In re Don Quixote et al

Don Quixote, the incomparable, comic, tragic, absurd, possessed by his destiny, dispossessed of his life by his destiny, an explorer who leaves home to find himself but loses himself in trying to find himself, someone perpetually homeless and proud of this homelessness as a quest for the impossible but imaginable. Sancho Panza, a man like other men, moored in a web of human relationships, not so very grand, but very real, a nobody who is somebody by reason of how he carries being a nobody, being as close to the earth as any other clod, capable of a loyalty that is itself a kind of realization of the imaginary, someone who lives as himself but not so much for his own sake. A distinguished, tall, thin. extremely learned, very ill elderly man came to see me looking for I didn’t at the time know exactly what and I still don’t know exactly what it was that he was seeking. I find myself thinking he was looking to be made whole. In life as in the law this concept of being made whole is no simple one. This man yearned to be restored to being who he thought he was. Actually it went far beyond yearning to an insistence that bordered not only on religious faith but on an idiosyncratic religious fanaticism – “I can only be if I am who I take myself to be, even if who I take myself to be is not only complicated but also multiplex, fabulous.” Ailing had been an integral part of his life, reaching back into childhood. Part of ailing was an... read more

Presence

I have worked on the telephone with patients from twenty-five to seventy-five, men and women of diverse backgrounds and dispositions. I have always started with them in the office and then good reasons intervened to make it make sense to go on on the telephone. This work has spanned states, countries, hemispheres, the complexities of time zones. It is a testimony to how remarkably robust communications infrastructure has become that this has been possible. There are limits, too. I have never tried working with a patient who was acutely or chronically suicidal in this way. I have never tried working with a floridly psychotic patient. One woman who was on the other side of Mississippi from where I am here in Baltimoreused to end each session by saying quite brightly, “See you next time.” It was some time before it struck me just how remarkable this sign off was because in the usual sense related to the visual apparatus it was precisely seeing each other that we could not do and would not do. But, of course, I think she meant another kind of seeing, one constituted by emotional presence in relationship mediated by inner attachment processes that guide imagination. So I found myself slowly wondering how presence is constituted. We often speak of it as if it had primarily to do with shared location in space and time. But perhaps it is much more imaginary than that. Yes, it requires some back and forth as a condition,but many different kinds of back and forth are possible. I realized that I had patients who came to see me in... read more

Working With Envy

The major work of psychotherapy is in the “being with,” a task that inevitably calls upon our resources in being with ourselves, a process that is always in development, that is, always involved with struggle, impasses, reevaluation, creative surges, disillusionment and reillusionment. To be useful to our patients in large part depends on our capacity because of her capacity to stay with our own difficult and distressing affective experience, in therapy and outside of therapy. It is the “being with” that brings affects from what we might refer to as a vapor state to condense until they achieve representability, even crystallization. Where we speak so much about affect containment, we might do well, as Erna Furman has pointed out, to speak of affect attainment. Of course, attainment and containment are two aspects of a single process. Our involvement with others is a mystery, not in the sense that we should remain quiet about it, following some dictum like Wittgenstein’s “Of that whereof we can not speak, thereof we should remain silent,” but in the sense that, whatever we may say about it, there is always more, something about what we have said that falls short, is wrong, does not fit, raises more questions than it answers, deeply unbalances us just when we thought settling the matter (and ourselves) might actually be in our grasp or at least almost in our grasp. Of this mystery of our involvement with others envy is a large and central part, a province teeming with life and hope and despair. Envy means lack, want, desire, insufficiency, incompleteness. Envy is a means, not just an... read more

Surfaces Of Shame

“I don’t know when shame came to live in my house,” observed a woman in her early fifties, “but once it did, it moved from room to room until it had taken over the whole house.” Although she did not say this in so many words, the implication was that once shame “had taken over her whole house,” there was no place for her to live. If we live in our minds, as surely we do, although not only there, then she was psychicly a homeless person, rendered so by her shame. Notice, too, that her shame is dynamic. It moves from room to room. It takes over. It grows and thrives at her expense. It is a very dangerous parasitic life form. Remember, too, that houses often stand for selves. These are often every bit as ramshackle as old homes, every bit as difficult to maintain. Where might shame come from? How does it enter our homes, ourselves? One place to start is with the name, itself, “shame.” The Oxford English Dictionary traces one speculative origin of the word “shame” back through a pre-Teutonic “skem” which in turn connects to “hame”, “A covering, esp. a natural covering, integument; skin, membrane, slough (of a serpent). It also quotes Darwin, in Emotions XII 321, “Under a keen sense of shame, there is a strong desire for concealment.” I am not learned enough to know if there is a word for shame in every language, but I can venture that most have such a word and if some do not, then the underlying cultures would be very interesting for the study... read more

How Borderline Patients Get At Us In Us

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... read more

Grief, Forgiveness And Creativity

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... read more

Shame And Loneliness

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... read more

What Is Listening?

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... read more

Doc, your medicine makes me sick

“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,... read more

Boundaries In Psychotherapy

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... read more
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