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Do You Feel Me?
By: Lana M. Ackaway, LCSW-R, NCPsyAv
I am a lay Certified Psychoanalyst (NCPsyA), a New York State licensed Clinical Social Worker (LCSW-R), and a New State Credentialed Alcoholism Counselor (CASAC). I am in private practice in New York City, providing assessment, intervention, counseling, psychotherapy and psychoanalysis to young adults and adults, in individual, couple and group modalities. I am also a co-founder of Heart To Heart, a high-quality professional consultation service for consumers who have not accessed or have had prior unsatisfactory experiences with psychotherapy or other mental health services. In addition, I train many mental health professionals how to work with addiction.
I have treated the range of personality disorders over the last 20+ years. It is my knowledge base that the entire range of personality disorders, to include "borderline" would best benefit from a depth-oriented psychodynamic psychoanalytically oriented long-term treatment.
Over the last 30 years several mental health "experts" looked more closely at their personal emotional reactions they were having when with a patient. They became more accepting of the term countertransference. Thus, they broadened the original definition of countertransference, which was defined as the analyst/physician/mental health worker’s effects on his understanding or technique of his/her unconscious needs and conflicts to include the patient’s personality, or the material he/she (patient) produces. In other words, rather than the original blank screen definition of countertransference, e.g., reactions belonging to the physicians’ personal past, the mental health literature now took into consideration the treating physician/mental health worker as a human being and a participant in the work with his/her patients. In addition, clinicians began to think about their own personal (emotional) reactions to a patient as a useful tool to understand, work with and treat their patients. In other words, where countertransference was defined only as a personal handicap, now mental health professional(s) broadened its meaning to include the professional(s)’OWN emotional reactions (with or without the behavior) toward patient(s). They now thought their personal/emotional reactions needed to be taken seriously and non-judgmentally. When these professionals better understood and accepted their personal (emotional) responses to a patient and/or to his/her material, the expert(s) could then with minimal bias begin to help—evaluate, intervene, counsel, and treat, someone else, to include patients with personality disorders.
I find that within the practice of psychotherapy, some clinicians do not sufficiently value their own personal emotional reactions (countertransference), some seemingly are unaware of them; others blame their patients, stating that patients with severe personality disorders do not have the capacity to withstand a depth-oriented therapy. Many mental health "experts" have not had the personal benefit of a psychodynamic based therapy. Others, who take a biological approach (psychiatry), give lip service to an unconscious in their views. Hence, their personal reactions do not come in play within their perspective. It is my opinion, that there are no patients without their "docs," and no "docs" without their patients (if in fact one is ‘engaged’ in a therapeutic process.) The silent, intellectual non-participating neutral screen—the "observer"—left the mental health field over 30 years ago! Even Herr Sigmund Freud did not support this stance! Many place value judgments and/or labels (diagnoses) on a patient or prospective patient. This view offers consumers in need of therapy, fewer choices—and in fact, limits access to the very therapy that has the best prognosis for the range of personality disorders--long-term psychodynamic psychoanalytically oriented therapy is most useful for the range of personality disorders.
I may have been considered several decades ago a borderline, a schizoid or a character disorder, depending on who was reading the DSM IV. For the purposes of a "good enough" treatment, the diagnosis doesn’t matter. What does matter is that with the help of my second lay psychoanalyst, I am relatively free of destructive unconscious emotional conflict. I left the dark rooms of rusty and dusty legal file cabinets; dark suits and/or shabby dressed lawyers’ offices and ambulance chasers to a comfortable Upper East Side office. I enjoy a fruitful private practice in psychotherapy and psychoanalysis for over 20 years. I also evaluate and give second opinions to those consumers who have questions or issues with their personal therapy for a variety of reasons. Today, some mental health experts may claim my diagnosis has/had been one within the mood disorders, but much more importantly, with access to quality psychoanalytic services, I am enriched in my work and personal life.
I am a very well trained mental health professional that takes my own personal reactions seriously when evaluating and/or treating all patient(s). I also take my own reactions seriously in every other area of my life. I trust my intuition and instincts and use them as effective diagnostic and therapeutic tools to help understand my patients and myself. My intuition is helpful to understand other people and I benefit here as well!
An example of a long-term case, utilizing my countertransference reactions might prove useful here. Some years ago, I was consulted by an attractive 37-year-old woman, working as a word processor while completing a PhD program in Clinical Psychology. I had a range of tender feelings for Jane and their magnitude made me take notice. These feelings were unusual as I had not had such feelings toward a woman for some years—notwithstanding that transference is ubiquitous--in fact, not since my own personal therapy—many years ago. I also came to feel over the initial few months of exploration with "Jane," shut out and as voiceless as I imagined her to feel. I was also aware of on occasion being angry with her. I noted my reactions, as I know this valuable information would prove useful in sorting out the case material, e.g., my countertransference so that I could better understand the transferences and the patient’s conflicts.
Jane’s grade point average was high. She eventually graduated magna cum laude. Jane told me she had difficulties in maintaining intimate, close connections. She also told me she found her moods frequently shifted to an empty and lonely sadness. When not sad, Jane felt anxious and irritable. In her past, she used alcohol in an attempt to medicate feelings, as she was prone, in her words to intense brooding and resentment. The alcohol "made it worse" she thought and with the help of a self-help, abstinent, group, Jane was able to tell me she gave up alcohol and other prescription medications; that in fact, she was proud to have been drug (to include alcohol) free for 13 years.
Jane, sought treatment for the second time after consulting another therapist that refused to see her with any session frequency. That therapist told her she needed a supportive environment and she would not benefit with an in-depth treatment. This was "strange," Jane reported, as she had been in a three times per week psychoanalysis when in her 20’s which lasted for four years. Jane thought she had then benefited and wanted to better understand her then abrupt departure as well as her current fears. She thought she could resume therapy when she felt more grounded and was able to afford the financial and emotional constraints of the therapy. (It took a few years into the therapy to actually find out that Jane abruptly ended her first long-term psychotherapy following her mother’s death!) Jane was never angry in therapy. It should be noted that Jane only became angry in treatment with me. Jane’s anger frightened her. It also covered her tender feelings—the ones that were my initial reactions to Jane—the arousal—when I first met her.
Jane’s prior therapist was also scared of Jane’s anger. Of course, this is conjecture; however, there were many instances, Jane reported over the initial period with me, that clued me that her then therapist was perhaps not in touch with either her own angry or tender feelings. As Dr. Freud said and I paraphrase, "One cannot take another (the patient) further than he/she has gone (emotionally.)" Jane also alerted me that she often felt "deprived" and feared a "loss of control" over angry feelings. No wonder why she could not maintain her prior therapy after her mother’s death! Jane was angry. She was good at being hostile, in an attempt to deny her angry feelings (Jane called her feelings "white rage"). I was aware of my own angry feelings when Jane tried hostility with me. However, I was able to use my countertransference to allow Jane to feel her rage over time. Rather than label Jane "untreatable," due to difficult intense feelings being aroused within me, I was able to use my feelings to better understand her. I was also able to feel and access my tender (empathy) feelings—the loving ones that many clinicians and consumers do not want to bear for a variety of vulnerable issues.
Jane was then seeking out treatment as she was beginning to feel close to a man in her graduating class and frightened about the desired closeness. She also let me know she knew she was still working in a clerical capacity and not risk feelings of competition.
As the "baby" in an immigrant Slavic family, Jane’s siblings were living outside of the home—decades older. Her mother, a homemaker, had suffered most of her life from depression, which was never treated. She was a rather needy woman and Jane was her object. Conflicted about mid-age pregnancy, Jane was referred to as her "mistake." Jane’s father was a passive-aggressive man, struggling with long labor hours as a shoemaker. He barely spoke. He ignored his wife and often Jane. However, Jane told me he "tried hard"—unlike her mom.
Jane did not deal with major self-object differentiation in her first therapy. Her addiction to alcohol initially masked a self-observing ego and no effort was seemingly made by her then therapist to address the addiction. Also, Jane was adept at denying the use of alcohol. She told me in the main, "it—the alcohol—never entered the ‘picture’." In any event, Jane was neither abstinent from alcohol nor sufficiently able at that time to engage in a self-reflective process that would help her put into language her feelings and thoughts, over time, strengthening her ego and capacity for self-regulation.
Jane "disappeared" as a child. The family used psychic solutions as escape routes from reality. Jane’s mother had her refrigerator and Jane as a narcissistic pursuit. The mother would use food and Jane’s body when in infancy to poke and prod her orifices as a way of masking emotions and defending against anxiety and her depressive states. Jane learned to hide under furniture when able to crawl; later, Jane used alcohol to disappear from her feelings and her anger. Jane would take a passive stance, in an attempt to disown her anger. She would "disappear" in the treatment room. Some days after long periods of silence, I would inquire—I learned not to—as Jane liked to be "found"—about her thoughts, to which she would wait another five minutes to say she "did not feel like giving anything." Asked what she thought had made her not wanting to, she would reply, "I just want to be gone." Later in treatment, the "gone" would refer to her "rage over dad running his mouth and Jane’s ‘disconnect’." Jane’s dad spoke only when very angry. What impetus did Jane have for language, to include a range of feelings and thoughts? Acting out through her hostility was far more gratifying at the time.
I took a quiet stance with Jane. Eventually she felt cornered and she had no place for her anger to go except within the treatment room. Jane and her resistances wore out—however, I did not. She tried to complain about others’ shortcomings and then attempted to call her comments "small, in the realm of it all." As quickly as she would have angry feelings toward a co-worker, she would undo her feelings, telling me how she helped Jane when Jane had too many word processing assignments. Jane would comment on her own ingratitude, thereby dismissing her feelings.
Punitive superego is often found within addiction and within borderline. It produces not only self-criticism, but also acts as a censorship over what is felt to be unacceptable thoughts and feelings—a resistance that offers a protection against shame and humiliation.
Many years ago this Certified Psychoanalyst left her "mute" skills on the analytic couch and began to free-associate. Today, I still free associate—only not out loud, but rather privately to myself—listening to my internal dialogue—to hear my personal reactions and to better understand and help my patients. I say more than "hmmmmm" or "ah-ha," or "Tell me what you think." I speak empathically and more directly with my patients. In fact, I speak (or try to) empathically and directly with colleagues, friends, associates, family, etc. I can emotionally connect with my patients by using myself. I understand my patients over time, the transference (reacting to someone in the present as one reacted in the past—"reenacting"), and oftentimes feeling and reaching for an in-depth understanding of my countertransference feelings and experiences (recognizing my own personal emotional reactions). I then can use these valuable tools(s) in more objectively understanding my patients and continuing along my own journey in emotional growth.
Like Jane, I too began a second treatment—psychoanalysis--in the 1980s--feeling more emotionally ready to look and understand myself--which on the surface looked only as a required training analysis. I wanted to learn more emotionally and grow and graduate from the oldest lay psychoanalytic training institute in the United States. Equally important, I wanted to enter a profession where I could help a variety of patients as well as unconsciously repair a dysfunctional family history. I wanted to know myself and have more than an intellectual understanding of myself. I desired significant and major change. I wanted to change, e.g., to become a competent professional, and continue to emotionally grow and repair. I am successful; I like myself and love my work.
With reference to alcohol, I like Jane abused alcohol when I became addicted to alcohol. I was addicted to alcohol very early in my life. Alcohol is a powerful legal drug that heightens, changes and conceals moods. Alcohol can medicate an emotional life, e.g., feelings, in an addicted person. Alcoholism is not ONLY a symptom of an underlying disorder. It is ALSO a progressive illness, which is debilitating and results in death. Without a significant abstinent period, alcohol conceals an accurate diagnosis. Alcohol abuse/dependency/alcoholism often overrides thoughts. Judgment is impaired in the addicted person. Alcohol is a legal drug and a depressive. Alcohol can give one an illusion of control when one is out of control. For a period in my life alcohol covered me—it obscured my feelings, thoughts, ideas, judgments, and core self. As long as I had a drink(s) of alcohol, it helped me avoid my feelings and escape, etc. It also induced angry feelings in me—the ones that frightened me. I have been drug free for over two-thirds of my life.
I believe that substance abuse originates in a complex interaction of bio-psycho-socio-cultural factors and persists to serve a multiplicity of functions for the abuser. These functions include self-medication of internal and external deficits; affect regulation and other aspects of self-regulations as well as management of narcissistic vulnerabilities and interpersonal activity. Control, in its various manifestations, also presents as a core issue for many addicted persons. In addition, any antecedent factors giving rise of substance abuse are generally worsened as a consequence of the addictive process. Problems directly caused by the progressive nature of addiction further imperil the affected person in relation to establishing a lifestyle free of maladaptive dependency. I believe that this complicated process becomes comprehensible and treatable when viewed from an integrative approach that relies on psychodynamic, cognitive-behavioral, and developmental prospective.
I am very connected to my soul, self and others. I like my anxiety, intensity, quick and accurate internal ("gut") reactions, and my keen intuitive and thought provoking mind. I particularly like to work with those individuals who present a challenge. Well, perhaps 50% of those that present a difficult challenge, e.g., borderline patients¸ other personality disorders, character and anxiety disorders, addiction disorders—the ones that are in and out of reality—are very creative! I can meet most individuals on their territory—being very aware of my own—and I’m available for in-depth two-session consultations (a "Heart To Heart"), short and longer voyages. One does not have to make any commitment to treatment with me, after a Heart To Heart. By all means, shop, shop and shop! I can help you, through my Heart To Heart to find someone you may feel comfortable with.
Yes, character may be steadfast. However, I believe anyone can change with a lot of good therapeutic work. The best treatment in my opinion is where one feels understood and accepted and has a good "working alliance" with a well-trained psychotherapist that emotionally believes in the power to change and knows himself/herself, thereby permitting the patient to embark on a voyage to embrace change.
I am fortunate. I enjoy good health. I appreciate my career. I am happily married. I was once a mute secretary. I was unhappily "single." Today, and for over 20 years, I am a committed lover, partner, wife, and stepparent.
Where would I have been without an unbiased and highly empathic professional helping me? The arousal of my tender feelings–my countertransference to Jane--was the result of remembering my second psychoanalyst—as well as my Dad. I was able to feel as a result of a very decent therapeutic experience. I shudder at the thought of less than ‘good enough’ treatments of other consumers in need.
Copyright 2006 Lana M. Ackaway, LCSW-R, NCPsyAv
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