the Spring/Summer 2012 AMERICAN Volume 46, No . 2 PSYCHOANALYST Quarterly Magazine of The American Psychoanalytic Association

INSIDE TAP… POLITICS and PUBLIC POLICY Election Results...... 4

Annual Meeting Fiducia, SCOTUS, and the in Chicago Therapeutic Dyad June 12–17 . . . . . 6 –11 Graham L. Spruiell Analytic Reflections It did not matter if Dr. Harold Eist was right information, with rare exception, clinicians on Mad Men. . . . . 13 or wrong: The Supreme Court of the United would decline. This decision would be based States (SCOTUS) declined to consider his upon professional ethics, the patient’s right to Special Section appeal. It was a blow to patient confidentiality. confidential treatment and physician-patient on Psychoanalysis Consequently, in Maryland if there is a com- privilege. The same privilege would exist if a & Psychosis plaint by a third party to the medical board, third party requested or demanded pro- the board can legally demand personal health tected information about a lawyer’s client or (Part 3)...... 17–20 information (PHI) from individual patients’ a priest’s penitent, although the legitimacy of medical records, without obtaining consent, such designations may be on the decline. Child Psychoanalysis . . . . 21 even if the patient objects. The board’s demand was in conflict with In the Eist case, the Maryland Board of everything Eist Physicians investigated psychoanalyst and understood child psychiatrist Harold Eist after receiving about his ethi- a frivolous complaint from the estranged cal obligations husband of his patient. Board investigators to his patient. demanded that Eist disclose confidential It also contra- records without his patient’s knowledge or dicted recom- consent, information that could be used mendations by against the complainant’s wife in a divorce his legal coun- proceeding. sel, advice ten- Besides affecting patients, the Eist case also dered despite a has implications for clinicians. Traditionally, if a Maryland stat- third party requests or demands confidential ute permitting board access to medical Graham L. Spruiell, M.D., is co-chair of the records during an investigation. Eist con- Committee on Government Relations and ceded and eventually complied with the Insurance and a member of the Program in board’s subpoena after informing his patient Psychiatry and the Law, Beth Israel Deaconess that he would do so unless she objected. Medical Center, Boston. Continued on page 26

THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 1 CONTENTS: Spring/Summer 2012 THE AMERICAN PSYCHOANALYTIC ASSOCIATION President: Warren R. Procci 3 Farewell after 10 Years of APsaA Leadership Warren R. Procci President-Elect: Robert L. Pyles Secretary: Beth J. Seelig Treasurer: William A. Myerson 4 APsaA Elections Executive Director: Dean K. Stein Honorary President 5 Historic Invitation to William Alanson White Institute Leo Rangell Colleen L. Carney and Beth Seelig

2012 Annual Meeting Highlights: June 12–17 Christine C. Kieffer THE AMERICAN PSYCHOANALYST 6 Magazine of the American Psychoanalytic Association 8 University Forum on Immigration Stanley Coen Editor Janis Chester Come to Chicago: 101st APsaA Annual Meeting: Editorial Board 9 Brenda Bauer, Vera J. Camden, June 12–17 Caryle Perlman Leslie Cummins, Phillip S. Freeman, Maxine Fenton Gann, Noreen Honeycutt, Film Workshops at Annual Meeting in Chicago Sheri Butler Hunt, Laura Jensen, 11 Navah Kaplan, Nadine Levinson, A. Michele Morgan, Julie Jaffee Nagel, Film: Parenting Lessons from Mad Men’s Betty Draper Frances Marie Rudden, Hinda Simon, Vaia Tsolas, 13 Dean K. Stein, ex officio Stephanie Newman and Bruce H. Sklarew, Film Column Editor Photographer Mervin Stewart COPE: The Female Body: Integrating Psychoanalytic 15 Manuscript and Production Editors and Biological Concepts Malkah Tolpin Notman Michael and Helene Wolff, Technology Management Communications Candidates’ Council: Candidate Connection Hilli Dagony-Clark 16 The American Psychoanalyst is published quar- terly. Subscriptions are provided automatically to members of The American Psychoanalytic Asso- SPECIAL SECTION ciation. For non-members, domestic and Cana- dian subscription rates are $36 for individuals and Psychosis $80 for institutions. Outside the U.S. and Canada, rates are $56 for individuals and $100 for institu- Psychoanalytic Treatment of Psychosis: tions. To subscribe to The American Psychoanalyst, 17 visit http://www.apsa.org/TAPSUB, or write TAP Part Three of a Three-Part Series— Subscriptions, The American Psychoanalytic Introduction Michael Slevin and Eric R. Marcus Association, 309 East 49th Street, New York, New York 10017; call 212-752-0450 x18 or e-mail [email protected]. Working at the Limits of Human Experience Danielle Knafo 17 Copyright © 2012 The American Psychoanalytic Association. All rights reserved. No part of this Creativity in Psychosis Eric R. Marcus publication may be reproduced, stored in a 19 retrieval system, or transmitted in any form or by any means without the written permission of The Aspects of Child Analysis Anita Schmukler and Paula Atkeson American Psychoanalytic Association, 309 East 21 49th Street, New York, New York 10017.

23 Cases from the Frenkel Files: A Case of Matricide John C. West ISSN 1052-7958 The American Psychoanalytic Association does Poetry: From the Unconscious Sheri Butler Hunt not hold itself responsible for statements made in 24 The American Psychoanalyst by contributors or advertisers. Unless otherwise stated, material in The American Psychoanalyst does not reflect the endorsement, official attitude, or position of The Correspondence and letters to the editor should be sent to TAP editor, American Psychoanalytic Association or The Janis Chester, at [email protected]. American Psychoanalyst.

2 THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 FROM THE PRESIDENT

TIME TO RECONSIDER OUR Farewell after 10 Years LEADERSHIP MODEL A third point is that we will need mecha- of APsaA Leadership nisms in place to assure that we can succeed Warren R. Procci in advancing our profession. With some per- sonal misgivings, I think APsaA needs more This is my last to be a most powerful method, albeit in the than a “volunteer” president and officers. opportunity to right hands and most certainly with the right Yes, I am paid a stipend, but it is not at all write to you as patients. Most of us who have been doing this commensurate with the task, and certainly president of work for any length of time have seen analy- the nominal salaries of the other officers do APsaA. A role I sands who make spectacular life changes, so not at all match their efforts. The world our have much en- our first and overwhelming concern is still to organization faces has changed. Once upon a joyed. It has not do what we have not been able to do in our time volunteer leaders could devote a few been without its hundred-year-plus history, and that is to make hours a week to APsaA and enough new tribulations, but the “unconscious conscious,” make the public candidates and patients came our way so it has always aware that we are a powerful tool for a dis- that we continued to grow and develop. That Warren R. Procci been an honor tinct group of patients. time is not now. Just as we decided, and in to be a leader of an organization that sup- A second task necessitated by my first retrospect quite wisely so, to move from an ports so noble an endeavor as psychoanaly- point is also something we have not done, at administrative director to an executive direc- sis. I will use my valedictory to describe some least during my tenure. My services as an tor several years ago, I believe it is now time of what I have learned during my tenure APsaA leader began with six years as your to have officers who do not attempt to fit and provide some strong recommenda- treasurer (2002-2008), a job that delighted the work of APsaA into busy clinical and tions that I have for all of you, as well as for me. It is always said that if you look at an teaching schedules. This is our equivalent of my successors. organization’s budget, you will understand its “the kindness of strangers.” We can no longer rely on the “tired energies of tired men” and that of tired women as well. … it has always been an honor to be a leader of an I’ll make one addendum to the above organization that supports so noble an endeavor point. We need a board of directors that can be the appropriate balance and catalyst for as psychoanalysis. our officers. We need a board that can meet more than twice a year and whose meetings allow time for ample opportunity to consider PUBLIC AWARENESS AND purpose and priorities. Unfortunately, this some critical issues in detail. We also need STRATEGIC PLANNING was not so clearly the case with APsaA. I well opportunities for board members to bond First of all, we are still a very well kept recall my first Budget and Finance Commit- with each other and build relationships. This secret. I was recently a discussant for the tee meeting. We considered requests for can help undermine the kind of fractiousness USC Residents’ Movie Night, remarking on funding from our melting pot of committees. and minority group efforts that have ham- David Cronenberg’s film “A Dangerous It seemed to me almost a “first come, first pered board function in recent years. Our Method.” There is a powerful scene where serve” process in our consideration for fund- Council has been hampered by its current Ferenczi, Freud, and Jung are on the deck of ing. There was little or no overall planning on structure, rather than any lack of good will. As the George Washington, the steamer that how best to utilize our limited funds in the a result, it has not been able to do those brought them to the United States for their service of an overarching APsaA purpose. things so necessary for an optimally function- famous 1909 visit. As they look at the Statue This cannot continue. This is in large mea- ing board. of Liberty, Jung enthusiastically comments sure why I have devoted much of my energy We also need major changes in our TA that here is the future. Freud, ever the realist, to bringing the concept of strategic planning system, which is why I joined in support of even the pessimist, comments that they are to APsaA. We must, as an organization, the Pyles-Perlman-Procci Proposal to help bringing the plague. A hundred years later, together develop our priority activities and achieve that. And we need to move the eval- this ambivalence remains. I consider analysis those must be the functions that we fund, uation of individual members outside of our and we must make certain that they succeed. Association if we intend to maintain the func- We are facing the risk of becoming an irrel- tion. The divisiveness that this has caused is Warren R. Procci, M.D., is president of the evancy in the health care world and our tool corrosive and should not continue. American Psychoanalytic Association. is far too valuable to go unused. Continued on page 4

THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 3

Farewell Continued from page 3

A FINAL POINT Here is my final point for this note. In order to accomplish these goals, our current resources, especially our financial resources, are simply not adequate. We desperately Run-Offelections Election Results need a program of development. Several times during my various campaigns, I have COUNCILOR-AT-LARGE-ELECT spoken about this to members. In many cases, Hilli Dagony-Clark—592 many of them did not have the slightest idea what is meant by “a program of develop- Jeffrey K. Seitelman—620 Elected ment.” This too must end. While my term is over, my devotion to our The balloting was as follows: profession and to APsaA remains intact as Of the 1,224 valid proxies received, 1,212 ballots were does my interest and my vigor. I assume that valid to count towards the run-off election for the office I will find ways to continue to serve our Councilor-at-Large-Elect of councilor-at-large. Association and, despite having an avowed Jeffrey K. Seitelman Freudian orientation, I hope to see your new visions for psychoanalysis in America far sur- pass that of Freud’s.

Associating with APsaA

AFFILIATION CATEGORIES FOR EDUCATORS, STUDENTS, RESIDENTS, PSYCHOTHERAPISTS, RESEARCHERS Over the last several years, APsaA has developed a number of categories of affiliation to allow colleagues and friends interested in psychoanalysis to establish a tie to our organization. Associates of APsaA get more out of the national meetings, can start to network nationally with like-minded professionals, and contribute to the richness and vibrancy of the psychoanalytic community. Each Associate category is sponsored and supported by a committee of the American Psychoanalytic Association. EDUCATOR ASSOCIATE—available for educators interested in the integration of psychoanalytic principles and ideas into their teaching and scholarship. Full-time academics— teachers, administrators, professors, faculty members, deans, directors, and school counselors at all levels of education, preschool through university—are eligible. PSYCHOTHERAPIST ASSOCIATE—available for psychoanalytic psychotherapists with a minimum of a master’s level degree and licensed and/or certified by the state in which they practice. Individual Psychotherapist Associates are listed in a National Directory of Psychotherapist Associates, prepared annually. RESEARCH ASSOCIATE—available for research scientists, research oriented clinicians, and others with an interest in psychoanalytically oriented research. The sponsoring committee will facilitate presentations of research at psychoanalytic meetings. STUDENT/RESIDENT ASSOCIATE—available to medical students, psychiatric residents, psychology, social work, graduate, and undergraduate students of all academic disciplines. Standard benefits provided to Associates in all the above categories include reduced APsaA meeting registration fees, advance notification of meetings, and subscriptions to this publication. Reduced subscription rates to the Journal of the American Psychoanalytic Association (JAPA) are also available. Please note: Individuals who qualify for full APsaA membership are not eligible to join as Associates. Enrollment forms are available online at: www.apsa.org/Associates or contact APsaA’s National Office for more information: 212-752-0450 ext. 26. E-mail: [email protected].

4 THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 FROM THE BOARD ON PROFESSIONAL STANDARDS

four supervised cases while APsaA requires Historic Invitation three cases. While they both require a train- ing analysis which is concurrent with the to William Alanson course work and supervised clinical work, APsaA’s TAs are required to be certified in White Institute psychoanalysis, having been immersed for Colleen L. Carney and Beth Seelig 3600 hours with four non-psychotic cases for five years post graduation. WAWI training At the January 2012 APsaA National some signifi- analysts are appointed after a minimum of Meeting at the Waldorf Astoria, the Board cant ways, is seven years post graduation, and go through on Professional Standards voted unani- an equiva- an internal vetting process comparable to mously to extend an invitation to the Wil- lent model our combined certification and training ana- liam Alanson White Institute (WAWI) to of psycho- lyst evaluation process, not unlike our new become an approved institute of the Ameri- analytic edu- developmental pathway process to certifica- can Psychoanalytic Association. This is a his- cation and training, a variation of the tion/TA appointment. toric decision for APsaA and one that has Eitington model. Most importantly, through In APsaA, supervising analysts have histori- the overwhelming support of the members these shared experiences the participating cally been appointed using the same criteria of the Committee on Free Standing Insti- analysts have developed collegial relation- and process as the TA appointment. How- tutes (CAFI), the Coordinating Committee, ships based on mutual respect and a deep ever, in our new standards we have separated and the Executive Council. As we await the commitment to psychoanalysis. these functions and are beginning to think response from WAWI, it might be helpful about and develop specific criteria for super- for our members to know how we got here, SIMILARITIES AND DIFFERENCES vising analysts that take into account the what it would mean for our organization, We are aware that while many of our central educative and synthesizing role of the and what it could mean for the profession members are excited about the opportu- supervising analyst. At WAWI, analysts are of psychoanalysis. nity that this invitation holds, others are qualified to be appointed as supervising ana- For more than 10 years, CAFI, a commit- puzzled: How could WAWI become an lysts five years post graduation and through a tee of BOPS, has met at least yearly with approved institute of APsaA when they separate interview/examination process. representatives of WAWI at our national meeting to explore the possibility of a formal affiliation between the two organizations. There is no question that the most controversial and confusing During that time, there have been represen- difference between these two training models has to do with tatives from WAWI serving as non-voting members on both the Board on Professional required frequency of analytic sessions and the use of the couch. Standards and the Executive Council of APsaA; members of our Association have been invited speakers at WAWI and many of have training standards that are different FREQUENCY their analysts have been featured speakers from our own? It is important to clarify that There is no question that the most contro- and presenters in our educational programs. some of their standards differ from ours but versial and confusing difference between In 2008, a Task Force on Training Models others are strikingly similar and even identical these two training models has to do with (TFTM), made up of members of WAWI to APsaA’s. For example, the admission crite- required frequency of analytic sessions and and members of APsaA was created to ria, the requirement of a training analysis, the use of the couch. It is probably well study the similarities and differences of the experience with at least three different known that the WAWI model requires their education and training in psychoanalysis. supervisors as well as experience with analy- candidates, as well as the control cases that The TFTM made its report to BOPS in Janu- sands of both genders are all identical they see, to be in analysis a minimum of three ary 2009. The TFTM concluded, and BOPS requirements in both APsaA and WAWI. to five times per week; these analyses are has agreed, that WAWI, though different in However, the training models do differ in conducted with the patient on the couch or some significant ways. face-to-face, contingent on diagnostic impres- APsaA’s didactic curriculum involves sions, treatment strategy, and the clinical judg- Colleen L. Carney, Ph.D., is chair of the roughly 450 hours of class time, spread over ment of the SA and the candidate. Board on Professional Standards, and Beth four to five years, while WAWI’s curriculum WAWI also permits the inclusion of bor- Seelig, M.D., is secretary of APsaA, a member includes 540 hours of class time distributed derline and psychotic cases as training cases. of CAFI, and was co-chair of the TFTM. over four to six years. WAWI requires at least Continued on page 27

THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 5 Annual Meeting in Chicago 2012 Annual Meeting Highlights June 12–17 Christine C. Kieffer

Chicago, Chi- In addition to a lecture by cago: It could be Bhabha, there will be a presen- your kind of town, tation by the cultural anthro- too. The 101st pologist, Richard Sweder, as Annual Meeting well as commentaries by Adri- of APsaA has enne Harris, Robert Paul, and much to offer its Carmela Perez. This University members, as Forum will challenge partici- well as our col- pants to confront their biases leagues and stu- toward foreign customs, as well as examine PANELS AND CLINICAL WORKSHOPS Christine C. Kieffer dents from other how the dominant group manages cultural The large panels that delve into current organizations. In addition to a stimulating practices of outsiders (immigrants), and will theoretical controversies and offer a variety program to deepen our understanding of also discuss how minorities resist and adapt of clinical perspectives are enduring features psychoanalysis, there will be valuable oppor- to pressures for assimilation. of our conferences. This June, five offerings tunities to reconnect with colleagues and to There will be a panel that focuses on will highlight some of the cutting-edge issues make new friends, to network and to col- aspects of analyzing the children of immi- of contemporary psychoanalysis. Friday laborate. Opportunities for learning and grants featuring Stanley Coen, Aisha Abbasi, afternoon’s controversial panel on “Sexual earning continuing education credits will be Shahrzad Siassi, Peggy Hutson, and Salman Aberrations: Do We Still Need the Concept? offered in large panels, symposia, and the more intimate clinical workshops and discus- sion groups. The workshops and discussion In addition to a stimulating program to deepen our groups will allow participants to enhance clinical skills and share work experiences understanding of psychoanalysis, there will be valuable with one another across a broad spectrum opportunities to reconnect with colleagues and to make of colleagues, including allied mental health professionals, candidates, students, educa- new friends, to network and to collaborate. tors, and scholars.

CONFERENCE-WITHIN-A- Akhtar. Their presentations will examine If So, Then When and Why? If Not, Why CONFERENCE: IMMIGRATION how similarities and differences between Not?”, will feature Donald Moss, Sydney At this conference, the Program Commit- patient and analyst aid, hinder, or defend Phillips, Richard Simpson, and Avgi Saketo- tee is experimenting with a mini-theme that against the analytic work. A special panel poulou. Each will present position state- will highlight aspects of immigration—theo- on child and adolescent psychoanalysis will ments, and then examine specific issues in a retical, clinical, and sociocultural—in panels, take place Saturday morning entitled, series of clinical vignettes. workshops, and symposia throughout the “Mothers, Children, and Immigration: Psy- Panel II will examine “Gay Male Desires meeting. We are pleased that the world- choanalytic Perspectives on Immigration.” and Sexualities: Clinical Encounters in the renowned scholar, Homi Bhabha, will present which will feature Monisha Akhtar, Mali 21st Century” and will feature Gary Gross- his work in the University Forum: “Immigra- Mann, Benjamin Garber, Bhaskar Sripada, man, Paul Lynch, Gilbert Cole, and Lynne tion: Collision, Assimilation or Integration?” and Kerry Kelly Novick. These presenters will Zeavin, who will discuss the varied experi- offer theoretical speculations on the struc- ences and complaints of gay male patients. Christine C. Kieffer, Ph.D., is on the faculty ture of immigrant parenting and the dynamic This panel will consider the psychological of the Chicago Institute for Psychoanalysis, of parent-child interaction. The presenters impact of contemporary culture on gay where she teaches and supervises. She also will assert that the challenges faced by an male identity, desires, and sexuality in the is a member of the APsaA Program Committee immigrant family may induce the clinician to context of emotionally challenging analytic as well as a member of the editorial board make modifications and adjustments to clin- encounters. of JAPA. ical technique. Continued on page 7

6 THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 Annual Meeting in Chicago

As described above, the third large panel will chaired by Alan Pollack; Dale Gody will pres- community-based psychoanalysis and will address various technical aspects of analyzing ent clinical material and the discussant will be examine the commonalities and differences the children of immigrants, with special consid- Jose Saporta. between clinical psychoanalysis and commu- eration given to realistic problems of immigra- I will chair the Child and Adolescent Two- nity-based interventions. He will make a case tion, the need to aid the integration of the Day Clinical Workshop. Daniel Prezant will for the utility and relevance for this subspe- patients’ origins with that of their new home- present case material and Phyllis Tyson will cialty of psychoanalysis. land, as well as examine how similarities and serve as the discussant. Jonathan Lear, a distinguished philosopher differences between patient and analyst may and psychoanalyst, will discuss his recent facilitate or interfere with therapeutic action. PLENARIES, SYMPOSIA, book, A Case For Irony. He will consider how Since the third panel takes up a specific MEET-THE-AUTHOR, AND MORE humans unconsciously pursue life plans that class of issues that may even lead to a clinical This June, Warren Procci will chair the are of essential importance to them but impasse, perhaps it will prepare us for the Presidential Symposium that features Con- which are often at odds with their conscious fourth panel: “How to Help Get Stuck Analy- gressman Patrick J. Kennedy and the “One understanding of what matters. Lear also will ses Unstuck,” a program that will feature the Mind for Research Campaign.” The project’s explore the concept of irony and how it can clinical work and wisdom of Rosemary Bal- current mission is to improve treatment of be clinically useful. sam, Dionne Powell, Francis Arnold, Stanley traumatic brain injury and post-traumatic A special Candidates Forum, “Developing a Coen, and Mitchell Wilson. The panelists will stress disorder among veterans. To learn Psychoanalytic Mind and Identity” will offer first focus upon three clinical vignettes of more about this effort see the box below reflections by Carlos Almeida, Deisy Boscan, analyses that seem to have reached impasses and visit http://1mind4research.org. Robin Deutsch, Ilene Dyller, Navah Kaplan, and will demonstrate the process by which We are proud to present as this year’s and Vanessa Sinclair. The panelists will describe the analyst struggled to get the analytic cou- plenarist, Stuart Twemlow, who will give an personal and clinical experiences that were ple unstuck and moving once again. The pan- address on “Community-Based Psychoanal- central in shaping their identity as analysts. elists will provide frank discussions of what ysis.” Twemlow will discuss the history of Continued on page 8 they had to manage in themselves and in their patients in order to move the treatment forward. The fifth panel, also described above, explores the triadic relationship of mother, child, and immigration. In each of these panels, there will be ample opportunity for discussion with pan- elists, with the formal presentations serving as a springboard for spontaneous dialogue among the panelists as well as engagement with the audience. The Two-Day Clinical Workshops continue to be among the meeting’s most popular and well-attended events. This June, we will fea- ture three clinical workshops that are part of a “Series in Analytic Process and Technique” and one workshop on “Psychotherapeutic Technique and Process.” The first workshop will be chaired by Irene Cairo; the presenter will be Alison Philips and the discussant will be Danielle Quinodoz. The second workshop will be chaired by Sharon Blum; the presenter and discussant are yet to be determined as TAP goes to press. The remaining workshop in the analytic series will be chaired by Rich- ard Zimmer, and the discussant will be Steven Cooper (the presenter is yet to be deter- mined). The clinical workshop on “Psycho- therapy Technique and Process” will be

THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 7 Annual Meeting in Chicago

against foreign customs that feel repugnant University Forum on Immigration to the dominant majority when they are Stanley Coen imported into our liberal democracies. He has described Norway wanting to place young The University Forum, Friday, June 15, from especially as it children in foster care because their South 2:00-5:00 p.m., “Immigration: Collision, Assim- is expressed in Asian Indian parents slept in the same bed ilation, or Integration?” complements the literature. His with them and fed them hand to mouth. Or adult and child/adolescent panels on immi- 1994 book, The he dares us not to immediately regard female gration, the theme for this part of our meet- Location of Cul- circumcision as genital mutilation when ing. We are delighted that Homi Bhabha and ture, is the bible sought by young women in the United States Richard Shweder will participate. Bhabha is of immigration from, say, Sierra Leone, Sudan, or Somalia. the Anne F. Rothenberg Professor of the studies. He is Adrienne Harris, psychoanalytic writer and Humanities in the Department of English, wonderful at cultural commentator, will be the discussant. director of the Humanities Center, and senior describing “walk- She has taught and written about the work Stanley Coen advisor on the humanities to the president ing the streets of Homi Bhabha. Harris is affiliated with the and provost of Harvard University. of Bombay” or commenting on the writings New York University Postdoctoral Program He is one of the world’s most influential of Salman Rushdie, Toni Morrison, or Derek in Psychoanalysis and Psychotherapy. Her writers and speakers on immigration, Walcott. How does the dominant group presentations at APsaA have been outstand- manage the cultural practices of outsider ing. Robert Paul will moderate and comment. immigrants? How do the outsiders resist and He is Charles Howard Candler Professor of Stanley Coen M.D., is a training and adapt to pressures for assimilation? Anthropology and Interdisciplinary Studies at supervising analyst and senior associate Richard Shweder is the William Claude the Graduate Institute of the Liberal Arts at director for academic affairs at Columbia Reavis Distinguished Service Professor of Emory University and a practicing psychoan- University. Human Development in the Department of alyst. Carmela Perez, the reporter, from the Adrienne Harris, Ph.D., and Robert Paul, Comparative Human Development at the Institute for Psychoanalytic Education affili- Ph.D., contributed to this article. Nancy University of Chicago. He is an astute, psy- ated with the New York University School of Chodorow, Ph.D., and Jeffrey Prager, chologically minded cultural anthropologist Medicine, has commented on issues related Ph.D., helped select speakers. who challenges us to confront our biases to immigration for public media.

Meeting Highlights from conscious processes—are supported Contributions to Psychoanalytic Views of Continued from page 7 by experimental evidence. Humankind.” In addition, there will be a workshop, And, of course, there will be 48 discussion We are pleased to feature a film workshop “Website Marketing to Grow Your Practice,” groups available, where participants can that examines the Ingmar Bergman film, Per- with Mark Smaller, William Braun, Gail Saltz, explore a wide array of topics relevant to sona, and includes a discussion by Kenneth and Greer Van Dyck. This workshop will offer practice, theory, and applied psychoanalysis. Newman and Bruce Sklarew. The presenters participants a basic understanding of website These will take place during Wednesday and will look at the variety of defenses against marketing and how to make use of it. Thursday of the meeting, throughout the day merger and homoeroticism. The Committee on Lesbian, Gay, Bisex- and evening. We also will offer a symposium on psy- ual, and Transgender Issues will present a choanalysis and neuroscience, “How a workshop, “Gender Shock: Do Not Believe TO LEARN MORE Comprehensive Psychoanalytic Theory Can What You Think,” co-chaired by Susan The Annual Meeting includes much more Integrate Clinical Observations and Neuro- McNamara and Patrick Haggard. The pre- than these highlights and we urge you to science Experiments in the Investigation of senters will be Robert Galatzer-Levy and examine the entire meeting brochure which Unconscious Processes and Primary Process Heidi Nast. is available online, through the APsaA website. Thinking.” This symposium, chaired by Please note that pre-registration closes on George Fishman, will feature a presentation TICHO MEMORIAL LECTURE May 21. If this will be your first time at an by Howard Shevrin that will demonstrate Nathan Szajnberg has been chosen to APsaA meeting, we recommend that you visit how two basic assumptions—the existence give this year’s Ticho Memorial Lecture. His http://apsa.org/Meetings/Making_the_Most_ of the unconscious and that unconscious talk is entitled “Mimesis: Representations of of_Scientific_Meetings_aspx, which offers a processes follow different rules of thought Inner Life in Western Literature and Their useful guide for new attendees.

8 THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 Annual Meeting in Chicago Come to Chicago 101st APsaA Annual Meeting June 12–17 Caryle Perlman

There is such a variety of wonderful things The Art Institute, in the Loop, is open to see and do in Chicago. At the risk of luring until 8:00 p.m. on Thursday night. Terzo you away from the meetings and out into the Piano, the beautifully situated restaurant city, I will share a few of my favorite things in the Modern Wing, is open for lunch that may be new for you. every day and for drinks and dinner on One block west of State Street is Dear- Thursday. There are two gardens on born Street, which has several incredible out- Michigan Avenue, one on each side of Flamingo, a Calder stabile door art pieces. Going north from Jackson the museum entrance, for sitting, read- Boulevard, you will come upon Flamingo, a ing, and talking. These are quiet, replen- If global warming has brought summer Calder stabile, Four Seasons, a Chagall mosaic, ishing oases. by mid-June, you will have several swimable and a monumental sculpture of a horse by Going south from the Art Institute is the beaches on the North Side. The Oak Street Picasso. Across Washington Street, near the Chicago Architecture Foundation, on the Beach, at the north end of Michigan Avenue, is Picasso is a smaller sculpture by Miró. Walk a corner of Jackson and Michigan. Here you a popular beach with a beachfront restaurant. can browse for gifts and There is a smaller beach at Navy Pier, where books about Chicago several boat cruises set sail on Lake Michigan. architecture and buy tick- ets for walking tours and A CITY OF NEIGHBORHOODS the highly recommended Chicago has been called a city of neigh- architectural boat tour. The borhoods and I would encourage you to Segway rental store is next visit some of them. On the North Side, door. I have not tried it yet, River North is home to a collection of art but if you’re brave you can galleries. Wicker Park, Bucktown, Logan take a tour around the Square, and Noble Square are hip neighbor- Loop on a Segway. hoods in various stages of gentrification. In Grant Park there are Continued on page 10 more outdoor sculptures, including a bust of Sir Four Seasons, a Chagall mosaic Georg Solti and a statue of Lincoln by Saint-Gaudens. block west to Clark Street and another block A little farther on, just south of the Adler north, and you will find Monument with Stand- Planetarium, is Northerly Island, which was ing Beast, by Dubuffet. The Dubuffet stands in home to Meigs Field Airport until our former front of the Thompson Center, a state office mayor, in a gloriously imperious moment, had building designed by Helmut Jahn. All these the runways torn up. Now it is a wildflower sculptures may be seen at any time of day or and bird sanctuary. Northerly Island is about night. Although children occasionally climb on a mile walk from the Palmer House. the Picasso and hide inside the Dubuffet, it Going north from the Art Institute on fills me with pleasure and pride that these Michigan Avenue, you will find the “Miracle sculptures are never vandalized. Mile,” our upscale shopping area, and the Museum of Contemporary Art (MCA). In Caryle Perlman, M.S., a training and addition to an interesting collection, the supervising analyst, is chairman of the Local MCA has an attractive terrace restaurant and Arrangements Committee for the 101st Annual an intriguing shop. The MCA is open late on Meeting in Chicago. Tuesday night. Horse by Picasso

THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 9 Annual Meeting in Chicago Come to Chicago Lloyd Wright. You Continued from page 9 can visit his home and studio, and take They are full of unique shops, boutiques, and a walking tour to enlivening vibes. Also on the North Side are see the exteriors of Boys’ Town, a heavily gay neighborhood, and several of his other Andersonville, a former Swedish neighbor- buildings. Ernest hood with a Swedish museum. Anderson- Hemingway’s boy- ville became a lesbian neighborhood, which hood home is also stabilized the area and led the way for gen- open for tours. trification. Great Lakes Pizza, which GQ called the best pizza in America, is here. All CHICAGO CUBS of these neighborhoods have good restau- AND CHICAGO rants and lively bars. Farther north, at the SYMPHONY Evanston/Wilmette border but still accessi- ORCHESTRA ble by public transportation, is a Bahai Tem- The Chicago Monument with Standing Beast, by Dubuffet ple, one of the largest and grandest. Cubs will be in On the South Side are Chinatown, with town the week of the meetings. Although the season on Wednesday, June 13, at 6:30 p.m. good restaurants and grocery stores, and Cubs remain incredibly popular and a lot of You can buy tickets for the better seats but Pilsen, a former Czech neighborhood that is games are sold out, you can get tickets from there are some free seats and seating on the now largely Mexican and is becoming an art- ticket agencies or before games from people lawn is always free. (See box on next page.) ists’ community. If you go to Pilsen, don’t miss on the street. Near Wrigley Field is Grace- Chicago has many famous restaurants and the National Museum of Mexican Art. land Cemetery, a green and enjoyable place several more excellent but not yet famous The West Side is largely residential and to walk. It is the final resting place of many ones. If you are pining to have dinner at one poor, and does not have as many attractions famous Chicagoans; Marshall Field, George of the hot restaurants, make your reserva- as the rest of the city. Perhaps the most nota- Pullman, Ludwig Mies van der Rohe, Potter tions now. It is already too late to get into ble is the Garfield Park Conservatory, the and Bertha Palmer are buried there. Next or Alinea, which are currently the hot- largest in the New World and second only to Chicago is famous for jazz. I will mention test places. Check out Time Out Chicago and the Royal Kew Gardens. To visit Garfield Park, only a few of the venues: the Green Mill Chicago magazine for restaurant reviews and you can take the on the North suggestions. Both of these are available on CTA Green Line on Side, Checker- line. (Time Out Chicago is also a good source the way to Oak Park. board Lounge of information for music and theater.) We Oak Park, the suburb in Hyde Park have innumerable ethnic restaurants that are immediately west of (not the same the footprints of the different immigrant Chicago, is famous as building but groups that have settled in the city, such as the home of Frank the descen- Chinese, Czech, German, Indian, Italian, Japa- dent of the nese, Mexican, Pakistani, Polish, Russian, Thai, place that Vietnamese, along with others. Many Chicago Muddy restaurants participate in Open Table, so it is Waters made easy to make reservations online. famous), and Chicago is as safe but no safer than most Jazz Showcase. big cities. You just need some street smarts If you prefer and have to pay attention to your surround- classical music, ings. All of the suggestions here are accessible Maestro Muti will by public transportation and it is easy to get be conducting the around the city that way. At night, taxis are Chicago Sym- sensible for return trips back to the hotel. phony Orchestra Our meetings will take place on some of the the week of the longest days of the year so we will have lots meetings. The of daylight. I hope you will take advantage of Grant Park Music it and enjoy Chicago’s lakefronts, parks, and Garfield Park Conservatory Festival opens its other attractions.

10 THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 Annual Meeting in Chicago

Concert Tickets The Grant Park Orchestra will be performing on Friday, June 15, at 6:30 p.m., and Saturday, June 17, at 7:30 pm. If you’re interested, you will have an opportunity to purchase seats for the Saturday concert as part of pre-registration.

Thursday, June 14, 2012 7:30-10:30 p.m. Persona Chair: Bruce H. Sklarew Presenter: Kenneth Newman

Bergman’s masterful 1966 film visualizes the intimacy between Elizabeth (Liv Ullmann), an actress who becomes mute while playing Electra, and her nurse, Alma (Bibi Andersson). Although the narrative structure is seemingly simple, Persona is dense and enigmatic. The film, like the dream, emphasizes images, rhythms, and choreographed movements rather than dialogue. Susan Sontag called it “a riddle without a sphinx.” It is a meta-film, a film about filmmaking.

Saturday, June 16, 2012 2:00-5:00 p.m. Intergenerational Transmission of Trauma in Incendies Chair and Presenter: Bruce H. Sklarew

Incendies, directed by Denis Villeneuve, was based on the play Scorched by Wajdi Mouawad. This delicate and fierce film intrigues the audience with a profound puzzle of mythic dimensions. Set in contemporary Montreal and the Lebanese civil war, it challenges us intellectually and leaves a haunting impact. The traumatic past of the Lebanese mother is revealed to her young adult twins as she sends them on a shattering mission to her homeland. The scorched earth violence is a metaphor for traumatic experience, scorched psyche, rage, and wishes for retaliation of the mother. After the film, there will be a roundtable discussion.

THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 11

Contacting the National Office

The American Psychoanalytic Association 309 East 49th Street New York, NY 10017 Phone: 212-752-0450 Fax: 212-593-0571 E-mail: [email protected] World Wide Web Site: http://apsa.org/

National Office Voice Mail Extensions Chris Broughton x19 Brian Canty x17 Sherkima Edwards x15 Tina Faison x23 Carolyn Gatto x20 James Guimaraes x12 Stephanie Kunzmann x28 Geralyn Lederman x29 Nerissa Steele-Browne x16 Dean K. Stein x30 Debbie Steinke Wardell x26

How to Participate in APsaA’s Scientific Program

Scientific papers for oral presentation must be no longer than 18 pages and timed for 40 minutes reading time. Submit all manuscripts by electronic mail and please include an abstract. Send one blind paper, with all references to the author deleted. The first page of the manuscript must show only the author’s name, address, phone number, and the title of the paper. The author’s name should not appear on any subsequent page. JAPA has right of first refusal on any paper accepted for presentation. The paper cannot have been accepted or be under consideration for publication by another journal. Panel proposals should be two pages maximum. The proposal should contain a description of the format, the objective of the panel, and names of possible participants (chair, panelists, discussant, if any). The Program Committee chooses panels one year in advance. Discussion group proposals should be two pages maximum. Decisions concerning new discussion groups are made based upon how subject matter relates to what is already taken up in existing groups and on space availability. Symposia explore the interface between psychoanalysis, society, and related disciplines, attempting to demonstrate how psychoanalytic thinking can be applied to non-psychoanalytic settings. Symposia must be in talking points format, 10 to 15 minutes per presentation (no papers read), with a minimum of 15 minutes for audience participation with emphasis on audience interaction. Submit a brief (two pages maximum) proposal outlining rationale, program format, and suggested speakers. The deadline for submission of panel proposals is October 1 for the National Meeting (January) and March 1 for the Annual Meeting (June). The deadline for all other submissions is May 1 for the National Meeting (January) and December 1 for the Annual Meeting (June). Address correspondence to Scientific Program Submissions, American Psychoanalytic Association, 309 East 49th Street, New York, New York, 10017 or email [email protected].

12 THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012

F I L M

Parenting Lessons from Mad Men’s Betty Draper Frances Stephanie Newman Bruce H. Sklarew, Film Column Editor

Who knows mother of “bebe.” better than a And those who psychoanalyst watch the televi- that infants and sion show Mad children need Men would not love, consistency, be surprised to know there is yet another and contain- incarnation; one long familiar to psychoana- Joan Crawford’s infamous rant (“NOOO ment if they are lysts: the Wire Mommy. WIRE HANGERS!”) appears tame in com- to thrive? What- In a new book, parison to Betty’s harsh invective. ever our per- Mad Men on the Although we know Betty to be a fictional Stephanie Newman sonal theoretical Couch (St. Martin’s character, failures in maternal empathy are an bent (“good enough” parents, attunement in Press), I have tried all too common occurrence in real life. Harry the infant-parent dyad, a steady holding envi- to show that the Harlow, a prominent psychologist/researcher ronment, or mirroring with the proper inter- fictional characters of the Mad Men era, explored the compo- section of empathy and limit setting, to toss of this popular tele- nents of maternal love by looking at the out a few well known concepts), most of us vision show about effect of deprivation on rhesus monkeys emphasize the critical importance of the life in the 1960s (chosen because they are known to display early “maternal” environment. advertising world similar emotions to people). In a famous Outside of our field the debate about the can be examined Continued on page 14 best way to parent is eternal. Recent books in and better understood when viewed the popular literature have introduced us to through the lens of analytic psychology. The maternal archetypes as varied as Amy Chua’s book is written for anyone who enjoys dis- uncompromising Tiger Mom and Paula secting the show—professional clinician or Druckerman’s balanced and at ease French armchair psychologist. One of Mad Men’s most psychologically complex characters is Betty Draper Frances, Stephanie Newman, Ph.D., a psychologist ex-wife of Don Draper, unhappy housewife, and psychoanalyst, is the author of Mad Men and mother of three. Betty is a maternal on the Couch (St. Martins-February 2012), train wreck. During the early seasons she is and a faculty member of the Institute for portrayed as an extremely cold and neglect- Psychoanalytic Education, affiliated with ful mother. She allows her daughter, Sally, to the School of Medicine, NYU. run around the house, head and body fully Bruce H. Sklarew, M.D., an associate submerged beneath a plastic dry cleaner’s editor and co-founder of the award-winning bag. She smacks her daughter and snaps at Projections: The Journal for Movies her son, “Go bang your head against the and Mind, organizes the film programs wall.” Though Betty’s misattuned and cruel at meetings of the American Psychoanalytic antics are painful to watch, many of us can- Association and has co-edited two books not stop craning our necks to view the on psychoanalysis and film. Drapers’ twisted emotional wreckage. Even Betty Draper Frances

THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 13 FILM

Parenting Lessons time with Gene. And we can Continued from page 13 surmise from her critical and apparently unfeeling interac- experiment, Harlow separated infant mon- tions with her older children keys from their mothers, placing them in two that she was not a terribly distinct groups: some fed by “mothers” cov- responsive caregiver who could ered in soft cloth, others by “mothers” made easily tune in to her babies’ of wire. All of Harlow’s monkeys ate and emotional needs. grew. But regardless of whether they had Seeing Bet- been fed by a cloth or wire mother, all chose ty’s cold and to cuddle with the cloth ones. And those critical behav- raised by wire mothers had difficulties in iors, it becomes from home, and once even mastur- their interactions with peers and could not apparent that bates at a sleepover with friends. soothe themselves in scary situations. she did not Eventually Betty is concerned Harlow’s films are painful to watch. Gen- receive ade- enough to follow her second hus- eralizing to human beings, he concluded that quate nurturing band’s advice and sign Sally on for loving physical interactions were necessary as a child, and treatment with a child analyst. This in the earliest months of life, and that with- that this early treatment is depicted in a positive out proper emotional engagement, babies— neglect has left her emotionally unavailable, way during the show’s fourth season. Sally is monkey and human—would forever be and greatly limited in her ability to comfort making strides and moving forward; she impaired; solid early attachments and and nurture her kids. And in fact, we know appears to have attained a more age appro- responsive caregivers were necessary in Betty’s mother was prone to hit and criticize priate level of development, and to have order for individuals to thrive as healthy her. She had years before given up a coveted overcome as best as anyone can, her early adults. Harlow also found that monkeys who job as a drafting engineer. Perhaps she years with a wire mommy. were emotionally neglected as infants could resented her daughter? The Drapers’ pre- As analysts we know that the emotional not adequately nurture adolescent Sally connection between mother and child is cru- when they became par- has certainly cial. But what goes on emotionally among par- ents. At least one adult suffered—she is ents, children, and caregivers in the earliest who had been raised by given to emo- months and years needs to be part of the a wire mommy bit off tional outbursts, public’s ongoing discussion—not just a corner- many of the fingers and to running away stone of our professional discourse. toes of her own infant when they were left alone together. Mad Men’s Betty Draper Frances repre- sents our fantasies of a wire mother. She is unable to provide the emotional support and loving interactions her children desperately need. She rarely displays empathy for Sally, Bobby, or Gene, and is usually intolerant and critical of their feelings. Betty routinely strikes her kids instead of verbally engaging them, spends little time parenting, and leaves most of the caregiving to her maid, Carla. She seems to derive no pleasure from interacting with her children, or from seeing them grow and develop. In fact, she mostly just wants the young Drapers to go to their rooms. While we did not see Betty parent Sally and Bobby in infancy and toddlerhood, it also appears that she does not spend much

14 THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012

COPE The Female Body: Integrating Psychoanalytic and Biological Concepts Malkah Tolpin Notman

When the COPE study group, The Female substance abuse. and her body. It has emerged from our dis- Body: Integrating Psychoanalytic and Biologi- Depression and cussion of clinical vignettes in which every- cal Concepts, started in 2006, the goal was its relationship thing that is known biologically about a to provide greater awareness of the female to female body patient is presented and then everything body and biological processes in psychoana- functions have that is known psychoanalytically about the lytic work, to better understand the interface also been dis- same patient is described. We then link the of psyche and soma. Psychoanalysis had, it cussed. Medical various elements of the somatic self to the seemed, moved away from the body, drives, illness, past or psychodynamic understanding we have of and sexuality. Although the expression of present, and the patient. feelings and thoughts in somatic ways was pain affect the Except in the case of “psychosomatic“ disor- Malkah Tolpin Notman an important aspect of Freud’s descriptions sense of com- ders, the somatic side of a woman’s experience of hysterical patients, and somatization is an fort with one’s body. often seems absent from the clinician’s think- important concept in medicine, it has not These presentations, with both current sci- ing and case formulation. Often an approach is been prominent in psychoanalytic teaching. entific data and clinical examples, have taken in which the biological and psychologi- We have been developing some ideas as to focused on how particular body functions cal understandings are seen as parallel tracks what issues are important to know and teach. and conditions influence a woman’s self con- that run adjacent to one another but repre- The integration of bodily changes and psy- cept and how her self concept, which can sent understandings from different paradigms chological phenomena has proven to be a include feeling beautiful or not, feeling old, or and cannot intersect in a clinically useful or complex task. There are complex meanings feeling athletic, influences body functioning. meaningful manner. Clinical data indicate that to “biological” and clinicians have different Although the presentation of research and these lines do relate closely with one another. levels of knowledge about physiological pro- theoretical ideas has been useful, clinical case Sometimes developmental experiences are cesses. In our discussions biological has come discussions have proven to be the most pro- critical. For example, masochistic traits are to mean more specifically “bodily.” ductive format for this group. often associated with having experienced Over the last two years, we have heard We discussed one clinical example of a painful medical procedures in childhood. scientific presentations that include current woman who, after her breast augmentation, These moments of virtual intersection of data about hormonal changes and their rela- felt that her breasts belonged to her mother. the biological paradigm and the psychoana- tionship to affective states and presentations Another patient expressed her experience lytic paradigm are important and potentially about biological and psychoanalytic aspects and response to a long period of sexual valuable in understanding psychosomatic of female body experiences, such as men- abuse, which started in early childhood, manifestations. These moments of virtual struation, pregnancy, menopause, and surgical through various bodily sensations, such as interaction may not be easily identifiable. modifications, such as breast augmentation. feeling she was choking and feeling that she Careful attention to bodily data, including We have also considered somatic experi- needed to be heavy so her legs always medical illness, juxtaposed with the patient’s ences, including sleep, sexuality, appetites, and touched. Another example was a woman subjective experience leads to the patient’s who was preoccupied with her body: “All she somatic self. Malkah Tolpin Notman, M.D., is a graduate talks about is her body.” We hope to refine our approach to case of the Boston Psychoanalytic Institute (BPSI). material in such a way as to bring to analytic She is a training and supervising analyst SOMATIC SELF training and to the continuing education of at BPSI, a clinical professor of psychiatry at A broad concept that has evolved from analysts a conceptual framework that Harvard Medical School, and senior faculty at our discussions is the “somatic self.” This includes the integration of biological and Cambridge Hospital/Cambridge Health Alliance. concept captures a woman’s sense of self psychological data.

THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 15

Candidates’ council Candidate Connection Hilli Dagony-Clark Hilli Dagony-Clark

The various branches of the Candi- training. More specific goals will be sharp- to her contributions. As in the past year, dates’ Council (CC) have continued to ened during the meeting. This group will the newsletter will continue to be printed expand in an effort to connect colleagues produce a publication and/or presenta- electronically. from across the country, and strengthen tions at its conclusion. In order to increase the presence of the internal sense of analytic identity and In the continued spirit of innovation in candidates on the APsaA website, and cohesion among our active members. candidate involvement, Navah Kaplan has provide easy access to information about Since the Candidates’ Council is now in an submitted a proposal to the American the Candidates’ Council, chair of the Digi- election year, I am enthusiastically encour- Psychoanalytic Foundation for funding for tal Media and Communications Commit- aging you to run for office of the Candi- the Candidates’ Scientific Paper Prize that tee, Vanessa Sinclair, has been working dates’ Council’s Executive Committee. would enlarge the scope of the program. tirelessly with the National Office over Positions include president-elect, treasurer, The proposal added the component of a the course of this academic year. At the and secretary. These positions not only Candidates’ Writing Workshop to further time of this writing, the staff at headquar- provide candidates with an opportunity the aim of helping candidates learn to ters is putting up a new link within the to sample the organizational life of APsaA write analytically. Monetary awards will main home page with updated informa- but also to closely bond with and help a continue for the winner and runner-up of tion on the Candidates’ Council. Sinclair is like-minded community of colleagues in a Candidates’ Scientific Paper Prize. also working to expand communication training. Please feel free to inquire more After four years as CC Program Com- of candidates through the use of Ning, a about these positions from me, or any mittee chair, Phoebe Cirio will step down social networking platform designed to other member of the Candidates’ Coun- from this position after the June meeting. inform candidates of one another’s prac- cil’s Executive Committee, including Presi- Her contributions to the scholastic branch tices. As the use of technology expands, dent-Elect Navah Kaplan, Treasurer Jamie of the Candidates’ Council have been these services become increasingly crucial Cromer, and Secretary Valerie Golden. outstanding and greatly appreciated. Sarah to maintain contact, foster communica- Election ballots will be sent out in the fall, L. Lusk, who is an adult candidate at the tion, and learn about our colleagues’ work. and candidates for office will be asked to Psychoanalytic Institute of New England The CC Executive Committee has also make their position statements during the (PINE) and child candidate at the Boston been working to further the candidate Candidates’ Council meeting this spring. Psychoanalytic Society and Institute (BPSI), cause. In addition to her work on the Our committees have been working will take her place. Lusk will be an excel- Candidate Paper Prize, Navah Kaplan has over the past several months to help fos- lent addition to the Candidates’ Council’s been helping to coordinate the candi- ter candidate involvement and empower- Steering Committee, and I welcome her date party for the June meetings. Jamie ment. I am thrilled to announce the launch to her new role. Cromer has been working on the Travel of the first candidate study group, chaired The Candidate Connection Newsletter is Grant Program, which will be awarded by Candidates’ Council’s education chair, also seeing a shift in leadership. Editors to several candidates during the Annual Caryn Schorr, and sponsored by the Michael Garfinkle and Jamieson Webster Meeting in Chicago. Valery Golden has Committee on Psychoanalytic Education. stepped down at the end of last year. I continued her efforts with the Master It will assemble during the Annual Meeting thank them both for their valuable contri- Teacher Award Program, particularly dis- in Chicago on Wednesday, June 13. This butions. Replacing them is Graciana cussing with her committee how to oper- group, comprising approximately 12 can- Lapetina, a candidate from the Institute ationalize the selection of master teachers didate and recent graduate members, for Psychoanalytic Education. I welcome and how to create a committee of judges. will address challenges candidates face in her to our community and look forward Continued on page 27

16 THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 SPECIAL SECTION: PSYCHOSIS

Psychoanalytic Treatment of Psychosis Part Three of a Three-Part Series

Introduction Michael Slevin and Eric R. Marcus

Now that the limits of medication treatment for seriously ill patients are becoming known, talking treatments are being rediscovered. Although no longer in the forefront of inpatient treatment, psychoanalysts have much to contribute to the debate over appropriate treatment models and systems. In the previous two issues of TAP, authors discussed the research supporting the Michael Slevin Eric R. Marcus use of psychoanalytically informed treatment for patients with psychosis, followed by the use of psychoanalytically informed treatment in a variety of settings. We conclude the series with articles by Eric Marcus and Danielle Knafo. Marcus considers the relationship between creative process and psychosis. Knafo wraps up our series of articles with a discussion of how we can train students and candidates to work dynamically with psychosis and, when doing so, allow the patients to be our teachers.

Michael Slevin, M.A., M.S.W., a former TAP editor, graduated as academic associate from the Baltimore Washington Institute for Psychoanalysis, where he completed as a clinician the Adult Psychotherapy Training Program. He works at Sheppard Pratt and has a private practice. Eric R. Marcus, M.D., is director of the Columbia University Center for Psychoanalytic Training and Research and has a long-standing interest in psychosis. His book on the topic is Psychosis and Near Psychosis: Ego Function, Symbol Structure, Treatment.

response to some unbearable situation, a Working at the Limits daring and dangerous radical departure from ordinary forms of coherence that almost of Human Experience always contains the hidden key to its own Danielle Knafo creative resolution. Additionally, I perceive some similarities While many may find psychosis frightening never have. In between psychotic experiences and the prod- or untreatable by psychoanalytic methods, I fact, I feel excited ucts of creative artists, though the two endeav- and privileged to ors are clearly different. Both involve fluid, work and create regressed self states and access to unconscious Danielle Knafo, Ph.D., is a professor Danielle Knafo at Long Island University, faculty and at the frontiers processes; both create new worlds to deal supervisor at NYU’s Postdoctoral Program of human experience. I have devoted three with pain; both are attempts at healing what is in Psychoanalysis. Her most recent book decades to studying and writing about cre- broken; both offer alternative ways of viewing is titled Dancing with the Unconscious: ativity, and during that time I have treated and experiencing reality. All acts of creativity The Art of Psychoanalysis and the dozens of individuals diagnosed as psychotic. take place on the threshold of the unknown. Psychoanalysis of Art (Routledge, 2012). I have come to view psychosis as a creative Continued on page 18

THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 17 SPECIAL SECTION: PSYCHOSIS

Human Experience inquire what their voices said, or whose Though psychoanalytic work with psy- Continued from page 17 voices they were, or whether the voices chotic patients can be extremely difficult, it were experienced as helpful or harmful. In can also be highly effective and profoundly ROLE OF REGRESSION response to not being heard, the Hearing rewarding. This is why I chair a doctoral pro- My experience working with individuals in Voices Network represents a wonderful gram in clinical psychology that trains stu- hospitals, institutional settings, and private development: Those who hear voices con- dents to work dynamically with serious practice has convinced me that regression is gregate to help themselves and each other mental illness. As far as I know, it is the only sometimes a necessary part of the healing by asking exactly these questions and more, one of its kind in the United States. Many of process; we sometimes must go back in as described by Gail Hornstein. my students tell me it is the first time they order to go forward. Like Winnicott, I view It is not true that all psychotics are rigid, hear that schizophrenia is not necessarily a regression as a psychic interruption or breach lack motivation, and fail to develop transfer- lifelong illness whose symptoms must be whose underlying purpose is to return the ence feelings or that they cannot experience stabilized with medication and for which patient to a traumatic episode or constella- conflict or insight. A patient I saw became there is no recovery. Imagine what options tion of such episodes in which a reactionary, delusional and insisted he was going blind. He this opens up for them as well as their armored self developed. The defenses then exhibited what Ping-Nie Pao called patients! Now my students report helping formed against such trauma prevent psycho- “organismic panic.” No sooner did we com- their patients’ progress in many ways: Their logical growth and limit the self’s possibilities. plete a session where he felt a sense of prog- patients learn to smile more, interact with The regressive return offers the opportunity ress, than he dismantled it completely, others, and cultivate more interests. They for self-repair by working through the original renouncing any perceived gain. His thoughts learn to have hope. trauma in a safe, holding environment. were broken; his self was in pieces. Here was I have always seen psychotic individuals in my private practice. Thankfully, I am not alone. I have been influenced by British object rela- …regression is sometimes a necessary part of the healing tions analysts who never shied away from process; we sometimes must go back in order to go forward. extreme states of human experience, people like Klein, Bion, Winnicott, and Khan. I am a member of the International Society for the Despite convincing evidence connecting Bion’s idea of “attacks on linking” in the flesh. Psychological and Social Approaches to psychosis to trauma (Monica Aas, Warren He had seen and felt too much and so he Psychosis (www.ISPS.org), an organization Larken, Anthony Morrison, Andrew Moskow- blinded himself in his attempt at restitution. whose goal is to promote humane under- itz, Ingo Schäfer, Martin Dorahy, John Read), To convey the primal terror he was experi- standing and treatment of psychotic distress this tie continues to be overlooked or mini- encing, he said, “I feel so helpless, as if I was and does not regard medication as being, mized in modern psychiatry, which prefers to literally just born and someone is saying, run necessarily, primary in this treatment or the relieve symptoms with medication rather than this company for me.” His destruction of sight first treatment of choice. explore their meaning with the patient. There reflected the need to rid himself of percep- Recently, I was thrilled to hear Christopher has been a medicalization of mental illness, a tion and thought, the very structures that Bollas say that psychoanalysis is the treat- development that I believe has deleteriously could distinguish the subjective and objective ment of choice for psychotics. He explained affected the care of those who suffer. Other aspects of reality. His “sickness” became the that when a patient of his is having a psy- than studying the brain’s neurobiological func- manifestation of his breakdown. chotic episode, he cancels all other sessions tioning, too few continue to study how the for the week and sees that patient every day mind goes astray. Beginning in the 1960s, for BREAKTHROUGH OR BREAKDOWN for the duration of his workday. Bollas’s reasons which Orna Ophir explicates well, My patient insightfully observed that he did approach is to see the psychotic person four psychoanalysts by and large turned over the not know if he was experiencing “a break- to five days a week, attempt to understand care of psychotic individuals to psychophar- through or a breakdown.” I have learned that his or her reasoning, and then communicate macology, thereby relinquishing their unique sometimes a breakdown is, with effective treat- that meaning to the patient. He emphasizes methods of treatment and research. One ment, the beginning of a breakthrough. Little by how it is reasonable for that person to patient said to me in the midst of a psychotic little, we began to observe what Franco De behave and think the way he or she does break, “My childhood was one big emergency. Masi termed “psychosis-free intervals,” during given the specific historical and psychic cir- I couldn’t get out of it. I could only hide. Now which he started to do some psychological cumstances. When I work with someone in they want me to hide inside a pill jar.” work aimed at understanding and “seeing” the an acute state of psychosis, I, too, maintain So many patients I have seen have told me meaning of his psychotic construction. As the daily contact with the person until the epi- that though their doctors asked whether intervals of lucidity grew, the psychosis dissi- sode subsides. they heard voices, they hardly bothered to pated. Insight gave way to eyesight. Continued on page 20

18 THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 SPECIAL SECTION: PSYCHOSIS

Psychoanalysts do this well; it is Creativity in Psychosis how they work with dreams, with Eric R. Marcus fantasy, with art, with literature, and with group symbolic repre- Creativity in psychosis has two aspects: the but rather in the plastic sentations. Medication can be making of the psychotic symptom and the mix of both described helpful, strengthening percept- use of these phenomena. by Winnicott as the concept-affect boundaries. To create a symptom, the primary process transitional space. Cre- Personality defenses, which are captures an area of reality experience of high ativity involves both well suited to psychoanalytic and emotional valence, constructing from it a primary and secondary psychodynamic work, surround symbol which reality testing erroneously processes, organized by the psychotic symbol guarding it affirms. This psychotic condensation appears complex ego functions from observing ego and reality Vincent Van Gogh in consciousness as a “thing presentation,” called tertiary pro- self-portrait, 1889 testing. Core personality conflicts which is an intense, sensory-affect object. cesses. First described appear in the psychotic symbol. Experienced as though it were an object in by Silvano Arietti in 1976, tertiary processes As the work opens up more of the psy- the external world, it arrives in consciousness integrate symbolic representations and use chotic process, the observing ego is given over sensory perceptual channels, through them for creative purposes: growth and more information about the dynamics of which it expresses its associated affect and development, and adaptation to inner and the capture of the reality chosen for sym- encodes its ideas. outer worlds. Tertiary processes are bolic use. The thing pre- complex ego functions that synthesize One can see these processes at work in sentation is thus primary and secondary process prod- art. Van Gogh, Munch, and Rothko, all likely a condensation ucts to form complex affect cogni- had psychotic mood disorders and painted in reality sensory tions. They are a hallmark of the during episodes, even as their moment of experience of highest cognitive functions. suicide approached. Their works are creative emotional con- Psychotherapy and psychoanalysis because the artists’ trained tertiary pro- flict in a form of focusing on the psychotic thing pre- cesses were intact, though the iconography compromise. sentation look carefully at sensory was impoverished relative to that in earlier Choosing the detail and the affective experiences work. They were unable to use the repre- reality nidus and condensed with that sensory detail. sentations of their illness in their work. Art altering it is a As the affective experiences become produced during an episode of the illness creative process more fully con- shares the orga- using condensa- scious, articulated, nizing features of Mark Rothko self-portrait, 1936 tion, displace- and investigated, the the illness. ment, symbolization, and secondary revision. concepts condensed in the The ego can Some of these products of the dreamwork thing presentation emerge. be creative even phenomena are concrete and hackneyed, The condensation opens when in the others are ingenious and unique. However, up into its component throes of psycho- once constructed the psychotic symbol parts: reality experience, sis, whether the remains reified, rigid, unchanging, stereo- emotional experience, and patient is an artist typed, and stymied in its growth and devel- their symbolic alterations. or not. As thera- opment. In psychosis, accessory ego functions These different aspects of pists, we use this are damaged and/or dissociated from the the experience are all valid in our work. We psychotic symbol. It cannot be further used but refer to very different help our patients creatively, existing in status niscendi, instead epistemological areas and understand the of as a true plastic representation. The statuses. Decondensation meaning of their patient experiences it as literally true and strengthens observing ego psychotic sym- therefore nothing further can or need be and reality testing. Once bols as they reach done with it. decondensed, the elements The Scream, Edvard Munch, 1893 creatively for new can be recombined in new and more adap- CREATIVE PROCESS representations that are truly plastic, tive compromises. Thus, the psychoanalyst True creativity does not occur in either expressing an affective rather than a literal or has much to offer patients who suffer from reality experience or emotional experience concrete reality. psychosis.

THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 19 SPECIAL SECTION: PSYCHOSIS

Human Experience feel well again, his or her sense of courage, Continued from page 18 and the urge for discipline and order. An example is a patient of mine who confessed Working analytically with psychosis to battling rats for nearly one hour each day requires dedication and patience. It involves outside my building prior to our sessions. meaning making on the part of both analyst One could easily chalk her statements up to and patient. In fact, one of the main reasons dark and pervasive hallucinations confirming patients stop taking their medication, aside her schizophrenic diagnosis. Or one could from the severe side effects, is because their see, as I did, her courage to fight through her symptoms contain the meaning they give to symptoms in order to reach me and her their lives and without meaning humans pre- determination to let nothing stop her from fer not to live. continuing our treatment. Podvoll called for Michael Eigen, author of The Psychotic Core compassionate action in the treatment of and many other books detailing therapy for psychosis. Indeed, the ground of the treat- serious psychopathology, has worked with ment is a compassionate relationship. psychotic patients for 50 years. He told me, “Through contact with ‘madness’ I contacted NOVEL APPROACH IN FINLAND myself in important ways.” Indeed, it behooves My experience has shown me that it is fre- popular belief that “once a schizophrenic, us to consider the ways we can grow by quently feasible to reverse a psychotic pro- always a schizophrenic.” I find it rather frus- working with those experiencing extreme cess when one intervenes quickly after a first trating to hear professionals comment on a states of consciousness. Again, Eigen said, break. Daniel Mackler’s recent documentary, recovered schizophrenic patient by claiming “This work enabled me to develop and use Open Dialogue, demonstrates how in Finland they were surely misdiagnosed because they myself, to grow in caring and resourceful- an approach to the treatment of psychosis could not truly be schizophrenic if they ness.” Eigen’s comments remind me that Har- has been developed which involves immedi- recovered. Yale graduate, law professor, old Searles, in 1977, wrote that the more ill ate intervention (after the first break) with schizophrenic, and author of The Center Can- the patients, the more they become our teams of practitioners working on a daily not Hold, Elyn Saks wrote that though medi- therapists. It is common knowledge that psy- basis with families and the client, in order to cation helped her, it is psychoanalysis that chotic patients read our unconscious minds avoid lifelong hospitalizations and stigma. saved her life. Our entire approach to treating severe and persistent mental disorder in the United It is common knowledge that psychotic patients States needs to be seriously reevaluated. read our unconscious minds and that “reading” can Sometimes medication is necessary and helpful. But the person is first and foremost a benefit us by expanding our self-awareness. living relational being whose derailment is often rooted in trauma. Unless we take the time to listen to our patients and hear what and that “reading” can benefit us by expand- Medications are used in only about a third of they are saying, the problems are likely to ing our self-awareness. Their use of projective cases. They have the highest success rate persist and become chronic. Ronald Bassman, identification also requires that we “stretch” (approximately 85 percent) in the world. a psychologist who was hospitalized and ourselves from habitual ways of being to Mackler is tracking alternate forms of treat- diagnosed with paranoid schizophrenia when inhabit others’ fantasies, Thomas Ogden said. ment of psychosis, mostly in Europe, and he was young, writes to the real psychiatrists I find it helpful in my work with psychotic delivering a harsh critique of traditional psy- he has known and to those he never met: patients to be alert for what Edward Podvoll chiatric approaches. called “islands of clarity,” areas where func- Indeed, it is unfortunately eye opening to This state you call schizophrenia has tion and ego integrity still exist. No one is 100 consider that psychotic patients fare much a vastly different meaning to me. percent psychotic. What parts still function better in third world countries than in our Dangerous, yes, but for those of us well? How does one align oneself with those own, according to Kim Hopper, Glynn Harri- who must battle the “disease” of parts? Podvoll, a Buddhist, reminds us not to son, Aleksandra Janca, and Norman Sartorius. feeling too much, of seeing what be too symptom focused and to take a his- The findings of Courtenay Harding’s remark- others do not see, and not meeting tory of sanity as well as one of illness, paying able longitudinal research show that over half expectations that were never our special attention to the patient’s repulsion to of psychotic patients recover without treat- own, it is ripe with opportunity to his or her symptoms, as well as the wish to ment, a finding that flies in the face of the transform ourselves.

20 THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 CHILD ANALYSIS

Aspects of Child Analysis Anita Schmukler and Paula Atkeson

Of primary impor- tance is the assessment of the child’s difficulties. Neurotic conflicts that are firmly rooted, in a child with good ego strength, are generally most responsive to Anita Schmukler Paula Atkeson analysis. In these cases, greater frequency per- When we examine the work of child anal- mits more opportunity to interpret defenses Karen, bright, curious, and psychologically ysis and child therapy, what do we find that and transference. One aspect of assessment minded, constructed play in which a good distinguishes these two modes of treatment? for child analysis is the way the child engages deal of transference references was patent. In current discussion of the topic, emphasis with the analyst and the response to early Gentle, careful work with this material led is upon frequency of sessions, with the con- interventions. Internalized conflict and access to some elaboration of her feelings, but she current challenge regarding frequency. In fact, to imaginative fantasies are crucial. was not able, in her twice-weekly sessions, it is the close connection among frequency, to work with transference conflicts. Why was analytic stance, and interventions (including CHOOSING THE RIGHT TREATMENT analysis not utilized in this case? While in interpretation of defenses and transference) For children with ego disturbances, psy- some cases the choice of treatment is based that determines whether an analytic process choanalytic psychotherapy may be the treat- upon psychological problems and ego struc- is taking place in work with a child. ment of choice, even when the frequency of ture, in this case it was based upon the child’s One feature that distinguishes work with meeting is four or five days weekly. This may living about 90 minutes from the closest psy- children is attention to particular develop- help the child in developing ego strengths. choanalyst and her being one of seven sib- mental issues: delays, lags, fixations. In work In comparing and contrasting such cases, lings, two of whom were physically challenged. with children whose primary symptoms are of only a careful examination of process notes Thus, the burden on the family was a consid- neurotic origin, the developmental issues are of many child cases of similar age and eration in making a recommendation. part of the analysis. A misperception in mod- ern times has been that helping children return to the path of development is the goal of One aspect of assessment for child analysis is the treatment. This notion fails to give sufficient way the child engages with the analyst and attention to the analysis of neurotic conflicts and may attend more to behavioral manifesta- the response to early interventions. tions than to internal conflicts and defenses.

pathology in which one child is treated in Stephanie was in a four-day/week analysis Anita Schmukler, D.O., is a training and analysis and another in therapy can demon- and, at nine, had developed a capacity for supervising analyst and child supervisor strate this perspective. insight and work with analytic material. Deal- at the Philadelphia Center for Psychoanalysis; With respect to transference, here is a ing with similar issues in play to those that supervisor of child analysis at the brief example of two children Anita Schmuk- Karen had brought, she constructed play in Psychoanalytic Institute of NYU, the Western ler treated. which a large toy cat had a mother who New England Psychoanalytic Institute, and Two nine-year-old girls had been in treat- stayed away for “four years” on business trips. the Cincinnati Institute of Psychoanalysis. ment for three years, one in analysis and In the play, the girl moved with her father and Paula Atkeson, Ph.D., is a training and the other in therapy. Both exhibited symp- siblings to 213 Main Street. supervising analyst, and supervisor of toms related to conflicts with their moth- After examining the associated feelings child analysis, at the Baltimore Washington ers, both of whom were relatively isolated from many perspectives, Schmukler wondered Institute for Psychoanalysis. Atkeson is one from their daughters, while also spending a about the relation between 213 and 212, her of the founders and governing board members good deal of time away from home in office suite. Stephanie looked surprised at first of the Jenny Waelder Hall Center for Children. work-related travel. Continued on page 22

THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 21 CHILD ANALYSIS

Child Analysis which it would not other- Continued from page 21 wise have lent itself. No one else, in my opinion, and then, tearfully, said she wished that she could possibly have pre- lived next door to Schmukler’s “real” home so vailed on the child to that the analyst could “share in the mothering” make any such avowals… and help the little girl to grow. There were multiple implications for posi- So Freud, at least in 1909, tive and negative transference and these could not fathom analysis of were examined in depth. transference in a child. His view seems to have affected genera- IS CHILD ANALYSIS REAL ANALYSIS? tions of analysts since that time. WHAT WOULD FREUD SAY? Freud’s daughter, Anna, devel- Even in 2012, we hear from some col- oped methods of analyzing leagues that “child analysis is not real analysis.” children and tried to find com- In reply, we can suggest that they examine promises between the analytic child analytic cases for evidence of work with methods established for adults defenses, transference, object relations, and and the educational approach the multiple perspectives from which we that children were thought to require. Anna that is so arduous and time consuming, espe- work. Examination of structural change and Freud resisted the notion that children could cially if the conviction about the vast poten- effective work at termination would also illu- develop intense transference neuroses in the tial of analytic treatment is not present. minate the study. course of analysis. SUBSTITUTING PLAY THERAPY FOR THE COUCH …the description of child analysis as simply resolving the Melanie Klein also tried to apply methods interferences to progressive development does not convey for adults in working with children. Initially, she tried to use the couch with young chil- the complexity of what takes place in child analysis. dren, and looked for free associations in this manner. She soon discovered that this was not a feasible approach, and she evolved a Child analysis involves regression in the The intermingling of interpretive work and mode of play therapy that was substantively context of the transference and analysis of educational approaches to working with chil- more fruitful. Overall, adult psychoanalysis conflict and defense, as well as addressing dren, in addition to inattention to transfer- was the model for working with children, impediments to development, but the ence, led many analysts to conclude that child which both delayed progress in the field of description of child analysis as simply resolv- analysis is not “real” analysis. Since many ana- child analysis and conveyed an impression ing the interferences to progressive develop- lysts of children present clinical material as if that child analysis was not “full analysis.” ment does not convey the complexity of “the play says it all,” with minimal interpretive That construct has influenced generations what takes place in child analysis. work, analysis of transference and resistance, of clinicians and is worthy of deep and thor- Freud did not think that analysis of children, and analysis of dreams may lead the listener ough examination. in the depth to which we analyze adults, was to suspect that perhaps child analysis is iden- possible. In 1909, commenting on Little Hans tical with therapy, only with more frequent CONTEMPORARY VIEW and the work that his father did with him, sessions. This would certainly make one Today we attend to transference neurosis Freud wrote: doubtful about recommending a treatment in children, we work with perceptions of ana- lyst as both transference object and It was only because the author- developmental object and both are ity of a father and of a physician subjected to analytic scrutiny. We are were united in a single person, aware that educational approaches, and because in him both affec- when they arise, can be subjected to tionate care and scientific inter- analysis as well. est were combined, that it was From this perspective, we can see possible in this one instance to that the analysis of children and ado- apply the method to a use to lescents is, indeed, analysis.

22 THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012

CASES from the Frenkel Files A Case of Matricide John C. West

Victor Brus- and bouts of heavy sweating. Bruscato also cato suffered started hearing voices telling him to kill, and from severe he became increasingly hostile toward his mental illness parents. On August 15, 2002, Bruscato killed Accordingly, in a unanimous decision, the when he came his mother by striking her head with a bat- Georgia Supreme Court affirmed the judg- under the care tery charger and then stabbing her 72 times. ment of the court of appeals (finding Brus- of Dr. Derek He was indicted for his mother’s death, but cato was entitled to sue) and sent the matter O’Brien. He had was found not competent to stand trial and back to the trial court for trial. A key factor in been diagnosed, was never convicted of a crime. Shortly after this case was that Bruscato was never found over the course the time of the homicide he was committed guilty of a crime and probably never will be. John C. West of his life, with to Central State Hospital, where he cur- This leads to the conclusion that Bruscato’s mental retardation, pervasive developmental rently resides. action was not intentional for the purposes disorder, schizophrenia, an unspecified psy- Bruscato, through his guardian, brought suit of forming the requisite legal intent to com- chotic disorder, organic mood disorder, inter- for medical malpractice against O’Brien. The mit a crime. Since Bruscato was incapable of mittent explosive disorder, and pedophilia. trial court dismissed the suit on public policy forming the legal intent to commit the crime, Bruscato had expressed homicidal thoughts grounds. It reasoned that Bruscato should his action could not be felonious. toward his parents, with whom he resided, not be entitled to profit from the murder of Treatment planning for patients with men- and had physically assaulted them, as well as his mother. The Georgia Court of Appeals tal health needs can raise complex and diffi- others. He also experienced auditory halluci- reversed the judgment of the trial court. cult issues requiring careful management in nations that commanded him to kill people Bruscato v. O’Brien, 307 Ga. App. 452, 705 S.E. the psychiatric practice. Changes in treat- or to molest girls. He was prescribed Zyprexa 2d 275 (Ct. App. Ga. 2010). An appeal to the ment plans should be approached cautiously and Luvox to help control his behavior. Supreme Court of Georgia ensued. with due regard for the safety of the patient In May 2002, O’Brien discontinued the The Supreme Court of Georgia held that, and those around him. O’Brien’s own expert Zyprexa and Luvox because he was con- when one knowingly commits a wrongful act, testified that Bruscato should have been hos- cerned that Bruscato might develop neuro- he cannot benefit from his wrongdoing. The pitalized to determine whether he had NMS, leptic malignancy syndrome (NMS), a court reviewed all the evidence of Bruscato’s and, with the benefit of hindsight, that would relatively rare disorder. O’Brien’s expert wit- mental illness and ruled that his psychiatric probably have been a more appropriate ness later testified that discontinuing these condition prevented him from exercising a course. Changes in treatment plans need to medications was the wrong course of treat- reasonable degree of care to prevent him be objectively justifiable and be made in the ment and not medically justified. from taking improper and illegal actions. It best interest of the patient and, where appro- further noted that Bruscato had never been priate, the public at large. INDICTED BUT INCOMPETENT convicted of a crime with respect to his In order to defend a case like this, the TO STAND TRIAL mother’s death. mental health professional needs to show Without medication, Bruscato’s behavior that s/he was duly diligent: (1) the patient was became more erratic and difficult to control. CRIMINALLY INSANE CAN SUE assessed appropriately, (2) the interventions He began having nightmares, panic attacks, DESPITE SLAYER STATUTE contemplated were objectively justifiable, The Supreme Court of Georgia had (3) due care was taken to ensure the safety John C. West, J.D., M.H.A., is a senior recently ruled on the Georgia “slayer statute.” of the patient and others around him/her, health care consultant with Global Loss In Levenson v. Word, 286 Ga. 114, 686 SE2d (4) all steps in the process were carefully Prevention, Inc., a Chartis company. This 236 (Ga. 2010), the court held that one who documented, and (5) the standard of care column constitutes general advice not legal feloniously and intentionally killed the was met. To do less is to invite liability. advice. Readers should consult with counsel deceased will be precluded from inheriting for legal concerns. For questions or comments from the estate of the deceased. This holding O’Brien v. Bruscato, 289 Ga. 739; contact [email protected]. was in line with the Levenson case. 715 S.E.2d 120 (Ga. 2011)

THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 23

From the Unconscious poetry Sheri Butler Hunt

Between Hours is a new collection

of poetry put together by Salman

Akhtar. It was a labor of love for

Akhtar and the 10 poets whose

work is featured in the anthology.

A unique compilation, it features

solely poetry written by

psychoanalysts. These are the hidden

weavings, inner visualizations, and

middle-of-the-night connections

produced by the deep workings

of psychoanalytic inspiration.

Ten poets, 10 thumbnail sketches

of each poet, and 10 poems each,

a prologue, and an epilogue

comprise this slim volume.

The poems on the following page

give a taste of what is in the

anthology; a collective of wisdom

and creation.

Sheri Butler Hunt, M.D., is a graduate analyst in the adult and child divisions at the Seattle Psychoanalytic Society and Institute. A published poet and member of TAP’s editorial board, she welcomes readers’ comments and suggestions at [email protected].

24 THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012

poetry (continued )

Poetry in the Suburbs (The reporter asks, “Why would this suburban town need a poet laureate?”)

Conceptions We don’t need poetry in the suburbs, here. We have drive-thru, and take-out, and delivery A big black cloud and that is plenty. dropped two smiling raindrops We have no midnights, where fear grows teeth in the purple courtyard and no daylight to pull them; we have burglar alarms. of the lotus on a satin lake. No ball ever bounces foul here; no hero quails. A blue owl We have X-box. and a pink mynah No mother sits vigil by her child’s bed at night, flew out of the flower. her chest so tight she hitches her breath And the flower undulated with waves of lusty pride. and offers everything she has, —Salman Akhtar everything she will ever have, grasping for the words to make the promise and the strength to say it—“please.” Worthless Angels We don’t need poetry here. No girl’s heart peers out from beneath the thorn bush of her On this fork in my trail discontent; Who can truly sense my conflict? No colt-legged boy wears his like a beacon, or a chain. Who can show me the right path? We have free parking, and mowed lawns, The one who cries with my pain And the smell of new paving never leaves the air. does not know And if the tattered man at the off ramp, holding a sign which way to go. “Homeless—Will work—Anything helps—God Bless” The one whose counsel is astute Makes us tremble and look away, we don’t need a way to say to him, feels not my longing to take the other route. “If what I think of you is wrong, I am most humbly sorry,” —Salman Akhtar Nor a way to go home afterward, and say to one another, over and over again, like poets do, how easily it all can be, will be, lost. —Rebecca Meredith

THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012 25

Therapeutic Dyad during an investigation. Continued from page 1 Eist was disciplined for failure to comply soon Nevertheless, enough, even though his Eist was fined for hesitation was in line refusing to coop- with his ethical beliefs erate in a timely and was a matter of fashion. This dis- weighing competing ciplinary action interests. He was disci- was reported plined for taking time to to the National consider his ethical Practitioner Data responsibilities before Bank. replying to the board, Graham L. Spruiell Consider the showing that mere con- disturbing implications that can be drawn: If a sideration of medical ethics can be grounds Clinical Health (HITECH) Act requires that Maryland physician is contacted by the board, for disciplinary action. physicians and other clinicians enter per- the physician must comply with its demand Will other state boards follow Maryland’s sonal health information into the EHR. Fail- for confidential patient information, even if lead? Given that the Federation of State ure to do so will result in penalties in the that compliance represents a violation of Medical Boards filed an amicus in support of form of decreased Medicare/Medicaid reim- professional ethics, violation of fiduciary the Maryland Board against Eist, other bursements. Additionally, some states are responsibility to the patient, and an act that boards bear watching. If our professional mandating familiarity with the EHR as a could potentially harm the patient. In this sce- ethics are to retain their intended meanings, requirement for licensure. nario the ethics of the physician and the wel- the Maryland statute should be overturned, The dilemma that Eist faced may not be so fare of the patient are interdicted by statutory and efforts in other states to enact similar far removed from our own experiences. We policies of the board. legislation must be opposed by our profes- will be figuring out whether our primary An ethical dilemma meets a disquieting sional organizations. responsibility is to our patients—or to our ending in Maryland: “My code tells me that I Despite huge financial and personal sacri- board overseers, payers, private insurers, and should not violate my patient’s confidentiality, fices to himself and his family over many the government. This defining dilemma rep- but the board informs me that according to years, Harold Eist heroically persevered in resents the most critical conflict of interest, statute I must do so during an investigation. doing what he believed was a conflict that biases the To avoid being disciplined, it appears that I right as a physician and right clinician in favor of third have little choice except to comply with the for the integrity of his profes- parties over the patient, board’s demand to disclose confidential sion, and ultimately what was and threatens to under- information without my patient’s consent.” right for his patients. The mine the clinician-patient American Psychoanalytic Asso- relationship. MATTERS OF CONSCIENCE ciation has supported Eist in I suspect that most cli- During the Vietnam War, the term, “consci- friend of court briefs, and he nicians, if put in the posi- entious objector,” was a common phrase. This received a Profile in Courage tion of Eist, would be phrase assumed that if someone was morally Award from the American Psy- willing to accept the opposed to war, that person should not be chiatric Association. board’s reinterpretation forced into combat. Physicians have histori- of their “ethical duties” cally enjoyed similar rights of conscience. A PPACA AND PRIVACY to their patients, as a way physician, for example, cannot be forced to The Eist case is an impor- Harold Eist of avoiding disciplinary perform an abortion, participate in assisted tant example of a psychiatrist action for noncompli- suicide against his ethical beliefs, or engage in weighing his responsibility to his patients ance. Similarly, if those same clinicians were a treatment that he believes will be harmful. and the board; but clinicians face similar informed that they were required to enter As a time-honored tradition, physicians have dilemmas. As part of the Patient Protection confidential information into the EHR in not been coerced into violating confidential- and Affordable Care Act (PPACA), the Elec- order to receive full compensation and ity, unless there was a subpoena from a judge tronic Health Record (EHR) poses a tre- maintain their licenses in good standing, or statutory requirement. mendous threat to confidentiality and the most would likely comply rather than run In the Eist case there was a statute that clinician-patient relationship. The Health afoul of the board. specifically allowed the board to access PHI Information Technology for Economic and Continued on page 27

26 THE AMERICAN PSYCHOANALYST • Volume 46, No. 2 • Spring/Summer 2012

Candidate Connection diligently to further candidates’ presence in the organization and enhance their Continued from page 16 Editor’s Note: training experiences. Consider joining us I have continued in my efforts to launch in our work. There is no better time to This is an abbreviated version the Pilot Mentorship Program. At the get to know APsaA’s organizational life, of the “President’s Letter” time of this writing, I have corresponded network, and develop a sense of analytic from the most recent issue with several institutes about participat- identity than during one’s training, when of the Candidate Connection ing in the trial program. I hope to have so many opportunities are available. You which can be read in its entirety at more information about how to imple- may contact me (hilli@dagony-clark. http://www.apsa.org/Publications/ ment the program by the time of the com) or any other member of the Can- The_Candidates_Council_ Annual Meeting. didates’ Council’s Executive Committee As I have illustrated, members of the for further information. I hope to see you Newsletter.aspx. Candidates’ Council are working in Chicago.

Therapeutic Dyad Historic Invitation three times a week. To equate the differences Continued from page 26 Continued from page 5 between the APsaA and WAWI models only with the difference of minimum frequency WINDOW OF OPPORTUNITY APsaA has been interested in the treatment misses the essence of their training philosophy, I am not confident about the outcome if of so-called widening scope patients for over as we understand it. BOPS voted to make it we keep moving in this direction, but there 50 years, but our training programs have not official policy of the Association that any insti- is still a small window of opportunity. been particularly geared toward the treat- tute approved by the American Psychoanalytic Whatever happens with the PPACA and ment of these patients. Yet, we know that Association wishing to adopt the WAWI varia- the EHR, if it can be legally established that many of the cases our candidates treat are tion in its entirety would be permitted to do the patient “owns” information contained probably in this diagnostic category. In this so. This change, which would require a change in the medical record, information that was regard, the focus of the WAWI model more in our standards, would be subject to the voluntarily proffered by the patient, and clearly acknowledges that some of our con- oversight of BOPS, with members from retains the right to safeguard that informa- trol cases may not be amenable to the same WAWI providing the leadership for such tion, then the EHR can become patient- technique of psychoanalytic treatment that oversight, should they accept our invitation. centered, a step beyond current technology. is usually the treatment of choice for most Finally, we would like to conclude with a In a patient-centered EHR the patient (or neurotically organized patients. What kind of broader reflection on the potential impact surrogate) alone determines disclosure to treatment is advisable for these patients? Are of this prospective historic union for the intended recipients, like a bank account. If, we training our candidates to recognize the profession of psychoanalysis. At a time when on the other hand, the EHR comes to mean full spectrum of psychopathology and to mental health treatment in general has the breaching of millions of medical records thoughtfully decide on the best treatment become fragmented, simplified, and at times in the cyber-ether, loss of confidentiality, based on the needs of the patient? Having dehumanized, a partnership of two organiza- and loss of trust in the clinician-patient rela- this focus included as a part of psychoanalytic tions that have been leaders in the training tionship, then the EHR represents a giant training is truly one of the great strengths and practice of psychoanalysis would pro- leap backward. of WAWI. In addition, their training model vide a meaningful unified front. We hope The Committee on Government Affairs includes supervised psychotherapy as a that the White Institute’s internal discourse and Insurance (CGRI) gladly accepts a win- required part of their training program. These in response to our invitation will reflect the dow of opportunity and will be working with are differences we hope to study, become same optimistic anticipation that such a pro- Jim Pyles (APsaA’s legislative counsel) on a familiar with, and learn from. posed partnership will open many doors for Patient’s Bill of Rights. We look forward to Some individuals might ask if this means that collaborative research, increased public visi- presenting that work to you in the next issue our own institutes will be free to let our can- bility, and ongoing dialogue, paving the way of TAP. didates see control cases at a frequency of for the future for psychoanalysis.

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