Original Sin

Yes, this is a strange topic for a psychology blog. Consider the following statement:

“In the Puritan ethos of seventeenth century England, for example, children were thought to be the carriers of original sin. They were liable to be dominated by wicked impulses and childhood was the time of life when control of these had to be instilled."

This is from an article by Michael Parsons, called Sexuality and Perversion a Hundred Years On: Discovering What Freud Discovered.

Often patients come into therapy with the idea that they are bad, not just damaged or broken or hurting, but bad. This badness goes back as far as they can remember. It seems to contain a mixture of shame and guilt, and it feels to them to be unfixable, just a basic fact of who they are.

When we explore this “badness”, it seems to reduce down to wanting something that a parent could not or would not give – love, affection, attention — things that we consider basic human needs. They may report it as wanting a toy or being alone in a hospital bed and wanting someone there to take away the pain, to mention two extremes, but the experience was of endlessly wanting something you could not have.

How does this turn into “badness”?

Let’s go back to Adam and Eve. God is all good, all-powerful (so the story goes). God gives Adam and Eve anything they want in the garden, except, of course, he holds back on the fruit of two trees: the tree of life and the tree of the knowledge of good and evil. (Commentary has it that eternal life and awareness of good and evil were the ways humankind differed from God.) Of course, if a parent says, “You can taste anything but this. This is mine” what is held back becomes the focus of desire. We all know what happened to Adam and Eve: Eve stole the apple, gave some to Adam (hey, remember Prometheus stealing fire? Same story.) God punished them – they were expelled from Eden; they experienced shame and suffering. God stayed all-powerful, and God’s goodness was not in question; Adam and Eve were bad.

For a child, even wanting what you can’t have makes you bad. If you are able, through whining or tantrums or other tactics, to succeed in getting what you desire so fiercely, it’s a pyrrhic victory. The gain is never worth the feeling that you are bad for wanting or for getting what is grudgingly given.

Back to Parsons: “They were liable to be dominated by wicked impulses and childhood was the time of life when control of these had to be instilled.” If we believe that impulses – drives in psychoanalytic language – are object based, then the wicked impulses that a child experiences have to do with either a desire for love (physical and emotional) and/or the expression of rage when his/her desires are thwarted directed at a parent, usually the mother (the object).

So how does the child end up being the bad one? In order for our gods to be loving and benevolent, not punitive and withholding, in the binary system of early development, we are to blame/at fault for our distress, anger, and longings. We need our gods to be good (and our parents are our first gods}, so we ourselves must be bad. Children need to believe their parents are both good and powerful – their sense of well-being, their security, and possibly, their lives, depend on it.

Frame vs. Boundaries

Frame vs. Boundaries

If we think of the frame as the room you are in, boundaries are your skin. If you have a good immune system, you don’t need to be in a sterile environment. Similarly, if you have good boundaries, your frame can be somewhat more flexible. However, even if we have good boundaries, our patients, frequently, do not.
Boundaries are how we know where we stop and the other person begins. As therapists, we often have fairly porous boundaries — we absorb information and feeling states from other people without knowing who is doing the feeling. (We may call this being intuitive.) When we are with patients who use projective identification as a defense, for instance, the patient projects onto us feelings that are intolerable, and often acts in ways to evoke those feelings in us. For example, if a patient is feeling inadequate, nothing we say will be right, and by the end of the hour, we may feel like we’ve chosen the wrong profession!
If we have good boundaries (or good consultation, therapy and/or experience), we will be able to identify more readily when the feelings do not originate in us. Sometimes particular feelings are more difficult to sort out than others; these are feelings that the patient holds that resonate with us or our own disowned, “shadow” material.
I may get sleepy when sitting with a patient, when I have felt rested or alert when the session began. This is a signal to me that there is a level of deadness in the room, usually when anger or another painful feeling is being suppressed. Although I cannot control the feeling of sleepiness, I have an understanding that the feeling may not originate in me, but my response shows my own vulnerability to taking that feeling on.
Margaret Atwood wrote a wonderful poem with the following lines, which I consider a metaphor for projective identification (about which I’ll write more when I write about defenses). She wrote:

You fit into me
like a hook into an eye
A fish hook
An open eye

We could even substitute “I” for eye, since it is usually our ego that makes us vulnerable. The idea, however, is that we connect with another, for better or worse, through our vulnerabilities. Sometimes we may make an interpretation that will feel like an attack to the patient – our hook hits their eye. Other times, what our patients say or do penetrates our boundaries.

It’s not always painful. Moments of closeness are also moments when our boundaries are loosened. Jung wrote of “being in the soup” with the patient as a way of describing the dissolving of boundaries that occurs when we do our deepest work. He held, and I concur, that it is necessary for some merging of the psyches between the analyst (or therapist) and the patient for therapy to be truly transformative.
I also believe, however, that the state of “being in the soup”, of merger, needs both to be a temporary experience, and one that is thoroughly explored and analyzed, even if not explicitly discussed.

Two random notes

Why do I refer to the people who come to see me for treatment as patients and not clients? I feel that therapists come from a lineage of healers, be they doctors, shamans, folk healers, spiritual healers, or the like. The word client seems to me to refer to someone who comes for a particular service, such as a legal service, but has nothing to do with someone who needs healing. The root of the word patient comes from the Greek word for suffering, pathos.

What is Mental Health?
Freud believed that the mark of one’s humanity was to be able to love and to work: “Love and work are the cornerstones of our humanness.” In thinking about what is mental health, I think that love, as ability to form attachments — including friendship and familial bonds — not just romantic love, is one of the criteria of mental health. Work, should be meaningful work, not necessarily paid work. A child’s work could be school or play; both develop essential skills. The work of a retired person might be spiritual work, readying oneself for the end of life.

There are other important elements to mental health as well. For one, the ability to adapt, to be flexible, is a key to survival. Again, Freud said (don’t ask me where, since I can’t find the reference), “If you can’t do it, give it up!”

Knowing when to give up and when to hold fast is an ongoing process. The 12-step programs have made this a part of their essential Serenity Prayer. When people are stuck with fixed ideas about themselves or others, they are not able to adapt.

In a related way, being stuck in a fixed mental state for long periods of time, is a sign of mental “illness” or dysfunction. One is then responding more to internal stimuli than external ones; there is no balance between the two. Extreme cases of this are catatonia and dementia. The inability to respond to what is actually happening around you, instead of your thoughts about it, is typical especially of mood disorders, but is present in all mental illness. So mental health would be an ability to be in the present, in the external situation, while able to maintain one’s own internal thoughts, and to have a balance between the two.

Other important constituents of mental health include creativity, spontaneity, humor. Thee are aspects of humanity that are not a result of a fixed or frozen state. These are not mere sublimations or defenses; they are expressions of who we are as people.

A final note: to me the ability to feel gratitude is a hallmark of mental health. Gratitude comes from a sense of fullness, wholeness, of being given to. Gratitude keeps us in the present. Fear, envy, anxiety and grief keep us in the past and future, and prevent us from feeling alive. It is difficult to feel grateful when you are suffering. If we are able to feel gratitude, we are experiencing some degree of health.

Many religions repeatedly give thanks throughout the day (all those Blessed art Thou's) — this seems to me to be a tool for returning to present time. Whether we're thinking of Ram Dass saying "Be here now" or Aldous Huxley's mynah birds saying "Here and now, boys; here and now", being present is inextricably linked to being grateful.

"Gratus animus est una virtus non solum maxima, sed etiam mater virtutum onmium reliquarum." [Latin: A thankful heart is not only the greatest virtue, but the parent of all the other virtues. ] Cicero

The Frame

It has been said that what takes place within a frame is symbolic. Whether a gilded frame surrounding canvas, the curtains on a stage, the beginning and ending credits at the movies, even between the bookends of a novel — the clear demarcation in space and time create a place/thing/event set apart from ordinary reality. Even representational photographs or documentaries make a choice about what to include and what to leave out. Allan Ginsburg said, "Notice what you notice." What we attend to narrows the experience to what we consider important.

What has this to do with psychotherapy? The frame in psychotherapy refers to the setting apart of space and time, the limiting of interactions, and the creation of what the Jungians refer to as the container. When we set the time, place, frequency and length of the meeting, determine who will be there, and what the fee will be, we are creating a symbolic space, separate from the rest of one's life.
There are complications with this, of course. When a therapist lives in a small community (or even in Berkeley!), s/he is likely to run into patients everywhere from the gym to the grocery store. A patient may see you at the farmers' market with your family, or covered in paint at the hardware store, or even at a mutual acquaintance's party.

If I know that I am likely to run into patients in the course of therapy, I speak of it early on, stating that if I am with others I most likely will not even acknowledge them in public (beyond a smile or nod of my head). I explain the reasons, and then when it happens, we discuss it.

My patients say it doesn't bother them. I don't buy it. Maybe sometimes a patient will be happy to see you have a life outside of the office, but more frequently it is a disruption and even a contamination, depending on the circumstances. My advice — frequently given — to new therapists: always analyze breaks in the frame. Bring it up, even in the beginning of a session. Dig deep, and if there is still nothing there, listen for derivatives (references in other topics that are representative of the transference material), especially in dreams.

Other breaks in the frame include vacations, fee changes and requests around the fee, missed and canceled appointments and the like. Other things that we often don't think about — referrals from a patient, requests to include a family member or partner in the session, our own self-disclosures — are frequently more complicated to unravel and understand.

I don't take referrals from current patients unless the connection is remote, say, the sister of an acquaintance. New therapists often wonder how they will build a practice if they don't take referrals from patients, but I have found that I am more likely to lose the patient I have than to gain a new one, if the referral is too close to the patient.

I try not to be too rigid. Once when a patient was diagnosed with breast cancer, she arrived for her appointment with her boyfriend with no advance notice. I was flustered, but knew enough to see them both together. I think if I hadn't, I would not have helped her fully share her need and her experience with her partner.

Another time, a woman I had been seeing for a couple of years requested that she be allowed to bring her daughter in for several sessions. This had been at the daughter's request, but the mother was all for it. Difficulty with the daughter had been the presenting problem, and in the course of treatment, she had gained awareness of how her envy of her daughter, and the lack of mothering she had herself received, contributed to the painfulness of the relationship. After discussing it for several sessions (and with doubt and trepidation), I agreed to see them together. What occurred in those joint sessions was transformative. She was able to repair old wounds by her willingness to share me, "her good mother", with her daughter. The therapy continued after the sessions with the daughter, but the bulk of the work had been done.

Next blog - frame vs. boundaries.

Reflection

Reflection is not only not valued in our society, but is viewed as neither functional nor productive. We all heard Sarah Palin extolling the fact that she "didn't blink" when offered the vice-president candidacy. Students taking SAT''s and writing essays in 20 minutes lose points if they take the time to think about the question. One certainly cannot pause to think when playing video games. Superficial and quick responses — soundbites and one-liners — are memorable and make the speaker sound intelligent and decisive. Hesitation looks weak; some believe that to pause before answering looks less than honest.

As therapists, one of our main tasks is to teach people how to reflect. When we ask a question, we are often looking for the answer that is not known, and not readily available to the conscious mind. If I ask a question and the response is a (seemingly unrelated) story, I know I am onto an association that might not yet be fully conscious, and which might lead us into new territory. The response "I don't know." is a starting point, not a dead end.

When patients develop the ability to reflect instead of to react, they are no longer ruled by their emotions. The creation of a space between the stimulus and the response, to use the language of behaviorists, is the window through which the observing ego can gaze. In this time, in the therapy hour, spontaneous associations can lead to epiphanies.

Introduction

I have thought of writing down my thoughts about psychotherapy for many years, but trying to publish a book frankly seemed both intimidating and time-consuming. I'd rather spend the time working with patients or teaching other therapists. This blog is especially for all my students over the years, but also for anyone interested in doing psychodynamic/psychoanalytic psychotherapy.

I am strongly influenced by the work of Melanie Klein and others in the British Object Relations School, but no one practices for very long without absorbing a variety of influences. I am as likely to refer to Jung as Freud. Euripides and "6 Feet Under" both are reference points - among thousands of other elements in my life. I believe in relational work, having a subject and an object. Tom Ogden's book, "Subjects of Analysis", illuminates this concept better than anyone else I have read. My main teachers, of course, have been my patients.

My idea for this blog will be that I will alternate random thoughts with theoretical material. I plan to include some case material, which will be disguised. If any of my patients happen across this blog, please consider carefully if you really wish to keep reading. If you do, we need to talk about it!