Review – Living Out Loud

Living Out Loud

A review of Clinical Implications of the Psychoanalyst’s Life Experience: When the Personal Becomes Professional, edited by Steven Kuchuck (2014), Routledge New York, 254 pages

By Sandra Buechler PhD

Originally published in Psychoanalytic Perspectives, May 2014, pages 198-204. Download full text.

What is the opposite of shame? I have always felt that it is self respect, rather than pride. This immensely engaging and significant book charts its contributors’ struggles to more fully assimilate their personal experience in how they work clinically. Each chapter can be read as a “coming of age” story in which a clinician faces and, eventually, embraces how our life histories shape the therapists we become. I felt as if the contributors were confiding in me, trusting me to listen empathically as they expressed their anguish, confusion, humiliation, and sorrow, as well as their moments of transcendent joy.

Perhaps some will find it odd that joy predominated as I read this book. After all, it includes reflections by Anna Ornstein (“Reflections on the Development of My Analytic Subjectivity”) on how her World War II concentration camp experiences have informed her analytic approach. Contributors opened their hearts to us, letting us hear how they have suffered physical and emotional abuse. They have allowed us entry, as they wonder how private life experience translates into overall theoretical preferences and moment-to-moment choices in sessions with patients. Each chapter called out a wide array of feelings, including intense sorrow. But while I listened to these authors tell me how it feels to be them, joy was my most frequent companion.

Of course, this speaks of me, as well as of this book. But I believe that many readers will feel joy as they witness the alchemy through which intense personal suffering transmutes into deeper compassion for oneself and others. My own joy reflects how much I identified with these writers and rooted for them. I wanted them to triumph over external and internal obstacles. In what follows, I discuss only a few of these obstacles, since it would be impossible for me to encompass them all in the space of a review. I will focus mostly on struggles to combat shame, forge a personal/professional identity, and integrate personal experiences of mourning into one’s clinical approach. I am aware that my emphasis reflects what most moves me, and other readers would select differently. This book provides such a rich array of human struggles that I challenge anyone to read it through without reaching for the tissues.

Surviving shame is a significant challenge for many of these authors. Personally, I think survival itself can be at stake when shame is intense. Excruciating shame is the subject of many of these chapters, but I will single out a few examples. Sally Bjorklund (“How Betty and Vincent Became Sally and Scott”) wonders if unacknowledged shame kept her from revealing that she was adopted until she was invited to contribute to this book. Kenneth A. Frank (“Out From Hiding”) expresses the acute self doubt he felt as a beginning clinician. Bluntly he admits, “During those early days, I felt ineffectual, like a poseur” (p. 66). Speaking for many of us, he remembers feeling that his “… lonely struggle to establish a sense of competence seemed to me at the time my unique problem” (p. 68). As Stephen A. Mitchell (1992) commented, we often treat our most challenging patients early in our careers, when we have not as yet accumulated experiences of being capable. The inexperienced clinician can suffer acutely shameful feelings of insufficiency.

Galit Atlas (“Sex, Lies, and Psychoanalysis”) poignantly describes what it was like to watch her Arab relatives try to cover up where they came from as they struggled to adapt to living in Israel. She portrays what it is like to have no home, to come from the “wrong” place, with the “wrong” language, music, and assumptions about sexuality. Eric Sherman (“Sweet Dreams Are Made of This”) tells us how being gay and coming out have affected his stance as an analyst and author (p. 115): “Having spent so many years hiding, it is imperative for me to be as open as possible, especially in my writing.” Sherman suggests that coming out is a good metaphor for the analytic process, since it entails getting in touch with previously dissociated aspects of the self. We listen as Sherman struggles to tell his college counselor about being gay, and we breathe a sigh of relief as she is neither shocked nor judgmental. Sherman reflects that his shame might have been exacerbated if the counselor had tried to take it away. Describing a key moment, Sherman gives us a beautiful example of a clinician’s graceful tact. “Intuiting the importance of the moment, she allowed me to tell my sneaker and she touched my soul. Here was the recognition I had always craved” (p. 117).

Deborah Pines’ chapter (“Stroke and the Fracturing of the Self: Rebuilding a Life and a Practice”) takes us through her harrowing experience of loss of her old self as she struggles to recover from a stroke. I was particularly struck with the shame she felt as she coped with disability. Pines expresses her feelings with courageous clarity. “As a result of my stroke, I have suffered tremendous shame with my patients, my colleagues, and my family. I still have the sense that I am less than they are, less than I was, and I’m constantly afraid I will always be less than I hope to be” (p. 232). Why are we ashamed of our illnesses, as though they were failures?

Reading this book has motivated me to revisit the subject of shame, in treatment and other walks of life. I have always liked Cal Izard’s definition.

Shame occurs typically, if not always, in the context of an emotional relationship. The sharp increase in self-attention (and sometimes the increased sensitivity of the face produced by blushing) causes the person to feel as though he were naked and exposed to the world. Shame motivates the desire to hide, to disappear. Shame can also produce a feeling of ineptness, incapacity, and a feeling of not belonging (Izard, 1977, p. 92).

Since treatment requires self exposure, it should not come as a surprise that it often engenders shame (in both participants). In my own work (2008, 2012) I have especially focused on the analyst’s vulnerability to shame, or, in Izard’s words, feelings of ineptness, incapacity, and not belonging. By generously sharing their experiences, these authors encourage us to formulate our own. They help us get in touch with the moments in sessions, and in our private reflections, when we feel insufficient in some sense. Given the nature of our work, how could it be otherwise? Patients come to us in profound despair, questioning the meaningfulness of their lives, tortured by anxiety, sunk in depression. At any moment we might be confronted with situations that correspond to our own worst nightmares. Personally, I don’t believe any training, or theory, or analytic stance can (or should) insulate us from feeling ill-equipped at times. No matter how modest our claims about what our work can and can’t accomplish, faced with life’s ultimate perplexities every hour, we are bound to have these moments. As I see it, for the clinician, falling short at times is inevitable. The challenge lies in how we live those moments. Reading this book can facilitate our living them out loud.

In my own book (2012) about the stages of a clinician’s career, I suggested that how we bear our shame experiences can make the difference between resilience versus early burnout. Just to give one example, when a patient terminates treatment abruptly, or unilaterally, or prematurely (from our point of view), clinicians frequently question whether we have failed in some sense. The authors in Kuchuck’s book can serve as models of meeting these feelings head on, and having the courage to share them. I believe this can contribute to detoxifying them, so they are less likely to promote early burnout. To me, burnout is a kind of death. It marks the loss of belief in the profession and/or oneself as a practitioner. Moments of shame and sorrow, if ignored or not properly mourned, pave the way to burnout. Careers, as well as people, can die of shame. Both events are more frequent than some might think. People die of shame every day. They are willing to kill other human beings or die themselves because someone insulted their family, or their country, or their religion. They commit suicide rather than face the shame of bankruptcy, or failure in school, or work, or love. Some people kill themselves when a bully threatens to expose their “shameful secrets.” Some take their time dying of shame, spreading it out over a lifetime, while others exit abruptly, but dying of shame is as old as humankind. Similarly, some of us burn out gradually, losing passion with each year we work, while others suddenly can’t face the rigors of practice.

Some of the authors explore how they developed their particular analytic identities. Experiences of shame and grief figure in many of these accounts. For example, Joyce Slochower (“The Professional Idiom and the Psychoanalytic Other”) examined how becoming clearer about her analytic self definition resulted (in part) from disidentifications (p. 40). “The ‘other,’ a partial caricature of an alternative, clashing theory, served an important organizing function; it helped me delineate and solidify my self-definition.” As I read it, this process was not without its painful moments, for example, when Slochower was accused of mixing up social work and psychoanalysis after offering parenting suggestions to a vulnerable patient who seemed to need them. I hear the supervisor as trying to shame Slochower with the most overused put-down in our field: “This is not psychoanalysis!” I think labeling someone’s work this way is an attempt to induce the feelings of ineptness, incapacity, and not belonging that Izard associated with shame (see above). Developing clarity about one’s position through opposition is also illustrated in an especially frank chapter by Irwin Hirsch (“Emerging from the Oppositional and the Negative”).

In his introduction, Kuchuck (p. xx) mentions a particularly pernicious example of shaming. “Having key elements of oneself labeled pathological, especially by the field you have turned to for healing, professional identity and development, wreaks havoc with even the most securely formed psyche.” When writing psychoanalytic papers, Sherman (see above) wonders (p. 115), “Will I be criticized or ostracized by the cool kids, in this case well-respected analytic thinkers? Will I be found wanting?” To me, these words convey how fully the author understands that, in our field, it is still distressingly likely for us to be judged inadequate when we “come out” in any sense. Sherman’s way of expressing what he fears (“found wanting”) is so poignant. The analytic authorities or “cool kids” can dismiss anyone who they decide is not up to snuff. And it can be particularly humiliating if it is discovered that the outcast really wanted to belong. Thus fearing one will be “found wanting” is a particularly apt double entendre.

Other obstacles encountered in developing a self-respecting professional identity include Chana Ullman’s stirring account (“The Personal Is Political, the Political Is Personal: On the Subjectivity of an Israeli Psychoanalyst”) of reconciling her personal, political, and analytic selves, which didn’t always easily integrate. Michael Eigen (“Moments That Count”) expresses how his development of an identity (analytic/personal) was affected by meeting Bion and Winnicott. Both encounters helped free Eigen to bring his whole self to his work. As Eigen describes his meeting with Bion, “As with Winnicott, a message came through: If he could be Bion, I could be me” (p. 134).

In his own chapter, Kuchuck (“Guess Who’s Going to Dinner? On the Arrival of the Uninvited Third”) describes a particularly challenging event, when his personal and professional lives crossed paths. I found his heartfelt effort to remain forthright, tactful, and empathic deeply moving. A crossover was also the subject of Hillary Grill’s beautiful account (“The Importance of Fathers”) of the reverberations of her father’s illness and death, and the experiences of one of her patients, whose father was treated for a brain tumor. In his chapter (“Becoming an Analyst: At Play in Three Acts”) Philip Ringstrom explores how his personal experiences during his wife’s miscarriages have informed his analytic stance, particularly in relation to trauma. In his conclusion, Ringstrom encourages “… all analysts to investigate the developmental roots of their thinking as an invaluable part of the work” (p. 159).

A chapter by Noah Glassman and Steven Botticelli (“Perspectives on Gay Fatherhood: Emotional Legacies and Clinical Reverberations”) touches on the themes of shame and identity formation, as well as the relationship between mourning and psychic change. As Glassman and Botticelli raise their son together, they face some of their own painful experiences growing up. Botticelli writes of the wish to put pain and shame behind him as part of the impetus for having a child. But this striving encumbered his clinical work with one patient, Gary. In Botticelli’s (p. 175) words, “… in making his life a memorial to seemingly irreparable damage, Gary succeeded in forcing me to feel again the shame and failure of my own childhood and young adult life, made me confront my idea of having ‘moved on’ as a turning away from something I could never fully separate from … .”

Botticelli believes that sometimes being a witness to injury is all we can do. Knowing that pain, shame, and loss are inevitable parts of life, what can we wish for each other? For his son, Botticelli wishes that “whatever the pain he experiences in his life, he’s able to make the most of it” (p. 176).

This brings me to the last of the three themes I highlight: how mourning informs treatment. In her chapter (“I Wanted the Stuff of Secrets to Be in the Light”), Susie Orbach states, “Our job requires us to enter into the emotional territories of hopelessness, mourning, and despair and not deny them” (p. 23). Like mourning, treatment doesn’t advance by flinching. Bonnie Zindel’s description of her analysis with Emmanuel Ghent (“A Bird that Thunders: My Analysis with Emmanuel Ghent”) includes a touching expression of what it was like for her when he died. I can’t remember a more vivid depiction of the idea that mourning often requires us to find ways to continue the relationship (rather than relinquish it to make room for new “cathexes,” as Freud at first believed). In Zindel’s (p. 222) words, “Time was up according to my Manny clock. I can talk to him outside of sessions. Walking down the street. I can summon his voice and when I need him, he appears. For him, in the real world, time is up, but in my being, our time is endless. If one can invent a clock, I can invent time.”

In her moving account of how experiences before, during, and after World War II affected her outlook, as an analyst and as a human being, Anna Ornstein (mentioned above) compares analytic change with the process of grieving (p. 92). “The psychological processes that bring about lasting changes in the course of an analysis are closely related to the processes of mourning; the two processes have a great deal in common. Mourning, writes Bowlby (1963), “is not restricted to the loss of another, changes of all kinds involve the process of mourning; moving progressively forward, we are continually mourning the loss of the old.”

At the age of 100, Martin Bergmann gives us all the enormous gift of his chapter, “Psychoanalysis in Old Age: The Patient and the Analyst.” This chapter reflects the deep- in-the-bones wisdom of a man who has devoted his life to studying the human condition. Writing about the treatment of older patients, who may have to face profound regrets as they review their lives, Bergmann succinctly states, “The therapist’s main function in the examination of the life lived is not to allow it to fall under the domination of the superego and result in depression” (p. 239). This is truly challenging. Can we help others (and ourselves) confront what must be mourned, secure that the love in our relationships, and in our own hearts, will rescue us from succumbing to unending despair?

I conclude that to mourn, to age, and to treat require faith in our own ability to sustain passion for life, despite whatever brings us shame and sorrow. What does it take to maintain that passion throughout our careers? In my own work I have emphasized two ballasts: an “internal chorus,” and a “non-narcissistic investment in life.” The internal chorus is the array of the voices of inspiring people we encounter in training and beyond. I suggest (2012) that it is especially important that these voices protect us from overwhelming shame or grief as we face the countless losses in a clinical career. A (relatively) non-narcissistic investment allows us to care about the patient’s life, our own life, and the treatment’s life, without worrying about how our work makes us look to ourselves or others. To make this investment we have to have a sturdy faith in ourselves as clinicians, so we don’t need today’s sessions to prove anything. When we can make relatively non-narcissistic investments in our patients’ lives, bolstered by a supportive internal chorus, we can find sustaining joy in our work. We can feel inspired by the privilege and challenge of making a difference in others’ lives.

But, as this terrific book teaches us, we have to be able to face how our particular characters and life experiences impact us as clinicians. I think Eric Mendelsohn put it beautifully in his chapter on what it was like to see patients while he was going through a separation from his wife, after 29 years of marriage. Reflecting on how his personal situation was affecting him as a clinician, he concludes that psychoanalysis “… is of us, and reflects our deepest passions and commitments. We engage in what we do with the entirety of our beings during times of relative equanimity, and times of disturbance and destabilization. Who we are gets carried in our work” (p. 204).

These authors engaged in what they wrote, with the entirety of their beings. I loved this book. I felt sorry when I finished it, until I realized that I never will.
References

1. Buechler, S. (2008). Making a difference in patients’ lives: Emotional experience in the therapeutic setting. New York: Routledge.
2. Buechler, S. (2012). Still practicing: The heartaches and joys of a clinical career. New York: Routledge.
3. Izard, C. E. (1977). Human emotions. New York: Plenum Press. [CrossRef]
4. Mitchell, S. A. (1992). Foreword. In R. W. McCleary, Conversing with uncertainty: Practicing psychotherapy in a hospital setting (pp. xi–xvi). Hillsdale, NJ: Analytic Press. [CrossRef]

Upcoming Presentations

October 11th-12th, 2017: Grand Rounds Presentations to Department of Psychiatry at SUNY Upstate Medical University and APsaA Psychoanalytic Study Group, Syracuse, New York.

October 21st, 2017, 9AM: 40th Annual International Association for Psychoanalytic Self-Psychology (IAPSP) International Conference: "Empathic Depths and Relational Leaps: Creating Therapeutic Possibility" Panel Discussant for “The Analyst's Subjectivity: A Double-Edged Sword”. This Panel's participants will provide clinical material and theory to further our thinking about the double-edged sword of the analyst’s unique subjectivity as it emerges in specific analytic relationships: the double edge being that the analyst’s subjectivity is the only lens through which we can see and engage therapeutically with our patients but at the same time is an aspect of the analyst’s person that at times can create barriers to emotional intimacy or pull for particular manifestations of the patient’s pain and his problems in living.
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December 9th, 2017 9 AM - 12:30 PM: Institute of Contemporary Psychotherapy and Psychoanalysis Annual Conference. The Love That Dare Not Speak its Name-- On the Therapeutic Action and the Limitations of Romance and Desire in Psychotherapy and Psychoanalysis. This presentation will address an historical and current-day taboo; the loving, romantic, and erotic feelings that often arise on both sides of the couch, but seldom get discussed in the literature. Through exploration of newly evolving theory and detailed case examples, Steven Kuchuck will explore ways in which these therapist--patient subjective responses become a vital component of the therapeutic action and/or interfere with progress in treatment. Particular attention will be paid to the implications of these dynamics for male analytic dyads in which sexual orientation is discordant. Ample time will be allotted for audience discussion. Silver Spring Civic Building 
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