Psychotherapy Session — May 22, 2017

I discussed my feeling of engulfment in relation to the therapist, a female. The therapist interpreted my feelings of engulfment as transference. I was transferring feelings that had their origin in my relationship with my mother onto the therapist. This is a valid interpretation. At the same time, it is useful to consider the possibility that the therapist is, in fact, an engulfing person — or perhaps oblivious to the downside of engulfment — and that my reaction to her reflected my hypersensitivity to actual engulfment rather than simply transference.

I note that the therapist’s professional profile states that she is interested in relationships and working with clients’ problems with relationships. It appears to me that the therapist is not really concerned with relationships. She is concerned with assessing a client’s perceptions of others, not appraising what actually happens between the client and others. Relational concerns center on the lived relationship, or interpersonal connectivities, rather than perceptions alone, though perceptions, or information processing styles, are a relevant factor. See, e.g., Rigazio-DiGilio S.A., “Relational diagnosis: a coconstructive-developmental perspective on assessment and treatment.” J Clin Psychol. 2000 Aug; 56(8):1017-36.

At my last session on May 22, 2017 I criticized my previous therapists, for the most part therapists in training at the D.C. Department of Behavioral Health (DBH), where I was a consumer from 1996 to 2016, twenty years. I had previously been a patient at GW where I saw two psychiatrists during a four-year period (one of these doctors diagnosed me with paranoid schizophrenia, the other as bipolar. I do not suffer from either disorder. Both doctors insisted I take antipsychotics, including Haldol). I stated to my current therapist that most of my previous therapists were “inadequate.” In fact, in 2016 I met with the attending psychiatrist at DBH, Monica Acharya, M.D., who terminated my work at DBH. Dr. Acharya made a startling admission. She said, “We failed you. You need psychodynamic therapy. Our therapists are all in training, and they concentrate on supportive psychotherapy. I hope that you can find a good psychodynamic therapist.” My current therapist pathologized my criticism of my previous therapists. She attributed my criticism to what Dr. Kernberg calls “identity diffusion,” or black-and-white thinking. “People who idealize also tend to debase other people,” she said. The therapist’s comment looked at my perception of my past therapists but did not look at the lived experience of a patient who, for twenty-five years, saw therapists who were inadequate for his needs. What was it like for me to have the experience — the lived relationship — of inadequate therapists? Now that would be relational.

(Note that my current therapist overlooked an issue of psychological interest about my act of attributing “inadequacy” to previous therapists. What happens when a person who has the lived experience of having had an inadequate mother once again in adulthood has the lived experience of having inadequate therapists? What is that lived experience like for the patient? What about the operation of the repetition compulsion, an issue of psychoanalytical interest? — Instead of confronting that relational issue, the therapist
treated my attribution of inadequacy to past therapists as an expression of splitting and projection, that is, black and white thinking.)

At other points in the session on May 22, 2017, the therapist called attention to my narcissistic traits. She said, “You want to be special. You want to be thought of as special.” At another point she said, “You want to be thought of as an ‘unforgettable’ patient.”

Be that as it may.

Let us now turn to genuine relational issues between me and the therapist — not transference and counter-transference issues. Is it possible that our perceptions of each other are artifacts of our disparate personalities? Perhaps I view the therapist as engulfing because I am an individualist and she is group oriented and therefore oblivious to the downside of engulfment. Perhaps she views me as intensely narcissistic because she is group oriented and I am an individualist, oblivious to the need to subvert my uniqueness to obtain group acceptance. Those are the genuine relational issues as I see them.

The psychoanalyst Wilfred Bion observed that people fall into one of two orientations with respect to groups. There are those who have a high fear of engulfment and a low fear of being an outsider. They derive their sense of identity and security by being individualists. Such people are not group oriented. Then there are people who have a low fear of engulfment and a high fear of being outsiders. These people are group oriented. They are unconcerned with being engulfed by the group. They freely pay the price of admission to groups, that is, giving up their personal identity to assume group membership. 1/

What happens in a situation in which a group oriented therapist — someone with a low fear of engulfment, who is affiliative, a joiner and follower dependent — is faced with treating a client who is an individualist, that is, someone who is self-reliant, solitary, resourceful, and self-sufficient, and has a high need for uniqueness, that is, someone who has a positive striving for being different relative to other people, someone who derives his sense of identity and security from being an outsider? See Snyder, C. R. and Fromkin, Howard L. “Abnormality as a Positive Characteristic: The Development and Validation of a Scale Measuring Need for Uniqueness.” Journal of Abnormal Psychology, 86(5) 518-27; Oct 77. It is important to distinguish my fears of intimacy from my individualism, which is not in itself pathological.

1. The group oriented therapist will view the individualistic patient’s fear of engulfment as purely pathological, when, in fact, it is to some degree simply an orientation, like extraversion or introversion. All individualists fear engulfment to some degree according to Bion. Group oriented people do not fear engulfment. The group oriented therapist will be oblivious to the psychological costs associated with engulfment (the loss of individual identity) and will tend to pathologize the patient’s fear of engulfment. Is it possible that my therapist is group oriented, that she is oblivious to the threat to individual identity that engulfment poses, and needs to depict my perception of her as engulfing as transference only? It is well to keep in mind: struggles about automony are a core issue in the treatment of gifted patients. Grobman, J. “A Psychodynamic Psychotherapy Approach to the Emotional Problems of Exceptionally and Profoundly Gifted Adolescents and Adults: A Psychiatrist’s Experience.” Journal for the Education of the Gifted, vol. 33, 2009.

2. The group oriented therapist will tend to view herself as part of a collective of therapists. She and other therapists are on the same team. When an individualistic patient criticizes his previous therapists, the group-oriented therapist will need to defend her colleagues and pathologize the patient’s criticism as, perhaps, an indication that the patient views the world in black and white terms or that the patient has extravagant expectations of therapists. The group therapist will view a critique of other therapists as an attack on herself. (In 1978 I complained about my then treating psychiatrist to another psychiatrist, a psychiatry resident named Jay D. Amsterdam, M.D. Dr. Amsterdam’s response? “Your psychiatrist sounds like a prick. I’d advise you to stop seeing him.” Dr. Amsterdam was an individualist with especially high moral values, someone who did not whitewash the inadequacies of his colleagues.)

3. The group oriented therapist may view the individualistic patient’s need for uniqueness as a symptom of narcissistic disturbance only, that is, as a need to be special or a need to be unforgettable. In fact a high need for uniqueness is associated with creativity — a sense of independence, anti-conformity, inventiveness, achievement, and self-esteem. (Dr. Amsterdam is — not merely coincidentally — a brilliant research psychiatrist who has made original contributions to the field of psychopharmacology. He has an 81-page curriculum vitae!). It is important to distinguish my narcissistic pathology — which is considerable — from my individualism.

1/ Bion’s dichotomy of group-oriented individual versus individualist perhaps parallels the anaclitic versus introjective personalities described by Sidney Blatt. The anaclitic type places a premium on interpersonal relatedness, while the introjective type emphasizes self-definition, identity, autonomy, and self worth. Blatt, S.J. “The differential effect of psychotherapy and psychoanalysis with anaclitic and introjective patients: the Menninger Psychotherapy Research Project revisited.” . J Am Psychoanal Assoc. 40(3): 691-724 (1992).