There is no greater agony than bearing an untold story inside you.
-Zora Neale Hurston
As a psychoanalytic candidate, the topic of sex in the consulting room tends to generate anxiety. Readings, conversations, and seminars on the topic only partially prepare us for when and how our patients talk about sex. Even more difficult, and perhaps less considered, is how analysts-in-training will react and work with sexual issues when they arise.
During my first year of training, one of my patients, a middle-aged married man, described a sexual encounter between himself, his wife, and another man. His description of the threesome was comprehensive and graphic, with detailed images of various intimate aspects of the experience. At first, I felt nervous, uncomfortable, and concerned about my reactions. I also worried that he would sense my anxiety. At the same time, I was intrigued and curious. Shortly after he began his narrative, I found myself lost in the scene he was describing, and feeling what he was experiencing. This fantasy continued until I realized that I was becoming aroused. The realization brought me back sharply to the reality of consulting room.
I reacted with surprise, followed by anxiety, shame, and a feeling that something bad had just happened. I worried that my sexual reaction was inappropriate and wrong, that I was unable to control my sexual fantasies, and that I had broken analytic boundaries with my patient. In addition to all of these feelings and thoughts, by nature internal, I was aware that, as a man, my sexual arousal might have been apparent, potentially noticed by my patient.
As I listened to my patient’s words, another part of my mind wondered why his vivid description of a sexual encounter made me so uneasy, and also why I felt so astonished by my reaction to his story. I came to realize that much of my feelings of anxiety and shame were associated with the topic of sexuality entering the consulting room.
Sex and sexuality can awaken in the analyst, and perhaps especially the analyst-in-training (definitely in myself), primitive emotions, archaic fears, shame, reticence, hidden desires, vulnerability, anxiety about losing control, and maybe even fear of acting on one’s own wishes and fantasies in the consulting room. These powerful internal experiences have the potential to create a sort of hubbub in ourselves which interferes with the “right now” moment we share with our patients. This consideration helped me calm down and realize that becoming aroused by a provocative sexual description was not something to be afraid of, but instead, a natural response to intense stimulation.
If our goal is to feel our patients’ experiences when they talk about their sexuality, it is critical that we be able to organize and analyze our emotions without being overwhelmed.
This is yet another instance in which I realized the importance of my own analysis. I believe that our analysis is perhaps the most powerful and effective tool to deal with the topic of sexuality, a key component in our psychoanalytic training. My analyses—one in Italy as a teenager, and a few in New York over the last twenty years—have greatly helped me to understand and become more comfortable with my own sexuality. My experiences as a psychoanalytic patient have made my fears and demons less frightening; in some ways, they have become travel companions that inform my work as an analyst today.
Lessening the fear of my own internal experience encourages openness to possibility. Perhaps my patient’s sexual description was an invitation to join his experience and connect on a more intimate level, in the security of the consulting room, safely framed by the boundaries of the psychoanalytic relationship. The threesome was, after all, with another man (maybe with me?), and my arousal an acceptance of his invitation.
Roberto Colangeli, PhD, is a 4th-year psychoanalytic candidate at the Manhattan Institute for Psychoanalysis and Assistant Professor of Microbiology at Rutgers University.
I can still recall how I made the decision to enter training. I had graduated from social work school eighteen months before, and fortunately had secured a well-paying, but probably temporary, job outside the field. So, I knew I had a narrow window of opportunity to start.
I had worked at a fee-for-service clinic, where not everyone was an analyst, nor aspiring to be, and where such training was often disparaged. Many therapists got by with private supervision, often under the wing of an octogenarian, Svengali-like supervisor, who taught his charges how to run lucrative groups, charge high fees, and keep patients in treatment indefinitely. I felt strongly that that wouldn’t be the right path for me. I needed something more comprehensive and, well, more ethical!
I looked at several institutes, but the interpersonal approach at Manhattan Institute, at the time unavailable to social workers anywhere else, seemed the best fit. Night classes, quality faculty who also taught at NYU Postdoc and the White Institute, reasonable tuition, and a warm, welcoming community all contributed to my decision. Also, my analyst at the time, who had graduated from MIP, said positive things about the institute and knew how to ask interesting questions—that piqued my curiosity. This maybe more than anything else motivated me to go further.
Before becoming a social worker, I trained as a music therapist. Most music therapists worked in hospitals, but I worked in a unique outpatient clinic that combined creative arts modalities with verbal therapy. So, by the time I got to Manhattan Institute, I had done a fair amount of what some might call psychotherapy: a mishmosh, I suppose, of Freudian interpretation, object relations, and interventions learned from a social work textbook. I was sincere and well-meaning, and some people said they found benefit in working with me, but, really, I had no idea what I was doing.
That all changed as my training progressed. Gradually, analytic training became a full immersion; classes, my own three times a week analysis, and especially expert supervision deepened my understanding year by year. The forthrightness of Elke Epstein; the street-wise pragmatism of Sheldon Kastner; the provocative yet kind Irwin Hirsch; the integrity of Willa Cobert and the wisdom of Gil Nachmani. These are remarkable people I don’t think I would have met any other way than through institute training.
Clinically, I began to know why I said the things I said. I asked questions that led to more depth. I could work in the moment in the transference, using my own feelings for the benefit of the patient. I absorbed the literature and gained the theoretical foundation I previously lacked. In those five years of training, I feel I truly became an analyst.
In many ways, graduating from training is only the beginning. Perhaps the most important aspect of post-candidate life is the community you join, the family you now belong to. It’s not unusual in our work to hear of candidates’ negative experiences at other institutes—feelings of shame, control cases being rejected, rigid orthodoxies, and hidebound instructors. I always marvel at these accounts because I simply cannot relate. To me, MIP is the most welcoming of analytic institutes.
In the years since my graduation, I’ve participated in the MIP community in many ways. I’ve served on the colloquium and curriculum committees, and now I supervise and teach. Starting a private practice can be difficult and isolating, but the friendships I’ve made at Manhattan have always helped the work go more easily, whether meeting a colleague for coffee or attending a colloquium after a long week.
I’ve been fortunate to have articles published and to host a podcast in which I interview psychoanalytic writers. I often feel that I might not have had the confidence to write or to put myself in the public eye had it not been for my formative experiences in training at Manhattan Institute. For that and so much more, I am grateful.
To learn more about training at MIP, join us for an open house and brunch on Sunday, June 11th, 11 am-1 pm. For location information and to RSVP, please click here.
Christopher Bandini is a psychoanalyst in private practice in New York City. He is trained as a clinical social worker and music therapist, and is a graduate of the Manhattan Institute for Psychoanalysis. He teaches and supervises at several psychoanalytic institutes, including MIP and the Institute for Contemporary Psychotherapies (ICP).
He is also a co-host of the podcast interview series New Books in Psychoanalysis.
Cynthia Chalker, CPP, Year 5:
“As part of this community, the candidates I have met, especially the last two years, have offered a sense of camaraderie and support I’ve craved.”
Justine Duhr, License Qualifying Program (LQP), Year 2:
“Before I entered training, I hardly knew what a psychoanalytic institute was, let alone what it would be like to be a member of one. Now that I know, I feel that I can never go back. I’m hard-pressed to remember a time I’ve felt more immersed and intellectually stimulated; the work is fascinating. Every day, I am challenged anew. Put simply, my training at MIP is an experience unlike any other that has changed the way I view myself and the world.”
Emily Fitton, Certificate Program in Trauma Studies (CPTS), Year 2:
“MIP has excellent, accomplished and published senior clinicians on the faculty! For example, I’ve had classes with Elizabeth Howell, a leading authority on dissociative processes, Fran Anderson, a leading authority on psycho-somatic work, Grant Brenner, highly accomplished in neurophysiology. MIP’s supervisor list is also made of up similar senior clinicians. I’ve had the privilege of supervising with Elizabeth Howell, and am currently supervising with Eli Zal. I appreciate being part of this community, as I’ve also expanded my network of other like-minded clinicians. The listserv is a great way to stay connected. My former post-graduate institute discouraged candidates from building community, but MIP seems to actively foster it, with the listserv and parties and educational events.”
Emily Haseltine, CPTS, Year 2:
“Being connected to MIP means that I am part of a community of learners. This is meaningful to me because I am part of an organization that enriches, supports, and enlivens my professional life.”
Yurilka Hernandez, One-Year Program in Psychoanalytic Psychotherapy (OYP):
“After graduating from college I realized that I wasn’t fully ready to work in a clinical setting because I was missing fundamental skills to treat people in a more intimate way. I looked at other institutes and decided on MIP because it had the one-year program. It is important for me to test the waters before signing on for a five-year commitment—not to mention it was one of the least expensive institutes out there. I have learned a great deal since I enrolled. It has been a great experience and I got to meet great people. The most enjoyable part is my clinical supervisor, Dr. Spitz.”
Yelena Ivanova, CPP, Year 2:
“As a social worker and psychotherapist, my drive to excel in my work and deepen my engagement with the field led me to MIP. Being connected to a community and individuals who are rich in experience and knowledge is an important aspect of my life.”
Mary Lippin, CPP, Year 3:
“Recently I’ve been feeling MIP is the best book club/study group ever. I am looking for a group I feel I belong to, the practice in doing what it takes to achieve that. In readings and classes (and analysis), I find people who are trying and sometimes succeeding in articulating things that resonate with me… things I never heard anyone talk about. So my deep longing for connection with people who “get” me is awakened. The persistence, dedication, and hard work it takes to keep this thing going is awesome.”
Karen Nelson, CPTS, Year 1:
“Being connected to an institute means not being completely untethered in the lonely field of psychoanalytic private practice. It means continuing to exercise my brain and stay mentally and intellectually engaged in the field. And it means maintaining a supportive relationship with a well-trained supervisor I can look to for guidance and validation.”
P.B., Certificate Program in Psychoanalysis (CPP), Year 2:
“Being able to get connected to teaching and practicing analysts who have been around and back…access to information not otherwise known or available to professionals who have never had an institute connection…evolve and grow with classmates who begin and graduate with you…referrals and resource goldmine from classmates, instructors, patients, supervisors, and more.”
Amy Storey, CPTS, Year 1:
“Being connected to an institute offers a tremendous opportunity to become part of a community of like-minded people with whom to study and converse. This is further enhanced by the fortuitous situation of psychoanalysis in New York City; many of the founding members and true giants within the field, spanning all diverse divisions of theory and practice, are HERE, alive and present, making the conversation very vital and poignant. Through this community we are introduced to some of the best minds around the world, past and present. I am very grateful to be able to participate; we are surrounded by excellence.”
Hili Tsarfati, CPTS, Year 1:
“A long-term supportive professional community.”
Rosemarie Verderame, CPTS, Year 2:
“Being connected to an institute means to me having a supportive community where I can develop as a therapist.”
Kaitlin Ziegler, OYP:
“Being at MIP has given me access to a community of knowledgeable professionals and a wealth of resources. Each instructor and classmate has contributed unique dynamics to the courses. The reading material is comprehensive, eye-opening, and philosophically intriguing. At the same time, the material is practical and relevant enough to apply clinically in daily practice.”
Interested to learn more about training at MIP? Join us for an open house on Friday, March 10 at 7 p.m. at the NYU Kimmel Center, 60 Washington Square South at La Guardia Place, Room KC #808.
Faculty and graduates will answer questions about MIP’s array of training programs, followed by a colloquium at 8 p.m. featuring Diane Barclay, LCSW, presenting “An Analyst Has a Birthday: Forgiveness as a Psychoanalytic Concept” with discussant Jody Messler Davies, PhD.
Justine Duhr, MFA, is a license qualifying candidate at MIP. She serves as web editor for the Analysis Now blog and chairs SCO-OP, MIP’s Student Cooperative. She owns and operates WriteByNight, a writers’ service dedicated to helping people achieve their creative potential and literary goals.
From a young age, I wanted to know what made people tick, in part because I wondered what made me tick. Like most children, I craved a sense of belonging and inclusiveness among my family and friend groups. At times I felt excluded, unwanted, and unworthy. Humans yearn for connection, and separateness from others can bring on feelings of pain, fear, and rejection.
As I think about my own need to feel attached, I think about British-born psychoanalyst John Bowlby, who developed attachment theory. Bowlby’s childhood was marked by separation and loss, his upper class parents leaving him and his five siblings in the care of nannies. At age four, his dearest nanny, to whom he felt most attached, left the household. Unlike this loving mother figure, his next nanny was cold and sharp. He later described this separation as akin to the tragic loss of a mother, one of many early caregiving experiences that left on Bowlby an indelible mark.
After studying psychology at Cambridge University, Bowlby worked at a school for emotionally disturbed children. This experience piqued his interest in developmental psychology and heavily influenced his professional trajectory. Here, he saw first-hand the effects of parental behavior on personality development, and decided to become a child psychiatrist. While still in medical school, he entered psychoanalytic training, vowing to consider the nature and impact of the child’s early relationships on subsequent development. He eventually proposed that a child develops a secure attachment to the caregiver (in his day, almost invariably the mother) who is attuned to her child’s needs and provides a dependable and safe environment.
Among the first clinicians to recognize that an infant enters the world predisposed to participate in social interaction, Bowlby asserted that disruption of the early caregiver-child relationship should be seen as a key precursor to mental disorder. His critical contribution—an unwavering focus on the infant’s need for a secure early attachment apart from other primary needs such as feeding—continues to be a central tenet of contemporary attachment theory.
As for me, I knew very early in my studies at NYU School of Social Work that I wanted to join a psychoanalytic institute, to continue my training and find a community where I could belong. After receiving my MSW, I worked at the Jewish Board of Family and Children’s Services (JBFCS) for more than 11 years, treating all kinds of people with a vast array of problems, and forming lasting friendships and a deep connection to the clinic. I began psychoanalytic training at the Manhattan Institute for Psychoanalysis (MIP) in my final years at JBFCS, and at MIP found the community I was looking for. Class with my peers, my personal analysis, supervision with seasoned psychoanalysts, and my work with patients all solidified my connection to a new and vital community.
Through these relationships I came to understand much more about the nature of relating, and the ways in which I, like my patients, perpetuated long-standing patterns that left me vulnerable in various ways. Fortunately, I found MIP to be a particularly warm and welcoming community, and a safe space in which to explore myself in relation to others, for which I am immensely grateful.
MIP continues to be a big part of my life, both professionally and personally. My psychoanalytic training at MIP has contributed immeasurably to my ability to inquire and make sense of my patients’ experiences, as well as my own. A psychoanalytic community such as MIP can be a psychological and emotional home, a place for exploration, openness, and curiosity about human nature in all its aspects. I cannot imagine doing this work without this deep level of training, and the ongoing opportunities to talk with colleagues about the challenges and dilemmas we encounter frequently in clinical work. I cherish the friendships I have formed over the years.
As a current faculty member, supervisor, and incoming co-director, I feel fortunate to be able to give back to the institute in new and meaningful ways. I hope to use my attachment to the people of MIP, and my curiosity and skills of inquiry, to understand the wants and needs of the community, its strengths, and its future direction while upholding its valued traditions. I want to ensure a sense of belonging in a safe environment where people can realize some of their dreams.
Naomi Cutner, LCSW, faculty, supervisor, and incoming co-director at the Manhattan Institute for Psychoanalysis, has a private practice in New York. She teaches attachment theory at MIP.
Having recently graduated, the question of what being part of a psychoanalytic community means to me feels more imperative than ever.
During psychoanalytic training, one takes for granted the connection to a community of classmates, supervisors, instructors, and our own analysts, not to mention psychoanalytic writers, ideas, and concepts. Alone with patients, one is never really alone. The content of our classes inevitably turns up in the consulting room. When studying dreams, patients present more dreams. While reading classic Freud, castration anxiety abounds. Learning about self psychology, we are more attuned to narcissistic injuries and repairs. And whatever the class, whatever the struggles with patients during the week, there is comfort in knowing that you can talk about it in class on Thursday night.
Outside of the classroom, I was able to participate in our community in so many important ways. I joined the curriculum committee, helping to establish MIP’s first-ever seminar series and reviewing the curriculum for opportunities to include conversations around race, sexuality, and diversity. As a member of the planning committee – aside from cleaning up after the holiday party! – we brought together candidates and graduates for the annual 11th week seminar to discuss, argue, probe, and ponder a variety of stimulating topics, from intergenerational transmission of trauma to dealing with money and technology to our transference towards the institute.
Last year, I started the Analysis Now blog, having no idea how much it would deepen my connection to the institute and members of the community. What a joy to be trusted to edit Irwin Hirsch, one of the most published interpersonal analysts of our time. Or to have the chance to inspire someone like Jonathan Kurfirst, a first-time blogger, to capture in words key aspects of his 30 years as an analyst on an inpatient unit. I have the pleasure of working closely with Willa Cobert, my former supervisor and one of MIP’s founders, and with the newest member of the editing team, Justine Duhr, a second-year LQP candidate, among others. I bring together faculty, supervisors, and candidates to brainstorm ideas and encourage members of the community to contribute, and in this way, I too stay connected. According to web editor Joe DiMattia, people around the globe read this blog! I never imagined community defined so broadly, and nothing could be more satisfying.
After graduation, how do we stay connected? At first, I was committed to taking a year off, reading fiction, and devoting Thursday nights to Netflix. That didn’t last long. I joined a reading group almost immediately. I found myself reading Ogden, Levenson, and Bromberg on the train to work. I even started a peer supervision group with MIP graduates whom I had gotten to know as part of the community, through seminars, colloquia, and committees. And, of course, I forge ahead with this blog!
The MIP community remains important to me as I grow my private practice. Clients referred to me by MIP’s clinic during my first years in the program are still in my practice. The relationships I’ve forged with close friends and colleagues at MIP will last long past my training days. I don’t know what more is in store for me in my professional life, but I know that MIP is a community that will continue to support me as an analyst, supervisor, teacher, and beyond.
Blair Casdin, LCSW, is a graduate of the Manhattan Institute for Psychoanalysis, and is in private practice in Manhattan. Blair is a co-editor of the Analysis Now blog.
What does being part of the Manhattan Institute mean to me? How has being in the institute benefited me? Contemplating these questions, I thought my answer would be simple, but as I began to write, I realized that it’s actually quite multi-layered and complex. The fact that many, if not most, of my referrals come through my contacts in the institute is of course a very practical benefit, but the intangible gifts of my MIP affiliation are far more significant and personal.
I come from a very small family: my father was an only child; my mother had only one sibling; I am an only child; and I had an only child. So, corny as it sounds, the institute is the closest thing I have to a large extended family, and I cherish it, warts and all.
When I started my psychoanalytic training at MIP, I was working full-time at an outpatient clinic at the Jewish Board and had only two private patients in an office in midtown that I rented by the hour. As my practice grew and I progressed at the institute, I gradually decreased my time at the clinic and expanded my private practice, but I was still overworked and stressed. I commuted between Riverdale and Manhattan, and worked late every night. I was exhausted, with barely enough time for my family, let alone for reading assigned articles for classes. Clinic work became less and less gratifying, but I agonized about quitting my job and going into private practice full-time, largely because I feared losing the sense of community and support I felt among my colleagues at the clinic. I remember vividly a moment in my analysis, obsessively going back and forth about whether to quit my job, when my analyst finally said dryly, “Perhaps being able to see your friends every day isn’t a good enough reason to stay in a job that gives you so little else.” Lightbulb moment! So, in my third year of analytic training I took the plunge, rented an office, and left my salaried job. The institute became my professional center, and it remains so to this day.
Psychoanalysis and private practice can be lonely endeavors. Or perhaps, as Irwin Hirsch astutely observes in his recent post, depriving ones. We analysts are with people all day long, but have limited opportunities to talk about our experiences: the emotional pulls, the depth of feelings, the anxieties, and yes, the joys. Having a community in which to do that gives me a sense of balance that would be almost impossible to generate elsewhere.
About 14 years ago my husband was offered a very tempting job in Cambridge, Massachusetts, and I thought seriously about what it would mean for me to move away from New York City and MIP. I couldn’t imagine starting over and recreating for myself what I had at the institute, or continuing to do my work without it. Luckily, my husband felt the same way about his job here, and I was spared having to confront that challenge head-on.
Because MIP offers its members unique and varied opportunities to participate in the community, encouraging professional advancement at every turn, my involvement takes many forms. I teach, supervise, serve on committees, develop programs, and more – a range of professional activities that diversifies my days in a way that sitting in the consulting room with patients from dawn to dusk would not. Different intellectual and emotional muscles get exercised, which helps me maintain my focus and stamina for the difficult work analysts do. I’ve even had the honor of being a co-director and of being able to give something back to the institute that has nurtured me for so long. I have gotten to know people whom I never would have met otherwise, and I’ve made friends who have sustained me through some very difficult times.
I’ve learned a great deal about myself, not just through my analytic training, but by being part of this community and by navigating the relationships, conflicts, and growing pains that are inevitable in any group of strong-minded, smart, committed people. Each new role I have taken on has stretched and altered me in ways that have been life-changing both in and out of the consulting room, and the institute has provided the arena in which all of this important work could take place.
Debora M. Worth, LCSW, is a graduate of the Manhattan Institute for Psychoanalysis. She is teaching and supervising faculty at MIP, and served as co-director of the institute from 2007 – 2012. In addition, she is teaching and supervising faculty in the Child and Adolescent Training Program at the William Alanson White Institute. She is in private practice in New York City, working with adults, couples, children and adolescents.
I suppose that as one of the seven founders and first director of the Manhattan Institute, I am a logical choice to write this opening piece to a new blog series addressing some of what it may mean to be part of a psychoanalytic institute – ours in particular.
Since 1978, when I and my six colleagues and then friends began planning to start a new institute, MIP has been my primary psychoanalytic community. Though I have a number of other institutional affiliations that I value, I have met and feel personally close with more people in this community than anywhere else. I believe that being part of a community is one of the two key reasons to pursue psychoanalytic training. The other is, of course, becoming educated and increasingly skilled, and maintaining and expanding one’s education and therapeutic talent.
I do not believe that anyone can learn to do this work effectively without considerable, specialized training. If one believes that the potential for significant personal growth is more likely to occur via the route of being an analytic patient than in any other form of psychotherapy, a long and arduous training process is necessary to meet our responsibility to those who seek us out for this aim. However, as most of us who go through analytic training come to realize, our education does not stop at graduation. It is very difficult to work psychoanalytically without continuous and long-term immersion in some form of supervision, attendance at educational meetings, and connection to the ever-evolving psychoanalytic literature. Active involvement in a psychoanalytic institute is the most likely and convenient avenue for graduate analysts to continue to grow, to gain skill at this very complex and difficult profession.
If one pursues professional growth in the context of continuous involvement in a psychoanalytic institute, it is likely that this collegial atmosphere will evolve into a network both of friendships and sources of private referrals. I do not believe, as some colleagues do, that doing psychoanalysis in the privacy of one’s office is a lonely enterprise. Indeed, I am with patients all day long, and usually grow to feel close to them and to benefit from human contact with them. What I often feel is difficult is the professional boundary that prohibits personal involvement beyond the parameters of our 45 minutes together. It is not that I am lonely without this desire being fulfilled; it comes closer to a feeling of deprivation. Being part of an analytic institute obviates this for me. It allows for personal relationships with fewer boundaries, with those doing similar work and sharing many similar concerns and worries. Independent of family relationships, intimate partners, and friends outside of our profession, these collegial connections help me feel that I am part of a community and the increased personal security that accompanies this.
I believe that life is easier when we feel an integral part of a community, professional, cultural, or otherwise. Pursuing psychoanalytic education, indeed a life-long commitment, allows for such immersion and acceptance, as well as professional advancement (e.g., teaching and supervising) in that community and beyond. It is personally gratifying for me to see that over the years, the vast majority of teaching, supervising, and administration at our institute has been taken over by our graduates. I believe that this is as it should be. Those who feel most deeply about this community are likely to have the strongest commitment to the work they perform. I also feel proud that MIP has developed a tradition of inviting decision-making and committee participation from all segments of the community – students, graduates, and faculty. Those of us who started this institute have seen our graduates expand meaningfully and successfully the scope of available personal and educational immersion – a one-year program, a trauma program, a license qualifying program, and initiatives on gender and sexuality and on racial and ethnic diversity.
Manhattan Institute has grown into a warm and welcoming community, promoting both continued education and friendship. My own involvement here, highlighted by the many wonderful people I have met and worked with, means a great deal to me. I encourage others to consider the range of benefits of active immersion in such a community, and what that rich experience might mean to you.
Irwin Hirsch, PhD, a founder of the Manhattan Institute for Psychoanalysis, is teaching and supervising faculty at the Manhattan Institute for Psychoanalysis and other institutes. He is in private practice in Manhattan.
“What is trauma therapy, and what’s so different about working with trauma?”
When I teach this subject here at Manhattan Institute and elsewhere, these questions naturally arise. If I redirect the first part of the question back to the participants, a common response may go something like this: “You ask the patients to describe their traumatic experiences in detail, and then you process each element of those memories until their distress subsides.” This model, founded on the cognitive therapy approaches of systematic desensitization and exposure therapy, is widely taught and utilized. Through a combination of repeated exposures to traumatic memories, images, and sensations, paired with relaxation techniques, the memories and anxious and fearful responses to them may become desensitized or reconditioned.
This variety of treatment undoubtedly has pertinent applications and benefits, when for example attending to a single-incident trauma or simple phobia. It is my belief and experience, though, that these methods become increasingly insufficient when attempting to treat more complex and persistent forms of psychological trauma, especially where dissociation is prominent.
In the late 19th Century, psychoanalytic pioneers Janet, Freud and Breuer began connecting what were then called hysterical symptoms (extreme emotionality often accompanied by amnesias and somatic conditions) with early life traumas. Breuer and Freud stressed the importance of recognizing the clinical implications of “traumatic memories which have not been . . . associatively linked with other thoughts” (Howell and Itzkowitz, p. 23). Their associationist and abreaction models called for the need to link and symbolize traumatic memories within the stream of normal consciousness in order to bring about symptom reduction. Thus, contemporary trauma treatment originated in the first psychoanalytic theories and therapies (see Howell and Itzkowitz, pp. 20-32).
In 1992, Judith Herman, in her now classic book Trauma and Recovery, proposed a new diagnosis that she called Complex Post-Traumatic Stress Disorder (C-PTSD). Added to the then-existing diagnostic classification of PTSD were criteria such as “alterations in affect regulation, consciousness, self-perception, relations with others, and alterations in systems of meaning [emphasis added]” (p. 121). While in the ensuing 20-plus years some of these features have been lightly incorporated into the current DSM-5 criteria for PTSD (see pp. 271-280), broad acknowledgment of the essential distinctions between the bio-behaviorally-based changes seen in simple PTSD (alternations between intrusive reliving and emotional numbness) and the multifaceted psychological manifestations evident in C-PTSD has not yet gained full official recognition. Analogously, the treatment modality (an example of which I briefly noted above) remains central in conventional educational settings, whereas the core psychoanalytic discoveries and contemporary relational approach to working with trauma are underestimated.
According to Courtois and Ford (2009), “Complex psychological trauma represents extreme forms of traumatic stress due to their nature and timing. . . . [T]hese experiences are typically chronic rather than one-time or limited, and they severely compromise the individual’s personality development and basic trust in primary relationships”(p.14). Further, the traumatic events typically involve direct harm, neglect, abandonment, and betrayal by a needed caregiver at developmentally vulnerable times in the individual’s life. In another suggested designation, “Developmental Trauma Disorder,” the specific affective sequence of “rage, betrayal, fear, resignation, defeat and shame” is the singular subjective criterion for complex stress disorders in children (Van der Kolk, 2005).
Richard Chefetz, an expert in the relational treatment of persistent trauma-based dissociative conditions, comments on the effects of early relational trauma on self-development: “Traumatic experience . . . alters the developmental trajectory of an individual through changes in the organization or constitution of their self-states[emphasis added], the ability to have emotional experience . . . the capacity to live in relationship with self and others, and the maintenance of an enduring sense of self” (p.191).
Taken together, these glimpses into the world of someone suffering with C-PTSD (complex, cumulative, and chronic) underscore the need for a treatment that engages the whole person in an in-depth therapeutic endeavor; one that reaches well beyond the scope of more recently developed trauma processing models (e.g., EMDR and Somatic Experiencing).
Howell and Itzkowitz (2016) point out that the psychoanalytic trauma clinician may at times be required to take a more active approach such as using relaxation, grounding, or hypnotic techniques (pp.7-19). I agree. These established methodologies, along with the newer trauma resolution procedures, are indeed worthy therapeutic adjuncts and tools; however, they are not equivalents of or substitutes for comprehensive and specific training in the psychotherapy of relationally-mediated complex trauma. A tool is only as useful as the skill of the person who handles it.
In the post 9/11 era, we have become much more cognizant of the reality and pervasiveness of trauma—massive and catastrophic as well as private and individual. This heightened awareness is coincident with the rise of the above-mentioned trauma therapy models and of briefer, “evidence-based” psychotherapies, many of which proffer fast-tracked resolution of even very complicated clinical portraits.
This emphasis on swiftness, it seems to me, is antithetical to the very nature of traumatic encryption and recall. The splits, fissures, and dissociative gaps in awareness became structured into the mind of a traumatized person to serve a crucial function—as protective barriers against that which was intolerable, terrifying, cruel, and disorganizing. As associative (versus dissociative) processes ensue in treatment, the unsymbolized markers and sensations of overwhelming terror, helplessness, annihilation, dread, etc., shift—sometimes lurch—into conscious awareness. Any therapist who has witnessed this phenomenon knows that as the isolated, dissociated self-states and fragments of traumatic memory come into closer connection with the patient’s consciousness, a degree of traumatization often recurs. This is one crucial dynamic that makes working through traumatic adaptations such challenging and sensitive work. How could these detached aspects of self-experience possibly be rapidly modified or integrated without posing serious risk of destabilization?
To the extent that complex traumatic syndromes represent adaptations to actualchronic and often cumulative harm from the outside, externality delivers constant cues and reminders of past traumatization. As such, C-PTSD frequently includes a limited facility for coping with numerous aspects of reality—both inner and outer. The dampening effects of derealization and depersonalization are ubiquitous features of dissociative responses to trauma, as are, paradoxically, vehemently felt but clinically impenetrable emotions, beliefs, and physical sensations (Steinberg and Schnall, 2003; Van der Hart, Nijenhuis, and Steele, 2006).
The psychoanalytic trauma therapist must recognize and respect these and other constraints upon the trauma patient’s capacity for growth, change, and cohesive relatedness. The work should be judiciously and purposefully paced, always moving in alignment with the shared level of comfort, safety, and trust in the therapeutic dyad. The sometimes necessary and unavoidable micro-retraumatizations that signal the linking of previously dissociated elements must be curated to a manageable level of tolerance. Because familiarity—positively or negatively charged—is synonymous with a felt sense of safety for many survivors (novelty connotes danger), the anticipated struggle against internalization of new experiences also cannot be overlooked. The practical titration of traumatic material, within the context of a safe-enough therapeutic container, is how we help to build resilience and promote healing; and not, as is frequently held, by walking with the patient directly into their trauma vortex (Levine, 2010).
Trauma-specific psychotherapy training provides the clinician with an indispensable foundation for carrying out this demanding, enormously compelling, and rewarding work.
Sandra L. Green, LCSW, SEP is Executive Director, Faculty, and Clinical Consultant at the Certificate Program in Trauma Studies, Manhattan Institute for Psychoanalysis.
For information on the Certificate Program in Trauma Studies at the Manhattan Institute for Psychoanalysis, click here.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Chefetz, R. (2015). Intensive Psychotherapy for Persistent Dissociative Processes – The Fear of Feeling Real. W.W. Norton & Company.
Courtois, C. and Ford, J. Eds. (2009). Treating Complex Traumatic Stress Disorders.Guilford Pr.
Herman, J.L. (1992). Trauma and Recovery. Basic Books.
Howell, E. and Itzkowitz, S., Eds. (2016). The Dissociative Mind in Psychoanalysis–Understanding and Working with Trauma. Routledge: Relational Perspectives Series.
Levine, P. (2010). In an Unspoken Voice. North Atlantic Books.
Steinberg, M. and Schnall, M. (2001). The Stranger in the Mirror: Dissociation – The Hidden Epidemic. Quill Publ.
Van der Hart, O., Nijenhuis, E., and Steele, K. (2006). The Haunted Self – Structural Dissociation and the Treatment of Chronic Dissociation. W.W. Norton.
Van der Kolk, B.A. (2005). Developmental trauma disorder, Psychiatric Annals 35,401-408.
Many mental health professionals hold the opinion that psychoanalysis has no place in the treatment of “seriously disturbed,” institutionalized people. As a psychoanalytically trained psychologist, I worked at an inpatient psychiatric facility for children and adolescents for over 30 years. While any job of this nature has its share of bureaucratic and administrative nightmares, I look back on my career with a great deal of satisfaction. I attribute this to the fact that the breadth and depth of psychoanalytic theory gave me the tools, and more importantly, the perspective, to be a more creative therapist in such a difficult context. Rather than feel burned out by such work, psychoanalytic training allowed me to get to know each new patient with an openness and flexibility informed by the rich body of theoretical knowledge regarding the factors operating in the human psyche. My training included supervisors and teachers who believed in the idea that psychoanalysis could be applied to a wide variety of conditions by understanding that there was more to this therapeutic approach than rigid technique. Further, I believe that it was the Interpersonal-Relational (I/R) approach which included both an in-depth appreciation for developmental concepts and an understanding of how to use one’s own subjective experiences to inform and enhance one’s ability to work therapeutically with patients whose core difficulties made such connection, to both themselves and others, difficult and frightening.
Despite the fact that working within a medical model ruled by DSM conceptualizations requires the clinician to be able to “talk shop” in that manner, my psychoanalytic training allowed me to “go outside that box” when actually doing my clinical work. The diagnoses that I formulated, aside from PTSD, were usually on Axis II (related to character or personality disorders) rather than on Axis I (associated with a medication regimen). I based my formulations on developmental concepts, theories about primitive emotional development, separation-individuation, self-states, or self psychology, to name a few. Using this approach, the diagnosis became more relevant to understanding the patient as a person rather than as a list of symptoms.
A further practical benefit to this approach is its view that the therapist’s reactivity is an essential aspect of treatment. Working with severe psychopathology typically engenders strong emotional reactions in a therapist. The I/R model of therapy allowed me to accept and use my subjectivity as a source of information about a patient’s relational tendencies and needs.
I’m not suggesting that this learning could be represented by a glowing lightbulb over my head! Far from it. Work with hospitalized patients is filled with frustrations and frequent questions about our abilities. Blows to our sense of therapeutic competency are as typical as affective reactions like anger, rage, sadness, or even love, affection, and protectiveness. By accepting without self-judgment any of the above subjectivities I was frequently able to understand something about the therapeutic relationship with a particular client, and to use this understanding to enhance the therapy.
Nowhere is the value of interpersonal-relational theory greater than in working with traumatized individuals. When I first began my career in the early ‘80s, trauma was narrowly defined, and it was not a variable often considered in formulating DSM-based diagnoses. The term “dissociation” only existed as a word to memorize on a list of “defense mechanisms.” Over the years, as reports of widespread abuse and neglect became increasingly acknowledged, and patient populations began to reflect this cultural phenomenon, trauma was more likely to be considered. However, this was not usually seen as a primary etiological factor, and did not include anything about the trauma victim’s internal experience. The acknowledgement of a role for dissociation as it impacts the psyche was addressed to some extent relatively recently with the advent of the diagnosis of PTSD and, to a lesser extent, Dissociative Identity Disorder. This relatively more enlightened appreciation of the impact of trauma at one point eventuated in administrative mandates for therapists to be trained in techniques like “Trauma-Focused Cognitive Behavior Therapy.” While a useful tool for certain patients and clinicians, the disregard for the presence of dissociative processes and their impact on the self rendered them, in my view, superficial and limited in potential applicability.
Interpersonal-relational psychoanalysts such as Howell, Davies and Frawley, Bromberg, to name a few, understood the primary significance of dissociation and its relation to the development and experience of a coherent self. This allowed for a deeper understanding of what it actually meant to be traumatized, and to create interventions accordingly. These writers, and many others, helped expand the concept of trauma beyond the traditional to include experiences within a familial or caretaker context. This was referred to as “relational trauma,” implying that the relationship to the traumatizing person(s), not just specific incidents of abuse and/or neglect, was essential for the understanding and treatment of the patient. Applying this expanded view of trauma, as well as the profound impact of dissociation on the developing psyche, allowed me to collect, organize and comprehend what I experienced with patients in a newer, more complete way.
The following descriptions provide a sense of how the application of I/R training informs my approach to treating profoundly traumatized adolescents. Patients whose symptomatology were characterized by violent, destructive and sometimes assaultive behavior were most often given an Axis I diagnosis of Major Affective Disorder, Bipolar Disorder, Psychosis NOS, or Intermittent Explosive Disorder. Such labels indicated nothing about the psyches of these individuals. Their behavior might as well be random. Understanding the concept of dissociation and self states, it was often very clear that these “violent” patients were really caught in a ”flashback self state,” or what could be described as previously “unexperienced experience.” Once I could identify and understand the process in the interpersonal context that triggered the episode, I could determine the best ways to use this information in the service of the patient’s healing. Another group of patients who became more “understandable” by utilizing I/R concepts were those who engaged in self-harmful behavior such as cutting. These patients, sometimes more verbal than the first group, could often describe their experiences while hurting themselves. Cutting seemed to relieve the pain associated with an internal conflict around separation from an abusive attachment. Understanding the behavior in this way allowed me to talk to them in ways that I might not have without such understanding.
In 2013, I joined the faculty of the Manhattan Institute’s two year Certificate Program in Trauma Studies. The program provides clinicians from many disciplines with a rich structure for treating trauma within a relational context. Many of the faculty are innovators and writers in the field of trauma, with the tools and perspective of interpersonal-relational psychoanalysis. Many of the students come from clinics, institutional settings, and private practice, and report how their experiences in the program have greatly enhanced their capacity to understand and treat their patients. The existence and availability of this type of training is a testament to the evolution of our ability to understand and work effectively with traumatized individuals.
Observing the evolution of the treatment of trauma is deeply satisfying. Early in my career, despite the fact that close to 100% of the patients I was working with were severely traumatized, theories of trauma and dissociation were dismissed. Thankfully interpersonal-relational theory has expanded the concept of trauma and its treatment to include a more comprehensive understanding essential to working with the dramatic impact of dissociative processes on the developing self. Idealistic as it may sound, maybe, at some point, administrators, bureaucrats, and all clinicians, will see that far from being irrelevant or inappropriate to the treatment of trauma, and severe pathology in general, the psychoanalytic approach is essential!
Jonathan Kurfirst, PhD is Faculty and Supervisor, Manhattan Institute for Psychoanalysis, Certificate Program in Trauma Studies. He received his postdoctoral training in psychoanalysis at Adelphi’s Derner Institute for Advanced Psychological Studies. He is in private practice in Park Slope, Brooklyn.
For information on the Certificate Program in Trauma Studies at the Manhattan Institute for Psychoanalysis, click here.
Karen sank into the sofa, sighing deeply. Her shoulders slumped down as she looked up. Fixing a determined gaze on me, she announced: “You’re my Buddha.”
I paused, and considered her words: the note of possession. The exclusivity. And finally, the Buddha. The tone of her voice was affectionate, authoritative.
This wasn’t the first time that Karen had proclaimed me her Buddha. In prior sessions she had called me Swami (an honorific that contained, at least for me, latent associations to a charlatan). We had analyzed in the transference her choice of words and her choice of me, a straight-identified Indian-American woman as her therapist. Buddhas were serene, peaceful, sexually removed, wise. Buddhas didn’t deal with the romantic turmoil that plagued mere mortals. After all, the real Buddha himself, Siddhartha Gautama had abandoned his royal post, his wife and son for a life of asceticism. In Karen’s eyes, she was the seeker, and I the found.
As a relational analyst, the exchange inevitably touched on who we are in the room: our race, ethnicity, class, gender and sexuality. As a professional queer-identified woman of Jewish parentage in her 30’s, Karen experienced an upbringing that intersected with my own in many ways. We were both women raised in upper-middle class homes in suburbia and socialized in a patriarchal culture. However, Karen dealt with bigotry for being both Jewish and queer. Her grandparents were Holocaust survivors. She struggled with issues of sexuality and identity.
My parents were part of a wave of professional immigrants welcomed into the U.S. after implementation of the 1965 Immigration & Nationality Act. The Act abolished the national origins quota system (to no more than 20,000 visas per year from any one country) that had been in place restricting Asian immigration to the U.S. Upon arrival, they like many other immigrants and people of color, were subject to racism and discrimination in their professional and personal lives.
We hailed from cultures that were stereotypically clannish, family oriented, and focused on educational and professional achievement at all costs.
While such common ground was tacitly acknowledged, being a Buddha implied Otherness. My analyst silence deemed wise. My measured response deemed spiritual. The act of holding space in the consulting room deemed holy.
Karen, of course, was commenting on aspects of my personality. In contrast to the decidedly non-Buddha-like women in her life, I embodied an Orientalist trope—an inscrutable, wise, serene therapist residing in the office/dream space: static, frozen, fixed eternally.
As Edward Said notes in Orientalism:
The very possibility of development, transformation, human movement—is denied the Orient and the Oriental. As a known and ultimately an immobilized or unproductive quality, they come to be identified with a bad sort of eternality: hence, when the Orient is being approved, such phrases as “the wisdom of the East.”
As a sign of this supposed wisdom, near my Union Square office, a number of yoga studios have proliferated over the years. The emphasis on “Eastern spirituality,” pseudo or not, is strong. Buddhism is in vogue. Sankskrit words/concepts like karma, dharma, moksha, and samsara trip off the tongue. The message is clear: The East rejects materialism in favor of spirituality, religion, yoga, and self-knowledge/growth. This one-dimensional view did not square with the complexities of the India I knew. As Gita Mehta wryly notes of this exchange between East & West in Karma Cola:
The seduction lay in the chaos. They thought they were simple. We thought they were neon. They thought we were profound. We knew we were provincial. Everybody thought everybody else was ridiculously exotic and everybody got it wrong.
On the other hand, I could not deny that Karen was also commenting on those aspects of me that were essentially unknowable, unreachable. She had repeatedly despaired of the lack of truly being able to “know” me though some self-disclosure had been made over the years we’d been working together. She admittedly worried that one day I would reveal myself to be the “mess” that she knew most women in her life were. That is, emotionally volatile & deceitful. In some ways, unacknowledged, she preferred the racist trope to the sexist. In doing so, she kept safe from those destructive aspects of myself she was afraid to know (one could argue that I was afraid to know) and protected the men (her father) in her life who had failed her. She rendered me a man—A Buddha who had abandoned the material world.
I often wondered if I were not Indian-American, would Karen have called me a Buddha or Swami? Or did my personality, not to mention my profession, make such a comparison inevitable? After all, most people initially found me hard to read. As analysts we are very often more observer than participant, hidden away in asymmetrical relationships. It was hard to tell.
I wondered too, how much I had colluded in this perception. Had I unconsciously adhered to a Buddha-like persona? W.E.B Dubois coined the idea of a “double consciousness,” a term describing the psychological challenge faced by African-Americans ‘of always looking at oneself through the eyes’ of a racist white society and attempting to reconcile their race/ethnicity with an upbringing in a European-dominated society.’ This struggle to deal with a multi-faceted conception of self was something Karen and I undoubtedly shared.
Reflecting on our dyad from a relational standpoint, I noted feeling boxed in—unseen by her comment, as though I was an idea or an ideal that she needed me to be: unchanging and static in my steadiness. A feeling of despair ensued where I imagined never quite being known by her. And I understood that very likely she felt this way in her life—that I, like her primary caregivers, would never quite know or understand her. And she felt boxed in by her need to please and fulfill expectation.
I began to realize that I was not the only Buddha in the room. A Buddha symbolized some shameful aspects in her—static, passive, unchanging, never roused to anger—that Karen had projected onto me.
By opening up the discussion and considering the myriad meanings of a word, the opportunity for greater freedom and spontaneity arose, a welcome and necessary outcome for the both of us.
Tara Chivukula, LCSW, is a graduate of the Manhattan Institute for Psychoanalysis. She is in private practice in New York City.
Double Consciousness. (March 31st, 2016). In Wikipedia: Retrieved: April 23, 2016, from: https://en.wikipedia.org/wiki/Double_consciousness
Mehta, Gita (1979). Karma Cola: Marketing the Mystic East. New York: Simon & Schuster.
Said, Edward (1978). Orientalism. New York: Random House.
*Names and other details have been changed for reasons of confidentiality.