Wednesday, February 15, 2012

GW Psychiatric Treatment: Letter 8/8/95

August 8, 1995
3801 Connecticut Ave., NW
#136
Washington, DC 20008-4530

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

Dear Dr. Georgopoulos:

This letter comments on an interpretation that you offered at my consultation on Monday August 7, 1995.

PATIENT'S REPORT:

How are you able to certify that I am not potentially violent? I could be a psychopath. If I were a psychopath I might have committed crimes, but I would be very adept at concealing my propensity for violence. How can you say that I am not potentially violent? Have you ruled out the possibility that I am a psychopath?

PSYCHIATRIST'S INTERPRETATION:

It's not important what I (or others) think. All that's important is what you think. All that's important is that you think you are not violent.

PATIENT'S RESPONSE:

What I think is not the only issue. I can think I am not violent, but will I get my job back?

PSYCHIATRIST'S RESPONSE:

[silence].

ASSESSMENT:

Interpersonal Mutuality Versus Dependence

The psychiatrist transforms an issue of mutuality as between the patient and persons in his environment into an issue of the patient's dependence. Rumors or accusations that the patient is potentially violent are manifestations of a defensive reaction to the patient. The rumors or accusations involve others' defensive reaction of fear and jealousy and are a form of retaliatory aggression, which have had severe consequences for the patient. In the psychiatrist's interpretation the patient's report or concern relates solely to the patient's dependency needs and poorly developed sense of self.  In the psychiatrist's view the patient's report or concern indicates the need of the psychiatrist to engage in supportive reassurance aimed at strengthening the patient's sense of self, independent of the psychiatrist's or others' possible view of him.

The psychiatrist's interpretation seems consistent with a world-view that holds that however other persons react to the patient is simply a willy-nilly happenstance, never the product of an unconsciously-determined, defensive reaction by others that involves mutuality between the patient's ego resources and the ego resources of the patient's peers. A corollary of such a world-view is that it can only be evidence of the patient's emotional dependence or paranoia that the patient attributes any meaning to others' view of him.

The essential psychotherapeutic dynamic expressed here, namely, the psychiatrist's transformation of an issue of mutuality into an issue relating to the patient's poor sense of self and dependence echoes throughout the psychiatrist's interpretations. A variation on this essential theme is discussed in the letter to Dr. Georgopoulos, dated June 1, 1995.
PATIENT'S REPORT:

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?”

PSYCHIATRIST'S INTERPRETATION:

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.

POSSIBLE DEFENSIVE ASPECTS OF PSYCHIATRIST'S INTERPRETATION:

DENIAL/(ANAL SADISM?)

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.
The final paragraph is of special relevance. The psychiatrist's statement on August 7, 1995 “It's not what I (or others) think about your potential for violence that is important, it is what you think that is important” once again shows the psychiatrist transforming the patient's concerns regarding peers' aggression into an issue of the patient's hypersensitivity and weakness.

Denial of Aggressive Element in Defamation – Ego Differentiation

In the psychiatrist's interpretation, the defamatory statements of the patients's peers are denuded of any aggressive or destructive component. When the psychiatrist was confronted with the aggressive component or destructive consequences of peers' defamatory statements, he responded with silence.

Other possible applications of the psychiatrist's rule of construction highlight the absurd—indeed, sadistically inhumane—quality of the psychiatrist's world-view.

Imagine saying to a Gypsy who is being led to a Nazi gas chamber: “Remember, its not important what the Nazis think, all that is important is that you believe you are not sub-human.” Imagine saying to Alfred Dreyfus, rotting on Devil's Island: “It's not important that the French Government thinks you are a traitor, what's important is that you believe in your innocence.” In each of these examples, the aggressive element and the objective consequences of the defamation are denied; the focus is narrowed to a simple concern regarding a subjective narcissistic injury for the victim.

In effect, the psychiatrist is treating the patient as if the patient were a small child who had complained to the therapist: “Doctor, while I was playing in the school yard some kids came by and called me a name.”

Thus, the psychiatrist's interpretation, by ignoring the objective consequences of aggressive defamation, betrays the thought processes and psychological concerns of a small child. For the psychiatrist, aggressive defamation, and its consequences, has no meaning whatsoever.  Like the small child, the psychiatrist can only empathize with the victim's feelings of hurt (narcissistic injury) but not the response of outrage 1/, which limitation suggests something about the psychiatrist's level of ego differentiation.

Inconsistencies with previous interpretations in analogous circumstances – Creation of Double Bind Situation

It is interesting to observe that the psychiatrist's handling of the patient's concerns regarding the defamatory accusation that the patient is potentially violent differs from his handling of the patient's so-called paranoid ideations.

In the case of the patient's so-called paranoid ideations, the psychiatrist did not say: "All that's important is that you think you are not paranoid. Whether or not I think you are paranoid is immaterial. I am a tolerant person who will permit you to think whatever you choose to think so long as you do not act on those ideas in a manner detrimental to yourself or others. Let us analyze your ideas.” To the contrary, the psychiatrist has never shown any reticence whatsoever in characterizing the patient's ideas as paranoid or in stating the absolute need to use medication to eliminate the ideas, despite the fact that the patient's ideations have no significant behavioral component.

Indeed, on one occasion the psychiatrist went out of his way to label as “improbable” (with the implication of paranoia) one of the patient's reports that was actually supported by documentary evidence, namely, that a senior partner at his previous place of employment had a government agency certify the patient insane on the basis of evidence the partner had fabricated.

Thus, the psychiatrist has created a curious double-bind. In complaining about others' defamatory accusations the patient will tend to face one of two consequences. Either the patient's report that he has been defamed will be interpreted as a paranoid perception or, if the report is accepted as accurate, the patient's reasonable concerns about the defamation will be cited as evidence of the patient's emotional dependency, weakness, and poorly developed sense of self (not merely coincidentally, attributes typically associated with homosexuals).

Sincerely,

Gary Freedman
__________________________________
1/    I suspect that the capacity to experience defamation or any mistreatment, or reports of same, as an “outrage” as opposed to a hurt (or narcissistic injury) relates to issues of ego differentiation—the development of a moral sense--as well as the individual's level of individuation and a capacity to tolerate disapproval or hostility (that of the other party or one's own) without fear of abandonment. Brenman-Gibson provides an exquisite example of the reaction of outrage by an ego-mature, identity-secure adult (in contradistinction to the hurt response of the identity-insecure child, emotionally dependent on his victimizer). Recounting an interaction with the aged father of playwright Clifford Odets, Brenman-Gibson states: "Once inside the car, there immediately ensued hostile, crude sexual advances of such magnitude that the sentence (often recorded by Odets in his diary as his own response to his father) 'How dare you!' kept running through my head. The total disregard of one's essence was the most outrageous part of the experience.” “My experience of outrage was not simply the repeated response of an 'underling' to the repeated affronts of an 'executive' of big business. It was his intrusive, narcissistic disregard of what I am that was so offensive.” Brenman-Gibson, M. Clifford Odets, n. 1.4 at 622, no. 13.7 at 645 (New York: Atheneum, 1982).

1 comment:

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).

Sincerely,

[signed]

Dimitrios Georgopoulos, M.D.