Thursday, February 23, 2012

GW Psychiatric Treatment: Letter October 15, 1995

October 15, 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 thoughts about a particular segment of our consultation on Thursday October 12, 1995.

PATIENT'S REPORT:

[The patient arrived at the Medical Center for his regularly scheduled consultation on Wednesday October 11, 1995. While the patient waited in the reception area of the psychiatry department, Jerry M. Wiener, M.D., the department chairman, entered the area, nodded to the patient in recognition, then walked out. Shortly thereafter, the receptionist advised the patient that Dr. Georgopoulos had canceled the appointment, and that he had unsuccessfully tried to contact the patient by telephone at home. Later, in the afternoon, Dr. Georgopoulos telephoned the patient at home and scheduled a make-up consultation for the following morning, October 12, 1995. On Wednesday October 11, 1995, the day the patient saw Dr. Wiener in the reception area, the Nobel Prizes for Physics and Chemistry were announced—the pertinence of which fact will become apparent at a later point in this discussion.]

[This letter appears to relate to my Nobel Prize Complex.  It would appear that early fall, which coincides with Columbus Day and the Nobel Prize announcements, is an affectively charged time of the year for me.  See the following two blog posts relating to, respectively, the fall of 1988 and the fall of 2004:



Consultation, Thursday , October 12, 1995:

I had something on my mind from yesterday. I was going to tell you this yesterday, if I had seen you, but the appointment was canceled. What's really strange is that last night I had a dream about the issue. Instead of telling you in real life what I had on my mind, I told Dr. Wiener in my dream. I had seen Dr. Wiener yesterday in the reception area while I was waiting for you. But then I found out you had cancelled, and I went home. But then last night I had a dream that I had a psychiatric consultation with Dr. Wiener, and in the dream I told him about what I had planned to tell you. What I told Dr. Wiener related to the issue of frustration, something that I had planned to discuss with you. I guess that says something about the way I handle frustration. I was frustrated in not being able to talk to you, but in my fantasy life, or dream life, I simply corrected for the deficiency in my waking life by creating what I really wanted. Once again, it reminds me of Weissman—that creative people had as infants the ability to withdraw their emotional investment in the mother, and create an ideal world in their fantasies.

[[Philip Weismann] believed that the future artist, as an infant, had the ability to hallucinate the mother’s breast independently of oral needs.  According to him the unusual capacities of the artist ‘may be traced to the infancy and childhood of the artist wherein we find that he is drawn by the nature of his artistic endowment to preserve (or immortalize) his hallucinated response to the mother’s breast independent of his needs gratifications” . . . .  One major concept of Weismann is the ‘dissociative function of the ego’ that he substitutes for Kris’s concept of regression in the service of the ego.  With the aid of this dissociative function, the creative person ‘may partially decathect the external object (mother’s breast) and hypercathect his imaginative perception of it.  He may then further elaborate and synthesize these self-created perceptions as anlagen or precursors of creative activity which must then await full maturation and development of his ego  and his talent for true creative expression.’  In simple words, according to Weismann, the child who will become creative has the ability to diverge the energy originally invested in primitive personal objects and to invest it again in creative work.” Arieti, S. Creativity: The Magic Synthesis, at 25-26 (Basic Books: 1976), quoting Weismann, P. “Psychological Concomitants of Ego Functioning in Creativity” International Journal of Psychoanalysis 49: 464-469 (1968).]

(Compare the Letter to Dr. Georgopoulos, dated July 10, 1995, which analyzes “The Dream of the Elephant Sanctuary.” In that dream the patient responds to feelings of frustration that arose as he is compelled to wait in the psychiatry department reception area to see his psychiatrist; the patient's thoughts turn to his friend Craig, 

[Note the deceptively situation appropriate resort to the third person, "his friend Craig."  The use of the third person "his" instead of the first person "my" indicates dissociation.]

an idealized figure. An interesting feature of the current dream about Dr. Wiener is that the instigating affect of the previous day, namely a feeling of frustration resulting from the resident's unanticipated cancellation of the consultation, is actualized exclusively in the content of the dream dialogue—an imagined discussion with Dr. Wiener concerning the topic of frustration while the affect present in the manifest dream is limited to awed idealization, drained of any frustration. Significantly in regard to the transference, the patient relieves feelings of frustration in connection with an unfulfilling relationship with his treating psychiatrist by means of dream thoughts about another (idealized) figure—and not by thoughts of a corrected, or idealized, version of the frustrating figure, Dr. Georgopoulos. This outcome parallels a statement the patient had made to the psychiatrist at a prior consultation in reaction to the psychiatrist's question, “What would you like to change about me?” The patient stated: “I don't like you, but I don't want to change anything about you; I just wish I could see somebody else.”)

[In the dream about Dr. Wiener, Dr. Wiener seemed especially erudite and scholarly, not unlike the idealized image one might have of a Nobel prize winner. This struck the patient as somehow odd in the dream. The patient had the following dream thought: “I knew he was a smart guy, but he seems like a real authority in a way I had never imagined.”]

PSYCHIATRIST'S COMMENT:

Something about dreams. You know, a person who appears in a dream can represent someone else. The Dr. Wiener figure in the dream might have represented someone else. For example,. The figure of Dr. Wiener could have represented some authority figure from your past.

INTERPRETATION:

The psychiatrist's gratuitous and disruptive comment concerning the nature of dream symbolism is peculiar in view of the patient's demonstrated knowledge concerning the nature of dreams and dream interpretation. The patient had previously provided the psychiatrist with detailed written analyses of his dreams that exhibited unusual insight regarding the dreams' latent content.

The gratuitous nature of the psychiatrist's comment tempts an explanation. One might offer the hypothesis that the psychiatrist's comment was motivated by the psychiatrist's own internal struggle concerning issues of shame and castration anxiety relating to the assimilation of parental, or authority figure, values. In the child the critical attitudes of authority figures cannot immediately be assimilated as one's own. It would be too deflating to self esteem to accept the full burden of blame all at once. Thus normally the child seeks to transiently project the blame for wrongdoing onto an imaginary companion, sibling, or toy. He attempts to work out his feelings by adopting the patent's critical attitude but directing the blame toward a scapegoat outside. This transient projection allows the child to internalize the blame gradually in small doses without being faced with the full force of self-blame all at once. Freeman, D. M A., Foulks, E.F., Freeman, P. A. “Superego Development and Psychopathology.” In: The Psychoanalytic Study of Society, vol. 7: 107-122, at 117-118 (New Haven: Yale University Press, 1976).

At the immediately previous consultation, the patient had submitted a letter to the psychiatrist (Letter to Dr. Georgopoulos, dated October 2, 1995) that discussed the psychiatrist's naive interpretation of one of the patient's dreams—an interpretation, or admonishment, that ascribed in a ridiculous manner undue importance to the dream's manifest content. The letter states:
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!"
One is tempted to infer that the psychiatrist's inappropriate admonishment to the patient at the current consultation, namely, that a manifest dream figure might represent someone else—a fact about which the patient is abundantly and obviously aware—may reflect the psychiatrist's response to a critical comment from a staff psychiatrist regarding the resident's psychoanalytic naivete, in the wake of the patient's letter dated October 2, 1995, which the resident had experienced as a narcissistic injury. In such a case, the psychiatrist might have experienced a need to work out his feelings by adopting the staff psychiatrist's critical attitude regarding dream interpretation but directing the admonishment to the patient qua scapegoat.

PATIENT'S REPORT (CONT'D):

While I was seeing Dr Palombo, I used to place a lot of emphasis on the importance of the oral injury I had when I was about 2½ years old. I thought that the injury, or my adjustment to the injury, had a significant effect on my personality development. I thought that it related to the issue of frustration[, superego development, and the internalization of parental values.] You know, it was a painful injury[, the body-ego equivalent of a narcissistic injury resulting from the incorporation of the parents' critical attitudes]. [At age 2½ the patient had injured himself with a metal curtain rod he had placed in his mouth; the metal rod had caused a puncture wound in the soft palate when the patient accidentally fell to the floor.]

The doctor had to cauterize the wound. I imagine it took some time to heal, and made eating painful for some period of time. Well, when I told Dr. Palombo about this he said the only significance the injury would have had was that it would have reawakened issues from infancy relating to oral frustration, that's all. 1/ The injury wouldn't have had any psychological effects.

[Note that I wrote this letter in October 1995.  It was not until 1998 that the psychoanalyst Joseph Fernando published a paper supporting my view that a physical injury in childhood might result in important and specific consequences for superego development.  See The Exceptions: Structural and Dynamic Aspects, The Psychoanalytic Study of the Child, 52: 17-28 (1997).  Fernando's female patient presented with an obsession with a male lover who was described as "handsome, intelligent, manipulative, and a womanizer."  Years into the analysis the patient disclosed that she had suffered a leg fracture as a child.  Fernando theorized that the injury (that breached the stimulus barrier) and the consequent blaming behavior by the patient's parents (that aroused feelings of "anxiety, anger, confusion, and humiliation") distorted her superego development.

According to Fernando, the injury and its aftermath (parental blaming behavior) caused a disturbance in her superego maturation, and led to the character type that Freud termed the "exceptions." In the "exceptions," the early idealized parental images are never metabolized as in the normal person, and the individual's superego remains warped. Such individuals attempt to recapture in their interpersonal relations in adulthood representations of their early idealized parental images. Fernando's patient was obsessed with two persons, her only friends--a male lover and a female friend. The patient was not simply lonely; she wanted to affiliate closely with these two persons because they matched her internalized and idealized images of her parents.

The patient's development foundered on her inability to accomplish one of the major tasks of late adolescence: the integration of previously unresolved traumas into the character structure, or what Peter Blos calls the "characterological stabilization of residual trauma."

The relative lack of superego maturation and integration in the exceptions affects the maturation of the ego ideal. It interferes with the deconcretization of the ego ideal and its integration into the personality as a substructure within the superego system, a process that normally takes place definitively in late adolescence. This interference was evident in Fernando's patient who found it impossible to relinquish her attachment to the idealized images of her parents and instead began a prolonged attempt, beginning in late adolescence, to recapture her ideals in concrete form in her relationship with her two friends
.]

But I think that's wrong. It just occurred to me in the last few days why that's wrong. If Dr. Palombo were here now I'd have to say to him: “You're wrong, Dr. Palombo.”

[Note here that I change voice from the third person "He (Dr. Palombo) is wrong" to the second person, "You (Dr. Palombo) are wrong."  The shifts in voice from first to second or third person are suggestive of early trauma, according to Leonard Shengold, M.D.]

[It is probably significant that the patient's thoughts or insights, about this issue arose contemporaneously with the patient's sister having informed the patient, just a few days earlier, that the patient's brother-in-law had just undergone surgery for esophageal cancer and had been fed via intubation.]

The idea just came to me a few days ago that there's something wrong with what Dr. Palombo said.  Psychoanalytic writers talk a lot of certain affects in infancy. Melanie Klein talks about the depressed position and the paranoid-schizoid position.

People like Kohut and Kernberg talk about feelings of rage and despair in adults that can be traced back to feelings of rage and despair in infancy. But nobody ever talks about feelings of frustration in infancy.

I don't feel rage or depression as an adult. The predominant affect I feel is frustration. It's an overwhelming feeling of frustration. Its always with me. [I feel as if I were in a straightjacket and there's nothing I can do about it.] But it just occurred to me a few days ago that infants don't feel frustration; you can't retrace adult feelings of frustration back to infancy. When you deprive an infant of its needs, it reacts with rage or despair, as Kohut and Kernberg point out. The infant just doesn't have the psychological apparatus, its ego hasn't developed to the point that it will react to the deprivation of its needs with feelings of frustration. If you don't feed an infant when it's hungry, it doesn't feel frustrated—it feels rage. So, that's why I think Dr. Palombo was wrong. The oral injury and oral frustration I experienced at 2½ could not have reawakened feelings of frustration, since an infant doesn't experience feelings of frustration. What I believe is that my current overwhelming feelings of frustration can't be traced back to infancy. They would have to be traced back to a period in which I was able to experience oral deprivation as “frustrating” and not as enraging. That could only be in early childhood, not infancy. If I had experienced overwhelming oral frustration in infancy, I would be overcome with feelings of rage in adulthood. But what I feel as an adult is not rage but overwhelming frustration.

INCIDENTAL COMMENT:

There is an intriguing correspondence, relating to the respective instigating events of the previous day, between the patient's dream about Dr. Wiener, described above, and an earlier dream about former treating psychiatrist, Stanley R, Palombo, M.D. In the case of the dream about Dr Wiener, the dream was occasioned in part by the announcement earlier in the day of the winners of the 1995 Nobel prizes in the categories of physics and chemistry.

In January 1992 the patient had a dream about Dr. Palombo, which is reproduced below. On the day preceding the dream the patient had been browsing in a bookstore (See Letter to Dr. Georgopoulos, dated August 10, 1995, analyzing “The Dream of Milton's Successor”) and had purchased an autobiographic work by Richard Feynman titled Surely You're Joking, Mr. FeynmanRichard Feynman, a physics professor at the California Institute of Technology who had, as a graduate student, worked on the Manhattan project that developed the first atomic bomb, was a Nobel prize winner in physics; he succumbed to colon cancer in February 1988. Feynman was of Jewish heritage, but apparently derived some pleasure from things Italian. Compare the "Dream of the Four Miltons” (Letter to Dr. Pitts, dated February 8, 1993).

Feynman's book, really a collection of anecdotes, includes a humorous entry titled “Latin or Italian,” which the patient had read the day preceding the dream about Dr Palombo, in January 1992.
There was an Italian radio station in Brooklyn, and as a boy I used to listen to it all the time. I LOVed the ROLLing SOUNds going over me, as if I was in the ocean, and the waves weren't very high. I used to sit there and have the water come over me, in this BEAUtiful iTALian. In the Italian programs there was always some kind of family situation where there were discussions and arguments between the mother and father:

High voice: "Nio teco TIEto capeto TUtto..."
Loud, low voice: "DRO tone pala TUtto!!" (with hand slapping).

It was great! So I learned to make all these emotions: I could cry; I could laugh; all this stuff. Italian is a lovely language.

There were a number of Italian people living near us in New York. Once while I was riding my bicycle, some Italian truck driver got upset at me,leaned out of his truck, and, gesturing, yelled something like, "Me aRRUcha LAMpe etta TIche!"

I felt like a crapper. What did he say to me? What should I yell back?

So I asked an Italian friend of mine at school, and he said, "Just say,'A te! A te!' -- which means 'The same to you! The same to you!'"

I thought it was a great idea. I would say "A te! A te!" back-gesturing, of course. Then, as I gained confidence, I developed my abilities further. I would be riding my bicycle, and some lady would be driving in her car and get in the way, and I'd say, "PUzzia a la maLOche!"-- and she'd shrink! Some terrible Italian boy had cursed a terrible curse at her! It was not so easy to recognize it as fake Italian.

Once, when I was at Princeton, as I was going into the parking lot at Palmer Laboratory on my bicycle, somebody got in the way. My habit was always the same: I gesture to the guy, "oREzze caBONca MIche!", slapping the back of one hand against the other.

And way up on the other side of a long area of grass, there's an Italian gardener putting in some plants. He stops, waves, and shouts happily, "REzza ma LIa!"

I call back, "RONte BALta!", returning the greeting. He didn't know I didn't know, and I didn't know what he said, and he didn't know what I said.

But it was OK! It was great! It works! After all, when they hear the intonation, they recognize it immediately as Italian -- maybe it's Milano instead of Romano, what the hell. But he's an iTALian! So it's just great.

But you have to have absolute confidence. Keep right on going, and nothing will happen.
The following dream, from January 1992, was apparently inspired in part by the Feynman autobiography, which the patient had been reading earlier in the day.


I had an appointment to see Dr. Palombo. I was no longer one of his regular patients, but I had made an appointment to see him because I wanted to discuss one important issue that was on my mind. As I was walking up Connecticut Avenue, I noticed that it was nearly 2:00 PM, and my appointment was at 2:00 PM. I grew somewhat frantic, because I thought that at the rate I was walking, I wouldn't get to Dr. Palombo's office until 2:15 to 2:30.

[Note the pressure of time.  Persons at a high level of ego strength are described as tense, high energy, impatient, driven, frustrated, over wrought, and time driven; persons at a lower level of ego strength are described as relaxed, placid, tranquil, torpid, patient, and composed low drive.

The following of my dreams express frantic concerns about the passage of time:





Someone in a car in back of me yelled out, “Gary!” I thought “that's my name, but I don't know anybody, so I may as well not turn around to see who it is.” The person called out more emphatically, “Gary!” This time I turned around. 

[Note the concern with personal identity.  The issue of personal identity is a notable feature of the "Dream of the Four Miltons," the very title of which includes a man's name.]

It was a group of middle-aged people in a car. I didn't recognize any of them. They all seemed to be Jewish. They were all very friendly, especially the man who had called out my name. He said, “You are Gary Freedman. We were friends of your father. He used to talk about you all the time.”

[My father had friends in Atlantic City, New Jersey.  When I was a boy my family stayed with the family every year at the beginning of July.]

I talked to the man for a while. And, for a brief time I forgot about my appointment with Dr. Palombo, although the possibility that I might be late for my appointment was still pressing on my mind somewhat. The people then drive off. I made my way to Dr. Palombo's office.

I arrived late at the office. Dr. Palombo was so happy to see me that he hugged me. I sat down. He talked on and on about social matters in a lively and friendly manner. At the same time I noticed, however, that he had aged terribly. He looked 15 years older instead of a year older. I thought he must be ill. He pulled a wig off his head; he was bald. I thought, “He must be dying of CA.” 

[The act of taking off the wig may be a castrative gesture.  It may also denote the act of disrobing and appearing naked.]

["CA" appears to be overdetermined.  In the context of this dream it refers to cancer.  But CA is also the postal code for California.  In the "Dream of Craig at Wanamakers" Craig tells me that he is moving to California, which signified the death of our friendship.]

I felt very sorry for him—and for myself. I thought, “I will never be able to tell him what I wanted to tell him. This session's almost over, so I can't discuss with him now what I wanted to tell him. And it appears that he doesn't have much time left on this earth, so I probably will never be able to tell him what I wanted to tell him.”

Dr. Palombo said, “The time is up.” We both stood, and he led me to the door.

[These thoughts merit comparison with a section of my book Significant Moments relating to the issue of anti-Semitism.

     In any event, Levi . . .
Peter Gay, Freud, Jews and Other Germans.
        
. . . the poor conductor, . . .
Cosima Wagner’s Diaries (Wednesday, June 29, 1881).
     
When he returned . . .
Louis Ginzberg, The Legends of the Jews.
     
Wagner stood "in the hall, . . .
Peter Gay, Freud, Jews and Other Germans.
           
. . . at the door . . .
Cosima Wagner's Diaries (Tuesday, December 23, 1879).
                 
. . . watch in hand, and . . .
Peter Gay, Freud, Jews and Other Germans.
                          
. . . looking at the timepiece . . .
H.G. Wells, The Time Machine.
                               
. . . said in a highly ceremonious, serious tone, . . .
Peter Gay, Freud, Jews and Other Germans.
                                             .
. . as if prearranged, . . .
Arnold Schoenberg, Survivor from Warsaw.
     
'You are ten minutes late! Unpunctuality is half infidelity! He who keeps others waiting is an egotist.'"
Peter Gay, Freud, Jews and Other Germans.
     
I must emphasize the fact that there was not a trace of personal jocularity or clownishness in his pose, manner, or behaviour. On the contrary, there was complete seriousness, an absence of any humorous appeal . . .
Thomas Mann, Mario and The Magician.

But I stopped him and said, “Dr. Palombo, I never got a chance to tell you what I came here to tell you.”I paused for a moment, then I said, “Don't you think that in itself is significant—that I made all this effort to come here to tell you something, and never got a chance to tell you what it was. It seems like the repetition compulsion.” Dr. Palombo said, “Yes, indeed. Psychoanalytically, it is quite important that after all the effort you took to come here to tell me something that you thought was significant, you never told me what it was that you wished to say. That in itself is far more important and revealing than whatever it was you came to tell me.

[These thoughts denote the issue of frustration.  I was frustrated -- by the constraints of time -- in my attempt to tell Dr. Palombo what I thought was vitally important.]

_______________________________
1/   Dr. Palombo's published work relating to dreams holds that “the dream compares the representation of an emotionally significant event of the past with the representation of an emotionally significant aspect of the previous day's experience.” Palombo, S.R. Dreaming and Memory, 219 (New York: Basic Books, 1978) cited in Storr, A. Solitude, 25 (New York: The Free Press, 1988). It is difficult to imagine how the patient's pervasive feelings of frustration in adulthood--which the patient associates with the oral frustration he experienced following his oral injury at age 2½—can be traced back to like feelings in infancy, since the infant does not experience the objective state of oral frustration as “frustrating” but rather as enraging. The term “oral frustration” is ambiguous; absent additional information the term in itself does not specifically communicate whether the individual is experiencing internal feelings of frustration or whether an external object is denying the individual oral gratification. In infancy “oral frustration" can only exist as an objective state, referring to the deprivation of the infant's oral needs, to which the infant responds with feelings of rage. Only at a later stage of development does the ego permit the individual to experience the objective state of oral deprivation as an internal feeling of “frustration.”

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.