Wednesday, July 14, 2010

Group Therapy 2004 -- Difficulties

During the period February to March 2004 I was in group therapy at the Spring Road Clinic, D.C. Department of Mental Health.  The group leaders were Nicole Raffanello, Ph.D. and Debra Kosch, Psy.D.  In my last group session (March 16, 2004) I got into a fierce argument with one of the group members.  The group leaders told me I could apologize to the other group member or I would have to leave the group and not come back.  I opted to leave the group and I asked for a security guard to escort me out of the building.  I was evaluated by Henry C. Barbot, M.D. to determine whether I posed a threat to myself or others.  Dr. Barbot's written evaluation will be found in my clinical chart.

My treating psychiatrist at that time was Betsy Jane Cooper, M.D. at the Spring Road Clinic.  Several days after I was ejected from group, I wrote the following memo to Dr. Cooper explaining what I believed to be the underlying psychological problems I faced in group therapy.

On March 17, 2004 Dr. Cooper diagnosed me with paranoid schizophrenia and prescribed the anti-psychotic medication Zyprexa 10 mg/day, which I began March 17.  At the time I wrote the following memorandum I was taking Zyprexa (10 mg/day).  I am currently on Geodon 20 mg/day, Effexor 150 mg/day, and Ativan 2 mg/day.  I reaffirm that the following memorandum reflects my current opinion.

TO: Betsy Jane Cooper, M.D.
FROM: Gary Freedman
DATE: March 22, 2004
RE: Group Therapy Termination--Psychological Observations
_______________________________

The following material summarizes issues that led to my angry outburst in Group on March 16, 2004, and my subsequent termination by the Group leaders, Debra Kosch and Nicole Raffanello, both interns in training at St. Elizabeths Hospital. I had five complete sessions in Group--February 10, 17, 24, March 2 and 9--in addition to one aborted session on March 16, 2004. Group sessions were 1.5 hours in length; membership comprised three patients (two males including myself, and a female) as well as the two female leaders.

1. NARCISSISTIC SUPPLY -- DEPLETION

a.) I experienced a strain caused by my inability to draw strength from the Group, and my concomitant need to draw narcissistic nourishment from within.

Compare Harold Clurman's observations about his participation in Group Theater: "I have to draw strength constantly from within--and the supply doesn't always seem inexhaustible." Brenman-Gibson, M., Clifford Odets: American Playwright at 203 (New York: Atheneum, 1980).

What happened to me in Group was unfortunate. I very much need the acceptance and corroboration of people I respect. I want desperately to have ties to people like Dr. Lawrence C. Sack, Dr. Stanley R. Palombo, and C. Wallace Dye. These connections give me narcissistic nourishment, and when I don't get it, it's a terrible strain for me. I provoked what happened, of course. But it's terribly unfortunate that I elicited all this reaction from Debra and Nicole and my telephone call concerning my wish not to talk in Group about my disability benefits. See Malcolm, J. In The Freud Archives (paraphrasing Leonard Shengold M.D.).

[I had left a telephone message with Nicole Raffanello stating that I did not want to discuss my Social Security disability claim in group. I stated that if the group persisted in talking about the issue I would write a complaint to the U.S. Attorney. One of the group members admitted in group that she was jealous of my receiving a steady income from the government. The other group member frequently talked about his concern of running out of money; he was apparently living on savings or monies from private sources.]

b.) I was unable to draw narcissistic nourishment from identification with conventionalized group norms. For me, conventionalized Group norms are a narcissistic threat, not a source of narcissistic supply. Metaphorically, what was "food" for others in Group was "poison" for me. This is so because of my specific superego disturbance.

In my case superego internalization appears to have occurred abruptly, defensively, and prematurely, without adequate neutralization. Shame and castration anxiety did not become integrated into a smoothly operating unconscious guilt mechanism. I am therefore subject to pathological guilt and regression to shame and castration anxiety in pathological manifestations. Freeman, D.M.A., Foulks, E.F. and Freeman, P.A. "Superego Development and Psychopathology." The Psychoanalytic Study of Society, 1976.

I am unable to derive a sense of narcissistic integrity by projecting superego functions onto the Group and its leaders and submit to authoritarian leadership. See Kernberg and Fernando. Compliance with conventionalized group norms is not a source of secondary narcissism for me; I derive a sense of secondary narcissism by complying with internal values. Cf. Arieti, S., Creativity: The Magic Synthesis at 349; Rothenberg, A. "Janusian Thinking and Creativity." The Psychoanalytic Study of Society, 1976 Vol. 7: 1-30 at 24 (The experience of ego mastery in the service of native talent and values can produce the overt emotion of pleasure).

c.) Social Security Disability Can Seen as a Metaphor for Narcissistic Supply.

Group members, in attacking my eligibility for benefits (an independent source of nourishment from outside group), were symbolically attacking my reliance on a source of narcissistic supply which they had no access to. In some sense my "financial independence" was a metaphor for my psychological independence. It is noteworthy that according to Kernberg, psychological independence will arouse aggression from a narcissistically-regressed group (i.e., a group whose members have regressed to a state of pre-autonomous superego functioning) for whose members the group serves as the all-important source of narcissistic supply.

Perhaps it is useful to observe that independence is the polar opposite of parasitism; while external sources of comfort are the polar opposite of intrapsychic pain. For the group leaders, depictions of me as a parasitic "malingerer" (Debra's term) negate their recognition of my "independent" qualities, qualities that for the leaders pose a narcissistic threat. Also depictions of me as being "comfortable" with my life negate the need to empathize with my intrapsychic pain.

2. GROUP ATTACHMENT MAY NOT OBVIATE THE NEED FOR INDEPENDENT PAIRING

Anecdotal evidence supports the view that for some individuals--particularly creative persons--the narcissistic nourishment provided by the psychotherapy-group-as-a-whole may not vitiate the need for individual pairing; that is, the need for an individual "selfobject" (see Kohut); a twin (see Burlingham); or comrade-in-arms, a kind of psychical ballast who acts as a sounding board or "straight man" (Brenman-Gibson, n. 3.10 at 629). Put another way, even successful participation in group may not obviate the need for a selfobject.

Brenman-Gibson writes of playwright Clifford Odets' friendship with Elia Kazan while both were involved in group theater:

During this summer [in the early 1930s] a lifelong friendship began to ripen between Odets and "a Greek from Turkey who seemed like a Jew": Elia Kazan, called "Gadget" because, as he himself put it, "I was so small and so odd." Odets admired Kazan's muscular intelligence, his fierce repudiation of his carpet-selling father, his degree from Williams College, and his ambitiousness. From the beginning, other members of the group observed the special tenderness, almost a physical charge, between these two men. Odets began to collect notes for a short story to be called "My Friend the Greek." He would never be satisfied with it, feeling it had not captured the complexities in his friend[.]" Clifford Odets: American Playwright at 294. "A great feeling flows between Gadget [Kazan] and me and when we met it was like a love making," Odets wrote. Brenman-Gibson at 373.

It remains an open question how the group in which I participated would have responded to my activity of "pairing" with another group member, perhaps it is instructive to view my relationship with Social Security (insurer/beneficiary) as symbolic, in an object-relations sense, of the following relations:

"Pre-Oedipal mother/infant" and "self/selfobject." It is noteworthy that in infancy I was reportedly beaten by a jealous father and in my two last employment situations my relationship with a male selfobject was invidiously tainted by co-workers as homoerotic.

3. GROUP DYNAMICS (RELATIONSHIP WITH CONVENTIONAL PRE-OEDIPAL MOTHER AS SYMBOL) VERSUS GROUP MEMBER WHO SUFFERS FROM STRUCTURAL SEQUELAE OF UNCONVENTIONAL EXPERIENCES OF AGGRESSION AND LOSS FROM A PRE-OEDIPAL STAGE

Kernberg espouses the view that the pre-oedipal mother can be seen as a model, or symbol for large-group psychology. The all-embracing and inexhaustible breast-mother (cf. U.S. Social Security Administration) gratifies the voracious, greedy, self-centered infant, whose characteristics symbolize those of crowds.

One useful orienting approach to assessing my outburst of rage (in connection with the group leaders' request that I review my desire to bar group discussion of my disability benefits) is to view that rage through the prism of my own specific pre-oedipal experiences.

Pertinent pre-oedipal experiences include:

a.) My having had two "breast mothers," or primary attachment objects until age 6 months; my loss at age 6 months of one of the objects (namely, my maternal grandmother) (cf. loss of social security benefits). Pertinent psychological issues, as they relate to adult functioning include rage and depression. See Goldman, G. "Freud's Aesthetic Response to the Moses of Michelangelo." The Annual of Psychoanalysis (Freud's loss of a primary attachment object in infancy left him susceptible to life-long depression); cf. Greenberg and Mitchell.

b.) Early rapprochement-phase disturbance centering on an inattentive, uninterested, or negligent (but paradoxically, overprotective) mother who was psychologically unable to immerse herself in the child's own world, see Greenberg and Mitchell.

c.) Rapprochement crisis centering on the mother's disturbed view of the child's phase-appropriate neediness and aggression (i.e., need for refueling as well as combativeness) as immaturity, dependence, and infantile voracity. This view would have been reinforced by envious relatives within a narcissistically-regressed family. See Greenberg and Mitchell; cf. Brodey, W. "On The Dynamics of Narcissism." The Psychoanalytical Study of the Child, 1965.

d.) Physical injury at age 2.5 in an erotogenic zone (the mouth) within a narcissistically-regressed family that featured blaming, projection, and envy. See Fernando; cf. Brodey. Recognized sequaelae of early childhood injury include lack of superego metabolization, and a tendency to intense primitive idealization, and a need for mirroring self-objects. See Fernando (citing Peter Blos).

e.) The presence of a jealous and rivalrous father who resorted to harsh physical punishment (whipping with straps and cat-o'-nine tails). See Blos, P. "Freud and the Father Complex." The Psychoanalytic Study of the Child (structural sequaelae of premature rivalry with father may feature the need for idealized selfobjects).

f.) The experience of intense rivalry with a six-year older sister who struggled to retain pride-of-place in the family.

4. EMPATHY

a.) I experienced a severe emotional strain caused by empathy with disturbed individuals.

b.) At the session on March 9, much of the time was devoted to the narrative of the female group member who reviewed her life problems: history of alcoholism, attendance at AA meetings, heavy financial debt, unemployment, depression, unsympathetic relatives, both parents disabled, mother dying after long struggle with Alzheimer's disease. One group leader's empathic comment was "It all sounds so hopeless. Do you feel hopeless? Do you see any hope?" (Nicole).

c). It is useful to look at the respective reactions of the two male group members to the female group member's narrative. The specific reactions of the two male group members (I and the other male) may have been functional equivalents, which indicate the specific psychology of both males.

i.) The other male responded (on March 9) with ideations relating to self-destruction. He referred to holding a gun to his head and blowing his brains out; he spoke of his identification with a woman who stabbed herself to death as reported in an article in The Washington Post Magazine; he mentioned, incongruously, "Donny Simpson," which may have been a symbolic reference to the O.J. Simpson case (O.J. Simpson was tried on a charge of stabbing his wife (Nicole!) to death). The other male also referred to anality--"I lived in Philadelphia [on Bainbridge Street) in an apartment with doggy poop."

ii.) I responded on March 16 with verbal rage directed outward -- rage directed to group leaders. The gist of the comments were "You are corrupt! You're exploiting us! You can't help any of us, yet you allow this charade of therapy to go on and on! -- You (the other group member), are corrupt. You were abused by your parents, but you forgive them for abusing you! You are a willing victim of brainwashing! You are all corrupt! I will sacrifice myself for your corruption! Call the security guards -- I want to expose all of you!" Unlike the other male (whose fantasies centered on self-annihilation) my fantasies centered on provoking the authorities (parents), possibly to destroy me. Note that one of the structural consequences of early childhood injury is rebelliousness. See Fernando. Also, the results of psychological testing performed by GW in 1994 (William Fabian, Ph.D.) disclosed that I tend to challenge authority to the point that I lose sight of my own best interests.

There is a parallel between, on the one hand, my rebellion against parent figures (group leaders) and my championing of other group members who I depict as helpless pawns of the system--and, on the other, H.G. Wells' novel "The Time Machine." In the Wells novel the "Time Traveler" champions the childlike and hapless "Eloi" who are being cannibalized by the Morlocks (a depiction of the cannibalistic parental imago). Wells writes in the novel: "The strange exaltation that so often seems to accompany hard fighting came upon me. I knew that both I and Weena [an "Eloi"] were lost. But I was determined to make the Morlocks pay for their meat." "The Time Machine" at Chapter 9. (Wells himself suffered a bone fracture in childhood resulting from an accidental fall; the recuperation period was long. According to Fernando, early childhood injury can lead to failure of superego metabolization and the behavior of rebellion).

5. SIGNS OF NARCISSISTIC DISTURBANCE IN GROUP LEADERS (EXPLOITIVENESS, LACK OF EMPATHY).

At an early group meeting (perhaps February 10), Nicole referred to the psychoanalyst Alfred Adler (a somewhat gratuitous and grandiose gesture). Nicole referred to Adler in connection with his observations about feelings of insecurity.

Be that as it may.

It is ironic that it was Adler who first observed that a patient's first utterances in analysis should be given special weight. Freud acknowledged Adler's insight: "Dr. Alfred Adler, who was formerly an analyst, once drew attention in a privately delivered paper to the peculiar importance which attaches to the very first communications made by patients." See Freud, S. "Notes Upon a Case of Obsessional Neurosis" at n. 3.

Group therapist Irvin D. Yalom, M.D. is in accord: "I always listen carefully to first statements. They are often preternaturally revealing and foreshadow the type of relationship I will be able to establish with a patient." Love's Executioner at 16.

It is therefore interesting, if not revealing, to look at group leader Nicole's very first comments to me on February 10, at the first session. She said: "Mr. Freedman, let me first tell you about my degree program. I'm in a doctoral program . . . " (Perhaps importantly, after my outburst on March 16, Nicole steadfastly refused to tell me what university she attends, perhaps an indication of insecurity on her part. "Mr. Freedman, I don't want to divulge any personal information.")

Applying Adler's insight about opening statements to Nicole's fickle academic "admissions," (pun intended) we might say, perhaps, that she was really saying: "I'm just here to fulfill my degree program. I don't care one iota what your problems are,-- I'm just here to exploit you."

(Other expressions of grandiosity by Nicole include her gratuitous reference to the late analyst Margaret Mahler as well as her use of the word "dialectical" while talking to the other male group member. The other male responded, "What?" Nicole rephrased, "polarized.")

6. POSSIBLE USE OF PROJECTIVE IDENTIFICATION BY GROUP LEADERS (NARCISSISTIC DISTURBANCE)

a. Projective identification (fundamentally, abreaction) is a crucial defense mechanism in narcissistically-regressed groups, allowing for the discharge of rage by the collective onto a scapegoat. See Brodey.

b. Why did the group leaders delay for one week talking about my threat to go to the U.S. Attorney's Office? The telephone message in question was made by me on about March 3. The next group meeting was March 9. Nothing was said about the telephone message, despite the seriousness of the infraction--my telephone message beached the group protocol that limits all communications to oral communications within the group meeting. It was not until March 16 that Debra and Nicole asked me to discus my telephone message of March 3.

c. One possible explanations is that the delay was an expression of a classic projective technique for inducing rage, namely, "the deceptive calm before the storm."

d. Debra and Nicole may have needed to abreact their own feelings of rage regarding my personality qualities of independence, thinking, and rationality, See Kernberg.

7. POSSIBLE EXPRESSION OF NARCISSISTIC DISTURBANCE BY DR. COOPER (BOUNDARY BREACH).

Thursday morning March 18 I left several obnoxious and disturbed phone message for Dr. Cooper. Later in the morning, I interrupted Dr Cooper on her cell phone line while she was consulting with a patient. I proceeded to tell Dr. Cooper about my bowel movement and my breakfast. Dr. Cooper was angered by my boundary breach.

I met with Dr. Cooper that afternoon, March 18. She stated forcefully and angrily: "Mr. Freedman, I don't want to ever get another phone call from you like the one you made this morning!"

Dr. Cooper then reviewed with me the indications for in-patient treatment at a local hospital, such as "The Washington Hospital Center" (at a considerable cost to the taxpayer, I might add. Ten-thousand dollars per week billed to Medicare/Medicaid starts to add up after several months!)

It is worth noting that psychoanalytically Dr. Cooper's hospitalization recommendation might be seen as an expression of her own reparative fantasy, aimed at repairing her narcissistic injury caused by my irritating behavior earlier that day. The full significance of Dr. Cooper's reparative fantasy goes beyond my expertise.

What I can address is the possibility that what sounds reality appropriate in Dr. Cooper's admonition ("no more boundary breaches--possibility that what sounds reality appropriate in Dr. Cooper's admonition ("no more boundary breaches," as it were) can be seen as projective.

On occasion Dr. Cooper has brought her teenage-children to the clinic, her son and her daughter Holly. On one occasion, my appointment appeared to interrupt Dr. Cooper's interaction with her son. On another occasion the daughter entered Dr. Cooper's office during my consult in order to perform routine office chores. Once, the daughter telephoned Dr. Cooper on Dr. Cooper's cell phone line. On yet anther occasion, Dr. Cooper's husband "Burton" telephoned Dr. Cooper. This covers my 19-month interaction with Dr. Cooper. Dr. Cooper's admonition to me ("No more boundary breaches") takes on a projective quality in light of her tolerance of boundary breaches of my own "personal space."

What did my acting out with Dr. Cooper say about my possibly reacting to Dr. Cooper's own inappropriate conduct?

Was I mimicking her, in effect, volunteering myself as a scapegoat to be cannibalized? Is there a structural relationship between (1) my serving as an object of abreaction by the group leaders (see 6, above) and (2) my volunteering to be a scapegoat for Dr. cooper's abreaction (concerning the issue of boundary breach) (a narcissistic symptom)?

1 comment:

Gary Freedman said...

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