GW Psychiatric Treatment: Letter to Dr. Georgopoulos

The following letter is useful in demonstrating how I deal with interpersonal disagreements and anger.  I do not become violent; I analyze.

March 9, 1995
3801 Connecticut Ave., NW
#136
Washington, DC  20008

D. Georgopoulos, M.D.
Dept. Psychiatry
GW Univ. Med. Ctr.
Washington, DC  20037

Dear Dr. Georgopoulos:

A seemingly insignificant exchange that took place at our session on Monday March 6, 1995 merits re-examination and analysis.

I stated that I had formed the conclusion that my friend Craig had an ego-dystonic homosexual attraction to me, and that Craig's conduct in relation to me could be interpreted in light of that attraction.

In response you stated that "we cannot get inside Craig's head"; "we cannot change Craig" (implying that whether or not my interpretation is correct is, for me, psychotherapeutically irrelevant); and that the only value that may be usefully ascribed to my interpretation is a projective value, namely, it is I who am attracted to Craig.

I take strong exception to the rigid and simplistic rule of construction that you applied in this circumstance.  I will attempt to show that, while your own interpretation may not be incorrect, it is not the only interpretation.  First, we can get inside Craig's head by means of empathy.  Second, whether my statement about Craig is correct carries a great deal of information about me, and that information is not limited to the facile interpretation of a projection.

The following outline compares two internally consistent sets of personality characteristics that emerge if one assumes, on the one hand, that my statement about Craig is projective, and, on the other, if one assumes that my statement about Craig is empathic.

Projective Construction of the statement “I believe Craig has an ego-dystonic homosexual attraction to me”

1a.  The statement is a projection of my own ego-dystonic attraction for Craig

In the case of projection, the individual is impelled to displace ego-dystonic thoughts and feelings onto an external object

2a.  My act of attributing a characteristic to Craig that properly applies to me indicates a lack of insight

3a.  The truth value of my statement is immaterial in the psychotherapeutic milieu since Craig is not present and we can’t change Craig

4a.  Content/process symmetry:  If we interpret my statement “Craig has an ego-dystonic homosexual attraction to me” as a projection of my homosexuality, the symmetry of content and process centers on the issues of homosexuality and paranoia, since the content of my statement relates to the issue of homosexuality and the process of the statement (which is projective) relates to the issue of homosexuality in that projection is an essential element of paranoia, a form of psychopathology that, according to Freud, has a strong homoerotic element.

5a.  Treatment-resistance issue: poor insight
__________________________________

Empathic Construction of the statement “I believe Craig as an ego-dystonic homosexual attraction to me”

1b.  The statement is based on my empathic understanding of Craig: empathy is defined as “[p]utting oneself into the psychological frame of reference of another, so that the other person’s thinking, feeling, and acting are understood and, to some extent, predictable.  Carl Rogers defines empathy as the ability to accompany another to wherever the other person’s feelings lead him, no matter how strong, deep, destructive, or abnormal they may seem.  Although communication and empathy are related, empathy is not primarily aimed at exchanging information or altering another’s belief or action systems.  On the contrary, empathy is concerned rather with aligning one’s state of mind with another’s in order to commune rather than communicate, and in order to expand the interactive repertoire between the participants rather than to transmit the knowledge of one to another.”  Campbell, R. J.  Psychiatric Dictionary, at 247. 6th ed. (New York: Oxford University Press: 1989).

Brenman-Gibson alludes to the creative transformation of identity diffusion and loss of sense of self as two factors underlying the capacity to empathize: “The gift of empathizing, central to such diverse arts as psychotherapy and playwriting, is little understood.  The special kind of imagination that permits one person to put himself ‘in the place of the other’ involves at the very least some experience of incompletion on the part of the ‘I,’ with the hope of closure by way of identification with the ‘thou,’ thus often thought of in Western culture as a feminine quality.  But there is more than this.  There is a diffusion of identity to accommodate-- . . . An inner ‘gallery of characters,’ and there is a detached ‘witnessing’ of the entire process.” Brenman-Gibson, M. Clifford Odets, 630 (New York: Atheneum, 1982).

The identity diffusion that my lie at the base of empathy may itself have its source in traumatic object loss, resulting in fixation at a level of ambivalent identification with the lost mother.  “Since identification as a consequence of loss [compare discussion of superego resistance, below, at paragraph 5b] is ambivalent and at [a particular] stage involves representations of part-objects, [the patient] may find it difficult to fuse the separate good and bad imagoes of the lost mother whom he has both loved and hated and thus to integrate his own split psyche [citations omitted].  If he remains a fragmented assemblage of incompatible desires, affective experiences, and identifications, he will be predisposed to splitting of his psyche and dissociation in later life.”  Ducey, C. “The Life History and Creative Psychopathology of the Shaman,” at 191.  The Psychoanalytic Study of Society, at 191.  Volume 7.  (New Haven: Yale University Press, 1976).

Differential diagnosis issues: sense of self-fragmentation, loss of sense of self and conflict of the self with objects, identity diffusion, and instability of cohesive self are all considered to be among the “typical” features of the borderline personality.  Campbell, at 101.

2b.  The capacity to empathize would appear to be consistent with a high capacity for insight which may be complemented by a highly-developed synthetic function.

An individual’s observations about and analyses of external objects may be impelled by and facilitated by the individual’s need and ability to synthesize external and internal elements, i.e., the “synthetic function.”  “In psychoanalytic psychology, synthesis is considered to be a complex ego function, probably a derivative of libido, which impels the person to harmonious unification and creativity in the broadest sense of the term.  Synthesis includes a tendency to simplify, to generalize, and ultimately to understand by assimilating external and internal elements [compare the ego defense of projection], by reconciling conflicting ideas, by uniting contrasts, and by seeking for causality.”  Campbell, at 734.

Note that the synthetic function may be greatly enhanced as a result of traumatic object loss:  “When the ego’s stability is most gravely threatened [with the loss of object libido] but yet it retains a certain measure of constructive energy, its synthetic functions are immeasurably extended.”  Nunberg, H.  “The Synthetic Function.”  Practice and Theory of Psychoanalysis, 127 (New York: International Universities Press, 1948).

Thus, both empathy and the development of a hypernormal synthetic function may have their source in traumatic object loss; in the case of empathy, traumatic object los may lead to identity diffusion, which, in turn, may be creatively transformed into a heightened capacity to empathize.  It would appear, therefore, that empathy and the synthetic function may be complementary creative ego functions (with their ultimate source attributable in certain cases to traumatic object loss).

Differential Diagnosis issue: lack of synthetic capacity is an important feature of the borderline personality.  Campbell, at 101.

3b.  The truth value of my statement is material in the psychotherapeutic milieu despite the fact that Craig is not present and we can’t change Craig.  Whether my statement is true relates to my own reality-testing, synthetic functioning, capacity to empathize; and, by implication, to the issues of object loss, identity diffusion, sense of guilt and resistance to therapy (see below).

4b.  Content/process symmetry:  If we interpret my statement “Craig has an ego-dystonic homosexual attraction to me” as reflecting my empathic understanding of Craig, the symmetry of content and process may me interpreted as centering on the issue of traumatic object loss and my consequent need for a selfobject to cure a defect in the self.  The content of my statement may relate to Craig’s empathic selfobject relation to me (and the satisfaction of my own narcissistic needs), which parallels my own empathic process of understanding Craig at a cognitive level.  See Greenberg, J.R. and Mitchell, S.A. Object Relations in Psychoanalytic Theory, at 353-355 (Cambridge: Harvard University Press, 1983).

5b.  Treatment resistance issue: super-ego resistance (with its source being an unconscious sense of guilt resulting from object loss).  Freud identifies superego resistance resulting from an unconscious sense of guilt as the most intractable of resistances.  “The battle with the obstacle of an unconscious sense of guilt is not made easy for the analyst.  Nothing can be done against it directly, and nothing indirectly but the slow procedure of unmasking its unconscious repressed roots, and of thus gradually changing it into a conscious sense of guilt.  One has a special opportunity for influencing it when the Ucs. sense of guilt is a ‘borrowed’ one--when it is the product of an identification with some other person who was once the object of an erotic cathexis [compare “identification as a consequence of loss” in connection with discussion of the identity diffusion/empathy issues, above, at paragraph 1b].  A sense of guilt that has been adopted in this way is often the sole remaining trace of the abandoned love-relation and not at all easy to recognize as such.  (The likeness between this process and what happens in melancholia is unmistakable.)  If one can unmask this former object-cathexes behind the Ucs. sense of guilt, the therapeutic success is often brilliant., but otherwise the outcome of one’s efforts is by no means certain.  It depends principally on the intensity of the sense of guilt; there is often no counteracting force of a similar order of strength which the treatment can oppose to it.  Perhaps it may depend, too, on whether the personality of the analyst allows of the patient’s putting him in the place of his ego ideal, and this involves a temptation for the analyst to play the part of prophet, savior and redeemer to the patient [which is forbidden to the analyst].”  Freud, S. The Ego and the Id.  (Compare my attributing the role of “prophet, savior and redeemer”--in Kohutian terms, a “selfobject”--to Craig).

Differential diagnosis issues: (1) narcissistic inaccessibility; (2) borderline personality in which the patient is unable to maintain a therapeutic alliance, which is disrupted by overwhelming feelings.

Sincerely,

Gary Freedman