Suffering, the Other, and a Vote for Trump CONTiNUED

False projection’s opposite, freedom from oppression, celebration of difference, neither mimesis nor domination, “would depend on whether the ruled, in face of absolute madness, could master themselves and hold the madness back. Only the liberation of thought from power, the abolition of violence, could realize the idea that has been unrealized until now: that the Jew”—the Black person, the Muslim refugee, the Mexican immigrant, the disabled person, the LGBTQ person, the woman—“is a human being,” (Horkheimer & Adorno, 1944/2002, p. 165). Such a step, Horkheimer and Adorno assert, “would indeed prove the turning point of history” (p. 165). In contrast to Freud’s evolutionary process of civilization as passive (Einstein et al., 1939), what is suggested here is active and arduous. True empathic realization of the humanity of others is difficult, and often comes at a personal cost. While systems of power larger than the individual shunt us into pathways of pathological projection and complicity, only an intentional and persistent process of self-exploration, followed by ego-syntonic political action, can lead to the end of violence. The exploration is shadowy and threatening. Like Aidan’s psychotherapy process, it will require encountering affects and complexes we would prefer to repress. Once they have been encountered again and again and recognized, however, we might have more flexibility regarding our choice of action, more control over the course of history.

Unconscious processes on individual and social scales will always affect the political environment. The solution to their eruption in unexpected and dangerous directions, arrived at with the help of Freud (Einstein et al., 1939) and the Frankfurt School, suggests that perhaps the vision of a better world where things are done on purpose and in keeping with the ego-syntonic American ethos can one day come to fruition. If so, however, the unconscious forces to be acknowledged and examined are formidable. The work required will be grueling, but meaningful.

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The Political Self: Understanding the Social Context for Mental Illness

By Roderick Tweedy (Ed.), London, UK: Karnac Books, 223pp., $46.95, 2017

Talking Politics in the Therapy Room

Blue Chevigny

 Over the last year, politics and social justice are moving to the front of the discussion in my exchanges with friends, family, acquaintances, the personal and professional groups in which I participate (both online and in person), and the conversations I am having with my patients in my work as a psychotherapist.

The topics my patients want to talk about have changed. They feel that they are living in a new context since the election. None of my patients support the Trump administration. They often want to talk about politics during sessions, and I have dispensed with whatever illusion of neutrality there may have been previously, sometimes commiserating when it comes to these topics. Many of my patients are now struggling more than they were before with questions of balance: how to tolerate the constant flow of new information, much of it distressing; how to take action on issues that seem urgent; and meanwhile, how to go about the business of being alive and being their “old selves” at the same time. In some cases these needs seem at odds. I find many of my patients to be swooping dramatically back and forth between the feelings of anger, fear and helplessness associated with following the events in our government, and daily life activities like preparing meals for themselves and, in some cases, their families, getting enough sleep, and completing whatever tasks are demanded by jobs or other pursuits. For many who had not been as politically tuned in or outraged previously, these two poles seem utterly unintegrated. It is almost as if each of us is two people, and we are allotting great effort to the job of being each of these two people, exhausting ourselves. My hope is that, over time, a more integrated sense of ourselves grows out of the current crisis, where an idea of ourselves as both grocery-shoppers and protesters can co-exist in our minds.

If you go by what is happening in my practice, people have become politicized. Some already were, and those that weren’t are now. We are involved. This essential fact, observed widely, is remarkable, and has helped energize me since the first day back at work after the election. This engagement has developed and grown rather than waned since November, and I continue to feel quite hopeful in my work. Based on this experience, I suspect that the election outcome may, in fact, be making people less myopic and self-involved.

People who were comfortable in the belief that progress was happening without too much of a fight, and that we could just sit back and more or less let it march forward, were rudely awakened. While some in my office do feel at times hopeless and overwhelmed, there are other moments in which they feel more resilient and clearer of purpose than they have in the past. There is a new awareness of the larger world and a sense that “now, it really matters what I do.” This is giving some who were not previously able to focus their attention on much, something to focus on. The Political Self, a collection of essays on the ‘social context for mental illness’ edited by Rod Tweedy (2017) thus arrives in a timely manner.

In Sue Gerhardt’s chapter, “The Selfish Society: the Current State of Things,” she writes about the erosion of empathy in individuals, and the rise of narcissism and self-interest (p. 69). Gerhardt points out that for those with depression and some character pathologies “the bottom line is that they have difficulties with the quality of their attachments to other people and often find it a struggle to think of others’ needs” (p. 84). Gerhardt argues that selfishness or unselfishness within a society is cultural—and that selfishness is connected to social isolation, impulsiveness, addiction, etcetera (pp.81-82). She is a drawn to a feminist “ethic of care” in which we become aware of and deliberate about the ways in which we care for, and are cared for by, others all day long. It promotes an openness to the ways in which others are different and experience things differently from ourselves (p. 76). Around me, in my practice and beyond, I see people forming community groups, gathering with others to talk and process what is happening, and strategizing actions and protests. Many have more of a connection to their neighbors and larger community than they did a few months ago. I really wonder whether this current Trump-resisting climate of raised consciousness, protest, and urgency, if sustained, could lead to a greater collective empathy and the ability to look beyond one’s self toward the interests of others. Perhaps this moment in history is an opportunity to change the culture.

But how does the shift on the cultural level translate into the work in the office? This leads to a point that has sharpened for me in these last weeks: my sense that actually being “in this together” with my patients has created something of therapeutic opportunity. The experience of learning about extraordinary developments in politics, and processing them simultaneously with my patients, having something momentous happen to us together, has been an equalizing force in the therapy room.

The principle that we are collaborators in the work of therapy, that I don’t hold the answers or possess any great wisdom to hand down to a patient about themselves, has guided my work as a central belief since long before the election. Believing in that principle, however, doesn’t by itself erase the power dynamic between therapist and patient. As Nick Totten explains in the chapter, “Power in the Therapeutic Relationship”,  my role in the relationship with my patients automatically confers on me some authority, and some of the ability to convince that goes with authority, whether we like it or not. To pretend otherwise is to willfully deny reality, and Totten writes that for therapists “its bad practice to pretend that we are not operating from a set of beliefs.” ( p. 36) He posits that we can work to repair this imbalance by not being seduced by the part of us that wants “to assert our authority as expert and healer” and by bringing “awareness, the magic ingredient, to the situation” (p. 39).

A positive byproduct, then, of this experience of our political climate, in which I am quite openly as perplexed as anyone else, is that it moves my idea of being my patient’s collaborator from principle into practice.  Any perceived authority is diminished by my clear lack of expertise in at least the area of the current crisis. Now, in conversations with my patients, I feel as though there is a freer way between us than there used to be, and that when I “throw an idea out there,” my patients are more likely to genuinely regard it as what I say it is: a trial balloon. This feeling now often pervades sessions. Whether we are speaking about the latest news out of Washington or about their grandmother’s possible motivation for commenting negatively on their appearance, I feel as if several of my patients are giving my words a little less weight. Because of the frequent reviewing of our social context, we are in the “conversation zone” more safely than we used to be, and I consider this an improvement over what, in retrospect, seems like it was at times a somewhat manufactured “therapy zone” which was more stilted, and at times awkward. This zone feels more creative and spontaneous. It feels as if, now, we are thinking together, rather than you, the patient, thinking over there in your chair, and me, the therapist, thinking over here in mine.

The idea that we, as therapists, think we are meant to be the source of insights is deeply flawed and always has been. It must be questioned repeatedly as we engage in psychotherapeutic processes. It turns out that when it comes to their own lives and choices, patients hold the keys and our job is to be able to be present, listening, and deepening the understanding on both sides, when the answers emerge. Totten compares this process to creating a new, unique language, a mixture of the languages with which the patient and therapist entered the treatment (p. 40). When it comes to larger questions of how to come back from the current crisis as a country, this small-scale creative action between two people may be transferable. The act of listening more carefully to one another, and acknowledging all the moments and all the ways in which we each don’t hold the answers, but are groping along together in the dark, is more essential than ever.

Literary Criticism, Psychoanalysis and the New Politics of Otherness

By Flora E. Lazar, Ph.D., L.S.W

I, like many of us, feel chronically behind in my reading not just with my New Yorkers, which I mercifully don’t see in stacks any longer thanks to my iPad e-subscriptions, but even with the New York Times. As someone who entered the clinical world after a long career in research and public policy, the pressure to “master the professional literature” is especially acute. So when my eye caught a small New York Times article about the seemingly effete topic of who gets to write novels about whom, I was surprised that I did not simply leave it to the literati. But I was intrigued that it had reached the top 20 on the Times Most Popular List, so I checked out this dispatch from this year’s celebrated Brisbane conference.

The article, it turns out, concerned the keynote speech by novelist Lionel Shriver about what she and others have referred to as identity politics gone mad, or to be more specific, the increasingly popular idea that writing about people who do not share one’s “identity” is an act of cultural appropriation akin to identity theft. In her speech, Shriver complained that the increasingly shrill critiques about writers with one identity writing about characters with another would ultimately produce characters “so hedged, so circumscribed, so tippy-toe, that we’d indeed be better off not writing the anodyne drivel to begin with.” (Shriver, 2016) Not long into the speech several of Shriver’s colleagues stood up and walked out, setting in motion a literary conflagration that spread to the pages of newspapers around the world and prompted the hasty organization of “counter-programming” to express the literary world’s consternation over her remarks.

Why should we, as psychoanalytically-informed psychotherapists, be concerned about this dust-up among writers at a literary enclave in a far corner of the world?  Because if differences of identity proscribe us from gaining an intimate understanding of the experiences of others, we are stripped of what psychoanalysts from Freud’s time have regarded as one of our most potent tools for helping those who seek our assistance. The singular importance that psychoanalyst Heinz Kohut attached to empathic understanding, which Kohut’s biographer Charles Strozier (2001) says he defined alternately as “vicarious introspection” and “feeling one's way into the experience of another,” is by now well known. But as psychoanalyst Steven T. Levy  has pointed out, the importance of empathic understanding in psychoanalysis is not new to Kohut, even if theorists have questioned its relative importance. Freud, himself, underscored the importance of empathy as a form of identification, calling it “the mechanism by means of which we are enabled to take up any attitude at all towards another mental life” and “the process…which plays the largest part in our understanding of what is inherently foreign to our ego in other people” (Freud , 2012)

Indeed, we are often called upon as psychotherapists to address—whether in our own minds or directly to our patients—the fundamental question raised by the work of French philosopher Emmanuel Levinas (1979) about whether it is possible, ultimately, to know “the other.” It is a question that goes to the heart of the promise of psychoanalysis and psychodynamic psychotherapy. Certainly some psychoanalysts have questioned the limits of empathic understanding, and they have done so in terrain less contentious than those that are part of the cultural appropriation debate. Intersubjective theorist Robert Stolorow’s (2011) has questioned the extent to which the trauma of one can be fully grasped by another. Russell Bryant Carr (2014) argues, from his work with combat veterans, that clinical effectiveness does not simply call into question the limits of our ability to understand certain experiences such as combat violence—it virtually demands that we admit it.

In the contemporary cultural appropriation debate that turned white hot in Brisbane, this question is posed far more narrowly. If we do not share a gender identity, sexual orientation, race, ethnicity, social class or other identity, can we truly know or identify with someone who carries that identity? And what is the price of this supposed blindness?

For decades such differences were assumed a priori to interfere with psychotherapy rather than to be an arena for dynamic exploration. As Kimberlyn Leary (2000), who has helped advance our thinking considerably on the psychoanalytic exploration of race, has noted, the relational turn in psychoanalysis has immeasurably enhanced our ability to work with the varied meanings of dimensions such as race in treatment. Underscoring Cheryl Thomson’s (1996) contention that “black is never simply black” and that racial content can have multiple meanings, even simultaneously, Leary perhaps unintentionally calls into question whether one has to possess an identity to understand that identity in another.

Over the years, a mushrooming scientific literature has examined what impact factors such as racial or gender matching have on the effectiveness of treatment. A meta-analytic review by Cabral & Smith (2011) of preferences, perceptions, and outcomes around racial/ethnic matching in mental health services provides compelling evidence that while patients may have a modest preference for such matching, it is hardly decisive in the impact of treatment. The study concluded that “across 53 studies of client outcomes in mental health treatment, the average effect size was 0.09, indicating almost no benefit to treatment outcomes from racial/ethnic matching of clients with therapists.” (Cabral, 2011, p.537)

All of this makes me wonder if we are not rolling back the clock by dividing ourselves between “me” and “not me.” Have not advances in understanding gender identity and sexual preference made us more circumspect about the idea of binaries? So far, the psychotherapy community has remained remarkably silent on the broader implications of the identity and cultural appropriation debates for our profession.

The consequences of this debate over identity, even if construed somewhat more narrowly, have historically had a profound, if not always acknowledged, affect not just on psychotherapy, but on many of the human services that are informed by our theories. Such questions have, for example, undergirded the preference for religious matching that dominated child welfare decisions until this system was successfully challenged in the Wilder case, only to return, somewhat ironically in the debate over the impact of transracial adoption (Bernstein, 2011; Samuels, 2009).

As a recent graduate of the University of Chicago social work school and survivor of the widely-reported campus identity debates—often conducted in the name of mental health—I have had a ring-side seat to these discussions and what they mean for psychotherapists. Those a bit more removed would do well to keep an eye on the latest incarnation of this debate, Brisbane’s literary spectacle, and its aftermath. It has both implicitly and explicitly invoked mental health as an outcome, but will almost certainly spill into our world as a question of method.  

The Indian journalist and novelist Hari Kunzru, whose most recent book was about the American Southwest, could have been writing for a psychoanalytic publication when he wrote in The Guardian in the aftermath of Brisbane, “Attempting to think one’s way into other subjectivities, other experiences, is an act of ethical urgency.” He went on to argue that “good writers transgress without transgressing, in part because they are humble about what they do not know. They treat their own experience of the world as provisional. They do not presume. They respect people, not by leaving them alone in the inviolability of their cultural authenticity, but by becoming involved with them.” (Kunzru, 2016)

Sound a bit like psychoanalysis? One of Lionel Shriver’s fiercest critics, Yassmin Abdel-Magied, notably claimed in a letter to the editor of the New York Times, “Difficult conversations will make us all uncomfortable. Good. That discomfort is how we improve.” I think I have heard that said of psychoanalysis. (Abdel-Magied, 2016)

References

Abdel-Magied, Y. (2016, October 5). [Letter to the editor]. Retrieved from https://www.nytimes.com/2016/10/06/opinion/a-call-for-difficult-conversations-not-censorship.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=1

Bernstein, N. (2011). The lost children of Wilder: The epic struggle to change foster care. New York, NY: Vintage.

Cabral, R. & Smith, T. (2011). Racial/ethnic matching of clients and therapists in mental health services: a meta-analytic review of preferences, perceptions, and outcomes. Journal of Counseling Psychology, 58(4), 537-554.

Carr, R. B. (2014). Authentic solicitude: What the madness of combat can teach us about authentically being-with our patients. International Journal of Psychoanalytic Self Psychology, 9(2), 115-130.

Freud, S. (1959). Recommendations for physicians on the psycho-analytic method of treatment. Collected papers (Vol. 2, pp. 323-333). (Original work published 1912c)

Kunzru, H. (2016, October 1). Whose life is it anyway? Novelists have their say on cultural appropriation. Retrieved from https://www.theguardian.com/books/2016/oct/01/novelists-cultural-appropriation-literature-lionel-shriver

Leary, K. (2000). Racial enactments in dynamic treatment. Psychoanalytic Dialogues, 10(4), 639-653.

Levinas, E. (1979). Totality and infinity: An essay on exteriority (Vol. 1). New York, NY: Springer Science & Business Media.

Samuels, G. M. (2009). “Being raised by White people”: Navigating racial difference among adopted multiracial adults. Journal of Marriage and Family,71(1), 80-94.

Shriver, L. (2016, September 8). Fiction and Identity Politics. Retrieved from https://www.theguardian.com/commentisfree/2016/sep/13/lionel-shrivers-full-speech-i-hope-the-concept-of-cultural-appropriation-is-a-passing-fad

Stolorow, R. D. (2011). World, affectivity, trauma: Heidegger and post-Cartesian psychoanalysis. New York, NY: Routledge.

Strozier, C. B. (2001). Heinz Kohut: The making of a psychoanalyst. New York, NY: Macmillan.

Thompson, C. (1996). The African-American patient in psychodynamic treatment. In Perez-Foster, R., & Moskowitz, M. (Eds.). Reaching across boundaries of culture and class: Widening the scope of psychotherapy. New York, NY: Jason Aronson, Incorporated.

 Is there a citation to accompany Steven Levy’s point?

 Citation for Freud 2012 reference?

Literary Criticism, Psychoanalysis and the New Politics of Otherness

By Flora E. Lazar, Ph.D., L.S.W

I, like many of us, feel chronically behind in my reading not just with my New Yorkers, which I mercifully don’t see in stacks any longer thanks to my iPad e-subscriptions, but even with the New York Times. As someone who entered the clinical world after a long career in research and public policy, the pressure to “master the professional literature” is especially acute. So when my eye caught a small New York Times article about the seemingly effete topic of who gets to write novels about whom, I was surprised that I did not simply leave it to the literati. But I was intrigued that it had reached the top 20 on the Times Most Popular List, so I checked out this dispatch from this year’s celebrated Brisbane conference.

The article, it turns out, concerned the keynote speech by novelist Lionel Shriver about what she and others have referred to as identity politics gone mad, or to be more specific, the increasingly popular idea that writing about people who do not share one’s “identity” is an act of cultural appropriation akin to identity theft. In her speech, Shriver complained that the increasingly shrill critiques about writers with one identity writing about characters with another would ultimately produce characters “so hedged, so circumscribed, so tippy-toe, that we’d indeed be better off not writing the anodyne drivel to begin with.” (Shriver, 2016) Not long into the speech several of Shriver’s colleagues stood up and walked out, setting in motion a literary conflagration that spread to the pages of newspapers around the world and prompted the hasty organization of “counter-programming” to express the literary world’s consternation over her remarks.

Why should we, as psychoanalytically-informed psychotherapists, be concerned about this dust-up among writers at a literary enclave in a far corner of the world?  Because if differences of identity proscribe us from gaining an intimate understanding of the experiences of others, we are stripped of what psychoanalysts from Freud’s time have regarded as one of our most potent tools for helping those who seek our assistance. The singular importance that psychoanalyst Heinz Kohut attached to empathic understanding, which Kohut’s biographer Charles Strozier (2001) says he defined alternately as “vicarious introspection” and “feeling one's way into the experience of another,” is by now well known. But as psychoanalyst Steven T. Levy  has pointed out, the importance of empathic understanding in psychoanalysis is not new to Kohut, even if theorists have questioned its relative importance. Freud, himself, underscored the importance of empathy as a form of identification, calling it “the mechanism by means of which we are enabled to take up any attitude at all towards another mental life” and “the process…which plays the largest part in our understanding of what is inherently foreign to our ego in other people” (Freud , 2012)

Indeed, we are often called upon as psychotherapists to address—whether in our own minds or directly to our patients—the fundamental question raised by the work of French philosopher Emmanuel Levinas (1979) about whether it is possible, ultimately, to know “the other.” It is a question that goes to the heart of the promise of psychoanalysis and psychodynamic psychotherapy. Certainly some psychoanalysts have questioned the limits of empathic understanding, and they have done so in terrain less contentious than those that are part of the cultural appropriation debate. Intersubjective theorist Robert Stolorow’s (2011) has questioned the extent to which the trauma of one can be fully grasped by another. Russell Bryant Carr (2014) argues, from his work with combat veterans, that clinical effectiveness does not simply call into question the limits of our ability to understand certain experiences such as combat violence—it virtually demands that we admit it.

In the contemporary cultural appropriation debate that turned white hot in Brisbane, this question is posed far more narrowly. If we do not share a gender identity, sexual orientation, race, ethnicity, social class or other identity, can we truly know or identify with someone who carries that identity? And what is the price of this supposed blindness?

For decades such differences were assumed a priori to interfere with psychotherapy rather than to be an arena for dynamic exploration. As Kimberlyn Leary (2000), who has helped advance our thinking considerably on the psychoanalytic exploration of race, has noted, the relational turn in psychoanalysis has immeasurably enhanced our ability to work with the varied meanings of dimensions such as race in treatment. Underscoring Cheryl Thomson’s (1996) contention that “black is never simply black” and that racial content can have multiple meanings, even simultaneously, Leary perhaps unintentionally calls into question whether one has to possess an identity to understand that identity in another.

Over the years, a mushrooming scientific literature has examined what impact factors such as racial or gender matching have on the effectiveness of treatment. A meta-analytic review by Cabral & Smith (2011) of preferences, perceptions, and outcomes around racial/ethnic matching in mental health services provides compelling evidence that while patients may have a modest preference for such matching, it is hardly decisive in the impact of treatment. The study concluded that “across 53 studies of client outcomes in mental health treatment, the average effect size was 0.09, indicating almost no benefit to treatment outcomes from racial/ethnic matching of clients with therapists.” (Cabral, 2011, p.537)

All of this makes me wonder if we are not rolling back the clock by dividing ourselves between “me” and “not me.” Have not advances in understanding gender identity and sexual preference made us more circumspect about the idea of binaries? So far, the psychotherapy community has remained remarkably silent on the broader implications of the identity and cultural appropriation debates for our profession.

The consequences of this debate over identity, even if construed somewhat more narrowly, have historically had a profound, if not always acknowledged, affect not just on psychotherapy, but on many of the human services that are informed by our theories. Such questions have, for example, undergirded the preference for religious matching that dominated child welfare decisions until this system was successfully challenged in the Wilder case, only to return, somewhat ironically in the debate over the impact of transracial adoption (Bernstein, 2011; Samuels, 2009).

As a recent graduate of the University of Chicago social work school and survivor of the widely-reported campus identity debates—often conducted in the name of mental health—I have had a ring-side seat to these discussions and what they mean for psychotherapists. Those a bit more removed would do well to keep an eye on the latest incarnation of this debate, Brisbane’s literary spectacle, and its aftermath. It has both implicitly and explicitly invoked mental health as an outcome, but will almost certainly spill into our world as a question of method.  

The Indian journalist and novelist Hari Kunzru, whose most recent book was about the American Southwest, could have been writing for a psychoanalytic publication when he wrote in The Guardian in the aftermath of Brisbane, “Attempting to think one’s way into other subjectivities, other experiences, is an act of ethical urgency.” He went on to argue that “good writers transgress without transgressing, in part because they are humble about what they do not know. They treat their own experience of the world as provisional. They do not presume. They respect people, not by leaving them alone in the inviolability of their cultural authenticity, but by becoming involved with them.” (Kunzru, 2016)

Sound a bit like psychoanalysis? One of Lionel Shriver’s fiercest critics, Yassmin Abdel-Magied, notably claimed in a letter to the editor of the New York Times, “Difficult conversations will make us all uncomfortable. Good. That discomfort is how we improve.” I think I have heard that said of psychoanalysis. (Abdel-Magied, 2016)

References

Abdel-Magied, Y. (2016, October 5). [Letter to the editor]. Retrieved from https://www.nytimes.com/2016/10/06/opinion/a-call-for-difficult-conversations-not-censorship.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=1

Bernstein, N. (2011). The lost children of Wilder: The epic struggle to change foster care. New York, NY: Vintage.

Cabral, R. & Smith, T. (2011). Racial/ethnic matching of clients and therapists in mental health services: a meta-analytic review of preferences, perceptions, and outcomes. Journal of Counseling Psychology, 58(4), 537-554.

Carr, R. B. (2014). Authentic solicitude: What the madness of combat can teach us about authentically being-with our patients. International Journal of Psychoanalytic Self Psychology, 9(2), 115-130.

Freud, S. (1959). Recommendations for physicians on the psycho-analytic method of treatment. Collected papers (Vol. 2, pp. 323-333). (Original work published 1912c)

Kunzru, H. (2016, October 1). Whose life is it anyway? Novelists have their say on cultural appropriation. Retrieved from https://www.theguardian.com/books/2016/oct/01/novelists-cultural-appropriation-literature-lionel-shriver

Leary, K. (2000). Racial enactments in dynamic treatment. Psychoanalytic Dialogues, 10(4), 639-653.

Levinas, E. (1979). Totality and infinity: An essay on exteriority (Vol. 1). New York, NY: Springer Science & Business Media.

Samuels, G. M. (2009). “Being raised by White people”: Navigating racial difference among adopted multiracial adults. Journal of Marriage and Family,71(1), 80-94.

Shriver, L. (2016, September 8). Fiction and Identity Politics. Retrieved from https://www.theguardian.com/commentisfree/2016/sep/13/lionel-shrivers-full-speech-i-hope-the-concept-of-cultural-appropriation-is-a-passing-fad

Stolorow, R. D. (2011). World, affectivity, trauma: Heidegger and post-Cartesian psychoanalysis. New York, NY: Routledge.

Strozier, C. B. (2001). Heinz Kohut: The making of a psychoanalyst. New York, NY: Macmillan.

Thompson, C. (1996). The African-American patient in psychodynamic treatment. In Perez-Foster, R., & Moskowitz, M. (Eds.). Reaching across boundaries of culture and class: Widening the scope of psychotherapy. New York, NY: Jason Aronson, Incorporated.

 Is there a citation to accompany Steven Levy’s point?

 Citation for Freud 2012 reference?

Some Uses of Narcissism

J. Todd Dean

            Everybody knows what narcissism is. It is a term everybody uses to describe bosses and coworkers, unpleasant neighbors, and certain politicians. From this, one could be forgiven for assuming the definition of the term is clear: if journalists and television anchors feel free to use it regularly, then it must be generally understood. But note that in a debate over the behavior of the recently elected 45th POTUS, experts in the field of mental health, including a former professor of psychiatry at Harvard and an editor of the DSM (Dodes, 2017; Frances, 2017), could not even agree that there was pathology present. This does suggest that there is less clarity than one might expect.

But perhaps not. Consider what historian Elizabeth Lunbeck has to say about the nature of narcissism in the introduction to her book The Americanization of Narcissism:

Generations of commentators, lamenting narcissism’s paradoxes and capaciousness, have tried to narrow its referents and settle, once and for all, its meaning. Narcissism’s protean nature, however, has proven as much a resource as a liability, and the concept has become too ubiquitous, and culturally and clinically useful, to submit to assiduous boundary policing…. Narcissism has always been simultaneously pathological and normal, and debates over selfishness, hedonism, and vanity have not arisen out of the idea of narcissism but, rather, are among the oldest questions we have asked ourselves. (2014, pp. 6-7).

So, at least as Lunbeck sees it (without giving references to those generations of commentators), narcissism is a concept that gets used in lots of different ways. Today, it is used almost constantly to attack Donald Trump. As we will see, the term is used quite differently again in Lunbeck’s history of 1970s social criticism, in the work of Christopher Lasch (1979/1991; 1984), and again in Kate Schechter’s study of developments in the history of the Chicago Institute for Psychoanalysis, Illusions of a Future (2014). Why narcissism would be used in so many different ways is an interesting question—one I hope to address in what follows. Before doing so, however, I would like to revisit the source of the confusion, Narcissus himself.

As described in Book 3 of The Metamorphoses (Ovid, 8 AD/2004), Narcissus is a hunter who wants all the people who chase after him to leave him alone—something inconceivable for Trump. It is not until he sees his own reflection that he does the same thing Echo and his myriad other admirers have done, becoming completely infatuated with an image. Like Echo, he dies for love of what he sees but can never touch (and why can’t he touch himself, we may reasonably ask—everybody else can). It will be remembered that Narcissus’s mother, Liriope, consulted the blind seer Tiresias to ask if her son, “already adorable” as he was being born (Ovid, 8 AD/2004, p. 109, l.345), would have a long life. She was told he would, so long as he never knows himself (p. 109, l.348). Later, a frustrated would-be lover prays that “Narcissus may fall in love and never obtain his desire!” (p. 112, ll.405-6). “His prayer was just,” we are told, “and Nemesis heard it.” When the beautiful boy finally stumbles on his own image and realizes that he cannot have what he sees, he cries, “I know you now and I know myself. Yes, I am the cause of the fire inside me, the fuel that burns and the flame that lights it./What can I do? Must I woo or be wooed? What else can I plead for?/All I desire I have. My wealth has left me a pauper.”(p. 115, ll.463-6). It is clear that Ovid’s Narcissus is nothing like Donald Trump. Furthermore, it would be a stretch to say he meets any of the criteria of the DSM personality disorder that bears his name, which is rather strange.

            Thus, Narcissus is not at all what the DSM-5 tells us a narcissist is today (American Psychiatric Association, 2013, p. 327), with a “grandiose sense of self-importance” and a requirement for “excessive admiration”; rather, he is completely unaware of himself, even to the point of not recognizing his image as his own. He knows what moves him and what he wants, but does not see it as relating to him in any way; consequently, he has all he desires, but he can’t enjoy any of it. Christopher Lasch observes (1984, p. 19) that “it is this confusion of the self and the not-self—not ‘egoism’—that distinguishes the plight of Narcissus.” So Lasch, at least, has some sense of how the myth works. We are still left with the question: what brought the story of Narcissus to be associated with the egoistic epithet that is so ubiquitous in the pages of The New York Times, at least since November 2016?

This confusion of Narcissus and the self-satisfied egoist is not a recent phenomenon, dating back at least to the later 19th century: Näcke, as reported by Freud, first uses the term “narcissism” in a psychiatric context to “denote the attitude of a person who treats his own body in the same way in which the body of a sexual object is ordinarily treated—who looks at it, that is to say, strokes it and fondles it till he obtains complete satisfaction through these activities” (Freud, 1914/1957, p. 73). This is striking because this is precisely what did not happen for Narcissus—he could never even figure out that the image he saw in the water corresponded to his own person; besides which, he never got sexual gratification at all, contra Näcke’s narcissist.

            It does not help clarify matters that in this text, Freud uses “narcissism” to describe different types of people in very different ways: does the narcissism of the psychotic, for example, relate to the narcissism of a woman or a homosexual, a person suffering from toothache (p. 82), or a parent (p. 91)? However, given all the confusion that surrounds the definition of narcissism, perhaps Freud’s lack of clarity is the most judicious way to approach the problem.

            Well before Freud developed a theory of narcissism, he was dealing with something very similar to the problem of Ovid’s Narcissus, I believe: a tension between how aware one is of oneself and what the subject of psychoanalysis is. Simply by labeling the conscious part of the subject “the I” (das Ich), he was making the point that “I” experience myself as what “I” am, even though there is a great deal more to the human subject than that self-awareness. Just as Ovid was making light of the Greek injunction to “know thyself” in describing the seer’s prediction to Liriope, Freud recognizes the problematics of self-knowledge at least from the time of his Project, where he first refers to the conscious self as “the I”.

            But again, this was not a particularly new idea by the time Freud was writing to Fliess. To take only one example of the questioning of self-awareness, there is one of Freud’s favorite writers, Nietzsche, for whom self-knowledge is an endlessly problematic idea: hardly a passage of The Gay Science (Nietzsche, 1887/1974) does not at least elliptically address the issue. Or consider the other father of modernity, Marx, who early in his career confronts the problematics of the subject. Eagleton summarizes an element of Marx’s second thesis on Feuerbach:  “…to know yourself in a new way is to alter yourself in that very act; so we have here a peculiar form of cognition in which the act of knowing alters what it contemplates. In trying to understand myself and my condition, I can never remain quite identical with myself, since the self which is doing the understanding, as well as the self understood, are now different from what they were before.” (1999, p. 4). Marx, like Nietzsche, Freud, and Lasch, understands that self-knowledge is always problematic, and it is problematic in ways that, at least since the 19th century, we have come to think of as narcissistic.

            I would suggest that one of Freud’s most attentive readers, Jean Laplanche, captures most succinctly the problem of narcissism for psychoanalysis: “What is at stake here, in Freud’s hesitations”—the various starts and stops Freud applies to this notion of narcissism—Laplanche (1970/1976, p. 74) notes, in a chapter on “The Ego and Narcissism,” “is, in fact, the actually ambiguous status of the ego: the ego, even though it is a reservoir of the libido cathecting it, can appear to be a source; it is not the subject of desire or wishes, nor even the site in which the drive originates… but it can pass itself off as such.” Like Narcissus, Freud’s ego thinks it has everything figured out: it is simply a matter of what one (correction: one’s ego) knows. Then something else happens and the certainty is lost.

            So why don’t we call the study of Marx, Freud, and Nietzsche “Narcissism Studies”? Had I never read The Americanization of Narcissism (Lunbeck, 2014) and Illusions of a Future (Schechter, 2014), I might never have asked myself that question. Reading Lunbeck and Schechter’s works, however, I found myself returning several times to questions of how and why we use the concept of narcissism in the way we do.

            Elizabeth Lunbeck’s The Americanization of Narcissism (2014) was widely reviewed when first published in non-academic journals like Bookforum, The New Yorker, Boston Review and others (Accocella, 2014; Camp, 2014; Gornick, 2014; Scialabba, 2014; Tumber, 2014). The author was interviewed in The New Republic (Robb, 2014), and also released a YouTube video in which she discusses the book. I was struck by this, because there is no other academic monograph focused on psychoanalysis I know of that has achieved such public recognition outside the academy. The book also won a prize from the American Psychoanalytic Association, the 2015 Courage to Dream award. 

            Lunbeck approaches the topic of narcissism from a very specific perspective: a critique of the way American social critics in the 1970s used the concept as it was being reworked by psychoanalysts, especially Kohut and Kernberg. She introduces her book by first describing the way she perceives those social critics:

It is a commonplace of social criticism that America has become, over the past half century or so, a nation of narcissists. Greedy, selfish, and self-absorbed, we narcissists are thriving, the critics tell us, in the culture of abundance that is modern, late-capitalist America. The disciplined, patriarchal Victorianism under which our stalwart forebears were raised has purportedly given way to a culture that asks nothing of us while at the same time promising to satisfy our every desire. (p. 1)

and then explains the relationship of these critics to developments in psychoanalytic thinking in the American Psychoanalytic Association:

Critics might never have latched on to the term and its meanings if not for the appearance of path breaking works on narcissism, in the late 1960s and early 1970s, by the Viennese émigré analysts Heinz Kohut and Otto Kernberg, which generated both excitement and fierce controversy among psychoanalysts. Celebrating what others condemned, Kohut boldly reframed narcissism as a desirable, even healthy, dimension of mature selfhood. He consistently underscored narcissism’s positive aspects, arguing that it fueled individuals’ ambitions, creativity, and fellow-feeling… (p. 3)

            As noted above, Lunbeck comments that narcissism means too many different things, in too many different contexts, to have a clear and clearly agreed-upon meaning. At the same time, it is too important to not be a focus of a great deal of attention. This seems to me a very striking observation, but it is also one that Lunbeck never develops further, so that we are left with the question, why should this be so? Also, from the beginning of her book it is clear that Lunbeck is raising another question: is narcissism a problem for society, or is it something more problematic than pathological, and, therefore, merely misunderstood by the social critics who decry it, rather than being a source of difficulty for the culture at large? From the ways she talks about the various approaches to narcissism of the social critics she is concerned with, especially Christopher Lasch, and the rethinking of narcissism she attributes to Kohut and Kernberg, it would appear that she sees narcissism more as a good thing than otherwise. But that doesn’t really address the paradoxes she describes at the beginning and at various points throughout her monograph: what makes narcissism impossible both to define and to ignore? And is it a real problem, or just a question of one’s perspective?

            Related, I believe, to these questions, is another one: what made it important to write this book now? It is a very pointed study of a trend in criticism of American society that became most prominent during the presidency of Jimmy Carter (described by Lunbeck as “part culture critic, part preacher-in-chief” [p. 13] because of his “malaise” speech), juxtaposed with a very detailed report on some developments in theorizing within the American Psychoanalytic Association that were going on in the same decade. Both of these have long since become old news: the influence of Lasch’s thought on public discourse since the appearance of his bestseller The Culture of Narcissism (1979) is close to nil, as one reviewer of this book noted (Camp, 2014); furthermore, it is hard to imagine that many people outside the world of clinical psychoanalysis have an interest in developments in the field, especially almost forty years after the fact. So why even go there?

            Reading with these questions in mind, I found myself thinking of how the concept of narcissism is used by the various players in the book. In this regard, Lunbeck’s description of Freud’s use of the term troubled me. For him, the author states, a healthy self was one “without needs” (p. 114), while psychoanalysis began as “a severe science of man” (p. 49). In fact, per Lunbeck, “Psychoanalysis at its inception had valorized independence, self-sufficiency, and freedom from needs, the same values Lasch was promoting in the 1970s” (p. 114).   I confess to being surprised to learn that that is what early psychoanalysis valorized. More surprisingly, I was struck by Lunbeck’s accusation that Freud, in his conceptualization of “primary narcissism,” did not recognize a distinction between fantasy and reality in his depiction of “the infant as omnipotent in its majestic independence, its narcissism expressed in its autoerotic love of self….Construing infancy as a state of sovereignty, [analysts] consistently blurred lines between fantasy (the infant as independent) and social relations (the infant as perforce dependent)...” (p. 114). She contrasts this with Kohut and Kernberg, who both make this distinction.

            This all has to come as a surprise to anyone who has studied the texts in question, because there is no doubt that Freud understood that primary narcissism was a fantasy of power, not a claim of fact, and that even among the dimmest of his followers, then or now, whatever controversies there were concerning the nature of primary narcissism—after all, the infans is not telling us how powerful she feels—nobody was making the claim that the child is or should really be “without needs,” though Lunbeck goes on to express incredulity at this misconception for a few more pages. Further, it is confusing how Lunbeck understands this: on the one hand, Freud, she says, is making the category mistake of treating a fantasy of omnipotence as a reality. At the same time, she seems to be saying, as noted above, that Freud “valorizes” this independence. It is entirely unclear from this what she is conveying that Freud is saying about primary narcissism: is it a fantasy of independence that he wishes were true but really is not, or is it a reality that he “valorizes”?

            Throughout this section, the author ties Lasch and those 70s social critics to these “classical” analytical positions. On the very next page, after making these confusing claims about what Freud said about primary narcissism, she asserts that

Lasch and his fellow social critics adopted this Freudian fantasy of the self without needs to condemn what they argued was a ubiquitous, feminized dependency threatening the body politic. The critics’ indictment gained force as they joined it to a critique of consumer society structured around a profound distrust of desire and fantasy, wants and needs (p. 115).

Here, as in her introduction to the text, Lunbeck links the critique of narcissism to the economic structure of contemporary society. But here, as also in her introduction, she does not address that link: what does “consumer society” or “late-capitalist America” have to do with narcissism? 

            I would like to suggest that here we start to get an answer to at least one of the questions I raised earlier: why write this book now? Lunbeck is lining up opposing sides in a conflict that has not really been defined: on the one side are “classical” analysts—chief among them Freud—who are committed to a way of seeing healthy people as totally “independent,” which would seem to mean even in infancy, strange as that seems. Aligned with this position are the social critics of the 1970s who, per Lunbeck, share these views. On the other side are “consumer society,” Heinz Kohut, and Otto Kernberg. At no point in her text does Lunbeck clarify how the socialist critique of late capitalism as presented by Lasch, or any other of the social critics she discusses,. is also a denial of “desire and fantasy, wants and needs.”    

            The way Lunbeck uses the concept of narcissism here is worth looking at in some detail. Per her reading, it is either a “Victorian” denigration of contemporary society or a healthy expression of “desire and fantasy, wants and needs.”  I.e., there is nothing in the concept of narcissism that is inherently a problem, except that thinking makes it so. She has made the entire issue of consumerism merely a matter of point of view: to Victorians like Freud and Lasch, consumerism is morally opprobrious; to the more enlightened, for whom narcissism is not an inherently bad thing, it is the means to freedom. 

            Consider the way in which, in the chapter on “gratification” (Lunbeck, 2014, pp. 164-201), she links a certain technical recommendation and developmental argument in Kohut’s work to the social criticism of Lasch’s The Culture of Narcissism (1979/1991). After going in great detail through a reading of issues related to the clinical theory of narcissism, she moves on to a discussion of Kohut’s developmental theory of “optimal frustration” and the developmental and clinical theory of gratification that arose from that work. Immediately afterwards, she relates her summary of Kohut with the main theme of her book: 

Me-Decade cultural critics associated narcissism with bottomless greed and blissful gratification, largely unaware that asceticism figured importantly in Freudian orthodoxy. Philip Rieff, Daniel Bell, and others lamented that asceticism as a cultural ideal had disappeared… (p. 194)  

She quickly makes the point that Lasch, who references Kohut in his own work, gets him completely wrong, radically misunderstanding the whole point of the theory of “optimal frustration.” She footnotes her argument by stating, “Lasch’s tendentiousness can be glimpsed in his confident assertion that love of the child ‘came to be regarded not as a danger but as a positive duty’” (Lunbeck, 2014, p. 330). This would indeed appear to be an obnoxious and wrong-headed take on the concept of “optimal frustration.” However, in looking up the reference in Lasch’s book, it is hard not to see Lunbeck’s use of it here as misleading. The line she quotes, which is 10 pages from the closest reference to Kohut, is part of a discussion of the development of “experts” in childrearing in the early decades of the twentieth century. As Lasch describes it, the growth of the “science” of childrearing was a consequence of the growing force of capitalism. The movement from an effort to remove parents from the picture entirely to one that favored “permissiveness” was his focus in this comment. Further, he explains his arguments in terms of the work of Hilde Baruch, a child analyst, pointing out that she

grasped the social and cultural transformation that has made science the handmaiden of industry—in this case, psychiatry the handmaiden of advertising, which enlists psychiatry in the attempt to exploit “parents’ desires to do right by their children.” By keeping parents in a state of chronic anxiety, psychiatry thus frustrates desires that advertising can then claim to satisfy. (Lasch, 1979/1991, p. 164)

            What is most striking in this is not simply that Lunbeck has misrepresented Lasch’s point, but she has done so in a way that completely ignores his larger argument: the problem with narcissism is not simply a matter of the definition of the concept or of tolerance of difference—how “ascetic” or “Victorian” one expects normal people to be—but is intimately connected to social issues. Also, he is tying narcissism to the question of what one knows: in this example, psychiatry has disturbed the self-understanding of parents, so that they are drawn to buy things to help them learn how to be better parents.

            More striking still is the argument Lunbeck makes regarding the relation of gratification and capitalism immediately after she has introduced the Me-Decade social critics in this. In particular, when she juxtaposes a critique by Daniel Bell (“’The one thing that would utterly destroy the new capitalism is the serious practice of deferred gratification,’ he wrote” [Lunbeck, 2014, p. 195]) with the argument of “the adman Ernest Dichter”: 

Dichter had, in 1960, made much the same point, arguing that the “economy would literally collapse overnight” were people to restrict themselves to fulfilling “immediate and necessary needs.” Dichter updated Thorstein Veblen’s work, suggesting that the gratification, thrill, and enjoyment to be found in using products ranging from cars to golf clubs to dictating machines, not their value as status symbols, accounted for their irresistible attraction to consumers. Where else but the marketplace would individuals experience satisfactions as intense as those afforded by the “first few minutes” with your new television and the first ten minutes driving your new car? Such pleasures, he argued, were unequaled, never again to be duplicated in the course of life. (Lunbeck, 2014, p. 195)

I found this argument confusing, but also relevant to two questions I raised earlier. First, it seems clear that Bell and Lasch, as reported by Lunbeck, are making a claim for a kind of problem that they are calling by the name “narcissism” that involves the consumption of goods that are not necessary for life, but which support this economy; by way of contrast, Lunbeck is arguing, with the help of the adman Ernest Dichter, that the pursuit of satisfaction through the enjoyment of consumer goods is not really a problem at all. (Except that the satisfaction does not seem to last very long—a matter of minutes, in these examples. But that is a problem for the consumer, per Dichter, not capitalism; indeed, the brevity of the enjoyment insures that the consumer will soon buy more cars and televisions.) Veblen’s theory of planned obsolescence—which is not elaborated further in Lunbeck’s discussion—assumed that the goal of the leisure class was to enhance prestige with ever-newer Things (Veblen, 1899/1994); Dichter makes the point that this isn’t really the case, per Lunbeck: it’s not prestige people are after, it’s enjoyment. This would appear to mean, then, that the problem is not consumerism, but the idea that enjoyment, as opposed to prestige, is morally opprobrious. To Bell, keeping capitalism going as it was in the 1970s would appear to be a bad thing; to Dichter, it is best for the commonweal that we all enjoy life as unselfconscious consumers, because that is how capitalism is maintained: there is no problem in pursuing an enjoyment, as opposed to a prestige. So we are back to the question I raised earlier: is there a problem in the world, regardless of what we name it, or is the problem that Bell and Lasch and the other social critics Lunbeck presents in her book. are just looking at things from an antiquated perspective? Lunbeck and Dichter’s argument here is based on the self-image of the consumer: I’m excited not because I have prestige, but because I’m enjoying myself. Here, again, the focus is entirely on how one sees the image of the happy consumer; there is no sense of anything beyond the question of the image.

            Indeed, reading Lunbeck, one could be forgiven for assuming the social critics she is describing were political and social conservatives of the highest order. She does mention that their critique is related to concerns about capitalism, but she does not say anything about what, specifically, that concern is. She goes to great lengths to critique Lasch’s arguments about authority in the family, for example, but never relates these to his larger point regarding capital, as outlined in the discussion of family planning I describe above. One could easily imagine that the most likely place to find these guys in the 1970s, after reading Lunbeck, would be standing next to Phyllis Schlafly at an anti-Equal Rights Amendment rally or at a Reagan fundraiser. The fact that social conservatism is not the point of the critiques presented—that Lasch even refers to socialism as a positive force (1979/1991, pp. 205-6; 232ff.)—is never mentioned.

            It is striking that Lunbeck sets up the contrast between Lasch and psychoanalytic authority for another reason: American psychoanalysis in the 1970s was a medical subspecialty. For a cultural critic like Lasch to hold forth on narcissism—a medical diagnosis—was tantamount to a physical education teacher diagnosing heart failure. This brings in an entire medical focus that is not obviously relevant when one reads Lasch. For example, Lunbeck makes the point that “Kernberg rejected the Laschian notion that society could produce narcissism…” (2014, p. 69), and does not really address the issue of cultural influence again. Not only might there be a lot more to say on the question of the influence of culture on the personality, but the point driven home is that such influence is irrelevant. Even in what she quotes from Kernberg, there is not a wholesale rejection of the idea that cultural forces may influence the expression of a psychiatric problem; rather, the psychiatrist makes the claim that cultural influence cannot cause the problem that would not have existed otherwise. Since Lunbeck does not reference a response to that claim by Lasch, we do not know if he would have argued this point.“As our case descriptions in clinics and conferences pile up, the wealth of evidence that the ‘normal’ home, as well as the broken home, fosters malnutrition, [etc, etc]…the conclusion grows, not that parents need education, but that a specialized agency had  better take over the whole matter of child rearing.” Quoted by Lasch (1979/1991, p. 159), from a book by Miriam Van Waters (a judge writing in the 1920s), Parents on Probation.

Another striking element in this argument in particular is his focus on the importance of contraception in the view of how political forces would impact the workings of a family. In this, his arguments are entirely consistent with Foucault’s conception of “biopolitics” (Foucault, 1976/2003, pp. 231-264). While this is entirely irrelevant to Lunbeck’s work, it does have a major role in Schechter’s (2014).

Italics added.  CONTINUED

Continued.....

            Time and again, the “Me-Decade social critics” she is writing about are dismissed in this way. Again, if they are so hopeless, why talk about them at all? And if they have some substance, even if there is something debatable in what they write, why not flesh it out more? In this example, of course, to dismiss the role of culture in the expression of narcissism is to dismiss the critique of capitalism on which the argument is based. But it is clear throughout the book that Lasch has no chance: the whole point of the book is that Lasch is irrelevant.

            By the time we get to the concluding chapter of the book, it is not hard to make a case for how Lunbeck (2014) is using narcissism when she quotes The New York Times columnist David Brooks, who lamented “that ‘grandiosity is out of style’”:

Collectively chastened by a financial crisis that was “fueled by people who got too big for their britches,” Brooks argues that we have traded boldness for caution, and calls for “a grandiosity rebound” to encourage the unpleasant, “ridiculously ambitious” people who can revive the nation’s once-formidable prosperity. “Most of all,” he writes in a challenge to the Laschians still among us, “there has to be a culture that gives two cheers to grandiosity,” even as he highlights the character flaws and limitations of the grandiose. Bold and creative, ruthless and soulless: Brooks’ cultural ideal, the entrepreneurial wizard as twenty-first-century narcissist, “has the vices of his virtues”. (Lunbeck, 2014, p. 253)

            Brooks (2012) was of course lamenting the aftereffects of the global recession of 2007-2008. This is the only place in her argument where Lunbeck mentions the financial crisis, but the existence of the financial crisis does offer an answer to my earlier question, why this book would be written now. She goes on to praise as model narcissists specifically Steve Jobs and Jack Welch. Here at the end, again, the point seems to be mostly that something can be thought of as a problem by people like Lasch, but really not be a problem at all. The “narcissistic” pursuit of pleasure is inextricably bound up in Lunbeck and Brooks’ reading with extreme wealth—but is it a problem, or is it just progress? “Progress is a moral judgement by a creature that loves to regard itself in the mirror” observes Paul Verhaeghe (2012/2014, p. 60), and one may infinitely rethink one’s judgments.

            But this is also a great example of how one may “use” narcissism. In this sense, Lunbeck’s book is an example of what Lasch and Ovid would call narcissistic, precisely because it is entirely focused on image. There is no problem addressed in the book that is not simply a matter of how one looks at it: that the “grandiosity,” as Brooks calls it, of the wealthy and ruthless may have played a part in the Great Recession is not relevant to Lunbeck’s argument. In the end, Lunbeck simply assumes that “healthy narcissism” is a characteristic of those who are most successful in the neoliberal economy simply because they are the most successful. Several times she makes the claim that Steve Jobs and Jack Welsh et al., the “ridiculously grand,” as Brooks (Lunbeck, 2014, quoted p. 254) called them, “are necessary,” without questioning why that is so. It is the image of the wildly successful that proves their necessity for the rest of us. However, Paul Verhaeghe, in his own recent study of narcissism and late capitalism (again, it is striking how these two topics seem to come together these days), discusses research that provides evidence that “[t]oo much economic inequality leads to a loss of respect, including self-respect—and, in psychosocial terms, this is about the worst thing that can happen to anyone” (2012/2014, p. 198). So, it would seem that there really is a problem at some level. Image is not everything.

            Kate Schechter’s Illusions of a Future (2014), published in the same year as Lunbeck’s book, also won the Courage to Dream prize from the American Psychoanalytic Association, though her work did not elicit the interest of the non-specialist media that Lunbeck’s received. Even in the Journal of the American Psychoanalytic Association, where it was reviewed in tandem with Lunbeck (Munich, 2016), Schechter’s book was cursorily dismissed (Carlson, 2016), while Lunbeck’s was viewed much more favorably. While Illusions of a Future is not a study of narcissism as such, it is very much concerned with the ways that psychoanalytic theory, and especially the theory of narcissism, is used. Schechter, a medical anthropologist by training, was a candidate at the Chicago Institute for Psychoanalysis, where this research was centered. While her focus is quite different from Lunbeck’s, a subtext of both books is the way theorizing and conceptualizing narcissism influences, and is influenced by, the larger issues raised in their respective works, be it the history of the 1970s in the USA or the fortunes of a large and storied psychoanalytic institute. The ways in which this motif is developed, however, could hardly be more different.

            Schechter announces the thesis of her work thus:

This book examines the development of the analyst-patient relationship as an occult object, a professional artifact that psychoanalysts at once disavow and espouse. I suggest that today’s psychoanalysts, in their effort to transcend their fears of irrelevance, play on the real relationship in a way that ends up heightening that very irrelevance. In effect, I argue, in seeking to resolve a conundrum that is central to their practice, in seeking to maintain themselves as psychoanalysts when they cannot practice what they define as psychoanalysis, they trade the real relationship against disciplinary failure. (Schechter, 2014, p. 2)

As I understand her point, Schechter is arguing that clinical psychoanalytic theory is molded in large part by the cultural context in which the practice occurs—specifically, a context in which psychoanalysis is increasingly seen as irrelevant—rather than by the progressive development of a science that more typically informs the narrative of how psychoanalytic theory has developed over the years.  

            Schechter also makes a claim for the specificity of psychoanalysis that seems to address observations about its ambiguity, such as Lunbeck’s description of how narcissism is defined, discussed above, or Kravis’s (2013) discussion of the analyst’s hatred of the ambiguity of analysis. Here, Schechter seems almost to be directly addressing Lunbeck’s observations on the ambiguous nature of narcissism a few pages on in her introduction, when she makes a note of “the intensification under neoliberalism of psychoanalysis’s problematic undecidability” (p. 8). For Lunbeck, the ambiguity of narcissism is a timeless feature of its existence; for Schechter, the “undecidability” of psychoanalysis is a product of its place in contemporary culture, not something inherent in psychoanalysis itself. She goes on to argue, in contrast to many critics of psychoanalysis, like Ian Hacking and Nikolas Rose, but also and for entirely different reasons in contrast to Lunbeck, that

the rationalization of psychoanalysis over the course of the latter half of the twentieth century presents a unique biopolitical trajectory precisely because of the centrality of forces and forms of disruption, both psychic and social, to the Freudian problematic: the negative, the death drive, ambivalence, the unconscious id, the repetition compulsion, the uncanny, the “beyond” (as in beyond the pleasure principle). It is the reflexive, disruptive tendency of psychoanalysis that distinguishes its rationalization from those processes of rationalization in other professions caught up in the shifts in governance characteristic of postmodernity. (pp. 9-10)

This is the most central point of the book. For Schechter, psychoanalysis is a legitimate discourse because it is disruptive of the “shifts of governance” characteristic of other discourses in our time. Further, this speaks to the disruptive nature of Ovid’s Narcissus story. It is a story about the failure of knowledge, which was also Lasch’s point when writing about narcissism. Ovid turns Plato’s injunction to “know thyself” on its head. Importantly, this is a very different kind of ambiguity from that proposed by Lunbeck. The psychoanalytic project, per Schechter, is specifically about the problematics of self-knowledge. And this is something that the neoliberal order would rather go away.

Consider, as one rather obvious example, the idea of defining emotional suffering by a series of “yes/no” answers to questions about symptoms—that is, by using the DSM as it exists today. This approach to mental health privileges a strategy for dealing with and understanding this emotional suffering in a way that inevitably satisfies the requirements of late capitalism: anything that gets in the way of the efficient workings of consumerism can be disposed of simply by changing a few answers on a checklist of symptoms. Verhaeghe’s discussion of the logic behind the symptom checklist model of the DSM (2012/2014, pp. 183-196), with its brilliant use of an analogy between the DSM model of diagnostics and the idea of diagnosing medical problems entirely as symptoms (e.g., “high fever” and “excessive sweating” as symptoms on a checklist), shows how the dominant model of psychiatric diagnosis obviates any awareness of a more complicated problem, be it the impact of extreme income inequality on mental health or the vicissitudes of life experience and unconscious fantasy in creating the symptom. In other words, the DSM is conceptually much more in the service of the economic status quo than it is in the service of any meaningful concept of mental health. As a psychiatric intern in the late 1980s, I was assigned a patient on the geriatric psychiatric ward whose symptom of loss of pleasure, or “anhedonia”—one of the cardinal features of the DSM-III-R diagnosis of major depression—was that, after years of sitting in the living room and doing nothing but watching television, she had stopped turning on the television. The fact that watching television was all this person had done for years, or other possible implications of her failure (sic) to continue doing so, was irrelevant to the assessment of this person’s condition. It also made a solution to her problem straightforward: we just had to get her to turn the TV on again.

            From this perspective, the very idea of fitting in with the medical and scientific world as it exists today is highly problematic for a field that depends on its capacity to be disruptive—of the governance of society or of the individual ego—such as psychoanalysis at its inception undoubtedly was. So how can one be both a mental health professional, compelled by the rules of the profession to use the nosology and theoretical bases of our time, and a psychoanalyst? “How and why,” Schechter asks (p. 21), “in the face of a broad corporate-state-consumer demand for rationalization and accountability in health care [i.e., in the face of the demand for “evidence-based practice”] does a community of psychoanalytic practice and argumentation inhabit and expand on its own contrary demands, desires, fantasies and fetishes?” As Schechter shows us, in her several interviews with practicing psychoanalysts, it ain’t easy.

             Schechter’s book is organized around these interviews. Each of her interlocutors acknowledges that there is a “crisis” in the profession, a crisis that has only grown since the 1970s—which fact makes for an interesting temporal connection to Lunbeck’s book. But, while everybody is agreed that there is a crisis, both of medical/scientific/cultural relevance and of financial viability for practitioners, there is a very wide range of ideas about what the crisis actually is. Thus, for some, it is the de-medicalization of psychoanalysis as a consequence of the lawsuit against the American Psychoanalytic Association that forced the issue of training non-physicians that led to the crisis; for others, it is the failure of psychoanalysis as a profession to provide empirical evidence of its validity that is the problem. The main focus of Schechter’s attention is a questioning of these various arguments for why the crisis exists, and how they have been used by the clinicians who make them, emphasizing the ways in which the theorizing of psychoanalysis responds to the crisis in analytic practice.

            After describing the distinction between psychoanalysis and psychotherapy that was formulated by the ego psychologists who were dominant in the CIP in the 1970s (pp. 41-46), Schechter observes that “it began to appear during that era as though the medical monopoly that underwrote psychoanalytic exclusivity was, in effect, putting psychoanalysis out of business” (p. 48). This happened, she argues, because analysis had a very precise (if completely circular) definition: it was the purely interpretive treatment of patients who were defined as analyzable. Further, this definition was very compatible with a “hierarchical” division of mental health labor, with psychiatrists at the top of the hierarchy. As Jonathan Lear has observed (1998, p. 18), “In the short run, this [division of labor] allowed the psychoanalytic profession to take advantage of the powerful positive transference which the American public extended to doctors through most of [the twentieth] century.” Over time, the definition of who was analyzable and what was an appropriate analytic intervention became much less straightforward, pari passu with the increasing scarcity of analytic patients. This in turn created a new problem for the theory of analysis, as it went from rigidly defined to something else—a something else that became increasingly “undecidable”. Talking with one of her interviewees who describes herself as relationalist in her theoretical orientation, Schechter asks “In terms of how you think about analysis… what is not analysis?” (p. 69). “That’s a good question” is the response, followed by “I guess if you put it that way I can’t think of anything.” Like Lunbeck’s description of narcissism as completely amorphous, analysis itself becomes infinitely malleable. It can be anything. And, of course, a given analysis can last forever, as long as the analysand comes to at least four sessions per week. But in the process, what Schechter sees as the “specificity” of psychoanalysis, its role as a disruptive discourse, is completely lost.

            It is important to note that Schechter is not arguing for the superiority of the pre-1970s model of clinical practice at the Chicago Institute. In noting, for example, that “In the era of the success of psychoanalysis, top psychoanalysts like [Maxwell] Gitelson had not needed the patient, either economically or (they believed) psychically” (p. 177), she points out another “pitfall of the business of getting a living”, a phrase she quotes from the anthropologist Edward Sapir (p. 69). The Chicago Institute was set up to maximize an idealization of the master analyst, a procedure that was highly favorable to pecuniary gain, at least for said masters, but one that was also not obviously more relevant to the “specifics” of the psychoanalytic enterprise than were subsequent theoretical developments. At the same time, the fact of the organizational hierarchy had enormous and unexamined effects on the process of psychoanalysis itself. The implications of this for analytic practice as described in Schechter’s work were profound.

            Schechter concludes her book with a chapter entitled “On Narcissism”, in which she describes a trajectory of psychoanalytic theory from ego psychology to relationalism that maps onto a trajectory of analytic practice from social prestige and financial success to cultural irrelevance and less obvious material success. In the process, the analyst’s view of himself is the hidden motivation, she argues, for how practices develop: so long as the patient needs the analyst, the analyst is sufficient unto himself, with no need for the patient; when the patient does not need the analyst—and has to be “converted”, no less, to participate in an analysis—the analyst’s self is much more vulnerable. It is in the context of the fall in prestige of psychoanalysis that more than one of Schechter’s interlocutors describes their own sense of narcissistic injury.

            This analytic self has, over time, become minimal, to borrow from a Christopher Lasch title (1984). In the process, the analyst has had to abandon more and more of the specificity of psychoanalysis, until finally he has had to practice in a way that merges more and more with the dominant market culture—exactly what Lasch argued happens to minimal selves under consumerism, as a matter of fact.

            Schechter sums up her work thus:

As a means of governing risk up close, the real relationship is an indigenous insurance policy that makes the analyst’s vulnerability seem manageable, calculable; it is a way of spreading risk and doing so on the analyst’s own theoretical terms. If neoliberal subjectivation blends distinctions between love work, politics, and life itself, it is through such intimate, risky relationships that psychoanalysts, dreaming of security, come to imagine their world as one of uncommodified “real” care, their affective labor as a form of sociality that is prudentially able to calculate quasi-familial, “real” dependencies. I have suggested, then, that this charged relationship emerges into view in a compensatory embrace of the very neoliberal logics of accountability that lead the desiring professional to remove the sexual, the drive, the unconscious, and the paternal law of desire from psychoanalysis, mutating it in a series of self-referential, self-authorizing labors of coordination with audit culture’s ideology of the preferred provider. (2014, pp. 185-186)

It’s not a pretty picture. If this is how psychoanalysis goes, then maybe it is an illusion to imagine it has a future. That being said, it seems implicit in her entire discussion that there is a way forward that is not so illusory: to simply do the “specific” work of psychoanalysis in a way that is cognizant of and consciously resistant to the forces that have decimated psychoanalysis since the 1970s. This would be a bold and challenging move, but it would be consistent with the role that psychoanalysis had (and continues to have, in some situations) as a creative and disruptive force in the lives of our patients and in the culture at large.

            Schechter ends her book by quoting one of her interview subjects in a way that is both more hopeful for a future and more specific to what psychoanalysis is: “‘It is reasonable,’ he said, ‘to expect that the fact that we are discussing the vicissitudes of narcissism will be most helpful in working through the narcissistic issues involved in the process of discussion’” (p. 187).

            Liriope was told that Narcissus would have a long life so long as he did not know himself. More than Ovid taking a crack at Plato, this speaks to a profound truth exemplified in both The Americanization of Narcissism and Illusions of a Future:  narcissism becomes a problem when the world, including our place in it, does not meet our (narcissistic) expectations. Both books address periods of uncertainty in self-understanding, whether at the Chicago Institute for Psychoanalysis or in the larger world of 1970s America. In both situations, how people understand themselves and their world has reached a crisis, as also happened in a different way after the Great Recession, when these books were being written. The differences in the way the two authors address the problematics of knowing oneself are instructive. I would suggest that the distinction between the “ambiguous” nature of Lunbeck’s narcissism and the “specificity” of Schechter’s psychoanalytic focus defines the distinction in the way these authors use the concept. For Lunbeck, narcissism pushes the neoliberal economy forward, as did Jobs and Welch: it’s just a question of how we look at it. For Schechter, it is the mark of our hopeless lack of self-awareness. Where does psychoanalysis as a clinical establishment stand between these two perspectives?

 As Robert Creeley (1991) has it:

            God knows

nothing is competent nothing is

all there is. The unsure

egoist is not

good for himself.

 

           

References

            Accocella, J. (2014, May 12). Selfie. The New Yorker, 77-81.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.

Brooks, D. (2012, September 21). Temerity at the top. The New York Times, p. A29.

Camp, J. (2014). The Americanization of narcissism by Elizabeth Lunbeck. Bookforum. Retrieved from http://www.bookforum.com/review/13398 

Carlson, D. (2016). Review: Illusions of a future: Psychoanalysis and the biopolitics of desire. Journal of the American Psychoanalytic Association, 64/1, 245-249.

Creeley, R. (1991). The immoral proposition. In Selected Poems. Berkeley, CA: University of California Press.

Dodes, L. (2017, February 13). Mental health professionals warn about Trump. The New York Times, p. A26.

Eagleton, T. (1999). Marx. Abingdon, UK: Routledge.

Foucault, M. (2003). “Society must be defended”: Lectures at the College de France, 1975-76 (David Macey, Trans.). New York, NY: Picador. (Original work published 1976)

Frances, A. (2017, February 14). An eminent psychiatrist demurs on Trump’s mental state. The New York Times, p. A26.

Freud, S. (1957). On narcissism: An introduction. In J. Strachey (Ed. and Trans.), Standard edition (Vol. 14, pp. 67-102). London, England: Hogarth Press. (Original work published 1914)

Gornick, V. (2014). In defense of narcissism. Retrieved from https://www.bostonreview.net/books-ideas/vivian-gornick-defense-narcissism-elizabeth-lunbeck-christopher-lasch-feminism

Kravis, N. (2013). The analyst’s hatred of analysis. The Psychoanalytic Quarterly, LXXXII, 89-114.

Laplanche, J. (1976). Life and death in psychoanalysis (Jeffrey Mehlman, Trans.). Baltimore, MD: Johns Hopkins. (Original work published 1970)

Lasch, C. (1991). The culture of narcissism: American life in an age of diminishing expectations. New York, NY: Norton. (Original work published 1978)

Lasch, C. (1984). The minimal self: Psychic survival in troubled times. New York, NY: Norton.

Lear, J. (1998). Open minded: Working out the logic of the soul. Cambridge, MA: Harvard.

Lunbeck, E. (2014). The Americanization of narcissism. Cambridge, MA: Harvard.

Munich, R. L. (2016). Review: The Americanization of narcissism. Journal of the American Psychoanalytic Association, 64/1, 250-252.

Nietzsche, F. (1974). The gay science (Walter Kaufmann, Trans.). New York, NY: Vintage. (Original work published 1887)

Ovid. (2004). Metamorphoses: A new verse translation (David Raeburn, Trans.). London, UK: Penguin Books. (Original work published 8 AD)

Robb, A. (2014, February 25). A little narcissism is good for you. New Republic. Retrieved from https://newrepublic.com/article/116748/americanization-narcissism-author-elizabeth-lunbeck-interview 

Schechter, K. (2014). Illusions of a future: psychoanalysis and the biopolitics of desire. Durham, NC: Duke.

Scialabba, G. (2014). The weak self: Christopher Lasch on narcissism. Retrieved from https://bostonreview.net/books-ideas/george-scialabba-vivian-gornick-christopher-lasch-narcissism 

Tumber, C. (2014, May 14). Dispatch from the narcissism wars. The Baffler. Retrieved from http://thebaffler.com/blog/dispatch-from-the-narcissism-wars 

Veblen, T. (1994). The theory of the leisure class. N. Chelmsford, MA: Courier (Original work published 1899)

Verhaeghe, P. (2014). What about me?: The struggle for identity in a market-based economy (Jane Hedley-Prole, Trans.). Brunswick, Australia: Scribe. (Original work published 2012)

Also to Paul Verhaeghe’s work, mentioned above: he dates changes in how we understand our identities to the 1970s (2012/2014, p. 39).

There is an increasing demand for us, as clinicians, to understand the digital lives of our patients. The framework I have come to employ in my practice is simple and, I think, not radical: to regard the patient’s relationship with the virtual world with the same curiosity, scrutiny, and compassion that one affords to their relationship with the corporeal one. This can be easier said than done, as there is substantial cultural and political noise that interferes with such a straightforward premise. Technologists, one on hand, espouse the transcendent nature of digital devices and media: how they make us better, smarter, and stronger. Conservative alarmists, alternately, decry our increased reliance on digital spaces as the decay of traditional values and an omen of society’s downfall: we are becoming antisocial, vain, and ugly — as though these qualities were new to the human condition.

As psychoanalytic psychologists it is our duty to maintain a heuristic of skepticism and see beyond the binary assertions of technology-as-savior or technology-as-destroyer, and instead focus on the paradoxical truth: digital space is both new and old, in that it provides us with novel ways to continue to be ourselves. As I have written about elsewhere (Kriss, 2016) with specific respect to videogames, the virtual world can offer a boundaried emotional experience akin to Winnicott’s (1971/2005) notion of potential space; a kind of proto-life in which experiences are simultaneously real and unreal, felt but not overwhelming. The fact of the matter is that all of our patients make some contact with this other world; we are symbiotically linked to it; parts of ourselves are uploaded to cyberspace as we curate our public personas, comment anonymously on articles and blogs, or simply play games idly on our phones. The question is no longer whether the digital is relevant to our patients but rather in what ways is it relevant.

Of course, this is not to deny that some people’s use of digital space is problematic. But understanding the nature of the problem — and therefore potentially making ourselves available to facilitate change — requires us to discard the simplistic cause-and-effect notions that technologists and alarmists propagate (technology leads to betterment or technology leads to disarray, respectively). We do this routinely with other aspects of psychic life, helping our patients to see beyond a reified sense of self. For instance, someone begins treatment with the narrative, “I am this way because my mother was cold and withholding, and as the past cannot be undone, I cannot change.” Is this any different from a mantra of “I am this way because I spend too much time looking at my phone, and as the digital world has sunk its claws into me, I cannot change”?

Much of the clinical discourse surrounding our relationships with digital selves occurs in the language of addiction theory: she is “hooked” on social media; he is “addicted” to the internet; they “can’t stop” playing this game. Crucially, the construct of addiction is centered around the idea that, while people vary in vulnerability depending on heredity and life experience, the addictive property lies within the thing itself. This is a compelling notion for substances like alcohol, nicotine, or cocaine — which chemically influence the brain to motivate future use — or even certain behaviors like gambling — which is specifically connected to the culturally valued promise of wealth acquisition.

Digital life doesn’t quite fit the bill. The internet is not a chemical you ingest, and thereby cannot exert immediate and consistent effects on the brain; nor do videogames promise material rewards that justify the amount of time so-called “addicts” put into them. The chief limitation to understanding digital addiction, then, is our use of the word “addiction.” It immediately frames the activity as a kind of infectious substance, obscuring what is really going on: compulsion. It is a small semantic change that carries a major shift in perspective. It is not the digital world which won’t release the individual from its clutches, but the individual who cannot bring herself to leave the digital world.

From a classical psychoanalytic perspective, a person engages in repetitive play as a means of recreating some trauma around which she feels “stuck,” in an unconscious effort to master the situation (Freud, 1920; Waelder, 1933). If playing fails to resolve her conflicted feelings, a compulsive loop can develop in which the person can neither abandon nor conquer the “game.” Each person has a unique reason for seeking solace in digital space, and sometimes this need is so intense that the behavior escalates to a level of pathological compulsion. But it is in understanding the internal motivation that relief can be found, not through condemning the digital world as inherently corruptive. For most people we treat, virtual space does not cause distress or play a significant role in their presenting problems; it simply occupies a portion of their psychic life, which, however big or small, should be seen as important by any empathic clinician.

WORKS CITED

Freud, S. (1920). Beyond the pleasure principle. S.E., 18, 3–64.

Kriss, A. (2016). The player and the game: Compulsion, relation, and potential space in video games. Psychoanalytic Psychology, 33(4), 571-584.

Waelder, R. (1933). The psychoanalytic theory of play. Psychoanalytic Quarterly, 2, 208–224.

Winnicott, D. W. (2005). Playing and reality. Abingdon, Oxon, England: Routledge. (Original work published 1971)

 

Reply

Karen Gilmore, M.D.

“We must make sense of our own times” (V Flanagan)

Alexander Kriss has written a timely plea for a more enlightened approach to our patients’ digital lives. He joins a number of clinicians, therapists, and psychoanalysts (including contributors such as Essig 2012, Lemma 2015 and myself (Gilmore 2017 in press; Meersand and Gilmore 2017, in press) in pointing out that the technocultural era is here to stay; indeed the daily experience of anyone living in our society is seamlessly mediated and continuous with digital space. There is no longer a distinction between virtual and actual. But like anything else, digital life can become an overwhelming focus, to the detriment of family relationships, school or employment, and physical well-being.  Kriss devotes a good part of his essay to an argument against the notion of internet/videogame addiction (which I will call IA), basing his contention on the absence of the chemical component that is the active agent in substance addictions. Like some researchers in the field (Aladwani and Almarzouq 2016), he prefers to describe excessive video gaming, social networking and the like as compulsions, distinguishing them from addictions by this designation.

Here he enters a debate that has a significant, albeit brief history in psychiatry and in the formulation of the DSM-V, where IA did not make the grade for an official addiction diagnosis. Heated controversy continues about this decision (see, for example, Pies 2009), especially as another behavioral addiction, gambling, was included among the addiction diagnoses. What is the argument in favor of the inclusion of AI? For one, in severe cases, interruption of usage can produce the array of behaviors associated with withdrawal. There is evidence that excessive users develop tolerance and that the activity has deleterious effects on schoolwork, job performance and relationships. There is also growing evidence that excessive immersion in video gaming (Han et al 2011; Ko et al 2009)), social networking (Vink et al 2015), and smartphone use (Liu et al 2016), to name a few examples, can produce brain changes consistent with other addictions. The literature from Asia has made this argument for many years, reporting smartphone addiction in infants, with characteristic brain changes (Park and Park 2014). There is no doubt that these activities produce altered mental states.

What is the advantage of calling these extreme users addicts? In my opinion, there is a considerable difference in the conceptualization and the treatment of the problem; Kriss’s description of the individual dynamics behind compulsions and the need to understand these dynamics are important, but working on this understanding, even with an insightful and cooperative patient, is of only limited benefit if the patient is addicted; it certainly does not treat the addiction itself. Addiction is the threshold problem that must be addressed in order work on psychodynamics. To quote a beloved in-patient psychiatrist, now deceased, no therapy is as good (and as immediately effective) as a drink. This applies to any addictive behavior that creates cravings, alters mood, induces state changes, produces withdrawal, and, of course, is perpetuated by compulsion. Addiction requires behavioral treatment; the dynamics can be addressed simultaneously or afterward.

 

Aladwani, A.M., Almarzouq, M. (2016) Understanding compulsive social media use: The premise of complementing self-conceptions mismatch with technology. Computers and Human Behavior 60: 575-581

Essig, T. (2012). Psychoanalysis Lost—And Found—In Our Culture of Simulation and Enhancement. Psychoanal. Inq., 32:438-453.

Flanagan, V.(2014) Technology and identity in young adult fiction: the posthuman subject. AIAA, 1841

Gilmore, K. (2017, in press) Development in the digital age: Introduction. Psychoanalytic Study of the Child.

Han, D.H., Bolo, N., Daniels, M.A. et al. (2011). Brain activity and desire for internet video game play. Comprehensive Psychiatry 32: 88-93

Ko, C.H., Liu, G.C.,Hsaio, S. et al.(2009) Brain activities associated with gaming urge of online gaming addiction. Journal of Psychiatric Research 43: 739-747

Lemma, A. (2015). Psychoanalysis in Times of Technoculture: Some Reflections on the Fate of the Body in Virtual Space. Int. J. Psycho-Anal., 96:569-582.

Meersand, P. and Gilmore, K. (2017, in press). Play therapy in the 21 st century. American Psychiatric Press Inc.

Park, C., & Park, Y. R. (2014). The conceptual model on smart phone addiction among early childhood. International Journal of Social Science and Humanity, 4(2), 147-150.

Pies, R.(2009) Should DSM-V designate “internet addiction” a mental disorder? Psychiatry (Edgmont). 2009 Feb; 6(2): 31–3)

Vink, J. M., van Beijsterveldt, T. C. E. M., Huppertz, C., Bartels, M., and Boomsma, D. I. (2016) Heritability of compulsive Internet use in adolescents. Addiction Biology, 21: 460–468.

 

“Response to Comments by Gilmore”

Alex Kriss, Ph.D

 

While my original piece focused on theory, Karen Gilmore brings up the equally important issue of technique. I agree with her wholeheartedly that for many suffering from digital compulsions, behavioral intervention may be a necessary first step to successful treatment. As with any acute situation, serious problems in daily functioning must be remediated before more reflective understanding can develop. I disagree simply with Gilmore’s suggestion that in order to engage with behavior and symptoms on a technical level, one must favor addiction over psychodynamics on a theoretical level. My argument is not that problems with digital life should only be addressed through formal psychoanalytic techniques such as interpretation, but that regardless of technique it is essential for the clinician — and ultimately the patient — to appreciate the problem’s point of origin.

 

About the Authors

Alexander Kriss, Ph.D. is a clinical psychologist and writer. He serves as an adjunct professor at Fordham University and clinical supervisor at The New School for Social Research and the City College of New York. For more information on Dr. Kriss’ private practice, visit www.alexkriss.com

Dr. Karen Gilmore is currently a Clinical Professor of Psychiatry and Senior Consultant at the Columbia University’s Center for Psychoanalytic Training and Research. She is the founder and past Director of its Child Division. She is a Training and Supervising Analyst at the Columbia institute. She is the author of a number of papers on development and co-authored two books on the topic recently published by American Psychiatric Press and Oxford University.

 

Tags: Alex Kriss, Karen Gilmore

Klug, G., Zimmerman, J., and Huber, D. (2016).  Outcome trajectories and mediation in psychotherapeutic treatments of major depression.  Journal of the American Psychoanalytic Association, 64, (2) 307-343.

 

Imagine my surprise to open the Journal of the American Psychoanalytic Association this spring and to find an article filled with numbers and comparatively little in the way of text.  Had I gotten the wrong journal by mistake?  No, I think APsA is embracing research.  This particular article by our friends in Germany, Gunther Klug, Johannes Zimmerman, and Dorothea Huber (2016) is the third report on a research study comparing patients who were randomly assigned (based on a diagnosis of moderate to severe depression without psychosis) to one of three treatments with therapists experienced in the approach – 35 in psychoanalysis (PA: defined as meeting two to three times a week and using the couch), 31 in psychodynamic psychotherapy (PD), and 34 in cognitive behavioral therapy (CBT).  While I don’t intend to mirror the JAPA article by including lots of numbers, I actually found it helpful to know that the length of treatment varied between the groups: PA lasted on average 39 months (range 3-91) with an average of 234 sessions (range 17-370), PD averaged 34 months (range 3-108) with 88 sessions (range 12-313), and CBT lasted on average 26 months (2-78) or 45 sessions (7-100 range).

I think psychoanalysts are “suddenly” interested in outcome research because we feel pressed to demonstrate that what we do is effective.  We believe – and I don’t know that it’s true – that if we have evidence that our treatments work, there will be third party payer support for those treatments.  So papers like Shedler’s “The Efficacy of Psychodynamic Psychotherapy” (2010) have been welcomed with open arms.  We want to be able to demonstrate, objectively, that what we do works.  What is less clear is that we want research to guide the way that we do treatment.  We have always relied on clinical lore, theory and intuition to guide our work – along with our native and learned communication skills.  Clinical lore and theory are built on our collective wisdom, hard won, based on closely attending to the process of treatment, hypothesizing (and asking) what the active treatment elements have been, and trying to pass along that wisdom while simultaneously expanding it.  To have a researcher, based on numbers, tell us how to engage in something as intimate, human and non-mathematical as a clinical interaction seems like anathema to some of us.

Well, this paper (and the other two papers in this series) straddles the fence – it both helps us make the case that what we do is valuable and it takes a peak under the hood to see what might be causing the good outcomes that we have.  All three treatments resulted in a dramatic reduction in symptoms during the first six months with steady, but not so dramatic reductions continuing throughout the duration of treatment.  Partly, I think, the reductions in rate of change are less dramatic after the first six months because, for instance, on the Beck Depression Inventory (BDI), symptoms have been cut in half on average in that time, and there simply aren’t enough symptoms left to continue abating at the initial rate.  In any case, it is intriguing that, post termination, the symptoms of the patients treated with PA continued to decrease, something not seen with the PD or the CBT group.  The differences were greatest with the CBT group – post termination PA patients had, on average, a 6 point lower endorsement of BDI symptoms.

OK, good.  Not only are we as good as the competition, when we look down the road, we are doing a little better (the PA results did not differ from the PD results which did not differ from the CBT results – they were in that order, but only the PA results were significantly different from the CBT results).  But this study wanted more than just to demonstrate the differences between the response to the different treatments – they wanted to demonstrate why those differences occurred – a loftier goal.  We might opine that the post treatment results occur because of the internalization of the analytic process as a result of the identification with the analytic functioning of the analyst – and this was indeed the hypothesis of the experimenters (in fact they cite Freud (1937), Horney (1942) and Hoffer (1950) to support this idea) – but how would we demonstrate that to have been the case?  They also point out that it could be that the patient could have learned to self-soothe or has internalized positive experiences with the analyst – rather than that it being the analyzing function that is internalized.  And, frankly, it is my guess that it is a bit of all of these and more – in different proportions for different people, which makes it hard to parse out one particular element in an experimental paradigm.

The authors tested their hypothesis indirectly – they didn’t measure internalization of analyzing function, but the level of alliance that the patient felt with the treater (and the treater with the patient) as a kind of stand in for internalization, and then measured whether there was a mediating effect of alliance.  That is, in those patients with greater alliance was there also a greater post treatment improvement?  They also included a measure of self-love vs. self-hate.  The results were tantalizing, but not significant, which was somewhat surprising as this result had been reported in three prior studies, but which was to be expected with a sample size that was this small.

Why might it be that these results are not significant?  Our interventions are manifold – the interactions with our patients include much useful and not so useful stuff.  We work to craft them, to help this particular patient with this particular problem and this particular mindset learn to be more open to themselves or to think differently – perhaps more broadly – about this particular issue.  And we come at that from various angles over the course of a treatment.  When we ask a patient or a therapist to give a global assessment of the level of alliance, that includes some sense of whether they feel that they have been on the same page as the interlocutor, but it doesn’t necessarily mean that they have “taken in” the therapists way of approaching problems and are ready to apply it on their own, but it might.  On the other hand, I’m not sure that we generally ask of our patients if they have done this – though we can sometimes see them doing it.

How is it that we might have been able to divine something clinically – from a smaller sample than 25 patients – that doesn’t show up in at least this test?  Many times I think it is our own experiences of our own analyses that inform us – perhaps more than we know – about what will be useful to our patients.  Despite that, at least in my institute, few of us talk directly about them in unguarded ways.   I think that we may attribute something to our patients that may be coming at least in part from our own experience and we need to bear in mind that our own analyses are of a particular kind – they are training analyses – and we are consciously intending to internalize the analyzing function.  We want to emulate our analysts.  This may privilege a component of the treatment process in our own minds – one that is likely present to some degree in all analyses.  For the impact of internalization to be statistically significant with a sample size of this magnitude, given that the measure is pretty indirect – the impact of internalization – or the related strains (certainly a positive experience with the therapist would have supported the mediation hypothesis in this design) – would have to be quite high.  The salience may not be as high in a group that is in treatment primarily to obtain symptom relief, not to learn to do analysis, even though the internalization of the analytic function may be occurring.

We have a result – the “most analytic” group continued to improve symptomatically post treatment.  We have a likely causal agent – the internalization of the analyzing function.  And we have a sophisticated design to test the relationship between the two.  In so far as internalization is an important element of the improvement in functioning of our patients, it is one strand in a complex tapestry and it is likely that many things are contributing even to the post treatment improvement.  It may be that we have elevated the influence on one likely factor (one that does appear from other studies and from the “promise” of this one to have some validity) and it may be that there are other sustaining factors that may not be as salient to those of us who have had a training analysis.  Another point of view is that it is in some sense surprising that we are able to divine – through clinical intuition guided by and guiding theory, or through research techniques – the manifold slender threads that are inter-related that lead to good treatment outcomes – as well as to divine those things that are less helpful – indeed toxic elements – in the treatment process.

 

Freud, S. (1937).  Analysis Terminable and Interminable.  Standard Edition 23:216-253.

Hoffer, W. (1950).  The three psychological criteria for the termination of treatment.  International Journal of Psychoanalysis  31:194-203.

Horney, K. (1942).  Self-Analysis.  New York: Norton.

Klug, G., Zimmerman, J., and Huber, D. (2016).  Outcome trajectories and mediation in psychotherapeutic treatments of major depression.  Journal of the American Psychoanalytic Association, 64, (2) 307-343.

Shedler, J. (2010).  The efficacy of psychodynamic psychotherapy.  The American Psychologist, 65(2), 98 –109.

 

If you are interested in responding to this post, please do so below.  If you have read a research article recently that you think would be of interest to an audience of clinicians and would like to write a 1000- 1500 word summary of that, please send it as an email attachment to Karl Stukenberg at stukenb@xavier.edu.  Include the words “Clinicians Reading Research” in the subject line.

Blatt, S. J. (1995).  The destructiveness of perfectionism:  Implications for the treatment of depression.  The American Psychologist, 50, 1003-1020.    http://psycnet.apa.org/journals/amp/50/12/1003.pdf.

 

The intent of this space is to highlight research and its implications for clinical practice.  When we envisioned this space, I, at least, thought that we would be looking at the current research literature – and I expect that much of what we review will be from the current literature (indeed, other entries – see here and here- are).  But Sydney Blatt’s work, work that I was not exposed to during my training, is so compelling that I do think it deserves mention.  Since I was not exposed to it, I’m not sure that this paper is the best representation of it, but I do think it articulates some basic ideas that may have been fleshed out later in slightly different ways.  I also think there may have been more compelling data that he later produced that supported the importance of long term depth therapy, but I (admittedly an easy mark) am quite convinced by what he references in this paper.

Blatt’s central premise in much of his work is that there are two kinds of depression – a dependent style, which Blatt calls the anaclitic, and a self-critical style, which he calls the introjective.  Blatt articulates in this paper – and doubtless elsewhere – that these styles are empirically supported and that they grow out of a theoretical assumption about a continuity between normal reactions to inevitable life events and reactions to severe disruptions.  These events cluster around two developmental poles – building interpersonal connections (or failing to do so) and creating individual and autonomous competencies that the person has confidence in (or failing to do so).  In this developmental model, when things go well, a positive, self-reinforcing spiral takes place in which increased interpersonal competence and confidence leads to increased abilities to take on and succeed at tasks independently.  When things go poorly, a similar, but much more destructive spiral ensues, where interpersonal failure undermines the capacity function independently and vice versa.

Despite the interrelationships between the two tasks, Blatt observed that there are distinct clinical presentations depending on how the trauma has been experienced.  Anaclitic depression, the dependent style, is characterized by a profound sense of loneliness, and a consequent sense of need for connection.  The person feels, especially when unsupported, helpless and weak.  They seek others out in order that they can get their needs for support, succorance, and love met by them.

Introjective depression – the autonomous kind, on the other hand, is characterized by intense self-criticism and there is frequently, then, an intense drive for achievement to offset the internalized sense of inferiority and self-scrutiny.  These individuals can be extremely critical of others as well as themselves and can be intensely competitive, often achieving a great deal, but with little sense of satisfaction – no amount of external validation seems to satisfy the harsh and demanding person that they can be in relationship to themselves.

One reason that I like this paper in particular is that Blatt is taking what he knows and applying it more broadly.  He starts by referring to three publicly described cases of perfectionism that resulted in suicide, including Clinton’s deputy counsel, Vincent Foster, someone whom many had considered a potential future Supreme Court Justice.  Blatt makes the case, based on evidence he provides, that these individuals would likely have benefited from long term intensive treatment – and, interestingly, were not likely to have received similar benefit from either short term care or from psychopharmacological treatment.  He nicely describes these individuals, their strengths, and what they had to offer society, and then deftly weaves their perfectionism into his system of organizing pathology.

He then goes beyond this to use this system to organize a variety of pathological styles, making a case for using this dichotomy to organize our system of pathology.  The nice thing about this is that it is not an empty exercise in putting things into boxes, but it has clear clinical and treatment implications – what kind of treatment are patients in the two groups likely to best respond to?  This kind of hypothesis is then testable – and we are off to the races – including being able to justify the expense of psychoanalytic treatment in certain cases.  If we are ever to move away from people getting the treatment they need through paying for it themselves (and, fortunately, those introjectives who are reasonably successful are those who are most likely to be able to afford longer term treatments) – but his point is that this is a societal value.  We should also question whether a more supportive and action oriented treatment like DBT or more supportive psychodynamic treatments might be more successful for some of our patients – particularly, as I read it, for the more Anaclitic/Dependent patients.

While I have not yet given this paper to a client (though I may at some point), I have integrated it into my psychopathology syllabus for the current candidate class at our institute.  I hope that they profit from it.  I think that being able to use a diagnostic understanding to help us think about how best to meet the needs of a particular patient so that we can help get them back onto a developmental track makes this research clinically useful.

 

If you are interested in responding to this post, please do so below.  If you have read a research article recently that you think would be of interest to an audience of clinicians and would like to write a summary of that, please send it as an email link to Karl Stukenberg at stukenb@xavier.edu.  Include the words “Clinicians Reading Research” in the subject line.

Freud was the quintessential empiricist.  He was trained by the leading biological researchers of his day and he applied what he learned, which was largely about keenly observing the world as experienced, to understanding the people who presented to him with perplexing problems and, perhaps most prominently, to understanding the working of his own mind.  He used free association as the particular lens through which to view these various minds, and he drew conclusions from his observations that were wildly at odds with traditional notions of the human mind – especially controversial for him and his peers was the idea that the mind is a place that is dominated, from an early age, by sexual thoughts – thoughts that are suppressed by culture through the family – but thoughts that continued to exist despite suppression and continued to impact the functioning of the mind despite their disavowed/repressed/unconscious status.

Despite being widely hailed as an explorer of the previously unknown parts of the human mind, Freud was also pilloried by many – especially the medical and scientific establishment who claimed that they had no “evidence” for what he was proposing.  In reaction to this, Freud defensively maintained that, without the psychoanalytic situation, his observations could not be corroborated, and so he dismissed “research” as an invalid means of studying the human mind.  Indeed, the study of consciousness, much less unconscious processes, is something that has been a problematic area for psychologists since the dawn of psychology (a time close in proximity to when Freud started writing).  That said, tremendous strides have been made in the inference making process about the mind and its conscious and unconscious components.  Researchers in such areas as cognitive science and prejudice have made strides in making scientifically validated inferences about the functioning of the conscious and unconscious mind, respectively.  Research is also viewed as the friend of psychotherapists when it can, as it does, demonstrate positive treatment outcomes (see e.g. Shedler, 2010).

Freud’s repudiation of empirical science led to powerful identifications with his position by other psychoanalysts.  Aaron Beck, the founder of Cognitive Behavioral Therapy and a trained analyst had his membership in the American Psychoanalytic Association revoked because he was engaging in empirical research.  Others among the psychoanalysts, including American Ego Psychologists (e.g. Hartman), tried to reconnect with the academic tradition by translating psychoanalytic principles into a language that was more closely connected to modern scientific perspectives on the mind.  Many academic clinical psychologists, frustrated by the complexities of the theory, by its long window of treatment which interfered with a publish or perish culture and perhaps angered at being excluded from the ranks of psychoanalysis proper by guild issues, increasingly moved towards presenting a caricatured view of psychoanalysis in text books and dismissing it as a crazy idea that early explorers of psychological functioning entertained.  Further, the research of the academic psychologists became focused on addressing narrow questions bound by local hypotheses rather than being united under an overarching theory of the mind like the psychoanalytic theory.

Now more than 100 years removed from Freud’s repudiation of the scientific procedure and after having seen the impact of that repudiation, we have the opportunity to reconsider the wisdom of his distance.  We also have increasingly sophisticated ways of describing and representing the characteristic functioning of the human mind as observed in the psychoanalytic consulting room.  There are a wealth of psychoanalytic theories about the mind that are useful within the consulting room and in understanding the human condition more generally.  The interaction between these ideas and ideas that are drawn from different traditions of observing the human condition can and should be an opportunity for us to engage in a fruitful dialogue – one that will move our clinical understanding forward and one that may inform others as they think about issues that are related to those that concern us.

Clinicians Reading Research is, then, a new feature of Division Review that endeavors to contribute interactive thought pieces about empirical papers in psychoanalysis proper and in other fields, to engage the reader in dialogic psychoanalytic research-reactive thought.  Enjoy!  And if you are interested in submitting a piece of 1000-1500 words for the series, please send it as an attachment to an email to Karl Stukenberg at stukenb@xavier.edu.

Shedler, J. (2010).  The efficacy of psychodynamic psychotherapy.  The American Psychologist, 65(2), 98–109.