Writings/Blog

A Brief Therapy Model for Adult-Onset PTSD Based on the work of Dr. Russell Carr, MD

Paper: Combat and Human Existence: Toward an Intersubjective Approach to Combat Related PTSD

Understanding trauma and how to treat it is a serious and important area of consideration in my line of work. Most of the research and methods I have used including Van der Kolk, Janina Fisher, material pertaining directly to dissociative disorders, Gabor Mate and others focus on early childhood trauma, the ACE study, and how disorganized attachment disorder leads to significant distress and maladaptive defenses in adulthood. Therefore I was very pleased to encounter another “tool”, so to speak, for managing trauma, specifically adult onset PTSD. This is a brief psychodynamic therapy based on Dr. Russell Carr’s experiences in the working as a psychologist in the combat arena of the Middle East, and is informed by Dr. Robert Storolow’s intersubjective systems theory and Storolow’s phenomenological-contextualist psychoanalytic perspective as applied to adult onset trauma.

 

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Carr developed this modality based on Storolow’s short book Trauma and Human Existence (2007), which Carr said he carried around with him during his deployment, reading, re-reading, and gradually integrating Stolorow’s Intersubjective Systems Theory approach to trauma into a brief therapy modality. In his book, Stolorow encourages a clinician to focus on how the subjective experience of trauma that has caused the presenting distress has shattered the patients relationship with being. Two methods Stolorow uses to perform therapy with a traumatized patient are empathic introspection (getting a sense of how the trauma feels to the patient) and contextualization of affect (understanding how the trauma affects the patient’s emotional reactions in his day-to-day life). In using this approach, it is necessary to develop a relational stance with the patient – to understand the subjective experience of the patient with as much of the clinician’s self as possible.

Carr determined that due to the logistical challenges of performing therapy in wartime, brief therapy was often all that could be provided to soldiers. Carr found a need form this approach due to the fact that most short-term therapies for trauma orient themselves around CBT. These therapies, while initially effective, have a high dropout rate (over 50 percent), and its effects often are not sustained in the long-term. Carr found necessity in a psychoanalytically informed approach, as he knew that psychoanalytic methods have a lower drop-out rate, and are ultimately more effective in the long term (Shedler, 2010) than CBT. Carr chose the intersubjective approach, because besides this approach, psychoanalytic theories do not address specifically adult-onset trauma without the presence of developmental trauma, and that many of Carr’s patients had relatively stable upbringings.

At the conclusion of the article, Carr states that he would ultimately like to make this brief modality appropriate to other individuals who are suffering from adult-onset PTSD, but who are not combat active or veteran military. In my work, I presently am not treating soldiers in active duty, nor am I treating veterans, per se. Therefore, I am leaving out elements that pertain to this specific origin of trauma. For example, In terms of a critical element of combat trauma, shame, being a soldier would likely add a layer of shame (potentially being seen as weak, and possibly more critically, not being united with his fellow soldiers) that a civilian may not possess. So whether working with shame would predominate the focus therapy with a civilian to the same degree or not is a matter of the individual. I am summarizing the method in terms of treatment of adult-onset trauma the general in a way I might use in my present practice. I am attempting some rudimentary variation of what Carr proposes, as I found his approach meaningful and potentially useful, in my own practice. I strongly encourage anyone interested in what I present to read the full article.

To inform his brief therapy method, Carr is using Storolow’s “intersubjective attitudes” to understand trauma:

Trauma is not the traumatic event, rather it is unbearable affect, or as Stolorow articulates, “an excruciating sense of singularity and solitude”. Besides manifesting as unbearable affect, there are other ways in which trauma presents, which includes loss of time – where past, present and future can seem indiscernible, “ontological unconscious” or loss of sense of being, loss of “absolutisms” or the things we take for granted in life (such as ones’ sense of safety of making it through the night), and informed by the philosopher Heidegger, a “being-toward-death”, or an immediately tangible and pervasive sense of one’s own mortality. Because the experience often has a very negative effect on the patient’s emotional navigation of day-to-day activity, and because trauma can often be extreme, the lack of attunement or even rejection from others can result in shame. Shame is a barrier to becoming attuned with others, and therefore is a barrier to healing overall.

The inability to bear emotions related to trauma is where the problem lies. Intersubjectively, traumatic emotion must be processed with other people through their understanding and empathy to be integrated. The patient must feel held by an attuned other or others who emotionally share the burden pain, with empathy and without judgment. Otherwise, this unendurable emotional state will be necessarily soothed in maladaptive ways – escaping them through dissociation or relegating through the body, where trama is expressed as physical symptoms. According to Carr/Stolorow, only through putting words to these dissociated or somatized traumatic experiences in the presence of an empathetic and attuned individual (or group) can it be processed and integrated.

 

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A Summary of the Method of Brief Intersubjective Therapy for Adult-Onset Trauma:

There are many methods of short-term psychodynamic therapy. I have previously written about two of them in the last blog, and the underlying structure is similar:

1. The intervention is prompt

2. the therapeutic alliance is built rapidly and with a more active stance on the part of the therapist in comparison with longer treatment

3. Goals are specific and time limited

4. A clear focus is identified and maintained throughout

5. That the treatment is time-limited is established from the onset. Elements of the treatment are defined through the specific theoretical lens used.

Phases of Treatment

Phase 1: Initial Consultation and Consent to Treatment

Due to the short-term nature of the treatment, the screening is basic, and looks for factors that would render the treatment appropriate for the patient, or if another intervention is warranted : Is the patient suicidal? What is the source of trauma? Is there co-occurring substance abuse? Is there developmental or brain trauma? In this phase, the therapist engages rapidly, educating the patient on the process (which is uncommon for standard psychodynamic approaches). During the screening, an alliance can begin to be built. The duration of this brief treatment, mutually agreed upon treatment goals, and what the expected partial recovery will look like.

Treatment begins during the first meeting, which in longer term therapy would be reserved for assessment. This method has a basis in the elements of Storolow’s intersubjective systems theory: empathetic attunement, faillability (allowing the patient to inform on trauma more than the therapist’s previous education), and the personal experiences of the therapist pertaining to trauma, as to create a subjective, empathetic alliance is the goal of this first phase.

Phase 2: Address Shame as the Therapy Begins

Shame is a real factor for patients, second only to lack of finding a “relational home” for the trauma. As I mentioned earlier, shame is likely to be present due to the lack of comprehension or even blame and rejection by others as to the way the trauma manifests emotionally in the patient, and transforms their affect, possibly is mitigated with dissociation, which is confounding to others, and effects societal functioning among many other possible symptoms. It is critical that the therapist not participate in this rejection, which will require tolerating the nature of the trauma, as horrifying as it could be, understanding the context for the patient’s feelings through empathic introspection, and refraining from minimizing the emotional experience in attempts to “make things better”. The therapist must always keep in mind the necessity of this trauma to be processed through empathetic attunement, and attunement must be maintained regardless of what material the patient brings.

Phase 3: Sessions About the Phenomenology of Trauma

Once shame is addressed, the next phase is determining how, through the subjective lens, understanding the trauma. This means that the therapist will optimally engage with the patient on the basis of the therapist’s own experience with trauma to understand the patient’s empathetically. However, due to this being short term therapy, the therapist must conceptualize the subjective experience of the patient with some efficiency, so Carr suggests that the therapist describe some possible experiences based on the present understanding of trauma in the form of psycho-education to see if any resonate with the patient. Carr uses, again, descriptions articulated by Storolow (for example, the experience of “flashbacks”). This comparison exercise is done with the stance of fallibility, in that just because these are common experiences on average, they may or may not describe the patient’s experience. As is inherent in this approach, the patient’s subjective experience is paramount.

Putting language to the experience is a necessary step in bearing the trauma, and the psycho-educational approach may be able to hasten that process. Once the words are facilitated, a patient can begin to feel that the therapist “gets it”, and both can begin a dialog. Once the patient feels understood, he can begin to connect with the therapist and the two can start to create the “relational home” where the trauma will be processed, and the “excruciating sense of singularity” is gradually undermined.

Phase 4: Seeking an Intersubjective Key with the Patient

This is a phase that may prolong therapy, as it is akin to a treasure hunt. However, Carr states, “it is probably the most important (phase) for the treatment to be effective”. There will be present in the traumatic experience, a key piece of information that needs to be uncovered that encapsulates the full impact of the traumatic experience. It’s importance lies in its cross-temporality; that it is a unifying factor over the often subjectively fragmented dimensions of time.

The intersubjective key may be happened upon through the therapist articulated some connection he has noticed, which the patient has felt but not been able to isolate through verbalization. Carr finds this discovery often happens unexpectedly, and often weeks into therapy. By this point, the patient feels safer understanding his shame and intense emotion. The therapist follows the basic intersubjective principle of following affect within an empathetic stance, and the opening of the patient’s emotional tableau provide material for the therapist to notice, draw attention to, and therefore the chance of the intersubjective key emerging is more likely at this juncture. As an example, the intersubjective key in the case Carr presents is a sense that the patient held his command leader at fault for what he felt was continually exposing them to unnecessary risk, one case which resulted in the death of his friend.

The emergence of the intersubjective key will almost invariably result in intense emotions. It is critical that these emotions be borne together by both, and regardless of the content of the experience or magnitude of the emotions, and that the therapist remain empathetic. To not do so may result in a catastrophic rupture of the connection between therapist and patient, and a loss of the sense of safety of the relational home. Ross states, “Again, this is why maintaining and empathetic introspective stance throughout each session is so important”.

Phase 5: Providing a Relational Home

The intersubjective key, as discussed in the last section, may result in the peak of emotional processing of the trauma. With a therapist operating from the stance of intersubjective empathy, the relationship in this modality transcends from patient/therapist to “two frail humans caught in the same finitude. The, therapist, through the introspective empathetic stance he has been employing since the first session, may even be reduced to tears himself as the two process the traumatic emotions. This relational home brings words to previously unexpressed emotion, which is how the trauma is acknowledged and integrated. The patient finds the attunement in the therapist that he was unable to find in the “real world”, and this is what allows him to bear and process the pain.

It is important that any relational expression by the therapist, be it tears or even offering a hand to hold, is done through the therapists experience of the patient and in the service of the patient. This is not a time for the therapist to process his own trauma, even if he has used his experience of trauma to understand the patient’s experience, and to share in this experience.

Phase 6: Terminating and Both Moving On

If the termination date is firm (and in Carr’s case, in military setting it almost always is), then both patient therapist may feel a bittersweet resolution to having processed the presenting trauma, but often a desire to continue therapy in more depth and of more conventional material – the patients past, defenses, relationship patterns etc., although sometimes the patient is ready to go, having made headway or even resolved the presenting problem and it is the therapist who wishes to continue.

This is a time for both to recognize that the patient is in the process of improving and has given words to the previously unarticulated nature of the emotional trauma. Perhaps further therapy is indeed warranted. Patient and therapist could make arrangements for this to occur, and possibly with each other.

As stated earlier, Carr indicates in this article that he would like to further develop this modality (specifically for the veteran’s administration. , which would require manualization and testing. He indicates that one avenue might be “phenomenology research”, in which military service members with PTSD report and possibly compare their subjective experience. As a clinician, I certainly see value in the relational approach to addressing PTSD in the population at large as it relates to adult-onset trauma. I am aware of scads of trauma literature, and certainly see reflected in this Carr’s assertion that rarely is adult-onset trauma the focus without also including childhood trauma. Therefore, I appreciate this method for that focus, as well as an opportunity to begin to practice the relational method and to expand my toolbox with another form of brief therapy, and overall approach which I find valuable.

 

 

 

Tao de Ching #9 – Pushing too hard

Fill your bowl to the brim
and it will spill.
Keep sharpening your knife
and it will blunt.
Chase after money and security
and your heart will never unclench.
Care about people’s approval
and you will be their prisoner. Do your work, then step back.
The only path to serenity.

We are a goal-driven species. We have an emotional system deep in our brain identified by the neuroscientist Jaak Panksepp as the “Seeking” system. This emotion gives us drive, and undergirds just about everything we do. It let’s us know what is “better”, whether it’s acquiring something or running away from something. Evolutionarily, we “seek” what will keep us alive long enough to procreate.

We also have the capacity to abstract, and to understand what we do now will pay off in the future. Therefore, if we find something good, we want it all…just in case. Thus, sometimes we get the impression that more of a good thing is better, but is this the case? This is where our seeking system gets waylaid. To be in harmony with Tao is to know when to stop. When the bowl is full enough, when the knife is sharp enough, and how much money is adequate for anything we want to do. If we want more and more, then the seeking system is in overdrive, is out of balance, has taken over our capacity to step back and appreciate.

A Word on Two Styles of Psychodynamic Brief Therapy

I love practicing psychodynamic therapy. To me, no other approach embraces the depth of what it means to be a human being more thoroughly than the psychodynamic approach. Psychodynamic therapy is a method that originates with Freud, and while now presents quite differently from the daily free-association of the psychoanalytic couch, retains some of the essential elements of Freudian psycho-analysis, including (but certainly not limited to):

The Unconscious: Stored away out of the realm of our perception, unconscious processes, whose development begins in very early childhood (even infancy), can profoundly influence our thoughts and behavior. As we look for the roots of painful or problematic thoughts or patterns, therapists help their patients access the unconscious through dreams, exploration of transference and noticing patterns in relationships, and use of defenses.

Insight: This therapy fosters insight into the unconscious influences of past experiences and relationships, by bringing this unconscious material to light. Once exposed, through the safety and authenticity of the therapeutic environment, therapist and patient collaborate to “re-frame” past experiences, dress and heal old wounds, and bring a sense of personal agency into how a patient can function now and into the future.

Childhood: Our earliest relationships and experiences often set the trajectory for subsequent ways of relating to others and of our worldview. Adaptions surrounding the preservation of the attachment relationship can become ingrained into the unconscious. These internalized adaptions can play out again and again in relationships, long past their “expiration date”, and what was adaptive in the past can be maladaptive in the present. Disappointments and trauma in childhood can manifest in seeing the world as threatening and hostile.

The Therapeutic Relationship: In a safe and thoroughly confidential environment, the relationship between client and therapist has great therapeutic value in uncovering, through transference, repetitive relationship patterns. A good therapeutic relationship can foster a sense of a secure attachment relationship with the therapist in which the client can express his authentic self, have it met with acceptance and encouragement, and subsequently grow an develop the neglected or suppressed “true self”.

As a therapist focusing on the use of psychodynamic therapy, I am aware of the implicit long-term nature of this approach and that open-ended therapy may not be appropriate or possible for a number of reasons. DC is a city of transience, and sometimes a patient is in the area for a limited period of time. Perhaps someone only wants to address a specific issue, of which a full course of dynamic therapy is overkill or for the depths of which they are not yet prepared. Possibly logistical or financial constraints don’t permit anymore than a few sessions.

Often immediate issues or short-term concerns are addressed with approaches whose main modality is Cognitive Behavioral Therapy (CBT), which assesses behavioral problems or maladaptive thoughts, and provides specific and effective tools to minimize these issues.

While I understand and appreciate the benefits of CBT, and may occasionally adapt some CBT methods for short-term symptom relief, I do not consider myself a CBT therapist. Therefore, I want to discuss a two short-term therapies based on the psychodynamic approach. While these therapies may integrate elements of CBT and of other affect and anxiety regulation methods such as mindfulness, the driving force of these therapies are psychodynamic. As a caveat, I am neither an expert in any of these therapies, nor do I have a certificate to indicate myself as such. However, I do have varying degrees of training, supervision in and knowledge of them. As my training progresses and my competence grows, I am increasingly integrating their strategies into my practice, so far with beneficial results.

 

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Intensive Short Term Dynamic Psychotherapy (ISTDP)

Often we are hijacked by anxiety, and this anxiety is triggered by relationships or other factors. ISTDP addresses the origin of this anxiety, which typically are underlying and often disavowed feelings. These feelings may long ago have been deemed “dangerous” by messages from caretakers or peers. Therefore, when they emerge, these feelings provoke anxiety that they are unacceptable and are met with defenses which have been evoked and learned to mitigate the painful sensation of anxiety. Sometimes these defenses are adaptive, but often they are not. Most of the symptoms and problems a patient experiences are due to these outdated defenses.

In ISTDP, the origin of this anxiety is met, which is the underlying feeling (often anger, but also grief, sadness, fear etc.). Through ISTDP method, whose primary paradigm is the triangled pattern of feeling-anxiety-defense, the therapist helps the client to become aware of the anxiety leading to the defense, block the defenses and reveal the underlying feelings. Once the feelings are identified, using the CBT method of exposure to the feelings, the patient becomes more able to tolerate these feelings. Once these feelings are able to be tolerated, the patient can begin a more authentic relationship with themselves and their true desires, and find usefulness and agency in these feelings. ISTDP typically is resolved when the defenses are exposed and managed, and feelings become tolerable and even useful.

ISTDP was developed by Dr. Habib Davanloo, a Montreal psychiatrist, as a way to cut through straight to the defenses, and in this way, to make therapy more efficient. Some of the world experts in this method are local clinicians, such as Jon Frederickson, and I am fortunate to be the beneficiary of their wisdom.

 

Object Relations Brief Therapy

Object Relations is a theory that focuses on the human need for relationship. This is a theory that originally developed from psychoanalysis by a loosely-related group of British analysts including Donald Winnicott, D.W Fairbairn, and Melanie Klein. Common to their theory was highlighting the earliest developmental experiences of the child in relation to their mother and other early caregivers, and how these relationships became internalized as “objects” (early conceptions of mother/caregivers which have become internalized) and how these objects significantly affected a patients subsequent relationships. Later John Bowlby, provided the capstone to this conception of the human psyche with his theory of Attachment to the primary caregiver and the ways the quality of this relationship strongly influenced a variety of factors in a person’s life. Object Relations Therapy uses the therapeutic relationship to strengthen and transform the patient’s defective internal objects into “good objects”, which impart a sense of security and self-worth.

Object Relations Brief Therapy begins by rapidly developing a therapeutic alliance and setting dual specific foci. This foci are symptomatic (for example, decrease a patient’s depression) and/or dynamic (become less reactive to mother in law). A working alliance is established through specific questions pertaining to a patient’s psychiatric, psychodynamic history, relational patterns, and whether/how a client tends to project his perceptions onto others. As the therapy progresses, patterns of behavior and relationship are revealed and worked through. Transference is used actively, as patient and therapist interpret and experience what happens between them. A paradigm of therapist-self-other is used as a guide to identify a patient’s view of their past relationships to those of the present.

Therapy uses interpretation of interactions between self and other to give insight into maladaptive patterns, and capitalizes on (as does ISTDP) the triad of feeling-anxiety-defense to further gain insight. The therapist also integrates some CBT or other non-psychodynamic symptom relief including stress management and cognitive restructuring to help address symptoms. Termination is addressed at the beginning of therapy, and the way the presenting focus of therapy will look when it has been satisfactorily addressed, in the context of brief therapy, is determined as an end goal. This modality typically lasts 6-26 sessions. After the first course of brief therapy is complete, subsequent sessions may be desired and encouraged in the future.

Objects Relations Brief Therapy was developed by highly regarded local psychologist, Dr. Michael Stadter, who, along with a primary emphasis on object relations and the therapeutic relationship, also drew on the brief therapy framework of Davanloo and other clinicians who were instrumental brief psychodynamic therapy.

Amongst my colleagues, and based on evidence, ongoing and open-ended therapy is the optimal “Gold Standard”. However, time and other constraints are often an unavoidable factors. Both of these therapies offer, colloquially, a lot of “bang for the buck”, while still incorporating the valuable time-honored tenets of psychodynamic psychotherapy. Also, some of the more targeted methods of rapidly exposing defenses can be useful in longer-term therapy when the patient is “stuck”. Brief therapy and methods within these modalities are often a valid and beneficial options. It is for these reasons I offer these methods within the realm of my competence, and continue to pursue training in brief therapy

Pet Your Rat! Dreams Let You Know What You Need

You are going to therapy to address a nagging dissatisfaction with your life. You went to art school and planned on a vibrant artistic career. Reality set in, and now you have a desk job designing publications. You like the artistic elements of the work, but detest doing the layout, which you tend to race through. While you are occasionally complimented on your creativity, your boss would like you to be more conscientious about the layout, which seems to be the priority. You would like to just be paid for being an artist, without having to do all the dreary organization. Today your boss informs you that a publication you designed caused her embarrassment during a meeting, as one of the executives found a major flaw in the layout. She has informed them you would fix it today. Usually a easy going person, you can tell right now, she is miffed. You have no choice but to stay late, after a day so busy, you didn’t even have a chance to have lunch.

That night you have a dream: you are being pursued by a woman who vaguely resembles your mother. She is wielding an axe, which she is swinging. She is wearing just slip and she is barefoot, and it is very cold. As you run away, you realize that you have dropped your mean little rat again, but you can’t worry about that, you need to run. She swings the axe, but misses. She stops suddenly and picks up the rat and hands it to you. “Take care of your rat!” You take the rat and pet it. It is not as mean ugly as you thought. In fact, it is downright cute. You suddenly realize that you have an extra coat. You hand this to the axe-wielder who puts it on and thanks you. She says she got the boots from you too. You notice she is wearing them and they are furry and warm looking.

You wake up puzzled. The feeling is, this is significant, but what does it mean? As your therapist has suggested, you write it down immediately.

Jung believed that dreams are “utterances of the unconscious” without the filters of the conscious mind, “concentration, limitation and exclusion”. This, Jung asserted, made dreams particularly useful to therapy as windows into the totality of the self. Jung believed that dreams often exhibit the latent “inferior” aspects of the personality that have been neglected and undeveloped. In order to be healthy, Jung believed, we need to become as close to a whole “self”as possible. These inferior, often distasteful and/or frightening aspects of ourselves must be investigated thoroughly and integrated. Otherwise, these “snakes in the garden” will rear their heads when least expected in the form of symptoms and problems. What’s more, there are aspects of these parts of ourselves that when integrated, make us stronger. Related to this important aspect of Jung’s overall approach to therapy is the assertion that dreams have a compensatory function; that our dreams are telling us to examine these things/aspects/functions we are avoiding/denying/repressing.

In this framework, Dreams serve the function of revealing these hidden parts in an organic attempt at achieving equilibrium. This is particularly relevant to psychotherapy, since to become what we can be requires an ability to use all our potential. If moving towards equilibrium, individuation – the systematic exploration and development of all parts of oneself, is the “end game” of Jungian-informed therapy, then a main therapeutic purpose of dreaming is to act as a tool to guide this direction by showing us what we are missing in our lives, not paying attention to, or just flat out repressing. These elements are stored deep in the unconscious, but come out in our dreams. In therapy, it can be well worth our while to explore them.

When beginning dream analysis, therapist and patient keep the complementary aspect in mind. Jung would first ask, “What conscious attitude does (the dream) compensate?” He would ask the patient to make associations from what feels to the patient like the most significant images in the dream. Ultimately, these associations are used to understand the dream as patient and therapist use this process to find what is hidden from consciousness. It is important, however, to have established in therapy what exactly the conscious attitude is. Jung states, “…the interpretation of dreams requires exact knowledge of the conscious status quo”; analysis must be accomplished while allowing the conscious personality to remain intact, and the experiences, views and beliefs that the patient presently holds be respected as much as the unconscious elements. Not “either/or”, but “both/and”.

Because the unconscious has its own language and actually, due to the suspension of conscious filters, has access to a broader vocabulary, the images are often perplexing. Sometimes flagrantly obvious, but usually buried in the mud, images in dreams contain pronounced symbolic elements. Because dream symbols have a tendency to represent a psychic element in all its time/space complexity, the symbol is often packed with meaning. The veritable richness of this concentration and potential to hold multi-layered and multi-faceted meaning denotes symbolism as a key element of dreams. Metaphor also, while less dense, can reveal the dynamics and elaborate meaning of dream elements. Flying high can represent a desire for upward mobility or a need to escape, as can running away. Sometimes linguistic metaphors become literally represented: your sadness might be represented by you wearing a blue dress.

So, back to our dream. Armed with this information, let’s play with it. A woman is coming at you with an axe. It’s vaguely your mother someone resembling mother is attacking you. You associate the mother figure with your manager. A parental figure, she was less than nurturing yesterday. She is armed with a powerful axe, and you realize that she can “give you the axe” at anytime. The axe is a symbol of the power this parental figure has to kill your professional self, giving you the axe is a literal representation of that metaphor. Another metaphor, running, feels to you like the demands of the job to “keep running on the hamster wheel”, as is expected of any rat. The woman is underdressed. She only has a superficial garment on in the cold environment.

Now how can this help? What is the compensatory element?  Did you discover the rat isn’t all that ugly? You long ago decided “I am not organized, an artist doesn’t need to be!” It was too boring to ever develop that dreary part of you; you weren’t going to be part of the rat race anyway.  But do you see the cost of this attitude? As is often the case with people with artistic inclination, your inferior function is your capacity to be conscientious. Perhaps you do need to explore and develop your ability to be moreso. After all, that necessary aspect of your job wouldn’t be as oppressive. Perhaps your boss wouldn’t have to be embarrassed in a cold boardroom in just a slip, leading to her fantasizing about giving you the axe. Instead, she’d be thanking you for the warm coat you provided by your good work. Perhaps if you could integrate a little more discipline and organization into your work, while maintaining the status quo of your creativity, the two could complement each other! Now, the work of therapy – how are we going to learn how to take care of your rat?

 

The Individuation of Bowie – Blackstar

The first album I ever purchased was David Bowie’s 1973 album Changes. I was 13. I have remained an ardent fan ever since and influenced by Bowie in many domains of life. I wrote this shortly after David Bowie’s death. I have been thinking about this video a lot lately, so I have decided to share this again. It is my stab at a Jungian interpretation of something so profoundly symbolic, and so connected to the entirety of Bowie’s persona, and is ultimately is an expression of his Self, his final attempt at individuation.

In reading a review of David Bowie’s final album, Blackstar, in the New Yorker, I was struck by the writer’s assertion that the imagery of Blackstar exemplifies Bowie’s typical “willingness to embrace meaninglessness” in the sense that imagery and narratives stylishly shocking and/or erotic but are fragmentary in the sense that they extract a sensibility from a would-be narrative, but are ultimately a post-modern exploration of linguistic and imagistic signifiers with no real reference back to any narrative. The author respectfully asserts that Blackstar is more of this same exploration of fragmentation. When the article was released, the author was unaware that in a few days, Bowie would be gone and that the doors of radical reinterpretation of the imagery would open wide. In fact, in a postscript, the author so much as acknowledges this necessity of re-assessment, and finds evidence of the images expressing Bowie’s attempt to “bridge life and death”. Nonetheless, the writer holds to his assertion that Bowie’s “struggled to articulate the human struggle to articulate”, as if Bowie has some difficulty in being coherent.

Bowie’s cryptic language and imagery could be construed as stylish and compelling, but ultimately fragmentary and meaningless, and indeed the writer of the article asserts, “It was rare for Bowie to embrace clear meaning”. However, “clear meaning” and “meaninglessness” are not necessarily opposed. I have always sensed that what Bowie has been able to do within the particular stylistic and narrative concepts of each album is to create fantasy worlds with their own suppositions and values, of which the strange references and phrasing are snippets of the experience, narrative and impressions of the players in their dystopian or dreamscape worlds, and as such, there is a coherence to his narrative in terms of that world. This coherence-in-context compares in a sense to the language and imagery of Clockwork Orange which Bowie has indicated as an early influence and whose language he does use in a track on the album.

Shortly before Bowie’s death, I had finally finished Jung’s “Archetypes of the Collective Unconscious”. Needless to say (as with most people who tackle any volume of the Collected works) this endeavor had a profound and assuredly permanent impact on my awareness, and I could not help but notice the strikingly mythological symbolism in the video and lyrics of the title track of the album, Blackstar. My own impression was that is was probably the most meaningful and possibly the most personal entry into Bowie’s long catalog of dramatic self-utilizing representational imagery. In the track Blackstar, I believe Bowie connects with one of the most profound experiences existence – personally and necessarily confronting the nature of death. In doing so, he explores its visceral and transcendent natures in powerfully symbolic language and image that is classically mythological in content; or an expression, if you will, of the collective unconscious.

As always, and again, in Blackstar Bowie establishes a world in which he is the protagonist of a fantasy drama in an alternate, but parallel world. The video begins with as shot of what any Bowie fan is probably going to agree is the space suit of Major Tom, bearing the “smiley face” patch, a symbol of era he was established as Bowie’s avatar. It is the story of Major Tom after his death. Through an unknown, mystical or ritualistic circumstance, the Major’s skeleton is separated and his skull is preserved and bejeweled. The skeleton body discarded and makes its way to a Black Star, where the implication is it will be immolated. The skull, preserved in Tom’s suit falls/is sent to ground on a planet discovered/collected by a female, cat-tailed humanoid resident of that planet, who immediately acknowledges its Messianic significance and transports it to her city, possibly to a castle on the hill, the “Villa of Ormen”, where a candle has been burning for all eternity. Later, in the narrative, a priestess uses the skull as a in a ritual of transformation of a group of female inhabitants.

In Jungian terms, the decapitation and separation of head from body symbolizes the separation of the base from the transcendent. The head is the “heaven of the body” and therefore the “heavenly stuff” is separated from the earthly. The earthly body will be reduced to “ashes” in the black star. Blackness symbolizes a return to the unconscious or the primordial – to the void. The blackness will later represent death in the video, and death is one of the most powerful implications of black in all symbolism. The skull is not only preserved, but is elevated to that which can transform. In alchemy, by which Jung was profoundly influenced, the philosopher’s stone is the substance that can transform base metals into gold – in the psychology of transformation, the fragmented person into the whole self. This is the jewel-encrusted skull of Major Tom. It is the ritual totem that is used as the catalyst for spiritual transformation.

In the Villa of Ormen stands a solitary candle which is an eternal light, but which is precious and must be earned and therefore is protected and hidden from common access up high in a castle. As the world of Black Star has no sun, this eternal candle may serve as well as the symbolic sun. The “Villa of Ormen” is the center of the world, as in the city Jerusalem. It is the heart of the planet and within that heart is the eternal light, gold, life – the attributes that are alchemically attributed to the sun. The black Star again is death of both body and spirit and will figure prominently in the second narrative. It is the counterpart to the start. Bowie sings hauntingly of the “solitary candle – and in the center of it all – your eyes”; eyes through which streams the light of consciousness; consciousness that is indeed “in the center of it all”. Consciousness is life.

A second, much less linear narrative is established in tandem and using much of the same symbolism, concerning what seems to be a series of impressions and vignettes which I see as expressing Bowie’s internal processing of his death. Bowie is directly the protagonist in these images. In this more dream-like or “active imagination” scenario, Bowie engages in a transformative process in a dark attic, through whose rafters shine a heavenly light. He is also a purveyor of “the word” in a shoddy black paperback emblazoned with a black star to a group of 3 vulnerable-looking younger people, a thin, white boy, a dark boy, and a girl with mousy hair. Later in this symbolic tableau, a shaman-like creature with a hooked arm menaces three decrepit and monstrous scarecrows that are crucified in a field.

In the attic, a man guides an unsettling dance of the three young people. There is a pale young man, (conceivably his persona), a dark man (his shadow) and a young woman (his anima). Bowie is blindfolded. He can no longer see. The light is not coming in to consciousness. There are buttons on his bandages, as if to say that his body, his eyes, are becoming a thing of the past – dead things. It is time for him to transform. The shaking is a symbol of transformation, of shaking off the material body. Death, at least in the material sense, called “Blackstar” has begun to overtake him. Death, with his dark sense of humor, taunts Bowie that his worldly possessions will be taken away – his passport, his drugs, his shoes – all symbols of aspects of material life and activity. Blackstar asserts, “I got game”. Of course he does, he will eventually take us all.

Bowie’s professed ambivalence toward religion, but obvious cultural possession over him (is this not the case for us all?), is expressed by his holding aloft of the shoddy little paperback that nonetheless projects well-thumbed with meaning. We have seen this gesture before, in the famous image of Chairman Mao holding aloft the red book, which likely was Bowie’s artistic influence, but most archetypically as Moses holding up the commandments. This is the “word” of God, and the book acts as a vehicle between heaven and earth. Via this book will come integration of Bowie and his “parts of the Self”, whose shadows are cast on the “sky”, an obvious backdrop, also symbolizing like the buttons-for-eyes the diminishment of things that are of prime importance in life, but which death will take as it ushers out the material world.

At the time Bowie created this video, he is obviously wrestling with the two paradoxical notions of death: that it is entirely transcendent and can yield an integration into the eternal, but that for the time being it is vile and taunting. The agonized scarecrows in the worst aspects of suffering death, crucified in a the dark primordial underworld of Chaos. Christ, crucified, is a symbol of the ultimate suffering – and are these crucified figures not imagistic metaphors of the excruciating attack by the slow decay of cancer? There is also an element of what Jung would call “the trickster” in shaman/sheep-like menace, taunting and terrorizing the inhabitants of the underworld with his hook for an arm. This also seems to represent the brutal force of disease that claws at us, bringing us down evermore. Yet, the central scarecrow taunts the creature right back by sticking out his tongue – a gesture of defiance in the face of the inevitable. It is said Bowie worked as hard as ever during the last months of his illness, and as all know, he bravely kept his illness from the public.

Why is it that the skull of Major Tom, an ordinary, fallible human being who who suffered from heroin addiction and possibly depression at one point in his life (we know Major Tom’s a junkie…hitting an all time low) transformed into the highest substance of transformation, the philosopher’s stone, after his death? As far as those of us who loved, are influenced by, and indeed “worshipped” Bowie we are concerned, the most poignant symbolism of the video. People who were influenced by Bowie, often were profoundly influenced. The author of the New Yorker review asserts Bowie “struggled to articulate” his message as an artist. I do not think he struggled at all. Bowie had the uncanny ability to tap into the collective unconscious and express it, perhaps not rationally, but on a much deeper level. That is what makes Bowie’s “meaningless” imagery so compelling – and this is an ability that great artists possess; a category to which Bowie has belonged from the beginning . It is indeed the output of his “jewel encrusted” creative mind, which is the philosopher’s stone for the artistic transformation of a generation of young people who felt somehow deeply connected to something unconventional and otherworldly. Bowie, if the response to his death is any indication, has himself become an archetype.

 

 

 

 

 

 

 

 

 

 

Our Perplexing Parts – My Introduction to the State Model of Consciousness

I am intrigued with the concepts of “parts of self” and all ways that different theorists characterize them. Freud, for example, iconically divided the psyche into Id, Ego and Superego. Object relations theorists, such as W. R. D. Fairbairn, suggested that parts of the self “split off” to merge with the inner (sometimes bad) characterizations of parents (objects), Winnicott indicated that a child must frequently develop a “false self” to similarly align with the perceived demands of the mother.  Carl Jung’s model of psyche was clear that it was a multiplicity, including persona, shadow, anima/animus, elements of the collective unconscious etc. If these theorists are describing a universal truth about human consciousness and implications for human behavior, which I believe they are, then how does this dynamic of “multiple selves” play out in our lives?

In my ongoing attempt to understand the effects of attachment, trauma-related and dissociative disorders, I have gone further in this realm, as the divided self is strongly associated with these issues. I recently attended the International Society for the Study of Trauma and Dissociation annual conference in Baltimore, at which I had the good fortune to hear a lecture by Dr. Frank W. Putnam, MD expert on childhood trauma and one of the leading experts on Dissociative Identity Disorder (an area of great interest for me). His exhilarating presentation prompted me to purchase his book, “The Way We Are – How States of Mind Influence Our Identities, Personality and Potential for Change”.

In his book, Putnam puts forth a “state” model of psyche, or how the consciousness of individuals is comprised of a multitude of states. We are all born multiple, and infant research has proven what we can observe – infants switch from state to state rapidly, each almost a different “baby” – sleepy, crying, sleeping, disconnected, smiling etc. As we grow, our “states” increase dramatically in number and become personalized with our experience. We build up a portfolio of ways of acting, feeling and being in different circumstances, and influenced by different emotions. This portfolio is what can be characterized as “selfhood”. How smoothly we transition from one state to the other is primarily determined by the quality early caregiving. Secure parenting can teach an infant to transition smoothly, and have an undergirding of continuous memory of each state. This dynamic decreases with more traumatic caregiving, in which the states must learn to “split off” or dissociate from each other in response to perceived or actual life threatening situations, often losing the continuity of memory.

However, if everyone exists as multiples, even healthy individuals, certainly the state model has some implications for moral behavior. Why is it that we say one thing and act another? Could the state theory explain the paradoxical nature of human belief? If we are truly comprised of multiples, then maybe that can explain much of our perplexing behavior – even our conflicting beliefs. Pertaining to one manifestation of this, hypocrisy, Putnam states:

True hypocrisy does exist, no doubt. But it is also likely that many inconsistencies of character that we point to as evidence of moral failure actually represent examples of state-dependent identity, learning and memory organized around conflicting roles and identities – so the individual behaves in contradictory ways but is not troubled by the discrepancy. What at first may seem like hypocrisy and duplicity may be more complicated and less calculated than they first appear.

The state model would certainly explain why certain politicians are so inconsistent! But it also sheds a light on our own perplexing behavior and the dynamics of our relationships. Who are you in front of your boss as opposed to your best friend? I am sure we have all experienced our partners as totally different people from time to time – some who we like more than others. How often have we awoken after a struggling through a particularly hard time or a period of illness felt like a “totally new person”? Can you become a raging inferno of anger out of the blue and then 10 minutes later shamefully wonder who that was?

Multiple-Personality-Disorder.jpg

The great psychological theorists have some form of acknowledging the existence of parts of self, and the state model is a fascinating characterization that holds many implications. The state model is, as Putnam characterizes it, “a big idea – that our consciousness can be chunked into basic units we call states…” Yes, it is a big idea, a new variation of long standing theories, and a fascinating way to make sense of behaviors, often perplexing, of yourself and others. I am excited to pursue this idea further, and to discover what gems it will offer for the enhancement of therapy.

Tao de Ching – #7, #8 – Containment

7

The Tao is infinite, eternal.
Why is it eternal?
It was never born;
thus it can never die.
Why is it infinite?
It has no desires for itself;
thus it is present for all beings.

The Master stays behind;
that is why she is ahead.
She is detached from all things;
that is why she is one with them.
Because she has let go of herself,
she is perfectly fulfilled.

8

The supreme good is like water,
which nourishes all things without trying to.
It is content with the low places that people disdain.
Thus it is like the Tao.

In dwelling, live close to the ground.
In thinking, keep to the simple.
In conflict, be fair and generous.
In governing, don’t try to control.
In work, do what you enjoy.
In family life, be completely present.

When you are content to be simply yourself
and don’t compare or compete,
everybody will respect you.

 

There is a concept in psychotherapy called “Containment”. This is the ability to sit with a patient in distress, sometimes dire, and tolerate the outflow of negative emotion – even if it appears levied toward the therapist. There is something about this that mirrors what should be the good attachment relationship that perhaps a patient has not sufficiently experienced now or in the past. Containment is a way of being with the patient that is non-judgmental, and that projects acceptance and love. What these two poems illustrate is that attitude. Containment is generous and selfless, without an egoic sense of superiority. It is more a joining with the patient in their experience, detached from “all things”, in the Buddhist sense of non-attachment to the flow of emotion whatever that may be, and one with that flow as the therapist receives it in all of its rawness.

In containing the patient, the therapist is attending closely to them in the moment. Negative affect and distress is allowed to be felt. In this secure one-on-one environment, the patient can be with their emotions and experience these feelings fully without the sense that they need to “get rid of” them. The therapist remains in the “low place” that perhaps the other people in the patient’s life have “disdained”. By the receiving, and working through the pain in the presence of someone just being there “nourishing without trying to”, the patient can feel “simply themself” as they are at that moment, and through this acceptance, the message is conveyed that as such, they are worthy of respect.