James Gorney, PhD

yeah okay well welcome everyone and and and welcome uh jim so jim gurney phd is an independent practice in knoxville tennessee he's the author of a number of papers on innovations and psychoanalytic technique served on the staff of austin riggs center and is taught at new york hospital cornell duquesne and university of tennessee and just today i heard that he received the bertram karen award right at this conference so welcome and i'll let you get started well uh hi everybody and this is a conference about trauma and we've just gone through some traumatic experience ourselves um but we're back and thank you to karen for making such a swift recovery um in my paper which i'm going to present now is uh it's meant to address one of the conference themes namely that of the role of love in the treatment of trauma and extreme states and that's the treatment i'll be reporting and i also want to just mention this is a once per week treatment and i think it does demonstrate how far one can go even once per week in a psychoanalytically informed treatment bert karen captured the essence of the psychoanalytic relationship by observing quote when in life do we have a bright concerned person really trying hard to understand us no matter how confusing terrifying or obscure our daily life may be such active efforts at understanding guides the therapist's empathic affirmative responsiveness it ultimately provides the patient with a tool kit and a road map facilitating the journey towards self-knowledge and personal truth yet for psychoanalytic therapy to achieve full efficacy the therapist's quest for understanding must also be supported by the provision of security respect acceptance and a core belief in the patient's potential for loving human connection growth and change thus in its essence the provision of a psychoanalytically informed relationship can be understood as the offering of a special form of love eric fromm discerned four basic elements common to all forms of love they are care responsibility respect and knowledge these properties constituting the fabric of love are exactly the same basic elements which optimally constitute the foundation of psychoanalytic treatment many other previous investigators have talked about the role of love and treatment um brattoy a finnish psychiatrist said psychoanalysis is to love the patient um jonathan lear said that um psychoanaly in psychoanaly analytic therapy facilitates individuation and thus it claims in that sense he says psychoanalysis is a manifestation of love perhaps the most eloquent expression of this point of view was provided by forensies disciple deforest when she insisted that within a psychoanalytic relationship quote the healing experience of love makes way for a mutually loving relationship it's important to note however that the vast majority of analytic theorists and clinicians have avoided the term love in characterizing the therapist's role there's been an understandable concern to differentiate sharply the therapeutic relationship from enactments of romantic or erotic love while i completely am in agreement with this important differentiation i align myself here with those psychoanalytic practitioners who've delineated a special form of non-transgressive love which can be actualized within the transference counter transference matrix by the dedicated clinician sustained genuine therapeutic love assumes a particular significance in the treatment of traumatized individuals whose lives have become marked and shadowed by psychosis unrepresented experience and other extreme states the traumatized often become victims of stigma marginalization and injustice thereby they're also especially vulnerable to the painful experiences of shame guilt and poor self-esteem consequently in the treatment of extreme states the provision of therapeutic love becomes uniquely transformative insofar as it becomes a powerful vehicle for the offer of safe trusting reliable and truthful human connection in the words of the poet rilke love connects us consistentness that two solitudes protect and touch and greet each other within the context of the clinicians generative love a primordial yes is conveyed to the traumatized patient from the first moment of the very first session such consistent affirmation mobilizes the patient's eventual willingness to face and name her traumatic place this transmuting process has been precisely characterized by francois de boin and jean-max gaudier quote this first yes from the analyst is a primal affirmation that opens out the field of speech yes something happened something happened to you it's not all in your head and what you're showing is the only way you could bear witness to it the evocation and impact of therapeutic love and the affirmation of yes will now be illustrated through the following account of three years of psychoanalytic therapy with a patient tormented by terrifying episodic psychotic states within this treatment a deepening mutuality affection and emerging loving connection between the two participants facilitated subsequent revelation of long buried childhood trauma amy arrived for her initial consultation precisely on time this petite wiry obviously fit woman strode seemingly confident into my office then surprisingly she sat down rather stiffly and awkwardly on the edge of her chair directly facing me she was attractive simply but stylishly dressed no makeup hair neatly pulled back in a ponytail she carried a leather briefcase which seemed too large for her tiny body she was trying to look composed but her eyes were wide with some sort of as yet unnamed anxiety i asked amy to tell me something about herself and what trouble had led her here articulate and in control she told me that she was 35 had a successful career as an architect in a major local firm she stated with sincerity and conviction that she was very happily married to bill also an architect they hoped to have a family but had not yet begun to try despite a lot of pressure within her work setting amy for the most part felt quote really blessed in her life she loved her dog her house the house they had renovated by themselves her tai chi classes and her regular intense workouts yet there was a problem five years ago there began sporadic episodes of inexplicable immobilizing anxiety this would manifest as if for no reason and had been increasing both in intensity and frequency she was alarmed and completely baffled by these frightening episodes when i asked her to tell me in detail about the attacks she flushed teared up a bit and in a now tremulous voice said my stomach tightens i feel light-headed i can feel my heart thumping in my chest i start to feel completely overwhelmed and that something terrible is about to happen it most often happens in the middle of the night when it gets really bad i put my fingers on the side of my neck to take my pulse i'm so embarrassed at night when i have to wake that i have to wake up bill because i'm so scared when he holds me and tells me i'm going to be okay that's the only thing that can calm me down i can't live with this anymore i want to get to the bottom of it that's why i'm here by this point there were a few tears that she quickly brushed away i've been listening intently and for a moment i weighed whether i should respond at the deepest level i could given that this was just our first meeting i sensed a core of strength in this woman so i stated when you're alone in the middle of the night you become terrified that you're about to die with this many more tears kleenex several more i'm sorry i said you don't have to apologize for tears amy i can see that you're also a strong person i can be strong amy responded but not when i begin to go crazy in the dark very hesitantly she continued there's something i've never told anyone not even bill recently it's been getting even more terrifying i feel pinned down i can't move i see blinding lights flashing i hear voices but i can't understand any words i don't know where i am or even who i am nothing is familiar everything seems lost and i'm in so much panic i can't even move my hands to feel my neck pulse at any moment everything could disappear and i could disappear i'm so frozen and alone i can't even reach out to bill at this instance in her narrative amy's words evaporated and her face became a mask of wide-eyed terror i leaned forward toward amy made eye contact and said with some emotion the horror in the dark is feeling yourself at the very edge of death and being completely forever alone leaning even further toward her i continued through telling me this for the very first time you've let someone be with you even for a moment in that death-filled nightmare zone it must feel like touching a place of breakdown or madness should we agree to go together into that dreadful terrifying place you will not feel completely alone in it anymore amy held my gaze for a long time and then gathering herself she remarked there's something important in my history i think you should know when i was born the doctors discovered i had a serious birth defect there was a constriction in my aorta so when i was two days old i had open heart surgery i was one of the first infants in the country ever to have had this procedure my frightened parents didn't know if i would make it they were told i would have to have a more extensive repair when i was older so when i was five i had open heart surgery again and it was successful the doctor said i was good to go and i could lead a normal life but there was the possibility i might need another repair sometime in the future when i grew up amy told me that she lived in perpetual dread of the day she might find out that she needed a third open heart surgery so it's been really important to be strong and succeed in leading a normal life i observed definitely she proudly replied except for the past five years with that she shamefully hung her head and averted my gaze let me show you something i said i got up and took a picture off the wall and gave it to her to look at it's a small surrealistic oil painting i've had in my office for many years that contains the words you must remember my dear the past is still with us i remarked your night terrors are a way of trying to remember something if you come into therapy the two of us can examine your life and understand the meaning of your terror i'll go there with you amy's lips quivered and her eyes misted we thereby agreed to engage in once weekly psychoanalytic psychotherapy over the next several sessions we pieced together the story of amy's life her parents were successful professionals who provided an organized home and family for amy and her older brother the children were well cared for and were provided every material and educational advantage both of her parents however seemed rather emotionally constricted and were remarkably unable to talk about feelings or emotions with each other or their children an emerging theme was amy's life-long effort to be normal successful and most of all strong physically and emotionally she was a tomboy becoming a star gymnast in grade school and high school she always strived to be perpetually competent and well adjusted over time amy established a wholesome put together fresh scrubbed persona which concealed deep underlying anxieties not only from others but from herself as well within myself i felt a genuine admiration for amy's determination to be robust and healthy while at the same time i noticed emerging feelings inside of myself of protectiveness and tenderness in regard to a profound underlying vulnerability that i sensed within her after history gathering i observed to amy that she'd moved rather rapidly through her account of the second heart surgery at age five and we needed to go back and probe it in more detail since it had been such a major likely traumatic event in her life this spurred amy to query her parents recollections they recalled they'd been told by the hospital not to tell their child anything about the operation in advance lest it terrify her consequently amy was not informed until the day before the surgery that she was going into the hospital she herself vividly remembered being alone and scared in the hospital that night in those days parents were not permitted to sleep with their child on the pediatric ward to provide a soothing experience her parents further reported that amy was placed in the intensive care unit for several days after the surgery but amy asserted to me that she had no direct memory of the icu what she did remember was coming home it was june and not being able to go out and play with the other kids for a month feeling weak and confined her parents avoided speaking with her about the operation she painfully described that summer as being filled with sadness loneliness and confusion my heart was touched by this brave little girl so alone left all on her own to deal with such an overwhelming certainly traumatic experience i know your parents did what they were told and had the best of intentions but amy being in the hospital as a five-year-old having a potentially life-threatening operation and then spending days in the nightmare world of the intensive care unit was in itself a major trauma what was even more awful was that this very scary situation was made even more traumatic by your parents not preparing you for it and not being there for comfort and to help you express your feelings before during and after this terrifying experience no wonder you're now having panic attacks breakdowns and dread of death when you're alone at night stunned amy's face and voice suffused with raw emotion i never realized how my parents were not able to be there for me emotionally when i needed them i can't believe they let me be all alone in it i was only five years old she uttered this last phrase mournfully and then choked up bruskly wiping away a cheer a tear she said that's why i so need bill to hold and reassure me at night he always listens to me and never gets impatient i think i must have married him because he's so different from my parents in that way but i still can't tell him that sometimes now i'm afraid that i'm going crazy at that moment amy's usual efficient self-sufficient stance melted giving way to a soft open trustfulness thank you for understanding how scary this all is for me and it means so much that you do not think that i'm weak or going insane or just making something up out of nothing moved by your gratitude i answered amy you're a survivor a resilient survivor i trust you i believe you following these revelations amy became vocal in her enthusiasm about therapy claiming that she was quote starting to put together the pieces of the jigsaw puzzle of my life subsequently amy arrived for a session in an agitated state saying well i've got something big to report she had decided to take a nap and laying on the bed alone as she began to think about our discussions of her stay in the hospital at age five she began to feel a wave of emotions spreading over her a surge of grief engulfed her chest i'm afraid i'll start to cry now she said you can let all the feeling out i responded i'm right here with you sobbing now amy blurted out i felt so alone so afraid i didn't know what was happening to me i couldn't remember any details just this overwhelming dread you must have feared the worst i replied even though your parents never talked with you about your heart problem they must have been afraid that you might die right after you were born even after that first heart operation they must have been afraid for you over your first five years children know everything and you must have sensed that they regarded you as vulnerable your deep sense of vulnerability and dread has been there all the way from the beginning you come by it honestly as amy's night terrors now diminished markedly in frequency and intensity i told that it was time for us to understand what had triggered the onset of these eruptions five years ago amy began to focus on her parents divorce she had previously told me that they were divorced but at this point she revealed to me that they had gotten divorced six years ago the parents continued to live together for another year only finally separating and then telling amy and her brother well after it had been legally decided that they had in fact been divorced the two siblings reacted with shock and outrage at their parents having withheld this long delayed news that was five years ago and shortly thereafter amy's panic attacks and night breakdowns had begun amy recognized now how bizarre her parents handling of their divorce had been and how extraordinarily avoidant her parents were in dealing with emotional issues in the family by withholding critical information about the divorce from you they created further distress and pain down the road and i said this concealment repeated the very structure of what made it so extra frightening and incomprehensible for you when you went into the hospital at age five no wonder it brought up to the surface that little girl's anxiety and her not knowing her panic about death this connection triggered further anger and outrage as amy confronted her parents emotional avoidance and withholding how this had exacerbated her child's and hospital trauma how this had precipitated her night terrors five years ago she then blurted out dr g i really love you for always telling the truth to me knowing that i'm strong enough to take it i replied i love you back as amy who was strong and amy who could also be very scared with the onset of amy's panic attacks five years prior she'd become immediately alarmed by the accompanying hyperventilation and tachycardia catastrophizing there might once again be something structurally defective in her aorta consequently she had decided to travel and schedule an evaluation with the same cardiologist who had performed her original childhood surgeries yet the very thought of meeting with this cardiologist elicited an enormous sense of dread the subsequent process of exams and procedures mri uh like endocardi echocardiogram etc five years ago had were an excruciating nightmare for her convinced that the findings would indicate that she needed another operation the only thing that got her through it at all was asking bill to hold her when she became flooded with anxiety that was all you ever wanted i remarked amy was trembling now i just don't want to be so weak it's not weak it's being you just human i said that's why i'm here with you right now because you need it and deserve it not because you're weak amy replied i feel safe every time i see you i love you for that sometimes in the middle of your night of the night i imagine your voice or the way your face lights up every time you see me in the waiting room it makes me less afraid when she finally received the cardiologist's final report in the mail amy was so anxious she had to wait until bill came home in order to open the letter she then had to read the letter three times to absorb the very positive findings yet even this good report did not succeed in dispelling her underlying dread there is one thing that the cardiologist recommended five years ago that i haven't told you yet i think because i'm ashamed about something he said even though i'm doing great i probably should have another evaluation if and when i decide to try to get pregnant just to be sure i'm still in good enough shape to withstand the extra cardiac load during my pregnancy bill and i really want to have a family but i can't tell you how much i'm dreading going to the cardiologist again i can barely stand it when my internist takes my blood pressure i'm embarrassed to say it but dreading another visit to the cardiologist and being sure that this time i'll really get bad news has been the biggest factor holding me back from trying to have a baby momentarily she began to appear tiny and frail in the big arm chair her cheeks were starting to burn i responded amy when i look at you i see a strong woman with a big heart with this a few tears trickle down her cheeks and she silently mouthed thank you so much i love you it was then a long tender silence and the gift of her love struck a resonant chord within me we decided it was now time that amy focused more actively upon trying to get pregnant however amy remained very fearful and stuck in regard to step one the cardiologist while she wanted to find a new doctor that was local competent and humane someone would be able to seriously listen to her anxieties and concerns she remained stalled out highly anxious and did not know how to begin knowing many physicians in the community i offered to network and launch a search she was both surprised and moved by my offer i told her that i would put the same care into this search as i would if she were my own daughter i was able to identify a well-respected female cardiologist and upon consulting with her in regard to amy's situation found her to be knowledgeable caring and a good listener while amy was excited at the prospect of seeing a female physician it took her a few months to actually make an appointment we kept analyzing her fear but what finally broke the ice jam was when i said jokingly why don't you ask the cardiologist if you can bring a special friend to the appointment then i can go with you she giggled then i went on to say of course we really can't do that but you sure can take bill along for the appointment you don't have to be afraid all alone her eyes again welled up with tears and she said thank you so much it never would have occurred to me all i kept imagining was having to do it all by myself i will go with bill but you'll be right there with me in spirit absolutely i responded i'll be there with you every step of the way with great apprehension on her part amy and bill went to the cardiologist the examination and tests evoked less anxiety than she feared and she really liked and respected the doctor to her astonishment and delight she was given the green light to move forward and try to conceive amy was particularly pleased that she tolerated the exam and the procedure surprisingly well she attributed some of this to the receptive and gentle manner of the doctor but most particularly to the important preparatory work we had done together in therapy amy went off the pill and waited until the end of the first month she arrived in my office in an upset state as her period had arrived two days before this triggered a flood of self-doubt and bodily mistrust what if there was something wrong with her and she could never get pregnant i interpreted that there was a primordial mistrust of her body originally sourced within her cardiac birth defect she understood this completely but the doubt and mistrust persisted finally i said what you need to do is visualize your beautiful healthy egg with a big smiley face on it waiting hopefully to welcome a happy little wriggling sperm she laughed a lot but then actually pledged to visualize it delighted by her response i responded amy i have great faith in your strong healthy body one month later she arrived and could hardly contain herself guess what i'm pregnant now there were two smiley faces beaming in the room the first trimester proceeded without a hitch but there were many concerns started up in the weeks prior to amniocentesis she knew that the rick's risk of miscarriage due to this procedure were one in 1500 but she insisted that one could be me i was one in a million who had to have open heart surgery at two days old amy also struggled with related fears that the fetus might itself be found to have some defect perhaps even a cardiac problem we went on to investigate how pervasive the fallout from early medical trauma had been in her life affecting her experience of past present and future i shared with her devon and gaudier's theory of collapsed time whereby trauma from the past can be in the present or even in the future she immediately understood the concept in this regard i shared with her a section from a book i had just been reading which i told her had immediately brought her to mind intern by sandeep jauhar he observes quote i had read that patients who make it out of intensive care units often liken the experience to combat many suffer chronic anxiety and depression others develop post-traumatic stress disorder drugs like morphine and fentanyl are used not just for pain relief but to keep patients from remembering their suffering it's well known end quote it's well known that an extended icu stay can persimmon precipitate situational psychosis the tubes emerging from every orifice arm and body restraints constant bright light strange noises unfamiliar environment post-operative distress disorienting medication all can contribute to panic the emergence of psychotic fragmentation and breakdown i further reminded amy and you were only a small child in that unnatural insane environment alone by yourself in that suffering it was surely this icu trauma that was re-experienced and remembered via amy's panic attacks and night breakdown terrors amy choked up but there was great determination in what she then said i finally understand why big guy getting pregnant has been so important for me if no when i have a healthy baby and get to be a really good mom then i will finally stop living in fear it'll finish the jigsaw puzzle i will finally be able to finish our therapy there was a long pause now i'm going to get all teary again amy muttered somewhat self-reproachfully i replied we'll both have to deal with much sadness whenever our work ends but first we have a whole pregnancy to get through and then we'll have a baby's birth to celebrate important work lies before us i'll see you next week as she got it for to leave amy paused and with great serious stated seriousness stated this is not only bills and my baby this is our baby you and i are going to get through all that my pregnancy fears together and i'm going to be healthy and have a healthy baby seven months later amy arrived for what was to be her final therapy session she did not come alone this time nestled in a baby blue blanket she held one-month-old samantha jane in her arms like the greatest prize in the universe she spoke excitedly at length of her deep joy in motherhood this is very emotional for me eventually she offered little sam to me for me to hold i held the baby rocked her a bit and kissed her on the forehead when i looked up at amy our gaze locked and there were tears in both of our eyes she said thank you i will never ever forget you and i said thank you amy i will never ever forget you as well we stood up and shook hands that was the first last and only time that we ever physically touched and exchanged a sad and grateful farewell in subsequent years there have been news filled letters from amy always expressing gratitude accounts and pictures of sam's growth birth of a new baby sister a new home bill's new job all signed love amy perhaps this clinical account which i've provided here is similarly authoritative heartfelt letter from me in return back to amy signed and kind as love dr g very brief conclusion now has observed that quite quote very often it's the witnessing of the fruits of our labor in the form of the analyzand's newfound trust in us and in their hard-earned healing and growth that evokes and further stimulates our loving feelings end quote this certainly was the case for amy and me throughout our psychoanalytic journey together my emerging therapeutic love for this patient was rooted in and sustained by each of the four elements common to the form all forms of love postulated by eric from which i cited earlier in this paper thus i held amy in concerned consistent care within the treatment frame i exercised responsibility through accompanying her calmly and thoughtfully in her traumatic struggles and extreme states i showed her respect by maintaining ethical therapeutic boundaries and affirming her unique individuality i engaged her from the outset in a quest for knowledge personal truth and the exploration of long buried trauma it could be said that by treating this patient in the ways just enumerated i was only doing my job as a psychoanalytic psychotherapist that is exactly the central point here in reflecting upon my treatment with amy harry stack sullivan asserted quote when the satisfaction and security of another person become almost as significant to one as is one's own then a state of love exists thereby the discipline of analytic technique and the provision of the treatment situation itself are both essentially framework and vessel for the emergence of a special precious form of healing love that's it folks and i'm

Channel: ISPS US

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Keywords: psychosis, recovery, extreme states

Id: ks98bN1Oa0Y

Length: 40min 40sec (2440 seconds)

Published: Wed Oct 28 2020