Friday, February 10, 2012

GW Psychiatric Treatment: Letter 6/1/95

June 1, 1995
3801 Connecticut Avenue., NW
Washington, DC 20008-4530

D. Georgopoulos, M.D.
Dept. Psychiatry
GW Univ. Med. Ctr.
2150 Pennsyvania Ave., NW
Washington, DC 20037

Dear Dr. Georgopoulos:

Interpretations that you offered at my consultation on May 18, 1995 confirm my long-standing belief that many of your comments and interpretations are not simply inappropriate or incorrect, but are defensive comments that reveal aspects of your reaction to me and, further, may provide clues to aspects of my interpersonal difficulties, generally. This communication discusses possible defensive features of your interpretations.


I react so differently to stimuli than others. When I was in kindergarten all the other students participated in a class project, and I was the only student who declined to participate. I am troubled by this. I think: “How can a psychiatrist ever understand me if so many aspects of my personality are different from the personalities of the psychiatrist's other patients? What clinical experiences does the psychiatrist have to compare me with?”


It sounds like you have a need to be understood. What you seem to be describing is that you have a poor sense of identity, and a need to stand out—a need to do things differently so that you can assert an individual identity.



The psychiatrist denies his own failure of empathy and lack of intellectual understanding of the patient, and places the burden of understanding exclusively on the patient's shoulders; in effect, the psychiatrist is saying “the fact I don't understand you is not my problem, the problem is that you have a need to be understood.”

A psychiatrist should respond affirmatively to the patient's need for identity confirmation, and should not interpret the patient's need for identity confirmation as an unreasonable demand on the psychiatrist or as a manifestation of psychopathology. Brenman-Gibson, discussing the importance of identity confirmation in adolescence, states: “According to Erikson, ' . . . it is of great relevance to the young individual's identity formation that he be responded to and be given function and status as a person whose gradual growth and transformation make sense to those who begin to make sense to him. . . . Such recognition provides an entirely indispensable support to the ego in the specific tasks of adolescing.'” Brenman-Gibson, M. Clifford Odets, at 631 n. 4.7 (New York: Atheneum, 1982), quoting Identity and the Life Cycle.  Erikson's comments seem equally applicable to the psychotherapeutic relationship, and the salutary need of the patient for identity confirmation and the affirmative duty of the therapist to understand the patient and to communicate the fact that he does understand the patient.

There is a disquieting parallel between the psychiatrist's shifting of the burden onto the patient 1/ and the behavior of the sadistic bully who denies his own aggression and attributes his victim's complaint to the victim's hypersensitivity and weakness.


There is a paranoid element in the psychiatrist's interpretation that the patient has a defiant need to be different in order to assert an identity that seems precarious to the patient. The psychiatrist's interpretation is inconsistent with the facts, specifically abundant evidence of the patient's tendency to follow his own, inner-directed problem solving style independent of input from or comparison with others.

The paranoid element in the psychiatrist's interpretation lies in the seeming fact that intellectual independence arouses fear and anxiety in the psychiatrist. The psychiatrist reacts defensively by interpreting instances of the patient's unusual problem solving style as a planned and calculated stratagem by the patient, rather than the naturally-occurring product of the patient's ego processes and ego strength. Curiously, this is the same reaction we find in the paranoiac, who despite all the evidence to the contrary, sees planning and calculation in others' actions. The degree to which the paranoid party sees calculation tends to be proportional to the paranoid party's own anxiety. Thus, the extent to which the psychiatrist sees calculation behind the patient's naturally occurring originality is proportional to the psychiatrist's own anxiety in the face of the patient's originality.

(It is noted that early in the therapy, the patient related an anecdote concerning an incident that occurred while the patient was in law school. The patient stated he and other students had been assigned an identical project by the professor; that the patient, working independently of the the other students, had arrived at a solution totally different from that of the other students and a solution that was not anticipated by the professor; the patient further reported that a fellow student later told the patient that the professor was noticeably angered by the patient's in-class presentation. The psychiatrist responded to the patient's report: “It was you who were angry. You were angry at the professor.” Here the psychiatrist's interpretation assumes that the patient's report is projective, in effect, displacing the professor's inappropriate aggression onto the patient. The psychiatrist's distortion of the patient's factual and objectively verifiable report must suggest something about the psychiatrist's defensive needs.)


I feel as if I were polarized between two needs: a need to ward off foreign elements or foreign contamination, but, at the same time, a need to fuse with certain people.


How can we get you to move toward the middle?



The patient's report indicates his sensitivity to the polarized nature of his ego, an ego structure typically found among creative persons. Storr writes: “Just as the average man is unaware that he possesses a feminine side, and identifies himself wholly with his masculinity, so he is unconscious of the fact that other characteristics, including some upon which he may pride himself, are counterbalanced by their opposites. There is good reason to suppose that creative people are distinguished by an exceptional degree of division between opposites, and also by an exceptional awareness of this division. . . . The increased awareness of opposites within, which characterizes the creative as opposed to the neurotic, may have its origin in the rather general enhancement of reaction to all stimuli which is also typical. Sensitivity to what is going on around, which may account for the premature development of the ego to which reference has already been made, is surely likely to be matched by a corresponding sensitivity to stimuli within.” The Dynamics of Creation, 196-197 (New York: Atheneum, 1972).

The particular opposing needs stated by the patient—a need to ward off foreign elements and the simultaneous, but paradoxical, need to fuse—are not specifically or exclusively pathological.

Storr states: “It has often been pointed out that creative people are skeptical, and reluctant to acquiesce in the findings of authority just because these have become generally accepted. There are also those who rebel for the sake of rebelling, and who have no creative alternatives to offer but these need not concern us. The point is that independence is seldom a simple trait. It is compounded of both strength and weakness, aggression and fear. As Hartman points out, 'in certain situations the resistance against contamination can be considered an indication of ego strength.'” The Dynamics of Creation, at 189-190.

With respect to the need for fusion, Greenberg and Mitchell state: “Adults need selfobjects even at the highest levels of psychological functioning, [Kohut] argues, pointing to the reliance on selfobjects by O'Neill, Nietzsche, and even Freud, particularly during persons of intense creative activity. An appreciation of this phenomenon, Kohut suggests, calls for a re-evaluation of our standards of psychological health and a reconsideration of the emphasis we place on autonomy. His psychology of the self, by emphasizing the enduring need for selfobject relations throughout life and by stressing that infantile demands are not only a source of disease but a 'wellspring of health and productivity' [citiation omitted], avoids the covert 'developmental morality' inherent in all other psychodynamic theories. Object Relations in Psychoanalytic Theory, at 368 (Cambridge: Harvard University Press, 1983) (Kohut does emphasize the move from addictive dependence to greater resilience and independence in self-selfobject relations, however).

It may be useful to consider the two incompatible but equally necessary models—Hartman's view of ego strength, which comprehends the ego's resistance against contamination; and the need to fuse as described by Kohut—to represent a conceptual antinomy of the creative ego. Cf. Davidson, L. and Strauss, J.S. “Beyond the Biopsychosocial Model: Integrating Disorder, Health, and Recovery.” Psychiatry, 58 (2): 44-55, at 46; February 1995 (Stanley R. Palombo, M.D., editorial adviser).

The psychiatrist's facile dismissal of the patient's concern (“How do we get you to move toward the middle?”) may be rooted in the psychiatrist's need for stereotypical, conventionalized thinking. If so, the psychiatrist's comment would reflect his ego's inability to accommodate any thinking that goes outside the zone of conventionality. The psychiatrist's comment suggests his tendency to define psychopathology as any thought or ego state that is not conventional and which, because of the nature of his ego resources, arouses anxiety in the psychiatrist; the psychiatrist's anxiety state would then need to be defended against.

Where a psychiatrist's ideals are stereotype and conventionality, his attempts to change the patient will not be empathic, but, rather, simply a way of alleviating the psychiatrist's own anxiety engendered by the patient's nonstereotypical thinking or atypical ego processes.


Gary Freedman

1/  At a previous session, the patient had repeatedly importuned the psychiatrist to prescribe the anti-depressant Prozac. The psychiatrist initially refused, explaining that the drug might cause serious side-effects in the patient's case. The psychiatrist finally gave in, but with the words: “I am only consenting to prescribe Prozac because you asked me to.”


Gary Freedman said...

The term self-object refers to any narcissistic experience in which the other is in the service of the self, the latter being defined as a structure that accounts for the experience of continuity, coherence, and well-being. It is a source of narcissistic feeling.

The notion of selfobject appeared in the work of Heinz Kohut as early as his 1968 article, "The Psychoanalytic Treatment of Narcissistic Personality Disorders," in his discussion of the narcissistic transference, in which the analyst is an archaic selfobject function in the narcissistic pathology. It was further developed in The Analysis of the Self (1971) in Kohut's reconceptualization of narcissism. It refers to a normal narcissistic function that evolves in stages. The selfobject can be the object of a fixation that is the basis for a narcissistic transference. When the object is narcissistically invested, the narcissistic object relation is opposed to object-love.

The hyphen (self-object) disappeared in The Restoration of the Self (1977), because the selfobject is not reducible to the archaic configurations of narcissism, but is rather defined as a dimension of experience. In 1979, Kohut generalized a selfobject that is inseparable from the self, of which it is the existential correlate and the source. At the beginning, Kohut reminded us in his 1980 article, "Selected Problems of Self Psychological Theory," the descriptor selfobject was reserved for pathology in the sense of an archaic fixation, with the emphasis being placed on the grandiose self or the omnipotent selfobject. Like the object, the selfobject is at first replaceable, before becoming meaningful. In the mature self/selfobject relationship, the archaic selfobjects continue to exist at a deep level and to resonate as leitmotivs at various times.

Gary Freedman said...

In How Does Analysis Cure? (1984), the selfobject became a dimension of experiencing another person whose functions are related to the self. The selfobject can thus be archaic or mature, anachronistic or appropriate. A support for the vulnerable self, it is the appropriate medium of the healthy self, like the oxygen that is necessary for life. The self is a feeling of unity, strength, and harmony if, at each stage of life, it receives the appropriate responses from the selfobject environment: availability and receptivity, the conditions for all mental life. The selfobject is an intra-psychic experience. In times of temporary vulnerabilty, the better equipped the subject is to find the selfobjects he or she needs, the healthier he or she will be. The selfobject is not necessarily a person; it can be music, an outing, a talent, culture, and so forth.

It is often difficult to distinguish between that which comes from the object and that which comes from the selfobject, especially in adults. In pathologies or in the context of treatment, the distinction is easier to make. The object is recognizable through representation and comes from desire. The selfobject is an archaic or mature function that comes from need. If the other is the target of desire, anger, love, or aggression, that other is an object. If the other maintains cohesion, strength, and personal harmony, it is a self-object. Object-loss results in mourning; the relationship to the selfobject cannot be lost but can instead undergo transformation.

Kohut's successors disagreed about the generalization of this term. In the view of some, the selfobject reflects vulnerability, even if it is temporary, in the self. An intact Self, according to this view, does not need a selfobject and the notion should be reserved for pathology. However, Kohut's view is clear: The selfobject is the oxygen that we are only aware of when we think about it. Deficiencies in the self result from the self/selfobject relationship. What was once limited to pathologies is generalizable to every subject and every course of treatment, and pathology stems from narcissism alone. The selfobject preserves the ambiguity of being simultaneously both a relationship and an experience. The metapsychology of the self underlying this concept can be criticized.

Gary Freedman said...

According to the George Washington University Medical Center Department of Psychiatry I suffered from paranoid schizophrenia when I wrote this letter:

George Washington University Medical Center
Department of Psychiatry and Behavioral Sciences

February 14, 1996

Dear Mr. Freedman,

This letter is being written per your request to know your diagnoses.

In my opinion my working diagnosis has been: Schizophrenia, Paranoid Type (295.30).



Dimitrios Georgopoulos, M.D.