Gene Kelly At The Waldorf

This is the main lobby at The Waldorf. The clock is taller than it seems in the photo. That's probably why I never noticed the little lady liberty at the top.

I want to write about one of the discussion groups I attended, the Service Members and Veterans Initiative that I mentioned in my previous post, Waldorf 2015. As preparation, I watched "Combat Fatigue Irritability",  a short film directed by and starring Gene Kelly, which was made for the Navy, to make people aware of symptoms of PTSD. The film was only referenced, not shown, during the group discussion, but it was interesting to hear from his daughter, Kerry Kelly Novick, who led the group. I kept wanting to ask her the completely irrelevant question of, "What is it like to see your father on the big screen?"

She did mention that her father was quite steadfast in his insistence on an accurate portrayal of the main character, Seaman Lucas', symptoms and behavior. He even had himself admitted to a psychiatric hospital to prepare for his role.

In the film, Lucas had worked on a ship that was blown up. His job was to monitor the pressure valves. He never went topside as part of his work. He never knew what was going on. He was not a gunner, so he had no active outlet. All he did was monitor the valves, and feel increasingly frightened and helpless. When his ship was destroyed, and he found himself in the water, he felt relieved, but also horrified at watching his buddies die around him.
After he is rescued and recovered, he has a 30 day furlough, and he returns home. At first things go well with his family, but he feels increasingly isolated and not understood, has trouble reuniting with his girlfriend, startles and gets angry when her little brother throws a paper airplane at him, gets into a fight with a bartender, and starts to shake uncontrollably when he goes hunting with his father, after which, he is hospitalized.
The film shows his coming to terms with some of his feelings in group therapy. The psychiatrist is portrayed as kind but somewhat patronizing and paternalistic, and places an emphasis on "fear that wasn't handled properly" as the origin of Lucas' symptoms. He is also shown sedating him, immediately following Lucas' breakthrough in understanding.

There were a number of interesting points made by various people, most of whom work with soldiers or veterans regularly. One idea that I hadn't considered is that the characters portrayed in the film, like most men in the military during World War II, were just regular guys who were drafted. Whereas today, we have an all-volunteer military, so those who have chosen to serve have done so with the intention of making it their career. They want to remain in the service, which makes them that much more reluctant to acknowledge when they are having emotional difficulties.

There was discussion about Lucas acting as "bad" as he felt he was, for his wish to escape from the boiler room, and then watching his comrades die. And of guilt as a defense against helplessness. Someone noted Freud's comment about the soldier's conflict between the wish to live and the wish to be a good soldier.

Isolation was another topic that came up in the discussion group, as illustrated by the sense Lucas has of not being understood by anyone who hadn't had similar experiences. The idea was that it's important for the clinician and for family members to recognize that this is so, but that those suffering from PTSD symptoms can use this isolation to defend against acknowledging feelings of guilt at their reactions to traumatic events, and feelings of loss-that to truly return to their former lives, they need to recognize that they have lost the versions of themselves that existed before the trauma.

One analyst has been working on petitioning the AMA to include military history as part of the social history for the E/M CPT code. Her group wanted the wording to be, "Have you or a loved one been in the military?" So far, they've gotten "you", but no "loved one".

An unfunded (by the military) area that someone brought up was pets. He said that the military has put together some research to show that pets are not that helpful in recovery for veterans, despite having evidence to the contrary. Basically, the military just doesn't want to pay for it. I don't think I came across this document when I wrote, The Comfort of Dogs.

The question of funding is an interesting one, especially in light of the opinion piece published in the NY Times a couple days later, After PTSD, More Trauma, written by a veteran, David Morris, who sought therapy for PTSD, and was placed in Prolonged Exposure Therapy, heavily promoted by the VA for its effectiveness. In this type of treatment, the patient repeatedly reviews his traumatic experience, over the course of a number of sessions. This turned out to be a bad choice of therapy for him, and he got worse, until he dropped out. He later underwent the VA's other PTSD therapy, Cognitive Processing Therapy, which he found helpful.

Morris notes the VA's contention that 85% of PTSD patients are helped by Prolonged Exposure Therapy. He cites a 2013 JAMA Psychiatry paper, Effectiveness of National Implementation of Prolonged Exposure Therapy in Veterans Affairs Care, that demonstrates evidence supporting the use of this treatment. It's open source, so you can read the whole thing, if you like. As usual, I'm skeptical about research that involves nothing but before and after checklists to establish efficacy, and a treatment for which the clinicians received 4 days of training, and then provided 8-15 sessions of therapy including, "(1) imaginal exposure or systematic and repeated exposure to the traumatic memory; (2) in vivo exposure or systematic and repeated engagement with nondangerous activities and situations that have been avoided because of trauma-related distress; (3) psychoeducation about treatment and common reactions to trauma; and (4) breathing retraining," to treat something so complicated.

Morris then goes on to state:

After my experience with prolonged exposure, I did some research and found that some red flags had been raised about it. In 1991, for example, Roger K. Pitman, a professor of psychiatry at Harvard Medical School, conducted a study of exposure therapy on Vietnam veterans and observed some troubling complications: One subject developed suicidal thoughts, and others became severely depressed or suffered panic attacks. A similar study, published in the Journal of Traumatic Stress in 1992, found that Israeli army veterans experienced an increase in the “extent and severity of their psychiatric symptomology.”

My concern is that the military has strong motivation for funding the most cost-effective, and not necessarily the most effective, treatments. No doubt it feels compelled to conserve its financial resources for use in war-related technological advances that will create more soldiers with PTSD.

It's also interesting to think about the contrast between what the military thought was useful treatment for PTSD back in 1945, and what it thinks now.

It was quite moving to hear people speak about their work with soldiers and veterans. Here's a link to the Service Members and Veterans Initiative page, if you want to learn more about the program.

The Rest of the Meeting

As much as I enjoy the annual APSaA meeting at the Waldorf, I find it exhausting. So I only have three more groups to write about, because that's all I could manage to get myself to.
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D. W. Winnicott

1. A Winnicottian Approach to the Treatment of Children and Adults with Asperger’s Syndrome: The Psychic Impact of Neurological Difference

This was another case-based group, so I'll have to stick to theory. A member of the British "middle school" (that's halfway between the Kleinians and the Freudians), Winnicott was a quintessentially British pediatrician. He had a drawing game he would play, particularly with children, where he would begin a drawing, and the child would add something, and they'd take turns, until he got a sense of what was happening emotionally for the child. His intuition with patients was astonishing. In The Piggle, he writes about his treatment of a young girl who went by the nickname, "Piggle". Her family lived far from him, so there were long stretches when they weren't meeting regularly. After one of those periods, she came to his office, and as soon as he opened the door and looked at her, he knew, without being told, that she needed to be called by her real name from then on.
Winnicott's writing is a little strange. His style is clear, but his concepts are often paradoxical. He was the originator of the term and concept, "transitional object", which he describes as an object that exists somewhere between fantasy and reality:

...the third part of the life of a human being, a part that we cannot ignore, is an 
intermediate area of experiencing, to which inner reality and external life both contribute.

If you've never read the paper, link to it, above. It's worth the time and effort.

He also originated the concepts of the "good enough mother", and the "holding environment". It's this last that is relevant for the treatment of Aspergers, or Autism Spectrum ( a term I seriously dislike, for reasons I can't get into).

Basically, the mother (or whoever is in that role) creates a safe, controlled environment for the baby, using her affection, often physical, and empathy for containment. "Spectrum" babies have great difficulty tolerating that kind of interaction, which they experience as intrusive. So from the get-go, things are different for those babies.

The presentation was about coming at the treatment from this perspective, and a lot of the focus was on helping the patient deal with the anxiety that goes with interacting with the world, for those with Aspergers, including pharmacological.

Nuff said.

2. Facing the Facts: Self-Disclosure and the Analytic Relationship

This group dovetailed nicely with the one about  the Analyst's Experience of Loss and Death, but it had a very different feel to it. There was something going on with the group, or the presentation maybe, that created a different environment in the room, so that people were not particularly forthcoming with their own experiences surrounding self disclosure.
There's always the tension between how much one tells ones patients about oneself, and how much one withholds. And either side can constitute a technical error. One thing that's difficult for people to talk about is the degree of sadism that exists in withholding information from patients. It's hard to remain cognizant of that, and at the same time, remember that there are good technical reasons not to tell the patient much about oneself. And I think that discomfort played out in the group discussion.

3. Research in Psychoanalysis: Concepts and Methodology of Single Case Research: the On-Line Archive

I was really excited about this group, and unlike the psychotherapy training group, I was not disappointed.

I've been thinking about this for a while. The typical analytic paper involves an initial section about the general topic, say, perversion,  with some relevant literature referenced, followed by a case presentation, including process, and finally a discussion. So what you're talking about here is an "n of 1".
The thing is, there are a boatload of "n's of 1" out there, so why not combine them into something analogous to a meta-analysis.

Well, this is happening. And it's called a "Meta-Synthesis"(qualitative, rather than quantitative). A group from the University of Ghent, in Belgium, is doing this work. They've compiled a whole bunch of single cases, and are starting to mine the data these cases generate.

They have a website, in English, called the Single Case Archive, where you can sign up for free, and search for different parameters within papers that have already been published. It's still pretty primitive, but it's expanding.

At the meeting, the Ghent people started out talking about why they decided to do this work. They were concerned about the overestimation of the quality of measures. In particular, with convergent validity. They modeled this, and it turned out that, if there are three different outcome measures used for the same data, the convergent validity is extremely poor (correlation coefficient 0.0-0.45).

They also modeled the impact of the measurement error, and it turns out to be abysmal.
Say you have a perfect measure, and you use it to measure 2 variables, x and y, and it turns out that x and y have a 0.60 correlation. If you then re-measure using a measure with a 0.45 correlation with the first, perfect measure, you will find that there is only a 0.12 correlation between x and y. So the true correlation between x and y is 0.60, but with a crappy measure, it looks like it's 0.12.
They figured this out with something called "Spearman's Disattenuation Formula".

One of the speakers showed a graph of a treatment, where interpersonal factors were being measured. There was an unequivocal improvement in the patient's ratings over the course of the treatment. However, this happened to be the speaker's patient, and he knew that the treatment was a disaster, and that the reason her interpersonal measures improved was that she was completely isolating herself.

So context is key, and you don't get that kind of data from a checklist. You get it from a detailed description. I can't wait to see where this research goes.


Well, that's my take on this year's meeting. Signing off.

Tales from the Waldorf

This week is the annual winter meeting of the American Psychoanalytic Association (APSaA), which always takes place at The Waldorf in NYC. I'll be attending a number of the sessions, and I'll report back on what I learn.

The first time I attended the meeting, I was a PGY-3, because my supervisor, a truly hard-core analyst, encouraged me to go. I was a bit skeptical, so instead of putting in for conference time, which I probably wouldn't have gotten anyway, I scheduled my call so I would be post-call on the first full day of the meeting (I could leave the hospital by 11, and I was off the rest of the day). Of course, I hadn't slept at all, and by the time I got there, I was psychotically tired. I'd never been to The Waldorf before, and I had no idea where I was going, but I spotted a man wearing a tweed jacket and a cashmere vest, and I figured he must be an analyst, so I followed him.
Worked like a charm.
In retrospect, I'd have to say that attending the meeting that first time was a nodal point in my decision to pursue analytic training. It was a bit intimidating-try sitting in a room with 50 analysts talking about masturbatory fantasies (not their own)- but people were warm and encouraging. They had a very reduced fee for residents, something like $25-, and they had special sessions intended just for residents and students.
The important part, though, was the experience of listening to case presentations. I was a PGY-3 then, so I'd written and listened to my share of intakes and H&P's. I had never heard a case presented in this way. I had never walked away from a case conference in residency or medical school with such a full, deep understanding of who the patient was-what his early life was like, how it influenced his way of being in the world, how he relatedness  to others, what his wishes and fears were, his sense of values, his conflicts, fantasies, imagination, sexuality, anxieties.
Amazing.
And even better were the questions people asked. The first group I attended was about Psychoanalysis and Technology. I went in thinking (granted, I hadn't slept) it would be about what technologies were useful, what new and cool gadgets were on the horizon. No. It was more like, How does one handle silence in a phone session? Has the patient put the phone down? Did the call get cut off? Is there more tension because there's nothing to look at? In a long distance analysis, where does one position the video camera? Should it be pointed at the analyst, or the ceiling above the couch? Where does the patient place her camera? What is the meaning of the camera to the patient? Does it become an object that represents attachment to the analyst, the way medication can? Does it contribute to voyeuristic fantasies?
Again, different from and so much more than I was accustomed to.

There are hundreds of discussion groups, workshops, symposia, etc. There are sometimes fun talks on Saturday afternoons. One year they had Lorraine Bracco talking about her role as the psychiatrist on The Sopranos. They had Andrew Jarecki showing extra clips from Capturing the Friedmans. They had Daniel Menaker speaking about his book, The Treatment, a novel about a man in analysis, and at the same talk, Oren Radovsky, who directed the movie based on the book.

Here's a smattering of some of the groups:

*The Analysis of Masturbatory Fantasies: Theory and Technique (I believe that's technique of analysis)
*The Integration of Psychoanalysis and Couples Therapy
*Schizoid Modes in Narcissistic and Borderline States
*Freud as a Letter Writer
*Pharmacotherapy and Psychoanalysis
*Conversations for Analysts: the Embodied Experience of Analytic Listening
*The Analyst's Pregnancy
*Effects of the Holocaust on Survivors and Family Members
*Emerging Perspectives on Gender and Sexuality: Online Relations
*Psychoanalysis of Twins
*Edward Albee's "Who's Afraid of Virginia Woolf?" Are You?
*Love, Sex, and the American Psyche: Political Sexual Scandal
*Psychoanalytic Aspects of Assisted Reproductive Technology
*Trauma and Mastery Through Art: The Life and Work of Frida Kahlo
*Research on the Relation of Psychoanalysis and Neuroscience
*"Facing Death" Psychoanalysis and Psychoanalytic Psychotherapy of Patients with Cancer
*Privacy: A Quaint and Anachronistic Concept? (for residents, trainees, and students)
*Happy Endings in Real Life and in the Cinema

I'll get to the details of the groups I've attended in the next post. So far, four, on supervision, psychotherapy training, psychosis, and loss/death.

Til Then...