Tuesday, February 21, 2012

GW Psychiatric Treatment: Letter 9/18/95

September 18, 1995 (rev'd 9/19/95)
3801 Connecticut Ave., NW
#136
Washington, DC 20008-4530

D. Georgopoulos, M.D.'
Dept. Psychiatry
GW Univ. Med Ctr.
Washington, DC 20008

Dear Dr. Georgopoulos:

This communication reports on several recent consultations.

By way of cover letter dated August 15, 1995 the patient submitted to the U.S. Secret Service an updated version of the letter to Dr Georgopoulos, dated July 26, 1995. The update comprised the following addition to footnote 3:
A revealing instance of the psychiatrist's distorted perception of aggression, and the relation of that distortion to the psychiatrist's object anxiety and fear of abandonment and isolation, is provided by the following anecdote.  In mid-November 1994 the patient reported a dream he had had that was prompted by the patient's concerns in connection with a pleading he was then preparing that was to be filed in a job discrimination action against his former employer.  The patient reported that he was experiencing considerable anxiety since it was important to him to come up with credible legal arguments, yet the appropriate legal arguments seemed to elude him.  The patient reported that he had a dream in which a judge castigated the patient for presenting "frivolous" arguments to the court.  (It is significant that the patient's anxieties disappeared at the moment he completed the pleading, indicating that the patient's anxieties centered on the issues of ego mastery and achievement.)  The psychiatrist stated: "Maybe the dream means that you are having thoughts that your action against your employer is frivolous." The psychiatrist had apparently transformed the patient's anxieties that centered on ego mastery and achievement in relation to the patient's own ideals into an issue relating to the patient's relations with the employer, suggesting that the patient's anxieties centered on his fear of punishment for having engaged in a "frivolous" act of rebellion and aggression against an authority figure.  In object relations terms the psychiatrist misinterpreted the patient's "self-shame" (experienced in relation to the patient's ego ideal) as an instance of "object anxiety" (in which the psychiatrist was expressing his own fears of the object being angry and abandoning him).

SESSION MONDAY AUGUST 21, 1995:

PSYCHIATRIST'S COMMENTS:

Psychiatrist says absolutely nothing.
______________________________________

SESSION MONDAY AUGUST 28, 1995:

PATIENT'S REPORT:

I notice that at this session you have made a few comments.  I made a mental note of the fact that at our session last Monday (August 21, 1995) you said absolutely nothing.

PSYCHIATRIST'S COMMENTS:

You say you like it when I say nothing, but it seems that you want me to interact with you.

[At a prior session, in July 1995, the patient was silent for a lengthy period.  The psychiatrist stated: "I am wondering whether your silence means that you have feelings of ambivalence about what you are supposed to be doing here."  Note, incidentally, the coercive connotation of the psychiatrist's phrase, "what you are supposed to be doing here."]

PATIENT'S RESPONSE:

If you make comments like the ones you usually make, I would prefer that you say nothing  But I do want you to react to me with worthwhile comments.

INTERPRETATION:

The psychiatrist's comment seems to focus on the patient's presumed ambivalence in relation to the psychiatrist.  The psychiatrist's comment suggests that the patient cannot make up his mind whether or not he wants interaction with the psychiatrist.

There may be a parallel between the psychiatrist's attribution of ambivalence relating to the patient's interaction with the psychiatrist and the psychiatrist's attribution of ambivalence at a previous session relating to the patient's feelings about his former employer ("Maybe your dream means that you are having thoughts that your action against your employer is frivolous.")

The psychiatrist suggests at the current session that the patient is torn between a desire that the psychiatrist interact with the patient and the opposite, a desire for no interaction.  At the previous session the psychiatrist interpreted the patient's dream to mean that the patient was torn between feelings of aggression against the employer and a feeling of fearful anxiety that the patient might suffer punishment for engaging in a "frivolous" legal action against his employer.

One suspects that the psychiatrist's attributions of ambivalence to the patient are in some way defensive, and represent the psychiatrist's need to ward off the anxiety engendered in the psychiatrist by the patient's aggression directed at the psychiatrist (as, for example, in the patient's statement to psychiatrist: "If you make comments like the ones you usually make, I would prefer that you say nothing") and aggression directed at the patient's employer (in the form of a job discrimination legal action).

The evidence suggests that one means employed by the psychiatrist to cope with the anxiety engendered by others' aggression is to imply that the aggression is not sincere.  The psychiatrist seems to attribute, or misattribute, ambivalence as a defense against his own anxiety. 1/  When the psychiatrist attributes ambivalence to the patient he seems to assign primacy or genuineness to only one of the patient's feelings (and of course that feeling will be the one syntonic with the psychiatrist's own needs) and any contradictory feeling or impulse, which will necessarily be dystonic with the psychiatrist's needs and therefore anxiety-provoking, is depicted to some extent as artificial or illusory 2/  In sum, the psychiatrist seems to attribute ambivalence to another in the service of his own denial: to deny or diminish what is anxiety-provoking for the psychiatrist and to affirm what is need-satisfying.

In neither of the cited instances in which the psychiatrist seems to have attributed ambivalence to the patient is the attribution appropriate.  With respect to the patient's anxious concern relating to ego mastery and achievement in connection with creating credible legal arguments in his action against his former employer, the psychiatrist misinterpreted the patient's "self-shame" (experienced in relation to the patient's ego-ideal) as an instance of "object anxiety" (in which the psychiatrist was expressing his own fears of the object being angry and abandoning him).  In so doing, the psychiatrist attributed to the patient the unstable (ambivalent) feelings of aggression (ameliorated in the psychiatrist's gloss as "frivolous") and fear of retaliation 3/ in relation to only one object, the employer.  This was an inappropriate attribution of ambivalent feelings to the patient vis-a-vis the employer since, in effect, the patient was expressing two different stable affects in relation to two distinct objects: 4/ aggression against his employer and simultaneous anxiety in relation to his own ego ideal.  (According to Rothenberg we do not experience ambivalent feelings simultaneously, but in alternating sequence,  Id.)

Likewise, the patient's seeming conflict over whether he does or does not want the psychiatrist to interact with the patient does not necessarily involve ambivalence.  The following parable illustrates the patient's feelings:
A starving Hindu makes his way to an encampment of Muslims where meat is being roasted for a feast.  The Hindu is desperately hungry, but if only meat is available, he would rather continue to starve.  The Hindu says to the host, "Masoud, I am starving.  Please give me some food."  Masoud replies: You are welcome to join in our feast.  Here, take some meat."  The devout Hindu says, "Masoud, you're not Hindu, Hindus don't eat meat!" 5/
In psychoanalytic terms, the patient's need for narcissistic nourishment and the patient's reaction to the frustration of that need is mischaracterized by the psychiatrist as an example of ambivalence.

The psychiatrist's recurring inappropriate attributions of ambivalence to the patient suggest the defensive nature of the psychiatrist's interpretations.


PATIENT'S REPORT:

There seems to be an inconsistency in the way Yu-Ling Han treated my paranoia as opposed to the way she dealt with my manic depression.  The tests failed to indicate that I suffer from either paranoia or bi-polar disorder.  With respect to the paranoia, Yu-Ling Han claims I lied to conceal the paranoia.

Yet with the bi-polar disorder--and I was diagnosed as being bi-polar--even though the testing failed to pick up that illness, I wasn't accused of lying to conceal manic depression.


PSYCHIATRIST'S RESPONSE:

Sometimes a person's paranoia doesn't show up on psychological testing. Sometimes the way a person views things differs at different times.  If you test a person a person at a certain time, you will find paranoia; if you test at another time, that same person may test differently.


INTERPRETATION:

First, the psychiatrist's comments are tangential and non-responsive. The gist of the patient's concern was the inconsistent nature of the accusation that he had lied on the testing not why the psychological testing failed to yield the diagnosis of paranoid.  The psychiatrist does not respond to the question why the patient was accused of lying to conceal paranoia but was not accused of lying to conceal bi-polar disorder.

Also, the psychiatrist consistently refuses to come to terms with the systematic, enduring, and stable nature of the patient's ideas and the diagnostic significance of that ideational consistency.  See Letter to Dr. Georgopoulos, dated September 6, 1995.  The patient's belief that he has been under surveillance by his former employer has remained constant since the inception of the belief, in late October 1988.  Indeed in August 1993 the chairman of the psychiatry department stated to the patient: "Nobody has ever been able to shake you of these ideas, have they?"

Further, paranoia has both cognitive/perceptual as well as dynamic features; paranoia involves not simply ideas but a style of perceiving, appraising, and responding to the environment.  Even among paranoid patients whose beliefs change over time, it is highly unlikely that these patients' manner of thinking about, and responding to, the environment would change so drastically over time so as to leave no discernible traces of paranoid cognitive style on psychological testing.  The Rorschach test for example, is highly sensitive to the distinctive dynamic, perceptual, and behavioral features of paranoia.  "Rorschach indices of [the various identifying features of paranoid status appear in all three of the major dimensions of subjects' responses to the test situation: the structure of their answers, their response content, and their behavior in dealing with the inkblots (citations omitted)."  Exner, J.E., Jr. and Weiner, I.  The Rorschach: A Comprehensive System.  Volume 3.  An Assessment of Children and Adolescents, at 230 (New York: John Wiley & Sons, 1982) (from the chapter "Paranoid Status," at 230-234.
___________________________________________

At the session on Wednesday August 30, 1995 the patient reads to the psychiatrist the text of a letter, dated September 1, 1995, addressed to the office of U.S. Attorney that discusses the patient's psychiatric treatment history.  See Letter to Dr. Georgopoulos, dated September 6, 1995.

On Thursday August 31, 1995 the patient hand delivers the letter to the Office of US. Attorney.

On Tuesday September 5, 1995 the patient hand delivers to the U.S. Secret Service a copy of the letter to the Office of U.S. Attorney dated September 1, 1995, and a copy of the Letter to Dr. Georgopoulos dated September 6, 1995, which discusses the psychiatric consultation on Wednesday August 30, 1995.
 __________________________________________

SESSION WEDNESDAY SEPTEMBER 6, 1995:


PSYCHIATRIST'S RESPONSE:

Psychiatrist says absolutely nothing.
____________________________________________

SESSION MONDAY SEPTEMBER 11, 1995:


PSYCHIATRIST'S COMMENTS:

Psychiatrist says absolutely nothing.
____________________________________________

SESSION WEDNESDAY SEPTEMBER 13, 1995:


PSYCHIATRIST'S COMMENT:

The psychiatrist makes one comment during the session.  During a lull in the patient's narrative, the psychiatrist says, "You're not saying anything."

Sincerely,

Gary Freedman
_______________________________________________
1/   There may be a symmetry between, one the one hand, the patient's own ready accommodation of opposites and his creative ego functioning and, on the other, the psychiatrist's apparent anxious response to the patient's creative idea production and his difficulty in coping with, and misapplication of, the concept of ambivalence  See Rothenberg, A. "Janusian Thinking and Creativity."  In: The Psychoanalytic Study of Society, vol. 7: 1-30, at 20.  Gertrude R. Ticho, M.D., consulting ed.  (New Haven: Yale University Press: 1976) (distinguishing ambivalence from the creative ego function of simultaneous defensive negation, and discussing the relation of ambivalence to creativity and schizophrenic processes).

2/  This interpretation is consistent with a previously observed response by the psychiatrist in another context.  The psychiatrist will dismiss the patient's reports relating to unusual experiences by classifying the reports "improbable," or paranoid, that is, artificial or illusory.

3/   The psychiatrist's misattribution, or projection of aggression and fear of retaliation to the patient in this instance may be relevant to an understanding of why the patient had been misdiagnosed by the assessing psychiatrist as suffering from bipolar disorder.  See Letter to Dr. Pitts, dated June 4, 1993: "A question for examination is whether the diagnosis 'cyclothymia (or mood disorder) may in fact have reflected a projection onto Rank of Jones's own hostility toward Rank.  Jones, unable to resolve his own contradictory feelings of aggressiveness (and consequent fear of retaliation) toward Rank vis-a-vis Freud, may have projected these feelings (i.e., aggression and fear) onto Rank so that in the end Rank appeared to Jones as someone torn between timidity (melancholia) and homicidal aggression (mania)."

4/  The phrase "two different stable affects in relation to two distinct objects" suggests, by way of remote association, the key inspirational thought underlying Einstein's General Theory of Relativity: "'[F]or an observer in free fall from the roof of a house there exists during his fall, no gravitational field--at least not in his immediate vicinity.  If the observer releases any objects, they will remain, relative to him, in a state of rest, or in a state of uniform motion, independent of their particular chemical and physical nature.  The observer is therefore justified in considering his state as one of  'rest'."  Rothenberg at 22, quoting Einstein, A.  "The Fundamental Idea of General Relativity in its Original Form."  According to Rothenberg Einstein's inspiration was the product of simultaneous defensive negation, not ambivalence.

5/  There is an intriguing and possibly significant shared dynamic between the parable which portrays the frustration of the patient's need for narcissistic nourishment, or identification--and the patient's dream about his legal action against his employer: both cases relate to the patient's handling of narcissistic needs and aggression, and suggest a symmetry between narcissism and aggression in the patient's psychic economy.  (Note that the following two complexes are polar opposites, therefore susceptible of simultaneous defensive negation in conscious thinking.  See Rothenberg at 5-9).
The parable depicts feelings of despair resulting from the unavailability of an external idealized object suitable for narcissistic identification coupled with aggression turned against the self (in the form of self-starvation that provides masochistic pleasure and satisfies a need for mastery through repetition [repetition compulsion]).

The dream about the legal action against the employer depicts aggression against an external object (which aggression provides sadistic pleasure) and simultaneous anxiety centered on achieving narcissistic compliance with superego/ego-ideal (internal objects) commands (which compliance ultimately provides a sense of ego mastery).
It is significant that these important distinctions relating to the patient's ego differentiation and affective economy, and the interplay of these variables with external objects, do not emerge if one applies the psychiatrist's simplistic "I love her, I love her not" ambivalence model.

Sincerely,

Gary Freedman

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.