Shattered Worlds/Psychotic States: A Post-Cartesian View of the Experience of Personal Annihilation

Many longtime readers of this blog are aware of my infatuation with the work of the intersubjectivist, relational psychoanalyst, George Atwood, a man who has specialized in working with psychosis in a field that once believed psychosis is untreatable.

The text below is from an article by Atwood, Donna Orange, and Robert Stolorow, Shattered Worlds/Psychotic States: A Post-Cartesian View of the Experience of Personal Annihilation, that appeared in the Spring 2002 issue of Psychoanalytic Psychology, 19(2), pages 281-306. Atwood is the lead author on this piece, which in their work indicates that these are predominantly his ideas. The paper was downloaded from his page, linked to above.

I deeply appreciate the relational context in which they view the symptoms of psychosis. Rather than seeing it as a brain disease, as does the majority of mental health professionals, they understand that, fundamentally, "the experience of personal annihilation reflects an intersubjective catastrophe in which psychologically sustaining relations to others have broken down at their most fundamental level" (Working Intersubjectively: Contextualism in Psychoanalytic Practice, Orange, Atwood, & Stolorow, 1997). I have seen, in depth, how this loss of psychologically sustaining relationships can push someone into a mind-state we have named psychosis.

[That book, by the way, is one of the best introductions to the intersubjective-systems theory of relational psychoanalysis.]

The text below offers one of the most succinct and compassionate elucidations of the subjective experience of psychosis.

The Experience of Personal Annihilation

An aura of impenetrability has always surrounded the psychoses, which have seemed far removed from ordinary experience and therefore extremely difficult or even impossible to reach empathically. This felt difficulty is indeed inherent in the very definition of these conditions, insofar as their essential feature is regarded as being a departure from the putatively true and real world a normal person inhabits. The obstacles to establishing empathy for the subjective states appearing in this extreme range of psychological disorder, however, are not in our view solely attributable to the experiences involved being at some distant remove from the average, normal life of a human being. A very powerful impediment arises from an altogether different source, namely, the assumptions of the observing clinician about the nature of experience itself and ultimately about the nature of a person. When one is regarded as possessing a mind, and this mind in turn is conceived as having an interior that is occupied by conscious (and perhaps unconscious) psychic contents, a structure is being imposed that sharply delineates the boundaries of one's personhood in respect to an objectively real outer world. Such a picture dichotomizes the subjective field into an inside and an outside, reifies and rigidifies the distinction between them, and envisions the resulting structure as constitutive of human existence in general.

Once we understand how the Cartesian view of the person reifies and universalizes this very specific pattern of experience, we can also see why the subjective states that appear so prominently in the psychoses could never be adequately encompassed by a conceptual system resting on Cartesian premises. These states include experiences of the dissolution of boundaries demarcating I and not-I, of the fragmentation and dispersal of one's very identity, and of the disintegration of reality itself. A phenomenological framework, by contrast, is unencumbered by objectifying images of mind, psyche, or psychical apparatus, and is therefore free to study experience without evaluating it for its veridicality with respect to a presumed external reality. The exploration of annihilation states accordingly presents no special philosophical difficulty, for we are concerned then only with the person and his or her world, in whatever state they may present themselves.

In the study of psychological annihilation, one may focus on self-experience or, more broadly, on world experience, where the former is seen as a central area included within the latter. Experiences of self and world are inextricably bound up with one another, in that any dramatic change in the one necessarily entails corresponding changes in the other. Self-dissolution, for example, is not a subjective event that could leave the world of the individual otherwise intact, with the selfhood of the person somehow subtracted out. The experience of self-loss means the loss of an enduring center in relation to which the totality of the individual's experiences are organized. The dissolution of one's selfhood thus produces an inevitable disintegrating effect on the person's experience in general, and results ultimately in the loss of coherence of the world itself. Likewise, the breakup of the unity of the world means the loss of a stable reality in relation to which the sense of self is defined and sustained, and an experience of self-fragmentation inevitably follows in its wake. World disintegration and self-dissolution are thus inseparable aspects of a single process, two faces of the same psychological catastrophe.

The experience of annihilation lies at the heart of the psychoses, and this is often expressed directly in statements to the effect that the person is dead or dying, that he or she has no self, does not exist, or is absent rather than present. It is also frequently said that the world is not real, that it has broken apart into pieces, and even that it is coming to an end. Sometimes the destruction of one's personal reality appears in an experience of falling forever, of spinning out of control, of shrinking endlessly and disappearing, or of being swallowed up into the environmental surround. More commonly, however, reparative and restorative efforts to reestablish a sense of existing predominate in the clinical picture, and these efforts appear in a wide variety of forms. A sense of being or becoming unreal, for example, gives rise to a preoccupation with one's mirror reflection, as if sustained attention to the visual outline of one's bodily being could compensate for a vanishing sense of personal selfhood. The experience of a deadness at the core of one's existence leads to asearch for a counteracting sense of aliveness, provided by the intensity of sensation in self-inflicted pain, in bizarre sexuality, or in thrilling, death-defying adventures. The dissolving of bodily boundaries and a terrifying feeling of melting into one's surroundings occasions the wearing of multiple sets of clothing, one on top of the next, expressing an attempt to reestablish and protect a devastated sense of bounded self-integrity. A breakup in the felt continuity of personal identity over time brings about an obsession with recalling and mentally reliving large numbers of events from the recent and remote past, the calling up of the various events embodying an effort to bring the temporally separated fragments of history together into a single whole. An experience of the disintegration of reality itself, of the falling apart of the world into a jumble of unconnected perceptions and meaningless happenings, gives way to delusions of reference in which the isolated elements are woven back together and given a sinister, directly personal significance. Small changes in the appearance of familiar persons seem to indicate global changes and breaches of identity, heralding the fragmentation of the world's stability into temporal chaos, and these breaks in continuity are repaired and smoothed over by the delusional idea that these persons have somehow been replaced by nefarious imposters. In each of these instances, a countervailing effort to reintegrate a fragmenting world and restore a sense of continuous and coherent being is most salient, while the underlying annihilation state recedes into the background.

In other cases, the annihilation itself is foregrounded, often in vividly concrete symbols, so that images of personal destruction pervade and dominate the individual's experience. Here the extremes to which the concretization is carried assist in maintaining the state of one's dissolving selfhood in focal awareness. The image of being poisoned by deadly chemicals or invisible gases, for example, concretely portrays a sense of being infiltrated and then killed off by the impinging, intrusive impacts of the social surround. Picturing a distant machine that sends influencing rays into one's mind and body, likewise, articulates an experience of the loss of agency [3] and of falling under the obliterating control of an alien agenda. Murdering assassins or conspiring government agents are imagined, and these figures concretize the threat of psychological obliteration in the face of irresistible pressures from emotionally significant others. A takeover of one's brain by a supernatural entity is suddenly felt to occur, symbolizing an overpowering invalidation and usurpation of one's subjectivity.

Sometimes the imagery of annihilation is intermixed with or even supplanted by what appear to be grandiose or highly idealized visions of oneself or others. These latter images express efforts to resurrect all those parts of one's selfhood and world that have become subject to shattering and erasure. The concepts of grandiosity and idealization are, however, problematic when understood in the context of the phenomenology of personal annihilation. Identifying a particular experience as idealized or grandiose involves a judgment and a standard defining what is and is not reasonable for a person to believe. Grandiosity means appropriating to oneself a significance, power, and perfection one actually does not possess. Idealization, as this term is traditionally employed, means correspondingly exaggerating the significance and perfection of some emotionally important other. In the context of personal annihilation, however, it cannot be said that so-called idealization and grandiosity appropriate or exaggerate anything. What appears, from an external point of reference, to be an outrageous exaggeration, may, subjectively regarded, be understood as accentuating the sense that one exists, that one possesses agency and subjectivity, that one's experiences belong to no one other than oneself, and that one's personal world has coherence and is enduringly real. A delusional claim to be the owner of the world, for example, may contain at its core a dissolving sense of one's perceptions and thoughts being one's own. Seemingly extravagant assertions of personal achievement and capability may crystallize and intensify an otherwise threatened experience of agency and autonomy. Visions of descending from a royal lineage or of being a specially chosen child of God accentuate and protect a disappearing sense of connection to a world-sustaining other. An idea that one has penetrated the ultimate secret of the cosmos, the key to understanding the interrelationships of all existing things, enshrines and preserves the integrity of one's personal world in the face of a threat of its total disintegration. In each of these last examples, the problematic issue is not that unrealistic grandiose or idealized qualities are being ascribed to oneself or others; it is rather that the individual's personal universe has come under assault and is in danger of annihilation. Let us turn now to the intersubjective contexts in which the experiences we have been describing take form.

The Intersubjective Context of Annihilation

In Working Intersubjectively: Contextualism in Psychoanalytic Practice (Orange, Atwood, & Stolorow, 1997), we said that the experience of personal annihilation reflects an intersubjective catastrophe in which psychologically sustaining relations to others have broken down at their most fundamental level. In what does this breakdown consist? It consists in the loss of affirming, validating connections to others and the shattering of the subjective world by impingement and usurpation. Although the concrete events and life circumstances playing a role in the origin of annihilation states are highly varied, they have in common an effect of undermining one's sense of existing and of being real in its most basic aspects, including the experience of oneself as being an active agent and subject, as possessing an identity that is coherent and felt as authentically one's own, as having a boundary delineating and delimiting I and not-I, and as being continuous in time and over history.

Viewing psychological annihilation in the context of an intersubjective field means that this experience is interpreted as occurring within a living system of mutual influence. The visible manifestations of the experience are therefore not seen to emanate from a pathological condition localized solely within the patient; nor, however, are they regarded simply as reactions to a primary victimization at the hands of others. Such unilateral conceptions, emphasizing an exclusive determination either from the side of the patient or from the side of the human environment, fails to take into account the complex transactional process occurring between the two. Sometimes persons undergoing the experiences described here are viewed as carrying a special vulnerability or even predisposition that is then seen as a determinative factor in the genesis of personal annihilation. The problem with such an idea is that it represents a return to Cartesian and objectivist thinking, within which factors somehow located "inside" an individual—in his or her mind or brain—become operative causes in the unfolding of subjective states. We then have a picture of an isolated mind, containing predisposing sensitivities and vulnerabilities, which collapses in the face of objective external pressures of some kind. In an intersubjective framework of understanding, there are no fully isolable vulnerabilities that exist inside anyone, because what appears or does not appear as a vulnerability only materializes within specific intersubjective fields.

Imagine a patient who feels she is not present, does not exist, and has no self. Imagine further that someone not familiar with such states asks her, "How are you today?" The use of the second-person pronoun "you" implies to the patient a degree of existence she does not experience, and a gulf of misunderstanding and invalidation opens up between her and the questioner. Perhaps the patient gives the answer, "A billion light years," expressing how far away she feels from the questioner in view of the naive assumption having been made that there is a "you" to whom the inquiry would be intelligible, a "you" that could report on how it feels at the time. Perhaps the patient also experiences an invasion and usurpation by the questioner's unfounded assumptions, and she begins to speak of a machine sending rays into the center of her brain, to give this deepening annihilation experience form and substance. From the standpoint of the questioner, one who takes a Cartesian view of things, the patient's replies are utterly incomprehensible. The question, after all, has been appropriate and clearly phrased, and the answers coming back are without apparent connection to all that is true and real. The patient is at most a few feet away rather than a billion light years away, and there is no machine in the world that can perform as the patient has now begun to claim. Clearly, he thinks, this patient's sensitivities and vulnerabilities are such that the slightest human interaction triggers bizarre reactions stemming from pathological processes taking place inside the patient's mind, body, or both. A reciprocally reinforcing intersubjective disjunction has thus arisen in which the questioner ascribes defects to the patient's mind and brain even as the patient experiences her mind and brain as being penetrated and inhabited by a foreign influence.

Now imagine a second individual who speaks to the patient differently, who finds a way to acknowledge her sense of nonbeing and who understands as well the patient's readiness to surrender herself to whatever is attributed to her. He speaks to the patient in the third person, conveys his knowledge of how terrible it is not to exist, and in a variety of highly concrete ways lets the patient know she is not alone in the catastrophe that is the ongoing situation of her life. The patient, surprised by this different approach, actually begins to feel understood and, paradoxically, begins also to feel a flickering of her own existence, moments of directly sensed being alternating with the continuing feeling of nonexistence or nonbeing. These moments of being, occurring because of the validating experience of being seen and acknowledged, have a painful aliveness about them, draniatically contrasting with the numbness and deadness accompanying the sense of nonexistence. Perhaps the patient, after a period, says she has been stung by a swarm of bees, concretizing the sporadically recurring moments of aliveness as they alternate with episodes of the familiar deadness and nonbeing. Let us imagine further that this second person perceives the metaphor of this transitory delusion as well and finds ways to address the ambivalent experience the patient is having of coming back to life. Her sense of existing thus becomes strengthened again, by the incomparable power of human recognition. The patient's readiness to surrender to others' attributions and definitions, itself embedded in a complex, lifelong history of intersubjective transactions, is not engaged in the foreground of this second interaction and therefore does not appear as an operative defect or vulnerability in the experiences that unfold. This is because the intersubjective field in this instance is characterized on the one side by gradually developing understanding and on the other by a predominance of validation and an increasing sense of being.

In the example cited, we see how a clinician operating on Cartesian assumptions is not in a position to understand experiences of nonbeing. To such an observer, it is simply not true that the patient does not exist, it is not true that she is absent, and her claims about penetrating rays from influencing machines appear extravagantly delusional. Any reaction on the part of the clinician communicating this view, of course, intensifies the patient's experience of invalidation and annihilation, giving rise to a spiraling of disjunctive worlds in which the patient elaborates ever more concretized images of her obliteration and the clinician becomes ever more appalled by the spectacle of madness unfolding before his eyes. The patient's so-called delusions, in the context of this vicious spiral, emerge as expressions of subjectivity under siege, products of a war of the worlds constituted by mutual misunderstanding and mutual invalidation.

To further define and illustrate the context of personal annihilation, let us consider another patient, a young Catholic woman who for years had been preoccupied with visions of herself as having a special connection to God. In vivid hallucinations and elaborate delusions, she experienced a oneness with God the Father and God the Son, variously identifying with the Holy Virgin, the Holy Ghost, and Jesus Christ Himself. Claiming at times to have undergone sexual union with Jesus, to have physically flown to Rome to be held in the arms of the Pope, and to be channeling God's healing, peacemaking powers to the entire human race, this patient's ideas and beliefs were such that those around her could not relate their own experiences to hers in meaningful dialogue. Accordingly, the patient was said to have lost contact with the real and to be psychotic. Phenomenologically, of course, no such judgment or diagnosis occurs, as one seeks instead to understand the patient in her own subjective terms, exploring the history of events that could make her situation humanly intelligible. This inquiry disclosed a pivotal incident in the patient's middle childhood years, the sudden suicide of her beloved father following devastating personal disappointments and failures in his professional life. It was discovered as well that the death was covered over by the family, falsely redefined as having been accidental, and then hidden away behind a wall of impenetrable silence. The affairs of the family thus continued as though the father's suicide had never occurred, so little being said of him that he was relegated to the effective status of someone who had never been. It was the family's turning away from the father's death and life that was the context of a gradually deepening sense of inner deadness and isolation in the years that followed. This was also the setting for her first ruminations on the figure of Jesus Christ and a special place she imagined for herself in the Holy Trinity. Over a period of more than a decade, secret religious thoughts about her relation to God gradually blossomed into full-fledged delusional realities, finally bursting forth in the family with great violence and precipitating the first of many psychiatric hospitalizations. Central in the patient's expressions at this time were loud, imperious demands that she immediately be united with Jesus, who she believed had been miraculously reincarnated in a church-affiliated counselor she had once known and depended on for a brief period.

The bond to the father, something that centrally sustained this patient as a young girl, had been lost when he died. Compounding this loss, however, his death occurred as an intentional suicide, which was unthinkable if, as she had believed during her early years, he actually loved her. Her unbearable experience of having been deserted by him, however, had itself been suppressed by the family's denial, so that the reality of all she had known with him when he was alive and all she had felt on losing him when he killed himself was undercut and nullified, eventually undermining her very selfhood as the feelings of deadness expanded and deepened. How is one to understand this patient's seemingly fantastic religious claims and demands, in view of this context of abandonment and personal devastation? The Cartesian analyst, following Freud, inevitably focuses on the wide disparity between the patient's beliefs and the purportedly objective truth of her life situation, perceiving a deficiency in reality testing, a break with the objectively real and the setting up of an idealized alternative in its place. The streaming religious fantasies and delusions, from such a viewpoint, appear as wish-fulfilling substitutes for the lost connection to the father, and the patient's disturbance seems to consist precisely in her immersion in these fantasies at the expense of attention to her actual, painfully sad situation. An intersubjective analysis, by contrast, focuses on how the patient's so-called delusions protect and preserve a shattered world, how they reinstate a personal reality that has been substantially annihilated, how they embody an effort to resurrect a world-sustaining tie in the midst of an experience of complete obliteration. Far from expressing a flight from painful reality, according to this post-Cartesian view, she is understood to have used the symbols of her faith to encapsulate a remnant of the destroyed bond to her father and thereby to maintain a hold on all that was most real in her experience of herself and her world. The patient's demands to be united with Jesus Christ, urgently and aggressively reiterated in the early course of her treatment, were thus cries for the world-preserving connection on which her very existence depended.

Viewing a person such as this as delusional highlights the disparity between her experiences and beliefs and the conditions of supposed external reality. From this perspective, a goal inevitably materializes to bring the patient's ideas into conformity with all that is generally agreed on as real and true. These normative beliefs have no place for special linkages to Jesus Christ and unassisted flights to Rome, such ideas being seen as pathological fantasies that need to be interpreted, relinquished, or suppressed. What, one may ask, is the effect on the patient of being seen and treated in this way? Such a view inevitably communicates a message that the patient's most urgently felt desires are misguided and that her sole remaining hopes for restoring herself and her reality are without foundation. This message repeats and reinforces the emotional abandonment and invalidation she experienced at the hands of her father and her family, and its effect is to accelerate the delusional process as the patient seeks her own survival in ever more concrete, vividly dramatized ways. A vicious spiral has thus again sprung into being, in which disjunctive worlds war with one another in unending cycles of misunderstanding and reciprocal invalidation.

An analyst who understands the meaning of this patient's cries, by contrast, comes to her with no agenda to realign the content of her experiences; his purpose is rather to introduce a new element into her devastated life, one around which she can refind the felt core of her existence. This element will be embodied in her experience of him and his understanding, something with a powerful emotional impact, calming and reassuring in its effect. This analyst will establish his presence, at first physically in space and time, by regularly appearing and reappearing, and by engaging- the patient's attention through concrete, simple interactions of various kinds. When eventually the full force of her delusional efforts to salvage herself and her world become directed toward him, as inevitably they will, and she pressures him to reunite her with the man she believes to be Jesus Christ, he will respond gently but definitively by telling her that there is only one person in the world she should be concerned about seeing, and that he is himself that person. He will explain further that there are to be no meetings with anyone except for those that he and she have with each other, for it is in their work together that she will become well again and return home to be with those who love her. In all of these interventions, the analyst is guided by an understanding that he must himself become the inheritor of the patient's strivings and that his relationship to the patient is the central battleground on which her psychological survival is to be worked out. How does she respond to all of these things? The delusional process, far from being exacerbated, actually begins to recede as the analyst is established as someone in relation to whom she can recover a sense of herself and of the reality of her destroyed world. At first, her dependence is extreme, and she even intimates that her newfound therapist might indeed himself have some special status with respect to God Almighty. Such expressions are understood as reflecting the power of the bond that is forming, a bond that undergirds a shattered universe in the process of being reassembled. The analyst accordingly gives no response to such attributions on the level of their literal content and occupies himself instead with reinforcing the developing connection she has begun to experience between them. Each step in the solidification of their tie is accompanied by a further stabilization of her world and a continuing decentralizing of her religious images as their function passes over onto the therapeutic relationship. In the early stages of this healing process, any disturbance in the tie that has been evolving produces extreme reactions of terror of abandonment, and sometimes also a resurgence of the religious fantasies. As the threatened tie is reinstated in each instance, the terror disappears and the religious imagery recedes. In this way, the conditions are gradually established within which her experiences of abandonment, betrayal, and invalidation can begin to be addressed and healed on a lasting foundation.

Once a post-Cartesian attitude toward the psychoses is adopted, as the two cases described here illustrate, new understandings crystallize and previously unseen opportunities for therapeutic intervention appear. Let us continue to pursue the implications of this shift in perspective by discussing two other important issues in clinical psychoanalysis to which an understanding of annihilation states is centrally relevant: the problem of mania and the nature of psychological trauma in its most extreme forms.


Note:

3. Terms such as agency, authenticity, cohesion, and others are used here in an exclusively phenomenological sense, referring to dimensions of self-experience along which annihilation states typically take form (Orange, Atwood, & Stolorow, 1997, chapter 4).

Traumatic Narcissism and the Traumatizing Narcissist

 

Below are some excerpts from Traumatic Narcissism: Relational Systems of Subjugation, by Daniel Shaw, a book that is completely revising the way I understand narcissism, in general, and the narcissistic wound, in particular.

I see a lot of traumatic narcissism in my clients, and until now I have not had a term for it. We all have seen books like Toxic Parents: Overcoming Their Hurtful Legacy and Reclaiming Your Life (Susan Forward), Children of the Self-Absorbed: A Grown-Up's Guide to Getting Over Narcissistic Parents (Nina Brown), or Trapped in the Mirror: Adult Children of Narcissists in their Struggle for Self (Golomb Elan). These are very useful books for our clients to read, but they do not offer much for the relationally-inclined, intersubjectively-focused psychoanalyst.

The great beauty of Shaw's book, for me, is that he approaches this topic from a relational perspective, which is aligned with my approach to therapy.

Narcissism can be understood as both traumatic and traumatizing:

• The developmental traumas that engender narcissism are transmitted intergenerationally
• The central trauma in the genesis of narcissism is chronic, insufficiently repaired failures on the part of caregivers to support the developing child's needs for recognition as a separate subject
• The chronic failures of recognition thwart the child's achievement of the capacity for intersubjective relatedness
• Most often, these chronic failures arise as a result of narcissistic disturbances in the parent
Pages 3-4

In his long suppressed, extraordinary final paper, "Confusion of Tongues" (Sandor Ferenczi 1933/1980), Ferenczi did much more than point to adult sexualization of children, rather than infantile sexuality and fantasy, as a cause of serious psychological damage the child carries into adulthood. Ferenczi went further, identifying the complex, cumulative emotional trauma the child who is neglected and/or abused experiences in the context of the developmental relationship. He went to describe how parents project their disavowed guilt (and shame) on to the child; and how resentful they were, no matter how well masked, of the child's dependence on them--because of their own disavowed wishes to be the focus of attention and care. He recognized that such parents dissociatively take advantage of  the child's instinctive willingness to "introject" the guilt and shame the parent disavows. The child, Ferenczi understood, does this by becoming self-blaming, self-loathing, and self-sacrificing. He becomes the caretaker of the parent, while dissociating the awareness of his own needs, along with his concomitant grief and rage about feeling abandoned and exploited.

Page 4

As with all forms of trauma, dissociation becomes a central survivor mode for the adult child of the traumatizing narcissism. Trauma theorists describe aspect of dissociation as the formation of the "protector/persecutor self" (Howell, 2005; Kalsched, 1996). ... The voice of the protector/persecutor says: "No. Do not believe in yourself, do not hope, do not dare. You'll only be hurt again." As the voice becomes more fearful of retraumatization, it becomes more laden with rejection and hostility, dissociatively identified with and mimicking the traumatizing narcissist caregiver: "You nothing, you loser! No one could or would ever love you, you're disgusting! Give up!"

Page 8

From here on, he spends several pages focused on how the child of narcissistic, traumatizing parents can turn their pain and wounding outward, rather than adopting the dissociative model presented above.

There is a different route taken by some children of traumatizing narcissists--involving externalization, rather than internalization, of the hostile projects of the narcissist parents. People in this group, the externalizers, might come to disdain needs altogether, and imagine that they themselves have no needs, that only others are weak and needy. This sort of person could become fixed in a subjective orientation, paving the way toward manic grandiosity and contempt for others, with a sense of entitlement and self-justification. The same cumulative traumatization to the sense of subjectivity as with the objectified child has taken place, but this child, rather than succumbing to a sense of helplessness and despairing of being able to feel recognized, instead develops as an adult into someone who arranges to wield the power to bestow, or not bestow, recognition upon others. ... Another way to think about this is to posit that the traumatized, thwarted subjective self of this child morphs into a protector self, which succeeds in preventing the internalization of shame and badness. Instead this super-defended self locates badness only in others--never in the self. Rather than persecute the self, this dissociated protector is quick to detect inferiority in others, and able to maintain the sense of superiority quite consistently.

Page 8

The patient who is labeled the deflated, thin-skinned pathological narcissist is usually someone who in development has suffered severe damage to their self-esteem system, and whose self-esteem regulation is therefore inconsistent and precarious, subject to the internal persecution of the split-off protector self. In my view, this person is more aptly deemed a sufferer of cumulative, developmental, post-traumatic stress. These patients are inhabited and often tormented by the ghosts of their traumatizers. 

Page 10

The overinflated narcissist is often someone much more like the original Narcissus of Ovid's Metamorphoses, as I understand the Narcissus myth: reveling in being wanted and adored by others, contemptuously deeming no one good enough; reinforcing his grandiose overvaluation of himself by sadistically negating the value and worth of others; and ultimately trapped and destroyed by his delusional obsession with what he perceives to be his own perfection. The narcissist in real life, a myth in his own mind, is so well defended against his developmental trauma, so skillful a disavower of the dependency and inadequacy that is so shameful to him, that he creates a delusional world in which he is a superior being in need of nothing he cannot provide for himself. To remain persuaded of his own perfection, he uses significant others whom he can subjugate. These spouses, siblings, children, or followers of the inflated narcissist strive anxiously to be what the narcissist wants them to be, for fear of being banished from his exalted presence. He is compelled to use those who depend on him to serve as hosts for his own disavowed and projected dependency, which for him signified profound inadequacy and is laden with shame and humiliation. To the extent that he succeeds in keeping inadequacy and dependency external, he can sustain in his internal world his delusions of shame-free, self-sufficient superiority.

Page 10-11

I am especially focusing on a particular type of the predominately overinflated, entitled, grandiose narcissist, and the way in which this person characteristically organizes relationships. I call this person the "traumatizing narcissist." In what I (Shaw, 2010) have previously termed "the pathological narcissist's relational system," I describe the narcissist who seeks hegemony for his subjectivity by weakening and suppressing the subjectivity of the other for the purpose of control and exploitation. The other is then left in grave doubt about the validity and even the reality of their own subjectivity. The sadistic, abusive aspect of narcissism stems from the belief, often held unconsciously, that the separate subjectivity of the other is a threat to the survival, literally and/or figuratively, of one's own subjectivity--and the other must therefore be captured and kept under control. 

Page 12

What is most characteristic of the traumatizing narcissist as I am defining him is his compelling need to suppress subjectivity in the other, so that the narcissist's subjectivity is always the exclusively important and only valid focus of any dyad or group. ... Unconsciously, he is using the other to identify with and internalize the disavowed, shameful dependency he projects onto others. In the case of a traumatizing narcissist parent, the child's subjectivity is attacked, suppressed, and shattered. In this situation, the developing child's ability to self-regulate and balance the innate narcissistic tendencies is not just unsupported, but actively derailed by the parent.

Page 12-13

 I'm sure that as I get deeper into the book, I will have more to share. Stay tuned.
   

Pilar Jennings - A Relational Understanding of the Student-Teacher Dyad in Spirituality

This is an excellent article from Tricycle Magazine on the relational and intersubjective nature of the student-teacher relationship in Buddhism. She goes so far as to say, "The relationship between the Buddhist teacher and student is a dyad comparable to the psychoanalytic one." I would add that this is true for spiritual traditions, not only Buddhism.

We don’t often take into account that even revered teachers may have childhood memories in need of integration, unexpected personal loss, or addictions influenced by genetic predispositions requiring treatment outside the spiritual realm. I suspect that, still young in our acquaintanceship with the dharma, we struggle to accept our teachers as people, both gifted and flawed. We tend to idolize them, as we did our parents, in order to feel safely bonded to an idealizable, all-powerful other. And while these may be sweeping claims, and idealizations are a natural part of any teacher-student relationship, I nevertheless see a pervasive struggle in developing a more adult capacity to understand our teachers in context and to accept their participation in ordinary human experience.

This reality becomes especially when the teacher or guru is damaged enough emotionally to be a narcissist or sociopath, or simply terribly immature in the psycho-sexual developmental line. It is entirely possible for a person to achieve advanced spiritual states or understands (spiritual and cognitive lines of development) and yet be highly toxic human beings who use and control others.

Within the integral community, Andrew Cohen and Marc Gafni are the obvious teachers to whom we can point and identify their destructive impact on many of their "students."

Looking into the Eyes of a Master

A relational psychotherapist explores how we can see our teachers as people, both gifted and flawed.

Pilar Jennings, PhD
Tricycle | Spring 2014


Last winter, on a chilly night just after the New Year, I sat in a darkened theater at the Rubin Museum of Art in Manhattan watching Crazy Wisdom, a documentary about the life of Chögyam Trungpa Rinpoche. Like most American Buddhists, I had heard the colorful stories about his unconventional, theatrical pedagogy—known as “crazy wisdom”—and more than a few anecdotes about his relationships to alcohol and women. I was curious to learn more about this legendary teacher who had influenced so many Western Buddhists, some who have become important teachers in their own right.

As the film progressed, I felt an increasing sense of dis-ease, or duhkha, as it’s called in Buddhist teachings. Images of a young Tibetan trying to find his way in a foreign country filled the screen as Trungpa Rinpoche recounted his loneliness and isolation and his painful recovery from a near-fatal car accident (possibly caused by his increasingly problematic alcohol use). But this footage was quickly eclipsed by the testimony of students who spoke with awe of his compelling presence and unorthodox teaching methods, his depth of insight and what—for them—was his obvious enlightenment. Indeed, the film marshaled extraordinary images: Trungpa, clad in an olive green uniform, arraying his cavalry and marching his students as if preparing for a military deployment; a preternatural rainbow radiating above his gravesite in the days after his death.

The students in the film described their enchantment with his charisma and prodigious energy but seemed oblivious to, or untroubled by, his traumatic background and what I perceived as his personal pain. The only seasoned American Buddhist scholar in the film, Robert Thurman, noted that Trungpa’s death at age 46, likely due to alcoholism, was lamentable. He could have lived much longer, Thurman suggested, carrying his teachings further. But the filmmakers didn’t linger over this analysis, returning instead to the steady flow of reverent praise.

Like other talented Tibetan monks in the 1970s and ’80s, Trungpa moved to the United States to introduce the dharma to Western students. I know other senior Tibetan teachers with comparable histories and have heard their stories of disorienting transitions to new countries, as if they’d landed on the moon without a space suit. For most of these teachers, including Trungpa, these dramatic shifts followed on the heels of a harrowing escape from the brutal Chinese occupation of Tibet. I imagined that Trungpa might also have suffered the ripple effects of culture shock and the loss of loved ones, and might have strained under the weight of his new American students’ expectations of the awakened master they wanted him to be.

As the documentary unfolded, it occurred to me that American Buddhists (with exceptions, of course) have skipped a developmental stage that would allow us to more readily notice and respond to our teacher’s subjectivity. We don’t often take into account that even revered teachers may have childhood memories in need of integration, unexpected personal loss, or addictions influenced by genetic predispositions requiring treatment outside the spiritual realm. I suspect that, still young in our acquaintanceship with the dharma, we struggle to accept our teachers as people, both gifted and flawed. We tend to idolize them, as we did our parents, in order to feel safely bonded to an idealizable, all-powerful other. And while these may be sweeping claims, and idealizations are a natural part of any teacher-student relationship, I nevertheless see a pervasive struggle in developing a more adult capacity to understand our teachers in context and to accept their participation in ordinary human experience.

Some of these struggles are complicated by practices that encourage students to envision their teachers as fully realized. Tibetan Buddhist teachings especially suggest that only when we recognize the buddhahood in our teachers may we receive the blessings of an awakened being. While these teachings offer the potential to expand and refine our awareness, they can also serve to split buddhahood from personhood, teacher from self. The restorative experience of turning to our teachers for their good counsel—which we do because we may see them as awakened—can trump the valuable activity of relying on our own capacity for wisdom and insight.

As a relational psychoanalyst, I have spent much of my training and professional life exploring how relationships—to oneself, to culture, and to loved ones—develop. As a Buddhist, I’ve been similarly engaged in examining how we cultivate a deeper and more authentic sense of connection. And as a Buddhist psychoanalyst, I’ve attempted to understand how these two disciplines might enhance our efforts to forge meaningful and sustainable relationships. For the past 30 years, Buddhist psychoanalysts have been contributing to a growing body of research and literature on the topic of the student-teacher relationship. Writers including the psychoanalysts Mark Finn, co-author of Object Relations Theory and Religion, Jeffrey Rubin, who wrote Psychotherapy and Buddhism, and Harvey Aronson, author of Buddhist Practice on Western Ground, have been exploring the ways in which Buddhist teachers bring their psychological experience to their teaching endeavors. In their work, informed by personal and professional experience, they have also considered how Buddhist students in the West might be confronted with formidable cross-cultural challenges studying with Asian-born and/or monastic teachers.

With all this in mind, in the days after seeing Crazy Wisdom I found myself revisiting the psychoanalytic theory known as intersubjectivity and drawing on its insight into how we develop the ability to be seen and known and to see and know others. The intersubjective perspective explores how babies develop a sense of self and other through their relationship with a caretaker, especially through the nuances of physical contact during feeding, bathing, play, and preparation for sleep. Ideally, through this ongoing exchange, the baby and caretaker experience a growing sense of attunement, and as a result, a bolstered trust that their basic needs, feelings, and intentions can be known to each other. One of the primary fruits of this mutual recognition is that the baby begins to see that the caretaker has his or her own reality that can be discerned and related to, just as the baby has been known by his mother or caretaker.

As the theory of intersubjectivity evolved, its proponents began to describe the psychological terrain that develops between the infant and its caretaker or, for that matter, between any two people, as a “third space.” Particularly relevant to Buddhism is the notion that such a space requires a temporary surrender of self, and that through this surrender a young child is able to sustain connection to the caretaker’s mind while more readily accepting her separateness and personhood. If the parent is distracted, however—suffering from trauma or depression, for instance—he or she may be unable to offer the baby the nuanced attunement it needs. Thus, when a third space never develops, or develops and breaks down, the child may feel he lacks the ability to affect his caretaker. He may feel reactive and “done to,” as the New York University psychoanalyst Jessica Benjamin, a leading theorist in this field, writes: it is a sense of being helplessly lost in the shadow of the other. Many adults see themselves in this helpless way when the third space in a relationship collapses—who hasn’t, at some point, been involved with someone who seems impervious to our subjectivity? What is harder to see are the ways through which we protect ourselves from a collapsed third space. Rather than suffer the terrible sense of being done to, we may opt to be the one who controls the collapsed space by dominating interactions within that relationship, opting to make others feel helpless instead of being on the receiving end of their efforts at control.

As skillful therapists from all schools of thought know, our ability to find and sustain healthy interpersonal experience does not depend on a history of perfect attunement. There is no such thing as two people—whether baby and mother, two lovers, or teacher and student—being perfectly in sync with each other’s needs and wishes. Real intimacy arises from an ongoing process of connection that at some point is disrupted and then, ideally, repaired. I think of this as an interpersonal crochet stitch: connection, disruption, repair, over and over again, until a fabric is created with enough strength and flexibility to endure the wear of any two people attempting to know one another.

But a “perfect match” is a compelling fantasy. When seeking romantic partners, we often hold out for “the one” who magically knows just how to talk to us, touch us, comfort us, without stress or discord. In seeking therapists, patients often expect to find that perfectly sage being who has transcended samsara and can serve as a knower of all truths, the perfect healer. And when seeking spiritual mentors, students are on the lookout for the enlightened being in their midst who glides graciously through life without effort and knows just how to usher the student toward awakening, as quickly as possible.

Having spent my entire adulthood and much of my childhood surrounded by Western Buddhists, I wonder if many of them had early relational experiences that stymied their capacity to feel safely engaged with a world beyond their control. People come to the dharma for many reasons, including a burgeoning sense that life could be more consistently fulfilling and joyful than previously imagined. And yet it seems to be true that relatively few arrive at Buddhist centers on the wings of psychic victory. Many people have a psychologically complex history, one influenced by trauma or loss. In this way, we practice to resolve thorny and entrenched forms of psychological pain.

The relationship between the Buddhist teacher and student is a dyad comparable to the psychoanalytic one. But in this case, it is the teacher and student who are enacting their individual emotional histories. As a result, the potential for boundary violations is rampant, and the possible victims include students who have felt manipulated and even abused by their teachers, and teachers who have felt manipulated and abused by their students. From what I have observed, both participants are vulnerable to their unconscious longing for perfect attunement, for a merger experience in which idealizations obscure a realistic view of an actual human being.

In much the same way that psychoanalytic research has emphasized the infant’s experience, and paid relatively little attention to the mother’s subjectivity, Buddhist scholars have attended to the more blatantly vulnerable actor in student-teacher relationships—the student. It is tempting to ignore the reality that there are two sentient beings in this dyad, and that both have psyches that make them capable of unskillful actions. Teachers, in fact, are vulnerable to the ways in which students project onto them both salvific and destructive capacities. And when a student idealizes the teacher to the point where he or she can’t see the guru as human, it becomes nearly impossible for that student to take into account both the teacher’s gifts and vulnerability.

But it takes two to build a third space. A teacher who has the maturity to be seen as a whole being—in addition to having a kind heart and a liberated mind—may invite the student to curb the idealizations and work instead toward cultivating the wisdom and agency they have been ascribing exclusively to the teacher. Teachers and students alike pay a price when this mutuality does not develop. Trungpa Rinpoche is not alone among famous spiritual teachers in having suffered in ways that may have required attention and treatment he never received. There are scores of senior Buddhist teachers (and I suspect this is true for all faith traditions) who privately undergo inner torment that is never addressed. The world was shocked when Mother Teresa’s journals were published, attesting to her 40 years of doubt and depression. What distressed me most was not that she had suffered depression, which is widespread, but that she was unable to seek help. Why was she left to manage such a long, dark night of the soul alone?

I can’t know whether or not Trungpa had concerned students who made efforts to respectfully confront him; I suspect there must have been some who were troubled by and worried about his alcohol use. Perhaps Trungpa resisted such concern. Whatever the case, it seems important to explore how Western Buddhist students can approach their teachers’ humanity and subjective struggles.

Having befriended a senior teacher in the Tibetan tradition, I am attempting, in my own right, to create a roomier third space between us. My teacher has a fantastic sense of humor and playfulness. We laugh together at the absurdity of our woeful human struggles. But if we’re looking to hide from a deeper, potentially more painful and healing exploration of these struggles, humor is a powerful defense. My teacher has lost some of his beloved students in the past few years, and when I asked him how he was feeling in the wake of these deaths, he replied with a joke: “How much are you gonna charge me for this session?” I laughed. When I mustered the courage to ask again, he dug his finger deep into his ear like a nervous kid, looked at the floor and said, “Truthfully, I feel numb.” I nodded. He looked at me and we nodded together. Then the phone rang, and the conversation was over.

A year ago, a senior monk and longtime friend of my teacher’s had a brain aneurism and fell into a coma for several weeks. We had all been together on retreat only a few months prior. When my teacher returned from his friend’s sickbed, I asked about his state of mind. There was more ear poking, more jokes. He shook his head, stared at his computer, his iPhone, his landline. Then he stared at the floor.

“When this happens I think, who’s next?”

For a fleeting moment we looked at each other. I added, “It’s rough when the people you know and care about get sick. Makes you feel vulnerable.”

He nodded, looked me dead in the eye and said, “How much is that gonna cost me?” I told him he should expect a hefty bill. We laughed and the phone rang, he received a text, and the conversation was over.

As I reflect on my concern for my teacher’s well-being, I see the complexity of this and other relationships that involve contrasting backgrounds and cultural influences. My teacher, like Trungpa, comes from a world shaped by his spiritual and monastic education, a world that prizes the freedom that comes from loosening attachment to personal experience. But this approach has its drawbacks. We must recognize the validity of seeing our teachers as individuals, too. My hope is that we may begin to bring them into clearer view, not only to better see their gifts of insight and compassion, but to accept the fullness of their own human struggle.

Pilar Jennings, PhD, is a psychoanalyst practicing in New York City. She is a lecturer in the graduate department of Psychiatry and Religion at Union Theological Seminary and a researcher at the Columbia University Center for Study of Science and Religion. A version of this essay was first published in Spring: A Journal of Archetype and Culture, vol. 89 (Spring 2013).

Join us this May for Enlightening Conversations 2014: "Opportunities and Obstacles in Human Awakening," a new conference series exploring the intersection of Buddhism and psychoanalysis, where Pilar Jennings will appear as a panelist.

Artwork by Tenzing Rigdol 
Image 1: Phew!, 2011, Acrylic on Canvas, Courtesy Rossi & Rossi.
Image 2: Kriti - From the Ashes of Agony, 2011, Acrylic on Canvas, Courtesy Rossi & Rossi.

PETER FONAGY - Psychoanalysis Today

Okay, so not quite today - this article is from 2003 - but this Psychoanalysis is so far from what Freud was teaching that they don't even seem cut from the same cloth. The one thing that binds them is the belief that unconscious factors affect mental health.

Here is some background info on Peter Fonagy from Wikipedia:

Peter Fonagy (born 1952) is a Hungarian-born British psychoanalyst and clinical psychologist. He studied clinical psychology at University College London. He is Freud Memorial Professor of Psychoanalysis and head of the department of Clinical, Educational and Health Psychology at University College London, Chief Executive of the Anna Freud Centre, a training and supervising analyst in the British Psycho-Analytical Society in child and adult analysis, a Fellow of the British Academy, and a registrant of the British Psychoanalytic Council. His clinical interests centre on issues of borderline psychopathology, violence, and early attachment relationships. His work attempts to integrate empirical research with psychoanalytic theory. He has published numerous articles and has authored or edited 16 books.[1]

The development of psychoanalysis has gone through a variety of new iterations, each one building on the past and moving farther and farther away from Freud's original vision. Here are some of the stages, with their Wikipedia links:

• Structural theory (Freud's id, ego, superego) 
• Ego psychology (Heinz Hartmann, Kris, Rappaport, Lowenstein, Otto Kernberg) 
• Object relations theory (Melanie Klein, Ronald Fairbairn, Donald Winnicott, Harry Guntrip, Otto Kernberg)
• Self psychology (Heinz Kohut, Ernest Wolf, Arnold Goldberg, Frank Lachmann, Paul and Anna Ornstein, Marian Tolpin) 
• Jacques Lacan and Lacanian psychoanalysis (Lacan) 
• Interpersonal psychoanalysis (Harry Stack Sullivan, Frieda Fromm-Reichmann, Clara Thompson, Erich Fromm) 
• Relational psychoanalysis (Stephen Mitchell, Lew Aron, Jessica Benjamin, Adrienne Harris, and Peter Fonagy) 
• Intersubjective psychoanalysis (George E. Atwood, Robert Stolorow, Stephen A. Mitchell, Jessica Benjamin, Bernard Brandchaft, J. Fosshage, Donna M.Orange, Colwyn Trewarthen, Beatrice Beebe, Frank M. Lachmann, Herbert Rosenfeld, and Daniel Stern)

As you can see from this list, Fonagy was one of the relational psychoanalysts, a group that grew out of Kohut's Self Psychology. Right now, the leaders in psychoanalytic thinking are the relational and intersubjective schools, with a lot of overlap between the two in theory and in practitioners.

The small I study with here in Tucson identify, very informally, as Intersubjective Relational Self Psychologists (the ordering of the terms reflects their centrality). 

Full Citation:
Fonagy, P. (2003, Jun). Psychoanalysis today. World Psychiatry; 2(2): 73–80.

Psychoanalysis Today

PETER FONAGY

Abstract

The paper discusses the precarious position of psychoanalysis, a therapeutic approach which historically has defined itself by freedom from constraint and counted treatment length not in terms of number of sessions but in terms of years, in today's era of empirically validated treatments and brief structured interventions. The evidence that exists for the effectiveness of psychoanalysis as a treatment for psychological disorder is reviewed. The evidence base is significant and growing, but less than might meet criteria for an empirically based therapy. The author goes on to argue that the absence of evidence may be symptomatic of the epistemic difficulties that psychoanalysis faces in the context of 21st century psychiatry, and examines some of the philosophical problems faced by psychoanalysis as a model of the mind. Finally some changes necessary in order to ensure a future for psychoanalysis and psychoanalytic therapies within psychiatry are suggested.
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Psychoanalysis today is an embattled discipline. What hope is there in the era of empirically validated treatments (1), which prizes brief structured interventions, for a therapeutic approach which defines itself by freedom from constraint and preconception (2), and counts treatment length not in terms of number of sessions but in terms of years? Can psychoanalysis ever demonstrate its effectiveness, let alone cost-effectiveness? After all, is psychoanalysis not a qualitatively different form of therapy which must surely require a qualitatively different kind of metric to reflect variations in its outcome? Symptom change as a sole indicator of therapeutic benefit must indeed be considered crude in relation to the complex interpersonal processes which evolve over the many hundreds of sessions of the average 3- 5 times weekly psychoanalytic treatment. Most psychoanalysts are sceptical about outcome investigations.

Surprisingly, given this unpropitious backdrop, there is, in fact, some suggestive evidence for the effectiveness of psychoanalysis as a treatment for psychological disorder. The evidence in relation to psychoanalytic outcomes was recently overviewed by Gabbard et al (3), and suggestions for enriching this literature with ongoing naturalistic follow- along investigations were offered. But the absence of evidence is only part of the problem. Indeed, it may be symptomatic of the scientific difficulties that psychoanalysis faces in the 21st century. I will review the evidence base of psychoanalytic treatments and go on to examine in more detail the problems faced by psychoanalysis as a body of ideas rather than as a mode of treatment.

DATA GATHERING AND PSYCHOANALYSIS

Psychoanalysts emulating the founder of the discipline take special pride in discovery. This has led to an abundance of psychoanalytic ideas. Yet this very overabundance of clinically rooted concepts is beginning to threaten the clinical enterprise (4). The plethora of clinical strategies and techniques that are not all mutually compatible creates almost insurmountable problems in the transmission of psychoanalytic knowledge and skills (5). Sadly, this also leads to resistance to the systematization of psychoanalytic knowledge, since those whose frame of reference depends on ambiguity and polymorphy can be threatened by the systematization of clinical reasoning. The source of the problem of theoretical diversity lies in psychoanalytic methods of data-gathering. As is well known, data is not the plural of anecdote. Psychoanalytic practice has profound limitations as a form of research. Psychoanalytic theory precludes the possibility that psychoanalysts can be adequate observers of their clinical work. The discovery of the pervasiveness of countertransference has totally discredited Freud's clinician- researcher model. In the absence of a genuine research tradition, academic disciplines will appropriately distance themselves from psychoanalytic study, in much the same way that they hold journalism at arm's length.

Progress in disciplines concerned with the mind has been remarkable. Excluding information from these disciplines is a high risk strategy at a time when interdisciplinary collaboration is perceived as the driving force of knowledge acquisition. Modern science is almost exclusively interdisciplinary. Many major universities have been restructured to facilitate interdisciplinary work. The impetus is for the abolition of discipline based departments and the re-configuring of medical faculties in terms of interdisciplinary research groupings (scientists working on similar problems regardless of their discipline of origin). It is likely that many basic questions that psychoanalysts have not been able adequately to answer, such as how psychological therapy cures, will only be illuminated by interdisciplinary (neuroscientific) research.

The last 30 years' advances in all the neurosciences have negated the reasons for the earlier psychoanalytic disregard of this field (6). Neuroscientists are no longer just concerned with cognitive disabilities or so-called organic disorders (7,8). Recent reviews of neuroscientific work confirm that many of Freud's original observations, not least the pervasive influence of non-conscious processes and the organizing function of emotions for thinking, have found confirmation in laboratory studies (9,10). If Freud were alive today, he would be keenly interested in new knowledge about brain functioning, such as how neural nets develop in relation to the quality of early relationships, the location of specific capacities with functional scans, the discoveries of molecular genetics and behavioral genomics (11) and he would surely not have abandoned his cherished Project for a Scientific Psychology (12), the abortive work in which he attempted to develop a neural model of behavior. Genetics has progressed particularly rapidly, and mechanisms that underpin and sustain a complex gene-environment interaction belie early assumptions about constitutional disabilities (13). In fact, for the past 15-20 years the field of neuroscience has been wide open for input from those with an adequate understanding of environmental determinants of development and adaptation.

It may be that the difficulty in pinpointing the curative factors in psychoanalytic treatment is directly related to the limitations of the uniquely clinical basis for psychoanalytic inquiry. The impact of psychoanalysis cannot be fully appreciated from clinical material alone. The repetition of patterns of emotional arousal in association with the interpretive process elaborates and strengthens structures of meaning and emotional response. This may have far-reaching effects, I would argue, even on the functioning of the brain and the expression of genetic potential. A range of studies have already suggested that the impact of psychotherapy can be seen in alterations in brain activity, using brain imaging techniques (14-16). These studies as a group provide a rationale for the hope that intensive psychoanalytic treatment might meaningfully affect biological as well as psychological vulnerability. This field is in its infancy but is progressing so fast that it seems highly likely that many future psychoanalytic discoveries about the mind will be made in conjunction and collaboration with biological science.

HOW PSYCHOANALYSIS WILL (COULD) BENEFIT FROM AN INTERDISCIPLINARY DIALOGUE

Whilst clinical psychoanalysis needs little help in getting to know an individual's subjectivity in the most detailed way possible, when we wish to generalize to a comprehensive model of the human mind, the discipline can no longer exist on its own. A general psychoanalytic model of mind, if it is to be credible, should be aligned with the wider knowledge of mind gained from a range of disciplines. This is already happening, albeit informally. Psychoanalysts cannot help incorporating advances about discoveries relevant to mental function because these are invariably contained in all our intuitive, common sense, folk psychologies or theories of the mind (17,18). Folk psychology develops alongside scientific discovery. The impact of psychoanalysis on psychiatric disorder over the course of the 20th century offers the best evidence for this. Our culture's acceptances of Freudian discoveries have made it more difficult for individuals to claim dramatic dysfunctions such as blindness, anesthesia, and paralysis. Medicine has advanced to a point where individuals must accept that the absence of a pathophysiological account for a bodily dysfunction implies emotional determinants - thus the disguise function of the physical symptom is lost and the point prevalence of conversion hysteria plummets. Just as common-sense knowledge of medicine and psychology impacts on our patients, so it must unconsciously influence the nature of psychoanalysts' theoretical musings. Thus, 'scientific advances' infiltrate psychoanalytic theory by the backdoor of the analyst's preconscious.

Mitchell (19), by contrast, claimed that 'no experiment or series of experiments will ever be able to serve as a final and conclusive arbiter of something as complex and elastic as the psychoanalytic theory'. Indeed, Mitchell writes that "ultimately it is the community of psychoanalytic practitioners who provide the crucial testing-ground in the crucible of daily clinical work". As we have seen, the community has been singularly unsuccessful in definitively eliminating theories, in part because of the loose definitions adopted to define underlying concepts. This is inevitable if the mechanisms or processes that underpin the surface function described are not well understood. The meaning of the construct has to be sensed or intuited. In psychoanalysis, communication, whether in writing or clinical discourse, occurs in terms of its impact upon the reader. As Phillips (20) puts it, paraphrasing Emerson, in psychoanalytic writing there is an attempt to "return the reader to his own thoughts whatever their majesty, to evoke by provocation. According to this way of doing it, thoroughness is not inciting. No amount of 'evidence' or research will convince the unamused that a joke is funny". In psychoanalysis we accept that something has been understood when the discourse about it is inciting. Elusiveness and ambiguity are not only permissible, they may be critical to accurately depict the complexity of human experience. It is here, in the specification of the mental mechanisms whose effects psychoanalytic writings describe and whose nature they allude to, that systematic research using psychoanalytic methods as well as methods from other disciplines will turn out to be so useful. Gill (21), in his discussion of the possible validation of psychoanalytic concepts, adopted a similar approach and suggested that Mitchell underestimated the potential contribution of systematic, not necessarily experimental, research on the psychoanalytic situation.

The above does not constitute an attempt to suggest that psychoanalytic concepts can be 'tested' or 'validated' by the methods of another science. Rather, systematic observations could be used to investigate the psychological processes underpinning clinical phenomena, which psychoanalysts currently use the metaphoric language of metapsychology to approximate. Inter-disciplinary research cannot test psychoanalytic theory, it cannot demonstrate that particular psychoanalytic ideas are true or false. What it can do is to elaborate the mental mechanisms that are at work in generating the phenomena that psychoanalytic writings describe. It is here, in the specification of the mental mechanisms whose effects psychoanalytic writings describe and whose nature they allude to, that systematic research using psychoanalytic methods as well as methods from other disciplines will be useful. This in turn will help to systematize the knowledge base of psychoanalysis so that integration with the new sciences of the mind becomes increasingly easier. Not only will psychoanalysts be able more readily to show that their treatment works, but they will have new possibilities of communicating with other scientists about their discoveries. It is to this set of opportunities that I would now like to turn. The integration of psychoanalytic ideas with modern science is unlikely to interest investigators from other disciplines unless psychoanalysis can actually contribute to directing or to informing data collection in these disciplines. For psychoanalysis to be taken seriously as a scientific study of the mind, it has to engage in systematic laboratory studies, epidemiological surveys or qualitative exploration in the social sciences.

Of course, methods for such systematic research are still in their infancy. The validation of theory poses a formidable challenge. Even apparently easily operationalisable constructs such as defense mechanisms have rarely been formulated with the kind of exactness required by research studies. Extra-clinical investigations, however, may help to constrain theorizing; for example our growing knowledge of infants' actual capacities may enable us to limit speculation concerning the impact of infancy on adult function. The projective processes of infancy are unlikely to work in the adultomorphic way described by Bion (22-24) and Klein (25-27), but this does not mean that these descriptions do not contain important truths about adult mental function, simply that 'infancy' is used metaphorically in these theorizations about mental process. For example, evidence from infant research provides strong evidence for Bion's containment concept. It uses the more readily operationalizable notion of 'marked mirroring' to denote the mother's capacity to reflect the infant's affect, while also communicating that the affect she is expressing is not hers but the infant's (28-30). Mothers who can 'mark' their emotional expression (add a special set of attributes, such as playfulness, to their expression of the child's affect that makes it clearly different from their own expression of that affect) appear to be able to soothe their baby considerably more rapidly. This may not be all that Bion meant by containment, but it seems to be linked to his hypotheses concerning the subsequent problems faced by individuals whose caregivers were unable to provide this mirroring encounter with emotion regulation. Restricting theory building to the clinical domain is foolhardy in the extreme.

To summarize, psychoanalysis could benefit from integrating its working theories with research findings from other fields by elaborating the psychoanalytic psychological models of the mechanisms involved in key mental processes. This in turn would help to systematize the psychoanalytic knowledge base, so that integration with the new sciences of the mind becomes increasingly easier. Not only will we be able more readily to show that our treatment works, but we will have new possibilities of communicating with other scientists about our discoveries. The integration of psychoanalytic ideas with modern science is unlikely to interest investigators from other disciplines unless psychoanalysis can actually contribute to directing or to informing data collection in these disciplines. Merely reviewing ideas in developmental science or neuroscience for their proximity to psychoanalytic hypotheses has scant relevance to them. For psychoanalysis to take its place at the high table of the scientific study of the mind, it has to show its mettle in the battlefield of systematic laboratory studies, epidemiological surveys or qualitative exploration in the social sciences.

THE EVIDENCE BASE OF PSYCHOANALYTIC TREATMENT

The evidence base for psychoanalytic therapy remains thin. There is little doubt that the absence of solid and persuasive evidence for the efficacy of psychoanalysis is the consequence of the self-imposed isolation of psychoanalysis from the empirical sciences. Few would dispute the assertion that psychoanalytic theory is in a perilous state. The psychoanalytic clinical situation might have yielded all that it can offer to advance our understanding of mind. Yet 'importing' extra-clinical data is often fiercely resisted and those psychoanalysts who have attempted to do so have commonly been subjected to subtle and not so subtle derision.

Psychoanalysts have been encouraged by the body of research that supports brief dynamic psychotherapy. A meta-analysis of 26 such studies has yielded effect sizes comparable to other approaches (31). It may even be slightly superior to some other therapies if long term follow-up is included in the design. One of the best designed randomized controlled trials (RCTs), the Sheffield Psychotherapy Project (32), found evidence for the effectiveness of a 16 session psychodynamic treatment based on Hobson's model (33) in the treatment of major depression. There is evidence for the effectiveness of psychodynamic therapy as an adjunct to drug dependence programs (34). There is ongoing work on a brief psychodynamic treatment for panic disorder (35). There is evidence for the use of brief psychodynamic approaches in work with older people (36).

There are psychotherapy process studies which offer qualified support for the psychoanalytic case. For example, psychoanalytic interpretations given to clients which are judged to be accurate are reported to be associated with relatively good outcome (37,38). There is even tentative evidence from the reanalysis of therapy tapes from the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program that the more the process of a brief therapy (e.g. cognitive-behavioural therapy, CBT) resembles that of a psychodynamic approach, the more likely it is to be effective (39).

Evidence is available to support therapeutic interventions which are clear derivatives of psychoanalysis. However, most analysts would consider that the aims and methods of short-term once a week psychotherapy are not comparable to 'full analysis'. What do we know about the value of intensive and long-term psychodynamic treatment? Here the evidence base becomes somewhat patchy.

The Boston Psychotherapy Study (40) compared longterm psychoanalytic therapy (two or more times a week) with supportive therapy for clients with schizophrenia in a randomized controlled design. There were some treatment specific outcomes, but on the whole clients who received psychoanalytic therapy fared no better than those who received supportive treatment. In a more recent randomized controlled study (41), individuals with a diagnosis of borderline personality disorder were assigned to a psychoanalytically oriented day-hospital treatment or treatment as usual. The psychoanalytic arm of the treatment included therapy groups three times a week as well as individual therapy once or twice a week over an 18 month period. There were considerable gains in this group relative to the controls and these differences were not only maintained in the 18 months following discharge, but increased, even though the day hospital group received less treatment than the control group (42). The cost-effectiveness of these treatments is surprisingly impressive, with the cost of psychoanalytic partial hospital treatment comparable to treatment as usual for these patients, and the costs of the treatment mostly recovered in terms of savings in service use within 18 months of the end of treatment (43-46). Trials with similar patient groups using comparisons of outpatient psychoanalytic therapy treatments with extended baselines have yielded relatively good outcomes (47) as did comparisons with treatment as usual (48). Several prospective follow-along studies using a pre-post design have suggested substantial improvements in patients given psychoanalytic therapies for personality disorders (49-51). Uncontrolled studies, however, particularly those with relatively small sample sizes and clinical populations whose condition is known to fluctuate wildly, cannot yield data of consequence concerning what type of treatment is likely to be effective for whom.

A further controlled trial of intensive psychoanalytic treatment of children with chronically poorly controlled diabetes reported significant gains in diabetic control in the treated group which was maintained at one year follow-up (52). Experimental single case studies carried out with the same population supported the causal relationship between interpretive work and improvement in diabetic control and physical growth (53). The work of Heinicke also suggests that four or five times weekly sessions may generate more marked improvements in children with specific learning difficulties than a less intensive psychoanalytic intervention (54).

One of the most interesting studies to emerge recently was the Stockholm Outcome of Psychotherapy and Psychoanalysis Project (55). The study followed 756 persons who received national insurance funded treatment for up to three years in psychoanalysis or in psychoanalytic psychotherapy. The groups were matched on many clinical variables. Four or five times weekly analysis had similar outcomes at termination when compared with one to two sessions per week psychotherapy. However, in measurements of symptomatic outcome using the Short Check List-90 (SCL-90), improvement on three year follow-up was substantially greater for individuals who received psychoanalysis than those in psychoanalytic psychotherapy. In fact, during the follow-up period, psychotherapy patients did not change, but those who had had psychoanalysis continued to improve, almost to a point where their scores were indistinguishable from those obtained from a non-clinical Swedish sample.

A large scale follow-up study of a representatively selected group of psychoanalytically and psychotherapeutically treated individuals was recently reported from the German Psychoanalytic Association's collaborative investigation (56). A selection of patients whose treatments had taken place in a designated time period were interviewed by independent assessors and outcomes assessed by both standardized and interviewer coded instruments. While the group had been quite impaired at the time of referral according to retrospective assessments, on follow-up over 80% showed good outcomes. Follow-up data was favorable in relation to both anxiety and depression and savings were also demonstrated in relation to the use of hospital and outpatient medical treatment of physical symptoms replicating earlier German investigations (57). This carefully conducted study also provided important qualitative data in relation to the experience of psychoanalytic treatment and the relatively common disjunction of psychological changes at the level of self-understanding, and interpersonal-relational and work-related domains.

Another large pre-post study of psychoanalytic treatments has examined the clinical records of 763 children who were evaluated and treated at the Anna Freud Centre, under the close supervision of Freud's daughter (58-61). Children with certain disorders (e.g. depression, autism, conduct disorder) appeared to benefit only marginally from psychoanalysis or psychoanalytic psychotherapy. Interestingly, children with severe emotional disorders (three or more Axis I diagnoses) did surprisingly well in psychoanalysis, although they did poorly in once or twice a week psychoanalytic psychotherapy. Younger children derived greatest benefit from intensive treatment. Adolescents appeared not to benefit from the increased frequency of sessions. The importance of the study is perhaps less in demonstrating that psychoanalysis is effective, although some of the effects on very severely disturbed children were quite remarkable, but more in identifying groups for whom the additional effort involved in intensive treatment appeared not to be warranted.

The Research Committee of the International Psychoanalytic Association has recently prepared a comprehensive review of North American and European outcome studies of psychoanalytic treatment (62). The Committee concluded that existing studies failed to unequivocally demonstrate that psychoanalysis is efficacious relative to either an alternative treatment or an active placebo, and identified a range of methodological and design problems in the fifty or so studies described in the report. Nevertheless, the report is encouraging to psychoanalysts. A number of studies testing psychoanalysis with 'state of the art' methodology are ongoing and are likely to produce more compelling evidence over the next years. Despite the limitations of the completed studies, evidence across a significant number of pre-post investigations suggested that psychoanalysis appears to be consistently helpful to patients with milder (neurotic) disorders and somewhat less consistently so for other, more severe groups. Across a range of uncontrolled or poorly controlled cohort studies, mostly carried out in Europe, longer intensive treatments tended to have better outcomes than shorter, non-intensive treatments. The impact of psychoanalysis was apparent beyond symptomatology, in measures of work functioning and reductions in health care costs.

THE LIMITATIONS OF THE EVIDENCE BASED APPROACH

There are limitations concerning the nature of the evidence base for all psychotherapies. These limitations are well-known and their implications go well beyond the evaluation of the current status of psychoanalysis. The outcomes literature concerns RCTs administered over relatively brief periods (three to six months) with short follow-ups and a failure to control for inter-current treatments over these periods. Most evidence-based treatment reviews have been uniquely based on RCTs. RCTs in psychosocial treatments are often regarded as inadequate because of their low external validity or generalizability (63). In brief, they are not relevant to clinical practice - a hotly debated issue in the field of psychotherapy (64) and psychiatric research (65). There are a number of well publicized reasons: a) the unrepresentativeness of healthcare professionals participating; b) the unrepresentativeness of participants screened for inclusion to maximize homogeneity; c) the possible use of atypical treatments designed for a single disorder; d) limiting the measurement of outcome to the symptom that is the focus of the study and is easily measurable (66).

Belief in the supremacy of RCTs opens the door to treatments which, even if effective, one may not wish to entertain. A recent report in the British Medical Journal on the effects of remote, retro-active intercessory prayer on the outcome of patients with bloodstream infection is salutary. Leonard Leibovici (67) from the Rabin Medical Centre in Israel randomized 3,393 adult patients whose bloodstream infection was detected in the hospital between 1990 and 1996. A list of the first names of the patients in the intervention group was given to a person who said a short prayer for the wellbeing and recovery of the group as a whole. It was argued that as God is unlikely to be limited by linear time, an intervention carried out 4-10 years after the patients' infection and hospitalization was as likely to be effective as one carried out during the infection. Staggeringly, there were significant results on two of the three outcome measures. Length of hospital stay and duration of fever were both shorter in the intervention group. Mortality was also lower in the intervention group but the difference was not statistically significant. As two other independent studies also support intercessory prayer (68,69) by the American Psychological Association's criteria for empirically based treatments, this intervention should be accepted except for the heterogeneity of the medical conditions for which the treatment was used. This finding highlights the risk associated with an atheoretical stance to evidence based practice that reifies and idealises a research design. RCTs unquestionably have the potential to yield clinically relevant data in the absence of an adequate understanding of the underlying process. When James Lind in 1753 determined that lemons and limes cured scurvy, he knew nothing about ascorbic acid, nor did he understand the concept of a nutrient. Yet Leibovici's study demonstrates the absurdity which can be created by bringing the world of rigorous measurement into a domain that is totally unsuited to it.

Most importantly from the standpoint of psychoanalysis, the current categorization in evidence-based psychotherapies conflates two radically different groups of treatments: those that have been adequately tested and found ineffective for a client group, and those that have not been tested at all. It is important to make this distinction, since the reason that a treatment has not been subjected to empirical scrutiny may have little to do with its likely effectiveness. It may have far more to do with the intellectual culture within which researchers operate, the availability of treatment manuals, and peer perceptions of the value of the treatment (which can be critical for both funding and publication). The British psychodynamically oriented psychiatrist Jeremy Holmes (70) has eloquently argued in the British Medical Journal that the absence of evidence for psychoanalytic treatment should not be confused with evidence of ineffectiveness. In particular, his concern was that cognitive therapy would be adopted by default because of its research and marketing strategy rather than its intrinsic superiority. He argued that: a) the foundations of cognitive therapy were less secure than often believed; b) the impact of CBT on long-term course of psychiatric illness was not well demonstrated; c) in one 'real life trial' at least the CBT arm had to be discontinued because of poor compliance from a problematic group of patients who nevertheless accepted and benefited from couples therapy (71); d) the effect size of CBT is exaggerated by comparisons with waiting list controls; e) the emergence of a post-CBT approach (e.g. 72,73) that leans increasingly on psychodynamic ideas.

Whilst the present author is entirely in sympathy with Holmes' perspective, even if his work with Roth (74) was one of the targets of his criticism, it is only fair to expose the shortcomings of his communication. Tarrier (75), in a commentary on Holmes' piece, writes with passion: "Holmes relies on the specious old adage that absence of evidence is not evidence of absence [of effectiveness]. [...] I would have more enthusiasm for this argument if traditional psychotherapy were new. It has been around for 100 years or so. The argument, therefore, becomes a little less compelling when psychotherapy's late arrival at the table of science has been triggered by a threat to pull the plug on public funding because of the absence of evidence". Sensky and Scott (76) were similarly outraged both by Holmes' selective review of evidence and his allegations that some cognitive therapists are starting to question aspects of their discipline. The message from the CBT camp is this: if psychoanalytic clinicians are going to address the issue of evidence based practice, they will have to do more than gripe and join in the general endeavour to acquire data.

Of course, psychodynamic clinicians are at a disadvantage and not simply because they are late starters (after all, many new treatments find a place at the table of evidence based practice). There are profound incompatibilities between psychoanalysis and modern natural science. Whittle (77) has drawn attention to the fundamental incompatibility of an approach that aims to fill in gaps in self-narrative with cognitive psychology's commitment to minimal elaboration of observations, a kind of Wittgensteinian cognitive asceticism. In the former context, success is measured as eloquence (or meaningfulness) which is not reducible to either symptom or suffering. Moreover, psychoanalytic explanations invoke personal history, but behaviour genetics has brought environmental accounts into disrepute. While CBT also has environmentalist social learning theory at its foundations, it has been more effective in moving away from a naïve environmentalist position. To make matters worse, within psychoanalysis there has been a tradition of regarding the uninitiated with contempt, scaring off most open-minded researchers.

Psychoanalysts are not yet fully committed to systematically collecting data with the potential to challenge and contradict as well as to confirm cherished ideas. The danger that must be avoided at all costs is that research is embraced selectively only when it confirms previously held views. This may be a worse outcome than the wholesale rejection of the entire enterprise of seeking evidence, since it immunizes against being affected by findings at the same time as creating an illusion of participation in the virtuous cycle of exploring, testing, modifying and re-exploring ideas.

But the absence of psychoanalytic research raises a related problem that particularly concerns me. A recent study from Luborsky's research team (78) demonstrates that the allegiance of the researcher predicts almost 70% of the variance in outcome across studies, with a remarkable multiple r of .85 if three different ways of measuring allegiance are simultaneously introduced. This means that 92% of the time we can predict which of two treatments compared will be most successful based on investigator allegiance alone. This becomes a pernicious self-fulfilling prophecy, as investigators who favour less focused more long-term treatment approaches are gradually excluded from the possibility of receiving funding and, if their treatments are subjected to systematic inquiry at all, these studies are performed by those with least interest in such treatments.

CONCLUSIONS

Our aim should be to assist the movement of psychoanalysis toward science. In order to ensure a future for psychoanalysis and psychoanalytic therapies within psychiatry, psychoanalytic practitioners must change their attitude in the direction of a more systematic outlook. This attitude shift would be characterized by several components: a) The evidence base of psychoanalysis should be strengthened by adopting additional data-gathering methods that are now widely available in biological and social science. New evidence may assist psychoanalysts in resolving theoretical differences, a feat which the current database of predominantly anecdotal clinical accounts have not been capable of achieving. b) The logic of psychoanalytic discourse would need to change from its overdependence on rhetoric and global constructs to using specific constructs that allow for cumulative data-gathering. c) Flaws in psychoanalytic scientific reasoning, such as failures to consider alternative accounts for observations (beyond that favored by the author), should be overcome and in particular, the issue of genetic and social influence should be approached with increased sophistication. d) The isolation of psychoanalysis should be replaced by active collaboration with other mental health disciplines. Instead of fearing that fields adjacent to psychoanalysis might destroy the unique insights offered by clinical work, we need to embrace the rapidly evolving 'knowledge chain' focused at different levels of the study of brain-behavior relationship, which, as Kandel (7,79) points out, may be the only route to the preservation of the hard won insights of psychoanalysis.

References are available at the NCBI/NIH website.