operate in favor of the collaboration between patient and psychotherapist, towards 'cure'; such positive factors are the fuel that drives the treatment successfully forward (Introductory Lectures On Psychoanalysis, Freud, S., 1920, Norton & Co., 1966, pp. 551-554).

 

43. Be emotionally present in the moment with the patient. Understanding one's emotional reactions to the patient serve as valuable clues towards understanding what the patient needs, and guides the clinician in what to do or say, or what not to do or say.

 

44. New emotional pathways appear in my therapeutic relationships, anchored in a growing bond of friendly trust. Accepting and allowing the mutual influence on one another, allows for more trusting, comfortable, meaningful, and playful human exchanges. Such exchanges strengthen the reality of a patient feeling cared for, and cared about.

 

45.  new concepts have emerged, such as "self-experience", "felt-experience", “lived experience”, "experience near”, “experience distant”, "attunement", "empathic resonance", "contextual", “feeling known", and "mutual co-creation”.

 

46. The technical term, “countertransference”,  is currently more precisely understood as “co-transference”, reflecting the mutual emotional influences simultaneously experienced by both clinician and patient, both consciously, or "explicitly", and unconsciously, or "implicitly". This concept, in turn, relates to the contemporary notion of enactment, "...the jointly created scenarios that reflect the initially unconscious, overlapping vulnerabilities and needs of patient and therapist...(Wallin, 2007, p. 122).

 

47. One must surrender the burdensome, adversarial role of an omnipotent provider and observer, and become a participating enactor.

 

48. One must step down from a defensive stance of elitist superiority.

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49. One develops an ever-increasing respect and humility towards the patient, as one searches into her circumstances, her perspectives, her perceptions, her way of seeing things, her manner of self-expression, and her self-experiencing of the world, forged in the crucibles of her genetic and environmental life circumstances.

 

50. Patients have good reasons to be cautious and “resistant” to opening their hearts to strangers - they are wary of professionals who have disappointed and exploited them, many patients having been abused, hurt, offended, and dismissed, by arrogant, poorly sensitive, or poorly prepared authority or parental figures, from both the recent and distant past.

 

51. Of course, through good fortune, not all patients are mistrusting: many report good quality current, and prior, therapeutic and other relational experiences, but the exigencies of life have brought them in to seek help now, reasonably needing and expecting good-enough therapy (as in Donald Winnicott's (1896-1971 "good-enough mother"), who provides attuned responsivity within a secure, "holding environment").

 

52. make efforts to be spontaneous, to allow the patient to see, hear, and experience much of one's natural emotional reactions (which they will see versions of anyway), such as surprise, or puzzlement, or admiration, while minimizing overt disapproval or negative judgements, which may occur as reflexive reactions of one's own internalized family and cultural biases of various kinds.

 

53. "decenter", do not personalize,  reactions to the patient.

 

54. engage in privileging, respecting, and prioritizing the patient’s emotional reactions, above all else.

 

55. We offer the patient a "corrective emotional experience" (Franz Alexander, 1891 - 1964), a new context of relating and understanding, a second chance at getting back on a developmental pathway, that releases the patients' psychic potentials, on their paths towards personal fulfillment, and emotional mastery.

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56. It is helpful to work at:

1) taking in, ‘wearing’, experiencing the patient’s point of view, i.e., at refining one's lis- tening skills, in order to sharpen one's empathic understanding and compassion for an- other's circumstances, which is a life-long study, a life-long effort;
2) letting down one's guard, one's defenses, in order to better imagine his or her mind- set; and,

3) being honest, transparent, and accountable with the patient, when his/her expectations towards the clinician and the world are impossible to fulfill.

 

57. The clinician must always be vigilant against attributing solely to the patient emotional reactions that are interweaved and embedded with his own.

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58. Subjectively felt experiences belong to the patient, and are valid for the patient. Within the realm of subjectivity, subjective language prevails; a more creative, social science research model is required, in order to capture the utter uniqueness of the features of each intersubjective, clinician-patient pair, or 'dyad'.

 

59. Perhaps an explanatory model of emotional understanding would aptly be called, in terms of an explanatory metapsychology, an “interpsychology”, which would better capture the therapeutic, inter-relational, co-created processes of psychoanalytical psychotherapy; 

 

60. as Knoblauch says:"...though the dream is the royal road to the unconscious for a psychology of repression, there may be other royal roads to affect recognition for a psychology of dissociation...[whereby] the co-constructed enactment is recognized as a psychic space in which meanings are played out rather than dreamed. Here the interaction sequence becomes the field of symbolic meanings for an interpsychic psychology as is the dream for an in- trapsychic psychology" (Knoblauch, S., The Musical Edge of Therapeutic Dialogue, 2000, p. 89).

 

61. In summary: professional growth, in the arena of psychoanalytic psychotherapy, requires the emergence of not so much the growth of technical skills, such as the skills of an airplane pilot; but is more related to one's capacities to promote a therapeutic atmosphere or milieu, wherein the patient perceives you and receives you, the clinician, as an authentically interested and caring person, capable of more or less accurately resonating with his/her experiential world; and perceives you, the clinician, as one who is appreciating the internal and interpersonal struggles and conflicts that rupture the patient's feelings and beliefs in contradictory directions, ruptures that render the patient feeling lost, victimized, helpless, impotent, humiliated, and angry.

 

62. It is this presence of an actively, affectively receptive, curious, listening stance, that promotes the patients' sense of inner unity and wholeness; that transforms inner chaos into deep, personal meaning; that fosters the patients' greater self-understanding and self-realizations; that, in turn, affirm a heightened sense of creative resourcefulness, in coping with the demands and opportunities of life's relentless unfolding revelations.