psychoanalysis – PsychiatryTalk

Review of Newly Released DVD: Robert Wallerstein: 65 Years at The Heart of Psychoanalysis

Robert Wallerstein: 65 Years at the Heart of Psychoanalysis – Interviewed and Produced by Shelley Nathans (Available in DVD and streaming from www.psychotherapy.net)

If you are a psychoanalyst, a psychoanalytically oriented psychiatrist, mental health professional or a student of psychoanalysis, you will appreciate this interview with Dr. Robert Wallerstein by Dr. Shelley Nathans. It presents Dr. Wallerstein as a warm, knowledgeable man who understands the legacy of his profession.

Dr. Wallerstein was born in Germany in 1921 and came to New York City with his mother at age two, to join his father, a physician who had come the previous year. He grew up in the depression and recalled apples being sold by grown men for five cents apiece in order to make a living. He graduated from high school at the age of 15 and was sent to live with his uncle in Mexico City and then returned to Columbia University, graduating in 1941 at the age of 20. After medical school, he joined the army as the war was ending. He then took his psychiatric and psychoanalytic training at Menninger Clinic. His years at the Menninger Clinic, of course, are quite intriguing. I never realized that the program there had at one time 100 residents, which was one-eighth of the total number of psychiatric residents in the United States. He notes that during his psychiatric residency, the main tools to treat severe mental illness were Chloral Hydrate, ECT and lobotomies.

Although his training was in the United States, he was a witness and then a participant in the growth of psychoanalysis in this country. In the interview, Dr. Wallerstein was able to trace the plight of Jewish psychoanalysts in Germany and then in Austria, who during the pre-World War II years were not able to take Arian patients and then ultimately had to leave their native country. American psychoanalysts set up funds to bring these psychoanalysts to the United States, mostly to New York. Dr. Wallerstein described the fascinating details of this situation and also spoke of the German, probably Nazi oriented psychoanalysts, who came to Brazil and the unusual circumstances that happened in that country in the post-war years. He had occasion to conduct an investigation into the details of this situation in the 1980s.

As a faculty member at the Menninger Clinic he proudly described hiring a young psychiatrist from Chile by the name of Otto Kernberg. He also discussed his two personal analyses and candidly admits that he felt that they could have gone further than they did. He tells about meeting his wife Judith and her career as a well-known researcher who studied and wrote about the impact of divorce on children.

Dr. Wallerstein was barely at his mid-career when he moved to San Francisco in 1966 and became established at Mt. Zion Hospital. Perhaps, his greatest insights into the psychoanalytic world came during his front row seat as President of the American Psychoanalytic Association and then President of the International Psychoanalytic Association. He describes the famous “lawsuit” which, of course, was a turning point in allowing non-psychiatrist to join the American Psychoanalytic Association and take an equal role in psychoanalysis in the United States. From his unique perspective, Dr. Wallerstein was able to reflect on the roles of different schools of psychoanalysis and their influence in the United States and even labeled Anna Freud’s recognition as the “crown princess.”

Dr. Shelley Nathans showed excellent technique in her interview as she stayed out of the way of Dr. Wallerstein and gently led him to new topics. This interview was done in July 2013 one and half years before Wallerstein died. While this DVD was only 1 hour and 22 minutes, there are a total of over five hours of the interview with him available in the archives. We are very appreciative of the efforts of the team led by Dr. Nathans that captured this interview and most of all, to Dr. Robert Wallerstein for his many contribution to our profession.

To learn more information about obtaining this and other related videos, contact psychotherapy.net

Discussion of the Patient Who Slapped a Child

During a recent blog , I presented two case histories which I thought might stimulate different points of view on how to react to the situations described . I asked two colleagues if they would respond . Today I will restate the first case and then I will present their views. I will also print comments from readers I encourage anyone therapist or not to weigh in on these cases in the comment section .

Case #1

The patient is a 26 year old young women who came into therapy because she was depressed about her inability to complete things. She had started college twice and dropped out and as a adolescent she came home from sleep away camp twice. Her goal was to go to nursing school some day in the future. She had many friends but had trouble keeping a boyfriend, She was attractive but was somewhat inhibited and only on occasion would allow herself to have sexual relations which she would enjoy. Her parents were divorced when she was 6 years old. Her father is a physician would visit her periodically as a child and when she was older she would visit him and his new wife . She always felt close to them and their two children. Her own mother was an alcoholic and when she was younger her behavior was quite erratic. At time she was physically abused by being slapped around. Other times she would have to take care of mother by making food for her and sometimes would even stay home from school . Despite poor attendance she got good grades. She herself does not drink or take drugs. She shows no evidence of a major depression or psychotic symptoms. She is often moody but doesn’t appear to have hypomania. She becomes angry when she is disappointed. As a preadolescent she saw several therapists and she had 2 or 3 brief trials of therapy in the past 3 years including several weeks of a trial on an SSRI which she didn’t feel made any difference. She is currently in treatment with psychodynamically oriented psychiatrist who has decided not use medication at present. She has been coming for 4 months 2x/week ( Tuesday and Friday). She says this is the first time she is making progress in therapy as she feels she can talk freely and is not being judged.

During her last session on a Friday very close to the end of session, she said , Whatever we say here is completely confidential, isn’t it?” The therapist replied, “Why do you ask this question ?” The patient then went on , “ You know that baby sitting job that I have been doing every Saturday nite for Mr. and Mrs. Woodman my neighbor’s 15 month child.?” Well last week the kid was a real problem. He was whinning all the time and wouldn’t listen to me. The final straw was that he spit on me. I lost it and slapped him real hard across the face. His face got really red and swollen. I put some ice on it. I will never do that again.” The therapist, was stunned and before she could say anything, the patient said , “Well, I know my time is up” and got up and left.

Should the therapist do anything with this information. Is the therapist required to notify anybody? What are the legal and therapeutic implications ?

Response from invited discussant Myron L. Glucksman, M.D. Dr. Glucksman is a psychiatrist and psychoanalyst practicing in Redding Connecticut and New York City. He is a Clinical Professor at N. Y. Medical College and a training analyst at the Psychoanalytic Institute at N. Y. Medical College.

In my opinion, the therapist has no legal obligation to report the slapping incident because, so far, it is an isolated episode and apparently did not result in a serious injury to the child. The therapist should explore the patient’s feelings about her behavior; in particular, her angry feelings when she feels disappointed. I suspect that her anger is, in part, connected to her feelings of rejection and abandonment by her alcoholic mother. Evidently, she was not adequately nurtured as a child, and was exploited by both her parents in regard to having to take care of her mother. As a babysitter, she again finds herself in a similar position and becomes enraged when the child spits on her – re-stimulating feelings of rejection and humiliation. However, I believe the therapist should warn her of the legal consequences of similar abusive behavior toward the child or others in the future.

Response from invited discussant Sheldon Frank. M.D.

Dr. Frank is a child and adult psychiatrist practicing in South Florida.

There is no doubt that the information must be reported to the state child protective services immediately, with, of course, communication to the patient that this is being done. The legal and ethical mandates are clear, regardless of effects on the therapy. The therapy may perhaps be unaffected or strengthened–though not necessarily. Certainly a therapeutic relationship which covers up a reportable abusive act and denies the possibility of future risk to this child or other children being cared for by the patient does not help her in the long run. The outburst of violence on her part was so impulsive, so over-reactive to the baby’s acting like a baby, that even her sincere conviction that she won’t do it again is suspect. In addition to dynamic interpretation, the patient might benefit from other psychiatric treatment tools. Her life pattern, her complaint about not finishing things, and, perhaps, this outburst, may reveal adult ADHD (a continuation of childhood ADHD). (One can’t say from the data in this case, but ADHD children are much more likely to be slapped, neglected, and/or abused than other children.) A trial on stimulant medications is a safe and effective way both of confirming the diagnosis and treating. Alternatively, a search for mood swings and bipolarity might establish a mood-based origin of her action, and a mood stabilizer could help her self-control. We child psychiatrists often confront these diagnostic alternatives, and usually opt to test first the ADHD possibility because of the rapid onset and cleaner side effect profile of stimulant medications.

Since the account came out at the end of the session a day before the next baby-sitting engagement, there is a quandary as to how and when communicating the report mandate to the patient is handled. Some state laws require a report within 24 hours of receiving the information–which is defined as information containing the suspicion of abuse/ neglect. (It is the agency’s job, not the therapist’s, to distinguish between abuse and, say physical discipline.) Hopefully, the child protective agency would act promptly. Professionals have the right to anonymous reporting, so the agency would not tell the patient the source of the report–it could have come, after all, from the child’s parents. Still, the chance of the therapeutic relationship being damaged is greater if the therapist waits until the Tuesday session to deal with this complication. If I were the therapist, I would call the patient and ask her to return the same day to continue the session, and use that extra time (? without extra charge) to communicate to her the necessity of reporting. The therapist didn’t answer directly the patient’s question on confidentiality; if pressed, he could have reminded her that the only exceptions were situations in which there was the danger of harm to herself or others.

Initial comments from readers of this blog :

Well, when you said “dilemma” you meant it. In the first case, it weighs the betrayal of trust of a confidential relationship for someone who appears to be genuinely interested in changing her anger responses, against the safety of a very young child from abuse. My response given the details here would be to file a CPS report, and talk to the patient about the legal reasons why that had to be filed in a candid way and trying to help her see the situation through several points of view. Though it would be tragic if the therapeutic relationship were not strong enough to withstand this, a child’s safety must take precedence.- Heather Fretwell

I certainly agree with Dr. Glucksman in this mater. Dr. Franks by the book, rather concrete approach is useless and harmful, as long as the patient is cooperative and open to suggestions. There is a question though of whether the child might need help in understanding and digesting what happened so that a traumatic scar is not left in his mind. I might have insisted that the patient talk this over frankly with the parents and take whatever steps are needed to protect the child and see to the child’s mental health.

Arnold Robbins MD.

Cambridge, MA

Responses and opinions from any readers of this blog are welcome and will be added as comments. The second case will be discussed in a future blog

What Should a Therapist Do in These Situations?

Being a psychotherapist is a complicated job. Not only must you be knowledgeable about human behavior, psychodynamics and various techniques of doing therapy, but you have to be prepared for unexpected dilemmas . Two cases are presented below which bring up potential legal and ethical issues as well as technical considerations, which the therapist has to take into account to best help the patient.

These vignettes are based on real cases which I have either been involved with as the therapist or as the supervisor or I have read about them or have been told about them by a colleague. Some details may have been changed to protect confidentiality.

All the cases are at least 10 years old. Readers of this blog are welcome to express their opinion about the cases. We all recognize that in a real clinical situations, there would be much more information available about the patient which might help in making a decision.

In a future blog, I will present further discussion about these two cases.

Case #1

Should the therapist do anything with this information. Is the therapist required to notify anybody? What are the legal and therapeutic implications ?

Case #2

A senior therapist is supervising the following case. The patient is a single 36 year old dental hygienist living in Manhattan who is in her second year of three times / week psychoanalysis. She entered treatment because of difficulty trusting men which has been related to an inconsistent and insensitive father who shared with the patient the fact that he was cheating on her mother. The therapy has been going well and the patient has made progress in her ability to accept interpretations, have her own insight and utilize insight through her understanding of the transference.

The patient came into a recent session a little anxious and perplexed. She related the following incident . The other day after coming home from work she rode up in the elevator with a young man a few years younger than her who lives across the hall from her with whom she has a causal acquaintance. She believes he has a minor position in the union and always viewed him as trying to act like a wannabe tough guy but “a nice kid.” He was pacing back and forth and seemed scared and she asked if everything was Ok. He asked her if she had a beer or a drink. She invited him and gave him a beer. She distinctively heard him say half to himself, “ I can’t believe I helped put someone to sleep.” When she asked him what did he say, he said it was nothing. They chatted about incidental things and he thanked her for her time and left. She wondered if that were something serious like someone being killed but then became scared and changed the subject and got into talking about her family, dreams and other things that were all continuation of issues she had been recently talking about. The therapist didn’t see any direct or indirect references to this subject in the next two sessions leading up to the supervisory session.

Does the supervisor t have any obligation to either to suggest or urge his supervisee to try to influence the patient to report this information to the authorities and is the therapist or the supervisor obligated to do so.? What are clinical and therapeutic implications for the therapist to spontaneously bring up this incident if the patient is not talking about it ?

A Dangerous Method

A new movie titled A Dangerous Method is reviewed. It is about Carl Gustav Jung played by Michael Fassbender. It also includes Sigmund Freud played by Viggo Mortensen and Sabina Spielrein , one of Jung’s patients, played by Keira Knightley.

A recently released movie is all about Carl Gustav Jung, his life, his theories and his various interactions including one with Sigmund Freud. It as titled A Dangerous Method. I wrote a review of this film in a movie blog that I write with my wife titled FilmRap.net.

It is reproduced below. As always your comments are invited. In two weeks my next blog will feature an interview about this movie with Dr. Thomas Kirsch a Jungian analyst.

A Dangerous Method

As people who have some some acquaintance with psychoanalytic theory and it’s history, we were drawn to want to see this movie. The psychiatrist among the two of us found it a more enjoyable experience although we both found many deficiencies in the movie. This movie, directed by David Cronenberg, with a screenplay by Christopher Hampton which came from a book by John Kerr, of course is based on real people and highlights the break between Sigmund Freud and Carl Gustav Jung who at one time Freud had thought would be his heir apparent to the psychoanalytic movement. The movie starts off in the early 1900s as a young women, Sabina Spielrein (Keira Knightley) is involuntarily brought to the Burgholzi, a psychiatric hospital in Zurich, Switzerland, run by the famed Eugen Bleuler. Her exaggerated mannerisms and dramatic presentation suggests the type of “hysterical” patients who were known to be hospitalized in those days. Jung (Michael Fassbender) becomes her psychiatrist at the hospital and begins to use the new psychoanalytic method which Sigmund Freud (Viggo Mortensen) in Vienna has advocated. He ultimately is shown becoming drawn into a sadomachistic sexual romantic affair with her. Jung travels to Vienna and meets with Freud several times in which they discuss theoretical issues as well as this patient. Over time Freud is depicted as becoming disenchanted with his previously highly regarded younger colleague. The reasons for this rift would appear to be Jung’s willingness to go beyond Freud’s concept of sexuality and psychic determinism and bring in such ideas as the supernatural, premonitions, telepathy, religion and many others that were not explained in much detail in the movie. In fact, the more well known ideas of Jung about the collective unconscious , symbolism and dream analysis were not very well clarified.

Freud appeared to be concerned that any significant deviation from his main thesis and what he believed was the scientific method might be a reason for his theories to fail to gain wide acceptance. As best we can determine, in reality the actual affair between Jung and Speilrein was suspected, but historically it was not universally agreed that it had actually occurred. In this movie it is shown that Speilrein wrote to Freud and told him of her affair after Jung rejected her. Freud did not believe her and she subsequently is depicted as convincing Jung to acknowledge the affair to Freud who then gave this as an additional reason for cutting his ties with Jung. Once again Freud is very concerned about the appearance of his analytic movement and such behavior as an affair with one’s patient at that time as well as at present would be highly unethical. The nature of the affair and the meaning of their attraction to each other is really a key part of this movie, whether it actually happened or not. The characters in their dialogue state that Jung, who is shown being torn by the relationship, views attraction to his patient to be on the “dark side” and that with his wife on the “loving” side. Yet he declares his undying love for Spelrein and is bereft by her leaving him. We are not provided with real insight inot this relationship nor any significant understanding of Jung’s conflict. The film also does not do enough to explicate Jung’s ideas and their influence on Spielrein. While we more often proclaim that a movie should have been tightened up and shortened we believe this film needed a clearer illustration of the ideas that this story was supposed to be about. The acting in the film was very strong. The atmosphere of Freud’s office, the streets , people’s dress, horse drawn vehicles and early motor cars made it a wonderful period piece. But alas, as much as we were interested to learn about these people, we felt we came up short in our understanding as well as in caring about them.

Coming Soon : Q & A About This Movie with Dr. Thomas Kirsch

The next PsychiatryTalk blog will feature a special interview with Dr. Thomas Kirsch, a psychoanalyst and leading expert on Dr. Jung. In it Dr. Kirsch will discuss how well it depicted the various people in the movie as well as Jung’s theories.

First CAPA Graduation Held In China

CAPA stands for Chinese American Psychoanalytic Alliance which is an organization created by Dr. Elise Snyder a New York psychoanalyst. The organization runs a training program where mostly American psychoanalysts teach Chinese psychoanalytic students theory and technique as well as providing individual supervision all via Skype. The first graduation of this two year program was recently held in Beijing China .

Report From Beijing

In the future when Chinese psychoanalysts look back at the beginnings of what may be a vigorous psychoanalytic movement in China, they will remember October 24, 2010 when The Chinese American Psychoanalytic Alliance (CAPA) held the first graduation ceremony of it’s psychoanalytic training program at the Mental Health Institute of Peking University. I had the pleasure and the honor of attending that graduation.

Elise Snyder, M.D. Driving Force Behind CAPA

The creative and driving force behind CAPA is a New York psychoanalyst by the name Elise Snyder. It all began several years ago when she was visiting China with her husband Michael Holquist who is Professor Emeritus of Comparative Literature at Yale University and was attending a conference there. Dr. Snyder met several Chinese mental health professionals who were very interested in learning more about psychoanalytic theory and practice. This led to a series of visits to China by Dr. Snyder where she gave lectures, held various meetings and did some consultations. She returned several times and also became very involved during a subsequent major earthquake where she was helpful in advising about mental health services.

Dr. Snyder was encouraged to set up a training program for Chinese therapists and students interested in learning about psychoanalysis and psychodynamic psychotherapy. She began to involve American colleagues and utilized Skype an Internet Video Conferencing tool. This evolved into a program which was training Chinese psychiatrists and other mental health professionals in 4 different cities. There would be 4 hours of classes per week via SKYPE. Each class would be an hour taught by an expert mostly in the United States, although psychoanalysts in Canada, Australia and France also were recruited as teachers. In addition the students were required to have one hour per week of a supervisory session for their own clinical work also done by Skype with CAPA instructors. Many students chose to have their own psychoanalysis or psychoanalytic therapy mostly via Skype.

CAPA is Non Profit but Students Pay a Fee

CAPA is a nonprofit organization. The students do pay a tuition, the equivalent of about $1500 /year, which goes towards administrative expenses. The teachers donate their time for teaching classes and supervising students. Those students, who are being treated, pay very modest fees in the range of $5-25/session, which means that most of the therapists are essentially donating their time. The students themselves are usually employed as mental health professionals. Some are psychiatric residents working in a hospital or if graduated may be working in mental health clinics or a few may be in private practice. There are even medical school faculty members in China who have chosen to get the credential as a CAPA graduate. Others are psychologists, counselors or other mental health professionals who may be working in clinics, hospitals or other settings.

I was asked to participate in in the CAPA teaching program about one year ago. I subsequently have taught classes in Wuhan and Shanghai, both via Skype. I am now supervising a young psychiatrist who is in Qingdao, Shandong Province, an eastern coastal city of China. There is a 16 hour difference between China and Los Angeles where I am located. So for example, on Tuesday evening at 11pm I sit in my office and fire up my computer and will be viewing my supervisee and chatting with him for his supervisory session on Wednesday at 3 pm in China. While I was in China with the recent CAPA tour I meet with him in person.

CAPA has caught on in China and in the United States. There are over 200 faculty members who donate their time to the training of psychoanalytic theory and therapy in China. Approximately 30 students were graduated in Beijing in October. There were also informal graduation ceremonies for another 20 students in Shanghai and Wuhan. This means that this nascent organization of Chinese and American professionals has close to 350 members and counting. In Beijing and in other cities where I traveled as part of the three week CAPA tour, I met Chinese professionals and professional students who were eager to learn about CAPA. Many were preparing themselves for a career in the mental health professions and were anxious to get training through CAPA.

The Historic First CAPA Graduation

Prior to the historic graduation and the handing out of diplomas, there was an academic program for the CAPA students, the faculty and for other guests from the Mental Health Institute at Peking University. The moderate size auditorium was quite filled. First, there was a case conference, which was led off by Dr. Ba Tong, one of the graduates who presented a clinical case in which she demonstrated her knowledge of transference and countertransference. Dr. Cecile Bassen, a psychoanalyst form Seattle, sensitively discussed the case. We later met Dr. Ba Tong who came across as a very capable young woman who showed us pictures of her new private office, which she will be sharing with a colleague as they start their private practice in Beijing. The second part of the academic program was a presentation by Dr. Shari Thurer from Boston who gave a lecture on Sexuality and Gender identity in which she reviewed homosexuality, transgender sexuality and transsexuality. There was a very interested response from the students in the audience some of whom told of their clinical experience with patients.

The program concluded with a few words from Dr. Snyder who is now seeing her “baby” coming to fruition. She seemed quite proud, as she should be as she called the graduates to the podium. There were also many beaming faculty in the audience. Dr. Snyder announced that there would soon be an advanced additional two year segment available in the CAPA training program, making a total of 4 years of training being provided by CAPA. I later asked Dr. Snyder what she was thinking as she saw the graduates come up to the podium to shake her hand and receive their certificate. She said, “I felt overwhelmingly moved. I felt happy. I started to cry and couldn’t believe it was happening.” She want on to explain how proud she was of the students and the faculty. She viewed this event as an historical moment . She ended by saying “This is really the beginning of an interest in psychoanalytic therapy (in China) that arises from the bottom rather than from the top down.”