Wednesday, February 22, 2012

GW Psychiatric Treatment: Letter October 2, 1995

October 2, 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 summarizes my refections on the consultation on Wednesday September 27, 1995.

PATIENT'S REPORT:

Today is the anniversary of my first day of college, 24 years ago, Monday September 27, 1971. I can still remember that day. My first class was introductory philosophy; it was at 2:00 PM. The teacher's name was Dr. Rieman—George Fred Rieman. I can remember that he took a picture of the class with an old Polaroid camera. You know, he had a seating chart, and he wanted to know people's names, he wanted to remember people; he coordinated the seating chart with the people in the picture. He counted down 'one alligator, two alligator'-- it was a Polaroid picture—he had to wait for the picture to develop.''

[I knew two of the students in the class: William DeVuono who was in my graduating class in high school and Gloria Goldsmith; she and I attended the same junior high school in Philadelphia, Wagner Junior High.]

Then late that afternoon I had my second class—introductory English with Dr. Smith. Then, the next day, Tuesday, I had French—that was with Dr. Smith. Actually it was a different Dr. Smith: Irma Jean Smith. She was from Kalamazoo, [Patient laughs.] She was the first person I ever knew from Kalamazoo. Actually, she's the only person I've ever known from Kalamazoo. You remember that telephone conversation I had with my sister? I gave you a copy of that tape.

[The referenced tape recorded a telephone conversation between my sister and me about my meeting earlier that day in August 1993 with GW Psychiatry Department Chairman, Jerry M. Wiener, M.D.  I said on the recording, "Dr. Wiener said my paranoia has crippled my life."]

[Throughout the narrative, until this point, the psychiatrist had nodded and smiled at the patient, acknowledging the patient's pleasure in recounting his experiences. At the moment the patient mentions the tape recording of the telephone conversation with the patient's sister, the psychiatrist becomes stone-faced. The psychiatrist stares blankly at the patient and does not acknowledge that he recalls the cited telephone-recording.]

Don't you remember? The tape where I say to my sister that Dr. Wiener is not just some doctor from Kalamazoo.

PSYCHIATRIST'S RESPONSE:

It sounds like that was a happy time for you.

[Euphoric memories can mask past trauma:  "The apparent reliving of a lost past in terms of grasping at the illusion of ecstasy can only represent a falsification of memory for the purpose of defence. And the dry, brittle memories of an emotionally arid childhood are as fearsome as those of more openly violent abuse.  J. Moussaieff Masson and Terri C. Masson, "Buried Memories on the Acropolis: Freud’s Response to Mysticism and Anti-Semitism." International Journal of Psychoanalysis (1978).]

PATIENT: [Later in the session]

A few weeks ago I was talking about the Diabelli variations by Beethoven. I said it was the greatest piece of music ever written. Coincidentally, I got a recording of the Diabelli variations about a month before I started college, in August 1971. When I started college I had the Diabelli variations running through my head. 1/ That was what I was thinking about at that time. Sitting in philosophy class, I could hear the Diabelli variations. I don't mean a hallucination; you know, I mean I was imagining the music.

Yes, my recollection now is that it was a special time. But, I'm sophisticated enough to know that it is my present recollection of the events that gives me pleasure, not the events themselves. It reminds me of what Weissman said—that creative people as infants had the ability to withdraw their emotional investment in the mother, and hypercathect their imaginative recollection of the mother. That's the way I feel right now. That it's my present recollection of what I experienced then that is giving me pleasure now. I wouldn't necessarily want to go back to that time to re-experience those events.  First of all, there are always new things to experience. But, also, I know that it's not the events themselves that were pleasurable, it's my recollection that is pleasurable. Well, this may sound like a devaluation, but I don't think you're sophisticated enough to see that distinction.

PATIENT: [Later in the session]

I'll tell you the impression I formed earlier in the session when you interrupted me, when you said: "That sounded like a happy time for you.” I thought it was a defensive reaction on your part. That my comments made you uncomfortable, that for you they were too unfocused, too non-directed. That that non-directed quality disturbs you. I had the feeling you were trying to get me to be more focused, trying to confer order on my rambling comments [comments that to you must have seemed like examples of circumstantiality].

PSYCHIATRIST:

What I was thinking was that your comments were very important.  I appreciate the fact that you were able to talk about your feelings.

PATIENT: 

See now, what I think about what you just said is that you're trying to placate me. I read your comments as mere words. They have no meaning. You're trying to placate me. My interpretation would be that you viewed my observation that my opening comments were too vague and unfocused as a hostile criticism, and that my hostility irritated you. You then tried to defuse my criticism by engaging in placating behavior, by saying,  "I thought your comments were very important.”

[In fact, there is come confirmation of the patient's interpretation. In the fall of 1994 the patient had told the psychiatrist that he had concerns that he was not doing therapy correctly.  The patient reported he had stated the same concern to a previous psychiatrist who responded: "You're doing fine.”  The current psychiatrist proceeded to state, or mimic, the phrase “You're doing fine.” Only a few sessions later, the patient stated his concern that he was not making progress in therapy, which triggered an irritated and revealing response from the psychiatrist, at odds with the previous reassurance “You're doing fine.” The psychiatrist stated: “I am feeling frustrated here. I have recommended medication. You do not follow my recommendation to take medication." The earlier reassurance. “You're doing fine: struck the patient as hypocritical in the face of the psychiatrist's later statement: “I am feeling frustrated here.”]

INTERPRETATION:

Whether or not the psychiatrist was sincere in stating that he thought the patient's comments were “very important,” we can say with certainty that in fact the psychiatrist had no knowledge of the true importance of the patient's narrative.  As with the latent content of a dream, the inner significance of a psychoanalytic narrative is “wrapped in disguises.” 2/ Linguistic analysis of psychoanalytic narratives confirms that the precise significance of a narrative may not be readily apparent to anyone. (An important corollary is that an attempt by a psychiatrist to confer meaning on superficial aspects of the patient's narrative may be ego destructive for the patient or will, at the very least, not advance the therapy and may, as in the patient case, derail the patient's train of associations.)

Janet Malcolm has reported ongoing work at the New York Psychoanalytic Institute by analyst Hartvig Dahl involving linguistic analyses of psychoanalytic narratives.
Through intensive linguistic and logical analysis of the verbatim transcript of a patient's hour, Dahl and Teller have attempted to lay bare the mental processes of analysis as they listen to tape recordings of an analysis with 'closely hovering attention' to a patient's utterances and find themselves forming hypotheses about their unconscious meaning.  For embedded in the transcript, like a message written in invisible ink, are innumerable, unmistakable traces of the patient's unconscious motives.  Invisible to the naked eye as such, they come into glaring view under the special linguistic and logical microscopy devised by Dahl and Teller from their singular demonstration of the existence of the unconscious.  . . .

Dahl proposed that I listen to Session Five as a preliminary to studying the annotated transcript. . . .
I remembered Freud's admonition in the first of his Introductory Lectures: “You cannot be present as an audience at a psychoanalytic treatment. You can only be told about it; and, in the strictest sense of the word, it is only by hearsay that you will get to know psychoanalysis. . . . The talk of which psychoanalytic treatment consisted brooks no listener.” I turned on the machine, and listened for fifty minutes to a young man's halting, rambling soliloquy describing ordinary trivial events and expressing commonplace thoughts and feelings. It was like listening to a boring, self-absorbed acquaintance. Freud had been right: an outsider eavesdropping on an analytic session gets almost nothing from it; he is like an eavesdropper on a conversation (or monologue) in a foreign language. Only later on reading the annotated transcription of the hour, did I laboriously decode the secret messages from the unconscious that the patient had wafted toward his analyst years before, and which Dahl, following Freud's instructions about loose, desireless, undirected listening, had “intuitively” grasped. Malcolm, J. Psychoanalysis: The Impossible Profession, 89-90 (New York: Vintage Books, 1982).
Instead of listening with “closely hovering attention" to the patient's utterances and forming hypotheses about the unconscious meaning as derived from the context of the patient's associations, this psychiatrist focuses on the most seemingly salient and /or recent component of the narrative, which procedure, consistently applied by this psychiatrist, betrays the psychiatrist's psychological naivete and, tragically, ignores the patient's underlying concerns.

Clues to the inner significance of the patient's narrative concerning his first day of college emerged only after the psychiatric consultation had concluded. The patient recalled the subject matter of the philosophy class to which he had referred at the consultation.  The topic under discussion had been “Duty and Responsibility.”'

Issues pertinent to the problem of duty and responsibility were illustrated by the facts of the Kitty Genovese case.

On an evening in 1964, in New York City, a young woman named Kitty 3/ Genovese was brutally attacked and murdered outside her apartment building. Thirty-eight people witnessed the protracted, bloody attack and not one tried to help or even call the police from behind the safety of their window blinds. The victim's desperate screams for help were ignored; some of the neighbors were not disturbed by the criminal attack per se, but were simply irritated by the victim's screams, which disrupted an otherwise peaceful evening. See Letter to Dr. Georgopoulos, dated July 17, 1995 (discussing the psychiatrist's interpretation of the patient's communications with law enforcement authorities as a narcissistic attention-seeking ploy).

That the patient's narrative in some way concerned issues of victimization, duty and responsibility is indicated by the patient's express reference only sessions earlier, to the Calderon play The Mayor of Salamea. 4/ In that play a proud and prosperous man of humble birth, the farmer Pedro Crespo, has civil authority in a town though which the army is passing. When his daughter Isabel is ravished by an hidalgo captain, Don Alvaro, Crespo maintains that however loyal to his country a man may be, his honor is his own.  He therefore arrests, then executes the captain.  King Philip II, passing through, checks further trouble by commending the mayor's action.

(Coincidentally, the Secret Service Agent with whom the patient has been in communication is named Philip Leadroot.)

Also, significantly, in the letters dated July 17, 1995 the patient indicates his personal identification with a victim of rape:
The psychiatrist's gloss of the patient's letter to the FBI as a rebellious attention-seeking ploy transforms the patient into a perpetrator and simultaneously transforms the patient's victimizers into innocent victims. On a sexual level, the psychiatrist's reinterpretation of the facts is identical to the strategy of a defense attorney in a rape case who portrays the rapist as an innocent victim of the female's attention-seeking game of sexual seduction. Stated in general terms, the relationships (penetrated / victim) – (penetrator / perpetrator) are transformed into (penetrator / victim ) – (penetrated / perpetrator).
Regrettably, the innumerable, unmistakable traces of the patient's unconscious concerns—like the desperate cries of Kitty Genovese—go unheeded, lost in the psychiatrist's defensive and disruptive preoccupation with the patient's manifest utterances.

One wonders, incidentally, whether the psychiatrist's history of tangential responses to the patient's comments, noted in previous letters, may be related to a cognitive style that, in the psychotherapeutic milieu, reduces his ability to derive meaning from the context of the patient's associations and actually leads to anxiety in the face of the patient's unusual level of associational fluency. The psychiatrist's apparent difficulties with semantic integration, as indicated by his occasional tangential responding, may be related to his reluctance or diminished capacity to integrate the patient's associations over the long-term, and his tendency to focus on the most seemingly salient and/or recent component of information communicated to him, which necessarily impairs or precludes the analysis of latent or unconscious meaning in the patient's utterances. Cf. Silverstein, S. M. and Palumbo, D.R. “Nonverbal Perceptual Organization Output Disability and Schizophrenia Spectrum Symptomatology.” Psychiatry 58(1): 66-81, at 76, 77-78; 1995 (Stanley R. Palombo, editorial adviser).

The psychiatrist's therapeutic technique, which focuses on appraising mere surface appearances (“It sounds like that was a happy time for you”), may actually be a compromise with a cognitive style that reduces his ability to generate a framework or context from the patient's associations within each session and, even more so, from session to session. Unfortunately, when the psychiatrist interacts with a patient with unusual associational fluency, the psychiatrist experiences anxiety with which he proceeds to deal defensively. Thus, the psychiatrist will tend to view the patient's associational fluency (a need and ability to associate dissimilar, but fundamentally related, ideas) as a picaresque ideational fugue, or manic “flight of ideas,” and his highly-refined ability to infer latent meaning from context as “paranoia” (see no. 2, above) (really the need and ability to shape and reshape reality in search of it inner significance). 

Confirmation for this speculation is provided by the psychiatrist's reaction to the patient in another context; the psychiatrist had mischaracterized the patient's unusual level of verbal fluency, objectively verified on the Wechsler Adult Intelligence Scales, as manic rapid speech (“You talk fast; I can give you medication for that.”) Thus, the psychiatrist had, by means of the ego defense of reversal (a key component in paranoia), transferred his own anxiety, in the face of the patient's verbal fluency, to the patient, attributing to the patient manic psychopathology in the form of “pressured, rapid speech,” which (projected anxiety might be remedied chemically with a major tranquilizer. (Compare the psychiatrist's express statement, or admission, at a previous session in which he indicated a desire to alter his own affective discomfort by prescribing medication to the patient: “I am feeling frustrated here. I have recommended medication. You do not follow my recommendation to take medication.”)

Sincerely,

Gary Freedman
________________________________

1/ There is a notable metaphoric, or poetic, quality to the patient's statement "I had the Diabelli variations running through my head" that symbolically communicates an important ego need of this patient, a need to synthesize remote ideas and to divine hidden meanings, which need to is frustrated by supportive (nonpsychoanalytic) therapy.  

[According to Frank Barron, an expert in creativity, creative persons  "become more aware of unconscious motives and fantasy life."]

The metaphoric quality of the patient's statement is laid bare by Maynard Solomon's eloquent description of the Diabelli variations.  Solomon's description indicates the affinity of this musical work with psychoanalysis itself, a therapeutic technique that permits--indeed, requires--the patient to associate facially dissimilar but fundamentally related ideas, and to shape and reshape reality in search of its inner significance.

[Maynard Solomon has also published articles in applied psychoanalysis.]

Solomon writes: "Variation [psychoanalysis] is potentially the most "open" of musical procedures [psychotherapeutic techniques], one which gives the greatest freedom to the composer's [patient's] fantasy. It mirrors the unpredictability and chance nature of human experience and keeps alive the openness of human expectation.  Fate cannot knock on the door in the variation form: such concepts as necessity and inevitability need a dialectical musical pattern within which to express their message, whereas the variation is discursive and peripatetic, in flight from all messages and ideologies.  Its subject is the adventurer, the picaro, the quick-change artist, the impostor, the phoenix who ever rises from the ashes, the rebel who, defeated, continues on his quest, the thinker who doubts perception, who shapes and reshapes reality in search of its inner significance, the omnipotent child who plays with matter as God plays with the universe. Variation is the form of shifting moods, alternations of feeling, shades of meaning, dislocations of perspective. It shatters appearance into splinters of previously unperceived reality and, by an act of will, reassembles the fragments at the close. The sense of time is effaced--expanded, contracted--by changes in tempo; space and mass dissolve into the barest outline of the harmonic progressions and build up once again into baroque structures laden with richly ornamented patterns. The theme remains throughout as an anchor to prevent fantasy from losing contact with the outer world, but it too dissolves into the memories, images, and feelings which underlies it simple reality. In this the theme is like the manifest dream--a simple, condensed sequence of images masking an infinity of latent dream thoughts. The manifest dream is deceptively simple, wrapped in disguises of distortion, censorship, condensation, and displacement. Analysis (variation) pierces these veils; recollection fills the dream (the theme) with a significance that illuminates the past and points toward future possibilities of transcendence and fulfillment."  Solomon, M. Beethoven, 303 (New York: Schirmer Books, 1979).

2/  At the very first session [with this psychiatrist in July 1994], the patient reported a dream the manifest content of which concerned a man's shirt.  The patient reported the following dream thought: "Only a queer would smell another guy's shirt." At this, the psychiatrist interrupted the patient to deliver a little lecture: "You shouldn't say that.  Homosexuals have an alternative lifestyle.  They deserve to be respected.  You shouldn't use words like 'queer.'"  The patient felt like saying: "Hello, it's a dream!"  In fact--uncannily, as this letter will later reveal--the latent content of the dream concerned a brutal double homicide in which one of the victims was a young woman. (It is significant that at the third session, the following week, the psychiatrist, after having read the patient's detailed written analysis of the subject dream, advised the patient (for the first time) that it was essential that the patient take anti-psychotic medication!)

3/  The name "Kitty" carries an association to Anne Frank, who addressed each of her diary entries to an imaginary friend named "Kitty."  (The patient had read The Diary of Anne Frank in the fall of 1967 [in ninth-grade English]).  Fortunately for posterity, Anne Frank had a "need to write things."

[The psychiatrist had criticized the patient for the act of writing down his thoughts. -- This is what Freud told one of his patients, an aspiring writer who was also a patient of his:  "Get it out, produce it, make something of it -- outside you, that is; give it an existence independently of you."]
4/  The patient had first heard about the play in  about 1983, and summarized the plot to the psychiatrist from present recollection.  In the patient's confabulatory recollection Pedro Crespo was remembered as being an impoverished peasant without any political power.  When his daughter is raped, Crespo's pleas for justice with the local authorities are ignored, and the perpetrator goes unpunished.  Crespo vows to attain political power by becoming mayor, and avenge his daughter's disgrace himself.  The patient's distorted recollection of the plot is revealing.  The patient had likened the play to the attainment of political sovereignty by Jews in 1948 with the establishment of the state of Israel, which permitted the capture of Adolf Eichmann by Simon Wiesenthal as an agent of a sovereign Jewish state, thereby avenging the victimization and murder of politically powerless Jews under the Nazi regime.

3 comments:

Gary Freedman said...

"'The talk of which psychoanalytic treatment consisted brooks no listener.' I turned on the machine, and listened for fifty minutes to a young man's halting, rambling soliloquy describing ordinary trivial events and expressing commonplace thoughts and feelings."

My former employer alleged that I suffered from severe mental illness that rendered me unemployable because, reportedly, I "attributed a negative meaning to 'trivial events.'"

http://dailstrug.blogspot.com/2009/12/social-security-administration-initial.html

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.

Gary Freedman said...

In psychoanalysis a patient's seemingly disjointed utterances can be compared with the fragments of an image as with a jigsaw puzzle. The analyst has to have the ability to defer judgement -- to "wait for the picture to develop."