There is no greater agony than bearing an untold story inside you.
-Zora Neale Hurston
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.