Jul 7, 2007 | Clinical, Psychiatric Writings |
To great personal benefit and at great personal cost, I have worked intensively in both inpatient and outpatient settings and in schools with borderline persons over the past thirty years.. What drove me to do this? What have I gained from it? What did it cost me? I hope you will forgive my framing this essay about borderline patients in such personal terms. I even hope that you will find it useful. I am sure many of you have had encounters, longer and shorter, with borderline patients that have left you wondering not only about the patients but about yourselves. A resident working with a borderline patient told me in supervision that she, herself, was holding her jaw so fiercely clenched that it hurt. “I’m so angry,” she said, “and this anger just isn’t me. “ I listened and thought, “No, it’s not,” and “Yes, I’m afraid it is.” This was one of Sheppard’s outstanding residents, a leader in her class, a leader in the environmental movement, who went on to do good work under difficult circumstances for the Indian Health Services in the Southwest. Certainly, that clenched jaw anger was not part of her normal experience of herself. It was not part of her preferred experience of herself. But she had experienced difficult abandonment early in her life, existential hurts from which there was no appeal and to which response in modulated symbolic terms does not come easily. Actually, when we are little, such modulation and response are beyond us. This is why the care of very young children is so important. In caring for them we help...
May 28, 2007 | Clinical, Psychiatric Writings |
Grief is an essential active internal process of emotional recycling that helps make us available for new living and new ways of living after loss, which is sure to come because it is part of the natural order of things. “Man is born to troubles as the sparks fly up from the fire,” says Job’s wise friend Eliphaz. Grief is central to how we modify ourselves to meet changed circumstances, often ones that fly in the face of our wishes and that we never imagined. As a man who had lost his wife suddenly in a freak accident put it to me about a year later, “Doc, this sure ain’t the way that I drew it up.” Loss is the dark and difficult side of attachment, which is such a fundamental in human life. We attach because we are built to attach. We attach because evolution has shaped our genius for attachment out of the primary materials of the mother-child mammalian bond. Striking footage exists of a group of elephants coming on their annual traverse of their territory back to where a female had died the previous year. One of the deceased elephant’s daughters, herself already fully grown, breaks away just a bit from the group and then lingers near the spot where her mother expired. With her trunk she nuzzles at a skull bare of flesh and bleached white, gently turning it over. So she makes contact with the remains of her mother, passes a few moments there with what is left of her mother – inside and out – and then submits to the necessity that life...
May 27, 2007 | Clinical, Psychiatric Writings |
I. One possibly quite useful way to think about shame is as an effort to ward off imagined loneliness that can produce real loneliness, even lethal isolation. “I can not be or seem this way or I will lose everyone and everything. I will find myself floating on an ice floe. I will send this part of myself, this experience, this feeling into exile lest I be myself exiled.” In a sense this is not so different than chopping off a leg in order to be free of the trap. Perhaps there is a short run freedom, even a life-saving freedom, but the leg is lost and that has terrible, crippling consequences. Shame is an ordinary and yet dire predicament for the self. It is hard to emphasize enough just how dire the predicament is. Shame is an inner ostracism that not only sets the shamed one apart from others, but also alienates him from a part of himself. The drama of shame is such that any incursion near the forbidden territory renews the original insult, producing once more a situation in which neither flight nor fight is a viable alternative. The pain of shame can be intense and repeated endlessly without any clear outward indication of what is transpiring. Shame is an anti-communicative stereotypy, the same pain over and over again without any real gain. It can set up particular experiences of hurt and rejection in the mind as institutions, engendering tenacious expectations of future hurt and rejection. Shame can spread, too, down associative pathways, until there is no psychic domain that is not under its sway. Shame...
May 27, 2007 | Clinical, Psychiatric Writings |
I confess defeat at the very outset. I can not tell you what listening is, because listening is not a what, because listening is never the same from instant to instant, from person to person, from pair to pair, from stage of life to stage of life, because, in short, I do not know. Yet, listening is what I do for a living, what I devote so much of my living to, as do so many of you. Listening is that particular set of mysteries in whose thrall, body and soul, we, psychotherapists, find ourselves. My purpose is to share with you both my fascination and my frustrations with the process of listening, the promise of listening, as well as the perils of listening, which are considerable. Nor should we fail to notice that listening, whatever it is and is not, is what is going on right now, as you listen to me, as I listen to myself and whoever else is in me, as you listen to yourselves and all the others within you, as I listen, imaginatively and intuitively and inaccurately, to your listening to me. We are together and apart in the predicament of listening. Neither of us knows where it will take us. We do know, though, that it is an embodied experience. You and I are both putting ourselves on the line, being open and closed in a variety of different ways that change from instant to instant. You fade from zone to zone in your mind as I do, looking at the world through filters of different emotional color. You are distracted in...
Apr 16, 2007 | Clinical, Psychiatric Writings |
“Doc,” said Walt, a burly manic depressive guy in his mid-twenties, “your medicine makes me sick. I’m fine until I see that pill heading for my mouth. I’m just fine. There isn’t anything wrong with me. Then I see your pill and it makes me feel sick. I’m telling you it’s hard to swallow. I’m doing my best, but I don’t know how long I’m going to be able to keep it up. I can’t help thinking I’d be a lot better off without the damn pills.” Why do we find it so hard to take medicine as prescribed even when we have sought out medical help and understand at least the surface rationale for the medicine? Why do we feel so often like the manic depressive patient quoted even if we don’t put it quite so baldly? “I don’t know,” Gideon remarked, “why I stopped taking the medication without telling you. I guess I just wanted to run an experiment. I wanted to see if I could do it on my own without the medicine. But it wasn’t only that. It was about power, too. I wanted to show that I was the one with the power. This primarily concerns me and I need to have the power.” “Can you believe I have to take eleven different medications each day,” said Diana, a highly educated eighty year old woman. “I’m not even sure that they’re helping me. I’m not sure that I could tell you what they’re all for. Every time I go to the doctor, he has to look at the chart to see what I’m taking,...
Apr 9, 2007 | Clinical, Psychiatric Writings |
The first thing to notice about boundaries is that they are not things, but processes. They are dynamic processes that change not only from season to season of our lives but from situation to situation in our lives. Both intra-psychic and inter-personal definitions and discriminations are implicated in boundary processes. Boundary processes depend on social cues and skills, social definitions of roles, on intra-psychic self and object representations and their differentiation. This list is just a beginning. Like borders, boundaries shape what passes back and forth across them, what kind of exchanges can be carried on and what materials, raw and otherwise. can be provided. I once asked an Indian physician who was applying for a residency position in psychiatry what she thought about psychotherapy. Her answer was utterly disingenuous and very instructive. She said she would not consider going into psychotherapy if she had a problem herself. Instead, she said she would find a trusted aunt or uncle or another member of her extended family with whom to consult. For people like most Americans who did not have extended family networks, she thought psychotherapy was a very good thing, because it was important to talk things over. In fact, the rise of psychotherapy in the United States does coincide in time with the relative eclipse of the extended family. Psychological boundary processes are complex living processes. They can be conceived and described at various levels of concreteness or abstraction. Perhaps, even, it is partly because they are so complicated, that so many boundary prescriptions take the form of boundary proscriptions, of rigid rules and prohibitions. Complexity can confuse...
