Terra Incognita : A Psychoanalyst Explores the Human Soul 9780761864059, 9780761864042

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Terra Incognita A Psychoanalyst Explores the Human Soul Joseph Isaac Abrahams

University Press of America,® Inc. Lanham • Boulder • New York • Toronto • Plymouth, UK

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Contents

Foreword

v

Preface Clarence G. Schultz, M.D.

vii

Acknowledgments

xi

Introduction

1

1 2 3 4 5 6

Wartime Beginnings: A Riot on VJ Day—“I had to, captain!” Washington, D.C. Early Practice 1950–1960: Institutes and Institutions Later Practice 1960–1970: Dream Work, Conferences, and Couples La Jolla 1971–1989: Midlife Career, Midlife Crisis Atascadero State Hospital 1990–1995: New Adventure, Unexpected Assault Post Retirement–1996 to Present: Six Iconic Cases and a Revealing Colloquy

7 15 103 141 211 219

Appendixes

247

Messianism and the Essential Nature of Psychoanalysis: A Talk by Joseph Abrahams, M.D.

249

My Contribution to the Psychoanalytic Literature

255

The Professional Identity of Medical Students

257

Psycho-Social Rehabilitation: PSR

275 iii

iv

Contents

Atascadero State Hospital’s CQI Experience

287

My Intuitometer Presentation: Peruvian Psychoanalytic Society, January 25, 2011

293

Glossary of Terms

303

Annotated Bibliography

323

Index

367

Foreword

Realizing the importance of a book’s title to its reach, I have sought alternates to Terra Incognita: A Psychoanalyst Explores the Human Soul, but all have fallen short. I’ve always found my thoughts and spirit thrust toward mapping the contours of my portion of this planet, outwards into the universe, and inwards into my very human soul and its interior life. I early saw myself as unique. In the writing of this volume I have inevitably come across the fact that in my uniqueness I was but a variant of a host of unique others, all seeking. Collectively they are verging on the concepts and formulations found in this volume. So why do you and I go through the trouble of the writing and reading of these many pages of scrupulously presented clinical data? My answer is my responsibility as a practitioner and scientist in the great epistemological venture that is humanity’s quest for knowledge. May the members of this host do likewise.

v

Preface Clarence G. Schultz, M.D.

In this, his latest book, Dr. Abrahams takes us on his lifelong odyssey to conceptualize the use of group members’ observations about themselves and each other in order to foster each member’s self-awareness of their conflicts as they are manifested within the group. His seminal pioneering work has promoted a treatment paradigm for administrators of incarcerated populations by providing a less labor expensive, psychotherapeutic dimension to the rehabilitation efforts for groups previously thought to be hopelessly fixated in durable psychotic and psychopathic psychopathology. My goal here is to place his achievements in a historical context outlining some of the events of the 20th century that both facilitated and obstructed the emergence of the implementation of his ideas. I will train my wide-angle lens on the medical, psychiatric and psychoanalytic aspects of the culture as these impinged on innovators of that time with a geographic emphasis on the Washington/Baltimore region, especially St. Elizabeth’s Hospital where much of his early work emerged. In the mid-1940s before the appearance of antipsychotic and antidepressant medication, St. Elizabeth’s in Southeast Washington, D.C., with 6000+ patients, served as the State Hospital for the District of Columbia as well as a federal recipient of patients from: Indian Reservations, Alaska, U.S. territories, members of the armed forces as well as paranoid out-of-state citizens who had come to Washington as a result of their delusional beliefs. Since 1904, when President Teddy Roosevelt appointed Dr. William Alanson White as the Superintendent, it became one of the outstanding psychiatric hospitals in the country. Dr. White, without formal psychoanalytic training allied himself with Freud’s psychoanalytic discoveries and fostered the developments of new treatments. In 1920 Dr. White arranged for a particular plasmodium strain of malaria utilized by Wagner von Jaregg in Europe as a vii

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treatment for advanced tertiary neurological syphilis to be instituted as a treatment at St. Elizabeth’s. This novel approach of using one disease to cure another and then treat the second disease became the standard throughout the country with the strain malaria made available from St. Elizabeth’s. In 1932, Dr. Jacob Moreno, who studied group processes in Heidelberg, Germany, first used the term “group psychotherapy” at an American Psychiatric Association meeting. In 1934, he brought psychodrama to St. Elizabeth’s when he joined the staff. A parallel academic development began in 1909 in nearby Baltimore after Dr. Adolph Meyer was appointed as chairman of the department of psychiatry at Johns Hopkins Medical School. Dr. Meyer, in contrast to most psychiatric thinkers, was optimistic about the outcome of the treatment of the psychoses. Initially he, too, was interested in psychoanalysis and helped in its establishment in America. This tradition of innovation continued with the arrival of Dr. Winfred Overholser at St. Elizabeth’s in 1937. The two pillars of White in Washington and Meyer in Baltimore gave prominence to the region as a source of research and innovation in attracting professionals in psychiatry. This influence expanded to include the Sheppard and Enoch Pratt Hospital and, later on, Chestnut Lodge in Rockville, Maryland. Freud’s psychoanalytic technique introduced a changed relationship of doctor with patient as compared to the traditional medical orientation. Prior to Freud, physicians often assumed a paternalistic attitude towards their patients. Doctors diagnosed what was wrong and prescribed what needed to be done to correct the problem. Suggestion and exhortation were often used. Freud, by contrast, elicited the patient’s observations about his thoughts, associations, dreams and subjective experience. Patients became partners with their doctors in the joint exploration of conflicts. Similarly a group therapy approach encouraged fellow patients, as well as the group leader, to join in making observations, as well as providing mutual support of the group members. Even though Freud himself made changes in the theory of psychoanalysis over the long span of his career, from the beginning he was concerned about the potential threats to modifications of psychoanalysis. Even close colleagues Jung, Rank, and Adler were eventually excluded from his inner circle. He was especially critical of analysis in the United States with concern that it could be diluted. These attitudes permeated some of the analytic immigrants from the Hitler era. Applying psychoanalysis in the psychotherapy of the psychoses and especially to group therapy were innovations ushered in to a hostile reception. In order to understand his concept of what Dr. Abrahams has called his “intuitometer,” one needs to know about the evolution of “countertransference.” Initially, Freud conceived of countertransference as a pathological

Preface

ix

interference on the part of the analyst’s conflicts in understanding the patient’s problems. This made it essential that the analyst undergo a training analysis in order to be able to sort out his own pathology from that of his patient. If the self-analysis could not clarify the situation, the patient should be referred to another analyst. But over time, it gradually evolved that analysts began to view their reactions as possible clues to the nature of what ailed the patient. Thus the relationship of the patient with the analyst stimulated reactions within the awareness of the analyst’s psyche. This subjective intuitive hunch could be used as information about the analysis. Dr. Abrahams described his physical subjective experience as his “intuitometer” alerting him as to what may be happening within the group. To sum up both: OBSTRUCTIONS Distrust of group therapy as a deviation by classical psychoanalysts. The philosophical conflict between punishment and treatment for those include in Abrahams’ patient population by virtue of the concept of “not guilty by reason of insanity.” Pervasive pessimism toward “untreatable” psychopaths and psychotics. Working collaboratively viewed as coddling offenders. and … FACILITATORS Receptive climate for novel treatment approaches especially those based on psychoanalytic principles. The already established regional psychotherapeutic approach to the treatment of the psychoses. The economic advantage of treating groups of patients instead of one at a time. The author’s insights are amply buttressed by clinical illustrations. His inclusion of a chapter combining hospitalized psychotic daughters with their mothers reminded me of the training-in-psychotherapy dimension of his technique. While I was a resident in the late 1940s at St. Elizabeth’s Hospital, Dr. Abrahams included me as co-therapist/observer for six months in his mother-daughter group sessions. Each scheduled hour was followed up immediately afterwards with a half-hour in which the two of us discussed what went on during the session. As a trainee, this introductory experience was

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invaluable in having a first-hand insight in doing psychotherapy for which I am grateful.

Acknowledgments

This essay into the known and unknown called for collaboration of many. First on the journey has been my wife Elisabeth. She has been intrepid and constant. Next I give credit to my editor, Susan Stewart, who has translated a great deal of the technical language of psychoanalysis, plus some that I have invented. Then there is a host of helpers and several computers—Michael, Stephanie, but above all Lukas. With each, I attempted to conceptualize my data, reaching a gratifying consensus, especially with Lukas. It has been a growth experience. Then there is the help of technology. It has met the challenge of my severe macular degeneration, which has obviated my capacity to read and produce text. Technology is still somewhat short of a natural conversation but I am sure that is in the offing.

xi

Introduction

In a time of shrinking interest in psychoanalysis, I will attempt in this volume to enlarge its scope and method. Employing the disciplines of history and psychoanalysis, I have been carried, through a career that spans some 70 years, to insights into the very process of forming hypotheses. My motives in pursuit of the science of psychoanalysis were highly complex. A dramatically successful wartime venture in the treatment of then untreatable psychopaths left me paradoxically uncertain of my professional capacity. I felt humbled, and sought instructions for a more systematic treatment of the individual, whom I had encountered as members of groups, but not in the depth that I sought. My experience with the untreatables is told in this book. I knew that at core I needed to understand myself. The story of my career, and the search for both self-understanding and a provable hypothesis, will be told chronologically, through a series of events and documents (some short, some long), accompanied by a running commentary documenting my authentic experience of them. Studded with summaries of published and significant unpublished articles and books, this historical account begins with my childhood development, followed by early wartime experience in therapeutic leadership. Professional education followed my time in the army and coincided with a beginning psychoanalytic practice in Washington, D.C. This practice was unique in that I initiated treatment with groups. I found that the group method prepared the individual for the self-inquiry inherent in the Freudian method. My assiduous work with dreams and with resistance to uncovering the earliest emotional states, prior to the capacity to verbalize, plus my engaged participation— considered by some to be unorthodox—carried me and the patient, whatever the diagnosis, into the core of their conflicts. Though I had touched on these defining concepts as early as in my graduation case, it took me until my 1

2

Introduction

second decade of practice to begin to understand their process and implication. I had to come to grips with this epiphanic understanding, so I applied to the Princeton Center for Advanced Study. Upon denial, I decided instead to engage in individual study by means of a sabbatical in California. During this sabbatical, I called upon the experiences of my Washington practice to further shape the series of hypotheses from nebulous to coherent; these I would study for the next four decades. Central was the concurrent realization that I was undergoing changes pertaining to my narcissism. This would come to be the focus for my subsequent study and private practice in La Jolla and San Luis Obispo. EARLY DEVELOPMENT: INCEPTION OF A PSYCHOANALYTIC CAREER My career in psychoanalysis had its anlage traceable to my earliest childhood. Curious about my environment, I was drawn to its study, both internal and external. An incident in my third year is illustrative. In a cold kitchen in Hartford, Connecticut, my mother laid me next to the stove, where over me loomed a plume of steam coming from the kettle. I had to find out its nature and from whence that plume came, and I reached up, pulling the kettle down on me. The consequent scalding has left a scar. I also conceived of the exploration of my newborn brother’s fontanel by insertion of my mother’s knitting needle, revealing a fiendish aspect of my brotherly intentions. A little later, during my latency years, I would venture forth to explore the countryside and charm the trolley conductor to take me to the local zoo. At the age of six, I insisted that my family give me a bathing suit so I could swim in and explore the cold waters off Savin Rock near New Haven, and I used that suit when I swam the next year in the East River off Lower Manhattan. Soon after, I began swimming in dangerous streams and out into the ocean, far beyond what was considered a safe distance from shore. I also embarked on a regimen of long-distance running; and I began to fight with other boys. I could not say what I was looking for, except that it was deep and largely intuitive. Just as I wondered about the plume of steam, I pondered the meaning of the death of the insects I killed. Then there were the rats my cousin and I had as playmates, and the connection I made between the larvae and newly hatched flies in our garbage cans. Lastly from that period, I remember precociously tending to my mother when she miscarried. Along with that basic nurturance, I became my mother’s helper, at the ready to aid her at home, figuring out how to fix things, light the coal of the kitchen stove, string her laundry line, and become the man of the family when my father was away to some distant city. But I soon became interested

Introduction

3

in the usual things boys my age do, and my family of origin reached a more settled state. My searching precocity went underground. I appeared “normal” except for a huge literary appetite and my poetic initiative, in the form of the exposition of The Life and Loves of a Cockroach. In my late teens, my relationships with my contemporaries were troubled, with only occasional friends. These could be classified as bookish and asocial, with their heads in the clouds. I was especially drawn to the study of the great revolutions—American, French, and Russian. I was sensitive to the role of personal initiative in each. This capacity impressed my history professor at Dewett Clinton High School, Dr. Bernstein, who encouraged me to further study. In my head I argued with Karl Marx, holding even then that the proletariat was alienated from self, rather than from the product of his labors. It was that self-alienation that hampered his capacity for political, economic, and social self-representation. This matter of alienation from self was to become latent until work with psychopaths at Fort Knox would bring it to the fore. I also had a rich fantasy life as cowboy, Indian fighter, and little Nijinsky. In high school, then college, I appeared to grasp science, history, and literature to a degree that engaged my mentors in advocating that I pursue their professions. The history of revolutions tipped the balance in favor of becoming an historian, and I was ready to enroll at Cornell University on a full scholarship. During those years I also had my first encounter with Freud and his dream book. I was fascinated, and tried my hand at divination of people’s dreams, and even more as a seer. I was able to see into people’s past lives. This was accompanied by deeply disturbing sensations in my head and I abandoned the practice. I made a conscious decision to restrict my inquiry to science, history, and culture. I was a devoted student, enjoyed studying, valued education, and became something of a bibliophile. Then too, I held opposing characteristics of introversion and extroversion, with both a highly developed sense of privacy and solitude in deep communion with the nature of the world, as well as great delight in being part of the family group and a member of a boys’ gang. It was about that time that along with beginning schooling, I took Hebrew lessons, and as much as I loved to learn, I grew to hate the teacher. The mohrer, or instructor, was a little bearded man with a Hassidic hat and caftan, who patrolled the aisle in quickstep, smashing the knuckles of laggards with his ruler. This was my first conscious experience with alienation, which in retrospect can be linked to a fracticidal impulsion toward my younger brother. Fortunately my father was a free-thinker and never queried me concerning my inner religious beliefs. I definitely did not believe in the instructor’s Jehovah, although I have been a life-long student of the subject.

4

Introduction

Just as I had explored lower Manhattan by foot on our move to the Bronx, the acquisition of a bicycle allowed me to cross the length and breadth of Crotona and Van Courtland Parks. My curiosity led me to somehow conjure up an early movie projector, and that initiative resulted in my becoming the projectionist for the school assembly when I was nine. I gloried in that enterprise, mastering the carbon-arc mechanism. Another interest dated from my earliest days at my birthplace, Texas, where I had been fascinated by the horses on the outskirts of Dallas. It was not long after that I responded to questions on what I was going to be when I grew up with a passionate “Cowboy!” This was reinforced by cowboy movies in which Tom Mix was my hero. Next came WWI aviation movies and aspirations to be a combat pilot. Then, of all things, I aspired to be a ballet dancer for a number of years after seeing Nijinsky in the movies and being fascinated by his enormous leaps into the air. My mother’s midlife depression turned me from that course, and I instead decided to begin studies close to home at New York City College. I continued the study of contemporary history but also became interested in the physical sciences. I began to excel at these classes and an entirely new world of intellectual content opened up to me. Resolution of my career conflicts came in the form of strong advice from a close friend already enrolled at Emory Medical School in Atlanta, Georgia. He promised me an exciting profession, well remunerated. I took advantage of a fast track policy that promised enrollment at Emory after just two years as an undergraduate, and subsequently followed his advice. There I excelled in biology and cultural subjects such as English and the history of religion with an emphasis on the progressive course displayed by the prophets, from Amus to Isaiah. I continued my studies and concentrated on advanced biological subjects, becoming an academic assistant to Prof. Baker. I also attained a status in my English studies of exemplary nature for what Prof. Miller cited was my unique style. Unique to my academic experience was a fall from grace; where once I was the leading student, always high on the dean’s list, I began to fail. At core there was panic on my part that stemmed from Prof. Blincoe’s arrogant manner. This was in the context of an implicit mission of a certain anatomy class to call out a third of the class. When I learned of my incipient demise as a student, I summarily mounted an aspect of my mental functioning that resulted in an imagistic and detailed comprehension of human anatomy and physiology. Then dramatic psychiatric interviews in my sophomore year in medical school reached me deeply. I had been inadvertently trained by life circumstance for that experience. In later years, I would make those connections to my prior life. For example, in a catatonic prisoner, I would sense the underlying rage, akin to that of my father. And there was something reminiscent of my mother in the despair of a black female patient.

Introduction

5

I infer now that in reaching out to the patients, I had touched something in me that lay behind my earlier questing self. I gradually became conscious of an inner determination to seek ever more deeply into the family’s tribulations, beginning with my own. Perhaps that was the real beginning of my career in psychoanalysis, the conscious choice of avenues to self-amelioration. These are the significant events and recollections of my childhood and early adulthood that laid the foundation for the success I would later achieve in my work with alienated individuals across many states, in myriad institutions, and in private practice. There was, in particular, a seminal and epiphanic encounter with a prisoner at the Fort Knox Rehabilitation Center very early in my career. Towards the end of my tenure at that center, I formed a significant relationship with an offender who eventually led a riot there. In the course of that riot, he sought and received a mortal wound. Before he died, as I held him in my arms, he declared to me that he had to do it. That declaration reverberated within me, and I determined to identify its genesis. As the story of my career unfolds, the reader will find repeated references to this early epiphany and the ways in which subsequent events served to strengthen and explain its significance. This and following experiences would eventually lead to the formation of a comprehensive professional hypothesis, arrived at toward the end of my career, and proved time and again by the patients and experiences I encountered over seven decades as a psychoanalyst. That hypothesis, stated concisely, is as follows: That at the root of all human psychic disorders—whether major (namely psychosis and psychopathy characterized by a distorted perception of reality such as delusion and hallucination) or minor (depression, anxiety, addictions of all sorts)—are degrees of alienation from self, from others, or both. I hold from my experience that this root is relational. However, it is obvious that there are organic factors that warrant exploration pertaining to the genome, ontogenetic and hormonal development, anthropologic, phylogenetic and other biologic factors. The task of analysis, then, is to get at the experiential heart of that alienation and to work through it, toward the goal of reconciliation, with self and with others; to become a whole and integrated being, no longer at odds with oneself and one’s fellows. An important corollary to this hypothesis is the arduous process of reconciliation (a process that often includes a death experience of psychic nature, and/or a mourning period), wherein the patient rediscovers his very soul, that part of him that is his unique essence—distinct, valuable, and separate from his family of origin and other early influences which may have been embodied along the way.

6

Introduction

Two essential elements of this hypothesis are the phenomena of transference and messianism. In the former, we unconsciously redirect our feelings from one person to another, as often happens between analyst and analysand. Transference can also manifest in the repetition of a childhood relationship in a present one. In the latter, a person’s behavior is driven by an unconscious desire to protect the other from infantile adversities, at the sacrifice of self. Both the transference and messianism are important elements in the process of moving from alienation to reconciliation. Of some moment is the issue of whether psychic evidence can be considered as valid data, to be studied scientifically. This concern has been present in the author’s mind throughout the experiences of his career and especially in the writing of this volume. I leave it to the reader to judge its verity, through attempts at replication and/ or proof of falsity.

Chapter One

Wartime Beginnings A Riot on VJ Day—“I had to, captain!”

LEADERSHIP OF A MEDICAL DETACHMENT We have traced the beginnings of my professional career as psychoanalyst to an early time in my life. Analytic inquiry leads me to hold that my intuitive capacity was engaged at the beginning. My professional role as such started during wartime circumstances of an urgent and compelling manner. During World War II, I was assigned the command of a medical detachment for the 608th tank destroyer battalion, a position of responsibility for both my section of the larger organization, and for the members’ health and wellbeing. Here, I set up organizational procedures and planned and executed programs pertaining to matters of extreme anxiety and mortal peril. This included preparation for living in the field, solving problems of sanitation, and conducting medical field clinics. At a regional hospital in White Sulphur Springs, West Virginia, I trained to proceed from medical officer to psychiatrist engaging in case workup. The training that the tank destroyer battalion afforded me was critical in my performance later in the mental health field, especially in understanding responsibility of leadership and its follow-through in organizations. As an important leader in the battalion, my duties called on me to relate to each member of the battalion and also to its hierarchical structure. I held this position for several years when I lost my capacity for combat duty because of the reoccurrence of childhood asthma. This was despite my vigor in relating to performance of my duties. We were preparing for the coming battle in North Africa. The design of the Tank Destroyer Battalion was centered on mounting extremely mobile, 7

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Chapter 1

relatively heavy artillery that could concentrate fire on the German Panzer divisions. The battlefield had shown itself to be widely dispersed with disjunction in communication. A capacity for comprehension of the situation of small military units was of utmost necessity. As a result, I trained my medical detachment to learn interventions far beyond those routinely called for. They had to act in my stead and to afford care to the sick and wounded soldier that was usually expected further on, on evacuation. Not only that, but I engaged in training the soldiers themselves in self-care and in initial care of the wounded. I was surprised by their resistance to the medical aspect of training. This all was of moment to the conceptualization and practice for a further assignment, a rehabilitation center for the treatment of military prisoners. My tank destroyer battalion and my medical detachment had achieved the higherorder of competence and a battlefield élan which was perceptible. I learned to hold the achievement of that elan essential to my performance as leader in subsequent endeavors. SEMINAL WORK AT THE REHABILITATION CENTER My assumption of leadership at the Fort Knox Rehabilitation Center was occasioned by an emergency. Capt. Alexander Wolf, the group analyst who had successfully initiated the large and small groups, and training the group leaders, was beset by the rehabilitees to the extent of physical threat, calling for a guard. The rehabilitees had turned on him. A sociologist, Lloyd W. McCorkle, assumed his duties. McCorkle changed the method from the group analytic, emphasizing inquiry into personal motivation, to that of the new way to deal with anti-social gangs he had learned in graduate studies in sociology at the University of Chicago, and also at the new Chicago-area project. His method could be characterized as enlistment of the rehabilitees in his pro-social gang through role modeling. In the latter, he had received extensive field training under the sociology professor, Clifford Shaw. On our initial encounter, he touted the method of that project and its spirit. I found myself assuming the role of a leader after watching him lead several sessions. McCorkle’s inculcation of the spirit and method in the rehabilitees resulted in success and I embarked on my career as group therapist, moving over to the method of my version of psychoanalysis as I went along. In a previous trial at group therapy, during my stay at Warner Springs Rehabilitation Hospital in West Virginia, I had successfully led groups of returnees suffering what was then called “war neurosis.” I simply asked the members to tell their stories, and after an initial phase of resistance, they settled down to the task. This method would later surface and have great significance in such self-help groups as Alcoholics Anonymous. At Fort

Wartime Beginnings

9

Knox, I similarly asked the members to tell their stories. And they did just that, to advantageous effect. The commanding officer of the Rehabilitation Center, Colonel George L. Miller, had read a report of an analogous venture in Vienna which was enacted during the interwar period. Colonel Miller, an educator in civilian life and a member of the Army reserve who had attended the Army War College and was acquainted with the top brass in the new wartime American Army, proved to be influential in the setting up of the nine rehabilitation centers scattered across the United States. He lectured about and exhibited our rehabilitation center to a steady stream of Army administrators and psychiatric personnel. I soon read the text, Wayward Youth; he touted and was impressed by the spirit and eloquence of its author, August Aichhorn. Aichhorn was an educator in Vienna, a rising figure in Freud’s circle of pioneering psychoanalysts. I had read Freud’s material as an adolescent and found Aichhorn to be as lucid. The members of my groups were largely psychopathic and alienated, exhibiting a characteristic boisterousness and ready tongue that I found interesting and led me to think, “These are my people!” They were like the Cherry Street gang of my lower east side days, a group I wanted to join, of tough Irish youths who would help me free myself from my soul’s bondage to be Mama’s good Jewish boy. In the group therapy sessions, the rehabilitees yielded their boisterousness, grew silent and contemplative, in effect joining my gang. At the same time, I experienced emotional connection to the group, manifested by a poignant sensation under my sternum. Their mein, manner, and very identity appeared changed, and they took initiative at reaching out to me and our program. I soon was able to teach my staff and visitors. Colonel Miller lent himself heart and soul to what he early recognized to be a revolutionary development. He was full of enthusiasm and élan, and participated in our conferences. In that atmosphere I felt free to come out with my hunches and thoughts. One of them had to do with the phenomenon I noted earlier of basic change on the part of the rehabilitees in apperception of reality. It appeared systematically in our treatment sessions. The inference we drew was that a certain degree of underlying emotional connection was central to the group’s success. We further observed that afterwards, the group members became sober and cooperative, unlike their formerly alienated and chaotic loudness. I characterized it operationally, as “From Gripe to Group.” The prisoners had joined our reality, leaving behind, pro tem, that of the psychopathic world. A corollary aphorism I developed at that time for teaching purposes was “scratch a psychopath and find a messiah.” I gradually became conscious of the special position history had placed me in, as leader. My men called me “Master.” From my lips came wise words and I was able to explore a new world of promise. On reflection I linked it with my devout mother’s elevated regard for her first son, tradition-

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Chapter 1

ally given to God in Jewish and Catholic families. It was embarrassing but significant, and explained in part what was going on in the groups. Soon, I made myself available for individual therapy of the rehabilitees, in the form of brief guided counseling of individuals as to their core conflicts. Together with the individual rehabilitee, I constructed a diagram of the triangle—father, mother, and child—and the emotional currents, depicted in arrows between them, resulting in overt impasses and fixations. As I went through this simple exercise, echoes of my formative struggles resounded within, gaining coherence. We recognized that the abandonment by the psychopath of his fondly held alienation and reconciliation with common reality was a paradigm changing event because common wisdom held that treatment of the psychopath was impossible. My staff and I set out on a search for explanatory theory and assemblage of the attendant phenomena. The rehabilitees had joined with us in silent communion, itself a new reality on the treatment scene. Some fervent, they professed allegiance to a common cause, the winning of the war. Many told the story of their lives, in an emotional engagement we took to be Freudian transference. Others sought to be closeted with us, for more or less systematic exploration of “how they had got there.” Based on the success at Fort Knox, I gained an initial comprehension of the transformative process and attended inferences in rehabilitation. The inference lead to theory, and the theory led to initial practice. Aichhorn had reported in his book, Wayward Youth, a similar experience. Equally important, I set on a course of scientific study of our surprising initiative. That inquiry set the stage for the professional careers to follow, each a research project. That search led me to look into my early years, even those of my forebears, for the anlage, or beginnings of these phenomena. There has been a thrust, a consistency to that search. I found myself leading the groups with some authority despite my freshman status. I soon noticed a systematic sensitivity in the region of my heart when the members of the group fell silent and became thoughtful. This basic change to me indicated an underlying movement in the therapy that warranted further scrutiny. I further noted a change in the leadership of the group from antisocial to pro-social. In our post-session conferences, I called attention to this set of phenomena. I appeared to make sense not only to my eight therapists, McCorkle, Colonel Miller, and other personnel, but also to the rehabilitees. All this had been going on to some extent previously, but somehow became systematic in the group’s mind; McCorkle and Miller were enthusiastic. Aichhorn’s mode of inquiry was now the dominant one of the group. The group found themselves inquiring systematically into how in their lives they had become antisocial. The educationally deficient rehabilitees were engaged in a corrective course by a very passionate educator who

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attended, Lt. Charles Leathers, who was proud of having raised the average intelligence score by 10 points. Each rehabilitee received combat training of a higher order and contributed through a hard labor gang to the beautification of Fort Knox. It was at Colonel Miller’s insistence that I began collaboration with a talented rehabilitee on the production of film strips about the problems in behavior. It was called the “Figure It Out” series. It called on the rehabilitees to collaborate with me in figuring out the nature of their problems, starting with their early development and family life. My artist was masterful in coming up with frames to compliment my messages. Colonel Miller collaborated by turning the Kodachrome film into durable slides. These were used to evoke discussion in the group therapy sessions and were quite popular. We produced large posters to decorate the walls and carry the therapeutic message. I went on expeditions to Louisville, Kentucky to get material for a radio station that we established, station AWOL. A weekly newspaper followed, The Rehab Roundup, later changed to Center Sun. All of this was done in collaboration with the rehabilitees. They took part in conceiving of and creating their post-social life, in contrast to the usual prison state of alienation and antisocial gang formation. In the course of its tenure, the Fort Knox rehabilitation center received acknowledgment of some significance, just short of a presidential citation. Postwar, progressive penologists pushed for the adoption of its methods to civilian life and in a federal prison service, forming an ongoing seminar to develop the new methodology. My staff meetings at Fort Knox turned into a conference on research and development. It fell on my staff and me to define the personal element that motivated me, and we settled on defining it as messianism. They noted that alongside the Christ on the cross were two criminals, similarly situated. This messianism was held to serve as a fulcrum and passageway for the psychopath, who had become self-alienated, and through messianism became reconciled to self and others. We applied that messianic hypothesis to August Aichhorn’s initiative and success. We also noted how often the leaders of the antisocial group became leaders of its pro-social version, evidencing character transformation. Noted was that for the individual to finish treatment and become truly himself they needed to be relieved and cured and that messianism played a part in curing them.

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THE VJ DAY RIOT AND THE LESSON LEARNED An important question for research was the personal element that drove the members toward psychopathy. After all, only 40% were deemed suitable for direct transfer to the combat units. In fact, after VJ day, the rehabilitees, now considered prisoners, were slated for passage to Fort Leavenworth, to serve the rest of their prison term. The loss of the possibility of restoration and the hope resident therein resulted in a return to alienated status. It is remarkable that they then en mass moved to free their leader who was in special containment. I had been engaging him in a process of inquiry into his alienation as part of the research I was doing concerning our failures in treatments. He responded to my efforts by jocularly stating that he was beyond treatment, and suggested that I help his fellows by stating: “Captain, give them group therapy.” The rioting prisoners assembled in the mess hall with their leader in a special place of honor. They conducted themselves in the manner of Jesus and the last supper. Following the meal, the situation grew dire with an attempt to escape by one of the prisoners, resulting in a rifle shot. McCorkle and others attempted to address the roving gangs of prisoners, resulting in their return to barracks to sleep. Next morning a few assembled to report for duty, but the rest milled around. By this time, troops from the post surrounded the compound, driving the prisoners into a more compact mass. The post commandant addressed the group to the effect that he was willing to talk with the group but that the leaders would have to be sent off immediately. He called out the names of eight and directed them to form a single file. The leader whom I had been interviewing was the last in line. As the group was commanded to march forward, he reached for the weapon of one of the guards, who shot him at close range. I ran forward to hold him as we waited for the ambulance. As he lay dying, I asked him why he had brought that on himself, knowing that he would be shot. He answered: “I had to, Captain.” His statement, that he had to, that there was inner compulsion of idealistic nature, touched me deeply. It was in concordance with an inner motivation on my part to get to the bottom of the subject of alienation. It was apparent that there was mythic foundation here, in which he was both afflicted, and leader. I took this to be a clue to a conundrum that both of us were addressing, and certainly a question I wished to pursue in my future profession. I could at that time identify with his single-minded pursuit of a cause, in his case heroic emancipation from authority and its oppressive ways. This then, is that seminal epiphanic moment referred to in the introduction of this work—the moment that would haunt me and guide me throughout my career. Toward the end of my tenure at Fort Knox, Colonel Miller and I traveled by train to Fort Leavenworth for a penology conference. This was an opportunity to review our work, person to person, and to plan for the future. We

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agreed on the revolutionary nature of the work and its import for our professions, he as educator and I as prospective psychoanalyst. Central there was the reconciliation of the alienated individual to self and society. He was intrigued by my messianic hypothesis and allowed as to how it facilitated his work. He was enthusiastic about the prospects of research into the genesis of psychopathy and the severe disorders, and moved for collaboration with the recovering individual in mounting pro-social careers after conversion to prosocial positions. He foresaw a bright future for progressive penology. POSTWAR DEVELOPMENTS: SHEDDING THE UNIFORM FOR TRAINING IN PSYCHIATRY AND PSYCHOANALYSIS The war was over and I needed to move on. After I was released from army duty, and under the GI Bill, I reestablished residence in New York City and aimed to build on my experience as a pioneer in group psychotherapy and prison program development to become formally trained in psychiatry, psychoanalysis and sociology. The success of the work at Fort Knox, and the sophistication of the program, led professionals to seek training in what was then a cutting-edge approach to treating the severe disorders. However, this entailed internal psychic contradictions and stress since I still had to achieve formal accreditation as a psychiatrist and psychoanalyst. In order to do so, I planned to enroll in the required basic courses in psychiatry, psychoanalysis and sociology. I considered sociology to be a necessary component because I discerned the processes of social alienation that reduced the American family to its nuclear core. I found myself vividly describing those processes to the head of the Sociology Department at Columbia University at the time, who forthwith accepted me as an advanced student. I was also accepted at Rockland State Hospital in nearby Orangeburg, New York for a residency in psychiatry, and intended to enroll in the Psychoanalytic Department of Columbia University. A fortuitous encounter with Dr. Florence Powdermaker altered these plans significantly. She held me in high esteem, after observing the successful group therapy at Fort Knox. She wanted me to demonstrate the group dynamic at Veterans Administration Hospitals which would call on me to situate myself in her department at the VA’s central office in Washington D.C. I would then proceed with my training at George Washington University and also at St. Elizabeth’s Hospital and the Washington Psychoanalytic Society and Institute. This appeared to be a tenable plan and I started work out of Dr. Blain’s office at the Veterans Administration. In time, I started a residency at St. Elizabeth’s Hospital in Washington, D.C. There I found an abundance of psychopathic and psychotic offenders to continue my inquiry, begun during the war with the psychopaths at Fort

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Knox and their leader who had brought on his own death. He had given testament to a moral imperative of malign nature and I had determined to continue research on his motivation, so akin to what I sensed to be my own internal drives. SUMMARY OF MY TENURE AT THE WASHINGTON PSYCHOANALYTIC SOCIETY AND INSTITUTE While working at the VA, I also registered as a student in 1946 at the Washington Psychoanalytic Institute, at the same time as registering for the Washington School of Psychiatry. Both schools were headed by the same individuals, Harry Stack Sullivan and Frieda Fromm-Reichmann pioneers in the treatment of the severe disorders. Both were psychoanalysts, but both conceptualized and practiced in a manner different from that of the standard method. The Washington School of Psychiatry exemplified Sullivan’s interest in social psychology, sociology and anthropology, and also relating with social and cultural disciplines. In the Washington Psychoanalytic Institute, the emphasis was on approaching standard psychoanalysis, but laxity towards the Sullivanian approach was permitted. An example of this was three times a week treatment, face to face, in contravention of the mandatory use of the couch four to five times a week. In seeking psychoanalytic training, I was intent on following in the footsteps of Sigmund Freud as exemplified in his writings, especially his dream book and his book on group psychology and analysis of the ego. I soon found that the reality in Washington was exemplified in a conflict between the Sullivanians and the Freudians. Both had their orthodoxies. I encountered the Sullivan orthodoxy, oddly enough, in the midst of my training analysis. My training analyst, Edith Weigert, interrupted my free associative train at the time to inform me that I had to stop doing my group therapy. In retrospect, this was a parameter of the worst sort, the interruption of an associative stream for an administrative end. It turned out, on my inquiry, that at issue was my departure from orthodoxy on the part of Frieda FrommReichmann, Dr. Weigert’s senior associate, whose dictum was that schizophrenics could not be treated in groups. As a student, I was already an established authority in group therapy and group dynamics, and inter-professional relations and respect called for mutual consultation on the issue. This administrative/therapeutic drama was consummated eight years later when Dr. Alexander Halperin, a senior member of the faculty, called on me for training in the group method, thereupon urging that I train psychoanalytic students in such.

Chapter Two

Washington, D.C. Early Practice 1950–1960 Institutes and Institutions

By this time I had moved my practice from my home to an apartment building at 3000 Connecticut, across from the Washington Zoo. 3000 Connecticut became a centerpiece in the Washington psychoanalytic firmament, with many of my young psychoanalytic colleagues practicing there. My office mate was Dr. Leon Yokelson, who soon became chief of the department of psychiatry of George Washington University. I had graduated from the Washington Psychoanalytic Institute in 1952 and the Washington School of Psychiatry in 1950 and was on the faculties of both of those institutions, teaching group therapy at the Washington School, and dream theory and practice, plus diagnosis and treatment of borderline disorder at the Washington Institute. About this time, an inchoate conception of psychoanalytic theory began to take form, in contradicting much of that of my mentors. I had also been in communication with ministers of the Protestant and Catholic faiths at St. Elizabeth’s hospital and extended my notions concerning messianism and the therapeutic process. ST. ELIZABETH’S HOSPITAL I began work at St. Elizabeth’s Hospital in Washington D.C. in the maximum security section, Howard Hall. Though I was recognized widely for the work at Fort Knox and was offered a special position at St. Elizabeth’s by Dr. Winfred Overholser, I requested resident status in order to facilitate later recognition by the post-graduate psychiatric board process. At Howard Hall, 15

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I did pioneering work with psychotic patients, using the methods we developed at Fort Knox. The representation I made to the initial group—in fact to the initial member of the group who accounted himself as the king—was that I was there to help them help themselves. Part of that was addressed to their emotional situation, and the rest to their material one. As an example, the patient who had once induced terror in me appeared to get the message and then volunteered to be the scribe of the group which was then in formation. I helped the members of this new group to call on the Red Cross for reading material and a dietician for improvement in their diet. Patients in the group process volunteered to help one another to learn to read and the Red Cross provided material for that process. Fortuitously, in the first year of the work, John Walker Powell appeared, volunteering to start an educational reading program. He had participated in the University of Wisconsin experiment in adult education, started by Dr. Meikeljohn. Its thesis was that disadvantaged males in prison in a mental hospital could be induced to improve their lot culturally by reading material stemming from their country of origin and other culturally relevant beginnings. I introduced Dr. Powell to my groups and he continued on his own successfully. It was remarkable how pertinent the members became in discussion of subjects like freedom, autonomy, the declaration of independence, and the constitution. Along the way, patients helped one another in making representation to the authority concerning their cases. Here—using my experiences from both Fort Knox and previously with the tank destroyer battalion—we collaborated with educational, occupational, and therapeutic disciplines, and were successful in turning the unit into a model therapeutic community. After successful therapeutic community with the black, white and then integrated groups, and the initiation of an occupational therapy program that included a patients’ newspaper, personnel at St. Elizabeth hospital recognized its potentiality. This led to a call by the hospital for the inception of a multi-disciplinary group work training program. At core there was what I called a professional identity group analysis experience. There the members, 30 in number, went through an exercise and inquiry into what they were doing at that point in their professional careers, what had induced them to seek such, and where they thought they wanted to be later. Systematically, we arrived at a deeply emotional and epiphanic point similar to the one I often had experienced at the inception of my career with the rehabilitees and staff at Fort Knox and during work with the battalion of tank destroyer soldiers.

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THE TRAINING OF PROFESSIONAL STAFF AT ST. ELIZABETH’S Training of the professional staff at St. Elizabeth’s Hospital to lead groups and individual patients into a return to reality involved traversal of a comparable experience in their professional development. The chief nurse, Lavonne Frey, and I planned this experience. She had requested me to conduct a group of her nursing staff to raise their concept of professional identity and competence from that of handmaiden to the doctor to one of relative equity in planning and affecting treatment on the ward. The work proved to be arduous and somewhat painful, but successful, since the nurses had become inured to a comfortable position as second class keepers of the order. They had gone through soul searching on what they were doing in medicine, leaving behind the tradition of Florence Nightingale and working out their own individual stars in the professional firmament. Lavonne Frey and her associate Helen Bar were enthusiastic about their accomplishment and ready for the next phase. It encompassed assemblage of the professional chiefs—psychiatry, psychology, dance therapy, education, psychodrama, music therapy, and chiefs of the catholic and protestant ministries—to engage in an exercise comparable to one that her nurses had traversed. I prepared and published a prospectus for this phase. This marked a feature of the program to follow in which printed publication preceded and succeeded each phase of development of the venture. Lavonne and I assembled a group and evoked its concept of professional identity, its natural history and prospects for St. Elizabeth’s Hospital. I supplied a brief description of my work in the army with delinquent soldiers and the phases of development of those groups and what I had learned there. The members of the group went the rounds on their sentiments and observation on the issues at hand, what they were doing in their profession, and how they had gotten their prospects. Most active were the catholic and protestant ministers who detailed when they had heard the call or seen the light. The others followed with depiction of their epiphany in their professions, when they had been inspired to become a psychologist, psycho-dramatist, etc. For some this had been early, for some later in their development. For all, it was marked by a sense and discipline of service. In traversal of this experience and the rendering of anecdotal material on their lives, the members gained trust of self, the other, and the group dynamic. They learned to guide themselves and the group in this experience, one central to group leadership. Seminal to the training in therapy, this would be analogous to the future course of their patients in therapy. They learned firsthand, their subjectivity, and how to be truly objective about what the patients would be going through, in an authentic manner. The emotions they traversed were raw and immediate, and thus, they were prepared for those of the patients.

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Combined with this were the skills they had learned in their professional development so far, and they were ready to lead groups of their fellow professionals to treat patients under guidance from myself and several others on the staff who had prior experience. Thus was formed the nucleus of the faculty, which then called for assemblage of a yearly student body, numbering 34, multidisciplinary. Following is a text of a publication generated at this point in the development of the professional identity program. OBSERVATIONS FROM THE WORKSHOP ON THE PROFESSIONAL IDENTITY GROUP It was clear from the reports of the working groups, that the members of the workshop in a very real way furthered the growth of group work in the hospital. In their work they demonstrated again the advantages, and in many instances, the necessity of working together to achieve agreement on issues met in the daily work of caring for the patients and their emergence into reality. There was universal agreement that this workshop was only a beginning. What was begun? Obviously it was not education in group work, for most of the members had at least some working skills that had stood them in good stead in the experiences they had reported. It was not a beginning of dedication to the hospital, because all there had demonstrated that by their efforts. The beginning rather had to do with getting together with one another for counsel, emotional support, exchange of experiences, and the other functions of human groups, not the least of which is work. This workshop had as its chief task, the formulation, from the members’ experience, of principles, goals, procedures, and the relationship that group work and the group worker had with the hospital. It revolved around establishing the identity of the function of group worker in the hospital. The group which discussed program development came up with an excellent statement of general principles and helpful guidelines for the administrator and personnel engaged in developing an active treatment program on a service. The group which discussed the management of a group assembled for us a most helpful set of suggestions and directives on starting and managing a group. The group discussing functions of groups grappled with the difficult problem of defining the similarities and differences in the functions of the different groups, and group leaders came up with a surprising number of similarities. I would like to briefly highlight some of these findings. Inception of a treatment program on a service called for dedicated endeavors by all the personnel, but more than that, for the development of certain relationships and channels of communication. Those are emphasized in the report. To a great extent, the development of a treatment program was

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the development of these relationships and channels. However, certain groundwork on this score was necessary to save needless frustration and defeat. Intimately related to this groundwork was the many sided question of initiative—real initiative in life itself in a mental hospital. However, when people took initiative in treatment operations, they in turn had to get something from others. This something ran from just plain attention, suggestion or instruction, to intensive personal help. This was an unfailing human reality we had to face, and which in good part had shaped the recommendations of the Workshop. The highlights of the report on management of the group, it seems to me, were its realistic common sense ideas on composing, starting groups, and dealing with simple down-to-earth topics and issues which arose. Emphasis on reality was generally good for both patients and group leaders. An important reality noted in the report was the recognition that group work, being a means to an end, needed to avoid being set in a mold, and to be continuously ready to change in accordance with changing situations. Again, remarkable similarities in experiences were noted. I would like to enlarge briefly on this theme. The group leaders seemed to have seen a need in the course of their daily work and developed a group to meet it. The development of initiative seemed to be a highly individual, personal process. It ran from recognizing the social and religious needs of patients, through getting the ward group together to “settle” some things, to forming a group around patients to consolidate their improvement under other treatments. Leadership seemed in part to revolve about motivating patients to conceive of whom they were as a group and to take appropriate initiative in changes they wanted. The leadership also depended on some awareness by the leader of who he was and what he was doing, his relationship to other personnel and the professional part he played in the life of the patient. These were stated for the most part in two ways: 1) Problems in initiative in working with groups in the hospital hierarchy; requests for aid in overcoming this resistance and its counterpart in the affected personnel were strongly stated. On-the-spot guidance and instruction were wanted. 2) It was universally agreed that each kind of personnel had a distinctive job to do: the attendant and nurse centered on the ward life, the doctor as catalyst initiated psychotherapeutic treatment, etc. There seemed to be little fuss among the workshop staff who were treating the patients. An indication of this was that the groups were designated as group meetings, classes, group administrative sessions, etc, rather than group therapy, which was generally reserved for a psychiatric context. Group work as described in these reports reflected a “now” and “then” function afforded the personnel who dealt directly with the patients in the hospital. This function, from what has been said, was best exercised in a flexible manner, in accordance with the needs of the service, and the interests, aptitudes, and professional development of the person involved. Most noteworthy, this

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function put a premium on collaboration and interdependence, a state in which the hospital could with confidence in time expect to enhance its therapeutic community. TRAINING AT THE WASHINGTON INSTITUTE OF PSYCHOANALYSIS As stated earlier, I had to relinquish my direct therapeutic work at St. Elizabeth’s due to conflict with Edith Weigert at the Washington Psychoanalytic Institute for conventional psychoanalysis. Instead I switched to supervision and leadership of a burgeoning therapeutic group work training program at St. Elizabeth’s, and with consultation throughout the Washington D.C. area, setting up programs of group therapy in a dozen institutions including the federal prison service, Bethesda Naval and Walter Reed Army Hospital, National Institute for Mental Health and a number of local clinics. I began my practice, determined to become proficient in standard psychoanalysis, situated behind the couch, on a one to one basis, even though I knew my mentors were misguided. This issue was never worked through in my training analysis nor that of my second analysis while at the Institute. The issue of group therapy for the severe disorders, concomitant with their psychoanalytic treatment centered around the messianism I had detected in my work at the Fort Knox Rehabilitation Center for military prisoners, and my mentors at the Institute were not equipped to analyze this issue. A number of my colleagues at the Washington Institute were also dissatisfied with the depth and penetration of the psychoanalytic theory and practice espoused by our chief mentors Harry Stack Sullivan, Frieda FrommReichmann, Edith Weigert, Winifred Whitman, and Robert T. Morse. My dissatisfaction stemmed from my penchant to question established principles and a desire to glean the truth through my own intrepid explorations. I had long prided myself on having a mind of my own, consciously starting when I rebelled against the strictures of my tyrannical teacher in Hebrew School. My partners and I gloried in the American ideology of independence and liberty. In my study of Freud as a teenager I had marveled at his audacity in pursuit of the innermost thoughts of his patients and of his designation of the ego or self of the patient as the Seele. This is the German for soul. I later came to appreciate the appropriateness of his initial designation, relinquished by him unfortunately in favor of the more scientific sounding Ego. The theory behind his initial writings involved defense against anxiety, with initial forays into the concept of regression. In my medical educative years and beginning years of my army service, I had carried my initial groupings into the to-be wonderland of psychoanalytic theory.

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My fellow trainees at the Washington Institute and I complained about the lack of attention from our mentors to the matter of psychoanalytic transference in theory and practice. I assembled a group of young analysts, including Dan Prager, Joseph Sheridan, Alan Drummond, Christopher Bever, Henry Myers and myself. We met weekly over a lunch hour, brownbag, to review the literature on transference, defense and counter-transference, both enunciated by Freud, and a range of other respected psychoanalysts. I espoused the thesis that Freud, in calling it Seele, was inadvertently cognizant of a spiritual side to the person’s ego. The curriculum of the initiative called for intense scrutiny of Freud’s work. I had gone over some of it as inspired by Harry Stack Sullivan, which appeared to be competitive in nature and advanced a new approach called interpersonal, which I considered an improvement in some respects over the Freudian, in ego psychology because it recognized the relationship of the personal to the social entities involved. By this time I had assimilated sociologic theory relative to this important issue, in the form of transactional theory. Transaction there was defined as a unity of interacting entities. The internal organization of this unity in the larger sociologic sphere would take on recognizable form in self-governance. Sullivan was a remarkable figure, small in stature, with the voice that tended to a high pitch and a brogue. He spoke in scientific parables, which themselves called for strict translation. He tended to give his lectures in a government building on Constitution Avenue, sitting pope-like at a distance from an audience of 150 students and faculty. He tended to mispronounce Freud, leading one to think it was close to frayed. In a class on the initial interview that in time attained some notoriety, he commented on a presentation of mine in his cryptic manner, “Can such things be?” I felt humiliated, but colleagues thought he was praising me. The context of much of this was the fact that at the time I had been working in Howard Hall successfully with forensic patients that were deemed impossible by my mentors. Inherent to our differences was the fact that I conducted a treatment program competitive to his at Sheppard Pratt Hospital. ST. ELIZABETH’S HOSPITAL AND ITS CHANGING RELATIONSHIP TO THE COMMUNITY In the mid-1950s, I chaired a workshop at St. Elizabeth’s whose alternate theme was “St. Elizabeth’s and the community, quo vamos—where are we going?” By way of introduction, I invited the participants to weave a tapestry of co-responsibility from three major “strands.” These three strands were 1) the new and burgeoning phenomenon of the therapeutic communities springing up in hospitals all over the country in which patients and their therapists

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had a co-responsible function. 2) the participation in the life of St. Elizabeth’s by its consultants. And 3) the changes in the Medical Society of St. Elizabeth’s; to wit its waning participants. The workshop, more formally titled St. Elizabeth’s and its Changing Relationship to the Community, was a multipurpose engagement, partaking of the dynamics of the mental health movement, with its then new ways of going about things, the concern of the professionals in the community as manifested by the consultants, and the special changes going on in the Medical Society of St. Elizabeth’s. Topics for discussion included: What the Hospital can do for and/or with its Patients; Training of the Psychiatrist; Further Care of the Patient; Hospital Facilities for Disturbed Children; Psychiatry and the Law; and Roles of Allied Personnel in Rehabilitation. The workshop was held as a full-day activity in Hitchcock Hall at St. Elizabeth’s Hospital. Thirty-eight participants, including the superintendent, several clinical directors and ward psychiatrists, plus members of the group work training program and a dozen members of the St. Elizabeth’s Medical Society. Many of them had been involved, in a publicly spirited fashion, with the Medical Society long before my tenure there and accepted the challenge of transmutation of the role of St. Elizabeth’s from its original role as hospital for the insane of the United States and its territories to care for the citizens of the District of Columbia. From here, the roles of the participants were defined, as were the tasks. Six sub-groups were formed, each tasked with addressing the six topics of discussion. At the end of the workshop, the leader of each of the six groups presented its findings by way of a presentation to the whole group. After these reports, a general discussion was held and summary comments were given. WHAT THE HOSPITAL CAN DO FOR AND/OR WITH ITS PATIENTS It became clear in the initial moments of our discussion that the group would restrict the question to the following: What can the hospital do for its patients? There was no discussion of what we should do with them. The answer was three-fold: To provide each patient with an individual needs assessment; to assess and to treat with a team approach; and to assure continuity of care. Patients with somewhat different management requirements were discussed, such as geriatric patients and those who had been convicted of crimes. Once again, a team treatment approach was advocated. The issue of wards was also discussed. In the end, it was agreed that perhaps we need to fit the ward program to the patient, rather than fit the patient to a particular ward.

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We next determined that the physician, particularly the resident, needs more training in administrative psychiatry and in the administration of wards, in the service of individual patients. One concern was that the hospital setting may be developing or had already developed a culture—a way of life—which is artificial. Do we possibly create in the hospital a situation in which the very conditions of living here at present make it harder and harder for the patient to make the transition? As a remedy, it was suggested that more of a village-type pattern of life be established in the hospital, something akin to some of the European experiments. It was recognized that while this is an easy suggestion to make, it will not be easy to implement. In sum, one basic issue became paramount. Namely, the continuity of the care of the patient with respect to the physician and those responsible for him throughout his course in the hospital. THE TRAINING OF PSYCHIATRISTS One of the first themes raised was that the experience afforded in psychotherapy at the hospital is limited, and an outpatient department was suggested. Even juniors should be given a supervised therapy experience with a schizophrenic patient of long standing. The idea that training should be an integral part of patient care was advanced, that there is no distinction between training and patient care. There was a pervasive and non-useful notion that staff has little or nothing to teach and little or no inclination to teach what they do know. The notion was aired that the severe pathologies in large numbers of patients infects staff attitudes, demoralizes them, leaving staff without hope, and it is not good for the patients to be exposed to it. Therefore, the training program should include an attempt to foster interest in the care and treatment of the long-term schizophrenic patient. Training of the psychiatrist was broken down into three large categories: (1) on-the-job training; (2) didactic presentations; (3) contact with consultants. The view was presented that on-the-job training was the weakest of these areas. There was considerable feeling expressed (particularly by the psychiatric residents in the group) that on-the-job training was mostly job and little or no training. The need was expressed for a more rigorous, more formalized course in basic psychiatry, not only for the first year but perhaps in the third year when it could be made more use of by the resident who now was in a position to understand much of what he was exposed to in the first and subsequent year but not able to digest.

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Perhaps the dilemma of how much does the hospital train and how much does it treat was expressed succinctly by a patient who was sitting in the second circle of our group, unbeknownst to us. After our group filed out and I was left alone, she spoke to me and I raised my head, and she muttered something which to me meant she was agreeing with me on some point. And then she said, “All these people come and go, but what happens to me?” FURTHER CARE We almost immediately took off on the question of whether or not the treatment of the functional psychoses should be done in hospitals, by the hospitals, or whether it is an interpersonal, intra-familial transaction which needs to be dealt with in its own milieu by psychotherapeutic intervention. The question of whether or not we are talking about care or treatment arises. Does the hospital want to go out of the business of providing chronic housing for chronically disabled people for whom all rehabilitative measures seem nil? If we’re talking about this group, we’re talking about half-way houses, and foster-care programs. If we’re talking about treatment, then immediately we are talking about a select group of people, younger, actively or newly psychotic, who seem accessible to some kind of psychological and/or psychotherapeutic intervention wherein we are hoping to resolve the psychopathology to the extent of improved social adjustment and improved function. However, we found we had much disagreement on who should do what, including whether we need more adequate use of neighborhood centers. If we get into the issue of who should be providing the treatment, then points about continuity of treatment are pertinent. Should it be the hospital or the community providing the basically continuous treatment? We had a great deal of discussion about half-way houses. We had no discussion about day hospitals, and we came to no definitive conclusions. HOSPITALIZATION FACILITIES FOR DISTURBED CHILDREN The first issue we considered was whether there is a need for a public hospital facility for children in the Metropolitan Area and if so, as all agreed, what type of facility and for what category of child. The consensus was that none of the institutions were equipped to handle the long-term care of (1) the severe behavioral disturbances and (2) psychotic illnesses, especially the adolescent age range from 12 up. This issue immediately raised the question of cost. It was an established fact that children’s units in state hospitals prove more markedly expensive than what is spent on adults. A second question pertained to children’s treatment centers for all degrees of severity or should there be different installations on different sites,

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for instance, an outpatient clinic in one place outside, a residential treatment center for moderately disturbed children at another, and perhaps the severely disturbed children in the hospital setting somewhere else. There was general agreement that it was very desirable to have just one large center, with all degrees of severity of disturbance being treated in the same area so that there could be a continuation of treatment and coordination of the whole program for any one child as he moved from one degree of disturbance to another. The third question was: if the patients are at Saint Elizabeth’s, should the children be on the adult wards as they now are or should they have their own separate unit for living as well as for treatment. There was not a great deal of discussion of this but the general feeling was that it was much better to have them separate. PSYCHIATRY AND THE LAW The principal problem with which we were concerned was that of the commitment procedures. They were antiquated and cumbersome; they were traumatic to the patients who were very much discouraged on coming to a hospital or coming for treatment. The community in general was receptive to changes. What was needed, it was felt, was a drastic overhauling of these ancient laws and rules and statutes that now encumbered the whole business of commitment procedures. One of the biggest difficulties in connection with any overhauling and modernization of commitment procedures was the response or reaction from the legal profession. In connection with voluntary commitment on procedures in 1948, the number had steadily increased. About 17 per cent of the past year’s D.C. admissions to Saint Elizabeth’s Hospital represented voluntary admissions at the time of the workshop. Voluntary admissions would also solve some of the legal problems that arise in regard to admissions, but one effective way to eliminate some of the difficulties would have been to separate the questions of mental illness and competency that exist at the time of admission. If these two problems were brought up totally separately it might have paved the way for people to be much more receptive to the idea of entering hospitals. An additional problem in this respect was one of finances. When an individual wanted to be admitted voluntarily, he immediately would be bombarded with questions of his financial ability to be hospitalized, and this acted as a very considerable deterrent. It was pointed out that at one time the District of Columbia had the worst commitment laws, but then with some liberalization, we only had the second worst commitment statutes in the country. There had been some efforts at modernization.

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There was strong agreement on the part of the participants of the workshop that a mentally ill person should and must be treated simply as a sick person in the same sense as a person with an upper respiratory sickness. His entry into the hospital should be considered along the same lines as any other person who is ill, and should not be encumbered with administrative difficulties. A better technique was sought after for dealing with people coming into the hospital. THE ROLES OF ALLIED PERSONNEL IN REHABILITATION There was a great deal of discussion as to what rehabilitation is. Is it a goal or is it a process? If you compare it with physical medicine, there it is considered more or less a process of restoration. When this was applied to psychiatric areas there was some feeling of the group that it was the development or perhaps redevelopment of the full human potential. This again led to the question of what is rehabilitation—is it synonymous with treatment or is it a continuum of treatment? One member expressed the idea that if we are thinking in terms of human potential then as we rehabilitate ourselves, we rehabilitate patients. I felt that rehabilitation should start in the admission suite. Finally I made some comments that obviously this was not always the case; that sometimes a great deal of time had elapsed between the admission suite and the process we call rehabilitation. After this, the discussion led into the area of does the patient have the choice. I think that we were not only considering the patient’s choice but our own. Group Discussion Following the six reports, an open whole-group discussion was held. Here, topics such as how current commitment procedures add to the difficulties inherent in the hospitalization and treatment of children; the need for an increase in the number of voluntary commitments by adult patients; the special and separate needs of the elderly; the problem of financial status versus commitment for treatment; and the advantages of joining the Interstate Compact were discussed. A discussion of how to discern a needy person (the transient, the alcoholic, the unemployed, the disabled) from a patient needing psychiatric treatment ensued, with the comment that St. Elizabeth’s ran the risk of acting like a mission. It was suggested, as a remedy, that St. Elizabeth’s begin to function in a more proactive and preventative fashion inside the community. As chair, I suggested that “We might save ourselves a lot of grief if we go out to meet the enemy in some of the areas that have been mentioned, work with the products and loci of social and family disorganization. Saint Elizabeth’s has

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something to contribute to what we have heretofore considered to be ‘normal’ sickness in our community’s social life—the breeding grounds of our alcoholics, bums, disturbed delinquents, unemployables, and others referred to in the last half hour. We can head off their advent and speed their passage back to the community by participating in an educative, consultative, or merely supportive capacity with ventures in community re-socialization already in being in this city or tried in other localities. Some examples of such pre-care are neighborhood projects with pre-delinquent adolescents, family care projects, neighborhood fellowship houses, and community reorganization projects, such as the later developments stemming from the Chicago Area Project of the 1930s.” Summary Following are the basic assumptions/outcomes achieved and agreed upon by the participants in this workshop: 1. Mentally ill persons are first of all human beings but with recognizable disorders; 2. The diagnosis and full treatment of a mentally ill person is basically a medical responsibility, but it involves in addition, definite social, psychological, training, and educational considerations; 3. Every mentally ill person has the right to easy and prompt access to programs and services appropriate to his particular needs; 4. It should be assumed that a mentally ill person wants treatment in an appropriate medical program, including a hospital, unless he actively objects. Therefore, he need not necessarily be presumed sufficiently competent to affirm actively his desire for treatment as a condition for allowing him to enter into a needed treatment program; 5. The human dignity and the rights of the mentally ill must be protected and are as important as any presumed need to protect society. Thus, elaborate criminal-like procedures carried out in the name of protecting the mentally ill against wrongful deprivation of liberty may unnecessarily invade other human rights such as that of privacy; 6. The nature of treatment provided to a particular mentally ill person should be based on his individual needs and not on the type of admission to service, that is, informal, voluntary, certified or adjudicated, nor on the ability of the patient or relatives to pay. An important principle underlying much that was said during the workshop was the concept of continuity—one treatment team following a particular patient throughout his entire period of hospitalization and preferably in the city as well. Responsibility and authority are also important issues. If

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there is to be continuity of care for the patient throughout his period of hospitalization, it is apparent that the treatment team must be given responsibility and commensurate authority to cope with the patient throughout his entire period of hospitalization. A second important and emergent issue was the problem of expectation and milieu. Patients as well as employees do respond to the environment in which they live and work to the expectations of others in that environment. Depending on the environment and attitudes, the responses may be helpful or harmful to particular patients. The concept of research and training in a hospital such as Saint Elizabeth’s was deemed primarily supportive of its fundamental mission of treating patients. We must have both training and research in order properly to provide good treatment. Finally, there were a few words on the law. It was agreed that it was important to separate a judicial finding relative to the compulsory detention of a patient for treatment from that having to do with his competence. It should be assumed that a mentally ill person wants treatment in an appropriate community program, including a hospital, unless he actively objects. Of course, protection against wrongful deprivation of liberty should always be available through the courts, utilizing procedures that do not unnecessarily invade privacy or make future treatment difficult. Conclusions The mandate assumed to be derived from these workshop findings was not exercised subsequently in any coherent recognizable fashion but did infuse the hospital’s policy, the policy of the District of Columbia, and also that of the National Institute of Mental Health which subsequently played an increasing role. Also, extant to the policy was contracting the population of the hospital by placement of patients in foster care facilities in the community. An aim hinted at in the report of the workshop of brick and mortar location of aspects of the hospital in the northeast, northwest, southeast and southwest of the community was never realized. THE VETERANS ADMINISTRATION GROUP PSYCHOTHERAPY RESEARCH PROJECT In 1950, Dr. Florence Powdermaker and Dr. Jerome Frank, plus Dr. Michael Pauloff, initiated a research project in group psychotherapy in the Veterans Administration (VA). Harold Searles, Edith Barrett, and I set about conceptualizing how to go about conducting research in group psychotherapy within the framework of the VA. We held an ongoing seminar for a while in how we went about our own research, its recording, and its analysis. I presented the

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transactional method that sociologist Lloyd McCorkle and I had arrived at in group psychotherapy at the Fort Knox rehabilitation center during the Second World War. It was based upon transactional theory and general group theory. Any one engagement of two or more individuals would be recorded to mark the events of verbal and physical interaction. Then came notation concerning the inner, psychoanalytic dynamics of the group, with special reference to the crises that developed. This significance of the roles and capacities of the members in mounting those crises would be noted separately. I initiated my part of the research project on one of the wards, CT2B with a group of schizophrenic women at St. Elizabeth’s Hospital. Along with twice weekly group therapy sessions done in the manner I had initiated at Howard Hall, I also started, at the instance of Mariane Chase, the hospital dance therapist, regular dance therapy sessions. There Mariane and I engaged with the members of the group in the middle of the room intuiting at her instance their mein, posture and movement. Much of it consisted of reflection from therapist to patient and vice versa until some state of mutuality was attained. I found myself experiencing intuitive connectedness. Mariane was enthusiastic. We advanced into a form of dance therapy called sculpting both on an interpersonal and family basis. There we assumed poses and action sequences exemplifying emotional situations between individuals and in the family of envelopment, entanglement, and flight. This project had been previously a project of the occupational therapy department which attempted to alter the behavior towards socialization of the women by having them wear acceptable clothing, and get used again to makeup. The results were minimal if not adversive, with torn clothing and bizarre smearing of lipstick and rouge. I responded to the request from the chief of service who had heard of the work in Howard Hall. The patients’ mothers obsessively visited their daughters, in contrast to the usual abandonment of patients by their relatives. The research project assigned Edith Varon as scribe and collaborator. We found this session protocol to conform to those experienced by McCorkle and myself previously. The project revealed data that conformed to the concept of alienation and reconciliation of the configuration. Other mothers and daughters took part in conceptualizing and reflecting to one another regarding their alienation from human status. The project was published by the International University Press in 1953 as Maternal Dependency and Schizophrenia: Mothers and Daughters in an Analytic Group. I employed this combined sociological and psychoanalytic framework in another project under the auspices of the Veterans Administration group psychotherapy project. It was part of the venture by doctors Florence Powdermaker and Jerome Frank that eventuated in a book, Group Therapy, published by the Harvard University Press in 1953. In it, I had a chapter, “The Large Group,” in which I reported the experience that I initiated in bringing

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all of the patients in this project together in a therapeutic community format, subjecting the protocol to analysis by a joint sociological-psychoanalytic framework. Again, crisis theory and notation of the dialectic that developed between combatant contending factions were duly noted. During the two years I spent at the Veteran’s Administration (1947–1949)—concurrent with study and work at St. Elizabeth’s, the Washington School of Psychiatry, and the Washington Psychoanalytic Institute—I demonstrated the new group therapy begun at Fort Knox and at several other VA mental hospitals and I became a sought-after expert on the topic. I would also introduce and employ the same innovative group therapy constructs at St. Elizabeth’s. MATERNAL DEPENDENCY AND SCHIZOPHRENIA: MOTHERS AND DAUGHTERS IN A THERAPEUTIC GROUP I have already briefly cited the dynamics of the mother-daughter group but wish at this point to mark its significance in the context of the larger work in the current volume. Here we brought the two populations of deeply regressed, schizophrenic daughters and their mothers into intimate transaction and, through the group method I had learned at Fort Knox and Howard Hall, enabled them to reach one another through their evident alienation. I was to apply this experience and the lessons learned to further work with troubled families and couples. The volume reporting the mother-daughter group was published in 1953 by the International Universities Press. All six mother-daughter pairs manifested developmental impasse, with massive regression. My thesis was that the powerful group dynamic I had experienced in my work with psychopaths, and now at Howard Hall with indurate schizophrenics, could be evoked in this small group. The schizophrenic members of the group were relatively young and their mothers were early middle-aged adults. The duration of the illness was 3 to 5 years. Doctors Frank, Powdermaker and I agreed on a modest goal for the venture: attainments by the members of a sense and state of reality and self would enable them to transact helpfully, in accordance with their life situations to renegotiate the impasses and transact. At the outset, their behavior demonstrated the obverse of this formulation. The mothers were consistently driven to attend to a narrow spectrum of their daughters’ behavior and situation control so they evidenced what they considered to be normality. The closest to subjectivity there was an unspoken martyrdom on the part of the mothers. The mothers were generally both dowdy and nun-like in appearance, leading to inferences on severe impairment of feminine identity. There was the exception of one who dressed in a rather flamboyant manner, displaying a version of her femininity in a seduc-

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tive way. All were devoutly consistent in attendance. Regarding the issue of femininity, the daughters were overtly man-like with the exception of Karen, who bizarrely seemed to be fixated on the recesses of her vagina and its secretion. THE NAMING OF THE PARTICIPANTS In changing the names of the participants for privacy purposes, special attention was given to characterization of their emotional and physical stances. It was apparent to the doctor and observer that Mrs. High held herself narcissistically superior—hence the name High—to the others in the group with the possible exception of Mrs. Knowland, who wore her bookishness on her sleeve and exhibited a compulsive need to know—hence the name Knowland. Mrs. Tennant was called such through her compulsive tenacity. Mrs. Roper held onto her daughter as to a rope. The Links acted mostly as links to others in the group. Both mother and daughter Angel, handsome in feature and form, alternated in appearance from angel to devil. Hence, the name Mrs. Angell. COURSES IN MOTHER-DAUGHTER COUPLING Each of the couplings followed its own particular path, altered by the action of the therapeutic group. At first rigid, in a pattern of behavior indicative of a profound impasse, the members loosened their hold on one another, assisting as fellow adults in dramatic fashion, achieving separation and relative autonomy. They then began exhibiting care and empathy for one another, assisting in their careers as mothers and daughters. MRS. HIGH AND HILDA Hilda, with attractive feature and physique, carried herself in a masculine manner, was striding like a man, and pressing her breasts flat with her forearms. She gazed off vacuously, at times staring intently in a violent manner at her mother. She spoke in short ejaculations, of pithy manner, reaching a point in the mid-experiment of stating with some affect, “I want my years back!” This expostulation appeared to be deeply disassociated and moving at the same time, leading to inference on a conjoint autistic and alienated state. She appeared to be in another world of her own making while attached to her mother at an emotional level. Mrs. High early had apparently idealized her daughter to the attainment of physician status, unavailable to herself. This idealization, of autistic nature, has been described as a variant of the interpersonal constellation found by early investigators of the genesis of schizophre-

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nia and called dementia praecox. The observer and doctor held that it was not more by chance that Hilda rattled paper in Mrs. High’s face, as an apparent rebuke. Still later, Hilda characterized her life in soul talk schizophrenese as that of an open wave. Her mother scornfully denied meaning to this poetic statement, but later, after her treatment, was able to attest to understanding her daughter’s situation. Mrs. High’s apparent domination of Hilda became the subject of the group for her mode of mothering and her way of speaking to the doctor. She tried to get Hilda to act “normally,” to sit and walk like she should as a young woman. She had a set opinion that schizophrenia was organic, and needed to be treated with medicine. When the doctor asked for association by the members as to what Hilda was telling us, Mrs. High acted as though she did not hear him, sticking to her guns of the organic nature of her daughter’s illness and the impossibility of analytically oriented treatment. These issues were exemplified from the inception of treatment. The data in the first three sessions were not specific, but indicative of the mobilization of the members into a mother subgroup, daughter subgroup, and linkage dyadic in nature between the two. When Hilda rattled paper in her mother’s face, the doctors called for comment by the members as to what Hilda and Mrs. High were communicating. Mrs. Nolan, who is to appear later in the account, supported Hilda and attested to Mrs. High’s mom-ism. Other members joined the fray, Mrs. Tennant and Tina, but especially Mrs. Link and Laura who were in conflict in a manner similar to that of the Highs. Laura defied both her mother and the doctor, leading to open defiance by Hilda, with the statement “goodbye mother.” When Mrs. Knowland empathically criticized Mrs. High’s dominance, it led to the next overt development in the group, expression by Mrs. High of her despair, echoed by the other mothers, and her overt martyrdom. She mentioned an incipient alienation between herself and her husband, in which he was frankly critical of her total commitment to this child. She reported that he pleaded with her to allow herself to have a life of her own. MRS. KNOWLAND AND KAREN Karen had handsome features, with an expression of sad assiduity. She laughed at times in a mocking manner, somewhat plump as she plunged her right hand into her genitals, to retrieve mucus which she then licked demonstratively. Her mother at this point looked agonized and martyred. From another, autistic world of hellish nature, Karen enacted a mythic prophet of the evil doom in which the mothers and daughters resided. Mrs. Knowland had read widely into the popular literature about schizophrenia and inferred isolative meaning to both Hilda’s and Karen’s behaviors. The thrust of her

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search for knowledge and meaning was matched by her daughter’s propulsive search into the recesses of her vagina. Later, in therapeutic alliance with the members of the group and the doctor, Mrs. Knowland furnished the information that she considered Mrs. High to be the opposite of her angelic self-concept, to be an embodiment of evil. Karen would manneristically stop her walk, to retrace her steps. Both mother and daughter rejoined in the group’s transactions, mother to voice sentiments, concerning the situations of the mothers as collaborative and also vindictive. Karen would come out of her deep autistic regression to join with a partner in such, Tina, another regressed member of the group, both muttering obscurely. However regressed she was at the inception of this work; it is notable on later emergence into reality that she made the most progress of the daughter members of that group. When another patient threw candy on the floor, Karen laughed, and Hilda came out with her statement of, “I want my years back.” Still later Mrs. High was able to express identification with her daughter on her daughter’s alienation and regression. MRS. TENNANT AND TINA Mrs. Tennant and Tina appeared to be an epitome of a bizarre and regressed state. In dimension, Tina, well formed, appeared to be half the expected size of a 23-year-old. Her features were distorted by a look of horror, combined with a derisive laugh. Devoutly muttering, Mrs. Tennant held her daughter close, on her lap, feeding her candy and cookies. The two then would settle into a frozen calm, suddenly interrupted by Tina’s hideous laugh which appeared to be aimed at her mother. Mrs. Tennant would then assert that her daughter did not understand anything, belying any possible meaning to her daughter’s laughter. The group was not long in its development before another mother reached out effectively, directing Mrs. Tennant to let go of her daughter and give her a chance. Thereafter, they sat alongside one another and when Mrs. Tennant reached out to Tina, Tina moved autonomously. Sometime later, Tina began speaking to other patients on the Ward. MRS. LINK AND LAURA This couple was closest to their feelings, arguing through their alienation to what they felt was complete reconciliation. Laura exhibited impulsiveness as her mother’s emissary, announcing to the doctor that she had no faith in him. Of the mothers, Mrs. Link attested to a role reversal with her own mother of being the supplier of physical love. There was alienation of Mrs. Link from her husband and she resorted to sleeping with Laura from infancy. These data

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emerged in the cycles of alienation and reconciliation of this couple in the course of the work. Importantly, Laura gave testimony to the doctor of restitution of appreciation of her feelings. MRS. ROPER AND RAE Mrs. Roper proved to be the most obtuse of the mothers in regard to insight into her own and daughter’s subjectivity. Rae for her part declared that she had no mother, adopting others on a superficial social basis. She was overtly rebellious and self-willed. It was apparent to the therapist and observer that there was a deep affective tie between the mother and daughter. Mother reported that she would go to pieces at the thought of separation. MRS. SPRINGER AND SALLY This pair, late in joining the group, was carefully oriented to it by other mothers and daughters. Sally thereupon moved out of her depressive state, feeling dead when “the black sky fell on her” and she reached out to her mother. Mrs. Springer along with Mrs. Roper attested to the need to reach out to the daughters to relieve their internal pressures. Thereupon Sally announced the coming of spring, hope. By the end of the experiment, Mrs. Springer was citing her and the other mothers’ insufficiencies in regard to maternal instincts. MRS. ANGELL AND ASTRID This couple was also a later arrival to the group. Astrid was the product of a previous marriage, and the nature of the divorce is unknown, except for the attestation on Astrid’s part that her mother saw her previous husband’s personality in her, rejecting her. Another datum that emerged in the sessions was the appearance of Mrs. Angel’s dreams of death prior to Astrid’s birth. Throughout the work, Astrid was preoccupied with states of death and suicide. Also prominent were cycles of alienation and reconciliation on the part of mother and daughter, and the role of grandmother as a refuge. Importantly, Astrid identified guilt on her mother’s part as genetic to her disorder. COMMENTARY This work immediately follows that in Howard Hall, and was done at the same time as my early psychoanalytic training, exemplified in my report, “A Case of Early Separation Trauma.” The sociology I learned from Lloyd W.

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McCorkle, especially identification of roles and passage of members through crises helped in assemblage of session protocols. My psychoanalytic mentors helped me with systematic presentation of individuals. Were I to replicate this study, I would have structured in the participation of both mother and daughter as individuals, through systematic interviews. Lack of such data is the main fault of this study. The other fault would be its early termination. Though we succeeded in getting the members of the couple, mother and daughter, unstuck and capable of relative autonomy, another several years of sessions would undoubtedly have afforded us answers to the question of the genesis of the disorder. Data of highly suggestive nature were obtained through individual psychoanalysis of troubled couples, presented elsewhere in this volume. This work was done at the time when Dr. Frieda Fromm-Reichmann was hypothesizing concerning these schizophreni-genic mothers. In fact, Dr. Fromm-Reichmann attended a session of this group and reported that the mothers there conform to her hypothesis. She also attested to the deep sense of revulsion she experienced towards them, a reaction shared by other visitors to the group. Having the mother and child in the group was a great opportunity to enlist that collaboration in inquiry into this hypothesis. The mothers were generally highly critical of one another for their intrusiveness, disassociated states, lack of maternal instincts, and lack of empathy. The daughters, almost uniformly acting as mothers to their mothers in a role reversal, were withering in their criticism. The mothers denied that their daughters comprehended and also subscribed to an organic cause of the disorder. As they reached out and empathized with other mothers’ daughters, they were able to see them as separate persons. As the mothers allow themselves to relinquish their obsessive, driven states, they became subjectively depressed and available for empathy by the other mothers and some daughters. Work with troubled couples later in this volume resulted in genetic formulation: the psychoanalytic data pertinent to the troubled couples may be summarized as a three-generation hypothesis, what I came to call an advent phenomenon preceding mourning, and a separation from the introject in a situation involving focal existential guilt. The first item, the three-generation hypothesis brought to the fore, the role of grandmother in limiting the capacity of the patient’s mother in her maternal role, resulting in arrest in development and subsequent autonomy on the part of the daughter. A mourning process did appear in most of the mother-daughter couplings, later in the work on the part of Mrs. Angell and Astrid. The advent phenomenon, parapsychological in nature, was absent from the protocols. One could infer that the members were tied to one another through guilt, through the devastating result of disruption of the time. The messianic nature of the time could be inferred evident as throughout.

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This work, which had the potential of being a Rosetta Stone on the genesis of psychic disorder, fell short of such, but served to introduce us to a number of dynamic formulations. The mothers were apparently fixated psychically, and were not susceptible to change from their rigid positioning. I had experienced this inherent state of impossibility and work with psychopaths and deeply regressed schizophrenics. The intervening variables in both cases were my messianism and group collaboration. When Mrs. High and Hilda engaged in their act of arrogant sickness matched by defiant wrestling with a paper, I called on the members of the group to mobilize their intellectual and emotional assets toward a concept and apperception of reality that could be of help to the troubled couple. Mrs. Nolan responded, citing her reading of the literature and observation of Mrs. High’s behavior, to the effect that Mrs. High was domineering to the extent of losing touch with herself and her daughter. In addition, she identified strongly with Hilda. Karen characterized to let go of her preoccupation with the recesses of her vagina to cite her opinion of Mrs. High. In sum, in my call for mobilization of the members’ assets, intellectual and emotional, I had made the first step towards therapeutic alliance with them. Mrs. High held that her daughter was in the grip of biochemical factors and needed behavioral guidance. Mrs. Nolan held that she and her daughter had lost their way and was completely helpless. Mrs. Tennant stated she had been studying the problem assiduously for many years. She then, while still holding on to her daughter, observed that Mrs. High was holding on to her daughter too hard. Mrs. High in time responded to the effect that Mrs. Tennant was misguided in her constant embrace of Tina. The mothers were getting to the soul of the matter of reality in operational terms. Next came a move by a representative of the daughters’ subgroup, Laura, when she threw the gift of flowers from her mother on the floor. Hilda then abandoned her highly symbolized self-represented rattling of paper in her mother’s face, to cite her position of abandoning her mother, and by implication their underlying compact. Then came the appearance of relationship cycles, chiefly manifested by the Highs. They reviewed data relative to affiliation and impasses of the past. This configuration was suggestive of the hypothesis that the core of the dementia-praecox formulation was autistic idealization. There, the adolescent child appeared caught up in the family’s idealization, which took over its sense of reality and on its termination resulted in the psychosis known as early dementia. Hilda was perhaps alluding to such an enterprise when she announced that “she wanted her years back.” She thereby demonstrated cognizance of loss of identity, leading, with other members of the group, her mother to recognition of that central consideration. My work with this unique group of mothers and daughters gave added fortification to my hypothesis that alienation is at the heart of human psychic

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disorders. And that group therapy and reconciliation is at the heart of their resolution. In the next section, we’ll turn to the role of large group psychotherapy in both my career, and in further strengthening this hypothesis. THE LARGE GROUP IN GROUP PSYCHOTHERAPY, POWDERMAKER AND FRANK, HARVARD PRESS, 1953 Here I give an account of the philosophy and practice I exercised in collaboration with the residents and staff at the Perry Point Veterans Administration Hospital in Maryland, the second part of the previously discussed VA research project. The experiment in group therapy of hospitalized schizophrenics had been extant for four months, arriving at an impasse and beginning regression manifested by mutism and further schizophrenic disorganization. Alarmed, the therapeutic staff yielded to my offer of leadership of the entire assemblage as a therapeutic community. I cited my success on this score at Fort Knox and Howard Hall. The 87 members of the patient population had been divided into four groups, with their treatment provided by the resident staff. The residents reported in our weekly consultation that the patients, originally responsive, had become resistive, sparse in verbal production. On the basis of my experience at Howard Hall at St. Elizabeth’s and at the Fort Knox Rehabilitation center for military prisoners, in which I had employed large groups to evoke the engagement of the negative leadership, I recommended that we mobilize the positive by accepting all 87 participants into the experiment. I volunteered to lead this group, which would also include the residents, research team and other staff members. From the first, the impasse reached was enacted in the large group. Sessions 1–5 At the first meeting, I introduced myself and the observer, told our purpose in being there, and what would be expected of the patients as members of the therapeutic discussion group. The early meetings were marked by an atmosphere of profound apathy interrupted by persistent verbal attacks on myself by two patients, and sporadic ones by several others. The group showed flashes of interest when my sincerity, understanding, and reflexive technique were being assailed. Following these attacks, problems would sometimes be presented by two of the members. On one occasion a member spoke up in a faltering, collaborative manner: “I am married and got into these things. Could a man be helpful to another man if he can? I want to go home. What’s their opinion of me? Doctor keeps me here.” I vigorously reflected this statement to the group members for their response. The members answered me with, “Come right out into the open. Why should a policeman take in all

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troubles of other people and put it all on his own shoulders?” His reply: “He is forced to by a bunch of jerks.” In their thinly veiled schizophrenic language, the members designated me as a correctional officer who was representing the hospital administration, itself designated as being comprised of impotent, unknowing people. However, the members of the group and I were engaging in a dialectic of meaningful sort. The majority was speaking to me through self-appointed representatives. The members were beginning to talk with one another, doing so through one member who spoke on behalf of the others, and to another, who commented in a detached way on their behavior. Occasionally patients would come out with asides about others, as when one of them asked, “Who are you—F.B.I.?” or “What do you call him: something sweet or soft (i.e., homosexual)?” This statement turned out to be a beginning communication about an outstanding issue in the identity in the membership, homosexuality. There was a brief discussion of the hospital as a reformatory, with four members participating, and then a quick switch to the subject of a train ride and a woman’s death. This thing of punishment and having been taken for a ride by a woman who deserved death came up repeatedly and more clearly later. During this interlocutory stage I replied to patients by reflecting back a “translated” condensation of their material, paraphrasing and referring questions to the group in order to train the patients in the associative process. This was of both socializing and psychoanalytic import. I also made connections between the remarks of various individuals based on my associations to their statements. As a part of the education of the group, I showed several film strips I had developed at Fort Knox, encouraging the patients to associate to the dynamic parent-child situations represented in order to figure out their meaning. The group associated freely to the pictures, at first jokingly (calling the characters by names in newspaper cartoons), and later with open hostility. This culminated in a hostile statement by a member who was usually compliant, in reference to a picture of a boy looking into a mirror, “I get mad when I shave. I get mad when I have to pay my compensation for shaving and haircuts.” By meeting 5, changes had begun to appear, in that the rivals for my attention took open cognizance of one another, other members of the group besides the original spokesmen participated, and the word “we” came into usage. Sessions 6–11 In the next few sessions the members advanced to the expression of open ambivalence towards me, as they tested their trust in the therapeutic process.

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Hilman: “What is wrong with a party holding a secret out on a person? It is best to leave secrets out in the air. Smells fresher than stale. Holding back causes big disturbances in government.” Doctor: “What does the group think about this secret? How about the secret right here in the group?” Unidentified speaker: “What is the secret?” Hilman:”That sweeping-the-floor people would not tell you when you came here, and also they did not tell you how long you were to stay here. Did they tell you they were going to give you electric shock treatment and that it was for the outstanding mind? No, they didn’t tell you.” Beaman: “What is the secret for us to see; numbers. I am not going to go out the way they brought me here.” Walks out of the room. Doctor: “What does the group think of what has been said here?” Hilman: “What is the purpose of this big session once a week?” Doctor: “Let’s ask the group. What does it do for Mr. Hilman?” Rutherford: “Gives him help.” Hilman: “What I mean, do I get any benefit from it?. . . Would the president be doing any injustice?. . . It’s what the group feels about me. Maybe I am rough and careless. I am not careless and rough. Nurses and attendants think I am terrible. They do not know.” He then went on to speak of the “outstanding chicken coop.” In their contention, the members were working their way through their resistance to what is called in the literature positive transference to the doctor and to the therapy. This is to my mind a necessary step in the formation of therapeutic alliance, one which facilitated the free associative process and creative inquiry into the condition of the patient and reached into genetic factors. The free associative process in the group was exemplified in an interpersonal fashion by a member who vocally disassociated himself from collaboration in the group. This was shown by an outbreak, after a frankly messianic self-representation by a member. The progress in becoming a dynamic group, one in which open ambivalence could be expressed in thought and action within limits of course, was reached when the following was expressed.

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Beaman: “We have to trust god.” The ambivalence toward the doctor in Meeting 8 was followed by an outbreak of intra-group hostility in Meeting 9. Rutherford asked, “Are they as crazy as they look, or are they just putting it on?” Hilman announced, “I am locked up to keep you guys from getting jobs in the White House.” Various members were described as unable to see their heads, sick, crazy, killers, or snakes, as having lost their personality through hospitalization or as injurious in the multiple. Hilman shouted that he did not want to be like the others in the hospital or participate in the group. “They put Henry Ford in a casket. Now all the Fords are dead. Curse on people locked up. Don’t want to get into anything, stay out of everything.” I consider this statement of alienation from self and others to be a seminal turning point at that phase of the group development. It is frank and open and not veiled in its schizophrenese. I also consider that the call by a member to trust in god to be equally seminal. The assertion of alienation presaged the next development in the group, in which an antisocial leader, Hillman, threatened assault on me, after members of the group showed affiliation towards him. In the next development, I suggested that the group constituted itself as a social entity, by election of a chairman, whose task was to moderate the emerging discussion. This chairman was deeply ambivalent, and showed obvious reluctance to perform his duties, thereby manifesting the intrapsychic and interpersonal positions of the members of the group. Group-centered discussions with thematic continuity: Meetings 12–15 By meeting 12, group control through a chairman had proved unfeasible, but the mores of group discussion had begun to emerge. Members showed cautious initiative in speaking of personal problems. The theme of sabotage was brought up by Gans for open discussion. Dialectically, Brink came out with affirmative self-revelation concerning his life course. In opposition, Hilman resorted to schizophrenese concerning maternal figures, disguised as cows. Gans, an early member to express himself, importantly asked how the group felt, a maneuver that the doctor had resorted to frequently. By session 13, members began to speak of their disillusionment, low selfesteem and sense of cowardice (yellow fever). By session 14, the group was able to center its attention on common themes and concerns, exemplifying them through revelation of the problems of individuals. By session 15 the members spontaneously determined to control the behavior of themselves and the behavior of others in the group.

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Members briefly rebelled against this development. Members asked for help with specific problems, prominent among which was self-alienation and homosexuality. Stumpf remarkably stated that he had a problem and needed help with its solution. Another member suggestively spoke of a psychological divorce between himself and the doctor. Members in concert spoke movingly of their alienated, crazy states. This state of affairs was exemplified in session 16 by Mr. Hilman, who stated in part: I am crazy all the way through; I’ve had brains in my shoes. . . . Have to talk about my troubles that happened twelve years ago. Now I have to confess. I might be in the way of somebody’s mind, the way of somebody else’s trouble to get out. Members in succeeding sessions spoke of difficulty in getting back their manhood, likening that with their problems in submission to their doctor and electric shock therapy. A spiritual path was suggested. They vividly discussed their problems in reordering their subjective experience, toward attainment of sanity. The group advanced to managing its own discussions, with the doctor increasingly playing an evocative role. Meetings 16 to Final By meeting 34 a member reported clearly his experience of almost reaching reality, during a visit home, and awareness and appreciation of the group’s role in this process. Giving in when the doctor turned off the radio broadcasting the World Series brought on a profound discussion of the problems of the members in submission to reality. The members expressed raw and immediate feelings of infantile and homosexual nature in therapy, alluding to early childhood experience with their mothers. A turning point in the group occurred when one member, a paranoid leader with great passion, addressed me as a person on why he should believe in me. I detected an underlying wish to do so. I employed an approach that I came to call “staying with the patient” as the patient became further drawn into intimate contact with me. This gave me further data and knowledge of the patients’ constitutions, and undoubtedly to the patient, of my makeup. This resulted in voluntary self-revelation of his problems and an affiliation move and invitation for the doctor to live with the patients. He interacted with a similarly constituted group concerning his loneliness, and the factors in his family of origin that left him less than a man, despite latent wishes for integrity. Like him, the members formed concussive alliances with one another on the way from their positions of low state, chiefly referring to issues in homosexuality. They began reporting gains in sociability and increased tolerance of visits from their families.

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The group situation developed in discernible stages, marked by progression and regression to previous ones. In a year and a half of meetings, these chronically ill young schizophrenic men had formed a platoon-sized bull session which was able to coherently and constructively work on representative members’ problems. Some surfaced from their schizophrenic state and were able to visit productively with their families. The group had gone through discernible phases of development. It took fifty sessions to work through profound apathy, marked by sporadic attacks on the doctor. The expression of ambivalence about the doctor was a major theme during meetings 8 to 11. In sessions 15 to 19, the members began engaging in group-centered discussions with thematic continuity and personalization of themes. These led to increasingly direct expressions of feelings, including ambivalence toward one another in meetings 20 to 62. Toward the end of this development, the group process culminated in the appearance of capacity on the part of representative members and the group for focused character analysis. In accordance with a name in this experience of instructing the residents in performing their roles and capacity in leading the small groups, I mounted at the end of this presentation an extensive inquiry into special problems in handling paranoid, hebephrenic, and catatonic patients. I also noted how monitoring my anxieties and inner associative processes were central to self-guidance and guidance of the group. COMMENTARY It is of moment that I discuss at this point my approach to this experience. My previous experience with schizophrenic individuals occurred as a medical student in my second year. The instructor, Prof. W.W. Young, speaking in a very low-key, natural way, instructed us to do likewise with the prospective patient. The middle-aged black lady and the catatonic offender responded in kind and were open about their problems. My next experience was in wartime, leading a group of neurotic soldiers at a stateside regional hospital. Again, this open, benign approach resulted in a dynamic group experience. At the Fort Knox rehabilitation center for military prisoners, I first observed the work of a practitioner who appeared to be on the surface a leader of a pro-social gang, Lloyd W. McCorkle, who spoke like a fellow gang member, yet with a trace of a professor of sociology. He appeared to be one of them, yet one leading them out of their dilemmas through study of their situation. Prior to training in medicine, my previous chosen profession was that of history. I was especially interested in the great revolutions—American, French, and Russian and the social upheavals in ancient and medieval times. The French revolution was an outstanding example of these, through its

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phases of development and inherent terror, and then through a process of transfer-mutation back to the ascendancy of an Emperor. I studied the phenomena that appeared in my groups at Fort Knox rehabilitation center and Howard Hall from the viewpoint of analogous phases of development. To that experience my new-found training in psychoanalysis and the free associative method added further depth to my leadership as a therapist. I was listening with a third ear and a mobilized mind when I set forth with this group at Perry Point VA hospital. To that, I wish to add one more observation, of an experience I had several years after this one. A pioneer in the treatment of schizophrenics, Dr. John Rosen, who published a volume, Direct Analysis, replied to my question on how he went about his work. This was at a cocktail party, where he reached out to a piece of cake and handed it to me with this statement, “Joe, have this cake!” I inferred that he was stating that he was in his therapy engaging with the patient in a generally benevolent and provident fashion; that is, giving them a gift. I wish to add one more item to this preface, that which I have come to call messianism. Prior to my psychoanalytic training, I had discerned, in collaboration with my personnel at Fort Knox, that I was exercising an underlying spiritual approach to the therapy in a capacity I had acquired as a child with my depressed mother. My personnel at the treatment prison thought that such an insight was pertinent, though unsettling to myself as a putative scientist. In my work in Howard Hall at St. Elizabeth’s my messianism became a central part of the therapeutic experience. I began teaching it in a training program at St. Elizabeth’s hospital, the pastoral Institute of greater Washington, and my various consultancies in the Washington area. Were I to have replicated this experience at Perry Point, I would have led the residents to conduct individual interviews with their patients, if only at intervals, so they would get to know them as persons. So if the members of this group of 87, as representatives of the group process, yielded a certain amount of personal and historical information in the process, they did so limited by the group situation. I had been taught by my sociologist mentor, Lloyd W. McCorkle, that traversal of crises in development was essential to the process. One did not get to the succeeding stage until one had tracked through the current one. Each stage was attended by historic regression to the previous one. I had also learned from experience to monitor my inner associative process as that of observation of what was going on within and about me. Another aspect was what I anticipated in the future toward the situation under scrutiny. Still another calling was my personal identification with the members of the group. I had seen myself in the subjects of my inquiry from the first, in my career.

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To a certain extent I was able to put myself in the shoes of the first patient I had interviewed as a medical student anticipating reporting to my fellow students. As I transacted with the catatonic offender under question, I harkened back to a fear of death as I was choking at age five from a severe case of asthma. During the interview with my second patient, a middle-aged black lady held in the dead of night in a hallway at Grady Hospital in Atlanta, Georgia, somehow brought me back to the despair I experienced with my mother’s miscarriage when I was a young boy. Again, I had identified with the lusty, boisterous young psychopaths in my groups at the Fort Knox rehabilitation center for military prisoners with the inner association of, “these are my people!” Likewise, during the initial phase of the large group of this current piece, I could feel into how the members shrunk from reality into autism. I had done so for brief periods after returning from the Army to civilian life, during episodes of self-doubt, in marked contrast to an exuberant self-confident façade. My recorder/observer made short shift of the first four sessions of the large group. I have learned, in monitoring and supervising the work of other therapists, to scrupulously attend to and examine their transaction with this subject. Likewise, were my examination of micro-detailed aspects of the encounter. Of note there, were conceptualizing the critical moments and the factors that led to that traversal, the establishment of impasse and of regression. An optimal report of that initial phase would go into such detail. Videotaping has been of inestimable value in that regard. By the fifth session, I had become a member of the group, to the extent that members came out sporadically with statements of trust and others cared enough to argue with me on whether they could trust someone. They had come out of their schizophrenic, autistic positions to the extent that they were present, referring to its bodily and spiritual aspect. The achievement of this group contradicts the theory advanced by Dr. Frieda Fromm-Reichmann at that point, to the effect that one could not treat schizophrenic individuals in groups. It also contradicts the assertion by orthodox psychoanalysis that one could not treat the schizophrenic individual per se. As was the case in the work with the mothers and daughters group at St. Elizabeth’s Hospital, the therapy here was peremptorily terminated, in accordance with a previously determined aim to do so when the groups had attained the capacity and self-confidence to help the individual in his clinical course. Especially missing from the report on the large group were data that would contribute to genetic formulations; or what rendered these young men vulnerable to service in the Army? Along with my work with consultation in institutions, one of them being at Perry Point, I engaged in instruction at the Washington Psychoanalytic

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Institute. This was done nightly and on weekends. After a period of didactic instruction, I found four cases for supervision deemed analyzable by the supervisors. With each I presented my notes for the week’s work in detail, to achieve the depth psychological survey and estimate that I had sorely sought in previous work at Fort Knox and St. Elizabeth’s. MY PATIENT POPULATION IN EARLY PRIVATE PRACTICE 1950–1970 I have already cited my transfer of practice to an apartment building opposite to the Washington D.C. Zoo. However I had begun that practice out of an office I established in my residence. Announcement of my practice was by word-of-mouth and a professional placement in the telephone directory. I initially received young adults, government employees of both sexes, plus a gay male who had been rounded up in a police sweep of the toilets downtown. Important there was the identification of those suitable for traditional psychoanalysis. The initial accession to my practice was a young woman just turned 20 who presented the complaint of confused states and insomnia, and who was relieved of these and regained her purpose and capacity to maneuver her way in Washington after two sessions, with no further intervention on my part. She did not wish further therapy, and though I held that it was what is called a transference cure, affected through the messianism that was manifested in the groups at Fort Knox and now at St. Elizabeth’s, I urged her to seek further therapy when she was financially more able. Then in rapid succession I gained six young male government employees each complaining of shyness, difficulty in living, and uncertainty about their life goals. A representative member of that cohort was a man in his thirties who came to analysis on recommendation of his physician, who was treating him for a duodenal ulcer. He was employed by the U.S. government in a clerkship position, but also was an entrepreneur in a business that he had conceived of as a vendor, installing and servicing street-vending machines. His academic career had been marked by brief periods of brilliance, but mostly average grades. Despite his capacity for initiative, he did not know what he wanted to do in life. In his hours, he reported periods of despondency, shyness and hesitancy and brief periods of courtship. He was so disgusted with his father’s failure to meet his fantasy of a good father, he found himself equally alien to caring about himself. This occurred in fits and starts, and long empty periods in which he sulked in his room, finally rousing himself to try making contact with people once again. Having achieved this meaningful understanding of himself in his hours, he was emboldened to inquire into the genesis of this

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problem. He arrived at the formulation that it stemmed from a mother who had renounced her motherhood and ended up in periods of despondency of a pattern similar to what he had discerned in himself. His emotional and intellectual grasp of these dilemmas gave him further confidence. I put him into a group of young men that I had started, and he became a mentor to them in finding themselves. I strove to convert their therapy to what was considered standard psychoanalysis, one which consisted of four hour-long sessions per week, including dream analysis. The latter emphasis on periodicity stemmed from the requirement in the American Psychoanalytic Association of a four to five times per week analyses. There was conflict between the Washington Psychoanalytic Institute and the National Organization. The Washington founding fathers, led by Harry Stack Sullivan and Frida From-Reichmann, held that three-times-a-week was sufficient. I had long accustomed myself to absence in my group work, as long as the members seemed to be going somewhere. My criteria on that score had to do with what I learned to be the establishment of a dialectic between the positive members and the negative members, as well as one that had to do with contention on the dimension or nature of the problem. Since the members appeared to be working in good faith on this issue, I did not interrupt the stream of conversation, which I estimated to be analogous to the free association of psychoanalysis, as long as the members seemed to be moving towards grasp of focal conflicts, with their identification within the group transaction. This was in contrast to my behavior in the large group held at the Perry Point Veteran’s Administration Hospital and those at Howard Hall and Fort Knox, where I was participant in each act transaction. Having looked at the important role of large group psychotherapy in my professional life, I wish now to look at the role of one-on-one psychotherapy in the formulation of my hypotheses regarding alienation, reconciliation, messianism, and the transference. What follows is the first of several iconic cases, with details illustrating their significant impact on my career. ICONIC CASE NUMBER ONE: EARLY SEPARATION TRAUMA The Washington psychoanalytic group had become famous for attempting research and practice with the severe disorders—schizophrenia, depression, borderline, and bipolar condition. When a depressed young woman appeared for treatment, my supervisor encouraged me to take her into psychoanalysis. She and her husband were sufficiently sophisticated to afford themselves that treatment, and we started her formal analysis in my second year of practice. This is an account of the work with that thirty-five year old married woman, who came to treatment complaining of chronic fatigue and insoluble

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conflicts over problems both in her marriage and writing career. The treatment extended over a period of three and a half years, with a total of four hundred and five hours. Of special interest in the treatment was the part played by screen identifications (see glossary) in the dream material and the transference. The analysis of these identifications as resistance material is followed in the case presentation by means of a running account and interpretive comment. This is done in some detail, in a collation and correlation of dream and other data, to render coherent the changing picture as the analysis proceeded. At the beginning of treatment she was thirty-one years old, married five years. She had two children, the first a girl, three and a half years old; the second a boy, six months old. Her husband was thirty-three years old. They were both Jewish, non-attending. In her historical account, she noted resentments and inadequacies as a mother and housewife, and disillusionment in her brilliant freelance writer husband. He was experiencing severe blocks in his work and had taken to leaning heavily on her and the bottle for initiative and support. She had expected her own writing talents to flourish in collaborative efforts with her husband; instead, she seemed to be able to do only editing and background work. She was the second child, born in a small Pennsylvania town two years after her sister. Her father ran a small hardware store, and was a charming, ebullient man with great business ambitions, and commensurate feelings of failure and recrimination under stress of demands in the family. Her mother, on patient’s report, died when she was very young and she was left with her grandparents. Deserted by her father who had a new family, she hiked from village to village to find him. On doing so, she was received coldly and turned back to his parents. The patient’s mother was reported to have been high spirited, beautiful and talented in singing and she had wanted an operatic career. She was frustrated in this by her own mother, who had pushed her to marry a promising man, settle down and avoid her own hard life. When the patient was two years old, a fire almost burned the home down, and the patient and others were barely saved from disaster. Her earliest memories related to her life with her maternal grandparents and two uncles in Pittsburgh. Her father had moved to New England to start a factory. The grandparents jointly ran a grocery store in a slum area. Her sister went to live with a married aunt, the oldest of grandmother’s children, in a well-to-do neighborhood. Grandmother was the dominant figure in the household, running the business, and by her sharp tongue and martyred ways, keeping the men in the household in line. There was a great deal of philosophically couched talk, initiated by grandmother, about the tragic situation of the patient. She was indulged by the four

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adults in the household. She described hiding under the table when visitors took pity on her. A finicky eater, very thin, she insisted on sitting at the edge of her chair, and ate meager amounts of grown-up food. She stood alone at the window a great deal, and preferred to watch mechanics at work at a neighboring garage to playing with other children. Prominent among her childhood memories were joyous visits to her aunt and sister, where she enthused over her sister’s dresses and lovely surroundings. On one of these visits, at age seven, her uncle, a quick tempered man, spanked her when she wet the bed. Her father visited infrequently, sending greetings and money by mail. The patient reported that the high point of her childhood, at age eight, was a surprise visit by her father to her classroom. She was transported with joy, jumping up and down, feeling that this would prove to the other children that she had a father, too. Coupled with this memory was a persistent sniffing of the air for cigarette smoke, which signified the presence in early childhood of her father. When she was eight years old her father remarried, in New England. She and her sister travelled by train alone to Boston, to visit with her stepmother’s relatives, and then to New Hampshire. She was extremely sad over leaving her grandmother, whose confidante she had become, and to whom she read the newspaper daily. She intensely disliked her new relatives. They were too fat and gross; she was thin and fastidious. Her stepmother was distant and strict. She was ushered up to her room and taught how to make her bed. At meals she was firmly directed to eat what was given to her. She joined with her sister in hating her stepmother. The alliance was directed also at saving her father from stepmother’s domination, and at saving the old family of three from the new one which grew with the birth of two children, a boy and a girl. In the course of her struggle with stepmother, the patient resorted to ruses such as pretense that she didn’t know how to say the word “mother.” The patient showed marked changes soon after arriving in New Hampshire. Under duress by stepmother, she began eating and gained weight rapidly. In school she showed outgoing tendencies. She excelled in scholarship, and was soon in the same class as her sister. While her sister was popular in dramatics, the patient became captain of the basketball team, then president of the Dramatics Club, and was voted the most popular girl in her class because of her evident vitality and sense of humor. Her sister was her closest friend during school years; there was a strong sense of helping one another in a hostile world. There were many school-girl friends, but an ever present feeling of exclusion from inner circles, as one of the few Jewish families in town. This was reinforced by father’s strict prohibition against dating gentile boys. She was very shy with boys through girlhood and adolescence, except in definite extracurricular activities, where she did very well as a leader. While in high school, she was courted briefly by a

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relatively wealthy Jewish boy from Boston. Her father refused (with the usual words, “you’re killing me”) to buy the dress the patient passionately felt was essential; she abruptly broke off the relationship. Her success in English in high school, and her father’s enthusiasm (he expected her to write a great novel) led her to major in English in the small woman’s college she and her sister attended. Her sister majored in dramatics. Their college careers were undistinguished, marked chiefly by concentration on their studies. On graduation at twenty-two, she tried to write freelance, on commission from a magazine editor, organizing a trek across the country, visiting campuses to assay the state of the student mind. Her sister and cousin, who went along, enjoyed the experience. On return, she found that the editor did not honor what she had taken to be a definite commitment. Humiliated, she took a job writing advertising copy for a department store, living in Pittsburgh with her grandmother. She found her to be aged and expecting death. In tearful scenes grandmother again related how the patient’s mother on her deathbed had bid her children, “Goodbye, you shall never see me again.” She related that life was a dream, without meaning, and that she expected death soon. She died quietly a year and a half later. Her sister, soon after she returned from the western trip, moved to New York City to do soap opera on the radio. In a year the patient took a cub reporter’s job on the Newark Evening News, under a kindly gray haired editor. She grew very fond of him. She worked hard at police and society reporting. She had several brief courtships, which she broke off because the men weren’t ambitious or talented enough. In a year she moved to her sister’s apartment out of loneliness. She wrote for the Writer’s War Board. She courted with one of her sister’s dates, a writer, and continued it by mail while he was overseas. He made an outstanding name for himself for his accurate and creative reportorial work there. He proposed on arrival home. She accepted, claiming surprise. They had premarital sexual relations, successful, but attended by great anxiety and guilt on the part of the patient. They moved to Washington, where he started on a freelance career. His initial articles centered on the problem of the discharged soldier and were quite successful. Moving in time to other topics he experienced blocks in conceptualizing and executing his work. He called on his wife, ostensibly for editorial help. This mostly resulted in wrangles and further difficulties. He started drinking for relief. During his absences to research material, the patient was panicky at night. She called on women friends to stay with her. Several attempts to write articles on her own ended in failure, because of difficulty in integrating her material after researching it. One of these, the latest, was a piece on the wonderful courage shown by the Women’s Air

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Corps in going about their important service selflessly and with good cheer. One and a half years after marriage she had her first baby, a girl. The child was planned, and was quite healthy and well. From the first, the patient consciously tried to give it affection and shield it from her own childhood experiences. She felt that her husband was preoccupied and insisted on her attention, rather than being affectionate with the child. She increasingly felt fatigued and discouraged about herself, her writing, and the impasses with her husband over his work. He sought analytic help in a year. His enthusiasm over his analyst and exacerbation of her complaints on becoming pregnant again brought her into her first spell of analysis. This lasted four and a half months, and was interrupted by the birth of a boy. Four months after this she sought treatment again; she was referred because her therapist was leaving town. Course in Treatment On initial interviews she appeared to be a dark, somewhat sallow, self-contained young woman, who told her story coherently and carefully, much as if she were writing an essay. Her complaints had been somewhat relieved in her previous therapy; she had learned she was carrying over childhood experiences into the present. However, she felt her inner problem to be subtle and difficult to identify. The kindness and understanding of her previous analyst had been a great comfort to her. After history-taking was over, she reported her current concerns dutifully. They went on at length. She observed her daughter’s clinging dependence and her husband’s competition with daughter for her approval. She related her veiled contempt for matrons of her acquaintance who cared only for pomp, money and their children’s doings. Her stepmother, several doctors, and a money-making builder were scored for their hypocritical natures. She told the story of her recent efforts to write on her own, this time on a subject she stated she identified with closely: the story of the stoical and selfless Women’s Air Corps. Her first dream in analysis, in the sixth hour, concerned her sister’s doctor husband, who was in tears. The patient tried to make him see what he had done to her sister. The patient was a Women’s Air Corps member and her husband was an enlisted man, and they were having trouble getting together. Associations related to her profound tiredness from responsibilities and her conflicting dream of being a mother and a writer. The presenting picture in her treatment seemed to have as a focal point her awareness of her inner problem as subtle and unidentifiable. From the first, she showed great difficulty and resistance to identifying her feelings sui generis. They were referred to through her identifications: her blocked husband, her martyred grandmother, the stoical women’s Air Corps members,

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her poor dependent daughter. She disavowed having anything like her husband’s dependent, slavish approach to analysis. She liked her former analyst for telling her reassuring things, of his own volition. The first dream seemed to exemplify this state of affairs: the dependent one was a male, a doctor, the husband of the sister who was dependent on her. The patient was trying to help him. In the same vein, the patient and her husband were identified through other roles in the Army, but were personally separate. However, in her associations, she was able to, though avoiding making connections with her manifest content, relate her very pertinent feelings over her inner conflicts as a mother and careerist. These feelings soon manifested themselves in the treatment hours in morose and sullen complaint about the futility of treatment, her husband’s troubles in writing and his supervision of her performance as a collaborator and wife. She was sorry she had married such a weak person, so like her father. She was giving up to mediocrity. The alternative was the philosophical approach of her grandmother, and living more through her daughter. The element of death first appeared in a dream in the seventeenth hour, in which her father was dizzy, which meant he was dying. She awoke with the feeling that he was too demanding. In her associations to the dream she felt trapped, completely on the defensive, that she was punishing herself for her bad thoughts against her sister and father. She did not wish to cling to the doctor, was only able to write sob and protest pieces, as she had in her article on the Women’s Air Corps members. Again, the identification was through a male, but closer to home, and directly related to her dependent guilt. Her transference was established to a “bad mother” masculine figure. The therapist was aware of wishes to placate the patient in her grousing, and some guilt and confusion at abstinence from this. She felt guilty about doing for herself, in coming to the hours. In the twenty-fourth hour she reported a dream, in which a girl showed her a little head in the corner of her husband’s letterhead, which on closer scrutiny, was a black tombstone. In her associations she felt this to be her tombstone, meaning that she belonged to that letterhead item, and she was glad. She hunted for his helplessness; he was like a little boy to his father, but a Hitler at home. Here she appeared to arrive at something closer to her own identity: the self-annihilating character of her little boy dependence on her husband, and identification with his career with implications relative to her “glad” alienation from her own feminine identity. Four months after beginning analysis she went on a trip to Europe, returning with stories about happy, uncomplicated European women and full of “realizations” of her past competitiveness with men to avoid her dependent, feminine status. This identification with that European cultural institution soon evaporated when subjected to scrutiny

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in the hours, and turned into bitter anger at the doctor, her husband, and children for their demands. She became openly contemptuous of what the doctor had to offer her. This culminated in a scene where she derided his appearance of confusion when she peremptorily quit the couch and stood over him. She stated she was leaving. He recouped sufficiently to state that was her choice, but that the act of abandoning him and herself was of little value to her. She subsequently accepted this interpretation and, renouncing her ambitions, began experiencing subjective depression and pains in her chest and uterus. She stated, with some paradoxical satisfaction, that she was in effect a guinea pig to the various doctors she consulted. Eight months after beginning treatment, she shyly but proudly brought in pictures of her children. She reported greater acceptance of her maternal role and dream dealing with associated fears. She dreamed in the fifty-eighth hour of a doctor in a yellow coat who resembled nobody she knew and who was head of a babies’ institution. He was asked about a milk formula. Suddenly he was cutting her pubic hair; she approved of this—she did it herself, for tight dresses, and also as a physical therapy. In her associations, she linked him with the doctor, as also pleasant and smiling, and rendering her a service which, while a needed break from her housework, she needed to cut down for financial reasons. Inquiry into feeding and cutting operations in the dream was met by passive resistance. In succeeding hours, the doctor was pictured as cold, critical, and clinical. She spoke intellectually of some possible homosexual leanings in the form of getting other women to confide in her, to avoid some attraction on her part. Giving up her virginity as the price of a relationship with a man was too big a price. She pictured herself as alone, not jealous, in a dream where her husband was pursuing another woman. Later in her oedipal fantasies and dreams, those of an idealized family conducted by an idealized father, she identified herself as a cast-off one, and her husband mocking her as he made love to another woman. Much of her work in the next year and a half dealt with this fixation and with learning to deal with its self-perpetuating identifications (with grandmother, father and mother). A cousin, son of a favorite aunt, died in Korea, at the end of her first year in treatment. This resulted in renewal of a feeling of futility in her therapeutic work, and a persistent headache. Her former passive resistance to therapeutic inquiry was transformed into anxious sitting up in an abstracted, wakeful position. When asked about this act she responded with a hostile, accusatory outburst about the doctor as an inquisitor. She had the first of recurrent cemetery dreams in the seventy-third hour: I was running from something, to a high place at the edge of a cemetery. I jumped down, glad I had made it onto a concrete floor. There were nine Negro

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boys ahead, laughing and talking in front of a steel cart, on which there were a flower pot and a casket. They agreed to push the cart with me on it, down a corridor. I was curious about them, afraid they worked for the undertaker.

In her associations, she made a vaguely superstitious point of the number nine. This was the number of pallbearers, her birthday, her parents’ marriage date, and the date of her mother’s death. She had always been an excellent jumper. She responded to “jumping down” by citing her siding with underdogs; she identified herself with them. In regard to the “negro boys,” she stated that the blacks had congregated on a concrete floor near her mother’s burial place. Black people had been unkind to her in the slum district in Pittsburgh in which she had lived as a child. A feeling of imminent death gripped her at times, when her husband was gone; she then had to talk to a woman. The appearance of an inquisitor brought the issue of guilt to the fore. This was in the hours related to the feelings she had in her abstracted, alienated sitting on the couch. This also was related to the fear of imminent death when she was alone, allayed when she talked to a maternal figure. After this, she reported some change, which she accounted as progress, in finding herself spontaneously dressing up for her husband. Also she cried on her sister’s shoulder during a recent visit, reversing their usual relationship. However, when her husband engaged an agent for the business end of his work, she declaimed that she’d rather die than submit to that humiliation. She developed severe neck and headaches, and expressed grave doubts about continuing analysis. She referred to herself as a rebellious boy, fighting for his precious independence and asserted that her hair would come down in the future. She reported scenes with her daughter and her husband over submission. The former related to her daughter’s rebellious exploitation of illness to “tyrannize” the household. In attempting to come to grips with the problem she at first threw her daughter onto a bed in a wild fury. Later she was more calmly firm. Afterwards, in the hour, she stated she realized how her image of herself as a forlorn helpless child had interfered with dealing with and really helping her daughter. She moved next to open anger at the doctor for taking away the satisfaction of her old “caring” ways. He had made her recognize her “monstrous” pushing aside of her husband’s concern over their daughter’s recent tonsillectomy. She was afraid of her daughter’s hostility to her own cold attitude. She developed drowsiness in the ninety-fourth hour and came up with the first of a series of dreams which brought in elements of her burning resentments and problems in submission and guilt. I was working downstairs on the catalogue (in reality, a work to earn money suggested by her husband). Somebody was at the door. The maid

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answered. It was two thugs, known for robbing and kidnapping. I closed and locked the door, looking out of the peep hole, and told the maid to look first, before opening it. I went to the basement, and saw a fire coming in. Next, I was at grandmother’s, which was right up against my house. Aunt D. was there. I said to grandmother, “Your house is catching my house on fire, too.” Her associations ran to her antagonism to all exploitive demands made on her by her children and the maid. The conflicts and demands in grandmother’s house were present in her own. She resented others coming first, and felt it in her stomach. She was ambivalent about the doctor’s request that she work this out. In succeeding hours she reported severe pain in her left breast, felt like shouting, and repeatedly and bitterly complained that the doctor was tough, unlike her former analyst. Data came out about her refusal of solace and fondness at grandmother’s, where she had been skinny, agitated, and persisted in looking out the window. She had a recrudescence of her setting up resistance in the hours. She stated that she was not going to be the favorite because she caused less trouble, as after moving to New Hampshire. Abstaining from her former identification with grandmother, and submitting martyr-like to others’ demands had left her exposed. She sank into her old identity of dry, agitated mourning in grandmother’s house. This mourning process was occurring in the hours. Her oral resistances and her alienated feeling for herself as a woman came to the fore again. Her sister, at age seven, had reassured her about her feminine attractiveness when her uncle ridiculed her masculine walk. This came under scrutiny on her own initiative with discussion of her “basic loneliness,” which she overcame by “guts,” leading a “successful life not being lonely.” She then reported a dream (127th hour) in which the setting was her daughter’s school, with her daughter’s teacher singing in a round stage. Then her daughter ran to the black maid on the stage. They embraced for a minute, and the maid sang to the people, who appeared to be in a dark, bare, wooden, ghostlike place. She awoke in anxiety. In her associations, the patient came to her identification with her daughter, and her conflicts with her over-obedience. She reported discovery in the past week, after her hours, of her own singing voice. She related her mother’s fatal obedience to her own prudish mother in not pursuing a stage career. She again bitterly denounced the doctor and her stepmother for their “cold potato” attitudes. Close on the heels of this dream, she had another one (128th hour) about her favorite aunt, in which the aunt was dying of cancer, and the patient was falsely reassured by a nurse and others. She looked out of the window at the sky (a feature of her disaster dream). In her association, she related to the effect that asking meant killing the other (father cited that the family was killing him with them), and she was liked by him for not requesting. Grandmother was strong, independent, and hated dependency on money.

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Making requests to her daughter and others evidently involved homicidal effects. She began recognizing how these were escaped from through identification with her “helpful” independent grandmother. Concomitantly, she reported a returning sense of identification with her mother (discovery of her singing voice). Her depressed feelings lifted, as she again renounced expecting anything from her husband and the treatment. However, she reported less need to control situations by acting the ideal helpful person that she had demanded the doctor to be; she helped her husband less and reported more energy. She found herself responding with anger to her daughter’s “Pittsburgh attitude” and rebellion, thereby diverging from her grandmother’s non-punitive ways. The theme of anger and dependence was followed in a dream (160th hour) in which her grandmother (with whom she was identified in the dream) grew smaller and more helpless as she was dying, while the patient was angry at some men who were making a mess outdoors, reminiscent of a cemetery scene. She associated to her profound and mute grief on making the transition from her grandmother to her father in New Hampshire. She reminisced over grandmother’s potato pancakes and care for her growing pains. This was the first show of anger in a dream. She brought together her identification with grandmother, the regression in size, and the role of man in making of messes and the death of women. This was also related to the loss of her grandmother. The mess showed up in the next dream (161st hour) in the form of a flood of dirty water in the basement, which she related to her sexual conflicts with her husband. Her husband had spurned her, and she was cold to him, stubbornly not approaching him, despite her desires. She stated that she wanted to maneuver him into the position of asking and then be denied. She left the hour sneering that she expected to get cured by her dentist! Her provocative challenge to the doctor led him to infer that she was requesting him to make her submit. Before that, she had to get her revenge by humiliating him. This was related to early struggles over cleaning up her mutely provocative messes with uncle and stepmother, in which the beating and humiliation she received relieved her of her oral guilt (see glossary). She came out with material on her heated and wrathful struggle with her son over bed wetting, recapitulating her with her stepmother, in which her sheets were hung out to chastise and humiliate. She reported learning through observing and identifying with the children in the neighborhood of their excluding and humiliating one another. She reported memory traces (“from beyond the black curtain”) of smelling for smoke early in her life, with her sister’s memories of the patient’s being wheeled out of their burning house, and another dream of a house belonging to her, her grandmother, and aunt, burning down. She associated to her destructive wishes toward her stepmoth-

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er and her current fears about the wires in her “cranky” daughter’s room being dangerously hot. She declaimed that the doctor’s crankiness was being appeased by her offerings in the hour. She could hardly contain her anger at him. She reported extreme anger at her sister and her daughter. Her daughter would have to fight her own problem about being shut out by her playmates. This theme was present in a train dream setting (182nd hour) for a rendezvous with a man, involving underwear. An interruption brought her to a station house, in which four accusers stated that her daughter hated her sister, and her son did not want her to leave the house. She awoke, feeling deserted. Her “shocking” hatred for her sister came to full realization in her associations. She passionately hated sewing for her husband. She remembered her guilt on turning her then single sister out of their apartment, when she married her husband, whom she had “taken” from her sister. Her extremely dependent feelings, her “heart on her sleeve,” and the extreme measures she took to cover them over were discussed. She reported a new feeling of less involvement in others’ difficulties, and that she was able to deny to others with less guilt. She reported a dream (168th hour) in which she turned down the doctor after he made sexual advances to her. Her aggressiveness showed in a dream (189th hour) in which a lion, associated with her jealousy and rivalry, scratched up her children. In association to this she cited an instance in which her “monstrous” anger broke an impasse with her daughter and resulted in a happy, singing child who blithely went off to school. She commented on herself as a guilty, dwarfed, pitiful creature because of her destructive jealousy. She elaborated further in several dreams (192nd, 193rd hours) in her rivalry with her college chums who came from prominent families, in scenes of struggle over who visits the other’s bed, and in which she found herself old, gray, unnoticed, and about to die—so they’d talk about her like they had her mother. Further data came out and childhood plans to run away from home in New Hampshire, and be missed like her mother, who also had an indulged and self-indulgent sister. She reported fantasies of whipping the maid in a jealous mood and that she had to feel terrible or contrite to ask things of people. Her depressed mood again left, and she asserted that the doctor was “wonderful.” With this work she confirmed her identifications with her mother and grandmother and the violently jealous and possessive emotions she was escaping from through these identifications. Her hold on this awareness was tenuous still, and needed considerably more working through. She still had a marked tendency to lose herself through identification with others. This became more consciously apparent to her as it was exemplified in her dreams.

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She reported turning against her grandmother. Then on her own she turned her attention to her own confused identity and its masculine identification. At that point the patient began dreaming more of her dead grandmother. Her grandmother hadn’t died. As a hooded, mythic figure, she approached and then merged with the patient. In horror, the patient attempted to separate herself psychically and spiritually. She began to sob deeply, entering mourning. She then knew how to deal with her husband’s imperious assertion of hegemony and her own need to take care of herself and their two young children. In a dream (206th hour) she was in a meal time situation with four handsome men, when a close friend walked in, scantily clad, also lacking pubic hair. She wondered if the men would pay attention to her. In her associations she broached her past idealization of a close friend whose company the patient had sought during moments of anxiety when her husband was away. She brought up her wish to swallow up the male. In another dream (218th hour) she was courted by a handsome tennis player, and turned from a plain girl in a beige dress (her marriage dress) into a beautiful girl. She wondered what to do about her virginity, suddenly turned into the boy, and became very considerate of this virgin girl. Her associations were to her early wishes to be a boy, who was less vulnerable in his love attachments. She discussed her past attachment to a married editor. She claimed that in childhood she was her father’s substitute lover. She actively denied being attracted by another woman. She reported markedly changing feelings towards the doctor—in the direction of increased satisfaction with him as a maternal figure. In the 222nd hour she dreamed: I was on the couch, my sister sitting in the room. At the end of the hour, an old woman in a black dress arose from a chair. You introduced her as your mother. Your sister said, “She must have been there all the time.” What she had heard hadn’t prejudiced her. Suddenly I was at a neighbor’s house party. We were eating and waiting for you to come. You came in, your back bent and towards me. In her associations she discerned that the doctor’s mother represented her own and then referred to the married editor who was so caring and fond of her. She claimed surprise at the doctor’s motherliness and the maternal figure’s not holding against her attitudes in analysis. She vividly recounted childhood experiences at visits to her mother’s grave when without tears she would read her mother’s name on the tombstone repeatedly to tell herself that there was such a person, while the others cried. The concept of “must have been there all the time” in the form of a maternal figure was clearly presented here. Her denial and guilt in regard to mother’s leaving lessened. The dream sequence in which the doctor was awaited at the eating party became clearer that he was the maternal figure.

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The element of denial (back towards) was still present. She worked over again her dislike of eating children’s foods, backed up by her grandmother, and her disciplinary problems at school, where she couldn’t be bothered learning, using instead “creative, intuitive flashes.” A dream followed (250th hour) in which her sister gave her a sanitary belt because she was pregnant. In another (253rd hour) she bore a baby girl unbeknownst to herself. She stated that this was the first wish she had fulfilled in a long time. She reported increased abstinence from “helping” her husband, and his recent surprising “appreciation” of her help. She felt her creative urges would come out in raising the children. The relationship between submission and creativity became a little clearer here. Realization of her oral wishes at grandmother’s had been blocked, as was the mourning process. Her stubborn efforts were towards making the other give in (grandmother, teacher) and push things on her. Her own morality was regressively expressed by her opposition to those she depended on. As a child, in an isolated narcissistic position, she insisted on identifying herself as an adult and indulged herself as a child with adult food. Likewise, she controlled and avoided a situation of dependence in school on maternal figures she was cut off from by hostility and guilt. She was her own mother, so to speak. In her dreams, her ambivalence towards real childbirth was exemplified by the defensive sanitary belt, and her uncontrolled giving birth to a baby girl. The latter in its lack of control was evidently a sign of progress. Two years after beginning treatment, she reported that her husband was increasingly loving and attentive to herself and the children. Her intense longing for him was uncovered when he was away for a week. She actively reminisced about her childhood need for her father, with turning from discipline and disappointment to visions of him and with a “terrific sense of possession—you belong to me and I to you.” She recovered a memory of a fall, at 3 or 4, with injury to her palm, during her father’s absence, through a dream (288th hour) of a scar on her father’s palm, with accompanying severe guilt over not showing her love for him. She dreamed (294th hour) she had lost a beauty content, later got it off her chest to friendly women. In the hour, she noted recent awareness of her great egocentricity and her need for a single other person. She reported a dream (297th hour) about a visit to a male obstetrician who turned into a woman obstetrician, on whose couch she lay, sleepy, an ambulance in the offing. In her associations, this evoked again her wish for a woman to take care of her, and her envy of a woman psychiatrist. She reported a dream (319th hour) in which she was a young man on the road in love with a married woman, on whom she pressed her love by kissing him. In association, she identified the woman as herself, with breaking through of her self-imposed loneliness. She reported feeling more like a

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woman, and more independent of her need for consolation from her husband for her “inconsolable loneliness.” She spoke of her fear of revealing her dependence on the doctor, because, as with her stepmother, that would give him the right to be critical. She defended herself by claiming to do a better job of taking care of herself than he could. In this dream there was further clarification of the approach of the accusatory masculine figure in former dreams. It was an alienated, oral part of herself seeking a maternal figure. There was an evident lessening of the guilt which drove her towards masculine identifications, and away from the danger of giving in and depending on a maternal figure. She was now freer to depend on and identify with a woman. In a dream in the 352nd hour, an experimental car with a silver fleece goat’s head and the patient parted company, the patient going off in convivial fashion with a group of women. In her associations she related the goat’s head car to her ties with her grandmother and kindly old men. She reported less fear of being hurt in sexual intercourse. She was evidently parting with the principal means of escape from her early oral and later oedipal guilt. She then dreamed (354th hour) of putting on a coat in the hour, against the cold outside (it was January). In the dream the doctor stated, “That is Millium-lined.” (Her nickname was Millie.) She and the doctor parted ways, he with his umbrella to an apartment. She cried, on the doctor’s interpretation that she had the warming lining in the coat all the time. She associated it with her femininity, and a feeling of being taken care of. She felt that, though the doctor was in a separate apartment, he would be available if needed. She dreamed, in the 360th hour, of being quite receptive sexually, and eager for toys which were around her. In her associations, she wondered why she was so relieved of her doubts and conflict. She concluded it related to having what she needed; having enabled her to depend on people instead of her own resources. She spoke of the cynical, powerful, noisy, angry, mean boy-woman her husband had to put up with in the past. She felt as though she had just come out of a temper tantrum. In regard to asking for things, writing was a way of telling the world about how she saw things. If her mother were alive she wouldn’t have to. This was exemplified in the comfort she experienced through the doctor’s statement about the lining in her coat. In tears, she felt the need to be somebody’s little girl. Her father had in the past asked her to repay him in a son’s way, confusing her. Her jealousy and rivalry towards her sisters and their escape through huddling against a common foe interfered with their love for each other. Her largely inner break with her husband on helping him with his career was reported to have helped “smooth out” their sexual relationship. She found herself more firmly relinquishing masculine aspirations, and actions; this most clearly applied to her dream of being a great writer, of having

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power and of hitting at things that hurt her. She submitted more comfortably to learning the things she had to do, and was rather aware of her undisciplined tendency to dream away elsewhere, especially to the past. In a dream (389th hour) she was courted by a tall, dark, graying man, who was still somewhat disappointed in her dress, which was not like that of another woman, covered with orchids. In her associations she asserted her frank wishes for money, power and marriage to a moneybag—plus more acceptant recognition of her own anxieties about her adequacy as a woman. She compared her relationship with her former and present doctor. In her previous relationship she attempted to face herself on a reasonable, rational plane, with a need underneath for reassurance that she was not so bad. In the current treatment, she had found herself “trying to out-compete him, crawled into a corner, and went a long way back.” She had tried to triumph, as with her grandmother, who had stated indulgently, “She can have all the pennies she wants, because she is going away next week,” thereby keeping the illusion of holding her destiny in her hands. Her father developed lympho-sarcoma. She experienced her old sense of unique aloneness, guilt over her past jealousy, hate and passiveness. However, she stated she faced his death with more of a relationship to him. She felt she was getting the upper hand with herself in her struggle for her own identity, her fight to keep from being swallowed up. She stated she didn’t have to grab onto him. She reported a dream of her father, of protesting her love to him, appearing as he looked in the scene in the second grade of elementary school; then she showed him and his wife where her husband worked. She reported, in the 394th hour, her last dream in analysis, of being a welcome visitor at a family with six children, possibly hers. There was a sudden shift to a department store, where she lost out to her sister on getting pretty clothes. Next she was acting as psychiatrist to a little boy with deformed legs, at first lying to his father that she had studied his records, but eventually becoming genuinely absorbed in the boy. In associations, she felt this was a recapitulation of her anxieties as a person and woman, and that she was getting onto her egocentricity and her decreasing need for her husband to be a man, to enable her to be a woman. She felt she couldn’t ask for better resources than she had. She used to feel she had the right to take love for granted. She was unhappy but sober about leaving analysis. Recapitulation and Formulation The presenting picture was one of a woman who dealt with an inner impoverishment through an altruistic concern for others, and through identifying with masculine figures. Early in her life she had experienced severe trauma, with

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the loss of her mother through childbirth, and the movement of her father to a distant location. There had been no mourning process; simultaneously she isolated herself from experiences which would evoke it. She identified with tough, competitive boys. She found in her maternal grandmother a similarly narcissistic, lonely, pathetic, and domineering woman. In caring for her grandchild, grandmother was undoing some of her own guilt and bitterness over her daughter’s death in a marriage for which she felt responsible. In her six years at grandmother’s, the patient developed indurated defenses of denial of her own underlying feelings and identity. She had fairly severe oral disturbances, and gross escape from dealing with attachments to men by identifying with grandmother or with the men at hand. She had autistic (see glossary) reveries about her absent father. In her identification with grandmother she would supervise, or philosophically look down on the man, feeding on his weakness. She avoided her own dependency wishes on grandmother by helping cheer her up, acting as her confidante and teaching her to read and write. She avoided relationships with children where she would have to identify herself as another child. With the few playmates in her slum neighborhood, she was a tough, self-sufficient, out-of-their-class individualist. Toward her sister and girls, she showed an identifying enthusiasm, taking up for them in a protective way. In her altruism she avoided feelings of deprivation and competition. In part, she assumed an identity as an independent, forlorn, but proud little tomboy. On movement to New England, at age eight, she was given an opportunity to have a diametrically different kind of mother figure. Her stepmother was an authoritarian, who exemplified many of the traits of the bad mother of her repressed feelings. She was able to respond to stepmother’s challenge on what appeared to be a retaliatory and competitive basis, and to progress enough to bring to awareness her hatreds and morality bound in them. She began eating food adequate to her age and needs, and became interested in competing in school. She engaged in active efforts to be father’s favorite. She developed a basis for existence during her schooling years which lasted until its breakdown brought her into analysis. She identified herself with and through external purposive enterprises, work and pleasure, depending on success in these to escape from an extremely severe, largely unconscious, internal governing principle or agency, referred to in psychoanalysis as superego. This superego stemmed principally from the internally dissociated, or repressed, experience of loss of her mother, reinforced by further identification with her grandmother, and to a lesser extent, identification with father. There was a brooding presentment of disaster attributable chiefly to her very early trauma.

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Much of her altruism seemed to be the enactment of an undoing process, where she avoided her own guilt over loss of mother through undoing the harm that “life” did to others. The enterprises she chiefly identified herself with were masculine in nature. She scorned a stereotyped “woman”—the housewife interested only in marriage and raising children. Oedipal anxieties, anxieties relative to her positioning with her father in the family, were dealt with chiefly by a process of identification with the male, with grandmother’s alienated identity, or with the rival female. Her once genuine experience with courting ended disastrously when her father destructively terminated it. In the analytic experience, she soon lost her controls previously exercised by insisting on certain good mother performances by the analyst, when the doctor abstained from such collusion. She reacted with regression and hostility. Her underlying identification with grandmother, and her own “tough lad” identity were revealed through acting out. Submission involved death, and was related to her loss of mother; she was deeply identified with her, but cut off from her through repression of the mourning process. That process was facilitated by the depression incurred by the abstinence of the analyst. It was marked in her dreaming by visitation of her grandmother’s ghost, merging with it, then separation from it. This iconic circumstance led the analyst to form an initial hypothesis relative to the introject, the incorporated essence of a forebear that held dominance in the inner psychic life. Having accomplished this massive and important intrapsychic event, she began to be able to see her children and husband as separate from herself with dependent needs and resistances against growth of their own. She began denying to them, formerly avoided out of guilt, and something she formerly had to be driven to do, and to be less punitive and retaliatory because of their dependent demands. Once the earlier developmental components pertinent to issues in orality and habit training were to some extent dealt with, her sexual problems in the analysis as represented by her sexual dreams, changed from a status of collusion in her own deception, to suppliant, then demanding, then retaliate for being wronged and humiliated. And finally, it changed to one where, though she recognized her inadequacies as a woman, she had worth as such in her own, the doctor’s, and to an increasing extent, her husband’s eyes. Termination seemed appropriate. Summary The course of the analysis of this woman centered about the trauma of abandonment in early childhood. She transferred to the analytic situation the repressed feelings relating to loss of her mother and father, and worked through some of the causes of her retaliative withdrawal of her oral wishes

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(and of some of their anal and genital derivatives). Prominent in the workingthrough process was analysis of the multiple identifications she had used to screen her withdrawal. A central identification was with her grandmother, as a dominant introject. Release of the effects bound in this earlier material was closely followed by work on her oedipal situation. Her infantile character, arrested in its development, was given opportunity to grow through her dream and fantasy life in the analysis, in which she lived through an underlying highly infantile attachment to the doctor, finally parting with him on more nearly an equal, mutually respecting level. During the initial phases of the work, my subjective experience parallel to the transference (termed counter-transference), was a definite problem in management because of the intensely provocative nature of her abandoning ways, as she struggled against her urgent dependent feelings and engaged in a fair amount of masochistic acting out in her marriage. This was the first of a series of iconic cases, marked by the appearance of a tie to the introject, manifested by a parapsychological phenomenon, the appearance of a haunt or ghost. An example of such is present in the literature with the appearance of Hamlet’s father’s ghost, and its dominance in Hamlet’s tragic course. ICONIC CASE NUMBER TWO: FATHER’S GHOSTLY FACE After this woman’s recovery from depression, she urged her husband to seek therapy with the author. He did so reluctantly. By this time with her help he had finished a major work on a space pioneer, This High Man, but was deep into a depression of his own complicated by alcoholism. I found it necessary to hospitalize him and proceeded to engage in what I learned in this time to be the necessary close communion. This extended to visiting with him in an isolation room, devoid of furniture. Seated side by side on the floor, he began staring straight ahead with a look of extreme fright. He reported seeing his father’s face looking intently at him. After a while he broke into sobbing which continued uncontrolled. After it subsided he reported feeling somehow relieved and smiled. I inferred that he had seen a ghost and the import of that visitation had penetrated his consciousness in a manner similar to the penetration by the ghost of her grandmother’s/mother’s visitor on his wife. Subsequently he was able to separate himself from an entity that had kept him in thrall and motivated him in an ad astra per aspera fashion towards becoming his own “high man.” We will visit the remaining three iconic cases later. For chronological ease, the next section follows my experiences with combing both group and

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individual psychoanalysis with patients. These experiences served to enrich my understanding of the transference. CORRELATIONS IN COMBINED GROUP AND INDIVIDUAL PSYCHOANALYSIS What follows is a paper I presented in May at the Panel on Comparison of Individual and Group Psychology, Annual Meeting of the American Psychoanalytic Association, Chicago; May 1957. The eight women in the group I present here differed from that first iconic case in the sense that they were unable to continue in the work with me on a psychoanalytic basis because of our inability to traverse the experience related to coming out with the transference. Again, the transference is defined as that resident within the psyche of the individual just presented as iconic case number one stemming from the past which because of fixations of traumatic and other origin interfere with and obviate the capacity to live in the present with self and the analyst. My previous individual patient was able to free-associate or reach without impersonal impediment into her personal past and come up with dream material indicative of a tie with her mother and grandmother, one of loss due to death with consequent inability to mourn. I placed these eight women in the group to support and facilitate their capacity to go through such experience. They had each arrived at an impasse in therapy with me, with regression into depressive and acting-out behavior. The report begins with a discussion of the relationship between my activities as a group analyst versus that as an analyst of an individual. Central there was the concept and practice of abstinence, an evocative detachment of dedicated nature. This replaced the usual activity of the therapist, indeed of the physician, in which the transaction of support, guidance, and counseling are prominent. The report goes on to introduce the members of the group in their life and current settings. Important there was the use of myth, legend, and drama to typify the relevant data. An instance there was that of a designation of an important member as Cindy, for the subject of the Cinderella Legend, as a devoted homemaker and family builder, alongside seeking a secret prince charming. The course of the group is then described, its mission of enabling the members to deal with their character resistances to the act of transference. Important there were the experiences of the formation of dyads and triads about issues in that character analysis. Central to the report is the presentation of a session protocol, and the inferences derived therefrom: The members had been able to form their own group in co-autonomy with the doctor, and in trusting regression and collaboration yielded their need for the active management imperative prior to its

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formation. This document is rendered largely in its original form because if its contemporaneity and pertinence to my central thesis, perhaps as a companion piece to my clinical account of iconic case number one. A companion paper was given by Leo Berman, M.D. on the relation of the individual to group psychoanalysis. This paper concentrated on clinical data in support of Dr. Berman’s thesis. Dr. Alfred Stanton was secretary of the section on group psychoanalysis which presented these papers in support of a proposal to incorporate group psychoanalysis within the body of standard psychoanalysis. The governing council of the American Psychoanalytic Association decided otherwise and the committee to study the subject was dissolved. Dr. Stanton went on to report both papers in the organizations proceedings, published in the Journal of American Psychoanalytic Association. PART I Whether group and individual psychoanalysis, however modified, are synergistic, or even compatible, are central questions in the exploration of the potentialities of group psychoanalysis. This paper is a preliminary clinical report in this area, on experiences in treatment of individuals by a combined individual-group method. The data are presented in sketches of the course of a therapeutic group from its inception, and of a record of a single session, correlated with data from the individual therapy of the group members. Some attention will be given to a form of dream analysis in the group setting. Throughout, an attempt will be made to present the phenomena simultaneously from the standpoint of individual and group psychology. First, a word about the therapist’s approach. Clarity on this score is necessary in the complex of relationships formed in a group. This necessity becomes a virtue in helping keep tangible and identifiable the inter ego aspects of the doctor-patient relationship. This ego psychological point, especially as it refers to the adequacy and appropriateness of the analytic working relationship, is one on which analyses too frequently founder, despite adherence to the standard technique. Basic in the therapist’s approach is the social contract between doctor and patient. This has a long history and tradition. In current usage, the doctor’s responsibility is primarily to the individual, but also to society, the family, and other social groups and social institutions. He is bound, but inherent in the contract is freedom of action appropriate to his professional and personal identity. It is in a portion of this social contract that the relationship attained in the standard analytic procedure lies. In it, the usual “active” ego functions per-

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formed by a doctor, of managing, guiding, exhorting, inspiring, counseling, etc., are abstained from and replaced by an evocative detachment. The activity is transposed to managing the transference evoked in the relationship, with its attendant resistances. As a result, those patients who are not able to trust enough to yield up their transferences, whose resistances to the act of transferring itself are manifested in calls for gross management, have been beyond the reach of psychoanalysis. The “active” ego functions involved in management of these patients have been attended to by the general psychiatrists, and to an increasing extent, by explorers from the field of psychoanalysis, in work with psychotics and borderline patients. In psychoanalytic therapeutic groups, the ego operations involved in this management of the resistances to transference, and its relationship to analysis of the transference itself, come to the fore. In a sense, the group is built on these functions, which may be why it has seemed so foreign to many classical analysts. However, this exercise of the therapist’s ego function is, as elsewhere in analysis, marked by economy, and continuous review and estimation of the therapeutic situation. Though still subject to the abstinence rule, the therapist’s ego functions are very much in evidence in the process of evocation, engagement and resolution of the resistances to transference. On attainment of relationships involving identifiable and usable transference elements, the standard technique is employed. Attention will be paid in this paper to this process of preparation of the patient for analysis, for which this and other authors have found the group so useful. This approach renders more meaningful the analytic aspect of the role and functioning of a group therapist. He leads the group in working through the members’ resistances to a trusting regression and the concomitant transferences. However, the social contract between a leader and a group entails responsibility for a separate social entity, the therapeutic group itself. This group is related to other social entities in our society, genetically, economically, dynamically, etc., and calls for conceptualization along political, economic, social psychological, sociological and anthropological lines. THE MEMBERS OF THE GROUP The group, composed of eight women, ages 28 to 48, had been meeting an hour once weekly, for fourteen months. But for one, treated by another analyst, the members were in individual therapy with the author. The couch and the usual standard technique were employed whenever possible; in only one did resistances preclude this. One patient was seen three times weekly, five twice weekly, and one once weekly. There was a remarkably broad spread in social and economic background, and in current social roles and position.

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To aid in identification of the many members, they have been given names from our cultural heritage, which serve to highlight both their characters and life courses. Cindy’s name was derived from the Cinderella story, after her lifelong obsession of dutiful, industrious homemaking. She was in her mid-30s, married 15 years, with four children. Her home in childhood was dominated by a father who preempted others’ concerns, and planned and worried for everyone. Her mother was profoundly submissive, identifying almost completely with him in his narcissism. Cindy did likewise, but adopted his mode of assertiveness, “for what was right,” and for the benefit of others. She began to break from this conformity when she suffered disappointment in her marriage. There she had engaged in a tremendous push to build a happy home, in a caricature through idealization of her father’s and mother’s approach. Ostensibly, she had realized her aims in a charming home, four children, and a successful husband. However, she became depressed and sought treatment to help free her of her current husband, and find a Prince Charming who would manage and take care of her. She approached her treatment as she had her marriage; she had to believe in it, and worked at it in Cinderella fashion. The therapist perforce became her Prince Charming, a picture to which she rigidly adhered. She was placed in the group, when, in the analytic process, the therapist’s abstinence began to uncover the transference proper. This was marked by a display of suffering, with agonized crying, cringing, and wringing of hands, in her mother’s mode. Data gradually emerged in her hours about a deeply repressed identification with her mother. Uncovered with this was a childhood fantasy of a husbandless family, derived largely from this identification. It was considered that the group would facilitate analysis of her obsessive and idealized investment in therapy, help her weather the panic and agony induced by the therapist’s abstinence, and later help mobilize her sadistic states in which she got even for experienced hurts and wrongs. Annie, in her mid-40s, married for several decades and with three children, was named for the straight-shooting Annie Oakley who beat the men at their own game. Annie’s father died when she was 13. There was no mourning; instead, identifying with him, she assumed an idealization of his role towards her mother and a younger brother. These defenses lasted through 20 years of marriage, until a family-wide crisis occurred, in which all the members sought to re-identify themselves, in developmental crises appropriate to their life stage. Her 18 year old son initiated the process by delinquent acting out. Annie, having to manage things, intruded herself into his psychotherapy, and then literally pulled her husband into it, later making him go to still another therapist. After discarding several therapists, she began intensive work with the author. Initial resistances centered about the masculine identification which

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was quite rewarding to the patient in ordinary living. She resisted the couch as humiliating; she felt it would make her like a whore. She went through cycles of bitter alienation from the therapist as an inquisitor. Both her resistance to the transference, and beginnings of transference were present in a developing image of the therapist as an “old man of the mountain,” who evoked confidence and confessionals. The transference which appeared on analysis of this screen identification centered about problems in mourning her father for the mothering he had given her, and an intolerable identification with her “bad” mother. She was placed in the group close to its inception to afford her relief from the panics she had formerly avoided by ordering and controlling things. At this point, the therapist welcomed the group to facilitate recovery from wounds to his narcissism, and getting even or impulses which were interfering with empathy with the patient. Mimi, named from the heroine of La Boheme, also faded away in her struggle about her man. 34, she sought psychiatric help for 7 years for panics and conversion symptoms centering about swallowing. This began when she realized she was incapable of leaving her immature, dependent husband, who himself escaped from oedipal anxieties by mothering her, instead of taking her in hand. Once during this course, she showed marked improvement when she formed a fantasy sweetheart attachment to a psychiatrist in a hospital setting. Her childhood and adulthood until marriage in her late 20s were dominated by a histrionic mother, who believed in the independent life. Her father was equally independent, showing it by obdurate passivity, eventually leaving home. There was a divorce when Mimi was 6. Mimi did not mourn his loss, but developed an intense, dissociated fantasy life, acted out periodically by masterful organization of the play activities of children usually older than her. Her choice of mate was made on conscious aversion to dominating males, in concert with her mother. Marriage to a “nice guy” quickly disillusioned her; she was then boxed in, between attachment to a man she could not stand and aversion to the one towards whom she strove. Treatment consisted of a long travail through a number of psychiatrists and several hospitalizations for study, with gradual uncovery and acting out of an abject yet dominating dependency, with compulsive need for physical union with a maternal figure, as a fugue-like escape from oedipal issues. It was in a struggle on this score that group treatment was requested for her by her analyst. Similar struggles, less physically dramatic, punctuated the treatment of a number of the group members; Mimi served to exemplify them in the sessions. Josephine, named for Napoleon’s lady, was the first acknowledged (by the group members) favorite of the therapist. In this she played a key role in introducing the members’ sibling and oedipal anxieties. She had come to

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treatment in great anxiety after failure in a series of courtships, and the realization she was intolerably dependent on her mother. In childhood, she had been strongly attached to her father who, a teacher by profession, neglected it for demonstratively masculine-like avocations and study of the (Napoleonic) heroes of the past, with whom he apparently identified. Her parents considered themselves emancipated moderns, going their own rational way in marriage and social relations. In practice, they called for utter conformity to their defenses, through becoming depressed, disinterested, or charming. Both were fixated and overtly ambivalent in the area of instinctual gratification. Josephine showed a preference for her indulging and self-indulgent father, achieving integration with him on the basis of intellectual tutelage. As with other members of the group, there was sublimation through artistic channels, in wholesome and prim behavior, and deep religious “walking in the paths of our fathers.” She had an accompanying sense of alienation and worthlessness, and perverted denial of her own inner wishes. There were abortive and disturbing attempts to emerge from this state in sadistic outbreaks against her brother (younger by two years, and the only sibling). In adolescence, she became close friends almost solely, and on the basis of worshipful identification, with girls of prominent families who were themselves working through emancipatory struggles. She helped and “understood” boys who were similar to her father, yet promising. With both sexes she offered the thing she prized the most, and wished to keep inviolate, her “clear mind.” Individual therapy was begun two years before the formation of the group, on a twice, then once a week basis, because of financial problems and exigencies on her job. Initial resistances were similar to Cindy’s but less intense. She early came across evidence of an idealization of her father, but in her case this existed side by side with a feeling of marked distaste for him. Analysis of the screen of idealization brought on sweet, nostalgic, then pathetic, then raging crying. She would become quite lost in this and suffered from gross anxiety. She was included in the group which was formed at this point for the support her defenses needed as her underlying depression emerged in the transference. Minerva, in the Roman myth, sprang fully armed from Zeus’ forehead, after he had swallowed her mother, Métis. (Cindy’s father showed this sort of behavior most openly). Minerva was the Goddess of Wisdom, patron of the arts of peace and war, ruler of storms, and guardian of cities. The owl, serpent, and cock were sacred to her. These qualities and functions were exemplified by the patient Minerva, complete to a compelling owl-like stare. Emphasis is placed on these aspects because of the intense meaning this member assumed to all the members of the group, in her frank exercise of the above mentioned functions, of patron, ruler, and guardian.

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A 36-year-old married woman with three children, herself the youngest of three, she came to therapy because of an aggressive panic state, a storm, which concluded her treatment with a woman therapist. In it, she desperately clung to and threatened her therapist and her family, also her own, especially her older son. This son originally brought her to consultation, then treatment, because of borderline larcenous delinquency. In her developmental background there was loss (by divorce) at 13 of a moody, at times charming father, leaving her with a mother who alternated between masterful self-sufficiency and withdrawn self-pity. A state of alienation from him set in. She and two older brothers engaged in sadistic rages towards one another as bosses, and intense, shifting loyalty battles. She retired to a semi-autistic life with books, alternating with nature-loving solitary sports and competitive couples games, such as tennis. She had an inexplicable sweet tooth, reminiscent of indulgence by her father, for which she stole money from her mother. Her son later repeated this pattern, but to sweeten up his friends. Marriage to a brilliant, personable, and narcissistic writer proved to be incompatible after several years of self-admiring and self-conscious “emancipated modern” family building. She had realized she was carrying a singlehanded load, centered about support of his needs for adoration, reassurance and fulfilling his role in the family. In renouncing this role, she came up against her incapacity to realize her own inner life, preempted as it had been by her parents’ concerns. As a step towards, and also in flight from her needs and wishes, she became sensitive to the demands of her children and husband, responding with frigidity and rage. Consultation with a school psychologist over her older son’s truancy and pre-delinquent behavior brought her and her husband into exploratory treatment with the psychologist. This rapidly developed a situation similar to Mimi’s; she found herself in a panic, aggressively pursuing and threatening the therapist. In an attempt to avoid hospitalization, treatment was terminated and she was given a choice of other therapists. She interviewed each, and though she chose the author, she came bitterly, still committed to her former therapist, whom she felt had thrown her out. She utilized all of the goddess Minerva’s considerable assets in fighting transference from the past, insisting that there was no connection between her current and meaningless therapy, and her recent or distant past. She attempted, and succeeded in rousing furious storms in the therapist. The therapist would have to prove himself; she would not be taken in by the wishful thinking she had with her other therapist. At most, she would accept him only as a counselor. She was placed in the newly forming group to help work through these initial resistances. Moving further into the ranks of the overtly embattled members of the group, we come to Carrie, named after Carrie Nation. This 43-year-old di-

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vorcee of 8 years possessed a remarkable axe-like tongue, used to shatter men who didn’t treat her like a lady. She came to therapy via a route similar to Minerva’s; a fire-setting fugue by the oldest of her two adoptive daughters resulted in parental counseling, then analytic therapy which was interrupted by an impasse involving erotic elements, similar to Mimi’s. Carrie’s homosexual impulses were unconscious, and acted out in enjoyment in masculine sports. In her impasse, she did not engage in violent struggles about submission, as did other group members; she was passed on from one therapist or counselor to another as having obtained maximum benefit. With each, her axe tongue was very much buried, to be exhumed when her resistance to transferring was worked through by the necessary authoritarian therapeutic maneuvers. The younger of two children, she was cared for by a succession of housekeepers, after her mother, a music teacher, developed a paranoid psychosis with acting out, when the patient was about one year old. Her father was a markedly taciturn and inadequate man, handicapped by progressive tabs, who sunk from lower middle class to slum life. He was suspicious of his daughter’s sexual life from an early age. Carrie early developed defenses involving a retaliatory crashing masculine mode of attack, or meek complying martyrdom, plus a compelling drive to better herself and become a “lady” at any cost. This drive was shown in assuming uplifting causes, on the personal level with people, eventuating in marriage to a personable but passive fellow “orphan.” Like Minerva, she succeeded in inspiring him and furthering his career, but found herself frigid and dissatisfied with appeasing his self-centeredness. As she grew self-righteous, he deviated morally. Divorce freed her to pursue a business career and a man to take care of her. In both of these areas, she made precarious integrations, when the boss or beau, though chosen for their need for her help, without explanation rebelled usually in some delinquent way against her control. Her daughter’s delinquency was of a piece with this, and brought her unwittingly to treatment. Magda was named from Mary Magdalene, who, on being saved from sin, sat at the feet of the Savior. She was 32 years old, married 6 years, with one child, and herself the oldest of 4. She was with her third therapist, the author, for 2 years when she entered the group. Authoritarian management had just terminated a fugue of promiscuity, itself an escape from panic which had appeared in her previous therapy. This panic resembled Minerva’s and Mimi’s and responded to decisive sobering interpretation to the effect that she was no longer dictating the situation. It was apparent that they had engaged in this behavior on the basis that abstinence from “support” of their need for (and measures in seeking) love warranted guilt on the part of the therapist.

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Magda, although hostile and castrating now in her hours, gradually developed guilt feelings. She defended herself from them by religiosity, working through successive masculine religionists to find one she could not seduce. She worshipped at the feet of each, asking to be saved from her sinful ways, as she aroused them sexually. She gave a past history of an extremely lonely and troubled childhood, with hysterical assaultive fugue states and what was probably emotional St. Vitus dance. She assumed a definite alter maternal role in the family, obviating, as did the others presented so far, her own developmental anxieties. This was reinforced by her mother’s prolonged absences in the course of work away from home. It was coupled with a fantasy incest affair with her father, with just enough participation on his part to mislead her. She developed massive obsessional and hysterical defenses against this. They broke down when the “nice boy” she married became “like the rest of them.” She became frigid, yet, unable to leave the mothering he gave her, went into open panic. Previous therapy had enabled her to conceive and verbalize about the ideal man she sought (someone similar to Cindy’s Prince Charming but even more Godlike). In current therapy, she was trying to drive herself to change into a woman “who could love and live with such a man.” In her case the chief obstacle was a deeply masochistic identification, fixated in earliest infancy, with a driving, man-hating, overtly depressed, controlling, and also abandoning mother. Alienated from her own orality, Magda fed her mother. This was enacted in her hours. She also enacted the alienation between her parents, with inversion of sexual roles, where her mother was the man in the family in decision making and in good part in earning their livelihood. In their alienation, each parent narcissistically took care of themselves, and asked nothing and gave nothing to the other. This formulation is gone into in this much detail, because this patient, most of all, was able to formulate experiences relating to ego boundaries, ego integrity, and identifications. Much of this was accomplished in the course of salvation-confessionals, as she sat at the feet of her doctor-savior, in a trance, holding her head from which gushed forth vividly detailed recall of experiences. In her previous therapy, in the course of uncovering her oedipal problems, things had gone awry when, unchecked, she turned to an identification with the therapist similar to Cindy’s, but on a more overtly autistic basis. In this autism she could not recognize that the therapist and patient were separate persons. As a doctor, he belonged to the needy patient. She called at all hours, haunted his neighborhood, frequently with her husband and child in tow. She “worked” on her treatment twenty-four hours a day, on her terms. In this struggle, despite and because of her overriding, supervising dependent stances, she succeeded in avoiding a real dependency relationship in which transference could develop, by inducing guilt in the therapist over abandonment of such a helpless, apparently cooperative patient.

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On transfer to the author, like Minerva and Carrie, she suffered bitterly through the sobering phase of abstinence from this narcissistic control of the situation. Also in this phase, there were acted out struggles over the earliest, issues of satisfaction and disappointment described by Erikson in his article, “The Problem of Ego Identity.” When she painfully moved from living through the therapist’s role, and began dealing with her own, she yielded material centering at first about houses, then a full-fledged erotic transference preceded by concerted resistance to it. Next she experienced entanglement with Annie’s and Cindy’s idealism. Then came screen oedipal memories and current fantasies. Analysis of these led to a painful and deeply repressed identification with her mother, and the concomitant inverted Oedipus noted in the others, both enacted in the transference. A prominent theme in the lives of the members of the group, but present in clearer form in the patient named Joan, was the Joan of Arc mission, which carried her away from fulfillment as a woman. Joan the patient was a 34-year-old teacher who came to treatment because of a deep dissatisfaction with herself for the poverty of her personal life and failures with men. The latter were marked by patronizing prudishness on her part, and utter alienation; or, in a complete about face, by profound submission, with promiscuity, until her career line took a turn towards evangelism for underprivileged groups. Then she could deal with man as an “equal,” with meaningful intercourse. She was the younger of two girls, with an extremely competent, ambitious, socially active mother, who carried on an un-verbalized struggle with her passive, easy going husband. From earliest childhood Joan suffered from wordless shyness, which she escaped through befriending her misunderstood father. She lived under the constant feeling she was a disappointment to the family. On leaving home to teach, she found her tongue in relationships with people like her idealization of her father, and in causes in her profession. When at 29 she sought treatment; like Cindy and Magda, she “helped the analyst” with prodigious efforts at compliance with her version of the standard technique. She expected appreciation and mutual self-revelation. On disappointment, she regressed into wordless panic and alienation, which eventually pervaded her social and professional life. She quit teaching and her therapist for work with underprivileged persons. In work with the author she repeatedly enacted this sequence in the hours. Progress was slow, and extremely painful, as she mourned the loss of her idealized identification figure, and was thrown back on her identification with her mother, and the early bipolar issues illustrated by Magda. Antigone, daughter of Oedipus, went loyally forth with him as his rod, later intransigently performed the burial service for her brother, and was in turn buried alive by Creon. The 48-year-old single woman named for her had

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suffered from a recurrent mixed psychosis, akin in her mind to burial, for 20 years, since breakup of an affair with a married man considerably older than herself. During her well periods she advanced in a scientific career, and had a wide circle of friends composed mainly of women and some married couples. She presented a background of loss, by desertion, of her father when she was a year old, and domination by a virulently non-hostile mother and maiden aunt. She successfully rebelled against an art career projected for her by her mother. The affair with the older man was her sole experience in courtship. She was relatively inaccessible in individual psychotherapy, because of a largely wordless panic, and then a protest that she was “all right,” and needed only counseling. There was evidence given, however, in a dream she grudgingly presented, of resistance to transference through the sort of idealization that Cindy and Magda exhibited. Pythia, the only member who dropped out of the group, played a peculiar oracular role. Like the priestess in the Delphic Temple, Pythia, she spoke forth the truth of the Gods, and with an inner ear heard underlying meanings. She carried herself like Mrs. FDR. 52 years old, with four children and several grandchildren, married to a prominent educator, she had begun suffering from depressions and frigidity on separating herself from a rigid devotion to his career. She requested group therapy in the course of treatment for a recurrent depression by a woman psychologist, because she experienced “greatest awareness of an underlying self” when she had “blowups” in a group. Otherwise in her dealings, she was agreeable and responsible, “lending myself to people.” As background she presented an intense attachment to a sweet, passive, minister father, and an openly and deeply ambivalent relationship with her high-strung, and at times, violent mother. Quite a lonely girl, she maintained successful integrations with others as a leader in controversial causes. She married an ambitious, maturely benevolent man who “goes to pieces when I’m not loving him.” She left the group after two sessions, because “he would have to come with me, or get too upset to work.” Comment These members are illustrative of my unusual psychoanalytic practice. They had sought treatment at fairly definable crises in their lives. For three, Annie, Carrie, and Minerva, severe behavioral disturbances in their children had led to parent counselling at school, then elsewhere, eventuating in psychotherapy by successive therapists, leading to analytic treatment. Increasingly apparent to them in this course was their sense of failure in marriage and career. Three members, Magda, Mimi, and Cindy, acted out, two in borderline regressive fashion, crises in their feelings about themselves as women in efforts toward leaving their passive husbands for some more masculine figure.

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The three single members, Joan, Josephine, and Antigone, came to treatment because of generalized anxiety related to failure in their obsessive career investments, and in regression during struggles to break a dependent tie to a woman or a therapist serving in that capacity. All were concerned about a loss of self-control. Most had prided themselves on their ability to stay “on top” of situations; now they were embroiled in helpless floundering. These members seemed to be involved in a number of variations of an identity crisis, as defined by Erikson in his article, “The Problem of Ego Identity.” Various aspects of this crisis, reflective of different ego structures and fixations at earlier stages of development, were exemplified by particular members. An aim in the group experience was to bring out these very differences, through identification and other processes, to the deepest extent, in their antithetical or opposite and complementary elements. In doing so, the members’ fixations would be mobilized, facilitating movement, in therapeutic regression and progression. The nature of this fixation was a matter of great concern throughout this volume. It had to do with the vulnerability of the members of this group in yielding to or fighting of identification with a member of their family, of autistic nature. The inference that I draw on the vulnerability of each of these members relates to their messianism at an early stage of their development. Similarly, in the case concerning early separation trauma of the women who mourned her grandmother, this was manifested by a tie to an introject, in which the person belonged, body and soul, to that introject. In the analytic process, the patient managed to become emancipated from that tie and to mourn the loss. THE COURSE OF THE GROUP Initial Phase: Sessions 1–8 Approach to the group started with recapitulation of previous instructions on analytic collaboration. However, privacy was stated to have an appropriate place. In addition, note was made of the members’ responsibility as citizens for their own and others’ person and property, in the inevitable conflicts arising in group life. The therapist asked for discussion of these instructions, and then for a round robin of brief presentation by the members of who they were, how they got there, and what they wanted of the experience. The members, for the most part, complied readily. I would like to digress for a moment to introduce the action which followed. This group, now started on its development, evolved through definable phases—phases which can be studied from any number of frames of

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reference, and which were pertinent to the problems of the members. These phases also showed marked changes in the involvement of the members appropriate to that phase. This phasic phenomenon was noticeable in most of the particular sessions as well, and will be gone into later, in the more detailed study of a particular session. Stated in general terms, it consisted of movement from relationships through defensive or screen identification to more coherent self-representation, with its concomitant object relations. Worked through at first were the anxieties involved in relinquishing screen identifications. Then, in stages and through successive identifications closer to those entailing object relations, manifested by emotional ties to another, based on underlying wishes, they moved along both from and to the developmental levels at which they had been fixated. Consonant with this, the members of the group formed patterns of change and social mobility analogous to those found in larger society, different in aims and goals, and on personal (as differentiated from social) bases. The crises involved in these changes were experienced on the group level grossly through a change in identity from meeting as a therapist’s group to one which, while it met under the therapist’s auspices, had an identity of its own, and used the therapist to a significant degree. In doing so, the group evolved its own life; its own institutions, specialization by individuals (special capacities, roles), its unique history, established patterns of usage and communication. In analytic exploration of underlying identity, members would pair off in dramatic diads manifesting deep emotion. The group established its pattern of participation, action and reaction, and development of issues which proceeded on its own momentum, regardless of the absence of individual members, or the occasional visit of a transient newcomer. Above all, it developed its own motivation and method of working through the transferences and resistances. This process began with the therapist’s approach of acceptance of the group as a separate entity. Through the initial round robin, the members came out with a range of positions about the anticipated experience, tending mostly to identification with a saving, magical, omnipotent father-mother figure, involving an un-verbalized stipulation that they supervise “how it should be done if we are to trust it” and that their participation obligated the therapist to reciprocate. Some engaged in a wait-and-see approach. On the other extreme, one member participated only because of medical prescription. These attitudes and initial investments, related only indirectly to the real figure of the therapist, were accompanied by assumption of roles appropriate to starting things—at first to the process of conception, with its act of insemination and “getting the idea,” moving on to the birth proper, or the launching of the group as a separate entity, and so on through developmental stages,

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with gradual learning of its ego functions and boundaries. These roles were engaged in symbiotically and reciprocally, in couplings and subgroupings. At first specialized in by members fixated and accomplished in the roles, they were gradually taken over by all the members in accordance with their and others’ needs. An example of this was the specialization in helping roles assumed by some members, acceded to by others, which gradually moved from messianic, hyper-emphatic speaking for others, or “understanding” without the need for spoken words or requests, to assumption of initiative and responsibility by all the members for discussion of their experiences in understanding and helping the other. The constellation of roles attendant on evocation by the messianic helpermember of another’s difficulties is reminiscent of the process of birth, and early infancy, where a soul is saved, or born, and nourished, perhaps given artificial respiration or nursed through some colic. It strikes this observer that for many borderline and most psychotic patients in office practice, such close attendance, replete with diaper changes via telephone several times a day, is indicated—and beneficial both for the helper and the helpee—if both are attended appropriately by the therapist. Among other important roles which enter are habit-training, ego boundary-defining ones—appropriate at the outset to cutting the cord or at least promoting its withering away, later to guiding, chastising, remonstrating, and inspiring members who “ask for it.” A last example of roles which are specialized in by members through defensive fixation and “natural” assets are those centering about the analytic function—weighing, reasoning, clarifying, comparing, planning, etc. In psychotic groups these listed functions may each be demonstrated only by a separate person, or by a combination of a number of persons, so shattered are the ego capacities of the members. This combination, when operating simultaneously and collaboratively, has proved of enormous restitutional value to the panicky members of the group. Situations similar to those found in psychotic groups were present in this group when super-ego issues were dealt with intensively. In the group presented here several members (Minerva and Josephine) were specialists at cool headedly figuring things out. The recipients of their efforts gradually took on their ways as those two became muddle headed. To return to the story of the group, of the members who “got the idea” from the therapist, Joan was the most ardent. As in her individual therapy, her “hard work” with its compulsive submission and trust—she had lain enthusiastically on the couch, free-associated and diligently rendered dreams—entitled her to “understanding” which apparently consisted in supportive assent to a position as the therapist’s supervisor and guide, and freedom from any hierarchically indicated criticism. In the group, part of her “hard work” lay in providing a sort of messianic political leadership, reflect-

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ing a deeply narcissistic position on the issue of receiving help. In concomitant individual hours, where previously she had been working on wordless panics about recent sexual experiences, she returned to issues that had been current early in her work. In the manner of an acolyte and fellow therapist, she reported, after the second group therapy hour, a manic exaltation, with profound insights and awareness of aspects of the others’ personalities and needs which the group experience could help. She voiced that it was parts of herself that she was seeing and feeding on between hours. She magically expected the group to put them together for her, each member helping the other out, for the doctor who had delivered this marvelous instrument to them. She alluded to previous experiences of this sort in her life, less intense, but still present at beginnings of relationships. Pythia, present for only the first two sessions, reported in the second seeing herself in each patient. She claimed insights into their problems and what each needed. She presented a dream: “On awakening, I heard a baby cry; it was Antigone (the silent member).” Josephine stated, “I had that feeling strongly. Poor me!” The helper-members, helping in a cause they set up for the therapist, engaged the others in such a priori understanding, acting to a large extent on proverbial issues. Both Joan and Pythia were quite blocked in verbalizing their underlying wants; commensurately they helped the others to verbalize theirs. At the other end of this position was Antigone, the one who had appeared in Pythia’s dream as a crying child. Antigone spoke only when spoken to, and at this stage of things spent a good part of the group hour in sleep. Her resistance to transferring was fairly obvious. Transferring would have meant opening up chapters in her life she had buried, along with herself. She evoked “helping” initiative in Joan commensurate with Joan’s own resistance in her individual hour, in which she also was wordless. In between extremes of Joan’s and Antigone’s positions were the others. Annie, like Joan, addressed herself to the assemblage, but grossly and consciously differentiated herself from them, calling them “you ladies, whom I have never understood.” In differentiating thusly, she brought to the fore a defense polar to Joan’s incorporative and “being swallowed up” functioning. Joan surrendered to the members, in manic fashion, to avoid such gross critical alienation. Later in the development of the group, Joan and Annie attempted to come to grips with what became acknowledged differences on this score. At this time, Annie was unable to explain to the members what she meant by “you ladies.” In her individual hours, alternating between accepting the therapist as a pragmatic magical helper and bitter disillusionment on that score, she on the main worked on shedding a rigid and very successful masculine identification as part of a vaguely conceived life plan of settling

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down and becoming a woman who “sat on a pink pillow.” On the couch, she experienced panics in which she felt inexplicably evil. She stated that women were a lifelong threat with whom she had nothing in common. She was comfortable only dealing with men, and found herself dealing with women as a man would, which also made her uncomfortable. Another time, in a martyred stance, she came up with a dream in which, swimming, she was towing all her family, including her mother, towards the surface through green waters. Like Joan, and Annie, Magda also addressed herself to the group. In a most compelling and clutching manner she literally invaded the others’ presence to interest each in her, and to reassure her by denying accusations she expected from them. Instead of being forward and assuming leadership like the other three, she assumed “leading” stances in which she clung to the others. Almost before the others could inquire, she claimed utter alienation from moral society because of “terrible things I’ve done.” It must be evident that in Magda the group had a leader in presentation of the immediately personal position of the group member. Magda was quite histrionic; Mary Magdalene and Joan were her best roles. In later ejaculations on the “terrible things” she had done, she cited her promiscuous behavior. In her individual hours, she had only recently begun emerging from panics manifested by massive, biting, castrative attacks on the therapist for his lack of understanding. She was moving from the largely oral pre-genital concerns brought out there into erotized resistances to the transference, in which the subject of her sexual fantasies about the therapist was brought up by attacks on him for his “wrong thoughts.” She seemed compelled to disgorge her “wrong thoughts” to the group before they could accuse her, and to disqualify herself as a bona fide competing and cooperating member. In either case, she avoided an intolerable state of dependency. She strongly maintained her resistances to the transference, for all her self-display, of “involvement” and profuse recall of memories of the past and their reenactment in the present. Antigone, oddly enough, provided the first significant and moving attack on the un-verbalized and still mostly unconscious resistances in the group. These resistances, to recapitulate, were embodied on a group level in the members’ growing “gang” which, basically loyal, was setting up their own secular theocratic state; and by individuals in their leadership way of submitting, that of challenging the others to follow or be scorned. As noted in her history, Antigone, in the identity crisis which brought her to treatment, had massively renounced identifications now moving the others and “hit bottom” all the way in a regressed ward of a state institution. She was painfully remaking her life in defiance of her mother’s career-ambitions for her, and groping towards a more feminine identity than in the past. This

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was attended by panics manifested in catatonic-like sleeps. At this point she could be easily aroused from them. As the members began to speak for themselves, and the group discussions to have consensualized meaning, in the initial avowedly emphatic vein, Antigone displayed sardonic, mocking grins which she could not explain, on inquiry by the members. She was embarrassed, and they annoyed. When members concentrated on one person, Antigone fell asleep. When pressed on this, she reiterated that the “girls” seemed all so normal, and as far as she could determine, needed no psychotherapy. Lastly, Antigone’s marked verbal abstinence, speaking only when spoken to, brought forth expressions of anger from some members who had “put out.” Members ambivalently took sides on how to “help” Antigone, and on her motives. They turned to their “magical helper” therapist, to find him lacking, by their lights. Members then took sides about the magical helper image they had projected onto him. Josephine “understood” his limitations. Magda, on the other hand, staged, “for the others,” intense scenes of recriminating, castrating rage, evoking an ego defining reaction by the therapist. Factions formed about investment in the therapist as a helper, initiating gradual “underground” realignments, which were to come into the open at a later date. A specific development on this score was a tentative coupling of Joan and Magda, with Magda as the leader. Both were identified together against the therapist in a “masculine protest,” with Joan significantly as the feminine partner. It was in this context that she could experience her dependent feelings, and show transference. At this point of realignments, both the group members’ resistances to the transference and their transference resistance came into focus. They were ready to start talk of their doubts and beliefs in themselves and the therapist, in meaningful form. Also at this point the therapist found his counter involvement, the correlate of their resistances to the transference, lessened. He no longer had to give the right, saving, deeply empathizing answer, or a negative thereof. He could investigate with them. Phase of Beginning Transferences: Sessions 8–40 Members began moving towards exploring their transferences to the other group members, moving from positions at which they had formerly been fixated. As usual, the ones who did this were the “natural” leaders who addressed the group as a whole. Annie, treating the group as a feminine entity, brought up the problems of the members as women dependent on each other, in asking for discussion of her feeling of estrangement from “you ladies,” now carrying on open note of disdain. She formed transient couplings with friend and foe as she seemed to grope towards what was

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bothering her. In her individual hours, however, she very loudly protested her revulsion at their sexually subordinate, useless lives, stating that her “top sergeant” career course was far preferable. Magda further involved the group in taking sides on the issue of whether she was hopelessly a whore and the others models of rectitude. Each of these members brought up problems pertinent to the others in a challenging fashion. They thereby led the others in the very act of receiving help. Their introduction of an estranged aspect of themselves was attended by an inner and interpersonal crisis which centered about acceptance. Once the over-determined inner identity they presented for analysis was revealed and accepted as a working problem, it served as an accepted group problem and role, with the innovator accepted as a specialist and contributor. It and she had a place in things, and she carried a sort of certificate to help others. At about this time, of people finding and being found in useful places in the group, most of the members reported how helpful the group was. It was apparent that the experience permitted them relatively conflict free regression to former defenses, pertinent to being taken care of. These regressions had usually resulted, in their individual therapy, in prolonged, stubborn and alienated stances, for which the members felt guilt and defeat. Coupling, present from the beginning of the group in the course of identification with the therapy, now made its appearance on the basis of deep personal affinities, and containing elements from each developmental period. It started in various stages of a relationship cycle noted elsewhere in the author’s group therapeutic work. Two of the most prominent couplings at this time were between Magda and Joan, and Cindy and Carrie. As noted earlier, the first one seemed to have had its inception during the struggle about identification with the therapist. Magda had taken an independent stand (to the effect that he should “take care” of them) in contrast to her servile, self-humiliating ways in comparing herself with the other women. She seemed to take satisfaction in defiant posturing for the other group members. Her face became flushed, after initial blanching; her underlying orality and sadism was at last engaged, for herself through the cause she pursued for the others. In her individual hours, she reported agonies of despair and repentance after the group hours. Likewise, a compulsive, defiant self-defining stance had been an agony for Joan in her individual hours. Magda’s success on this score in the group seemed to ease Joan’s need, with resultant increased collaboration in one-onone sessions. Also, Joan became occupied with “understanding” why Magda was convinced she was considered a whore by the others. She also wondered at the growing distance from Josephine, with whom she previously had much in common on a cultural level, as two “nice” girls. She began to lean on Magda in between hours, in phone calls and visits to her home. In a “separation” panic while away from town, she turned to Magda as much as to the

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therapist. Magda helped her put her dependent wishes into words, especially those in the oral aggressive and talion mode, which in due time were ventilated in her individual hours with increasing satisfaction. For a year prior to her entrance into the group, this panic had been screened by a wordless depression which had repeatedly appeared when her controlling ways failed. Magda, who understood early developmental problems when present in another, was of unique help through deep empathic communication. She was receptive in long conversations between group hours; Joan separated herself when she felt fully fed. Magda also took initiative in calling Joan. In effect, she nursed Joan through the long series of crises involved in Joan’s relinquishment of early defenses in the group. While this was going on she worked in her individual hours, on this involvement, in at times frankly homosexual terms. On the other hand, Joan was of great value to Magda in regard to Magda’s megalomanic and cruel superego, and her deep sense of alienation from herself and other women. Magda leaned on Joan as a kinder, auxiliary superego and to ease the panic which came when she relinquished her battle for self-determination and integrity. Joan reflected back and reassured her on her very real assets, and weighed her doubts in her dealings with the other group members and the therapist. Both in a sense retired from the group to lick their wounds to their narcissism, and returned renewed. The Joan-Magda diad exemplified the deepest problems in relinquishment of resistances to transference, involving the grossly traumatic early identifications delineated in their histories—a combination of deprivation, compounded inversion of parent-child and sexual roles—and painful groping towards attainment of separate identity. The use of primitive identification mechanisms (i. e. , they “swallowed each other up” alternately) and great paucity of adequate object relations (they did not know what to do with each other outside of feeding each other and groping about their problems) were in full display. Pre-genital issues were to the fore. Working Through the Relationship Cycles: Sessions 40–49 However, the members as a group were moving towards later libidinal, preoedipal and oedipal issues, and as they moved, an un-worded truce on rivalry was broken. Serious talk, previously only sporadic, arose of favorites and favoritism, and of failures as wives and mothers. A new coupling appeared, closer to these issues than the Joan-Magda one, between Cindy and Carrie, a member relatively new to the group. This consisted of a friendship and falling-out experience between Carrie and Cindy. Carrie, to recapitulate, exemplified a combination of flagrant masculine identification, and underlying but openly pathetic little girl ways. Cindy was the most openly feminine and accomplished, as a sort of careerist

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homemaker, and was remarkably doll-like in appearance and manner. There seemed to be an obversive mirror imaging, with underlying, oddly dissociated little girl ways. Both also suffered from an underlying sense of alienation, which was kept in check by strong ego formations. They seemed drawn together by complementary purposes. Carrie attempted to fulfill unrequited longings to be taken care of by a respectable middle class woman, and, by identifying with her, escape from an enormous sense of cultural deprivation and sexual guilt. Cindy, seeking emancipation, was attracted to a woman who was forceful and forthright, who seemed to be free of crippling inhibitions, and who looked up to her. However, Carrie, instead of acting directly on her dependent strivings, followed her usual pattern of supervising and patronizing, “seeing” through Cindy’s inadequacies, recapitulating her own resistances to transference in individual hours. Cindy, expecting to lean on Carrie, found herself to be bedeviled and abandoned. In the crisis which followed, both abandoned one another, retaliating in impulsive uncontrolled sadomasochistic sallies in the group, and coming face to face with their guilt at abandonment of the other. Both became depressed and in time elated, the latter in finding that they were free to hurt the other without guilt. As they moved along in the various stages of several cycles of reconciliation and abandonment, they became increasingly interested in the underlying affects they were experiencing, and reported gain in awareness of previously largely unconscious impulses. The group was in the midst of examination of the problems exemplified by this diad at the time of the session protocol to be presented. However, a note about several ancillary constellations is in order. Magda was by this time moving from Joan to coupling with Annie (on the way to Minerva). This was evidently on the basis of coming more fully to grips with her early identifications and inverted oedipal constellation and moving to the more conventional model. Annie undoubtedly represented a step in that direction, personally as well as culturally. These couplings were on the usual ambivalent basis where both at first appeared attracted and repelled by the other. Another coupling was Carrie and Josephine, on the issue of setting limits to Carrie’s frequent obstinate monopolizing of the group. Josephine had similar tendencies, manifested, however, in polite, abstracted, wandering accounts of things. This provoked Josephine, on the basis of “not submitting to it,” to compel Carrie to “get to the point”—her alienation from the group members as women. This occurred in the course of several sadomasochistic encounters; Josephine was subsequently able to separate herself from her mother’s guiltprovoking demands with considerably less difficulty.

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Session #50 Josephine began the session with a dream of the previous weekend, saying … I had to come to the group, grumbling that I hadn’t gotten anything out of it. As I walked out, I saw Carrie, who looked like my cousin Christine. I asked her why she was late. She said she was coming from a trip to the Caribbean; all the members were to go on after the group. I was annoyed, because I was only coming for the group. I then saw someone who looked like Minerva; she had galoshes on, striding through the mud. I said, Do you mind standing with me, though I don’t have on galoshes? She said okay and I did.

Josephine stated that Minerva had always seemed the outdoor type, not scary like herself and the others in the group. Minerva responded that she had been timid until after she left home. There she had stayed in her room and read books. Magda and Josephine stated they also had had this experience. Mimi broke in with the cryptic statement, “Minerva wished to do it, and tried to forget it.” She reported a dream apropos of this, in which a man was trying to get into her house, and she was frantically closing the door on him. Carrie blurted out, “I had that dream, and closed the door; the man had a long neck like Andy Gump. I associate him with Dr. Abrahams!” Magda reported her old, semi-hallucinatory fear of night robbers. Mimi told of a dream of an evil terrible bird—to touch it or be near it could kill or bite! She didn’t like to dream of birds. Carrie and Cindy suddenly erupted with their running fight, centering now on guilt and humiliating the other to a third party. Carrie, who was against “squealing,” brought up an alleged offense by Cindy on that score. However, after several exchanges in which they unashamedly enjoyed their sallies, evidencing relief and wonder at this, they talked more calmly and with less need for interposition and interpretation from the group members. Minerva broke in disgustedly, stating, “This is a waste of time!” Cindy defended the quarrel, “We need to work it through and to us it is not a small matter.” Minerva felt it was, but wanted to report a small matter of her own—after a fight last night with her husband, she felt free and unencumbered by guilt for the first time. She felt wonderful! Carrie stated she felt miserable lately, in a vacuum. Mimi stated she felt similarly, and proceeded to engage the group members, chiefly Cindy and Carrie, in reassuring her that she had a place in the group like the others, and was not alone in her inability to free herself from her dreads, and to be like the other women.

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Analysis of Session #50 The dream was one of a series by this and other patients, revolving in manifest content about their problems in identity and identification on various levels, and utilizing group members in screen identifications. It brought up specific problems which had appeared “late” in Josephine’s transference. As in other sessions, dreams and other material were rendered in association, as well as interpersonal configurations exemplifying this material. In the previous session, Josephine, in a dream involving the group circle, had left a rich pink icing cake set on a blanket in a field, and whined assertively, “I’m tired of just saying things when there is a silence!” In the dream, she had then turned to Carrie, and recommended she “try psychotherapy.” In her individual hours, Josephine was aware she was approaching some “absent” part of herself through Carrie, and bringing up late (related somehow to her habit of coming late) something between herself and the therapist. It vaguely concerned feelings about him as a man and about homosexual concerns. She further identified the problem by citing her partisanship in the CarrieCindy coupling, and in her own coupling with Carrie. In the latter she noted with wonder Carrie’s ability to evoke in her an involuntary peremptory demand for submission. She related this to incidents of stubbornness and impasse between her mother and herself in various vicissitudes in their early and later relationship. In confronting the therapist, Josephine brought into focus a situation terminal in analysis, of “squaring away.” Certain members of the group exemplified abortive but still overt, strivings in this direction. Carrie was the prime example. She looked the others and their superego-laden meaning full in the face and provoking the bad parent, “gave back as good as took,” but was proverbially blocked on giving her own. Minerva was also fixated in the situation of confrontation, but, having the words and being unable to say them, experienced panic and impotent fury, and fled, to avoid a physically destructive outcome. Mimi’s superego organization and its relationship to the ego was similar to Minerva’s but resulted in an acted out surrender, with clinging and sucking, but retaining awareness and ability to concretely delineate what was going on, in what to Minerva was “only a cloud of panic.” In the group session under scrutiny, Josephine, the “favorite” of the therapist’s helpers, confronting the therapist and the group, “gave” this dream. She then remained relatively passive to the end of the session, letting the group speak for her. The therapist did not call for association to specific elements of the dream, expecting, on the basis of the group’s ability to carry on in this regard, elucidation by and through the group members—especially through their free inter-member association. In the dream itself, Josephine, a latecomer, ap-

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proached the group as a whole, and came upon an alienated part of herself in the form of Carrie. This was related to the problem of becoming like other women, who fulfilled themselves by a trip to the Caribbean. Annie, who to Josephine represented a past genital realization (she had recently claimed such) had actually just returned from there. In both of her dreams, Josephine was leaving something behind, the cake and blanket, and the mother-group. She moved towards the modes of autonomous self-assertion she associated with Carrie and Minerva. Both were outdoors types, leaving fears behind, engaging in external action. On the other side of that coin, both had in reality to leave the analytic room, which took on personal meanings and became crowded with nameless dreads. Also, Josephine had identified Minerva with a friend she had idolized, who had been eminently successful in her own rights, far different from her relative failure of a mother. In the dream, this successful person was asked to stand by her efforts towards facing her pre-oedipal and oedipal guilt and fear (and eventually work those through with her). As noted earlier, she identified her own defensive masculine identifications through Minerva (and Carrie), but felt inferior to Minerva on that score. The whole group did. By her own token, she took a subordinate, dependent position there, much as a gang member would be more apt to listen to the tough gang leader’s request to go straight than that of a settlement worker akin to Joan’s subordination to Magda. In the session the group members picked up the dream story and configurations, to exemplify them, moving from manifest to latent meanings. They worked on the courage-timidity aspect of the infantile, oedipal, and adolescent identity crisis, with Josephine identifying with her compeers and older girls in the group in moving out of her latency “room.” Mimi broke out of her diffidence and of the group’s resistance to transference, breaking into the grown up circle. She acted out a superego and anal resistance figure in alleging insights into Minerva’s oedipal strivings and guilt, and her repressive mechanisms. In doing this, she was also taking initiative in “standing by” Minerva herself, for Minerva’s good. Carrie, irrepressibly not to be outdone, jumped into the act, in great contrast to her extreme difficulty in remembering dreams in her individual hours without the crutch of writing them down. The male intruder-superego transference figure had been acted out in her individual hours in a fugue-like intrusion into the therapist’s garden, and by a barely checked and highly anal-urethral curiosity about his private life. The projected image was carried further by the two members whose instinctual material was closest to awareness—to the superego—figures of night robbers and evil bird, involving issues of orality, morality, and physical closeness. Mimi was currently in a struggle with her therapist, in which panicky flight from this bird was central. In a sucking, touching, clutching, blindly

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innocent mode she denied herself a separate identity and fought against seeing the evil bird in their relationship. In the group session at this point, the members moved from their competitively affirmative self-revelation to an in situ representation of the bird-inthe-other. Carrie and Cindy erupted, with their argument, into presenting the meaning of the third party (other group members, and their own previously withheld opinions) as superego and oedipal figures. They abandoned themselves to post mortems about genetic factors in their falling out, and about the narcissistic alienated positions to which they were driven. They engaged in tallon exercises, and showed unashamed delight in hurting the other, with relief at their lack of guilt on this score. In the course of these interactions, Carrie had accused Cindy of disloyal, destructive, and competitive behavior. Carrie projected, evoked, and selected out the killer-bird in Cindy’s character and behavior, against which Cindy’s defenses were massively organized through repression, sublimation, and undoing. Cindy “broke down” and “chewed Carrie out” in masterful fashion, gaining some perception of her deadly alienated bird-superego self. Carrie, engaged similarly, was gratified that she had “got to” Cindy. Their passion subsided and they again broached the subject of guilt and genesis—what each brought to the breakdown in relations, a first step towards a mutually respecting separation, or reconciliation. They told how they had idealized each other in a manner full of deeply private meanings and needs. In doing so, they were giving themselves away to a third party, Minerva, to whom such movement from an isolated, itself idealized narcissistic position, to depending on a real other person, brought on panic, and who in defense and competition, scorned their efforts. In her individual work, she had pressed the therapist for a confrontive, mutually self-revelatory approach, to which her first therapist had disastrously complied. This had been a cover for her panic on issues calling for initiative on her part. Cindy, in response to Minerva, indicated a valid identity to this small (clitoral) infantile part of their selves. For all three, as well as the other members of the group, working through in the transference (and with their husbands) was still intolerably humiliating. For Cindy, who previously was extremely timid with Minerva, her defense against Minerva’s attack was doubly significant. Minerva in her action had brought in the issue of impatience and disdain with something that was small and feminine. She had closed the group’s cycle of getting to the bird via the Carrie-Cindy duet and carried it to a more directly man-woman configuration. She had enacted hers with the big game itself, a man! This showing off was done in a surprisingly phallic fashion, in marked contrast to her bored and disavowing entrance into the conversation.

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At this point, Carrie, who had boasted of her triumphs over men on their own terms in individual and group hours, brought in her underlying affect of loss. In previous group hours, she had compulsively turned gay when the other mourned. In her individual hours, this mourning affect had been alluded to, but not experienced in this frank form. It was currently related to an actual loss in courting with a man who was able to make her feel like a little girl, a situation not unlike the initial one with Cindy. Mimi exemplified the clinging dependent state she fought off. Then, finally, the group came full cycle to the fought-off, dependent, striving state, this time represented by Mimi, who characteristically for herself and the current stage of development of the group, addressed herself to the group as a whole. She was in effect asking the members to work with her in efforts at reconciliative movement from the isolated bird position of the dream. From the beginning of the session, when Josephine submitted her dream about genital emancipation and self-assertion, and her still unexpressed need for identification with a mothering woman secure in this regard, the group had moved through several cycles exemplifying their versions of and involvements in Josephine’s underlying conflicts. Josephine’s presentation of the dream and her subsequently receptive but still passive participation was itself part of her own relationship cycle, moving towards engagement, in the transference, of alienated aspects of her superego and ego. She grew closer to getting something for herself, her trip to the Caribbean. Summary The data presented in this paper would indicate that the group members had gone through discernible and correlative movement in their relationships in the group and in their individual therapeutic work. They had relinquished controls during the sessions, in moving through successive identifications, involving progressively more mature object relations. The role of analysis proper in these movements was in elucidation of the issues and involvements of the individuals, especially during crises and impasses in the various stages of their development. Gross management functions, usually not considered analytic, dealt with resistances to transferences. As these cleared up, management problems dwindled away. As it was, most of the management function, prominent in the individual therapy of the members before starting the group, ceased to be a problem soon after its inception. There was increasingly self-responsible participation. They were doing things, not for the therapist, or the treatment, but because they wanted to. They could be expected, projecting the current trends, to deal more deeply, and with less acting out, with transference material from all stages of devel-

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opment. The group as a whole could be expected to relate to the therapist and other social entities, in an interdependent fashion, with an identity of its own. It had evolved its own group relevant roles, institutions, mores, and usages— a life of its own. In the relationship cycles defined, resistances to transference were dealt with largely by utilizing the leadership potential in the group. Minerva and Carrie were giving Josephine the courage to abstain from her defensive identification with her transference father, as a wordless reproach to and escape from her unresolved earlier ties with her mother. She was then freer to work through both her oedipal and homosexual problems. In her individual hours, she brought up material on both counts, as “late” material, with exemplification in the transference. A NOTE ON MY RESEARCH DESIGN In presenting this paper at the American Psychoanalytic Association I attained a pivotal point in my career as a psychoanalyst, co-relating the individual and group phenomena encountered in the therapeutic process. My theses were rejected by the American Psychoanalytic Association, undoubtedly because of their radical import. Upon review it appears to me that my approach to the phenomena involved was at first shaped by my original interest in becoming an historian. There I had learned to honor the occurrence of events in the historical process and to attribute meaning to the traversal of crisis in that development. I was particularly interested there in the turn of the French revolution under Dalton and Robespierre, away from the incipient democratic process eventuating in the rise of Napoleon and its historic regression. My sociologist colleague, Lloyd McCorkle, was interested in dynamics of the small group, and the gang in the Chicago slums, and we extrapolated a working hypothesis as to the turn from antisocial to pro-social under his and my leadership. Important there was denotation of the role assumption of the members of our groups as they switched from anti- to pro-social status. McCorkle and I never did our book on these matters but I found our hypotheses applicable in my work at Howard Hall and in my small group in private practice. I further, under guidance of my supervisors, inquired into the intrapsychic and interpersonal dynamics of the members of this new group with special attention to its incipiency and traversal of initial developmental crisis and their relationship to character analysis and the primitive psyche, the psyche of the earlier child. The language that McCorkle and I originally applied to the group process stemmed from history and sociology. In this piece I adduce the new language of psychoanalysis involving Freud’s libido

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theory, repression, and the disassociation designated later in the literature as splitting. The patients in this piece admittedly did not finish mourning their tie to their maternal object, as did the one in my first iconic case. Were they to have done so, I think I would have developed more fully a concept that was beginning to take hold within my psyche of alienation from self. That concept became clearer as I worked with the iconic cases to follow. Before we venture into these cases, however, a look at the role of consultation is in order. THE ROLE OF CONSULTATION IN PSYCHOANALYTIC THERAPY Except for a brief period at the beginning of my career in Washington D.C., secondary to a growing reputation, I acted as a consultant to a number of institutions and agencies in the Washington D.C. area. I was applying there my new-found experience in the treatment of the psychopaths and the severe disorders. My mode of presentation ranged from a simple account of my work, to close scrutiny of the problems presented by the agency to intensive applied group analysis. It is important to understand the background to each of these consultancies, in the exposition of their nature. My work with the Federal Prison Service and that at the Fairfax Falls Church Mental Health Center is a case in point. THE FEDERAL PRISON SERVICE PROJECT Directly applicable to my consultancy to the federal prison service was my prior work at Fort Knox. There, in my capacity as chief of group and individual therapy, I formed relationships with other aspects of the Center, such as the hard-labor gang, the broadcasting station, the bulletin, the combat training regiment, and above all the restoration board. The CI insisted that I’d be the chair of that latter group. I initiated and was head of a program on orientation to the war. I related to each of these aspects of the life at the center, at their and mine felt instance. The reader will ask how I maintained the confidentiality and close relationship with the rehabilitees demanded in psychoanalytic therapy with such a widespread commitment to external reality. Therein lies an important component of the success of this venture; trust on the part of the rehabilitee that I and the other members of the therapy group would not betray confidences, and if we did, it would be done responsibly in their favor.

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As a result, I felt comfortable in leaving the analytic position behind the couch, for work in the community of Washington D.C., when its various mental health institutions called on me, at that time the sole authority on inception of group psychotherapy programs in the area. I did not worry about meeting and transacting with my patients out in the community. Another important factor here was my experience with Col. Miller, my commandant at the Fort Knox rehabilitation center, in regard to his way of consulting with me on an ongoing basis about his concerns for democratic ethos within an authoritarian setting. In addition, in a long conversation toward the end of our tenancy there, on the way to and from Leavenworth for a prison conference, he indicated the role of a proper mental health facility in educating the community and reaching out to it in that regard. With all this in mind, I took on early in my practice in Washington D.C., consultancies with the national institute of mental health, the Bethesda Naval Hospital, the Walter Reed Hospital, the federal prison service, and a range of clinics and schools in the Washington area. These, spread out, occupied forty percent of my schedule. In the course of these consultations I became involved with projects in a number of these institutions. BETHESDA NAVAL HOSPITAL A rewarding one was at the Bethesda Naval Facility, in which the Doctor in charge of the psychiatric ward, a Naval Captain, and I conducted a group of generally seventy plus patients, non-commission and officers. The session lasted an hour and a half, monthly, with the captain meeting with the group the other three weeks of the month. The remarkable thing about this was his institutions of equity, pro tem, during the session, in which they laid aside theirs stars and bars and spoke in simple human terms, on their pressing concerns. The underlying group dynamic took over and by the end of the session had carried into deep authenticity. This was the closest of any consultations to a psychoanalytic format, resembling that recorded by the psychoanalyst August Eichhorn in his book, Wayward Youth. A dictum on the part of the naval department to the effect that hospitalization for a psychiatric reason precluded any further service was in utter contradiction to this advance in treatment. DR. DURRELL AT THE NATIONAL INSTITUTE OF MENTAL HEALTH Another consultation at the National Institute of Mental Health was with Dr. Jack Durrell on the role of psychosomatic disorder in organic disease. Again, this remarkable man instituted a group process with a relatively large group

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(50–60) with attainment of intimacy and authenticity comparable to that of the Bethesda Naval Hospital. The other consultation consisted of work with the dynamics of the group potentially administrating the therapy, in which we worked on their report of presenting experiences in their groups. A certain amount of analytic relevance was attained. This was remarkable in the work with the top level of the federal prison service impressing them, through their freer interaction with the potentiality of therapy itself. They formed an autonomous agency called the Correctional Service Associates, which held a workshop and ongoing publication looking towards the institution of Fort Knox like programs in the federal prison service. They selected the national training school for boys for a trial program, and I began monthly visits there, in consultation. THE DEMONSTRATION COUNSELING PROGRAM AT THE NATIONAL TRAINING SCHOOL My work with the Fairfax County child guidance clinic in nearby Virginia led to a joint venture on the part of the clinic and the training school in what was called a Demonstration Counseling Program. There the head of the clinic and his chief associate Dr. James Thorpe and Dr. Arthur Kassof played a chief role. The program that ensued was for four and a half years duration and consisted of four phases. In the first I taught both didactically and dynamically, starting with my theory of alienation and the role of therapy on reconciliation. I utilized the dynamics of the teaching group to exemplify my points. The second phase consisted of establishment of a treatment group in one of the cottages. There, the chief psychologist led discussions modeled on the Fort Knox model of counseling nature. The third phase consisted of spreading this program to the other cottages. In the fourth, the program was handled by the Captain and his staff, trained in consultation by the psychologist who had previously instituted the program. Along the way, a series of experimental approaches were tried, using behavioral techniques like giving points for compliance, and comparing the results with the dynamically based method generally perused. This experiment progressed, and as the Correctional Service associate developed, all was reportedly backed by President Lyndon Johnson, as one of the projects in his Great Society. However, his emersion in the Vietnam War resulted in his abandonment of our project. I terminated my connection in 1970, with initiation of a sabbatical and a move to California to asses my work so far.

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“NORMALIZATION” OF AUTISTIC AND DISTURBED CHILDREN Towards the end of my Washington span, I consulted with Mildred-Elliot Berl at her Agnes-Bruce-Greig School. We shared the mode of communion I had developed in my group work, particularly with the backboard catatonics at St. Elizabeth’s, to reinforce her procedure in settling down and normalizing the disturbed and autistic children she treated. I encouraged Mildred to just sit there, communing with self and the group, with awareness of her intuitive processes and connection with her subjects. FAIRFAX HOUSE Consultation with the Fairfax-Falls Church mental health clinic resulted in initiative in the establishment of a halfway house for delinquent youth. A wave of assaults, larceny, and robbery in Fairfax County, a suburb of Washington, led to citizen outcry and appointment of a committee to investigate the situation and recommend remedial action. The clinic recommended that I be chair of the committee. After almost a year of meetings, we decided on a format similar to that established a decade and a half earlier by Lloyd McCorkle, my sociologist collaborator of army days. The thesis was that it would collaborate with the existing clinic to avoid institutionalization, and the institution would reach out into the community to deal with problems before they became too severe. McCorkle’s halfway house was called Highfields, and I had visited it several times to observe its operations, and had engaged in extensive discussion with Dr. Lloyd McCorkle during its stages of development. McCorkle and I had agreed on the theory behind the project, namely the alienation of youth from their proper self-regard and the role of counseling by a resident family, supported by outside consultation. To that end I gathered a committee with a Ms. Duffy acting as its administrator. We met biweekly, at first transacting about the philosophy in practice of the halfway house, its place in the Fairfax county administration. It was to be semi-autonomous in nature, with adequate financing to house no more than 16 troubled youth. It was to work with their families as a condition of their acceptance. The program was to resemble that of Highfields. The committee found an adequate house but soon found resistance on the part of its neighboring homes. It went through a tempestuous phase of nonacceptance until a decision was made to build a new facility on government property. The committee assembled and interviewed the crucially important director, and he proceeded to flesh out his institution. Following is a report on three of the first court-referred boys to Fairfax House. I include it here as an illustrative sampling of the work done there.

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WORKSHOP ON HARDENED DELINQUENTS The workshop I described in the following pages was held just prior to my change of venue from Washington to California. I was in the process of gathering the data on the inception of the correctional service associates and the many years of consultation at the national training school for boys. We were also accumulating data for a volume on institutional transformation by a correctional community. Along the way, I participated in the successful formation of a halfway house for delinquent youth in Fairfax County, Virginia. A central event in the dramatic story of the venture at the national training school for boys was the negative therapeutic reaction towards the principal therapeutic figure, Dr. James Thorpe, an event analogous to that which occurred to Dr. Alexander Wolf at the Fort Knox rehabilitation center. Inference on underlying dynamics, common to both, led me to thoughts on my own impasses in therapy, into which I became drawn by Fritz Redle’s “Role Suction,” itself secondary to unresolved developmental issues. Dr. Wolf could not let himself join the “bad boys’ gang” as I apparently was able to do, and Dr. Thorpe later demonstrated antisocial views and affiliation which caused the boys to haze him as when one joins a fraternity. What follows are the narrative notes from this workshop. OPENING REMARKS At considerable cost, I will make these introductory remarks brief, because we have much work ahead in the scant three hours allotted to this very important workshop. It will be work, because we have a tremendous amount of material to cover, relating to many levels of social structure and function, and from many points of view. It is important, because the endeavors reported here are of great moment for correction as well as treatment purposes in general, for they point the way towards systematic transmutation of the currently enormous penal structure into truly correctional communities. It is the theme and process of social transmutation we will be hearing this afternoon—that of transformation of a social structure in such a way that, though it may be composed of essentially the same individuals, it functions in time, on a different level and in an entirely different manner. In effect, it becomes a different institution. In introducing this intriguing, and, on the face of it, over idealistic challenge, I would like to provide some backdrop to the account of one of the projects we will hear about today, that at the National Training School for Boys, in Washington, D. C. Let us have the story begin in 1946 when a group of professionals—Mr. John Galvin was prominent among them in the field of correction formed by

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the Correctional Service Associates, as an affiliate of the American Prison Association. It set about studying and fostering new treatment modalities, mostly developed during war, in the Federal Prison Service and elsewhere. Simultaneously, as seems to happen, people came along to work in one of the projects, on the Washington scene. This was a multidisciplinary group of psychiatrists and psychologists, Drs. Thorpe and Sadel, and Messers, Kassoff, Smith and Hartman. A group therapy project was launched at the National Training School at an impressive meeting in 1947, at the School, then under the benevolent direction of Mr. Hegstrom. It was an ambitious undertaking, which attempted to recapitulate some main elements of the successful work at the wartime Fort Knox Rehabilitation Center for Military Prisoners— an attempt to alter the sociology and psychology of an entire prison population by working with that population as a whole and individually. Meetings, conducted by a psychiatrist or psychologist, were held with the entire cottage population of 75 in two cottages, with two held as controls. That deviation, in the service of scientific control, from the principle of treatment of the entire population and its individuals may have been in part a fatal flaw, among others. Science would have been better served to have the controls resident in a comparable institution. The meetings were followed by discussion with the cottage personnel. Smaller group discussions were organized to deal with individual problems the large sessions brought into focus. There was a well-developed testing program to help assay changes in the individual. There was continuous consultation between the “treatment” personnel and the custodial personnel, and sessions for training custodial personnel in modern correctional aims and procedures. This phase of the venture, foundered in mid-1949. Cottage life had become increasingly tumultuous and the personnel disaffected. The groups were moved out of the cottages to the Academic School building and their size reduced by half. The groups still foundered until the older, aggressive and borderline elements were removed and the size of the groups brought down to about 12. Dr. Thorpe and associates reported the groups were operating satisfactorily when the two of the projects had been traversed. The team was disbanded, leaving one psychologist, Mr. Kassoff, who bravely and stubbornly carried on the group work in the segregation unit. The team members “knew” about the factors which had led to the failure in the cottage intervention program. From the first, they had known that the personnel, from the top on down needed not only to be approached as fully fledged members of the treatment team, but trained as well. But trained as what? The training amounted to the creation of a new correctional officer, who synthesized a new combination of the latest in custody and counseling. The commandant of the Fort Knox Rehabilitation Center might be cited as a prototype

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of such. Col. George L. Miller was an educator, student of August Aichorn, and an accomplished artillery officer who could run a tight ship, to mix metaphors and services. At the stage of development of correctional communities extant in 1947–49, the custodial personnel, in large part, shied away from commitment until the validity of the new methods were proven. They participated mostly because the job at the moment required it. There was an enormous cleavage and gulf between the treatment team and the custodial personnel. The team itself in time shied away from its essential task and decided to mostly train people through participation in the work as it went along that. This observer would like to point out that the program was extrude from the cottage by a mostly unwitting, but in some cases witting ganging up on the treatment venture by both the personnel and the boys. But this extrusion was only a temporary affair, lasting 9 years. Group work stayed out of the cottages, and was based on work in the hospital, with boys who, because of inner, neurotic conflict were aware of need for psychological help. Personnel participated in the program indirectly, as through recommending boys for treatment. Also, a succession of psychiatrists and psychologists who passed through the School during this period and who were trained in group therapy, ventured first, using the group method, into orienting the personnel to treatment concepts, then into training in guidance and counseling. First meeting almost casually, on their mutual lunch hour, the psychiatrist (first Dr. Donald Bloch) and personnel, over the years, formed a valid institutional investment, to the point where, in 1958, it was set up under Dr. Rubenfeld’s auspices, as an Employees Counseling Training Program. At this point, it seems appropriate to comment on some crucial sociopolitical considerations. In commenting on the original cottage intervention program, at the Congress of Correction of the American Prison Association in 1948, Dr. Lloyd McCorkle, who had done pioneer work in correctional communities with this consultant, stated that a major aspect of the program was manifested by the simple fact that the timing of it had been squeezed into the program of the large group meetings in the cottages, borrowing from the boys’ free time at noon. He held that the natural resentment of the boys and the treatment program’s correlate lack of proper status would handicap, if not defeat the venture. However, a change of schedule would have called for a complete revamping of the School’s schedule, to bring it concordant with this new venture which still had to prove itself, especially to the hardened anti-do-gooders in the personnel. The employee counseling training program which developed over the years could proceed in a more evolutionary manner, starting with the better

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motivated employees, and so it successfully traversed the pitfall of the lunch hour. By this time, 1956, the wheel of history and developments in the study of institutional structure and function had proceeded to the point where Dr. Rubenfeld felt motivated and competent to organize a research team and mount a successful study of clique formations in several of the cottages. He enlisted and received close support in this important venture by Dr. Louis Jacobs, then Superintendent of the School and the central office of the Federal Prison Service. The next psychologist, Dr. David Twain, ten years after the initial cottage intervention, made the plunge and took on the cottage group of 75, and succeeded in forming it into an entity capable of constructively discussing and dealing with its concerns. This group formation, a sort of town meeting, came to be known in time as the Forum. In addition, Dr. Rubenfeld, after “graduating” from the School, returned as alumnus consultant, to help carry on the personnel training program he had started. Something was going again! Dr. Twain’s initiative picked up speed, and he conceived of a research and action project at about the time as a similar project with enabling funds was conceived in the Central Office. This brings us to 1961, the beginning of an exciting development. In setting forth this synoptic view, I find myself comparing this venture to the landing at Anzio in the Second World War. We mobilized, landed, and moved about the landscape; then came the battle proper. In both battles the beachhead was a lively and segregated place, but enormous effort, the support of headquarters and reinforcements brought the changes which carried us up the boot of Italy instead of vice versa. As we consolidate what we like to think are gains, we are attempting to figure out just what has happened in this venture, especially in the past three and a half years, the period of the most coherent and systematic operation. We wish to compare it with the ventures engaged in by our resource panelists and of the participants in this group at large. It is in the spirit of free and open inquiry that we open this workshop. The findings of the workshop were of generally positive nature, leading to a proposal for publication of a volume on the treatment of hard delinquents. Dr. Rubenfeld went on to publish his findings in a volume called “Family of Outcasts,” cited in the Annotated Bibliography. On June 23 1965, the Charles D. Thomas publishers proposed a monograph on the treatment of hardened delinquents based upon eighteen years’ experience with the Federal Prison Service and the National Training School for boys in organization of a coherent and distinctive treatment program. Professionals from the field of penology, psychiatry, psychoanalysis, education, and community clinics had agreed to participate in an upcoming volume. This communication with a publication editor can serve as a view into

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the breadth and depth of the topics and concerns of the workshop on hardened delinquents. There, the Correctional Service Associates, my associate Dr. Lloyd McCorkle, the staff at the national training school and at the Fairfax Falls Church Mental Health Clinic produced the material for the outlined book. I consider it most unfortunate that administrative difficulties caused a failure in its publication. However a host of other publications stem from this venture. Principally to my mind is the book by Dr. Rubenfeld, “Family of Outcasts,” in which he discusses theory and practice with young alienated individuals. And now, in keeping with our look at the role of consultation in the psychoanalytic profession, and to preserve the chronological presentation of events, following is a summary of my work with the Pastoral Care Movement. WORK WITH THE PASTORAL CARE MOVEMENT For a decade, 1957 to 1970, I engaged intensively with a project initiated by protestant ministers in the Washington D.C. area. Reverent Charles Jaekle, of the Pastoral Institute of greater Washington, had gotten wind of my work with ministerial students in the course of the training program in group work. They had communicated the value of the training group in helping them center on their pastoral identity and function; also its value in the treatment of alienated individuals. He approached me to help with organizing therapy groups at the pastoral institutes. When he ventured into a full-fledged project, organizing a half dozen pastoral care centers on a number of parishes in the Washington area (titled The Pastoral Counseling and Consultation Centers of Greater Washington), he called on me to conduct the training and supervision of a large number of pastoral personal. I did so in a manner similar to what I did on professional identity at St. Elizabeth’s. There, prominently, I found myself using the word soul instead of self or ego, also the form of intuitive connectedness I came to call my intuitometer. It is of note that in the group therapy, especially the new couples groups at the pastoral institute, the members yielded their resistance to consanguinity versus their alienation. However I did find difficulty in going into their problems with depth analysis. My inference is that the very messianism of our dominant therapeutic relationship was used as resistance. They were following the Christian mandate of “love thine enemy and neighbor,” extending it to their spouses and children. They were loath to go into their personal motivation except in the course of their devotion to religious principles and practices.

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However, I found the work here to be facilitated by the strong organization pioneered by Rev. Jaekel. I conducted a biweekly seminar, communicating didactic and clinical data, with presentation by the pastoral counselors of their work with individuals and groups. My growing theses of alienation from self, the centrality of the human soul, and the essential role of messianism were readily and widely accepted here. I found this to be at variance with my experience in coming out with what I considered advanced ideas and practices within my psychoanalytic fold at that time. TRAINING OF FOREIGN PROFESSIONALS News of the pioneering work with psychopaths and indurate psychotic individuals spread early to professionals who looked to America for leadership. Psychiatrists from Australia, Brazil, Guatemala, and Japan visited my work in Howard Hall and consulted with me at length on its applicability to their local situation. One of them, Dr. Cesar Meza, was effective in replacing me during an absence on my part. Another, Dr. Yoshiko Ikeda, a Japanese psychoanalyst, attained the designation by my patients as my sidekick, as she accompanied me daily for several stints, lasting a year. We corresponded for several decades relevant to her work in Japan in the study of twins and small group formations. Her many publications attest to the penetration by psychoanalysis and group analysis of Japanese psychiatry. PSYCHODRAMATIC CONSULTATION A trainee in James Enneis’s psychodrama department at St. Elizabeth’s sought to observe my work in Howard Hall and thereupon we entered lifelong collaboration and friendship. A culmination therein was reached in a seminar she mounted at the University of California San Diego in 1989. There an inherent group dynamic in Dr. Jacob Moreno’s approach resulted in my endowment with the status of a star, mandating the performance on a stage of a crisis in my life, and to my surprise in my juvenile period I found myself mortified at exclusion from the family bedroom, after a seemingly unwarranted assault by my brother. Further analysis let me to awareness of my original fracticidal position. I was impressed by the depth and immediacy of my colleague’s approach, that of a pioneer analytic psychodramatist. It was truly terra incognita for me and is still. An examination of the role of consultation would not be complete without a cursory summary of the “borderland” experiences of my career. What follows is that summary.

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BORDERLAND INITIATIVES DURING MY CAREER I have mentioned throughout this volume groups that I formed de novo to inquire into and accomplish tasks of therapeutic moment along the way. The first was a steady group at Fort Knox consisting of my staff and our commandant to understand the epic developments we experienced on the part of the rehabilitees in which they changed their character profoundly. Next came an informal grouping at St. Elizabeth’s consisting of my chief of service, the section administrator, the superintendent, the chief of nursing, and the head nurse in Howard Hall. Those were the people I transacted with informally and in consistent pairs, to attain a state of mutual enterprise and confidence. This pertained at first to the issue of whether they would let me do dynamic therapy with its, to them obvious, dangers. They at first relied on my reports of success in the army during the war years. I kept them closely advised of my course and they learned to relax and trust to my methods. I hold such informal grouping to be essential to security-bound institutions. From that informal grouping we mounted a large scale group effort in formulating and effecting a multidisciplinary training program that encompassed most of the hospital in due time. The formation of the next group came naturally to me in accordance with my need for formal education in psychoanalysis, a study group composed of six of my peers who had just graduated from the institute. That group continued until I left Washington for my Sabbatical in California. Unlike another such group formed alongside in which the members attempted to analyze another, this group was devoted to affirmation of work with difficult cases. A group which had formed itself to undertake the massive task of establishment of correctional community in the federal prison service engaged me in consultation, with the attainment of a significant degree of mutual enterprise and collaboration, but which was terminated when president Johnson abandoned his great society as he became mired in Vietnam. Beyond that, I formed a study group in La Jolla, California of likeminded analysts, which like the group in Washington resisted self-analysis. I found the members of a political study group that I formed subsequently to lend themselves more to that task and to the formation of a professional identity training group. Lastly I have described in this volume groups that I formed in Atascadero State Hospital that opened the way to further development of therapeutic community. Along the way in this journey I have learned the necessity of scrupulous attention to the steps and details in development of a state of mutual enterprise and confidence in the therapeutic process and have endeavored to exemplify them in my reports. Thus concludes the first two decades—the 1940s and ‘50s—of my life as a psychoanalyst, and the first inklings of the hypotheses that are the hallmarks of my life’s work. In Chapter 3, we will explore the 1960s and 1970s

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wherein Iconic Cases 3, 4, and 5 appear. An extensive study of dreams, a seminar for troubled couples, an essay on the psychoanalyst and his society, a look at the emerging role of conferences on the profession, and an early but critically important workshop on the development of professional identity are included.

Chapter Three

Later Practice 1960–1970 Dream Work, Conferences, and Couples

By 1960 my practice had developed into its final form. Central there was work with troubled individuals, couples, families, and institutions. I searched into the earliest ties of the individual. Paradigmatic was the revelation in my graduation paper of a haunt from the past of the woman’s tie to her grandmother, one of my critical cases, cemented by existential guilt at severance of the tie. This was to be exemplified in another iconic case of a young physician who was haunted by a ghost, beset by the impossibility of alteration of a rigidly held tie to the incorporated introject of his father. Along the way as a member of the faculty of the psychoanalytic institute, I taught beginning and advanced courses in dream analysis, analysis of the severe disorders, and a course in early development. My analytic study group met once per week, moving onto exposition by the members of their special concerns. Dr. Preger presented an elegant paper on masochism, while Dr. Drummond developed an abstruse paper on an analogy between advanced photography and psychoanalytic theory. Dr. Bever and Dr. D’Amore did advanced study in historical theory applying it to the history of psychoanalysis. Though I waxed elegantly and in great detail on my work and during our weekly sessions, the members of our group, growing increasingly close, avoided transaction with me on this subject. Conflict between the conservative and liberal members of the psychoanalytic institute brought on the prospect of a split. The more orthodox members of the Institute with whom I had exchanged on our adherence to and reverence for Freud’s contribution, who shied away from me for my work with groups, accepted my initiative towards a workshop to deal with the issues. Its success and my mentorship with him undoubtedly led to Dr. Halperin’s 103

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suggestion that I introduce group psychoanalysis as part of the training of the candidates but I demurred in favor of a sabbatical, scheduled privately to begin in 1970. In my practice, I saw patients individually in classical psychoanalysis, but in large part responded to my growing reputation for the treatment of impossible cases that presented themselves in the context of troubled couples and families. ICONIC CASES NUMBERS THREE AND FOUR: ROTTING CORPSE AND GHOST OF MOTHER Obviously, operation of a practice involving families and couples was highly complex, at least administratively so. I would like to cut through those complexities by presenting two cases which illustrate my employment of group formations to enable the psychoanalytic relationship and process to emerge and be carried through to a relatively successful outcome. The presentation will of necessity be in rough sketch, skewed in favor of specifics of the therapeutic alliance with difficult patients, the occasion for use of parameters, or deviation from the standard analytic procedure, and their relinquishment as the analytic process took hold. A GHOST PRECEDING MOURNING This patient constituting my third iconic case had been hospitalized at Chestnut Lodge for a schizophrenic episode in which she was severely abstracted from reality to the point where she was incapable of self-care and expression. She babbled constantly. Improvement enabled her to return to her family and I took her on as a patient provided the family collaborated in treatment. This they did and the patient revealed the cause of her difficulty, a regression to the death of her mother several years prior. In her hours, she found herself apprehensive of what was behind the door of the room adjacent to the doctor’s office, and cited that she knew it was her dead mother. Thereupon, she burst into tears and began mourning, with the return of meaningful speech. Recovery followed. The inference again here is that analysis enabled the patient to change characterologically to deal with appropriate mourning. Moreover, the appearance—a haunt parapsychological in nature—appears related to the mourning process. Following this case, I have noted this phenomenon to be systematic, and have given it a designation as an advent phenomenon, borrowing from its spiritual precedence. In the Jesus story, advent preceded the resurrection. In my cases it preceded recognition of the finality of death.

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FATHER’S ROTTING CORPSE The advent phenomenon was integral to the patient in my fourth iconic case. It began for this then 38-year-old pathologist when he attempted suicide with the morphine to which he was addicted. He was referred by his friend, a colleague of mine, as a “last resort.” Because of exigencies in my practice I asked another colleague to be the principal therapist, intending to utilize my analytic group to help stabilize the treatment. The patient’s illness had begun at age 26, soon after the death of his father which just preceded his graduation from medical school. He “saw” his father sitting ominously in his burial suit in the back seat of the car on the way from the funeral. He could not sleep thereafter, was agitated, medicated himself with hypnotics, then stimulants, and began the psychotherapeutic course which ultimately lasted twenty-two years. There were numerous suicidal attempts, a self-inflicted gunshot wound to the leg, a number of hospitalizations (one lasting for a year and a half at a psychoanalytic hospital), and in the course of treatment by another psychoanalyst for five years, one of the five psychiatrists who attempted to work with him. I agreed to see him in consultation with a view towards including him in my analytic group therapy. In the first hour he expressed a monumental sense of failure in all dimensions of his life, especially in his relations with other men. He reported alternating between high idealism to black disillusionment. Aware of being driven—he had to climb the mast of a boat he and his colleagues had sailed, to cap the experience—he was helpless to alter his course. The picture emerged of an individual who pursued quixotic dreams and who had been struggling with himself, since early childhood. He kept his family and friends engaged in wrestling for his soul, and was in a state between despair and hope. His wife and three children (female, teenage) were, at this point, verging on alienation, because of his preoccupation with his careers in addiction and self-destructiveness, which kept him away on the streets, in hospitals and doctors’ offices. He reported that he had been restless and “psychopathic” since earliest childhood, taking after his father with whom he had a “weird” empathy, and exquisite awareness of his hurts. His father had been an amateur boxer, given to furious assaults on his opponent, leading to the death of one of them. The patient, in a psychotic fury, assaulted the wall of his isolation room at the psychoanalytic hospital, chestnut lodge, fracturing his knuckles. It is important to note that during periods of relative competency in the course of his bipolar illness, this patient was a paradigm of calm competence when in charge of the hospital unit in the Washington area. He greeted his sister’s birth at first with murderous intentions, bringing on scenes where both he and his mother, previously “fast friends,” went at each

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other literally tooth and nail. He turned protector and exemplary brother upon the birth. He was aware that this sort of rivalry was going on now with his daughter’s boyfriends, in contrast to the warm, loving and understanding man he would like to be. In the next hour he reported a recurring dream of lying in a Chinese junk, in a coffin, with everything black and peaceful. He awoke with a strong impulse to cut his throat. Associations were to murderous rage toward his mother, and female surrogates; men calmed him. A number of psychiatrists had tried tranquilizers and antidepressants to help him fight this “terrible depression,” to no avail. I asked if he had developed any therapeutic relationship where he had encountered some trust and mutuality. He replied he had, for several years, and he “had not lied.” He had broken faith when the analyst had confronted him, asking him to “stand things” without the drugs. At that point he had become outraged, alienated and alienating; only one person, a friend, who believed that his drugs kept him alive, could help him out of his extreme self-destructiveness. This friend had referred him to the author. To my surprise, during this exchange I experienced empathy with him. I felt his depressive affect, which seemed to center about his father’s death and of the ideals they had. He went on to tell how he had recently broken with the friend who had referred him. It was over their psychic impotence; my patient refused to blame his wife even though she was calling him a “eunuch.” It turned out that in that break he had completed the break from the network of relationships in his life. In his alienation from his previous analyst he had reassumed the ambience of an addict, pursuing his perversity with characteristic assiduity and compulsivity. Paradoxically, in the midst of this, when assigned the role of the acting head of a large hospital on overnight or “weekend duty” he became a veritable Osler. In the meanwhile, in his current course, he had several treatment hours with the colleague who had agreed to be his principal therapist. Then, over the weekend, he made another suicidal attempt, leaving clues by which his wife saved and hospitalized him. Because of the manifest negativity of this patient, my colleague bowed out of the case as principal therapist. While he was hospitalized, the patient’s wife asked for counseling. I agreed to see her in marital counseling. I focused on their desperate situation and her conception of her part in it. She responded eloquently that they were unable to live their lives or help each other to do so, despite their immense efforts. She realized that she lived through the marriage and saving him, but did not know how to do otherwise; not following the lead he had left to the place of his suicide that would have resulted in his death. She went on concerning her mother’s self-immolation in her marriage; she ended with, “If I would just disappear, no one’d ever know I was there.”

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In the second hour she revealed that they had “found” each other when quite young and formed an extremely idealistic union, some 16 years previously. It was marked immediately by profound jealousy on his part and obdurate devotion on hers. While they were alienated they were closely tied through their ideals. It became even more apparent that their morale was at the moment at a very low point, and they were looking for relief from their martyrdom through death. She reported that they were able to perceive the ego deficits of the other with great clarity, and expressed a deep disappointment in the other, self, and the marriage. It was apparent that both, while disavowing such, assumed the authoritarian and preemptive roles of their families of origin, which happened to be Jewish, and rebelled against one another, and self. In addition, they exhibited, because of their internal conflicts and ego deficits, an inability to be consistent. They were obtusely enmeshed in a web of principles and ideals. The task of analytic marital counseling was to deal with the nadir status of their morale and the despair that accompanied it, then mobilize their capacity to take counsel about their marital union, firstly on whether they wanted to stay together long enough to resolve their impasse, to resume their marital course, or part. They were capable of taking counsel with one another only to the extent of deciding on a moratorium on that decision, sufficient to work their way through this crisis. Despite their profound ego deficits, we were able to form an alliance in the ego ideal, or earliest ideal aspirations and sentiments, sufficient to serve as a mandate for me to work with them individually and collectively; we would be responsible to one another as we proceeded in the mutual enterprise. Parenthetically, I had learned the necessity for such an engagement in my previous work in therapeutic community, to form a therapeutic symbiosis first, as part of the therapeutic alliance. I have learned subsequently to attend as scrupulously and systematically to that aspect of the individual therapeutic relationship. In this instance, I would have followed this patient to the hospital and engaged in an intensive and prolonged encounter until the alliance in the ego ideal we had formed at the inception was reconfirmed and continued. I estimate that the clinical course would have been much less stormy and prolonged. He succeeded in alienating the personnel in subsequent hospitalizations, six in number, occasioned by either suicide or its threat, or severely obtuse and addictive behavior. On his seventh, however, he was admitted to a therapeutic community I had started, but in which I did not directly participate. There he immediately changed from Hyde to Jekyll, “adopting” another patient, an old man he sensed to be like his father, and participated with warmth and vigor in the doings of the therapeutic community. On discharge he resumed his therapeutic regimen with me in a more analytic manner, abstained

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from drugs, reconciled with his wife and family, and engaged in productive work for the first time in five years. The marital counseling in the inceptive phase of the treatment succeeded in so altering their way of transacting that both parties began to let go of their locked-in idealistic union, and to mourn its loss, versus their previously impotent, perverse rage. After hospitalization the patient entered formal therapy with me. In his version of free association, he revealed evidence of his desperate and important ties to his family of origin—dreams of compulsive, violent intercourse with his mother and fantasies of Don Juan-like ventures in the world of women, plus accounts of his failures in his work and marriage. However, having once “hooked” me and then been “hooked” into our idealistic enterprise, he seemed to cleave to a separate world; he resisted coming to the hours on time or at all. It became apparent that in tendering material to me he was patronizing this “bourgeois, straight” analyst who was going to convert him to his enslaving values, away from the freedom of alienation. The superior position, of narcissistic nature entailed here, had enabled him to resist the efforts of his previous therapists, despite his and their long efforts. On an intra-psychic level, it involved a self-transcendence, in which he was above, and below, and outside of being human. Later in the therapy he cited his own and his wife’s expectations that he be superhuman. It was in his human situation that the transference lay. Relinquishment of his narcissistic position brought him to the edge of grief and rage concerning his father’s death, his life course, and the immediacy of an incestuous tie to his mother and her surrogate, his wife. He had developed an automatic response to the emotions inherent in relations with those aspects in his life, “I’ve got to die!” From the first, we experienced relationship cycles, in which he broke from treatment and family to repair to the world of an addict (morphine, dexamyl, phenobarbital, and ritalin), and also to the hospital for treatment of his many physical disabilities, such as pneumonia, broken ribs, and traumatic arthritis. Sometimes the cycles were preceded by dreams or fantasy-urges relative to his home or work situation. “I dreamt of my daughter being hurt and awoke to pop a dexamyl.” Mostly they were obscure in origin, “I couldn’t stand it.” It became even more apparent that the journey back to his premorbid personality, away from his profound self-alienation, sufficient for analysis to take place, called for further structuring of his therapeutic experience so that it rather than drugs would sustain him as against what was going on within him. The optimal situation would have been a live-in therapeutic community in a half-way situation. Such was not available. Therefore, soon after inception of treatment, as I had originally expected, I put him in my analytic therapy group, which met for an hour and a half, plus 2 individual sessions, and a marital counseling session every week or every other week.

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In the analytic group, during the turns of the cycle when he attended, he reported a deep sense of difference from the others there—he was sicker, more perverse, beyond help, the slowest of the group in conceiving of his selfhood, for all of a pronounced messianism and grandiose ambitions. At the same time he was the most impatient and ardent in supporting the group as an instrument of hope for the others and, in exemplification of what they should be doing, reported on his internal states and dream life, in a manner approximating free association. In experiencing his internal states for the group (climbing this mast in superhuman fashion), he felt a deep malaise, that he was dying. This marked the transition from narcissistic resistance to the transference and the appearance of the transference itself. He then began dreaming of his dead father’s return. In one dream his dead father came to live in his basement. Then, subsequent to an encounter with a patient in a therapeutic community who resembled his father, he dreamt that he had his father’s rotting corpse within him. He convulsively attempted to jump out of his very skin. In his explosive flight from self he crippled his knee. Thereupon ensued another long absence from therapy, for physical treatment. On return to his hours, after some resistance, he went into frank mourning for his father, with prolonged sobbing, allowing me to be empathetic with him. A flood of memories of life with his father accompanied this, and awareness of a terrible inability to feel compassion toward women, in loyalty to his father’s code. This was accompanied by awareness of enormous pressure to “knock over the king,” and to be knocked over. This led to awareness of a lack of constancy and life within himself, and of an internal incapacity to reward himself for constructive behavior. He later wished to destroy himself to reproach his wife for his failure in life. He would awake from dreams of killing her for compulsive intrusion on his person. She at the same time had a dream of breaking off his penis diagonally and keeping the piece alive inside her, for him. They were able to discuss their contributions to each other’s impotence, a far cry from their mutual self-immolation at the beginning of the therapy. He proceeded in therapy with infinite slowness through a complex of individual hours (which would number from zero to three per week), a group session (of an hour and a half), a family session (with his wife and one to three daughters present), plus individual counseling with the wife and daughters. After the first year of alarms and emergencies his pathologic regressions grew less dangerous, and in accordance with the thesis of medical parsimony I moved to associating with the family only on their and my demand and during crises, attempting nevertheless to maintain a state of mutual enterprise and confidence. I had become a relatively steady fixture in their lives, much like the family doctor of yore. As the family moved from its nadir status, the children made representations about their parents’ enmeshment, asking them to assume their proper

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roles, and helping each other to avoid their parents’ rebelliousness, bossiness, and self-sacrifice. The patient increasingly found himself accepted as the father in the family, occasions marked often by tears on his and the others’ part. They were relinquishing the past, moving into reconciliation in the present. My patient would then come to the hours in position to work in the analytic mode. He slowly moved from doing it for the benefit of his family and the group. It is of interest that advance also followed leads from his dream life, leads that preceded the appearance in the transference by several weeks. He relinquished his special, narcissistic role and capacity in the treatment group. It is of interest that this development happened in the groups before occurring in his individual treatment. Soon after termination, apparently stable and reconciled with his family, he found employment as a counselor in a drug rehabilitation program. SUMMARY OF THE TREATMENT This patient called for the maximum extension of my practice at the time. I have of necessity presented only enough material to indicate his passage from a state of utter nadirhood and alienation to one of renewed selfhood, after a period of mourning centered chiefly about his paternal introject, and reconciliation, internal and external. I have noted the role the psychoanalytic method played in both the administration of his therapy and the analysis proper, to enable him to work through his profound problems in individuation. His first problem centered on the formation of an alliance and working arrangement with me. He had ended his previous analytic work in a negative therapeutic reaction, intent on suicide as his ultimate solution. Our alliance was achieved chiefly through special attention to a messianic aspect of his ego ideal and establishment of an effective dialogue. As important was the relationship I established with his family, especially his wife. He exhibited profound ego deficits and modification of developmental nature, plus alienation attendant on mounting failures in his profession and therapy. This alienation made it impossible to participate in the therapeutic work, much less engage in free association. I had to utilize my analytic therapy group and his family group; while I could not entirely contain his cycles of alienation, as would have been possible had there been a therapeutic community at the inception of treatment. He was able to assume a special place in the analytic group paradoxically as devoted leader and exemplification of resistance. In exhibiting them he began relinquishment of his narcissistic defenses. In entering the transaction with the other human beings in the group he established an external platform for the analytic relationship and free association which he gradually internalized. Dream analysis, begun in

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his individual hours and continued in the group, enabled him to engage and mobilize the aspect of his ego he in his survivor’s guilt had no right to have—having been caught in and preempted by an autistic sacrificial compact with his dead father. Work on his maternal identification followed on the heels of a growing capacity to experience himself as a full member of the group and as an analysand in his hours, both in dream material and transferences in the group. This coincided with further pressure by the children in his family to bring their parents into their proper roles; there also were useful exchanges about the repetition of the family’s difficulties in the three generations of the family, on both sides of the family tree. Finally, the patient responded spectacularly to participation in a therapeutic community which would have been maximally useful earlier in treatment. Readied by his previous therapeutic work, it enabled him to form a messianic relationship with a patient resembling his father, which opened him to the transference of the mourning he had failed to experience on his death. That mourning took full expression in his individual, group, and marital counseling hours. Concomitantly he returned to his premorbid personality. He was almost literally Dr. Jekyll again. From that vantage point he required no further structuring of his treatment situation to deal with his alienation. He proceeded to analyze the narcissism of that character defense and to termination. DISCUSSION I chose this case as the focus of my thesis concerning the extended practice of psychoanalysis because of the extraordinary difficulty in structuring his treatment so that he could go through the process of personal change along analytic lines. This was supported through the inception of three groups: an analytic family group, an analytic therapy group, and an analytically oriented therapeutic community. Establishment of an effective therapeutic alliance called for establishment of a state of mutual confidence and enterprise with his family, especially his wife, alongside the special one necessary with narcissistic and alienated individuals. He was most able to relate in a free associative manner in the group analysis, in conjunction with his individual work with me, despite use of the couch, and frequent hours. In the individual work, despite his best intentions, he resisted the transference through living in the alien world of the addict, or an obsessive-compulsive compliance. When he did come into the transference he had a direct, very vivid, and quite traumatic experience in mourning his dead father. Then he mourned the losses sustained in his developmental

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eras, centering on his maternal object and the transferences to his wife and myself. As he worked through the alienation incurred in his previous treatment and life experiences as an addict and failures in his careers in marriage and profession, his cycles of alienation and reconciliation in the treatment became less dangerous, calling for decreasing need for administrative management. Though he tended to act out in the treatment group, the availability of his unconscious was of great help to the highly repressed neurotics there. It is one of my contentions that the massive investment of time and concern extended to this patient was indicated to bring him into the mode of treatment necessary for work on his alienation and his narcissistic defenses, so that the transference and the inception of analysis proper could occur. Not only was it indicated on that count, but I consider it that it comported with the principle of therapeutic parsimony. Beyond that, this patient could have been considered a candidate for chronic individualism and hospitalization, a most costly outcome. CONCLUSIONS At first alienated and suicidal, the patient I have chosen to illustrate formed a therapeutic alliance in which, after work on his narcissistic defenses against the transference, he began free association and dreaming indicative of the inception of a mourning process which continued through much of his treatment, culminating in a profoundly moving experience. The transaction involved working through of pre- and post-oedipal issues about his paternal and maternal introject. Issues of acting out because of the character disordered aspect of his personality were dealt with only with partial success, until he participated in a therapeutic community toward the end of his course of treatment. I had noted in an earlier case the appearance prior to mourning of the introject of a haunt significant to that tie. In that case it was the patient’s dead grandmother who appeared prior to mourning. The inference was that he was characterologically incapable of mourning and that the analysis had rendered a change in this regard. The change was that of relinquishment of a categorical tie to his father and transference of such to the analyst. Since the patients who made up the majority of my iconic cases reported dreams that were significant to them and to me, we will explore the value of dream analysis in the treatment process in the next section.

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SOME CLINICAL ASPECTS OF DREAMING AND PSYCHOSIS When not behind the couch or in conference, I read extensively into the literature on dreaming and became deeply immersed in the question of whether one could, with safety, work with the psychotic patient on their dreams. I noted that psychoanalysis has, from the first, shown particular interest in dreaming and psychosis for the subject’s ever recrudescent promise of insights into the essential nature of both. Freud begins The Interpretation of Dreams (Introductory Note) citing the dream as an “abnormal psychic function whose explanation is necessary to understanding the phobias and obsessive and delusional ideas or to influence them by therapeutic methods.” Later in that volume he “glanced,” in most cogent fashion, at the literature for examples of clinical and etiological relations between dreams and psychosis. He cited a number of examples of decisive or gradual onsets of psychosis attended by a dream or series of dreams, and others in which the morbid state is confined largely to the dream life, or to the night, in which sleep is replaced by intermittent insanity. In recovery from the psychosis, the dream life may lag in return to health. The psychosis is found to manifest clinical characteristics of the dream and vice versa. Through this brief and pithy summary, Freud seemed to point to a presumptive position the dream held in the course of psychosis, or, at the least, its place in attending its events. He quoted Greisinger on specific characteristics of both dreams and psychosis-absurd combination of ideas, weakness of judgment, overestimation of one’s mental capacity, rapid flux of imaginings, absence of measure of time, splitting of personality, recurrence (of stereotyped delusions and identical dreams), and subjective perception of the dream state. Freud ended the exposition in a summary statement to the effect that such close similarity was a strong confirmation of what he calls the medical theory of dream life—“a useless and disturbing process and the expression of diminished psychic activity.” However, through the elucidation of the mystery of dreams we will work towards exploration of the psychosis. In his Introduction to Chapter VII, Freud stated, after citing the incompleteness of the psychology of dreams, the peril of new assumptions conjecturing the structure of the mental apparatus and its energies, because of the incompleteness of the preliminary statement of the elementary data: We shall not be able to arrive at any conclusion as to the structure and function of the psychic instrument from even the most careful investigation of dreams, or of any other isolated activity; or at all events, we shall not be able to confirm our conclusions. To do this we shall have to collate such phenomena, as the comparative study of a whole series of psychic activities proves to be reliably constant. So the psychological assumptions which we base on the analysis of the dream processes will have to mark time, as it were, until they

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My study attempted another approach, presaged, however, in Freud’s own “glance” at the literature, and in his differences with Maeder and Adler over the purposive or conative aspects of dreaming. It involved collation of the entire dream series of patients in treatment, correlation of the manifest dreams with analytic material with special reference to the ego states as they changed in the course of treatment, and comparison of the patterns which become manifest in the various nosologic entities. To return to the literature, Alexander (1925) reported on dreams in pairs and series, pointing to the way in which business begun in the first dream was finished in the second. Noble (1951) presented a study of dreams in schizophrenia and allied states, with attention to their form and content, changes in their character in the course of the illness, and use made of them in psychoanalytic psychotherapy. He found them to be like those in neurotic patients, except for a tendency to a primitive nature and simple frank statements of basic problems with little elaboration; also an absence of dreams of standing apart, observing. He asserted their essential usefulness in stabilizing treatment, with especial reference to the transference. Kant (1952) reported work on collections (200) of dreams of schizophrenics, finding little differences, with the exception of bizarre and cosmic dreams; he considered dreams in schizophrenics of little value therapeutically. Jung (1952) in Integration of Personality discussed dreams and psychosis, introducing a series of dreams of patients. He held that dreams and hallucinations were the product of repressed complexes, were teleological, and manifested themselves side by side with the waking state, in psychosis. The personality suffered disintegration as a result of metabolic change occasioned by strong affects in schizophrenia; a congealing occurred in the higher nervous system, leading to predominance of impulses of lower centers. Lewin (1950) reported a case of a woman who had no less than four schizo-affective episodes, initiated by a blank dream, held by Lewin to be associated with ecstatic union with the mother. French (1954) in The Integration of Behavior, Vol. II, painstakingly developed the thesis of the dream as an integrative problem-solving aspect of the mind. Erikson (1954) carried the inquiry a step further in The Dream Specimen of Psychoanalysis, demonstrating the dream (Freud’s Irma dream) as an active locus and agent of Freud’s personal and professional development. Knapp (1956) focused on sensory impressions in dreams in a survey of 554 dreams, following Lewin’s interest in the broadening emotionally adaptive aspects of dreaming (indistinct, blank vs. clear). He concluded that the majority of dreams may be characterized as “colorless, soundless, motionless, tasteless.” An overall lifelessness is implied, consonant with the protec-

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tive nature of the dream work forming a barrier against the vividness of sensations that are charged with affect and promote wakefulness. Katan (1960) in a paper on dreams and psychosis cited the normal dream as a manifestation through wish fulfillment of effort by the ego in regression to a preverbal state to ward off the drive of the unconscious instinctual demands towards contact with reality. The persecutory character of the dream in psychosis manifests regression to the undifferentiated state (of Hartmann) by the psychotic ego of “… early processes of primary introjection and primary projections as tools to establish a new reality to avoid contact with objective reality.” The urge in the ego’s unconscious state is no longer recathected; the energy is invested in an outside persecutory object. The ego loses control and discharges directly from the id. However, in his dreams, the psychotic individual may return to relationships which would be impossible for him to maintain in waking hours. In the dream the psychotic is in the same state of mind as any other person. But, whereas the psychotic dwells on a higher level in the dream than he is able to maintain in his psychosis, the normal person in his dreams steps down to this level. The dream presents the wish fulfillment relative to persecutory objects—a secondary projection presents the unconscious (homosexual) passive (selfdestructive) state of the person, which he is unable to master in waking life, and which also occurs as a delusion. The Kris Study Group, using only manifest dreams in a series, succeeded in reconstruction of a significant childhood event in a patient. This was reported by Richardson and Moore (1963) in an article, “On the Manifest Dream in Schizophrenia.” They also noted the controversy that developed in that group on whether there is anything distinctive in the dreams of schizophrenics, and an account of a research project which grew out of that controversy and in effect continued it. There was some agreement that schizophrenic dreams tended to convey a “sense of bizarreness, uncanniness, unreality, strangeness, or a cosmic quality.” Richardson and Moore account for this quality as secondary to an increment of an especially labile neutralized energy which bolsters repression in the dreaming ego’s dream work, resulting in distortion and disguise; failure of the psychotic ego’s processes of secondary revision because of a defect in secondary thought processes, plus a sluggishness on awakening, results in retention of bizarreness. The neurophysiological investigation of dreaming, begun in 1955, developed into a vast enterprise. Some of the studies refuted Freud’s ideas (as regarding the instantaneous dream), cast a shadow on the concept of the dream as the guardian of sleep, but generally confirmed the role of sexuality (prominence of penile erections and erotic content) and the concept of the dual topographic regression (day residues making connection with the unconscious, then of the unconscious to the perceptual system).

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The experimenters soon turned to work with mental disorders. Dream deprivation produced deep seated, disintegrative, and regressive changes in human and animal subjects (Dement and Fisher, 1963). Dement and Fisher also found borderline schizophrenics to have increased dream time. Alcohol, amphetamine, barbiturates and the tranquilizers were found to decrease REM’s, while LSD increases REM time markedly, held to be related to the hallucination experienced (Berger and Oswa Ld, 1962). An important panel on Dreams and Psychosis, held at an Annual Meeting of the American Psychoanalytic Association in 1968, was chaired by Frosch and reported by Mack (1969). The discussion about whether there was anything distinctive about dreaming in psychosis led to the designation of nightmares, world destructive dreams and dreams reflecting loss of ego control as of significance. Reference was made to Walder’s observation that a return of denied libido can lead to a frenzied psychosis in the form of a violent delusional assertion. Eissler noted that the task of the dream and dream work in the schizophrenic may be too great, because of the extent and intensity of the latent dream thought. Eissler also observed that the confusion of distinction between dream and reality and confusion of their own fantasies with reality can be seen in very talented people at times of creative productivity. The literature pertinent to this subject also includes work done on psychoanalytic treatment of psychosis, and on conceptualization of the nature of the causative trauma. A STUDY OF THE NATURAL HISTORY OF DREAMING IN PSYCHOSIS The preceding paper on relation of dreams and psychosis led to a survey of the dreams of my psychotic patients. The rationale for this study lay in an attempt to approach the problem both from a synoptic and particulate view, from consideration of the mass of dreams and the details of the treatment and life situation of the dreamer. An attempt was made to survey the dream life as evidenced by reported dreams (and associations) of the segment of the patients in the author’s analytic practice who experienced psychosis during some period of the treatment. The diagnosis of psychosis rested on evidence of a definite break with inner and outer reality, regressive changes in ego functioning, evidences of ego disintegration, and of secondary restitutional distortions. The data on the dream life consisted of the manifest dream, the associations, the therapeutic situation, and the relevant life data. While at this stage of the inquiry the material was not approached statistically, aggregations and patterns were sought, as a step towards formation of hypotheses on the focus

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of the study, the nature of the dream in the context of the psychotic experience. The material was gathered over the course of a practice of somewhat more than two decades, from the productions (in note form, most of it accumulated in situ), of twenty-five patients, with dreams (and associations) totaling 875. The assemblage of the mass of dreams as a gestalt led to a review of my course in collecting the data, development of a grasp of the material and theoretic alias. A serious attempt was made to view the aggregate afresh, with a relatively open mind. The aim had been the discernment and representation of the dreams which attend the course of psychosis—antecedent, inception, psychotic crisis or course, and recovery. Identification, on the basis of evident patterning, of what is distinctive of dreams, and dreaming in the psychotic state was sought, and attempts made to arrive at specific patterns in specific cases as they traverse the experience of psychosis. Special attention was paid to manifestations in dreams of the self-concept and identity in relation to the life course of the individual. Those cases will be made. A GENERAL SURVEY OF THE DREAM LIFE IN THE PATIENTS STUDIED This segment of my practice was more interested in its dreams, despite a state of ego decompensation, and more intuitive in grasping their meaning. Noble and others have made the same observation. The exercise of a capacity to observe self, reflected in their dreams, (this denied by Noble) served as a mainstay in traversing the vicissitudes of treatment, alongside of affiliative feelings in the therapeutic work. They were seen from to seven times per week, varying with the course of illness where more dreams were reported during more intensive periods. The form of the dreams ranged from brief thoughts and images, pithy statements in allegory or metaphor of the dreamer’s own course and situation, to long, involved experiential accounts. The depicted situations ranged from warmly human (this in contradiction to the idea of affectlessness of the dreams in schizophrenics), to highly morbid, bizarre, and terrifying. The setting ranged from natural or ecologically relevant (yielding highly meaningful associations related to body ego and image, and developmental eras) to utterly bizarre, cosmic, and outlandish ones. They were presented in language ranging from highly abstract and symbolic to specific vocal recapitulations. While in the dreams of neurotics, patients walk through muddy waters, those in this group tended to the eating of feces, cleaning of cesspools, suffering horrendous defects, or incursions of devastating and demeaning

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nature. There seemed to be somewhat more direct dealing with animals and other aspects of nature in the dreams of psychotics—either identifying self as animal, persecuted, or protected by them. E.g.: “A flea and myself were to have a baby. With a feeling of absurdity, I woke up.” Some reported direct instinctual enactments or evident symbolic statements of such. E.g. “I was having intercourse with my mother. I couldn’t stop. I became frantic and awoke. She was urging me on. I was disturbed. I was in my mother’s house. I had some ice cream. There was one flavor left over. It was purple. Maybe grape. Not concentrated.” Associations: Grape means purple penises, lavender. Purple is royalty, our family, myself. Left over, that’s me. I scream. Another example: “I saw Dr. S. last night. He leered and loomed over me. He was the Devil. I was terrified.” More often than not at the onset of the psychosis there was compulsive repetitive dreaming, involving helpless engulfment by external threat, efforts at escape, surmounting of obstacles, accomplishment of tasks, or direct, blissful fulfillment of wishes. There frequently was the experience of a fall, slide, slip, or death. Awakening from the dream was more frequently than otherwise variously in terror, exhaustion, suicidal compulsion, assumption of saviorist status, or blissful elevation, as in floating in the sky. Comment This survey is the product of a reading of the mass of dreams and the development of hypothesis. General impression of the clinical data; statistics await leading to categories of classifications. As has been found in the literature, the indicators of destruction lay in the segment of dreams which are highly bizarre and world destructive. A secondary characteristic seemed to lie in what may be termed affiliation with objects indicating alienation from self, animals, aspects of nature and the God-head. The predominance of content and action in the dreams centering about life course, value and meanings of things, guilt and redemption, led this observer to the thought that the dreams exemplify concern with or fixation about functions, ascribed to the ego ideal and secondarily the superego. There is a skewing of the dreams in the direction noted in the literature: bizarreness, cosmic quality, and world destruction. Richardson and Moore accounted for this as a distortion and disguise resulting from bolstered dream work potentiated by especially labile neutralized energy followed by failure of secondary revision, or attempts by the ego to alter the data in conferment with its concept of reality. Noble also noted such failure. The latter hypothesis seems quite tenable; however, rather than the concept of excess neutralized energy, it would seem that there is evidence of a state of profound passivity and vacuity, (of the nature described by Balint in The Basic Fault),

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of abandonment of the ego by its institutions (ego ideal and superego), a concept first put forth by Freud (1894) prior to the topographic theory, in which the ego is conceived to defend itself against an incompatible idea (homosexuality) by detachment of the affect from the idea, itself so inseparably connected with reality, the ego detaches itself from reality. I have found this process of dis-association to be central in the severe disorders leading to splits in the ego. A PRESUMPTIVE OVERALL PATTERNING WITH REFERENCE TO THE PSYCHOSIS AND LIFE COURSE The focus will now be narrowed to identifying the pattern of dreams found during the course of a psychosis—before, during, and after. The dream’s antecedent seemed to fall into two categories—those much earlier in life, and those just prior to the illness. The former were far greater in number, were sometimes recurrent, and were remembered with relative clarity. There was a quality of prophecy, and expectancy. Within the dream there may be expectation of assumption of a mission, prediction or presentiment of tragedy, or death by a certain age or incident. The death itself may appear in symbolic or allegorical form, as well as physical enactment of death or near death. Here the individual perhaps is hinting at a death of spirit and resurrection, “When I was a young girl, I had no dreams, except one. Someday I’ll meet a man, very dashing. He will love me and all I will do is to tell him how much I have suffered since I was a child.” Dreams immediately preceding the psychosis had prodromal characteristics, showing relationship in form and content to the soon-to-develop psychosis. There were overt intimations or statements telling of the coming denouement. The prodromal or precursory dream may take the form of a solitary or perseverating dream, in which the patient is in a blank state, on a journey, chased or cornered by some feral, charismatic, or unknown threat, in a situation of guilt, threat, or involved in a statement of life purpose. They may experience in this prodromal dream portions of a scene of loss, often through death of a loved one: “There was an atomic explosion, and I was to be killed. I was supposed to die because I was supposed to go back to before Life. That was nice.” PSYCHOTIC CRISIS The onset of the psychosis itself might be marked by a blank dream, from which the individual awakens in manic state. It is as though the dream triggers or marks the advent of the illness. The dream might take the form of a devastating falling or slipping dream, which on inquiry the patient relates to

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loss of social or personal position. The patient may dream of being cornered by a known or unknown threat. Lastly, the individual may experience death, or see himself dead in a dream: “I dreamed witches were taking over. There were black pits all around. Everything was destroyed. I asked myself, was I one of the witches?” Dreams during the psychosis in the patients studied seemed to follow a general pattern centering about relationship with a parent or parental figure, or an aspect of self. Through assemblage of fragments and patterns, the author has discerned a drama enacted about the advent of an alienated presence, such as a ghost, animal, ecologic feature, or aspect of the God head (with good or evil figuring prominently). This advent was variously gradual or precipitous, subtle or overwhelming, or both together. On confrontation, the dream gave way to dream experiences indicating the death of a parental figure and/or aspect of self. The dreaming ego was in a state of isolation, absolute vacuity, terror, guilt, loss (as in mourning) or shame. In most cases the affect experienced by the dreaming ego is intolerable but for the therapeutic alliance. However, the most intolerable aspect seemed to be the aloneness, isolation, and alienation experienced on abandonment by the dreaming ego of the parental introject. In this drama, pieced together by this observer, the parental figure then returns in recognizable form in a complex confrontation enacting factors involved in alienation and reconciliation. As an example of this core consideration we will cite the patient who was tied in dreams to having intercourse with his mother, who reconciled with her to the extent that he no longer felt guilty about leaving her, whereupon the compulsive incestuous dreaming stopped. Having (in his concept, in his ego ideal of their symbiosis) reconciled her (as an introject) to her aloneness, he could reestablish relations with her; after working through aggressive feelings having to do with being wronged, and also working through impulses delivered at the very root of his being, his identity and his ego ideal. I was on trial at the Lodge. I was found guilty. I accepted it. Associations: Men, my father died, I vowed I’d become him, for him. I hallucinated him, smoked cigars for him. I feel terrible inability to feel compassion with women. He was ashamed of having deserted my mother. My father was alive, living with us. He had deserted us, came back. Every time he tried to explain, the terror of it I just tolerated. I closed him off. I had a pointing abscess of the groin. I was in a brothel. My father was there, in a round tub. I said to my father, with contempt, ‘Why don’t you wash yourself?’ I put on a coat. It was a different colored coat. I knew I had it made. I awoke in terror. My father’s corpse was inside me. I leaped out of bed, and fell, rupturing my knee.

Lastly, the remission from the psychosis was marked in dreams by evidences of new hope, in which the individual reinvests in a new ego and life.

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It may appear as an element sometimes barely discernible in the middle of the psychotic crisis. A patient who had been hospitalized for psychosis for three years recovered by suppressing and repressing her personal and familial expectations and concerns. On inception of office treatment she revealed, after the doctor questioned her about her apprehensiveness over an opened closet door, that she sensed something around the edge of it. She further revealed that she had not told the psychiatrist at the hospital a dream of a presence that had haunted her from the inception of her illness: “I dreamed I saw a figure around the side of the door. I look off in the distance and see a shape. I see this shape at nightfall sometimes. I don’t know who it is.” In her next hour, she reported a dream: I dreamt I saw the face of my mother, in a coffin. She is not dead. She is big and fat, about to die. She poured hot water on a big spider. Little spiders crawled away. I dreamed over and over again while I was in the hospital that they were eating my brain. I realized I was saddled with her, even there, and couldn’t get away. But I will. Another patient, in the mid-point of his psychosis, dreamed these two dreams: You (Dr. A. and the Reverend) were there. You became one. I blew your head off with a shotgun. You are trying, conspiring to finish me off, have me belong to the establishment. My only hope is to kill you. I have to kill my father also. I was climbing this building, which was like a tower. Something was after me. I came to a part that curved over, and couldn’t hold on. I yelled, ‘Daddy, daddy, daddy.’ I won’t give in to him. He failed us, all along. My only hope is outside the family.

Dreams after recovery reflect the concerns and interests of assimilating the soul-shaking experience, the conflict of returning to the mode of life, and enterprise developed during the illness, vs. living in a world which contains a confusing mixture of boredom, mundaneness (compared with the pre-psychotic frequently exceptional expectations), and promise: I dreamed I was psychotic again. I was at a long table with people eating. I did something violent, like throwing a bowl of cereal. Everybody was shocked. It is like a movie, like a table in a cafeteria at High School, or at camp. I feel on the edge of desperation. No place in the world. My cat is my alter-ego. I want to die, to dream, not awaken.

This study may be considered to be a preparation for the dream studies to come in this volume and reflective of my investment in the first two decades of my practice in work with the more severe disorders.

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DREAM STUDY GROUP After graduation from the Washington Psychoanalytic Institute in 1952, I helped organize and participated in a study group with five of my class mates, to complete my psychoanalytic education and to help master the challenges of my new psychoanalytic practice. Important there was making up for what I considered to be a deficiency in my education regarding psychoanalytic theory. At issue was the concept of transference, which Harry Stack Sullivan, a chief mentor, had wholly ignored. He emphasized neologisms such as parataxis and prototaxis, his designation for aspects of the self, of defensive nature. My colleagues and I engaged in reading the literature and applying it to our new cases. I attempted to introduce them to my new theory regarding messianism and they resisted, their eye glazing over. However, we avidly engaged in discussion of Freud’s dream theory and of Dr. Noble’s class on dreams during our training. Important to me, but not to them, was Dr. Ernest Hadley’s teaching of the analysis of schizophrenics on the couch and his success in through active engagement avoiding isolation on their part and regression. By 1968, I had begun teaching courses on development and the treatment of the severe disorders, especially borderline states. I had engaged in dream analysis as a core procedure in all my therapy and contrary to the literature found it to be of particular use in treatment of psychosis. As a result, the convening of a dream study group in 1969 by Dr. Douglass Noble was most welcome. To it came a group of eight advanced members of the psychoanalytic institute, exchanging on theory and practice of analysis of dreams in the psychotic individual. Following is a report of five sessions of the study group, taken from ongoing notes. In the course of five sessions, the members, eight in number, observed their reactions to a dream presented by an advanced student. It occurred at the onset of a florid psychosis, marked by severe incapacitation and regression. Unfortunately I don’t have the recorded dream. But the discussion was lively and increasingly coherent, and the participation of the members became more cogent and less disjointed and more discernibly related to one another. My concern here is to cite my participation. DREAM STUDY GROUP, JANUARY 11TH 1969 In the context of discussing the connection between the dream and the waking reality, and the onset of regression from it, I interjected: . . . those cases seemed to be suffering from alienation from a previously important problem relative to acquisition of narcissistic supplies. Failure there results in extreme isolation. This in turn resulted in symptoms of psychological

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deprivation, hence appearance of frank psychosis. Then I went on to elaborate that this process was one of yielding or falling into a state of isolation from the instincts and the unconscious, rather than the incursion of the unconscious. I groped my way to conceiving of such energy as stemming from countering a profound feeling of loss, eventually of psychic death.

I noted that through the creative stimulus of the group he felt impelled to communicate two disparate but somehow related thoughts: an extension theory of Dr. Drummond’s hydraulic hypothesis involving a chemical state akin to a three dimensional photographic plate, altering its image as a whole and in waves; and also an application of role theory to the clinical illustration of Dr. Schultz’s patient. The role integration the patient sought was an executioner-condemned criminal. The patient had yielded to anticipation and his ego was flooded with simultaneously conception and perception of his trial/ execution. He was cut off from thoughts of a savior, or rescuer, or from comfort of a pre-existing introject. I was here matching a colleague’s psychosomatically couched theory with my nascent initiative at introducing sociologic role theory to psychoanalytic phenomenology. I was here enacting a helpful if not saviorist role with Dr. Drummond in envisioning and setting forth to the group a mental process previously marked by great residence and turbidity on his part, an affect with which I closely identified. In so doing I was touching on my own problem of an alienated tie to my maternal introject and its relationship to my precoxlike adolescent regressive states. ICONIC CASE NUMBER FIVE: CONJOINTLY BEATING HEARTS Especially appropriate are the dreams of a patient who turned out to be iconic case number five. The patient was a 36-year-old woman treated for eight years by psychoanalytic psychotherapy which was advanced to such analysis for a schizoid depression, itself of close to a year’s duration. She was at the time hospitalized following a potentially serious suicidal attempt, reconstituted rapidly, and was able to maintain herself and her family of a husband and 6-year old daughter despite a constricted personal and social life, nighttime panic and insomnia, and apathetic depression. The patient was unable to offer genetic material during the first years; after two years of therapy, she realized her illness began when her daughter, 5, began to have a personality and life of her own. The treatment marked from the first by parameters, gradually settled into an analytic framework, the couch coming into use in the 5th year. In order to insure a rapid return home, after preparatory interviews in the hospital, the husband and patient were seen together. A severe state of mutual and hitherto

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unacknowledged alienation was uncovered, which had crept in on a marriage of fulsome but one-sided display of mutuality by the patient. In her interviews with her husband and the doctor, she was shy and retiring, somewhat flat, but daring to pose problems, and indicate disaffection with her husband’s distancing and patronizing ways. In her hours she was at first vacuous and inchoate, then tearful, revealing in time a fragmented thought on awakening of wishing her mother were alive. Her mother had died when the patient was 8, in a gruesome manner, involving a scene with the patient nursing her and standing by helplessly, in which she convulsed, vomited bloody bile, fell out of bed, hitting her head on furniture on the way. The patient then began bringing in fragments of “dreams” which apparently consisted of thoughts on awakening. They seemed to involve what amounted to stories alluding to meaningful memories. A dream about a man directing a choir in her associations led to an account of seduction by a choir director in adolescence. One of a kidnap-murder of her daughter brought out the patient’s alienation from her family. Another about a big house (the first of her big house-body image dreams) brought out her revulsion about her obese and also very feminine body, envy of her brother’s penis, and mortification at submission to the therapeutic experience. She vomited blood in her 5th dream, leading to awakening in terror. She was unable to associate to that dream. In dream #6, reported in the 5th month of treatment, she had the doctor as an ally, gently guiding her hand in writing her name, which turned out to be her mother’s maiden name. In association to this dream, she recovered a recurrent dream of childhood of walls coming in on her, her hands and fingers big as elephants. In her hours she showed signs of regression to a trust manifested by investing in the doctor as a savior-priest, on the pedestal she indicated had (and still) was occupied by her mother. The doctor entered into this parameter to stabilize the treatment, gradually engaging her capacity to observe herself in dreams and interpersonal situations, and experience untoward and pleasurable affects to tolerance. Dreams thereafter played a central role in her treatment, along with analysis of the transference. A series of dreams about a “fatal attraction” to feminine men led to one about an affair with a woman. One in which her husband was alive and eloquent led to another in which she was dead and jealous. The doctor was alive, not dead, in a dream presaging stirrings of hope for herself, and resumption of her education and the artistic endeavor her mother had sponsored, and in which the patient showed talent. She began feeling alive, put together, and apparently more able to deal with her inner self. The monstrous aspect of self previously held in check by denial and splitting began appearing in her dreams and the hours as a masculine megalomaniac, “a sex fiend in the house.” She at the same time walked away from a form of mutuality with the analyst, messianic in nature sufficiently to reveal

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religious prejudice. This was marked by a dream about a war in the house, with a man with a spyglass on the roof. She then began literally rehearsing her artistic endeavors and aggressive engagements in her dreams. In the eighth year of treatment, she had a series of oral dreams, indicating disgust with her feminine self. They led to a dream of a man serving up a baked puppy, then attempting to kill her, to which she associated that was her way of killing off the limb that offended her. She was so lonely she could die. She was still relatively mute in dealing with the transference mother. A dream about a car in reverse gear, yet going forward, then one in which the analyst and she were checked in to separate hotel rooms far away led to an hour in which she fell asleep and awoke, with awareness of a third person in the room, and called out, “Go away, Mom.” This situation of illusions and hallucination with variations continued for a month in the hours. She worked through to a position of beginning mourning involving an introject that apparently had completely taken over her ego ideal, “You were life and you were me.” She brought in pictures of her mother and self, demonstrating an identity of facial expression which may be characterized as being “dreamers together,” and a dawning realization she was dreaming her mother’s dreams in her waking life, to vindicate her mother’s life which the patient sensed was a failure. She reported dreams involving blank walls and windows, characteristically accompanied by a dream involving clarity. These were interspersed with dreams of new life, coming in her 52nd dream, to one involving a body image of an inverted V, her whole front exposed and bloody, with awareness of a recent castration, and associations to violently bitter feelings towards her mother for making her identical and dependent, and for groveling as a pig to make someone accept her. Thereupon followed an expression of strong negative feelings about the doctor’s leaving for California, with dreams of castrating him, and with associations of masochistic fantasies of self-mutilation, hunching up with (navel) pain, and identification with her mother for a burn she received from boiling water during the incapacitation preceding her death. She reported her mother looking down at her in her bedroom and in the hours. A dream in which the analyst’s wife fainted when in a rivalry situation was awakened from in fear, but was followed by dreams in which she was apprentice to a prominent artist, acknowledged her husband as the man of the family, made love on top of a priest (the analyst), and was in love with a black man, who turned out to be her brother, with the Holy Ghost in the background. The rivalry-mutuality, catching up with life, and getting back at things continued to develop, in dreams in which she was in bed competing with her mother for her father’s affection, and another in which she experienced a rivalry-seduction scene with her brother, followed by a series of large house dreams repeating those themes anew in conglomerate.

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During this period, the patient reported gains in her daily life, reconciliative moves with her husband and daughter, a new interest in her feminine self and body, and acceptance, with a struggle, of the analyst’s leaving. Her insomnia and status as a “night person” began changing back to the normal pattern, and with a feeling of self-assurance and the “pieces put back together,” her compulsive eating ceased. The outstanding development in this case involves a concomitant change in this patient’s ego functioning during the hours and in the dreaming state, the two joining at the nodal point in her series of dreams, in which she experienced what seemed to be a blank dream, attended by a hallucination on awakening. She had regained, or gained for the first time, the capacity to dream through the array of dreams encountered in the normal and neurotic individual. Though dreams were reported almost from the first, they were cryptic, with relatively little affect, and held to have no meaning until related. The element or situation she had traversed in her dreams, and which by implication was blocking this dreaming was one pertaining to union with and separation from the introject, a situation posited by Lewin, in his thesis that blank dreams involved blissful union with the maternal introject. The thesis presented in this study is that the panic and devastation experienced by the psychotic is caused by the peril attendant on separation from that introject. The separation in this patient was marked by the hallucination and the dream of castration. The nodal point in the total pattern of dreams seemed to be the one concerning the body image of the inverted V, preceded by sleep in the hour, and hallucination of her mother. The castration, it is posited, involved a complex of loss of her position with the maternal introject, and of her feminine identity in favor of her mother’s needs in the maternal-infant symbiosis. SUMMARY AND INFERENCES These dreams of individuals in active psychosis indicate a state of mobilization and coherence of the individual’s dreaming ego not manifested during the waking state. It may be commented that regression during sleep is very much in the service of the ego. It is as if the dreaming ego, temporarily released from the conative enterprise of the waking state can integrate and communicate within its parts when the waking ego in helpless, fragmented, negativistic, or resistive in other ways. Even in patients whose psychosis occurred nightly, the dream life seemed to serve the individual as a time of self-communion and counsel concerning their life situation. This would be in accordance with the concept that the dreaming state is a core function in integration and restitution of the ego in the normal person, and more so in the individual in active decompensation. The dreams would

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indicate a truly crucial (life or death) life situation, and extraordinary attempts by the dreamer to solve the problem of whether to continue existence, and the conditions stated in terms of the ego ideal, attendant on change of life mode, status, and strivings. Moreover, they indicate a change-over from the dreaming of the psychotic ego to that of a neurotic one. In accordance with Freudian theory, they would involve inner changes in which there would be reworking of that part of the ego relating to values, ideals, and life purposes, the ego ideal. This involves renegotiation with the introjects, at a most primitive level, the ego ideal being formed earliest of the ego structures. Such occurs theoretically at all points in human growth and change, as outlined by Erikson. In the individual disposed to psychosis, these negotiations with the introjects occur as a stark and momentous drama. The individuals encountered in this study seemed to have as a preponderant part of the personality makeup egos serving the function of the ego ideal. In identification and reaction from their parental introjects, they were driven to elevated, special positions and life goals, setting themselves apart from others as “dreamers” and creators. They entered into and were presumably trained in these roles and capacities in a form of the maternal-child symbiosis in which a role reversal occurred, the mother depending on the child for psychic survival, change from which would be at peril to the maternal introject, who herself suffered from her version of that form of autism. This version of the concept of oral guilt is close to that held first by Lewis Hill. Freud, in his Group Psychology and Analysis of the Ego refers to Bleuler’s concept of autism in differentiating a form of narcissism which completely separates the individual from others. It may be added that in such separation the individual, in a messianic stance, creates a life for himself, and becomes his own God-head. The careers involved in such autisms reach an end, occasioned by the imperative towards separation-individuation. This results in a fall or further transcendence. In the former, the individual experiences self and the world as isolated, morbid, and evil, with the introject coming from without as persecutor. Being alienated from self and cut off from the formerly close symbiote, the ego experiences the deprivation we know results in that aspect of psychosis developed in experimental sensory and dream deprivation. Recovery in treatment involves recathecting aspects of the ego abandoned in the original trauma in favor of primitive identification and introjection, after mourning the loss of the state of symbiosis, the guilt and terror concerning the survival off the introject, whose very existence seemed to depend on its preservation. In addition to the dream analysis that characterized much of my career during these years, I embarked on a new adventure—the study of, and therapy with, troubled couples. A discussion of that adventure follows.

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SEMINAR ON TROUBLED COUPLES At the tail end of these professionally formative years in the Washington D.C. area, I held a seminar based on my growing work with troubled couples. What follows is a summary of that seminar. That review initiated to identify the occurrence of problematic couples in my practice, extended, by its end, to my entire patient population pro tem. The first couples listed were the least investigated, namely the affiliation of detainees at the Fort Knox rehabilitation center during the war years with young women, who out of love and altruism sought to visit them. Under the then current methodology, my department inquired as to what was going on, in order to turn it towards therapeutic ends. But all we did was speculate on possible messianic motivation on the part of these young women. What we did notice was that the presumptive tie between the rehabilitees and the young women was of transcendent nature. What we mostly were able to determine was they were in despair over the future prospects of their putative union with these errant young man. Les Farber wrote on the therapeutic despair. When he felt at despair he found out that he needed to live through that despair, and he noted that living through this despair helped the therapeutic process. From that I inferred that a frontal inquiry into the subject of despair was necessary in the therapeutic process. The next troubled couples to appear now in my early practice consisted of two young authors, married, both in despair over their writers block. The wife, whose therapeutic course has been detailed in the iconic course number one, set out to save her despondent husband who eventually engaged me in therapy, abandoning his previous psychoanalyst and his bottle. He then experienced what I called the advent phenomena, manifested by the appearance of his father’s ghost. The third troubled couple consisted of a young physician who could not mourn his father and whose family assisted me in the therapy. Iconic case number three again was a troubled family, which went through an experience analogous to the previous two. Finally, I engaged in a decade’s long struggle with a troubled couple. They were highly sophisticated and lent themselves to the task of evocation of underlying concerns, present both in her dreams and fragmented utterances. She finally identified the core problem, a tie to the introject analogous to that of the other iconic cases. In my review I encountered the mass of work that I did with my pastoral colleagues in resolution of the problems of a number of troubled couples. In contrast to the taxing work with the iconic cases and their mates, my pastoral colleagues and I found ourselves able to disentangle the couples, who then proceeded with their marriages. On review I noticed the contrast between those two populations and attempted to identify what made the difference. What came to my mind was the prominence of messianism, in the form of Christ in the work with the pastoral couples. Another point of difference was

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the depth achieved by the iconic couples, who had transacted intrapsychically with the incorporated parental figure to whom they were tied by the love ties with survivors’ guilt. Their belied in Christ had rendered such inquiry unnecessary. In retrospect, analysis of that belief might have opened the members of the group to the depth of inquiry achieved by the iconic cases. COMMENTARY As I have noted, this seminar was a relatively unplanned occurrence at the instinct of younger colleagues who were curious about this aspect of my practice. As I tracked through the experience with them and its concomitant data I became clearer about its inherent theory and practice. It is of note that another group of young psychoanalysts induced me to hold another such seminar, in which I go over previous material, in more pointed fashion. It is called a Second Seminar on Work with Troubled Couples, to be found in the next chapter. First, however, we’ll switch from troubled couples to the next phase in my career: my involvement with the Washington Psychoanalytic Institute and the exploration of our role as practitioners in the current society. THE PSYCHOANALYST AND HIS SOCIETY By late 1969, I had added to my office-based activities, my consultant positions in the community, my membership on the faculty of the Washington Psychoanalytic Society and Institute, a project entitled “A Plenary Workshop” on the problems of the Washington Psychoanalytic Institute. Just prior to my departure from Washington for a sabbatical, the plenary workshop group that I had been leading moved to have a full workshop on the changes it had been hatching. I shared the podium with Dr. Edward Kushner. The following is the speech I gave. I appreciate the opportunity to present some of my views on the topic of the evening—nay, the concern of our day, a concern of such crucial importance, our very survival as a discipline calls for appropriate consideration and attention. It is the pressure of this concern that has been rocking and moving our Society the past several years. What concern am I talking about? For all its immediacy and moment, it is difficult at first to characterize. It is a sense of change in the air, in our patients, in our ways as analysts, in the ways of our society, in the ways of the American, in the ways of our national and local mental health movements, and in society in general. But, you will ask, why such concern now; hasn’t each stage in the development of psychoanalysis been attended by alarms, tremors, and panics, and hasn’t psychoanalysis come out with strengthened identity? In answer, I will say that this time, it is different. We are witness nowadays to great and valid

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Chapter 3 phenomena in the field of mental health, the formation of treatment communities in networks and centers, led by, with, and in spite of mental health personnel: Alcoholics Anonymous, Recovery, Inc., Parents without Partners, neighborhood intervention programs, and mental health center therapeutic communities of all complexions. It is feared by some that the Therapeutic State is imminent! Whether or not, what is not imminent, but is present, is a demand from these developments to psychoanalysis to participate or be left behind. The helping professions are gaining in competence, as are therapists and investigators in depth psychological aspects of behavior, and they are asking for positions as team members rather than as subordinates. Behavioral scientists are relying on psycho-analysis for interdisciplinary collaboration and are hailing its tenets in the psychoanalytic movement. There are currents and cross currents of parallel beneficial dynamics. Local psychoanalytic societies are, with increasing tempo, leading feudal societies in the direction of more collaborative, open, pluralistic entities, based on the democratic principles emergent in larger society. The psychoanalytic community, as a profession, needs to take extraordinary initiative. The apprehension expressed by Freud in 1909, that psychoanalysis would be adulterated and diluted in America, is a very real one. The locus of this initiative, in my opinion, needs to be a joint endeavor on the part of the local psychoanalytic society and the individual psychoanalyst. They need to work together in a concerted effort to conceptualize the nature of the changes confronting them as individuals and as a group, and engage in specific ventures, group and individual. But, you will ask, hasn’t this always been the locus? Haven’t the advances of psychoanalysis been made by the societies and individual psychoanalysts, working together and separately? Yes, but it may be fairly stated that the chief locus has been, for a complex of reasons, the central, hierarchically significant organization of individuals. Psychoanalysis has from the first addressed itself to society and its ills, chiefly from the standpoint of the individual. Society has responded, and both psychoanalysis and society have moved, despite periods of talking down to one another, misunderstandings and mistakes, into generally the same universe of discourse. Psychoanalysis and society are now in the position of almost ready co-workers, almost ready to work on the same level, having something to gain from one another. It is on the level of the local community that the most useful and appropriate transactions can occur, those concerning specific collaboration about specific situations and individuals. Psychoanalysis has something unique and essential to say to and about the individual, both the professional and the patient or client. And it is the individual who is both the foundation stone and the keystone of the social edifices we are remodeling and erecting. This extraordinary situation of ferment and change within and without our society has been the real mover behind the plenary group we have been holding for the past several years. It is our problem in giving up to the necessary changes in roles and positions that has caused the tumult. Working out the changes called for will entail extraordinary efforts at conceptualization and action projects involving the entire psychoanalytic society. It will take all hands to rethink our problems and decide what new tacks to take.

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What is proposed in this communication is that we recognize an emerging social fact that we, the psychoanalyst and his society are in a new, active partnership, answerable to one another. This is a different social entity, supplementing the entity, psychoanalyst-in-his-society. This new social psychological entity is conceptually an advance from that of the fellowship of Freud’s early circle, though similarly, of partnership in a new, hazardous, but promising venture, in that the group there was born through Freud, and at his instance, with no or limited autonomy of its staff. The co-autonomous, coresponsible format of the concept psychoanalyst-and-his-society, with mutually dependent roles and role expectations, is similar to the co-responsible entity of the new therapeutic community. In the latter the patient is a participating member in and with a hospital or clinic community which is answerable to him, and vice versa. This pertains also in citizens’ action groups in the mental health and community intervention programs where the resource person and the larger group have a co-responsible relationship. What is sacrificially envisioned for this co-responsible fraternity? The answer to this question is already under discussion. We have action-study programs in being in the representative areas noted at the beginning of this presentation, known to us all and through which we expect to change, and effect changes. The action study programs consist of: • Workgroup on orientation and relation to the community at large. • Workgroup on the postgraduate development of the psychoanalyst with view towards conceptualizing the theory and practice of psychoanalysis and nature of current developments and their pertinence to the essentials of psychoanalysis. • Workgroup on working out relations with the allied disciplines. • Workgroup in aiding members of the Society as individuals and groups on research and development projects • Plenary group which works on the nature of our Society as it manifests itself in the essentials of psychoanalysis with emphasis on its progressive frontiers. To my mind this development comports with what I envisioned in my presentation. A feature of its functioning in the interim was a spring workshop in which members and students, members and faculty presumptively presented creative developments in their psychoanalytic careers. The plenary group I addressed in giving this paper had assumed a mandate of transforming the society through the workgroups listed above (i through v). It is apparent to me that the challenges faced by these various subgroups are still to be met by the field of psychoanalysis.

To my understanding, the spring workshop continues to this day. In it the members do not envision and enact the various projects in changing the society and its relationship to the community at large but do so to foster creativity within the careers of its members. They present their work on hunches and initiatives in their grasp of theory and clinical work.

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It is of further note that the society has undergone a transformation from its former futile hierarchy, to the partnership mode, with the participation of the citizen members of the Washington community. It is now called the Washington Center for Psychoanalysis. Similar issues to those which rocked our local society are now doing so in the American Psychoanalytic Association with the Board of Professional Standards at the epicenter. One need not look far or deep into the American political and social scene for analogous conflict and renegotiation. Of equal importance to the role of psychoanalysis in society was the burgeoning phenomenon of conferences on our profession. What follows is a review of this valuable forum. A REVIEW ON THE DYNAMICS OF CONFERENCES PERTINENT TO PSYCHOANALYSIS Also late in my tenure in the Washington area, I emerged as a central figure in the negotiation on change of the psychoanalytic institute and society to a psychoanalytic center. It involved a basic change toward democracy, and one I had been urging on my fellow psychoanalysts. In light of the anticipated conferences that were to come in the transition from Institute to Center, I presented the following study paper to my fellow psychoanalysts. Conferences play a focal part in the life of workers in the field of psychoanalysis, perhaps as their distinctive way of life. Our psychoanalytic society was born in conference, and has been conferring since. This essay is a preliminary attempt at a simultaneously overall yet somewhat particulate view of the many forms of conferences extant, combining an exposition of their structure and function with hypotheses as to their underlying dynamics. Then, brief application of this material will be made. First, let us assemble the conferences in their diversity. Sorting will be from the largest and most complex to the smallest and apparently simplest. Convention Conference Forum Institute Round Table Colloquium Workshop Panel Discussion Seminar Laboratory Symposium Lecture, Classroom Let us start with the largest of the aggregations, the Convention. Its structure is known to us all. Paradoxically, its very complexity makes its function simple to discern. Its institutions within the larger entity results in specific, concrete representation of functions and tasks that conference forms, like the seminar, manifest only subtly. A committee on standards with published codes leaves very little unsaid on a point that a seminar has to continually bring to light and renegotiate. The professional convention by definition

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performs all of a number of tasks called for by the professional community, or it is not adequately representative. These tasks may be defined as: • Exchanges and consolidation of advances in body of scientific knowledge and skills. • Education of the professional and the community. • Working through of problems of status and position and their formal organizational representation in the profession. • Confirmation to the profession of its corporate self and image. The convention represents the body of the profession in a directly political way; its conveners are the elected officers who are ultimately responsible to their electorate for accomplishment of the tasks noted and fair representation of the range of its political spectrum. The representative principle is not manifested in overt political parties; because of the very nature of a profession, a more patriarchal, authoritarian structure is called for, combined with an egalitarian fellowship. Whatever the form of representation, both the conveners and the convention itself are responsible to the body politic of the profession, and through it, to one another. They are co-responsible. In only one other of the conferences listed, the workshop is this all-important coresponsibility, co-relational aspect as clearly defined. In the workshop, to anticipate this exposition, the product of the deliberations of the separate task-groups is presented to the plenary group, the workshop as a whole, for discussion and acceptance. The negotiations which follow often result in enactments which serve as living examples of the issues and problems under consideration. Choices are made on the basis of taking sides and identifications which lead to a renewed and strengthened sense of identity of the members. The professional feels a gain in his sense of self at the end of the convention, and of attainment, which may be confirmed by accolades for accomplishments, by a new position in the organization. Perhaps he gets a new job to boot. The convention takes two to four days to transact its business. There is a great sense of living together. The conventioneers attain agreement on tasks and underlying orientations in the profession based not only on conference transactions, but participation in meals, entertainment, and drinking. The ancient Greeks started the Symposium, or drinking party where intellectual discussion went on to the tune of music and clinking vessels. In other words, the conventioneer works out through formal and informal ways, a firmer sense of his professional identity through participation in multilevel and multi-ocular transactional systems which stimulate and guide the personal change and mobility appropriate to a professional career. The Institute, held usually for instructional purposes, is similar to the convention in that it takes several days, has a convener and steering group,

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and has a sense of participation of a formal and informal sort. As with the workshop, the task of the group usually lends itself to relatively clear delineation, and also pertains to specific professional codes. Institutes are often held at stages in the development of the profession where the cause of pioneering and progress elicits intense interest. The zeal of the participants may well be enhanced by a chance to be upwardly mobile in the profession, if not to displace older heads. As a result, the Institute usually develops a discrete identity and corporate self-image. It is then aware of its place and role in the history of the development of the profession, and elicits participation by members in tasks defined by the group, or group-relevant tasks. The members have the sense of “doing something” and “getting somewhere.” The group confers recognition to members for specific actions pertaining to its mission. The internal structure of the Institute is patterned for its task. It has a committee serving as a base of support for its endeavor, justifying its existence. It has a director and a faculty. These serve as administrators in a small institute; in larger ones, an administrative apparatus is worked out, which acts as a continuing agency for a series of institutes. The symposium can be considered, for this exposition, to lie halfway between the complex and simpler forms of conferences. Its internal organization reflects its chief function, formal and evocative presentation of a number of points on a subject. It has a moderator, a number of speakers, and an audience. The symposium may take the form of a forum, in which opposite sides discuss an important issue. The presentations are usually well prepared, and the moderator or discussant summarizes the material covered prior to participation by the audience. Here the moderator is usually responsible for and to the formal presentation, rather than to the body, who listens and later participates briefly. The Panel Discussion is again, a multi-speaker conference form guided by a moderator, and dealing with aspects of a particular subject or concern. It is usually less formal than a symposium, with ready give and take among the panelists, whose prepared presentation is aimed at setting forth topics sufficient to stimulate active discussion by the panelists, and later, the audience. The moderator plays an active role in guiding the interactions of the panelist subgroup, and later the audience, towards dealing comprehensively with the subject. Then it verges on other conference forms like the workshop and institute. The word Colloquium bespeaks its own definition. It evokes imagery of a collation of speakers, not writers, who are expected to wax eloquently, to speak deeply and loquaciously on their chosen subject. The number of locutors is necessarily limited, to enable them to speak together at any length, and the audience limited to auditors. As in all these conference forms, a moderator is necessary. That is, unless the locutors each take on the function of a moderator.

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Another variation is assumption of a rotating chairmanship. This mutual leadership is in contrast to the so-called leaderless group in which there is a tacit agreement to resist initiative in the group towards leadership-fellowship integrations, a condition necessary in group life. The anti-leadership bias in group work, manifested by leaderless groups, has its correlate in the psychotherapeutic movement in non-directive therapy, itself stemming from a misuse of the neutral screen aspect of the functioning of the psychoanalyst. The word Seminar is derived from the Greek seminar and Latin seminariu, the seed plot or nursery garden. The idea of nursing seedlings would seem to apply to beginning students, not to advanced ones for whom seminars are designed. However, fledgling students need to remain in seed until they are ready to engage in meetings of the mind with the teacher. So we put them in educational conference forums where they are protected from the exposure they would suffer in the seminar. This lends itself to relatively clear delineation, and also pertains to specific professional concerns. The Workshop is similar in many ways to the Institute. Its name indicates the chief difference: production; a report, or some tangible task, as dissemination of information or measurable gain in competency through brief but intensive training. To that end, the workshop is organized into task forces. The plenary session found in institutes becomes a group which commissions tasks for subgroups, which report back to it. A final report, usually by the director or surrogate, is derived from the reports of the subgroups and the discussion of the plenary group. The workshop tends to develop a sense of mission and identity, even stronger than does the institute, both because of the specific role participation and camaraderie that develops in the course of accomplishment of a tangible piece of work, and the somewhat missionary tasks undertaken by the workshop. The Conference is cousin to the workshop and institute. It, like them, is convened in the service of a larger professional body, and by a central group which steers the enterprise. In some instances, it is called a conferenceworkshop, or institute-conference. Or, it meets simply as a plenary group of moderate size, to confer, as the name indicates, with a minimum of inner organization, and with no report or evidence of responsibility to the conference body than the bread which was cast on the waters through the act of conferring itself. The student body in a Seminar, numbering no more than ten, exercises a certain amount of autonomy in the conduct of the course. This is something not present in the lecture, the last of the conference forms to be looked at. The word lecture is derived from the Latin lectura, a reading. The lecture would then consist of passing on what was written; discussion (derived from the Latin discutire to strike asunder, shake apart) is out, unless it is a lecturediscussion, where the two very different transactions are discrete and separate.

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The lecture group can be any size. The discussion group is a different animal indeed. Without appropriate leadership it shakes apart like the verb from which it was derived. Implicit in this presentation is the thesis that all of the groups mentioned in this rambling discourse have a similar inherent structure. Some show it more explicitly than others, in accordance with size and opportunity for autonomous development. To illustrate, suppose the group mentioned last, the lecture group, had a hundred members. Let us give it a task to discuss and render a report on its grasp and position or positions regarding the lecture. It would then have to form a plenary group, negotiate within itself politically, to the point of assumption of representative leadership by the members. The leadership would then, on the basis of its grasp of the problem and organizing talents, divide the group into task forces. In this exercise, the group would certainly demonstrate social (and personal) regression and the group (and personal) equivalent of transference (from the history of representative government), perhaps going back to Freud’s primal horde. In sum, understanding the nature of group formations is an exercise in ego psychology, political science, sociology, anthropology, etc., etc., let alone the genetic considerations broached by Freud in his Group Analysis of the Ego, of which the primal horde hypothesis was one. Whether or not there is such a thing as a group as a separate social entity (Zilboorg was vehement to the effect that the group is a collection of individuals, who made believe they were a group), we sense it to be so and act on it as a social fact. The core of this presentation has been delineation of the ways this social entity changes to meet different situations. It is the contention of this observer that discussion in a group (large or small) of mutual concerns can be coherent and productive, if the autonomous is respected and guided appropriately. Free discussion need not fall apart, contrary to the definition. Paradoxically, planning and appropriate guidance are the necessary ingredients for a free and successful discussion. In the foregoing, an attempt has been made to present enough facts and hypotheses about conferences to serve as guidelines for designing and operating a conference tailor-made to our needs. Indeed, it would seem that mature professionals would be able to change the form of conference at will to meet changed situations! Before further exposition, let us summarize important elements leading to a successful conference: • Respect for the autonomy of the conference as whole: The conference is a separate social entity, with a development of its own. It does not belong to the convener, or steering body, or vice versa. • The principle of co-responsibility: The body of the conference and its administrative structure are both responsible for its course and outcome. Between the two, issues and goals need to be negotiated and consensual-

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ized, as much and as little as appropriate. It is this mutual and self-steering functioning that is at the heart of most successful conferences. Covert and overt politics, prolonged ambiguity, bitter complaints, and restitutional maneuvers such as calls for a “strong” leader, indicate serious failures in the conception and design of the conference. On the other hand, a certain amount of political maneuvering is an important substratum of the life of the conference. • Appropriate Planning: Anything left undone or ambiguous in planning by the convening body and steering committee will have to be done by the conference group itself. To do so adequately, it would have to recapitulate previous developments in the convening and steering body. This would lead to cross politics. Workshops and institutes usually have a plenary session to set the stage for the enterprise. At this time, a contract, with mutually defined roles and expectations, is formed between the larger group and the leadership. As noted earlier, the group forms its separate entity. The members engage in initial identifications with the enterprise. This is done through complex processes of identification with the idea of the conference, the leadership, and one another. In fact, our society more than most has always been an ongoing workshop. Lately, it has been even more so. The aim of the individual subgroup is evolution of a good discussion of one subject at hand. Most of us go about this naturally, without giving it a thought. Let us take a closer look at the initial phase of this development, the most important. The first step is one of negotiation between the group and its leadership of their models for the sought-after entity, the good discussion group. The moderator thinks of what he wants it to be and do, and evokes from the group what it wants it to be and do, and guides the negotiation of the models. This may take an instant; or the group may become arrested at this point, even though it ostensibly proceeds with its scientific discussions for years. Successful negotiation of this phase lays the backbone for the collaborative discussions in which the underlying socio-political structure is split asunder. On the other hand, once the backbone is laid down properly, the discussion group continues to be relatively coherent and self-guiding. After several sessions of the subgroups at our workshop, they will be merged into a plenary group whose task may be characterized as spontaneous representation, in the larger group, of the findings of the smaller groups. The task of the moderator in this setting will be immense and challenging. However, here again, the continuing workshop nature of our Society will undoubtedly enable the moderator and co-responsible leadership in the large group itself to grasp the situation and guide the discussion into pertinent and representative

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channels. This communication has been set forth in such length, because in this case, attainment of coherent meaning called for sufficient exposition. It is hoped that it will enhance the workshop’s capacity for self-guidance. It is the earnest sentiment of this participant that out of such collaborative engagements will come a strengthened and freer sense of identity as psychoanalysts, appropriate to our changing times. A review of my career to this point would not be complete without mention of a subject of critical importance to the practice of psychiatry, psychoanalysis, and the helping professions in general. That subject is the concept of professional identity. So valuable is this concept, that a course on its development was given. What follows is a summary of that course. SUMMARY: A PILOT COURSE ON THE PROFESSIONAL IDENTITY OF THE MEDICAL STUDENT A course in the professional identity of the medical student rounded out my work on the subject of professional identity in the Washington area. I collated the pertinent material and subjected it to a synthesis during the sabbatical which was to come. This is a summary of that article. Dr. Haikaz Gregorian and I submitted it to the Journal of Medical Education, following our work at the George Washington University School of medicine 1965 to 1968. In its wisdom, the Journal refused to publish it. Somehow, Dr. Gregorian and I lost touch with each other on my move to California, and I failed to press further for publication. However, re-reading this piece in the course of a review of my career convinces me of the needed immediacy of its material. I recommend highly that the reader repair to the appendix in hopeful scrutiny of this piece. The task of training is inherent to every treatment program, as an ongoing feature. In my work at Fort Knox, I was trained in leading groups by observing its ongoing practitioner, Sgt. McCorkle, who was simultaneously under my supervision. Sgt. McCorkle and I conducted an ongoing training program for 4 to 6 enlisted personnel, to lead a variety of groups. This we did by having them attend our groups as observers, and then participation as students of the group process in that training group and as assimilated of didactic material and that derived from observation of other groups. In the course of that, their subjective experience emerged as a central feature leading to experience analogous to that they had observed in the therapeutic groups. Central there were states of self-alienation, perplexity, helplessness and their genetic antecedents and determinants. The role of ideals came to the fore. At my insistence, we came to the concept of messianism in the therapeutic process.

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When the hospital authorities at St. Elizabeth’s asked me to initiate a hospital-wide training program in group psychotherapy at the 6700-bed St. Elizabeth’s hospital, I counseled that we start with a training group that had a format similar to the one I described to them as having worked at Fort Knox. The chief of nurses, LaVonne Frey, asked to have one first tried in her nursing department. She aimed to have the nurses become full partners to the physicians, versus their handmaiden. Her assistant, Helen Barr and I met with a group of nurses, then at various stages in their careers, weekly for an hour and a half. The subject was their careers in nursing, their initial investment, what had happened in them, and where they wanted them to go. The members became passionate in reporting their experience and a wish to have their profession grow into a true one. This involved formulation and attainment of a nursing diagnosis, autonomous in nature. Nursing treatment stems from that. They would be members of the treatment team, exercising themselves in not only the traditional nursing posture function, but also in their theses of competency. With that, they had arrived at a more contemporaneous concept and practice of professional identity, having gone through ambiguity and growing pains in the group experience. After almost a year of such an exercise, LaVonne Frey estimated that her department was ready to join in a multidisciplinary training program. This encompassed the broad range of allied disciplines extant at St. Elizabeth’s hospital: psychiatry, psychology, nursing, social work, rehabilitation therapy, occupational therapy, psychodrama, dance therapy, educational therapy, and the denominations of pastoral care. To accommodate a multiple of each discipline, we decided that group be 34 in number, and it was led by LaVonne Frey and myself. As before in the stages of my experience in training therapists, the members naturally went into what brought them into that experience, what they felt they were doing there and what they wanted out of it. The dynamics of that encounter were remarkable similar to those in the previous training and treatment groups, with the evocation of both ideals and states of alienation. Both of those were subject to scrutiny by the members of the group and identification of analogous states. The pastoral members, with their messianism, took leading roles in advocacy and self-revelation. The group took on an identity of its own, enabling both Ms. Frey and myself to assume coordinate status. The members had been trained in the assumption of the role of both patients and professional in the process. Needless to say, the trainees received education in didactic materials and supervision of their work, on the way to graduation into full status as group therapists. The success of this program caught the attention of the faculty at George Washington University Medical School, leading to the project described in “A pilot course on the professional identity of the medical students.” A member, Dr. Haikaz Gregorian, was assigned. We consulted with

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the faculty of the medical school and arrived at a pilot project consisting of two quarters’ investment in the sophomore year on the part of eight volunteer students. Again, we were surprised at their readiness to inquire into their careers. They eventually arrived at formation and exemplification of states of alienation which they transcended through mythic, messianic role assumption. In presenting these data, we preceded with a review of the literature on the history of medical education and its evolution, the nature of a profession, the role of identity, and the special place of the mythic called apostolic in the history of medicine. Special attention was placed on the changing nature of medicine, from hierarchic to democratic, as well as on society in general. Of note was the enormous amount of technical data the student had to master in a short period of time, as well as that of an ever growing number of procedures. The reader is urged to assimilate this material as it is presented in the appendix, with special reference to what I estimate to be the core transaction between the professional and the patient, having to do with a concept of underlying need or state of alienation of the patient and the special mythic role of the professional.

Chapter Four

La Jolla 1971–1989 Midlife Career, Midlife Crisis

CALIFORNIA SABBATICAL By 1970 I had thought a great deal about planning for an interim period of at least a year to process extensive notes and to cogitate concerning theory and my future course. My discovery of the advent phenomenon was but the latest in a string of such theories that had begun at Fort Knox. There I had noted the period of silent communion that resulted in change in the rehabilitees from psychopathy to current reality. Following that came the clinical manifestation of mourning that momentous change. Those plans were aborted however, because of a conflict with my spouse that interfered with the financing of this interval. Fortuitously I was advised of the inception of a new psychoanalytic institute in San Diego and decided to initiate practice in Rancho Santa Fe, 24 miles from La Jolla. At least I would be given an opportunity by collaborating with my fellow faculty members in fathering this new institute and rethinking my theory of psychoanalysis, down to basics. Along with this I would reform and restructure my practice to conform to that of a standard psychoanalyst, seeing patients four to five times per week, and comparing the results with those that I had achieved in Washington. One of my mentors there, Ernest Hadley had claimed that he had applied the standard psychoanalytic method to schizophrenic, depressive, and obsessive patients. While I was able to adhere to the standard method with a select few of my patients, with most I had to develop my group approach to assist their faltering egos. Then I was able to utilize the standard method at the end of my work with these patients. A task of the sabbatical was to understand the 141

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relationship of that parameter to the nature of the disorder of the patient. I suspected that important there was the element of messianism, lowering the anxiety level of the patient. Furthermore in my previous historical studies I had become interested in the evolution of institutions within the body politic. Here Colonel Mela, Lloyd McCorkle, and I had an opportunity to evolve our own institution, in an authoritarian yet democratic setting. We learned that the fundamental changes of the rehabilitees from psychopathy toward reality called for participation in developing the rehabilitation center alongside us, in the context of an authoritarian army-culture. Fort Knox served as a model for me in work at St. Elizabeth’s Hospital at Howard Hall. The multidisciplinary group work training program which ensued promised to change this 6,700-bed hospital in a basic way. Concomitant to the work at St. Elizabeth’s, I engaged in self-change through psychoanalytic training. A basic goal in the training was equipping myself to further growing intra-psychic change in the patient through standard and allowed analytic practice, including dream analysis. My reputation for working with severe disorders resulted in referral of large numbers of difficult cases that I had learned to deal with previously through assemblage in working groups. Yet my basic aim with all of these cases was to finish the work in a traditional psychoanalytic way, if possible utilizing the couch. During the interim period between closing down my practice in Washington and initiating work in California, I set myself the task of formulating the theory and practice I had achieved in the past 25 years. I had been attempting to make sense of the conundrum posed to me by the dying Army prisoner who “had to” get himself shot. Why did he “have to?” Details on what was driving him became clearer to me in the stories of the patients in Howard Hall, the mother-daughter research group, my cases for graduation from the Psychoanalytic Institute, and now critical, borderline “impossible” patients in my practice. These last people could not live in the present, for what appeared to be mythic attachment to forebears. Severing those attachments would result in psychosis. Three were literally haunted, and on an intense emotional confrontation with the haunt, experienced transference from the past, then open grief. The groups I had developed in my practice enabled the individual to go through those harrowing analytic experiences. I recognized that I had attained the goals I had set on leaving the Army: validating the group approach and its attendant phenomena (intuitometer, messianism), training myself in the analytic method, penetration in my own analysis of the analysis of the state of specialness that was at the core of the resistance to the transference. At this point in my personal and professional development I began realizing aspects of my narcissism that had been obscure to me. An identity of special mission and personal qualities strangely

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similar to those of my patients and that of the self-sacrificing prisoner at Fort Knox came to the fore of my consciousness. I entered a period of internal crisis. I began dreaming productively, manifested first by a dream of death in a coffin, then a series of dreams exemplifying its genesis and outcome. I had been through two analyses with competent analysts, knew that they had not reached the depth I was doing with my patients, but despaired of finding one who could. But looking backwards, I erred in two regards, having to do with my concept of the nature of my practice. My schedule soon filled, but I failed to exclude the “impossible” cases sent to me. Then there was the matter of management of the considerable sum I had set aside to fund the sabbatical. I left it in the purview of my spouse who became alienated by the move. I deferred the sabbatical, until a retirement from practice, to occur several decades later. My practice evolved in the direction of that on the East Coast, utilizing group and family therapy, therapeutic community, multifamily therapy, also a professional identity group therapy within an academic setting. I utilized an established private therapeutic community called Hanbleceya, or Vision Quest, in the course of treatment of a deeply psychotic individual who came to me on an emergency basis. I was able to pursue from behind the couch, the leads towards the analysis of resistance to the analysis of the transference. I recognized the difference between the two, as central to the work with the severe disorders. The psychopaths in my early career resisted transacting with me on the simply human level that Sullivan had talked about. When they did so and left behind the psychopathic world, they became depressed, confused, and even transiently psychotic. They then were able to open up to me and themselves about that from the past which had impeded their development as persons. This appeared as the Freudian transference. I considered the differentiating of the resistance to the act of transference from the transference proper to be a major achievement and a guiding principle in my work to come. To translate, this psychoanalytic formulation into plain English, when the misguided psychopathic youth relinquished their “don’t give a damn” ideology, they then became available to look into their ties to the past as father’s bane and mother’s darling. The therapeutic process opened to view the carryover or transference from the past. The heterodoxy mode of practice ran afoul of the needs of the faculty of the new San Diego Psychoanalytic Institute for orthodoxy in the ranks of the sponsoring Los Angeles Institutes, resulting in restriction of my faculty status. It was analogous to that at the beginning of my psychoanalytic career. Instead of continuing on the faculty, I embarked on a career in local politics, utilizing my group skills in building grassroots clubs and councils. A publication, Democracy from the Grassroots: a Guide to Creative Politics re-

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sulted. Important in my work was establishment of training programs in the professional identity of the politician and political activist. I found that exercise to be essentially similar to the previous ones at St. Elizabeth’s and George Washington University. INFERENCES DRAWN TO DATE Each stage in this journey to date appears on reflection to be as momentous as the preceding. The common denominator would be venturesomeness. I appeared to have the courage and capacity of my forebears in venturing into this new land. In their story, regression played a part only in the case of my mother who, tied to her mother and unable to mourn loss of her, did not show the steadfastness of my father, who met each challenge head-on. However, it must be said that he did so in obdurate fashion, in which he denied his subjectivity. That denial showed itself dramatically in a lifelong alienation from his wife—my mother—for her tie to her dead mother and her shtetl culture. Whether or not the probability of his father’s suicide on coming to America is pertinent is a matter of conjecture. These matters of character and furtherance of ideals appeared to be central. In my five-year analysis with Edith Weigert, sparseness in her interpretation, somnolence, and a disassociation manifested by picking a sore spot in her left thumb attendant in an impasse that neither analyst nor analysand were capable of resolving. The impasse appeared to center about my practice of group therapy and Dr. Weigert’s adherence to current authority. Dr. Weigert later wrote an evocative volume titled The Courage to Love. In this volume, I infer that the courage, which Weigert failed to manifest in our analytic adventure, was resident in my character and kept me going in my analytic process to the point where I was able to separate a driven nature analogous to that of the prisoner who lay dying in my arms and the patient who finally separated himself from the rotting corpse of his father. This courage was derived from experience with my parents. As my practice in La Jolla grew, so did my reputation. And so, too, did my profession. What follows is a review of what was happening in the practice of psychoanalysis at the time. A GROWTH CRISIS IN PSYCHOANALYSIS In his Group Psychology and Analysis of the Ego, Freud depicted man’s emancipation from the domination of group life as the achievement of modern culture. It is becoming apparent that the issue is not emancipation from the group, but the attainment of the ongoing vision of autonomy, and the coexistence of man and his group. In that schema, the transference from the

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past can be expected to always be there. Likewise, we can expect regular regression into past cultural modes, and that we can learn to avoid pathologic regression, as in Germany and Yugoslavia. As elsewhere in society, old orders give way in science. The time for theoretical redefinitions and reworking has finally come in psychoanalysis. Because of change in its political climate, psychoanalysis has grown to permit relative autonomy in its theoreticians. They are assuming coordinate status with classical theorists, in intergenerational competition and cooperation. Moves are being made by psychoanalysts to accept status in the study of man coordinate with other scientists, each contributing from their vantage points. Once we accept this state of affairs as a social fact, of coordinate entities abjuring previous archaic autonomy and the hierarchy inherent thereto, we create the condition for change of the mythologic infrastructure of the relationships. Once such basic changes occur, we can “see” what has been going on in the past, the relationship of social organization to ideology. Under Kruschev, the nature of Stalin’s ideology and rule became apparent to the Russians who had previously become “used to it.” They could then see what the world had seen for decades; that Stalin had propelled Russia backwards into feudalism, in the name of utopian progress. In sum, the myths of Narcissus and Echo dramatically exemplify humanity’s psychic imprisonment, through ties in the ego ideal, in a transactional entity with previous generations. Like Oedipus, Narcissus had reason to fear self-knowledge. His fear stemmed from his inherent biologic and psychologic mythopoetic function, his experience of his own myth, his life story. This emerging fact brought him into conflict with his god system, the god-system of Mount Olympus, from Zeus to Prometheus. In fealty, he had to protect his gods from the death and loss of meaning stemming from his attainment, personal and social, of human autonomy. Of central moment to the crisis in psychoanalysis is a piece that I wrote during the sabbatical on the myth of Narcissus. THE MYTH OF NARCISSUS A centerpiece of my theorizing concerned a conception of narcissism that itself related to Narcissus and the vicissitudes of his career and that of his mate Echo. I derived this from the myth concerning the spring flowers which flourished in the rainy beginning of the year in the Middle East, dying out later. This endowment of Godlike qualities I averred marked a state of narcissism, to humans, followed by depression and then rebirth. This work was started decades ago as an exploration of the place that the analytic concept the ego ideal occupies in the narcissistic condition. It grew

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in size and scope. Early on, it became apparent that to communicate the ideas developed, only a comprehensive approach would suffice. At times, the project essayed into epistemology, the study of knowledge itself, and a range of scholarly disciplines, alongside the psychoanalytic. The delay in the presentation of the complex of ideas I evolved stems in good part from their novelty, but also from perplexity on how to go about it. I have decided to simply proceed, stating the ideas as they have matured, including their attendant experiences and reasoning. My interest in the element of idealism itself began a half century ago, in the unlikely arena of the correctional treatment of delinquents. I observed that, under their profession of amorality, these delinquents were mostly highly idealistic and compelled to offend society in accordance with a code of alienation. Correctional treatment in a program similar to Aichorn’s in which I participated during WWII, brought about an experience of loss in the rehabilitees, when they left the world of alienation. Patients in a treatment program I began later at the maximum security unit at St. Elizabeth’s Hospital went through a similar experience. They went through states of psychic decompensation, as they yielded their previous misanthropic and autistic certainties and entertained society’s ambiguities and values. Many reported feeling that they deserved punishment from their peers for betraying their code. I inferred that, far from caring only for themselves, these men, labeled in those days as psychopaths or sociopaths, were suffering from alienation from themselves. They individually and in concert maintained a facade of misanthropic values and narcissistic self-love. I learned in subsequent work in analytic practice, that the more severely disabled of my patient population suffered from difficulties of an analogous sort. These difficulties were based on an autistic brand of idealism coupled with difficulty with themselves, namely disaffection and alienation from self. On reflection, I came to understand that in the most successful therapeutic experiences with both, I had been transacting about their value systems and the roles they assumed in their espousal. Involved was a growing awareness of the importance of the analysis of the ego ideal, as differentiated from the super ego. Following the work with delinquents and psychotics, I came into research work in family therapy, of mother-daughter pairs, utilizing a group analytic approach. Close study of session protocols revealed changes of central importance in social positioning in the mother-daughter dyads, and in the treatment group itself. This led to awareness of the importance of the role concept in interpersonal and intrapsychic functioning, and further inquiry into the phenomenon of world and ego functioning. Also noted at this time were phenomena attendant on crises in the treatment, involving, as previously noted, a fall from internally and externally held positions. These phenomena heralded the crises, and the designation of

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advent phenomena seemed appropriate. Hamlet’s father was a presence from the past who was more than the figure of his father. He was the soul of unrequitement, a mythic figure. My patient in later practice who saw his father, in hallucinated form, in the back seat of his car on the way from his father’s funeral launched a Hamlet-like mission to reify and avenge an idealized mythic father. Analytic treatment enabled him to mourn, but first, ante lithium, I had to psychologically help him relinquish his manic mission, and the mythic position he was maintaining as his father’s emissary. It became evident to me that what had looked like a father transference, towards me and concerning his father, was really a defense against the act of transferring itself, a defense against the transference. To my mind, this comported with Freud’s thesis that narcissistic and schizoid individuals do not transfer. It seemed to me that they were fixed in mythic positions, from which they were able to reign over our therapeutic relationship, obviating my most cogent interpretation. Study of cases I have struggled with unsuccessfully in individual analytic relationship, and who were “brought to earth” in psychoanalytic group therapy revealed this with increasing clarity. The members of the treatment group were able to identify with one another in ways closed to me. One was in their profession of position and purpose, in which they were able to act as psychologic mirrors in the manner that occurs regularly in alcoholics anonymous groups. The unity thus obtained enabled them to relinquish their defensiveness, feel human, and receptive to reflection and communication from others. Further study of these group phenomena revealed the importance of the concept of transaction, at that time popularized by Berne. Transaction may be defined as a unity of interacting entities. In the formation of that unity, the autonomous analyst and patient yield an aspect of their autonomy to form a separate, unique psychologic entity. Both the analyst and severely disordered have difficulty marshalling the degree and kind of trust called for in that unity. Experience and observation led me to identify the chief component of that special trust, messianism. Further reflection led me to the observation that messianism is present in latent to overt form ubiquitously, as a derivative or precursor of religious affiliation. The prominence of the deity in Alcoholics Anonymous transactions became understandable. I found that messianic component in the trainees (and faculty) in my Group Work Training Program at St. Elizabeth’s Hospital, and also sophomore medical students at George Washington University School of Medicine. It explained why young professionals could form therapeutic alliances with confirmed schizophrenics when older ones failed. Through that component of my group analytic therapy, I was able to form a union in the ego ideal with extremely resistive patients that carried over into the individual analyst-analysand relationship. Most importantly, this special unity enabled the patients to trust sufficiently to yield their resistance

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to the act of transference. Paradoxically, this special group experience was the instrument of individuation, of relinquishment of defensive, narcissistic autonomy on the part of both patient and analyst. The transference which followed was a creative enactment. It became apparent to me that the necessary change in attitude and orientation could be best thought through in terms of role theory and the place of myth in the development of the ego ideal. I began a systematic study of myths for their capacity to reach into meaning in the earliest stages of psychic development. Deeper study led me to view myth as the organizing mode and product of the unconscious, and the ego ideal as a terra incognita in psychoanalysis. Psychoanalytic theory building is in great ferment, much of late centering on our study of narcissism. In our search for a basic design of human motivation, it is not by chance that the Myth of Narcissus has come to fore alongside that of Oedipus. This myth, more than any of the great array of myths and legends of the ancient peoples, exemplifies man’s difficulty, not only with how he loved himself, but how he looked at and ascertained reality. Narcissus appeared to love himself and only himself, but one may also hold that behind this self-love was a driven need to keep alive an ideal image of self and a view of the world that was derived from elsewhere, so that he was apprehending and enacting someone else’s reality. My thesis is that Narcissus was enacting for his day and station, what Cronus, of a prior generation of gods, enacted when he swallowed his children. Narcissus, in enacting the values of the previous generation of gods, was swallowed by (and was a prisoner of) their ideals and self-concepts. Cronus somehow knew that he, in accordance with the order of the day, was fated for castration at the hands of one of his children (Zeus). Cronus and his children could not coexist, a state of being mankind is now enacting here and there, for moments. Accordingly, Narcissus would be taken over by the ideals and ways of the past, the martial and self-glorifying ways of a primal father. Freud posited the myth of the Primal Father and Primal Horde as an early stage of the development of man. Only in the past few generations have we been outgrowing this patriarchal view of man and his destiny. The central point occurred early in the Twentieth Century with the death of god and of the glory concept of manhood, and its related social order. There, in a preview of the Holocaust, on the fields of Verdun, nearly a million young men were sacrificed, an end they’d joyously embraced at the inception of the war, in a mass exercise of strength and fervor, of narcissism. The thesis that Narcissus was a sacrifice to the gods gains credence when we consider the myth of Narcissus in the context of the trio of Greek myths about the death of ideal youths caught in the toils of their elders, and their resurrection as spring flowers. These were the golden narcissus, the purple lily hyacinth, and the crimson anemone. The anemone sprang from the blood

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of Adonis, over whom Aphrodite and Persephone fought. The hyacinth was derived from Hyacinthus, who was beloved and killed by his elder and lover, Apollo. While Hyacinthus seemed to have some choice in associating with Apollo, Narcissus was thoroughly and blindly compulsive in worshipping his parents’ ideals. Tiresias the Seer may be considered the social representative of his day of man’s capacity for insight and foresight, capacities barely nascent in Cronus’ apprehensiveness for his future at the hands of his children. Tiresias saw into Narcissus’ self-delusionary ways and informed him that he would die when he got to know himself. In those days, more than now, the birth of new knowledge was attended by the death of the old and its possessor. At this point, I wish to introduce an outline of a theoretic model perhaps comprehensive enough to account for the complex of phenomena encountered in the narcissistic condition. I wish to emphasize the necessity for a broad view of mythology, and the centrality of the mythopoetic function to the human personality. I wish to relate mythopoesis and theory building as obligatory human activities. Finally, I wish to indicate some implications of the Narcissus myth for psychoanalysis as a science among sciences, and some developments in the social and biological sciences pertinent to psychoanalysis. Reality was once what the king saw to be the true nature of the world; now it is a matter for all members of society to define. The theocratic king/ leader saw himself first as God Incarnate, the Primal Father, the Ideal; then, historically, he moved to be the minion of God; then, with Henry VIII and his struggle with the Pope, took the step to be a person in his own right, although still performing a divinely ordained function. Finally, in democratic society, the king graduated to president or prime minister, as a man of the people, with a special mandate from the whole. Freud’s Primal Father exhibited some qualities of a deity—a sense of absolute centrality, hegemony, and omnipotence. In Freud’s designation, the Primal Father was not answerable to God, as were later rulers. Reality for Narcissus, according to my concept, was defined by Zeus, the god of the previous generation. He was separated by several millennia from the Germanic Wandervogel Kinder or the American flower children, who worshipped gods of the past, but also paved the way for later generations by exemplifying the thesis that they were developing an internal godhead, for their generation. In contrast, again, our Narcissus would be a hapless victim of a past reality, cut off from and unable to face his present and future. What he looked for in the pool of waters was a threat to the ideas and ideals of the gods, a reality newly developed by himself and his peers, as foreseen by Tiresias. He was cut off from them, as well as from any initiative toward selfdetermination, which is one of the chief tasks of adolescence and early adult-

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hood. This self-determination was the public task, the republic of the emerging democracy of the eighteenth century, to bring about the emergence of the state of personhood, the right to selfhood, as exemplified in the American Bill of Rights. Inherent here is the right to the present moment in time, not pre-empted by a glorious or baneful past, or a Utopian or fated future. In my version of the myth, Narcissus, despite himself, saw the self Tiresias alluded to (“when you get to know yourself”) in the pool of waters. His inherited a self-concept that no longer pertained. He might have followed another course; instead of becoming depressed and eventually dying psychically; he might have joined likeminded youths, and with the help of Tiresias (as analyst), worked out a contemporaneous grasp of reality. Important in the Narcissus myth is his feminine counterpart, Echo. She could be conceived of as a tragic victim of a family dynamic of that time. She was reduced to an echo by Hera, Zeus’s wife, for warning Zeus (through her chattering) of Hera’s advent, during his amorous peregrinations. He was enacting his version of the ancient rite de signeur, with Echo’s former sister nymphs. Narcissus rejected Echo, his alter ego, both for the defect of echoing and as a consequence of his arrogant self-absorption. She pined away in a cave, finally ending in Hades as nothing more than an echo. Narcissus, himself but an echo of his father’s self-aggrandizing ways, eventually joined her to gaze eternally at the River Styx. Like Hamlet and Ophelia, they can be considered sacrifices to their parents’ ideals. Theory building may be viewed as an historical development which came into being as an autonomous social and personal function within the emerging democracy in Greece. We must remember that democracy then was for the chosen few, and scarcely altered the autocratic way of life of the top segments of society. Democracy in full flower would entail growth to a new, supra-ordinate level of social and personal self-conception and of integration; it would be a new form of living, of life. The individual in a democratic state would live at a higher level of autonomy, a different world; he would be thinking for himself. He would thereby be his own scientist, a man who would no longer have God and his representatives to enunciate past, present, and future myth and verity. The groups he formed would likewise seek their own entity, as exemplified by the struggle for existence of the British Parliament and the Russian Duma. In the autonomy entailed in this state of being, a person in the presence of the death of the old self-concept would be prey to the state Kirkegaard in the 19th Century characterized as that of fear and trembling. Courage and close alliance with other persons would be necessary to live in and to develop the emerging state of being and the new knowledge that goes with it. The individual and the group would first experience, as current myth, new ideas which appeared as a result of mythopoesis. They would then proceed to recognize these ideas as assumptions and render them testable. After due

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societal transactions, they would consensualize them as the theoretic reality of the day. After this exercise of establishment, a new cycle in the generations of thought would be aborning. In this cycle, though, it would be presumed that all of a population would experience the naturally occurring mythopoesis; only a segment would be free to manifest it. The resulting mythic product would be enunciated as assumptions, and slated to vie with the then current theory. Standing on the shoulders of the theoreticians, the ancient mythmakers, and the myth relayers (the troubadours from Freud’s Primal Horde), the emerging scientists, existing in a new world, would find themselves ever ready to regress into social enactments of the past. In each regression, these descendants of Narcissus would be enacting a form of scientific social transference, entailing guilt toward the figures and ideals of the past. This guilt may be considered a form of survivor’s guilt. Implicit in the thesis advanced here is that human personality and relationships would be changing in the successive generations of science. This changed self is different in its functioning, in its way of governing itself, in its set of ideals, in its very soul. Narcissus would see with his own eyes more in each generation, and would be more capable of being human. Metapsychology, an approach to theory building about that which is distinctively human, may be viewed as a necessary component of epistemology, the study of knowledge, since man, the student, is central to the endeavor. If psychoanalysis, the study of the essential aspects of our internal and relational life, did not have a metapsychology, we would have to invent one. It was conceived by Freud out of consciousness of man’s awareness and motivation. Attention was first restricted to the workings of man’s conation, his striving, formulated as instinctual drive, and the internal conflicts they engendered. Freud cited the instincts as “mythical entities … magnificent in their indefiniteness.” Earlier in his work, he attempted to build a model of the workings of the mind on solely physicalist principles; but laid it aside for his metapsychology, which evolved into a presentation of assumptions based primarily on psychology itself. The drive discharge aspects of Freud’s metapsychology may be considered a valid pre-stage in scientific endeavors, on the level of immediate experience, of the phenomenon of energy in the psyche. Latterday thinkers in psychoanalysis hold the drive discharge hypothesis to be an oversimplification, inasmuch as the human organism is also plainly seeking. We seek satisfaction of hungers and the fulfillment of inherent life goals, as well as the discharge of the pent-up libido and aggression occasioned in that seeking. Drives are expressed in the context of coupling with objects in a variety of transactions, only one of which involves energetic discharge.

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It is increasingly apparent that the phenomena encountered in the study of human motivation are of a nature and complexity that can best be dealt with on a level of theory significantly more complex than energetic definitions of chemical and physical equations. Theory, in its developmental pre-stage, is experienced as myth, and Freud, in his wealth of theories, held to the Oedipal myth as the central paradigm. When we hearken, internally and externally, to myths for the purpose of discerning meaning, we experience things and events in a context both human and meaningful; there is a cohesion of both the phenomenon and its story. The tensions and emotional mechanisms we experience in our lives were also exemplified in the life dilemma of a Cronus (who had to kill or be killed). Progressing to modern myth, we may unwittingly be enacting the roles of Cinderella, Joan of Arc, Horatio Alger, or Roy Whitman, the Texas tower killer. We experience a complex of myths, past, present, and future, operating within and outside of ourselves. In the world of myths, with their stories of death and rebirth, fixedness and transmutation, regression and progression, transcendence and fall, and in the march of generations, we catch glimpses of an arena pertaining to the structural core of human motivation, of creation itself, relatively untouched by scientific study. Study here calls for great sophistication and conjoint work with historians and political and social scientists. The biological and physical sciences are approaching levels of comprehension and methodology which promise meaningful collaboration, as they approach the complexity of myths. This comprehensive view of myth extends beyond the Oedipus complex; Oedipus was a late occurrence in the classic mythic generations. A story of similar configuration exists in the myth of Prometheus, a god progenitor of Oedipus. Like Oedipus, he also was left to die on a mountain, but later in his life; this event occurred in the course of a struggle with his father (or brother) and the rest of the god system, over the birth of man’s civilization, as exemplified by his act of transferring fire to man. In the Semitic version, Abraham in fealty took Isaac to the mountain to sacrifice him before God. God relented and called no more for human sacrifice; God had grown to the point that he could co-exist with man, though uneasily. The knowledge Oedipus gained in his long search for meaning in his life and identity related to the struggle for power within man’s family. Further, it was his lot, as decreed by the Fates, to do as the gods had done before him, living out the story of their lives, thus symbolically becoming one of them, while still human. The configuration here would be similar to the JudeoChristian eschatology, in preparation for joining the God of Hosts. Oedipus, like Narcissus, could not tolerate the liberating implications of the insight he obtained into the workings of the gods. Instead of suffering the guilt of abandoning his gods, he plucked out his eyes. Antigone, his daugh-

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ter, like Echo, could not live her own life; she lived for Oedipus, and died through burial at Creon’s hands. It is not generally known that the Oedipus myth ends on the note that, beyond being blinded (to dangerous insight), Oedipus lived to a happy old age. The core aspect of the self that Narcissus struggled with was his soul. This has been a province hitherto of the theological, philosophic, and artistic elements of society. Freud, according to Bettleheim, had the seele, or soul, as the centerpiece of his psychology, through choosing that word as the designation of the ego of the human being. His translators obviated that consideration for the while. Soul is a concept concerning an aspect of self-expression on a different, higher level, one we may term supra-ordinate. The experience of soul figures large in and out of classical myths and in the beginnings of psychology, but has fallen into disrepute as a subject for scientific study. Together with myth, it is an important consideration in this work. Beyond Oedipus lay Christ, who existed between God and man, and who was sacrificed for his Father. Joan of Arc was a latter-day godsend to the Dauphin, the French ruler, and also was an eventual sacrifice. Another sacrifice was the French soldier who, in fealty to God and his military fathers (prominent among whom was Napoleon), cried “revanche” on the way to the slaughterhouse of Verdun. It would seem that our political and social system calls for human sacrifice each step of the way. The old order and its myths die hard, prior to permitting man to call his soul and entity his own. THE PLACE OF DEATH IN THE LIFE OF MAN Just as in my early years I had to investigate the nature of a plume of steam as I lay beside the warm stove in a cold Hartford kitchen, so in mid-career I felt impelled to enquire into the presence of death in the histories of my iconic cases, also in my psychic life. In this essay I aim to search out the place of that death in the life of man. We are accustomed to search for death at the end of life, or from inter-current pathology or accident. Freud, in attempting to account for its prominence, elevated it to the level of an instinct, equal to Eros or life, impelling oblivion at the very inception of existence. He came to this view after observing the tremendous, joyful drive of nations toward mass slaughter in the beginning of battle in World War I. He needed some method of accounting for the seemingly innate self-destructiveness of man and his personal relations (e.g., the many forms of perversity). He postulated a drive within the substance of man, toward a wholly inanimate state. This animate drive within inanimate matter is epistemologically untenable, as in much of his use of metaphors to explain in his psychology,

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that which is essentially human and that which he termed meta-psychological. My hypothesis is that man at birth and in earliest life is an obligatory coparticipant in a two-person system whose vicissitudes affect him profoundly. In this dyad, he is biologically and spiritually more powerful; also inherently more sensitive to flux, and quicker to restitute saving himself. The fire of life is almost extinguished and its equilibrium is recovered rapidly. This earliest individual experience, I call psychic death. The mother and the newborn child in this system play symbiotic roles in maintaining their situation, and its survival. The child assumes a saving position. This savior position, entered into in earliest life and occasioned by psychic death, involves a quantum leap of transcendence into a mystical selfhood. The first coming is the original psychic death and the assumption of the messianic role; the second is the physical death and rebirth or resurrection. In the third coming, man relinquishes the mythic by suffering through the original psychic death. This situation pertains to the one posed by the apocalyptic thinkers: instead, this is the time of man’s coming into his own (not God’s) estate. This is not a traditional second coming but one which will undo the previous coming because civilization must graduate from the realm. The human necessity is to evolve through the individual life to go forward. In this coming, there is a tendency to regress to past forms (historical regression) through the various roles (e.g., myth as essential story in life) since roles in life are assumed in accordance with mythic scripts. There is a role complementarily: mother supports child and child supports mother. When mother fails, the child falls into a state of despair akin to death. The restitution to a state of positive affiliation results in re-establishment in a loving mutuality. Each time the individual’s equilibrium is disturbed throughout his lifetime, a multiplicity of times, he undergoes a psychic death. Each in restituting saves himself from extinction. The newborn child has within himself a tremendous sense of the life force capacity to revitalize himself. The mother learns to depend upon him in a subliminal and then more potent fashion, but the stronger attribute is in the child so there is a reversal of role in the child who becomes in effect his mother’s mother. This role reversal is reinforced by tradition in eastern and western cultures of the child-savior in which all humans look upon the newborn as their hope, salvation and decadency. This self-saving mechanism rescues the child and later the man (woman) he/she becomes. On a universal plane, man’s belief in his prospective immortality through saviorism has been breached by a theory of knowledge where he cannot accept saviorism; so he becomes responsible for himself and coincidentally for the first time fully faces what Kierkegaard called “fear and trembling; the sickness unto death.” In relinquishing belief, he is plunged into the original situation which he thought he had transcended for all time.

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Thus the individual psychic death can be seen to be inherent in all historical situations as, for example, in Nazism. Germany, in World Wars I and II, was attempting to assume her version of the missionary state role (it is hardly an accident that the national anthem is “Deutschland Über Alles”). She underwent a national identity crisis after the Treaty of Versailles vastly diminished her territorial holdings and caused her to admit defeat when she had to assume the place of one among many nations rather than the ascendant singular world power. Hitler, as a fanatical believer in Germany’s mission in the world, was alienated by his background of Prussian-like discipline, among other things. He assumed the dyad relationship with Germany which worshipped a man who was going to restore the momentum of Germany’s wished-for destiny. Thus Germany created the man and the reciprocity of his dependence. The fascist personality cannot tolerate defect because it means death and disability internally. So the concept of concentration camps as the “final solution” (death to the defect) eradicated that flaw from self. This manifested itself in the national psychic death. One can discern cycles involving regression toward psychic death on the way toward relinquishing the myths of the past that involve hierarchy, patriarchy, matriarchy, and transcendent gods which have locked man in perpetual guilt. Of course, what one sees depends on what one looks for. We need to clear our eyes from the myths of the past. I hope to establish man’s beachhead on his future and define his right to outgrow his past without guilt in order to “tell the dancer from the dance.” In this act of emergence of man from the thrall of the past the figure of death still looms large. It appeared toward the end of the analysis of my iconic cases in this volume, in my experience with death in my dream life, and of my family history in the form of the tie of my mother to her dead mother and the probable suicide of my grandfather. Analyses of my patients and self-analysis have vastly loosened that tie, the tie to one’s dead forebears, enabling creative evolution. At the same time one encountered the waning of narcissism of the subjects involved. In my search for a theory of the part that death plays in the life of man, I have posited the existence of psychic death, experienced as real by the subject. I have traced its appearance to the earliest developmental period, as inherent to human vicissitudes, intrauterine and beyond, attended by revival and resurrection. This matter of death and resurrection appeared to be integral to history of generational succession of gods and man. I have adduced role-theory to this formulation, in which mother and infant transact, dealing with each other’s deprivation in restitutive fashion. In addition, I have applied my theory of messianism as inherent and effective, to resurrective ends. In positing this complex of theories, I opposed them alongside the Freudian formulation of the death instinct, eros and thanatos.

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As I continued to build and hone my personal hypotheses and approaches to help patients, a new California institute arose which influenced me, and which in turn, benefitted from my influence on it. THE SAN DIEGO PSYCHOANALYTIC INSTITUTE AND SOCIETY This new institute was begun as a foundation, supported in its effort by the hitherto complete Psychoanalytic Institute in Los Angeles. To strengthen my grasp of developmental issues I signed up to teach a course on development. As in the Washington Institute, I talked of dream analysis. The fly in the ointment turned out to be the nature of the referrals I received from my colleagues, patients who were more severely disordered and caught in entangling situations, which called for the type of collaborative method I had pioneered in Washington. Much to my dismay I quickly developed a patient population similar in nature to the one on the East Coast. This caused my fellow faculty members anxiety over the issue of recognition of our new Institute by the reigning Institute on the East Coast. They feared to be declared as deviant, anathema in the American psychoanalytic scene, when they sought to be as orthodox as possible. As mentioned previously, I had had significant conflict with a mentor, Frieda Fromm-Reichman, concerning my group therapy endeavors at Howard Hall. While analyzing with my training analyst, Edith Weigert, she informed me of Frieda’s proscription against group treatment of schizophrenics. Frieda held that sessions needed to be individual and that group participation could do nothing but harm. She later recanted this dictum after visiting one of my groups in Washington D.C. Again I viewed the obdurate nature of the positions assumed in favor of orthodoxy to block any resolution of perceived conflict, and the enablement of integration of my methods into the psychoanalytic format. As in Washington, a schism within the ranks of institute members was resolved in a workshop I had initiated. The workshop method became a feature of the society’s programs in the future, one notably held on teaching psychoanalysis. The result here was loss of my faculty position and transfer of my initiative to application of my group method to local politics. This turned out to be fortuitous, resulting in time in a book on the subject. It also afforded me the opportunity to compare the dynamics of political governing groups with those in psychoanalysis, and expand my theoretic grasp. From 1972 to 1990 I led a residence group at the University of California at San Diego medical school, applying the method I had developed in the training program at St. Elizabeth’s, the Pastoral Counseling Institute, and the numerous consultancies in the Washington D.C. area. Since this experience was psychoanalytic in nature, it provided these young doctors with a boost to

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their psychoanalytic education, should they choose such. Several eventuated as officers in the San Diego Psychoanalytic Institute. The sabbatical itself was deferred to the termination of my long practice, and efforts of that nature were made throughout my tenure in California through the conception and writing of my ideas, theory, and practice. Greatly facilitative was the use of the new computer technology. What follows here are highlights of that practice. PRIVATE PRACTICE IN LA JOLLA This period of 20 years, beginning with my sabbatical, served as further formulation of the hypotheses I had developed in the previous 24 years. I had learned to combine group and individual psychoanalysis, finishing the patient’s course with a period on the couch. For a series of distinctive cases I concentrated on an approach with the standard procedure, engaging in parameters when necessary to further the process. At any one time, I had three to four individuals whom I saw 3–4 times per week, several troubled families, and several embroiled couples, all in analytic psychotherapy. THE ANDREWS FAMILY: A LITTLE CHILD SHALL LEAD THEM An illustrative troubled family was the Andrews Family. The first member of this family to present herself for treatment was a 46-year-old married woman who tearfully announced that she could not stand her husband and wanted to divorce him. This conviction was growing on her for about a decade. She felt that she was weak and indecisive and somehow feminine. The doctor contracted with her to inquire more deeply into her sentiments and life course. The next event in their relationship involved an urgent call from the husband to the doctor. His wife had repaired to the daughter’s playhouse in her nightgown situated on the front porch, was crying disconsolately, refusing to go about her wifely duties. The doctor visited the wife who was in her nightgown in that setting, and she readily agreed to marital counseling. It appeared that there were two teenage children, fourteen and seventeen, a boy and a girl, who had in effect separated themselves from the parental mess. Marital counseling soon resulted in an impasse, with the wife and husband adamant as to a future course for the family. I requested that the family with all its members meet in my office, before the situation deteriorated further and the wife required hospitalization. They complied, and the teenage children separated themselves physically from the other. There was a long silence which grew increasingly poignant with my perceived intuitometer. Suddenly, the youngest daughter cried out, “Mummy

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and Daddy, why don’t you love each other anymore?” Both parents broke into tears followed by the teenagers and the Doctor. In a strong voice, the husband announced that he would accept his wife’s request for a divorce, so that they could continue loving each other, though separated. The teenagers stated that was the only sensible thing to do, rushing over to the younger daughter and hugging her, all in tears. Following this crisis, the course of the couple was one of review of their relationship, with consensus on their discrepancies. Individual therapy of the mother continued for another year and a half, eventuating in the definition of her tie to her mother and resulting in a masculine identification. There was considerable work with the father of the family as he courted a younger woman and led to changes in the families through the divorce and then the pregnancy of his bride. A COMPLEX AND CREATIVE DRAMA ABOUT THE INTROJECT: ICONIC CASE NUMBER SIX A decade after starting practice in California, I engaged in work with a private residential facility, Hanbleceya. I had found it necessary, as in the case of the suicidal physician in Washington, to stabilize the situation of a disturbed young woman. She was in her early thirties and applied for therapy in the early 1980s. She and her husband had moved from the San Francisco area when her analyst there had terminated her treatment upon learning that she intended to kill him, so he would be available as a ghostly presence to treat her dead father. Her father was now actually dead for more than a year but she nursed an image of him secreted in a mountain hideaway which she visited by means of a helicopter, piloted by a mignon named Morris. In relating these data on initial interview, the patient came across the idea of the death of her father, whereupon she encountered tears on her part. This was evidently a shock to her and resulted in a regression in which she isolated herself, refusing food or any contact. Alarmed, her husband appealed for intervention and I hospitalized the patient at a local psychiatric hospital in the San Diego area. There the admitting interview was remarkable. The patient had covered herself with a blanket and remained mute for a long period. Harking back to my experience at St. Elizabeth with the mute black psychotic patients, I attended to the phenomenon via my intuitometer. The patient cleared her throat in a feral manner, just as the patient at St. Elizabeth’s had, who had announced that he was Christ. She stated that she knew that I was trying to help her and I experienced a strong sensation in my chest via my intuitometer in confirmation. She drew the blanket off her head, but would not look at me. I cited that her anorexia presented an emergency and that we would have to talk it

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through. I also cited that I was aware of her lethal intentions towards her psychiatrist and that I wanted to remain very much alive so that I could help her. Her husband, the patient, and I discussed the practical aspects of her hospitalization and she agreed to eat, however sparingly. There then ensued twice daily visits on my part with the patient. Her husband revealed that her brother and sister-in-law were alienated due to the threat to their existence. We instituted, at my insistence, family therapy to deal with that contingency and I recognized the need for a specialized therapeutic community. I fortunately found one that existed in Lemon Grove in California initiated by Dr. Moira Fitzpatrick, a recovered schizophrenic. It turned out that Moira had the capacity to discuss the patient’s delusions in a deeply empathetic fashion. The patient became a member of her therapeutic community, avidly joining in its life. An important ritual there was called The Procedure. Personnel, themselves recovered schizophrenics, would surround the patient attempting to make eye contact with her. At a certain point in the encounter, they raised her body high, held her momentarily there where she began sobbing, and then lowered her to Dr. Fitzpatrick’s breast. The patient’s face flushed at this point, and she moved her mouth as though sucking. She then slept and upon awakening was able to look Moira and others in the eye. Dr. Fitzpatrick would engage with the members of the group in arguing through their illusions and did so with Francis. Eventually, the patient accepted her father as dead and collaborated in a burial ceremony. Eventually, the patient was able to come to my office in La Jolla, and to proceed with analytic transactions, prominent there being her many dreams. She engaged in rehabilitative activity such as book repair. As an outpatient, she participated in therapeutic community, a prominent feature of which was multiple family therapy. She appeared to profit from the progressive/regressive process. She was able to access, heretofore, her previously inaccessible conscious mind. This sixth iconic succeeded in furthering my early-formed hypothesis that alienation is at the root of hers and other human psychic disorders. The next section will re-visit my study of dreams and their significance in the treatment and recovery process. DREAM ANALYSIS In this inquiry I consider that I was following in the footsteps of Freud and the audacious adventure of his dream book. Looking back I can remember the excitement on reading it as a teenager and the impetus I experienced towards analyzing the dreams of my relatives. I did not know how to evoke their associations to the manifest dream, and resorted directly to what could be called dream divination. Again, looking backwards this could be a mani-

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festation of my messianism which by definition is a mission from the deity. Along with the dream divination I found myself competent experiencing insights into the matter of the souls of these relatives and where they had been in their lives all the way down to geographic locations. Along with this capacity, I experienced a deep discomfort within my head and its functioning, amounting to a feeling that I was going crazy. I determined to quit the practice in favor of science. Inquiry into the dreams of my patients and myself has played a central role in my professional identity and its course, along with their focal meaning in my research endeavors. Mastery there was central to my confidence in myself as a teacher of psychoanalysis at the Washington and San Diego Institutes. I taught courses in basic and advanced dream analysis. However, I did not have the confidence to publish my findings, which are scattered throughout this volume. That lack of confidence played a part in my abstention from fighting through my removal from faculty status at the San Diego Institute. By the time I had become acquainted with the literature on dream analysis and working with my patient’s dreams for almost three decades, plus presented papers on dreaming and psychosis, I felt competent to tackle the issue of a full-scale paper on dreaming per se. My entering query related to the manifest dream in psychoanalysis, and the immediate impetus stemmed from the paper by Erik Erickson on the “Dream Specimen in Psychoanalysis.” On rereading the following paper I am struck by its compactness and my use of psychoanalytic terminology to the extreme. However I offer it in mostly its original form to illustrate my attainment by this time of psychoanalytic theory and practice. The centrality of dream analysis with my patients evoked my interest in further mastery of the subject. I sought to master the literature and to bring out the dream material of all my patients. Ernest Hadley, a psychoanalytic mentor, had instructed us on the relative safety of that procedure with the severe disorders, when engaged in a proper relationship with the therapist, including the attainment of a degree of trust. I began a dream journal of my own, collecting in time over 400 dreams. I took process notes on each case, and also of the events which transpired within the groups, and placed the dream in a prominent position on the page, along with its associations. I wish at this point to interrupt my story with a hopefully cogent exposition on the importance of dreams in analysis. It is a moment at which the reader is made aware of the psychoanalytic language to come, through which the founding fathers attempted to make scientific sense of this shadowy yet brightly meaningful world beneath, in reality. This material serves as a nexus for a course in dream analysis at both the Washington and San Diego Psychoanalytic Institutes. I advise the reader to repair to the glossary at the end of this volume for meanings and translations.

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The importance and even special significance of dreams to psychoanalytic practice has been accepted since Freud published The Interpretation of Dreams in 1900. Understanding the dream process itself is a difficult task. Freud’s magnificent work has served as the cornerstone of our hypotheses. As the theoretical foundations of psychoanalysis grew, new and important concepts were added. Perhaps the most significant of these is structural theory, the ego psychological approach. This paper will present a look at dreaming from an ego psychological viewpoint, then that of the still emergent selfpsychology, then the communication theory of Rosenblatt and Thickstun, and finally theory that I have evolved. I will attempt to do this by focusing on the manifest dream. Manifest content (or the dream experience as related by the individual) may be approached from two standpoints. The first of these is the standard approach of using the associations of the dreamer to assign meaning or latent content. The second and less frequently utilized approach is an attempt to look at the manifest dream itself without the use of these created associations. Ascertaining meaning or latent content directly from the manifest dream does not imply belief in the verbatim message of dreams. Inferences are made about the dreamer by the style of presentation of the dream. These two methods of approaching manifest content are mutually compatible and synergistic. As ego psychological theorizing became more sophisticated, important papers on cognition have been published. One of the most significant of these was Pinchas Noy’s redefinition of primary and secondary processes. Noy considered secondary process as that aspect of cognition that utilizes reality orienting feedback, and primary process as operating without feedback. He did not regard these processes as operating in hierarchical fashion, but postulated that they subserve different functions. I will attempt to look at manifest content utilizing this approach. The presentational (or ego) model can view displacement and condensation—the dream work—as routine manifestations of primary process cognition and not only defensive in purpose. With this new perspective, we can add to our analytic repertoire. The goal is still the understanding of latent meaning. Widening the scope of our investigation of the manifest content can potentially enhance our understanding of the meaning of a dream. Since the publication of The Interpretation of Dreams, by Freud’s teachings and example, psychoanalysis has utilized the investigation of the “hidden meaning,” i.e., latent content of dreams as prime “objective” data of our clinical explorations. The special significance of psychoanalysis to dreams as the “royal road to the Unconscious” has been extensively discussed. Dreams were considered primarily expressions of the Unconscious and later, the id, which revealed upon close scrutiny, the fantasied fulfillment of a hypothesized wish, whether or not the dream, as it was recalled by the awakened

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dreamer, appeared to do so. The type of cognitive process involved in dreaming was called the primary process. This process has been defined by the mobility of presumed energic cathexis, by its primitive, irrational type of wish-fulfilling thought, dominated by emotion and close to the instinctual drives. It is characterized by condensation, displacement, and extensive use of symbols. From the first, I considered subjective manifestations of energy to be just that, and not a drive to be discharged but to be a vector in striving, towards attainment. That striving, or connation, would have ideational components which could be researched further through the associative process. Looking backwards, I was setting myself on a course of development of my own dream theory, which turned out to be pursued by other psychoanalysts. Again, the dream image and/or narrative recalled upon awakening were called the manifest dream. In the analytic literature, as well as in the clinical practice of psychoanalysis, the manifest dream has been ignored or treated as a stepchild at best, in comparison to the emphasis on the latent content ascertained by associations to the components of the dream narrative. The Interpretation of Dreams reflected Freud’s then current hypothesis regarding the causal elements of a conflict situation, and consequently, his theory (and technique). Making the Unconscious conscious was the cornerstone of his theory, and the technique used to do this was associative—the so called “free association”—which had recently replaced the hypnotic-abreactive model. The manifest dream picture was therefore, in Freud’s terms, the “facade” or “cheap material” which was produced by defensive distortion in an attempt to prevent the dreamer from confronting unconscious instinctive material. That the dream picture in and of itself, if appropriately investigated, might provide useful analytic information that could add to the undeniably significant data obtained via the associational method was not seriously considered; in fact, it was considered non-analytic. Significant theorists, for the past quarter century, have begun to question and refine these ideas from an ego psychological standpoint. Erikson initiated the reevaluation of the manifest dream in his “Irma” paper, while Rapaport, Holt, Noy and others started to reexamine primary process cognition. Rapaport reported that primary process was culturally influenced. Holt observed that primary process contained “structure,” and was capable of maturation, something impossible by old definitions, and dropped energic definitions entirely. Noy has gone much farther and redefined primary process from a “systems” standpoint, wherein primary process is distinguished from secondary process by the absence of reality-oriented feedback. He described the primary process in ego-adaptive terms as being related to “affective selfregulation.” If we take these ideas to be worthwhile and important contributions, as I feel we must, then there are some interesting questions that may arise in connection with our conceptualization of the dream in process. Is there an-

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other way to view what dreams are all about? Is it possible that manifest dreams are not merely “cheap material” created by defensive distortion via the dream censor, but can be themselves significant analytic information? Obviously, by the thrust of my comments I think the answers are in the affirmative. This of course, should not be misunderstood as an attempt to supplant, bypass, or diminish the importance of the classical method of dealing with latent dream material. I approach the matter in the spirit of Freud’s hopeful statement, “When we have established all the improvements in technique to which deeper experience must lead us, then our medical practice will reach a degree of precision and certainty which is not to be had in all medical specialties.” In the early chapters of The Interpretation of Dreams, Freud evidenced his vast knowledge of previously published dream literature. Interestingly enough, Freud said little of Biblical references to dreams, and nothing at all of Talmudic references, despite speculation in the analytic literature about Freud’s identification with Jacob’s favored son Joseph, the great dream interpreter of the Old Testament. Dreams in the Bible were taken as direct communication from God, and were most often prophetic. The dreams of Jacob’s ladder and Joseph’s “dream of the sheaves” bowing down to his sheaf were prophetic, wish-fulfillment dreams interpreted simply and directly from manifest content. Joseph’s interpretation of the Pharaoh’s dream was more sophisticated. Symbolism was used more extensively although, as was always the case, no associations from the dreamer were utilized. Solomon received wisdom from God in dreams. Jacob railed against God’s persecution of him in dreams. The practice of prophesying with manifest dream interpretation became so widespread that “false prophets” made their reputation by this method, until Jeremiah felt the need to preach against them as heretics—a practice that Freud and other psychoanalysts would continue. The New Testament continued the practice and would continue in searching out the heretic. The most prominent example of this was Joseph’s dream of the birth of Jesus. Lorand (1957) writes, if the dreams of the Talmud were so compiled, its 217 references to dreams would make its own “dream book.” Not only were there numerous references, but they were surprisingly sophisticated. Although no associations of the dreamer were utilized (only those of the interpreter), there was an appreciation of both external and internal (i.e., psychological) causes of the dream. That things in dreams may represent the opposite was frequently discussed. There was a consideration of multiple determinants that influence the appearance of things, people, and words in a dream. Great emphasis was placed on the importance of sexual drives in dream formation. A closer look reveals use of concepts foreshadowing those of superego and ego ideal as well as the consideration of ego and character structure in the manifest content—considerations at which Freud might well

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have taken a closer look. Incidentally, assumption of universal symbols is prominent, the door of a house representing a woman, birds being sexual (i.e., the pigeon is female and the dove male). Again, the one obvious difference between Talmudic and Freudian approaches is that the meaning that is attributed to these dreams was not extracted from the associations of the dreamer. Still, the degree of sophistication of interpretation leads one to suspect that somewhere in the isolated manifest content there was information that was processed in some as yet undefined manner to allow the interpreter to draw conclusions surprisingly similar to sophisticated analytic interpretation. FREUD’S DREAMING AND HIS PROFESSIONAL DEVELOPMENT As Jones reports, Freud came to his scientific interest in dreams from a long history of involvement with his own dreams. He thought about them and wrote them down as early as his adolescence. Frequently, he wrote Martha of his dreams, always alluding to some meaning he was attempting to derive from them. It is no wonder then, that he would turn to what proved to be the key to his self-analysis, his own dreams. There were, of course, additional factors emanating from his professional experiences which contributed to his approach to his dreams. Most significant was the treatment of Emmy Von N (reported in 1889), in which the associative technique replaced the hypnoticabreactive technique previously utilized. In Emmy’s associations, she included associations to her dreams. To restate, by the time of his writing The Interpretation of Dreams, Freud had already distinguished “primary” and “secondary” processes. To the primary process, he had attributed an essentially “id” character. It was “egoistic,” wish-fulfilling, and drive-oriented. In non-psychotic individuals, this type of thinking was seen to occur in the unconscious. Moreover, not entirely as a result of, but influenced by, his experiences with Charcot, Freud clearly felt that making the unconscious conscious was the key maneuver in analytic treatment and understanding. What then could be more appropriate for the study and treatment of neurosis than dreams, which provide such ready access to the unconscious? In order to do this, one must first dispense with the manifest content, which Freud refers to as the “facade” or “cheap material” of the dream and which again gets directly to the heart of the matter, the latent dream. The latent dream is in Freud’s words, “What the dreamer actually dreams.” To derive meaning by attempting to devise methods to glean information from the dream image was not considered, except for use of universal symbols. The vast array of scientific and philosophic speculations on dreams that Freud felt obligated, for purposes of scientific completeness, to include in

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The Interpretation of Dreams were, I feel, passed over too quickly by Freud and by subsequent readers of these chapters. Freud’s disdain for the contributions of most of these authors is apparent. (Schemer, the philosopher, is a notable exception.) Yet, upon closer inspection, various elements of these writers’ theories seem at least worth considering. In Chapter I, part D of The Interpretation of Dreams, several factors are suggested by Strumpell and Benini to explain why dreams are forgotten. The analytic hypothesis on the mechanism of operation of repression (not the concept of repression itself), are to a great extent, based on a concept of memory composed of traces of veridical impressions. If, for the sake of argument, we can agree that current scientific literature indicates that this is essentially not true, then the suggestions laid down as to why dreams are forgotten must be given more attention. The first suggestion is that dreams may be forgotten because the perception was too weak or the attachment to the memory was too slight. Motive may certainly be an influence in recall. A second suggestion was that dreams are easily forgotten because they contain isolated perceptions, not “properly arranged” and placed in relevant order. It is a well-known psychological truth that one does, in fact, better recall sentences or groups of words that are in logical sequence than are groups or nonsense syllables or even words that do not readily connect. The point is essentially that forgetting may not always be due to repression. Defense may not be the sole motive for what is either forgotten or for the configuration of what is recalled, i.e., the manifest dream. In Chapter I, part E, Strumpell and Delhoeuf seemed to have come remarkably close to anticipating Noy and his redefinition of the primary process, in their descriptions of the cognitive processes they observed operating in dreams. Strumpell (1877) states that dreams are “true and real mental experiences of the same kind that occur in the waking state.” He speaks of spatial configuration in dreams. Errors in perception in dreams arise from an inability to subject the perception to external reality. Delboeuf regards detachment from the external world as the factor most markedly determining features of dream life. However, one is left with the impression from Freud’s comments that Strumpell’s major contribution was limited to his comparison of dreaming to the ten fingers of man “who knows nothing of music wandering over the keys of a piano.” The dream, as a wish fulfillment, is said to function as a discharge for unconscious excitation via a lowering of repression. The manifest content is fashioned from latent dream thoughts via condensation, displacement, and symbolization, and functions to keep the dream thoughts disguised. Secondary revision is an apostulated mechanism which makes a smooth, integrated, totality of percept—or at least tries to do so! Secondary revision is a mechanism which was rather unclear in Freud’s writings. His references to secondary revision show contradictions. In The

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Interpretation of Dreams (1900, p. 499), Freud states that this process is part of dream-work and takes place during formation of the dream. At another time in The Interpretation of Dreams (1900, p. 313; 1923, p. 241; and New Introductory Lectures, p. 21), he states that secondary revision occurs after dream-work has been completed. At another time (1914, p. 52), he states that this takes place after waking. So there are three separate and quite possibly contradictory statements as to the time when secondary revision is thought to occur. There is additional possible contradiction in terms of the functioning and nature of secondary revision. Freud states at one time that it is a “somewhat arbitrary reunion of the dream content by the conscious agency of our mental life.” At another point Freud states that it is not exactly arbitrary and haphazard but analogous to a physical force. At other times Freud lists the various functions of secondary revision as changing the dream into a daydream, ordering and selecting material, and reducing anxiety by interpreting the dream in a certain fashion. Once again, Freud states that his theory of dreams is not based on a consideration of the manifest content, i.e., without association, but the thoughts shown by interpretation to be behind the dream. “As compared to the processes we have come to know in it (dream work), interest in the manifest content must pale in significance.” The one exception that he allows is that of children’s dreams which may be simple and undisguised wish fulfillments, where manifest and latent content are the same. The manifest content is related to preconscious thoughts and current events. The day residue is portrayed as the “entrepreneur” of the dream and the manifest content as the “façade.” The latent dream thoughts derive from unconscious sources and infantile wishes and experiences, and are the “capitalist” in dream formation. This indicates bias toward latent content, is understood in topographic terms, and predates ego psychology. The investigation of the manifest content of the dream was relegated to relative unimportance, and at times was seen as dangerously undermining what Freud and early psychoanalysts were so concerned with—the unmasking of the unconscious. What is somewhat surprising is that as Freud’s theoretical concepts developed over the years, with old concepts revised and replaced, his theory of dreams and their analytic utility underwent remarkably little alteration. The only major change was to introduce the superego as the censor. Structural theory, with concepts of character formation and defenses, were not explicitly applied to the manifest dream. In more recent times, although object relations theory, systems theory, etc. have been applied to other areas of psychoanalysis, they too, play too little a role in the consideration of the manifest dream content in the day-to-day work of clinical psychoanalysts. Why this status in dream theory has existed can only be a subject for speculation. It is possible that Freud’s discovery of the meaning of dreams,

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which may have been synonymous for him with the uncovering of his own Unconscious, was so personally significant that he would not tamper with it. Moreover, standard psychoanalysis has equated interest in manifest content with being anti-analytic. Dissenters, such as Jung (who stated, “To me, dreams are a part of nature, which harbors no intention to deceive, but expresses something as best it can”), and Adler (with his interest in the “life style” of the dreamer), began to utilize interpretation of the manifest content as meaningful and important for its own sake, not as Freud termed it, “some cheap material.” Unfortunately, they did so while denying the instinctual drive motivations which contribute so importantly to dreaming. These political-ideological splits have made the use of manifest content to assign meaning tantamount to being anti-analytic, and even to this day such suspicion persists. ERIKSON AND THE MANIFEST DREAM The first major breakthrough in the analytic attitude toward manifest dream content occurred in 1954 (more than 50 years after the publication of The Interpretation of Dreams), with Erikson’s “The Dream Specimen of Psychoanalysis.” In this landmark paper, he surveys the dimensions of the manifest dream, giving as he states, “new depth to the surface.” He clearly points out the continuum from the “crust to the core.” He asserts, however, that standard psychoanalysis bypasses the problem of the manifest dream to go directly to the latent dream thoughts, and in so doing, “hinders a full meeting of ego psychology and dream life.” To ignore manifest content is to induce the analyst to premature closure with the conviction that he has understood a dream. Erikson then emphasizes the uses of the manifest dream to understand the dreamer in terms of ego identity and life plan, mechanism of defense and mechanism of integration. He looks at the manifest configuration relating to interpersonal, objective, spatial, and temporal configurations. Although widely read, taught and respected, in my opinion this paper seems to have had little effect in altering the clinical approach to the dream in analytic practice. Perhaps Erikson’s exposition utilized detailed research into one dream of an individual, about which he had more retrospective information than we can possibly have at our fingertips during an ongoing analysis. Use of a series of dreams consecutively or throughout an analysis makes this work more clinically feasible and reliable. In 1950, Blitszten, Eissler, and Eissler discussed the role of the ego and character structure as portrayed by modes of association to the manifest dream. They felt that attention to this aspect of associating can help spot and identify defects in ego structure that can be valuable to the analyst in his ongoing assessment of the clinical material.

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Dorothy Eggan (1952, in The American Anthropologist), in a well-constructed and widely quoted study of the Hopi Indians, discussed the role of the manifest dream as a personal arrangement of effectual events which is limited by the dreamer’s perception of the Universe. The forms and processes underlying dream and reality experiences (and verbalizations regarding them) are shaped and defined by the cultural perception of them. Other studies (Dement and Wolpert, 1955; Kramer, 1964; Offenkrantz and Rechtschaffein, 1965), have indicated a connection from dream to dream (manifest content) in one night, including continuity of plot, character and affect. This is an observation commonly known to all analysts. DREAMS AND DIAGNOSTIC ENTITIES, OR NOSOLOGY Leon Saul was in the forefront of analysts studying manifest dreams. One example of his efforts is an article by Saul and Sheppard, in 1956, who conducted a controlled study of the manifest content of the dreams of hypertensives and non-hypertensives. They were able to distinguish clearly between the two. Saul suggested that differences among hysterics, compulsives, and psychosomatic disorders lie in the quantitative factors involving id, ego, and superego forces, and that dreams of borderlines and psychotics may well be distinguishable with more accurate observation of these factors in the manifest dream. Richardson and Moore (1963) studied manifest dream content of schizophrenic and non-schizophrenic patients in another controlled study. They could not verify that the manifest content of schizophrenics contained more undisguised sexual and aggressive material. They did, however, conclude that in contrast to the dreams of non-schizophrenics, the manifest dreams of schizophrenics convey a sense of bizarreness, strangeness, and incomprehensibility. The theoretical discussion that followed their conclusion utilized drive and energy to discuss possible failure of secondary revision, but they really did not approach their observation from an ego psychological standpoint. Various other studies of manifest content (such as Calvin Hall’s in the Journal of Abnormal Psychology)—again without the benefit of association—were able to distinguish between males and females. One study of adolescents (Buckley, 1971) indicated that girls had a significantly higher aggressive content in their dreams. Studies of homosexuals (Wingett and Fanell, 1971) indicated that their manifest content is often heterosexual. A study of transsexuals (Krippner, 1971) indicated a much greater identity with that of the female than that of homosexuals—a most interesting clinical observation with theoretical implications. Dreams of the aged often reveal

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concern for lost resources (Altschuler, 1963). From Altman’s book on dreams we can extract these observations on manifest dream formation: 1. They reflect contributions from id, ego, and superego—an outcome of conflicts in the psychic apparatus via compromise formation; 2. The modes of presentation, association, and/or avoidance reveal a characteristic style; 3. Adaptive and creative elements of ego contribute to dream formation; 4. Dreams often herald a growing capacity for recognition of reality, containment of impulse, and formation of new identifications. Their recognition may create insight into impending change of function brought about through modification of unconscious forces before one sees changes in the clinical picture. As the ego grows, powers of synthesis, perception, integration and control (e.g., as superego goes from a more primitive to a more idealistic level) also grow. THE ADAPTIVE FUNCTION OF THE DREAM: THE KRIS STUDY GROUP AND GIOVACCHINI From the Kris study group on the manifest dream, we obtain the following observations and proposals: 1. A series of manifest dreams may be used to reconstruct a traumatic episode; 2. The relationship between preconscious dream thoughts and unconscious dream thoughts contribute in independent, but inter-related fashion to manifest content; 3. Formation of the manifest dream may not always be the result of defensive dream work, but may, on some occasions, be explained as attempts at mastery by the adaptive ego. (This would, of course, explain the bizarre quality of the borderline dream, i.e., the deficiency of adaptive ego); 4. As defenses become analyzed, wishes and feelings become more successful in achieving direct expression in manifest content; 5. Dreams may be viewed as regression in the service of the analysis; 6. The style of the manifest content may be ascribed to the synthetic function of the ego; 7. It is possible that the same forces which create masturbation fantasies contribute in some form to dream formation, involving “A retreat from pressures to integrate and resynthesize with a resultant relief of tension.”

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Giovacchini, in his study of dreams, focused on the ego’s operation in the creative process as reflected in the manifest dream. He discussed two dreams of the same individual. One dream occurred during a time where the patient was in a conflicted state of inhibited creativity, and the other occurred during a period where the patient was able to create in effortless fashion. The dreams were similar if not identical in setting. In the former, the dream elements became disruptive, and in the latter, there occurred an expansion and rearrangement of the dream setting, reflecting in pictorial form the ego’s increased synthesis and increased sensitivity to internal and external stimuli associated with the process of creative discovery. Kramer et al, in a presentation to the 1975 meeting to the American Psychiatric Association (unpublished), tested the hypothesis that manifest dreams of the same individual from different nights, dreams of different individuals, and the position of a dream within a series of dreams were distinguishable. All three distinctions could be made, with better results obtained in non-schizophrenics. They emphasized the reactive and adaptive function of dreams, and came to the accurate but disappointingly meager conclusion that “dreams may be reactive and have meaning.” Robert Holt, in an important paper titled, “The Development of Primary Process: A Structural View,” makes an excellent case for consideration of the primary process as a cognitive process that is not innate but undergoes development and maturation, contains structure, and has synthetic capacity. Although Holt repudiates energy theory, he asserts that standard psychoanalysis has distinguished primary and secondary processes primarily in terms of energic differences, but has been vague as to which structures generate the energy, transmit it, transform it, and use it to do work. Freud, in the early years, assumed these structures were anatomical but when he ostensibly gave up the idea, nothing was left to take its place. Even with the classical descriptions of dream work (which involves primary process activity), there is usually the assumption of a structured network of memories, i.e., Rapaport’s drive organization of memory. Since condensation and displacement are not random and arbitrary—here too, there must be some structure or organization. A case in point is that dreams contain repeated elements—a remarkable series of coincidences without structured dream work. Holt further postulates that primary process does not emerge full grown at birth, but it presupposes completion of many of Piaget’s sensorimotor stages of cognition. “Until an infant can attain object constancy, nothing worthy of the name of thought can go on.” Therefore, according to Holt, primary process is a cognitive process which develops concomitantly with a maturing central nervous system. It is influenced by experience and culture (e.g. universal myths and tales), involves structure, and exhibits its own brand of synthesis. Synthetic function in and of itself is not a sine qua non of secondary process.

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FROMM ON THE DREAM AS A PROBLEM-SOLVING ACTIVITY In a 1969 article in the International Journal of Psychoanalysis, Pinchas Noy wrote what I consider to be one of the truly important articles of the ‘60s, in which he suggested a total revision of the theory of the primary process. What is challenged most directly is the concept of primary process as a primitive regressive process in comparison to secondary process. He quotes George Klein who also does not deal with primary process as regressive, but as the result of disinhibition. Noy develops the thesis that primary process is not primitive or regressive but continues to develop as evidenced by increasing sophistication of condensation, displacement, and symbolization. Noy quotes French and Fromm, who viewed the dream as a problem-solving activity, and subsequent papers, which regarded dreaming as an ego function in the service of synthesis, integration, and mastery. He quotes Fiss, who wrote, “We believe a truly comprehensive psychology of the dream process must be an ego psychology as well as an id psychology and as such must take special cognizance of the ego’s synthetic and integrative functions, its tendency to structure and organize its experiences by giving it unity and meaning.” Following Klein’s work, Noy considered all mental processes to reflect one system; from it, a group of functions is differentiated in development. Secondary process becomes differentiated through its dependency on a feedback monitoring system. The mental functions aimed at reality orientation operate according to secondary process cognition, while the mental processes aimed at preserving self-integration operate according to primary process organization. Secondary processes are reality-oriented; primary processes are self-oriented. Noy pointed out that in the very early development of the infant, when he is unable to discriminate discrete objects, let alone internalize them, and “thinking” is primarily enactive, this primary process mode of cognition utilizes condensation and displacement of perceptions that are intimately related to the affective subjective state of the infant, and later of the adult. This primary process cognition behavior is related throughout to affective self-centered subjective integration and synthesis. This brings to mind, the time-honored significance the dreamer’s affect has had in dream investigation, beginning with Freud’s advice to follow the affects. In his discussion on the function of primary process, Noy lists an ego task of the primary process, i.e., the integration of inner needs with outer reality; it must preserve the continuity and integrity of the self. Encountering reality and self-integration must proceed hand in hand. Dreaming may help make this possible. This review of the literature, although incomplete, represents the major trends of clinical research in manifest content and theoretical research in primary process. One conclusion I have drawn is that most analysts are

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relatively unfamiliar with the work done on the manifest content in the last twenty-five years. Another, which closely follows, is that many analysts who do feel that they make optimum use of the manifest dream in their work could do so more extensively. In addition to the theoretical points I am trying to make about the dreaming process as a whole, I hope to encourage a more open and active approach to our clinical armamentarium by increasing involvement in teaching, clinical research, and clinical utilization of the manifest dream. Without these efforts we have been limited in our repertoire of dream investigation. Not to do so would neglect major developments in psychoanalysis, spanning the last forty years. Ego psychology, object relations theory, newer concepts of dream formation (stimulated by REM studies), increasing interest in the nature of the primary process, creativity, and application of systems theory, all find expression in the manifest dream. It is unfortunate that good, important research into manifest content, such as Kramer’s, is not complemented by analytic sophistication which could now add new and important dimensions to our clinical and theoretical understanding. Let me begin by referring to the case which alerted my attention to what might be gleaned from direct observation of manifest dream content. ILLUSTRATIVE DREAMS My patient’s associations to her dreams were apparently unrelated to the manifest dream. They were vague and bizarre “off the wall” associations, which not only could not be used to ascribe meaning to the dream, but which left me silently staring in disbelief. Other associations similarly left me with little useful information. The patient, a woman in her late 20s, was a mental health professional. She was an attractive, single woman, who complained primarily of difficulties in interpersonal relationships, especially lasting and meaningful relationships with men. Her early relationships were described vaguely and appeared distant; and there was more than the usual difficulty with separation. There were two conversion episodes described and several episodes of hysterical loss of control. Although the initial tentative diagnosis was that of an hysterical disorder, there was always the question of an underlying borderline state. Standard methods of analytic understanding were yielding insufficient and confusing information. A major method that was utilized to better comprehend the material was my developing attention to the manifest content of this woman’s dreams (she had an average of two dreams a week). Eventually, a pattern developed in the manifest dream which could be distinguished. She was never alone, and the dreams all contained a number of people who were identifiable. Nearly all the dreams contained references to food and eating. There was evidence of hunger, deprivation, and also, an aversion, even fear, of eating. This woman, who functioned ade-

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quately in her work, had under the stress of the analysis defensively regressed and her ego fragmented. Her fear was that of developing a meaningful communication and relationship with the analyst. Now I could begin to understand the severity of this woman’s difficulty with significant object relationships, as well as the unique nature of her primary and secondary process thinking. The manifest dream was not in this case utilized by the analyst as a verbatim message or even as identical to a waking association. A series of dreams was utilized to comprehend the nature of this woman’s fears, to ascertain her capacity for ego synthesis, to understand her style, to assess her capacity for object relationships, and very importantly, to understand how delicately this woman had to be approached. It helped the analyst determine the very sensitive position that he must assume vis-a-vis this patient. Nacht discusses this concept by the term “rapproche”—not too close, but not too far! In the course of the analysis (perhaps a year later), it became apparent that the structure of the manifest dream was markedly different. The constant references to food were no longer evident. There were fewer people in the dreams. At times she was alone. She began to relate to these people, who could be identified, with a much wider range of impulses. Then babies were frequently in evidence, especially references to giving birth. There were not only references to giving birth to a new self, but to the developing of an intense transference to the analyst. She was developing a greater capacity for ego synthesis, confidence in the containment of her impulses, a beginning change in her capacity for object relationships, and now regression more in the service of the analysis. The implications of this case in terms of the revised view of primary process are important. What became obvious in the course of the analysis was a defect in synthetic ego operations, which only to a minor degree reflected itself in the reality-oriented feedback supplying aspects of the woman’s life. To be sure, there were problems in this area. But what was most incapacitating was the failure of ego synthesis involving self-integration. She clearly had a primary process that was functioning in a grossly disrupted manner. As a result of the analysis, there was a growth, healing if you will, of that level of synthesis and organization, so that she could not only better communicate with herself, but with the analyst as well. Nowhere was this better reflected than in her dreams—both the manifest dream narrative and her increasing capacity to associate meaningfully to them. To a greater or lesser degree, I feel that this occurs with good analytic result in most, if not all, patients. The Kris study group’s observation that latent meaning more closely approximates manifest content as the analysis progresses may well be a reflection of this. Two cases, which I will present here are illustrative of this point.

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The first case, related to me in a personal communication, was very striking. There were literally a hundred dreams ( in the course of a ten year analysis) which dealt with this woman’s feeling of oral deprivation (e.g., going into the candy store with friends and being left out of the “goodies”). Her last dream in the analysis was that of baking a cake, cutting it into pieces, and giving a piece to several of her friends. This represented presumptive evidence of significant structural change. A second example of the significance of dreams occurred in my own clinical practice during the termination phase of an analysis of a woman in her mid-20s. She had come into the analysis after the dissolution of a relationship with a man with whom she was living. This had precipitated an acute exacerbation of a chronic depression which dated from the death of her parents when she was in mid adolescence. Her mother died of a lung cancer after a chronic illness wherein the patient was primarily responsible for her care. Additional information revealed that the major reason for her incomplete mourning of her mother’s death centered around an unwillingness and inability to acknowledge her death. The patient was an enuretic and unconsciously felt responsible via her enuresis for facilitating her mother’s death. The unresolved guilt and repression caused inhibited relationships with men, the compulsive need to “save everyone” and an inability to finish college and pursue personal success. Her working through of this was successful, and validation for this success and evidence of her readiness for termination was illustrated in two manifest dreams which were, on investigation, seen to be very close to the latent content. The first dream was a scene where she was standing in an autopsy room with doctors who were doing an autopsy on her mother. They took out her lung. There was a definable mass in the lung. All that was said was, “That was what she died from!” The second dream, the last of the analysis, involved her sitting with me, watching a sports event. She left me to see the game from a different vantage point. She looked back, saw me sitting with another woman, and felt somewhat saddened, but felt this was the way it had to be. I believe that this is a good example of manifest and latent content more closely approximating toward the end of a successful analytic experience. The dreams deal clearly with her resolution of guilt and capacity to accept her mother’s death. It also clearly demonstrates a beginning resolution of her transference neurosis, a heightened concept of self, and confidence in her capacity to accept separation and loss. Hawkins (1966), who reviewed analytic dream theory in an attempt to correlate it with psycho-physiological research, questions old concepts, such as the dream being the “guardian of sleep” and representing “wish fulfillment.” He suggests that this new research shows the main emphasis of dreaming to be an attempt at playing out of drives and solving conflictual issues. Roland (1971), critically questions the likening of cognition in dreams to ego fragmentation in waking life. Further, he challenges the concept of

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seeing the pictorial quality of dreams as similar to the regressive, primary process thinking of childhood (i.e., more archaic, primitive, and inferior to adult, rational, conceptual, verbal, and scientific secondary process thinking). Noy’s new approach to the definition of primary process by its function relating to the integration and expression of the self is an excellent description of its use in dreams. As Noy states, “Rather than being inferior to rational, secondary process thinking, symbolically expressive thinking of a metaphorical nature, using primary process mechanisms, is intrinsically far better suited to represent simultaneously and in depth a far broader spectrum of psychic life than other rational modes, and becomes the basis for meaningful and valuable paradoxes.” These theories apparently challenge the wish-defense approach to dreaming upon which the classical manifest-latent dream distinction is based. Brenneis, in an article in the International Journal of Psychoanalysis, advocates dropping this conflict-centered theory and adopting a representation (ego)centered theory which is more interested in how wishes, motives, or defenses are presented, i.e., their form and structure. Erikson emphasizes this issue by his comment in the “Irma” paper, “in addition to a dream’s striving for representability, then, we would postulate a style of representation which is by no means a shell to the kernel, the latent dream.” Other writers have discussed the function of the dream as a communication to the analyst as an object and/or as a plea for assistance. It is postulated that the dream is related to current reality, the analytic transference, and the future in terms of wish fulfillment. Roland, in the article previously referred to, combines Noy’s primary process ideas (emphasizing symbolic fit and integrative capacity), with the communicative nature of the dream. My own feelings on this matter tend to disagree somewhat with Roland’s postulation. That during an analysis, dreams are remembered and used to communicate to the analyst does not necessarily imply that this is the purpose in dreaming. It only indicates that the need to communicate with the analyst provides the motive for remembering the dream. I do, however, feel that dreams, as a function of the primary process, are an attempt to communicate. It seems worth considering at least that we view the dream as a symbolically pictorial “play,” a creative, adaptive, and integrative self-communication. The dream, then, would function to process and integrate the internal and external information impinging upon the psychic apparatus, and serves a self-regulating and stabilizing function. I consider this concept to be totally consistent with Noy’s understanding of the primary process. Confirming evidence is the experimental data indicating disorganization and disorientation when the subject is not permitted to dream. We must now consider a somewhat different concept of what a dream is. In the information processing language of Rosenblatt and Thickstun, we might try to conceptualize a dream as a reflection of symbolic processing of

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input from a previous waking period, which, for whatever reason (low priority, repression, etc), was not completely processed, i.e., connected with previous memories and associations, categorized, etc. This processing, then, in the dream, occurs in a primary process mode. This mode uses presentational affective symbols, in contrast to the discursive symbols of the secondary process mode. The remembered dream may be experienced and/or utilized by the dreamer as problem solving, or resolution, or expression of repressed impulse or conflict, depending on the motivation of the dreamer at the time of recall. Moreover, we must reconsider the old assumptions. Is it really necessary to postulate “two dreams,” the meaningful latent dream, and the distorted manifest dream? Can they not be seen as a single creation of the primary process? Must the hypothesis of wish defense always be the major motive? If we take this only one step farther, then we might bring into question the concepts of “dream work” and secondary revision. As stated earlier, there are internal contradictions in the concept of secondary revision. Breznitz (International Journal of Psychoanalysis), felt he could shore up the theory of secondary revision by dividing it into primary, secondary, and tertiary revision. These ad hoc explanations, although not uncommon in analytic theorizing, only further confuse the issues. If there is only one dream, then one aspect of the dream is not secondary to another portion of it, and we do not need this specialized concept in relationship to dreams. This would apply to “dream work” (displacement, condensation, and symbolization) as well. This kind of thinking is no different from the primary process mechanism of our waking thoughts, and therefore, not specific to the waking process. The manifest dream may now take on a new emphasis. It is no longer just the “façade,” the “cheap material,” which only defensively distorts the true dream (although there may still be a defensive function to manifest content). It is the most accessible evidence of the synthesizing, integrating, creating, and self-regulating thought processes which provide the stabilizing self-integration necessary for an adaptive and healthy emotional life. This primary process thinking subserves the functions of what we have called id, ego, and superego. SUMMARY In this ego psychological critique of the analytic concept of dreaming, in keeping with a new understanding of primary process cognition, I proposed that we were working with one dream, not two. It reaffirmed the concept of our working with the total person, not someone artificially divided into hypothetical structures. Furthermore, the idea that the motivation for dreaming lay in the drives (i.e., sexual, aggressive), is now only seen as partially true. The list can go on and on, and must include integration of the past, present, and

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the anticipation of the future. The manifest dream, this very special creative process of the dreamer, could be seen as a most important reflection of a selfintegrative system. It included defensive or character style, synthetic ego, ego ideal, and all the various modes of adaptation. It became our task to adequately investigate this dream picture to help ascertain this vital information. The literature was replete with a variety of methods designed to accomplish this task. Brenneis had his ideas; Saul, Jones and others all had their own. The author considered that this extensive presentation was a mere introduction to the creative tide that has ensued in psychoanalytic literature. PATIENT SUMMARY AS REPRESENTATIVE SAMPLE OF WORK AT HANBLECEYA COMMUNITY Following is a summarized history of a male patient I worked with at Hanbleceya (with identity-revealing facts deliberately obscured), offered as a representative sample of my work in this therapeutic setting. Here, I continued my search for the underlying motivations of patients and their behavior that had begun some 40 years previously at the inception of my career. I refer to the epiphanic event at Fort Knox wherein a psychopathic patient laid dying in my arms, saying “I had to, Captain” as his explanation for deliberately getting himself shot. The patient described here, and others at Hanbleceya, provided yet more insight into the motivations of psychopathic behavior. I first met this 30-year-old white male—we shall call him Bill, though that is not his real name—during the late 1980s at Hanbleceya, where he had been sent following a decade-long history of mental illness, violent behavior, multiple diagnoses, and at least two incidents of assault with a deadly weapon. He had recently been given a verdict of “not guilty by reason of insanity,” and was remanded to Hanbleceya in order to determine whether he should be treated in an inpatient or an outpatient facility. This patient had been diagnosed as bipolar (then termed manic-depressive) and been in and out of institutions since his first offense at the age of 19. Two years prior to my work with this man, during his confinement in the seclusion room of an area hospital, Bill started an argument with a nurse and subsequently used chairs and other available heavy items to break windows and destroy hospital property. He escaped the seclusion room and assaulted two female patients, physically harming them, and verbally threatening to kill them. The treating psychiatrist at the time stated that the defendant was dangerous, exhibiting hyper-verbosity, hostility, grandiosity, inappropriateness and gang associations. Bill had a history of refusing to take medications citing “allergies” to them. He also had several prior arrests, serving jail time for

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possession of a firearm and vagrancy. Bill also admitted using methamphetamine, cocaine, valium, LSD, hashish, marijuana, and Percodan. He had started attending college but the onset of his illness cut his education short. He held several low-wage jobs and was given SSI disability early on. Minor criminal offenses and various manic episodes were documented from the time of his early 20s, including some reported by his father. His final diagnosis was Bipolar Disorder-Manic, moderate; and Borderline Personality Disorder. It was determined that the insanity plea was appropriate because Bill could not distinguish between right and wrong. Described by one physician as a “rapid recycler,” Bill experienced long periods of depression (some lasting 10 months) followed by short manic periods. I began individual psychoanalytic psychotherapy with Bill at Hanbleceya in the attempt to alter his basic behavioral patterns. I anticipated that as Bill relinquished his “psychopathic armor,” he would encounter the underlying psychosis. I also discovered a deeply messianic, mystic identity exemplified by Bill’s declaration that he was Jesus Christ. During his stay at Hanbleceya, Bill formed an ambivalent tie to the therapeutic community there, engaging in lengthy dialogue about his messianic identity and his alienation from himself, his family and society. I believed he was showing an increasing capacity to stay in social and personal reality without recourse to “psychopathy or psychosis.” My diagnosis was schizoaffective disorder, bipolar type; personality disorder, borderline and antisocial. The director of the Hanbleceya Community at the time, Moira Fitzpatrick, recommended continued treatment there, having determined Bill was not a physical threat to others at the time. Bill continued to meet with me twice a week at Hanbleceya. When asked about the history of his mental disorder, Bill said it began 11 years ago and had been aggravated by the use of illegal drugs. He stated that when he is psychotic, during his manic episodes, he does not behave as he usually does. He believes that he is a “kind individual” and that he is a “normal human being” who is very sensitive to other people’s needs. Bill agreed to take medications at Hanbleceya, where, in addition to seeing me twice a week, he also attended a bipolar group, a treatment group, a peer group, and a substance abuse group. He saw other practitioners and attended a health club for physical exercise. Bill stated that the Hanbleceya Community was helpful to him because it helped him deal with what he called the “emptiness in my deepest self.” Bill was given a series of psychological tests including the Minnesota Multiphasic Personality Inventory (MMPI), a standardized assessment of personality and psychiatric characteristics. Test results indicated Bill was currently experiencing mild symptoms of depression, and had a sense of low morale. He was anxious, ruminative, worrisome, and fearful. Test results also

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indicated that Bill was quite suspicious and distrustful of other people, but not to a delusional degree at that time. Based on our collective evaluation of Bill, the Therapeutic Community at Hanbleceya offered the court a list of findings and recommended continued treatment. The penal code stated that “Any felony involving death, great bodily injury or an act which poses a serious threat of bodily harm to another person, outpatient status under this title shall not be available until such person has actually been confined in a state hospital or other facility for 180 days or more after having been committed under the provisions of law specified in Section 1600.” We recommended that Bill be committed to Patton State Hospital for at least a period of 180 days, wherein he would be able to continue his treatment and would not present a danger to the community. The issue of his continued psychoanalytic treatment was obviated by action on the part of his father after his term at Patton State Hospital. He was moved then to an eastern facility. We did not learn anything further relative to this patient’s interior life beyond his awareness of messianism, a deep disturbance of his soul, and recurrent oppression. My work with Bill and the lessons therein led to even more “proof” of my hypotheses while at Hanbleceya. Alienation and reconciliation, as well as their companions, transference and messianism, were further illustrated in my work with multi-family groups at Hanbleceya. THE MULTIFAMILY GROUP AT HANBLECEYA The presentation of the multiple family therapy community at Hanbleceya is preceded here by an extensive review of the literature of multiple family therapy of that period. Psychoanalysis, family therapy, and therapeutic community join forces in the family community (multifamily) group. I compared the family community group and the psychoanalytic dyad, in theory and practice—their synergy and usefulness in the treatment of schizophrenia in a therapeutic community. Identifying through the common elements in their crises, the many families in the group attain a sense of current reality. From this vantage point they develop the motivation and group mandate to essay the changes (inter- and intra-familial and intra-psychic) necessary to traverse the growth crises inherent in their pathology. Since the personnel of the therapeutic community, including the director, collaborate in conducting the group, its group process becomes widespread. It was useful for training of personnel and introduction of new families to the therapeutic community. A session protocol and commentary are presented. When first approached it would seem that the mass assemblage I am calling the Family Community Group and the dyad of psychoanalysis could

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not be further apart in concept and practice. I wish in this piece to demonstrate their similarities, but more importantly, their usefulness in the treatment of the most difficult challenge of all: schizophrenia. I am calling it Family Community Group rather than Multi-Family Group to emphasize the sense of community that arises in this enterprise and that is its chief underlying dynamic. In my practice and the literature it consists of a number of families, three to as many as a dozen, which meet, generally in the context of a therapeutic or correctional community for mutual assistance through the crisis that accompanies the illness of the family member. The crises in the families of this group have been generally developmental and family-wide and marked by autism and alienation, appearing from under a facade of normalcy. The child was often exemplary until adolescence or early adulthood, the dementia praecox of several generations ago. The mother was a model mother until the onset of an involutional melancholia at her daughter’s menarche. The father was a pillar of the community until a midlife crisis and a depressive outcome. Or the family was deeply troubled from the start, but transcended its difficulties until growth of its members threatened its autistic basis of existence. Psychoanalysis has contributed immeasurably to crisis theory through its concepts of individual and intergenerational lines of development, and the various modes of ego distortion and functioning, among which are fixation, arrest, and regression. In the successful outcome of the oedipal struggle in the family, the child enters apprenticeship for the role to be played in its own family-to-be. In the pre-oedipal experience, it learns its roles by collaborating and competing, first with its mother in the act of nurturance; next in habit training, and as a toddler in separation-individuation. After the oedipal struggle it finds its place in the world of children in play and practice; leaving childhood and approaching adulthood as an adolescent; preparing for a family in young adulthood; establishment of a family of its own as an adult; in midlife, coming to terms with ties to forebears and life investment in family. Without a concept of the internal psychic workings of the individual, this schema of phases and stages of development would be two-dimensional. Psychoanalysis, for all the ambiguities and contradictions of its theories, has given depth to developmental theory, and an approach to the individual in the system. Chief among its contributions are the structural theory and ego psychology, and the latter day contributions of object relations and selfpsychology. They not only aid in conceiving how the child takes in its family environment and maintains itself, but how it grows as it traverses developmental crises. Freud posited an archaic family, the Primal Horde which comes close in size to the upper limits of our family community and has some of the characteristics of a clan. In his construct the father was the originator and head of a

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number of subfamilies, ruling and servicing all. His sons, excluded from their proper roles, murdered, then ate him, and emplaced him as a totem god. This fantastic story has commanded the serious attention of anthropologists and religionists for its explanatory value. There seems to be something to the thesis of oral incorporation reflected in religious ritual, human sacrifice, and the evolution of the godhead. More than that, in their regression in morale and functioning, the families of the mentally ill take on the characteristics of this primal family, the primal horde: incestuous object ties, a sole reigning head who is martyred, and an autistic ego ideal, with a primitive god system. A follower of Freud, J.C. Flugel, studied the family from a theoretic point of view in The Psychoanalytic Study of the Family (1921). He applied what came to be known a quarter of a century later as systems theory in his description of the oedipal family system and the Herd collectivity. To this he added a rather extensive primitive cosmogony that went back to the beginnings of the Greek god system. Most important was his reach into the role of myth in family development, and phenomena attendant on intergenerational dynamics, role reversal, the participation of the child in its developmental interactions with its mother, plus a three-generational hypothesis. In the psychoanalytic treatment dyad, the triadic consideration, the love triangle of mother, father, and child, figures large. An aspect of that, the primal scene, makes its appearance in the psychoanalytic situation, in the transference. A phenomenon of some moment is the family romance, in which the individual holds self to be of royal origin. The transference, central to psychoanalysis, consists of the appearance in the present of unworked through situations mostly stemming from experience in the family of origin. Despite these family relevant considerations, the family itself has been excluded from the psychoanalytic encounter. Such would be an intrusion on the free associative and regressive processes, impugning the purity and clarity of the emerging material. Psychotic, psychopathic, and borderline individuals were judged unsuitable for psychoanalysis after the “neutral” analytic experience was found to be too threatening, except when what came to be called parameters were utilized. In the great emergency that was WWII, a number of analysts and analysts-to-be worked with these excluded individuals, freely utilizing parameters, one of which was group therapy. I was fortunate to be inducted in the therapeutic community approach, modified for a correctional community. Following my bent, I developed a multi-therapist approach which was to presage the work reported in this paper. The results of our correctional community were extremely encouraging; hardened and alienated prisoners were reconciled to Army service. After the war, the approach developed in that crucible was of service in work with maximum security, and other patients, at St. Elizabeth’s Hospital.

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On one of the wards for the chronically ill, a spontaneously formed group of mothers and daughters sat me down to discuss their problems. I noticed a remarkable increase in their capacity to verbalize, and a corresponding one in the morale of the mothers. Out of it came a two-year therapeutic encounter and a research report, Maternal Dependency and Schizophrenia. I helped institute and supervised full-scale multi-family groups at St. Elizabeth’s, several clinics, and at NIMH. The results were promising and became a long term feature of most of those programs. The most elaborate one took place at NIMH, where the chief of service, a half dozen therapists and forty family members and patients met in a highly interactive and personalized encounter. These ventures uniformly reported a heightened sense of purposiveness and morale of the family members and patients, and their reorientation. Reaching a jointly arrived at understanding of their families’ situation, they experienced a mandate to transact on issues in each other’s lives. They reflected their observations and interpretations in the group process and formed alliances in helping one another. Based on successes achieved in the group, they sought further counseling and psychotherapy as families and individuals. The effect was to render the manifest patient more accessible to depth psychological intervention. Multidisciplinary in nature, these groups were also useful in training therapists, and in bringing the disciplines together in action. I have used the family community approach in my practice in a derivative group formation, couples’ groups, and work with extended, at times four-generational families. It is interesting that couples groups became the principal approach of Murray Bowen, one of the pioneers in family and multiple family therapy, and the most prominent contributor to its literature. Bowen started thirty years ago, with a five-year project at NIMH. Entire families (three to five) lived in that clinical setting for as long as thirty months, in an attempt to search out the family’s role in the genesis and alteration of the schizophrenic state. During the first year of this experiment, the families together were observed, and oriented toward individual therapy. Next, the family was studied as the unit of illness, and fathers were required to join the living unit. The research endeavor became a community of families, research and treatment staffs. Communication became open, and all records and meetings were open to all. The therapists and families were enthusiastic, but impasses appeared among the therapists, resolved by the stratagem of placing one therapist in charge at a time. In the last year, Bowen called on one family to present at a time, silencing the others, so they could “listen.” In another project, Bowen used the multi-family approach with patients referred by the local school system and Juvenile Court with, according to Bowen, “mediocre” results. Bowen complained that much time was spent on

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parents’ complaints about the child, and that termination happened in about a year, without the deep seated changes he sought. In his subsequent work he attempted to bring order out of the chaos of free inter-member association by instituting a system of guided counseling. He interviewed one couple at a time. He had them speak to the “I,” and stay with the subject at hand, their experience in the marriage and family. He set himself the task, as therapist, of keeping himself “de-triangulated from the family emotional system—not too close, nor too distant.” He taught the couples to recognize the patterns of closeness and apartness, “ego fusion,” and the steps towards self-differentiation. He found that once monthly sessions were sufficient to accomplish this work. Lacquer was the most prominent contributor to the literature on multifamily group therapy, having treated 1500 families in the past 26 years. Favoring general systems theory, he employed an eclectic approach, in which the group, randomly assembled, was challenged to change itself and its members. He encouraged it to have confidence in itself as an agent for change. He emphasized the greater power of the group vs. the families in its composition (through lessening of the power of the controlling members through the presence of multiple authorities in the group). He led the group in breaking the intra-familial code, and emphasized the usefulness of role playing, learning by analogy and identification, and the use of families as co-therapists. He delineated three stages of development in his groups: 1) Initial interest, in which relief is expressed in magical expectation; 2) Resistance, in which the group perceives the real situation and the changes called for, and doubts experienced, and as changes are made, confidence restored; 3) Working through, in which rigidities give way to flexibility and pertinence, and new ways are learned, through the working relationships established. Szymanski and Kiernan were an example of the new breed of therapists employing the multifamily approach. They reported essentially the same stages as Lacquer, and growth in capacity for autonomous expression in renegotiation of family relationships, as well as the mutual support families and individual members render one another in the experience of loss, isolation, and handicap. Cunningham and Matthews worked with parallel latency age and parent groups; then, because of resistances, combined them. They reported gains in problem solving capacity, effective use of the “I” position, and training in communication skills, plus ready role modeling by therapists and members of other families. There was a great deal of attention to psychic autonomy in theory and practice in this literature. The chief exponent was Bowen, who apparently was at once the most authoritarian therapist. Bowen excluded the child, had the couples speak when spoken to, and sat apart. He terminated his try at a psychoanalytic group dynamic, to set up a structured guidance-counseling

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system, and to keep from “triangulation,” or loss of his own self to an “undifferentiated ego mass.” The other contributors to the literature apparently allowed the families in their groups to participate as full or partial families, and the group situation to evolve in the usual group analytic manner. Again, the central focus was on the autonomy of the individual, discernment of the special code and system that psychologically bound the individuals to the family of the past, and the evolution of more appropriate, and contemporaneous relationships. Mention was made of the two-generational family hypotheses, but the genetic dynamics of psychoanalysis were given short shrift, as are the depth relevant concepts of the self. EXAMPLE OF A FAMILY COMMUNITY GROUP The therapeutic community Hanbleceya, in which the family community group herein reported was situated, had been in existence for eight years. Hanbleceya had seventeen residents and another ten in day care. They were all young adult schizophrenics, equal male and female, ill on an average of eight years, up to seventeen years. Half were from out of state. Hanbleceya, meaning vision quest, was begun by a recovered schizophrenic who had gone on to attain a doctorate in psychology. For staff, she utilized recovered residents, who likewise proceed with professional training, and psychology and marriage and family counseling graduates and internees. Several psychiatrists, one of whom was a psychoanalyst, attended to pharmacotherapy and hospitalization. All residents participated in a variety of therapy groups flexibly formed for their concerns as they proceeded through treatment: sexual issues, bipolar issues, dreams and nightmares, recreational and movement therapy, drama therapy, and ad hoc assemblages which helped the resident to focus in reality. Most important, however, was the daily therapeutic community group, where the events of the night and day were worked through, in common concern. Individual and group responsibility was the motif, as well as collaboration of staff and residents as persons, on the same level. Begun as a substitute family in which the director enacted the role of mother to the residents to the point of legal adoption of some, Hanbleceya was gradually changed to incorporate the families of the residents, and an increasing psychoanalytic bent in its treatment program. Each resident underwent a thorough anamnesis, had a counselor-therapist, plus a family counselor.

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THE COMMUNITY OF FAMILIES I began the community of families which eventually included the family community group to help relate the families of the residents to the program, and to serve as a demonstration-training device for the staff. Portions and whole families of six local and one or two from out-of-town residents attended regularly, plus three to six staff members, making thirty to forty members. At first, to ensure equitable and significant participation, the staff and I “went the rounds,” evoking self-representation by the residents and their families. They told their stories, mostly dramatically. In the telling, they unwittingly demonstrated their underlying family dynamics to the group. Families compared their histories, and exchanged interpretations and estimates, revealing that they were old hands at traversing institutions and private struggles with psychosis. They developed a supportive way of going, at first general and messianic, but increasingly sophisticated, as they searched deeper into each other’s situations for underlying meanings and factors. The parents formed an association in support of the program, helping to underwrite the purchase of Hanbleceya’s building. Residents formed linkages with families other than their own. In a year the group attained competence in participation in the sessions sufficient to permit relatively free association on the group level. The aim, in accordance with the psychoanalytic group method, had been to work out a therapeutic alliance in which I sought the autonomous participation of the group. On evidence of the capacity for inter-member free association, and the group’s ability to deal with its vicissitudes, I began pulling back to the analytic position, of working alongside the group, participating more in the identification and analysis of the resistances to group transference. In this group of severely impaired egos, that point was attained for a portion of a session, usually towards the end. Ever present had been regressions into psychotic and narcissistic states, which were traversed, by use of the special methods of this therapeutic community. Sessions #52 and #59 are here presented, for comparison, illustrative of the dynamics of this group. SESSION #52, FAMILY COMMUNITY GROUP The group had a specially scheduled meeting, requested by Melanie, to help her with her relationship with her family, attending from out of town. In addition to her mother and father, there were sixteen residents, ten other family members, and four staff. They all sat in a circle in the usual meeting place for this group, the large living room. Melanie started by introducing her family. After they exchanged pleasantries with the group, she launched into a description of her tie with her

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father, which she held to be crucial now. She stated she could not express her emotions regarding it, without becoming violent, wanting to kill him. He asked her what specifically upset her. She stated it would not make sense to him now, but that she had anger towards him since he pulled back from her at age five, when she told him she loved him and wanted to marry him. One of the parents in the group told her that it was understandable that she would have that wish. Melanie’s mother stated that the problem wasn’t Melanie’s request, but, turning to her husband, “your withholding ways.” He appeared startled by this. Recovering, he sat still, then stated with some poignancy that he was very aware of how much he had missed in the family by keeping his feelings in. Melanie’s mother responded that she had over the years become so angry at him that she had wanted to hit him. Mario, a resident, interrupted with a guttural noise, then spoke up. He stated he was violently angry at, yet longed for his father. His father was considering going back to his marriage with his mother, and was “crazy and unreliable,” and he, Mario, heard a voice which resembled his father calling him “roach.” It should be noted that there were many in the group who had been lately having such experiences of low self-esteem, combined with hallucinations. Stewart and John agreed. Mark’s grandmother, Josephine, then stated she realizes she had lost contact with her daughter, Mark’s mother, at a time in Mark’s infancy when she was herself sick and preoccupied with other members of the family. Stanley and Beth, parents of another resident, Rocky, brought up how, when pursuing their ideas of how things should be, they lost contact with Rocky as a person. They could readily see this failing in their marital partner, but had difficulty seeing it in themselves. Stanley pointed out how Beth puts him and everyone else down, infantilizing them, when they violate her high ideals for them. Beth reciprocated, by describing how he did the same with her and others, behaving exactly like his father. He admitted that he was struggling with the father within him. Jackie, John’s mother, broke in to state that John was longing to make up with his father, and though he was dead, did not want anything to do with her, or anything else. Members of the group made efforts to reach him emotionally, but John would only mumble that he was angry at his mother and wanted to be left alone. Helen’s parents then gave an account of her alienation from the family during her puberty with intense use of drugs. Helen, on inquiry by the other parents, confirmed their account, and went on to a reconciliative exchange with her parents, in which all were crying. The session ended on a warm and mutual note, and I summarized, concerning the alienation (from self and family) that had supervened in the families in the group as they developed. Melanie at the very end tearfully stated how fragile she felt her father was now.

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Review of the Session As Melanie, her father and mother presented their situation to the group, they had, in this therapeutically structured situation, regressed into their usual family bind, with a hint of family transference. The group exhibited the capacity to act as auxiliary egos, to observe, evaluate, and intuit, especially to identify with and develop insights into aspects of the family being discussed that pertained to them. In Melanie’s family, the parental diad came into focus first. In that context, Melanie’s mother demonstrated her alienation from herself, and her marriage. As the group proceeded with its inter-member and intra-psychic free associative process, she touched on the violence that had plagued both mother and daughter. Mario, in a step towards exemplification of that violence, spoke of his violent feelings, acting the part of an alienated child whose autistic idealism had been violated. Then followed a run of associations, all concerning alienation, in time moving towards reconciliation. That note was begun by Mark’s grandmother, who at the time of her self-representation in the group, was “experience near,” as the Kohutians describe it. This was followed by Stanley and Beth’s attestation to their loss of contact with their son. They broached and began enactment of a behavioral sequence in which they enacted their parents’ ideals and their rebellious reactions to the other’s parental introject. Jackie, John’s mother, described their relationship, and her son enacted mute rebellion against his former close tie with her. He was moving towards identification with his father, who had become alienated from Jackie when he regressed to Victorian authoritarianism in managing his family. This had led to a divorce, and a breakup of their family. John, in his catatonia, exemplified his father’s bossiness and defiance before he left the family, and then died. This note, of devoutly held rebellion, came up in Maria’s situation in her family, with an active reconciliative display. Melanie then exemplified the depressed and martyred position of a child tied, in a role reversal, to a similarly situated parent. SESSION #59: FAMILY COMMUNITIES GROUP Rocky was giggling and grimacing in a hebephrenic manner at the beginning of the session. Melanie began by recounting where she had been in the last three months, and asked for feedback about her current dilemmas. Should she go to visit her father, and when? I noted her feeling three months ago that her father was fragile. She replied that she still felt that way, and that he was actually fragile, physically and emotionally.

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She went on to state plaintively that for the last several days she was “shut down” emotionally and physically. For the previous three weeks, she had been in an enormous “escalation,” in anticipation of visiting with her father prior to and after his planned heart valve operation. In the course of her escalation, she had been overwhelmed by punishing hatred, alternating with guilt and grief, resulting in several hospitalizations. In episodes in the therapeutic community, she, ordinarily very cooperative, both refused to and was incapable of coming into reality and “dealing” with the group. After a pause, Beth, Rocky’s mother, stated, with feeling, she knew the grief Melanie was experiencing. Stan, Rocky’s father, joined her, citing his experience with his own parents. They attested to the depth and compelling nature of the tie to their parents. Rocky joined in, noting, in lofty language, their spiritual natures. Melanie then asked how she could settle herself so she could go home and not be overwhelmed emotionally. Josephine, Mark’s grandmother, reported she calmed and oriented herself by taking walks and stating to herself, “I free you,” repeatedly, arriving at, “Why not free yourself?” Ruth advised stating “I forgive you” repeatedly. Paul, one of the residents, described his experience with his mother, who could not let him go off to school, without getting very upset. Rocky stated he could understand that very well. Paul went on to state how he had broken with his mother’s church, and gone into mystical religions to find his own soul. Rocky proclaimed against cults. I wondered if Ruth and Josephine were attempting to transcend emotions of loss. Jane stated she could not follow any of this. Paul burst forth with his feeling that his mother could not deal with her own life, so she loaded it onto him, and he refused to feel guilty. Mario, as in previous sessions, made a guttural, low choking noise, and I asked him what was the trouble. The chief contribution of this group experience lay not in the realm of psychoanalytic transactions per se, but in enabling the members to attain positions and orientations in the institution, their families, and intra-psychically, to envision the deep seated changes we associate with psychoanalysis. Psychoanalytic ego theory and theory of family functioning are of vital importance in rendering comprehensible the paradoxical, archaic, and dreamlike phenomena of schizophrenia. Psychoanalytic concepts of therapeutic alliance, resistance, regression, and transference are essential in understanding the process and stages of development that are described in the literature. Each session, the group members rediscovered the phenomena special to schizophrenic-autistic worlds, role reversals, remarkable intuitive capacities to “read” the other, florid mythic role assumptions, deep regression, as well as an oddly preternatural appreciation of reality. Alcoholics and their families, in the AA movement, have afforded themselves of the lifesaving support of the family community experience. The

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mental health movement could very well follow their lead. Psychoanalysis has an essential part to play in such a momentous undertaking. SUMMARY In the work at Hanbleceya we had arrived at confirmation of the hypotheses concerning the intergenerational ties of the iconic cases to their forebears. In the 50th family community session, Melanie attained insight into how she cared for her father, perceiving his intra-psychic needs and fragility. The iconic cases preceding in this volume all had arrived at a similar emotional configuration that I hold to be messianic in nature. The group processes that enabled the members to attain their autonomy and free themselves from the malign aspects of these ties include joint recognition in current reality. They had repositioned themselves in the manner of the psychoanalytic diad as had the members of the mother-daughter group cited earlier in this volume and the iconic cases, let alone the large group formations in the Army Rehabilitation Center, Howard Hall, Perry Point VA, and the training groups at St. Elizabeth’s. This social, interpersonal, and intra-psychic repositioning was of the essence. It enabled the members to move from impervious alienation, where the more the members tried to reach each other the further apart they grew, with attendant phenomena of bizarreness and autism. Unfortunately, in this study I was not able (because of exegencies in my career) to complete the process to its logical outcome. In the work at Hanbleceya this would have involved further work by the group members on the character defenses of Melanie’s mother and Melanie in a manner and mode begun in the mother daughter group cited earlier in this volume. Lastly, I wish to cite the treatment, largely at Hanbleceya, of a floridly psychotic woman. She was my iconic case number five in this volume, her story told in some detail in the colloquy reported later in this volume. Remarkable, at the inception of her treatment was the definite activation of my intuitometer as she cried in mourning for her father at the inception of our work. A massively negative therapeutic reaction ensued, with deep regression, dealt with by scrupulous adherence to the close therapeutic alliance I had learned to honor and adhere to by this time. In her psychotic delusion she lived in another world, populated by a dramatic supportive cast. Moira Fitzpatrick, the director of Hanbleceya fortunately was able to join me in a closely held dialogue with this patient, arguing with her with appropriate affect. We argued our way into and out of this patient’s psychosis and she finally yielded her delusions to reality. In the report on the multifamily group, it becomes apparent that the patients and personnel there talked with one another, on a simply human level, the level cited by Harry Stack Sullivan when he stated: “We are all much

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more human than otherwise.” If one notes that this transactional mode was in that of mutual messianism, one will be completing the paradigm. My work at Hanbleceya was based upon my office-based practice comparable to that on the east coast. Integral and of moment in this practice were the troubled couples reported in the following section. A GENERAL INTRODUCTION TO THE SUBJECT: TROUBLED COUPLES This presentation was occasioned by a review of 30 years work with couples, just prior to my stint at the Atascadero State Hospital. I started work in this arena in 1962. I took this opportunity to assemble my thoughts and feelings on this cogent matter. My intention was to traverse my entire patient population, those whose therapy was interfered with or facilitated by the participation of thousands. I attempted to discern what the couple did for, against, or whatever to the therapy of the individual. I also was interested in those that I saw before I got into the analytic method. For an instance of the latter, I return to the work I did in a treatment prison during the Second World War. There, young women attempted to altruistically help prisoners, with whom they had formed a prior relationship. Often these were ministers’ daughters, who seem to have an affinity for these antisocial characters. In the course of the seminar, with more advanced students than in the Washington area, I arrived at a conception of a variant of the issue of the troubled couple, the analyst and the analysand as such. A member of the seminar commented on my interest in messianism as appropriate to that situation. I then went on to cite my natural history approach to the data, how the work with troubled couples occurred in the course of my practice. Another concern was the couple per se, people who presented themselves as a couple, or became involved with me as a couple. Others would intrude themselves into therapy of their spouse. I would not exclude them peremptorily, in the service of guarding the integrity of the psychoanalytic situation. My bias there differs from that of the standard psychoanalyst. I would work with a couple then, along with the individual involved. Another item was the engagement with the family of the member. Still another was the analogy of the therapist and patient as a couple, to be studied as such, to work into the question of the day treatment, the relationship dyad and the monad. My thoughts started to move in that direction, and as an analyst my thoughts moved towards the issue of autonomy of the individual and of the couple as an entity. Allied to that problem we get into our middle years when we determine for ourselves our status, facing the hand of death in

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our relations with our forebears. We begin to face our narcissism and in the course of becoming truly ourselves we differentiate ourselves from our parents’ lives. A corollary task in marriage is that of the individual with help of the other to work through these issues. The paradigm I have in my work with couples is the role of the partner to help the other to become his- or herself. That was a conclusion that stemmed from my initial bias in this study. I made that leap stemming from a bias that I held at the inception of this study, in regard to all that occurred in the course of my ruminations. A member of the seminar asked a question concerning record-keeping in regard to this mass of data. I answered that in my record-keeping I kept a natural history of the individual and couple, including a process record of each session. The member cited that he did such also, and that he had been accumulating a drawer-full of written records. I cited that I had file cabinets. The members cited that he also has been accumulating tape recordings of sessions. He also dictated notes. In this regard, we need to define what we mean by troubled couple. Important there is that the troubled couple troubles the therapist to the point of impasse, bordering on alienation. I divided my illustrative material into three categories of couples. Category 1: People who presented themselves as individuals but were so tied up with their partner that individual therapy was difficult if not impossible. Category 2: Couples who presented themselves for treatment as such, concerning their problems as couple. Category 3: The psychoanalyst and the patient as a couple analogous to that of a marriage. CATEGORY ONE: AN ILLUSTRATIVE HISTORY OF TROUBLED COUPLES An example was a woman who complained that she could not leave her husband because this would violate her deepest ideals, despite that fact that he was physically abusive. She induced a sense of deep frustration in me. Another patient was a man who had a perfect vision of an ideal couple. When his spouse deviated in the least from this he cast her into obloquy and wanted to kill her. He made plans to kill this lowest of preachers. A member of the seminar cited an instance of a husband who felt entitled to access sexual contact on demand, and whose wife would not tolerate that, and they engaged in mortal combat. I cited that that gets to the core of the matter. I brought up Don Jackson’s book, the Carl Rogers of marriage in regard to the ideology of the members of the couple. It appeared that the

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members deserved one another in the hypothesized ideal relationship. The members strove to rigidly adhere to this central consideration. The big problem with them is identifying this core consideration. A member of the seminar stated that when the individual steps out of that sphere, they feel guilty. I added that the task of the other is to enable the partner to move forward in their agreed upon endeavor. The member of the seminar events cited that the vulnerable partner assumes position under the purview of the other. I cited that both husband and wife here shared a concept of the man as a weak vessel who needed to be kept in order by the wife, in Christ. It was up to her to preserve the marriage and keep it going. Then she will make it to the other world, in devotion. The seminar member stated that she would still be the good one then. I stated then their love here had to do with an ideological, religious kind of formulation. I then cited that the work with troubled couples turns out to be an analysis of ideology. One gets deeply into the members’ belief systems. Involved there is the natural history of the development of the belief system, both in terms of the natural history of the marriage, its phases of development, how they met, history of their family of origin, how they developed their own, laying it out for the couple in systematic fashion as the phenomena became apparent. I found that the most effective intervention in this regard is in couples group therapy. The group members are able to discern these factors much more quickly and accurately, with the least amount of trauma and chaff, especially in marathon therapy. There the members get to live with one another intimately, and get the hang of each other’s operations. This calls for parameters, movement away from the usual analytic model. It also calls for counseling and, at times guidance. I got into the whole thing because of my own troubled marriage. I had engaged in a very discrepant union, together believing in the American dream, namely that in America anything is possible, one could mount any discrepant situation. Through that belief, one could work it out and once committed, I determined to make it work. In my practice, and because of my original work in groups, it was a natural thing to get people to work together in discrepant situations. The more I studied them, the more I understood my marital situation and myself. There was a direct connection between my studies in my own marital endeavor. I report this as part of an honest scientific endeavor. Laying out the data in a natural history manner is an initial step in the scientific method. A member of the seminar asked whether I wanted to synthesize for myself what I had done with all these people, with the natural courses of experience there. I agreed, including the inferences along the way. I stated that two categories occurred to my mind. An example of the first category was a patient about whom I had written my graduation paper for the Institute. This woman came for therapy because

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of anxiety and depression. She wanted to be a writer and found herself with a writing block, which came on after marriage to a fellow writer, who himself had a block. His block would be obviated by her participation in his writing. So she would sacrifice herself for him. He would write at night, by having a dialogue with her. In the course of this dialogue he would berate her concerning her stupidity. They would spend the night working on his writing, and she would have to get up in the morning to take care of the children. She would ask, why do I do this, Dr.? Her husband was always in the foreground of the analytic enterprise leading to a feeling of helplessness and futility on the part of the analyst. Nevertheless I persisted with the help of my supervisor and with analysis of her resistances she was able to proceed. Were it not for my commitment the psychoanalytic protocol, I would proceed with a couple’s therapy. When I finished with her, he applied for therapy. She was with me in therapy for three and a half years. She had encountered the problem of mourning the loss of both the mother and grandmother, concomitantly she had some very telling dreams. In them grandmother hadn’t died. As a hooded, mythic figure, she approached and then merged with the patient. In horror, the patient attempted to separate herself psychically and spiritually. She began to sob deeply, entering mourning. She then knew how to deal with her husband’s imperious assertion of hegemony and her own need to take care of herself and their two young children. Impressed by his wife’s characterological change, the patient’s husband applied for therapy with me. I hospitalized him, to separate him from the bottle on which he had become reliant. In a marathon midnight session, he experienced a transient psychosis marked by hallucination, in which his father’s face appeared coincident with his own. He began mourning the death of his father and attested to a deep sense of relief. I inferred that his wife’s success in analysis had enabled him to engage in his own analytic task to that effect. They both attained the capacity to mourn, he his father and she her grandmother. He had let go of a narcissistic state in which he was above everybody in a transcendent mission, also below everybody, also beyond human consideration. In his above-everybody state he was the genius of the century. He thought that he was better than Hemingway. He was superior to everybody and inferior to everybody, and nothing in between. Sinking into his human state, he was able to cry and mourn his father. Until then he was immensely arrogant. In other words, both members of this couple had a thing about their forebears, of being claimed body and soul by them. On an unconscious level, they were both compulsively devoted to their forebears and in effect sacrificed themselves. Their lives were driven narcissistically by their ties to any project derived from the previous generation.

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In another troubled couple in my practice a decade later, the couple had plighted their troth of similar high minded manner in which she played a role in supporting his brilliant career in medicine. They had three daughters in quick succession early in the marriage. In its eighth year, his father died and morbidity appeared in the shape of his father’s ghost sitting in the backseat of the car on the way back from the funeral. Persistent insomnia resulted in recourse to sleep medicine, eventually to morphine. He appeared to be swallowed up in the world of an addiction, desperately seeking his next fix. He began a series of suicidal attempts. She was able to shock him out of agitation by shaking and shouting at him. He was hospitalized for one suicidal attempt at Chestnut Lodge. This revealed a seminal factor: his tie to his father. His father had been an amateur boxer, given to furious assaults on his opponent, leading to the death of one of them. The patient, in a psychotic fury assaulted the wall of his isolation room at Chestnut Lodge, fracturing his knuckles. It is important to note that during periods of relative competency in the course of his bipolar illness, this patient was a paradigm of calm competence, when in charge of the hospital unit in the Washington area. I marshaled all the interventions to attempt to stabilize the situation and to strengthen his ego in reality. In one attempt, the daughters, now teenagers, made representation to their mother concerning her ego integrity and the nature of her bond with their father, and in tears enunciated their transcendent affiliation. It became apparent to me that we were approaching the core issue, the trouble with this troubled marriage. It was out of this world, of superordinate status, and the daughters’ messianic bent, that the very souls of their parents were called back to reality. It is also of moment to note that his wife was able to attain a state of competence in regard to his agitated periods. In her attunement, she was able to ascertain and interrupt at least one of his suicidal plans. All this individual psychoanalytic intervention, couples therapy, family therapy, analytic group therapy slowly brought the patient towards reality, away from his compulsive drive, but insufficiently. It was only when I intervened with therapeutic community at the George Washington University Hospital, by means of a program I newly instituted there, that I was able to hold him still, so he could separate himself from his dead father’s imago, and mourn his loss. This patient threw himself into participation in the therapeutic community there, adopting an older man in a wheelchair for attendant care. This patient had in previous hospitalization soon turned aggressively paranoid, demanding discharge on the basis of an assumed competence. In the therapeutic community he was able to relax, become convivial and collaborative. His messianism was overt. He reported seeing his father everywhere. In my analytic work with him, he started to mourn his father to a certain extent. Situated back with his family, he had a dream in which his father’s ghost

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appeared within him as a rotting corpse. With that, he compulsively proceeded to jump out of his very skin, away from an enormous self-loathing. He returned to his hours, in deep mourning, tears streaming down to my carpet. He rents his garments, in a morning ritual. He came out of it, at peace and was renewed. In the family therapy, with the collaboration of his daughters, he assumed his proper role and capacity. The family helped create a holding environment during the transition to his and its reality. I inferred that the engaged couple’s trouble started in their families of origin with a transcendent messianic member who had an autistic self-concept and had established a tie with a vulnerable child. In the first instance, the vulnerability stems from loss of mother at age 1. The source of the vulnerability in the second instance was not determined. A special feature in these cases was the appearance of a mythic figure prior to the onset of separation and mourning. This was confirmed in a number of other cases and I tentatively enunciated it as an advent phenomenon. The appearance of Hamlet’s ghost, his father calling on him for vengeance, is an instance in the literature. He would be in guilt, mortal guilt were he to spurn that dictum. The messianic aspect of the tie to the therapist serves to relieve that guilt, and allows the individual to pursue their own life courses. Then there was the therapeutic dyad, analyst and patient, in which I was able to see myself in that situation, to a certain extent. There was also the messianic transference to leavening his severe pathology; he did not wish to hurt my feelings through suicide. In another case, the husband became very jealous of the wife’s attachment to me. She came to me with two guns, asking what she should do with them, reporting that her husband had a third one, by which he would kill her. The husband did not want to support the therapy. Through assembling the entire family, I was able to get him into therapy. Central to the rationale for such assemblage of the family was mobilization of its capacity to reach the errant member. In that mobilization, the family is called on to face its situation and take initiative at its furtherance. In one instance, that initiative was taken by the five-year-old daughter, who messianically appealed to her divorcing parents and asocial teenagers to love one another, as they had once done. This brought on a flood of tears on the part of the members and they reconciled to agree to a more humane outcome of the family conflict. The family had been split into multiple fragments in the course of traversing its crisis. The seminar moved on to examination of the nature of a psychologic entity. I again returned to socio-psychological theory and the concept of transaction as a unity of interacting entities. This unity existed on a superordinate level, and the analyst needed to exist on that level transacted within that world, become part of its entity, to effect change. In the cases cited, the

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members existed in and wanted to stay stuck in their entity, from which they needed to be free, into the autonomy necessary for their psychoanalysis to proceed. A member of the seminar advanced the thesis that some couples are so deeply in love with one another that they live in another world, separate from others, including the children. The children’s lives are altered thereby towards pathology. Lyman Winne, a pioneer investigator into family pathology calls this pseudo-mutuality. It is a mutuality that looks like mutuality, except for an essential difference. A member of the seminar cited that this diagnostic process needs to proceed the therapeutic intervention called for. Recognition of the autistic entity is an extension aspect of the therapeutic process. I noted that seeing the patient in the family and couples context ruins the possibility of pure psychoanalysis. The essential nature of the analytic process, the emergence of the transference, and the resistances will facilitate analysis of those resistances. What follows is how one defines resistances and transference. The transference occurs in a situation where the analyst is recognized as a person, and the patient presents him/herself as such. In the illustrative cases the members lived in other worlds, and needed to be brought down to earth and themselves, before the transference could be experienced. The author I mentioned had an enormous resistance to the transference will. He acted as though he was superhuman. He wrote a book about a space pioneer and his mind was devoted to those issues. He could not stand the mundane aspects of family life, the kids and their concerns. He was meant for eternity. His analyst made the mistake of not attending to this autistic reality. There is the comparable exercise that is the weekend marathon. Outside of the intense human encounter, that is four to five times per week, couchborne psychoanalysis is the weekend marathon, analytically oriented. The participants lay aside their resistances in a natural manner, finding in the early morning hours what lies underneath. Along the way they would learn to ground themselves in contemporaneous reality, complete with dream material. The morning evidence in the illustrations of troubled couples I cited earlier becomes a prominent feature. This occurs in the course of transference from the past. The membership of the seminar was assimilating the previous theory and practice. I found myself revisiting the material relative to the author who had writer’s block. The author I cited earlier sought insight which only came when he let go of his hypomanic foreword. This had been reinforced by a super ordinate status. The ghost of this signaled the advent of the transference from the past, followed by the onset of deep mourning, itself relative to the loss upon death and separation from the father’s ego ideal. The father’s ego ideal had become his. He devoutly resisted any separation from what was conceived to be his father’s way. He had invested in his analysis and his

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analyst in a like manner. In reciprocation, his analyst unwittingly cooperated with this very willing patient. Stated in other words, this patient paradoxically became his own person when he relinquished his narcissistic life goals. I emphasized at this point that the members of the troubled couple resist experiencing one another as separate persons who could be of help to them. They resisted being the subject of the helping. On the way there, they experience a series of phenomena that I designate under the term advent, that which is coming. The phenomena common in mythic form, as savior or devil. Then comes much anxiety, as they assume human status. Usually, these are untoward states of being. In marathon sessions they are vividly experienced. People impulsively run out of the room, seized by a necessity unknown in character to them. The seminar members reviewed the course of the couple on relinquishing their idealized images of self and other, through disillusionment, to self in a simply human status. They cited this as a characteristic course in marriage itself. I agree that the first year, from the honeymoon phase to becoming more for real, results in a more effective marriage somewhere in their 40s and 50s. They let go of their former preconceptions and accept each other as people. Over the generations, more and more marriages are real, on acceptant of the tin types of their parents’ marriage, or reaction formations towards their parents’ marriage. Moreover, people are making real marriages that are contemporaneous and creative. In another way of looking at it, people have to wait until they had coronaries before they envision their own self-respecting life course. On the face of it, in the midst of this terrible state of affairs, I see hope. Members of the seminar existing on the other side of the coin gave illustrations. One has only so much time in life, and if there’s a way to make better use of it, the better. I noted that I had made a decision to not sacrifice myself. It involved traversal of a very hard road. CATEGORY TWO: TREATMENT OF THE MEMBERS AS A COUPLE PER SE In treatment of the couple per se, where they present themselves as a couple, I had first difficulty in coming up with illustrative data, in marked contrast to the previous illustration. The work that was done in the context of the pastoral Institute of Washington D.C., and its bias against concomitant individual therapy may be the reason. These were professional couples and I must take that they were not as interested dynamically. In accordance with clinical practice, they tended to bring in their entire families. We had very good results. But I was not able to bring them out as individuals and enter into an analytic framework.

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The same happened after I came out to California with a series of troubled couples. The center cases were successful if they got to themselves into depth psychoanalysis, through free association, dream analysis of resistance, and appearance in working through transferences. They do not necessarily need to become couch borne. Here, the individual therapy would be concomitant to the coupled therapy. I think with couples resisting individuation, the variable lay in their bias against analysis. They believed in a messianically couched dictum, “Dr. heal me!” When I fixed the estate of discrepancy, they were ready to quit. A member of the seminar asked where did individual therapy fit with this model. The central issue there was the need to recognize the reality of the psychological entity, the couple in the context of the family. The individual is engaged as such in the context of the group and through such engagement is freed from its thrall. Concomitant individual psychoanalytic therapy, with its free association, analysis of resistances and dream analysis is helpful. This issue of the concomitant analysis of the individual and the group was exemplified in singular fashion in the work of a colleague, Dr. D’Agostino. He was a Jesuit minister who became a physician, and then a psychoanalyst in family therapy, in that progression. He developed a vivid coincidence of group and individual therapy. He would assemble a group of four or five couples in a semicircle, addressing himself to each couple in turn. He would say, how are you, what are your dreams; turn to the next couple, repeating that until all had reported. No one could speak without raising their hand. Such initiative would be occasioned by involvement of the members in each other’s exposition. My method differed entirely. I assembled the group, implicitly or explicitly inducing the members to take counsel with themselves as individuals and as a group on their emotional and psychological state, in a free association of matter, with relatively ready access to dream material. The group thereupon would become its own entity, with individuals taking part. They would participate in the formation of the entity. They would assume roles and capacities reflective of their psychological constitution and life experience. The members would become representative of that process and outcome. Along the way I would be seeing them in individual psychoanalysis with or without employment of the couch. CATEGORY THREE: NATURAL HISTORY, WORKING WITH THE INTIMATE TIES A member of the seminar asked concerning the third-category couples. I replied that it involved the patient and analyst as a couple, in which I intend to, by analogy draw on the career line in understanding the problems that

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have arisen between me and my individual patient. That career line has been singular and reflected in my pioneering in this field. At this point in the inquiry it is of special moment to review my personal and professional training for the career in intimacy occasioned by the psychoanalytic experience. In the examination of my career as the therapist in disregard I encountered awareness of my pre-analytic training phase. Regarding the intimate transaction of therapy with the individual, let alone that of a married couple, or even that of a family, at first I was to all effects an innocent babe in the woods as a professional psychoanalyst. That babe had been prepared with a set of scruples of the highest order in the course of developmental phases of nurturance and habit training. At core I had already developed the anlage of a set of ideals and aims relative to the people in my career. I was fortunate to have instructors who were scrupulous and dedicated to transact with the most particular details of the patient’s and my history and functioning. I had started my intensive career as the therapist without a stitch of formal training. I had read Freud as an adolescent, to a certain extent. Then I went into other interests—historian, physical scientist and novelist. In medical school, I began following an interest in bacteriologic and epidemiological research, and I found myself in my psychiatry class, with a catatonic male offender and middle-aged black woman who suffered from schizoid depression. During World War Two, I was thrust into situation leadership and group therapy in a treatment prison. I was in charge, along with my Sergeant, a sociologist mentor in sociological theory and practice of group therapy, also importantly in role theory. He had been trained in a successful community-intervention program in Chicago, and demonstrated techniques to me. I found myself successfully running a large therapy group, then became bent on exploring its mechanisms and its explication to my staff. While apparently competent, I subjectively felt abysmally ignorant of the interior life of my charges. This dilemma led me to seek psychoanalysis, as an avenue to individuation of both therapist and patient. I needed to learn about myself and from mentors experienced in working with individuals in the Freudian manner. I had in mind the almost tragic outcome of my predecessor at Fort Knox, Dr. Alexander Wolf, who had to be protected from assault by a guard. The rehabilitee prisoners had discerned his socialist views and threatened assault, stemming from their fascist orientation. A psychotic patient in Howard Hall in St. Elizabeth’s caused my hair to stand on end in terror when he threatened assault. I was frightened in my subsequent private practice by the prospect of failure with the much better behaved young men and women who sought my psychoanalytic services. I was grateful for the opportunity the psychoanalytic institute offered me in didactic instruction, but more so in close supervision of the four cases I needed for graduation.

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I had got on well because of my fascist appearance as a young man. I was fond of riding spirited horses at the officers club at Fort Knox. To their liking I learned something of how prisoners were deeply ideological, under a veneer of alienation. Later, my analytic trainers felt very threatened by me, for whatever I was, in my success doing those great deeds during the war. Harry Stack Sullivan had done pioneering work on the treatment of schizophrenics at Sheppard Pratt Hospital. My theses about the social formation to deal with individual pathology were in conflict with his, and we never did expose that conflict to open discussion. This might have opened us to view an inquiry into both his and my narcissism, that enabled us to tackle the severe disorders that were deemed by Freud impossible for analysis. I was aware of my messianism and a tendency to heroic stances. Of my analysts, only the last, Lewis Wineshel, appeared to be capable of attunement in that regard, as a portal to the analytic process. I had experienced that attunement in my earliest work, prior to analytic training, as a medical student and then in work with the psychopaths at Fort Knox. With the latter, I have the conscious awareness of the words, “these are my people,” in the midst of transacting with them. That identification extended even into understanding what the psychopath was experiencing when he was rushing to assault me, itself stemming from my physical confrontation during an impasse with my father at age fourteen. It must be clear to the reader by now, what a trouble I was to my mentors in the psychoanalytic institute, how my first three analysts had difficulty in forming the intuitive connectedness analogous to a marriage with me, capable of the productive outcomes they must have had with their trainee analysands. It was left to me, my wives, and my friends to struggle with my narcissism and the introject, chiefly derived from my mother that they came to see as my problem with professional dedication and an inherent stubbornness. All three analysts I worked with tried mightily to make sense of what drove this patient so out of reach of standard psychoanalysis through a talent which was both a glory and a bane. Only one colleague, Dr. Alexander Helperin, found himself consonant with this factor, and called on me for instruction in its employment. We worked together for several years, a partnership that I regret discontinued on my move to California. This partnership, amounting to a marriage, in which there is a union in the ego ideal and close assumption roles and capacities towards helping the other member through developmental crises and an assumption of responsibility in these regards to one another, was exemplified by the patient, the physician who transacted Hamlet-like with his father’s ghost. Friends and colleagues of this physician-patient joined forces to free him from a tight marriage he had formed with the ideology of an addict and self-sacrifice in favor of his father’s ghost. I was only marginally successful with him in a nine-year

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course in therapy until I immersed him in analytic therapeutic community. This I formed, against the ethos of the private psychiatric and psychoanalytic practitioners who did not want to have their patient’s mode of confidentiality challenged by that therapeutic community. That therapeutic community was only possible through the intervention of a close union I had formed with Dr. Leon Yochelson, the chair of the department of psychiatry at the George Washington University Hospital of Psychiatry. I had formed a union in the ego ideal with this strong leader who made it possible for me to start the therapeutic community in the George Washington University Hospital that was crucial to the recovery of the physician patient. It appeared to me that there was an analogous tie between the patient and the introject of confidential nature, super ordinate, making it inaccessible to standard psychoanalysis. All of these exclusive transactions, those of the difficult patient, the transit tradition bound family, the Mafia like psychopathic compact, as well as the professional, socially sanctioned compact are of the nature of a closed transaction, a union of interacting entities. That entity is deserving of further study, since it is of such governing nature. In practice, it needs to be confronted analytically. That confrontation calls for a concomitant attunement. The object in psychoanalysis is derivation of the individual as an autonomous entity and that starts in the mind of the analyst and of the analysand. A good marriage is one that is able to traverse the phases of its development to the point where the emotional limitations of the partners are worked through and they learn to collaborate and help one another assume their proper roles and capacities with satisfaction. An entity that did not permit that would be autistic in nature. Couples experiencing such autistic love shut out the world, which would include their children. Lyman Winne, an investigator of such marriages held them to be pseudo-mutual in nature. It would be a mutuality that appears on its face to be such mutuality, but denies recognition of external reality. The author in my illustration of troubled couples had invested nine years into a psychoanalysis which she held to be one of a close working relationship, which resulted to be one of a pseudo-mutual relationship. A member of the seminar noted that this consideration would be central to the diagnostic process. He noted that in an instance where the child comes in with a homosexual problem, getting the family together and assessing the nature of its entity would be called for. More than the homosexual individual would end up in treatment, after the diagnostic process, which itself would be integral to the treatment process. I noted that this goes contrary to the analytic thesis that if one sees the individual in the family context, it runs contrary to possibility of psychoanalysis. The analytic process itself is a powerful one in which the transference is an almost inevitable enactment. In the case of the author in the iconic case

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number two, he had left the world for another of existence in outer space. He came to the earth alongside of me in the isolation room at George Washington University Hospital, semi-psychotic, hallucinating his father’s face. He then entered a state of grief over his loss not only of his father but for all the years of living an illusion. There was transference to me as his father, also his mother. He was ready for analysis. As I have noted elsewhere in this volume, the closest thing to the analytic situation outside of analysis proper is the weekend marathon, couples and otherwise. The members are eased into free association and dropping of defenses culminating in their drowsy states around 3 a.m., with the appearance of unconscious material of transference in nature. They find themselves taken with the imperatives of positive and negative nature. What I call the advent phenomenon prior to mourning aspects of their lives. All of this is strange and foreign to the participants in their waking lives. They resist, as individuals and couples, this transference. Other members find themselves able to help in ways a couple finds blocked by their resistances. The advent phenomena I have noted include those of Savior Lord and that of his correlate, Satan. The members of the couple learn to occupy those roles from the other members of the group and to help one another in ways previously inaccessible. A member of the seminar confirmed the immediacy of the nighttime phenomena and how he had become sick in the midst of the transaction. Another member noted that the idealized images give way to something more immediately human and personal. I noted that the person with the idealized image is in a superordinate position, above the rest of the human spirit and that all the person is hoping and wishing for, is a missionary position. That leads to disillusion and the affect is depressive. If they have enough sense of self, they survive this and through their apperception of reality assume a more appropriate position, and try psychically and interpersonally. There is a certain natural history to marriage, in which the parties come off of it and in their disillusion, they transact, off the honeymoon phase. They become more real with one another and are then in position to be truly married. This occurs somewhere in their 40s and 50s. More and more marriages are real, in the sense that they are not tin types of their parents’ marriage, or reaction formation against them, or even marriages in conformity to their generation. I have noted with gratification changes that are occurring in marriage, of creative and self-determinative makeup. In response to a member of the seminar, I remarked that people had to wait until they had coronaries to open themselves to contemporaneous love and self-care. On the face of it, the marriage situation looks terrible, but I find it hopeful. Members agreed that that was the other side of the coin. One can make better use of one’s life.

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I had arrived as analyst and patient as married couple by way of Shakespeare’s Sonnet 116: Let me not to the marriage of true minds Admit impediments, love is not love Which alters when it alteration finds Oh no, it is an ever-fixed mark

The analytic experience may be conceived of as a marriage of true minds, in search of truth concerning the human condition of its participants. To it the analyst brings his life experience, professional and personal, and the analysand his problematics. In their coupling, they must arrive at a sense and state of mutuality and commitment to intimate revelation on the part of one, and correlate participation on the part of the other. But whether the analysand is really helped to go on with his life depends on the imponderability of marriage. We have seen in this account stark demonstration of the blocks to that marriage on the part of the series of ostensibly already married couples. We have seen how they required uncoupling from predecessors and alternate defensive ideologies, so that they can help and allow themselves to be helped by their spouses. Not only that, but there are institutional blocks to that outcome. I encountered a form of that in the couples which readily patched up their marriages by their Christ-like belief in my psychoanalytic intervention. That brings us to the issue of what Shakespeare meant by “One’s true mind.” I would have applied the natural history method to the initial tentative courtship, engagement, marriage and generativity. To start with, in this conception, one would need to consider what the analyst brings to the marriage in the realm of ideology, usages. Mine went back to my experience with physicians as a child, my medical school training, culminating in the Hippocratic oath and the societal mandate of a physician. Added to that came my special experience of iconic nature with alienated individuals, my tribulations in the psychoanalytic training process, and a problem I traversed of a development in my own troubled family. I brought all this to bear when I presented myself in Washington to treat troubled individuals. I have already cited the extraordinary capacity involved in my account of the traumatic exit from the scene at Fort Knox of my predecessor, Capt. Alexander Wolf. I was especially interested in deeply motivated alienated individuals and their coupling with others. My strength, of narcissistic nature was topped off by a messianism. This gave me the presumption to engage professionally with deeply troubled people. It was an enormous challenge to my mentors, to let me, my patients and my family, engage in a lifetime of self-analysis. I was ahead of my time in the utilization of group formations in treatment and also to wait until my midlife crisis to uncover analytic data by way of dreams and free association.

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Important there was my ability to see deeply difficult patients as alter egos. I was somehow able to see myself in the recipients of my services, employing it to self-analytic effect. An early example was the thought that I had in a turbulent session: “These are my people!” I have a thesis about the core of the professional identity of the physician to be messianic in nature. The young doctor wishes to save others, but the aphorism, “Physician heal thyself” is appropriate. Therein lies the vulnerability of the professional to the sexual needs and advances of the patient, also the vulnerability to the dominance of drugs, and finally to burnout. Knowing this, somehow the physician sets up blocks within his personality, including blocks towards intuitive intimacy with the patient. A thorough training analysis should conceivably prepare the young psychoanalysts for all these contingencies and outcomes. If the end product of marriage is a mature individual, able to live one’s golden years in harmony with self and fellow citizens, wouldn’t that be what psychoanalysis is about, where analyst and patient reports into equity? The seminar concluded on this note, on the need for further inquiry and elaboration. MULTIPLE FAMILY THERAPY There is another social formation that I find very useful, multi-family therapy, in which one brings a number of families together. A member of the seminar stated that he had difficulty orienting himself to the multiple variables involved. I cited that on the contrary, the larger context and the enlistment of multiple viewpoints, plus a vocational mobilization of a sense of responsibility for the members of the family and the larger group, outweighed the administrative tasks there. The members compared themselves in their life situation and generated perspectives and insight they would otherwise be unable to obtain. Analysts complain that they can’t in any way conceive of analytic processes there because of the multiple variables. A member of the seminar cited an experience in which one could never predict which member of the family would show up in any one session. I answered that family involvement was expressed in that fashion per se. That was the family reality and its multiple resistances to the therapy. COMMENTARY In this exercise we have summarized my experience in theory and practice of work with this seminal population. It began in my professional career with the tangential work with the prisoners at the Fort Knox rehabilitation center and their girlfriends. It moved then to intensive work with a couple, a mother and her schizophrenic daughter, at St. Elizabeth’s hospital. Next came the

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incorporation of the spouse of a patient slated for my graduation paper from the psychoanalytic institute. A series of similarly constituted couples followed, culminating in work with an errant physician and his wife. Then came a series of couples who came to be treated per se, secondary to my growing reputation for work in that field. It is of significance that the deepest penetration into the nature of the tie of the problematic couple occurred with the most obviously sick individuals. Along the way, I discovered what I called the advent phenomenon, marking the appearance in the data of parapsychological, mythic entities. These marked and led to data that preceded mourning of the tie to the antecedent. Hot on the heels of this phenomenon lay the Freudian transference and a characterologic change on the part of the patient. With each therapeutic experience, my comprehension of this conundrum grew. I related it to the psychoanalytic theory of introjection, the incorporation within the very soul of the antecedent and its relationship to the soul of the patient. It became apparent to me that the result was that both aspects of the personality were present in a special world. This world would be of transcendent nature, manifesting aspects of spirituality considered foreign to most analytic theories of the time. I related all this to my concept and experience of messianism as a portal to this seminal work. In this seminar I oriented the participants to this key, to unblock the door to conception and perception of this order of phenomena. Having traversed my career in psychoanalysis thus far, it is fitting to explore a concurrent interest: politics. Here, I found the same principles at play that had long guided my professional life. A DEMOCRATIC WORKSHOP Prior to my interest in medicine, I had been interested in being a historian. This interest led me in Washington D.C. to walk or drive precincts in the Falls-Church and Potomac areas. I also held a leading role there in fundraising for the Democratic Party during the Goldwater-Johnson campaign. However, preparing for my sabbatical caused me to limit my political activities. Soon after settling in La Jolla, I discerned an opportunity to walk precincts in the mild California weather and was elected to the presidency of the La Jolla Democratic Club. Again, my interest in institutional matters led me to reach across to the La Jolla Republican Club to engage in a campaign to “ban large office buildings.” We successfully mounted workshops that influenced the San Diego city fathers to stop the developers from placing large office buildings in central La Jolla, looming over its magnificent beaches. I next found myself organizing a Council of Clubs in San Diego County, expanding its number from 14 to 36. I found time to engage more fully in my

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political activity when the faculty of the San Diego Psychoanalytic Institute determined that my practice and teaching were heterodox. Were the students and fellow faculty members to adopt my mode of thinking and practicing, they would be straying from the standard psychoanalytic method. Such had begun to happen in the last phase of my tenure at the Washington Psychoanalytic Institute. Responding to a call to run for community college board, I mounted a campaign with the collaboration of the local teachers’ unions of the five community colleges in the San Diego area. I narrowly lost, but achieved name recognition sufficient for the party to ask me to run for Congress. I demurred, because of the problem of fundraising and its year-long call for investment. I found the political groups extant in San Diego and La Jolla to reflect Harry Stack Sullivan’s dictum, “We are all much more simply human than otherwise.” I simply ascertained what was at issue, engaging with the membership in a manner almost identical to that in my private and institutional practice. The result was that the groups tended to run themselves. The identity of the members and their professed aims and goals became an essential part of their transactions in the meetings. This was analogous to my inquiry into professional identity at St. Elizabeth’s. It was one step from that to establishment of a training program in political action and candidacy, under the auspices of the San Diego Central Democratic Committee, graduating a series of aspirant politicians and activists. Together with several veteran activists, we established a training program which had a student body of six. The chief training activity was, again, the professional identity of the politician. As in the previous ventures in professional identity, the members in a group and also individually, inquired into the natural history of their motivation into politics. I was delighted to see them come out with confirmation of my theses about the assumption of the professional identity in a generally epiphanic manner, in resolution of conflict, intrapsychic and intrapersonal, earlier in life. The trainees went through an experience of an espousal of cause that was subjected to analysis similar to that in the previous professional identity exercises. There was discussion of the current political structure, locally, regionally, and state-wide, with inferences on the motivation of the contending parties. The trainees on graduation evidenced satisfaction and a sense of renewal. Though the citizens involved in this political venture were “normal,” they responded to my initiatives in a manner similar to those who were patients and prisoners. This was most clearly exemplified in the formation of the Council of Clubs. At that time, 12 in number, the presidents of the democratic clubs, which totaled 24, reported that they were about to disband due to alienating features of the personalities of several of the members. In addition, there were schisms over the shoulds and oughts of policies and procedures going forward. I cited my previous experience with the workshop method

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and we soon worked through our differences. All 24 members began attending regular Saturday meetings at my residence, showing enthusiasm for organizing effective precinct work, year-round club educational activities, and expansion of the number of clubs, which eventually totaled 36. Much of this change I ascribed to my inherent messianism, and an underlying American urge towards democracy. These characteristics were evidenced in the democratic nature of the groups at Fort Knox, Howard Hall, and Hanbleceya, and also later at the meetings of the members of the Tiananmen Square Foundation, the topic of the next presentation. THE GODDESS OF DEMOCRACY—TIANANMEN SQUARE The spirit of the Chinese students who shed their blood for democracy at Tiananmen Square was made manifest at the Del Mar Fair at the University of California at San Diego, where I was on the faculty of the school of medicine. There, the Chinese students and scholars of UCSD, in a low key affair, unveiled their Goddess of Democracy. The witnesses were mostly Americans, drawn by the intensity of the statue and the speakers. Their message, spoken simply and with passion, was that they were going to carry on for their fallen comrades. They appreciated the temporary haven and support our democracy afforded them. Choked with feeling, they acknowledged that they were still mourning their dead. Craig Dunavan, the Solana Beach artist who sculpted the 30-foot statue, thanked the multitude, Chinese and American, who had put in 12 days of loving labor. Deeply emotional, he declared his belief in their cause. They read a message from Jim Bates, a local political leader, allying himself with them for democracy. They acknowledged efforts, unfortunately fruitless, by Senators Dixon and Wilson to transport their Goddess by military air to Washington for July 4th. The next target date for the Goddess was Bastille Day, Paris, July 14. The local Chinese community enunciated their support and hopes. That was it. No soaring rhetoric. But along the way they did note that they, students and scholars, aimed at no less than freedom for a quarter of the world’s population, a billion people, from an age old tyranny. Scattered in the crowd, they each looked fragile. The Goddess, modeled from a delicate Chinese student, was slight of figure. But Dunavan had given consummate expression to their soaring spirit and determined strength. This was the start of a long journey, from our democratic Fourth of July midst at Del Mar to eventual realization of freedom for their people. Inspired, I invited their leaders to conduct a seminar on the psychology of political liberation in my home. Eight students and a middle-aged female Chinese entrepreneur met biweekly for a number of months, prior to my tenure at the Atascadero State Hospital in central California. There I began as

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usual to introduce them to the dynamics of a group, with rough outline of its natural history. We then held the usual round-robin with the now not surprising revelation of passion and personal statement in more contrast to the usual reserve of the Chinese. In the course of this, their contacts with the Chinese community in San Francisco and on the East Coast became apparent, with data concerning its leadership. Then ensued what appeared to me to be realistic fears as to their safety and that of their families in China. The need for confidentiality and discipline surfaced. We were planning campaigns locally when I departed for my work at Atascadero State Hospital. It appeared to me that this group of young and one middle aged Chinese were searching out their identity vis a vis their ties to traditional China and their forebears. That identity had at its core as change agents its analog in my professional groups, both training and treatment. There joy of reconciliation through the democratic ethos appeared to attest to my hypothesis of fundamental self-alienation. THE PSYCHOANALYTIC RETREAT, 1987 Between the time I lost my faculty position and the next phase of my professional life, return to institutional work in 1990, I occupied myself with my psychoanalytic practice, work with the private psychiatric hospital residents, and I conducted a professional identity group of residents at the University of California at San Diego medical school. I attended meetings of the San Diego Psychoanalytic Society and institution faculty, monitoring their activities. As a member of both, I voiced concern that there was a growing schism, a phenomenon I had been well acquainted with in Washington. The schism related to a situation in psychoanalytic institutes in America, the purity of psychoanalytic teaching and its adherence to Freud’s original concept. I had long been an advocate of the use of workshops in the psychoanalytic format, for their mode of bringing contending factions together toward resolution of conflict and the attainment of the productive ends. To this end I suggested in 1987 a retreat, to be held in workshop manner to deal with the anxieties and growing disaffection and disaffiliation of members. I had been adequately occupied with a venture into local politics, in which I had been basically researching the professional identity of the politician, both in role assumption of the politician on my own and in this training of politicians and activists. In calling for the retreat exemplified below, I aimed to get a snapshot of what was going on in the Institute as a small society. Its importance to me and to psychoanalysis warrants extensive account. The participants included recent graduates of the psychoanalytic training program, who had entered it following their experience in my professional identity group for residents at the medical school. The other members were

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members of the faculty of the Psychoanalytic Institute, who previously had decided to separate me from the faculty because of my supposedly deviant views and practices. The retreat was held over a weekend, and consisted of three sessions. The initial speaker was a former resident, whom I had supervised. He was a young psychiatrist who characteristically smiled in a manner that I estimated to be a manifestation of a narcissistic constitution. He had evidenced great idealism and purposefulness in the residence group and held himself to be a leader of such. He started the session in the retreat by announcing that he was leaving La Jolla for work at the Austin Riggs Institute in Massachusetts. He was vaguely dissatisfied with his training and his prospects advised him to move his practice to San Diego. My association at that time was to my own postgraduate state at the Washington Psychoanalytic Institute in which I was dissatisfied with the insufficiently Freudian part of my training, and organized a study group to complete my understanding, through study of the literature and discussion with my fellow students of matters like transference and countertransference, which had hardly been broached by my mentors. It was my impression that this man still was caught up in his original narcissism, since the smiley countenance I had originally noted in our interviews was still present. Retrospectively I would posit that the task of this man’s training analysis was relieved from his narcissism. I would further posit that his training analysts had their version of this man’s narcissism, resulting in impasses in their psychoanalytic dialogue. This man’s complaint as well as that of his fellows related to impediments put in their way in acceptance by the American Psychoanalytic Association due to anomalies in their training such as frequency of hours and case presentations. Also, the complaints of the younger, recently graduated members related to the hierarchic distances of the older members of the faculty. These complaints were resolved in the workshop and the integrity of the institute preserved. It is of note that decades later these issues arose in the National Psychoanalytic Association leading to threats of splits between an old guard entrenched in the Board of Professional Standards (BOPS) and the general membership represented by the council. Also to this observers view pertinent has been an extension of psychoanalytic theory and practice, analogous to that of this author. In the workshop subsequently a compromise was reached concerning membership of the disaffected graduates in the American. They would be considered valid psychoanalysts locally and their future course held in ambiguity. They could not afford to split away as had the more orthodox graduate members of the Washington Institute. Similar compromises regarding orthodoxy and heterodoxy were arrived at in the international psychoanalytic organization, with the recognition of a number of training tracks. My

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hypothesis concerning the splits relates to my theory of narcissism and its resolution through the analytic experience. Its analysis on an organizational level calls for open recognition of the problem and mutative transformation between contending elements in the American Psychoanalytic and the international organization. Analogous confrontations and transactions are impending in the larger society between liberal and conservative segments.

Chapter Five

Atascadero State Hospital 1990–1995 New Adventure, Unexpected Assault

My treatment failure with the patient named Bill at Hanbleceya had subsequently brought home to me my inexperience with the depth analysis of the psychopath. In my work at Fort Knox and Howard Hall I had reached deeply into their psychology, but not in the systematic personal mode of psychoanalysis. During my visits to Patten State Hospital to continue my contact with the patient Bill brought me into repeated conference with his psychiatrist there and I was informed of the existence of the treatment facility, Atascadero State Hospital. I jumped at the chance of referring the patient there and lateral at completion of my training in the psychoanalytic training in the psychoanalysis of the psychopath. Mulling it over I decided to apply for a stint at Atascadero, of duration sufficient to learn by experience, then to return to La Jolla and eventually move to the dessert at Borrego Springs. Genesis of the Atascadero State Hospital stems from a heinous murder committed by a sick psychopath in 1951. This aroused public sentiment, leading to a special session of the legislature, called by Gov. Earl Warren. They determined, as did the Army in 1940, and Fairfax County Virginia in 1964, that the creation of an institution was necessary to meet the challenge of the rising tide of crime. The legislature decided that the institution would contain, treat and hopefully do research on the mounting problem of sex psychopathy. Dr. Daniel Blain, former director of psychiatry at the Veterans Administration, who had been my employer briefly in 1946, chose a Dr. Rood, Executive Director at Metropolitan State Hospital as an Executive Director of Atascadero State Hospital (ASH). Dr. Rood said, in inquiring into the architecture and setting of this new institution, which would have a farm associated with it, that he had a profound belief in the possibility of treatment 211

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for the sexual psychopath and mentally disordered offender. It turned out that there was a strong spiritual component to this belief. He also held that his new hospital would need to have strong community support. Despite his good intentions and devotion to the task, escapes began to occur, gradually mounting in frequency. He was able to elicit dedication on the part of the psychiatric staff nurses and psychiatric technicians. An example of the therapy administered to the sexual psychopaths was a group conducted by a psychologist named Dr. Fred Cutter of patients who he trained through the group process to run their own groups on their wards. According to protocol, each Ward had a mandate to form a therapeutic community. This was not adhered to generally, however. After four years, marked by periods of calm broken by escapes and assaults, Dr. Blain transferred Dr. Rood to another institution, replacing him with a Dr. Sand Ritter. Dr. Sand Ritter lasted another four years, followed by Dr. Ricci. Along the way the hospital developed a multidisciplinary treatment team protocol for each Ward, with increasingly sophisticated participation by psychologists, social workers and rehabilitation therapists. The farm was gradually phased out of the picture, as the hospital became more security minded, with the development of a presciently trained police force. The Department of Nursing developed a relatively advanced training program for the psychiatric technicians. Foremost, in collaboration with the psychiatric technicians they developed an emergency alert system and special emergency cohorts to confront situations of danger. WARD 10 I joined the staff early in 1990 and was assigned to Ward 10, the unit that trained patients to achieve competency to stand trial. Most were in acute psychosis which required treatment of psychopharmacologic and psychotherapeutic nature. I served under the mentorship of Dr. Michael German, who was to instruct me in contemporary medication. The latter was a considerable task, as medicine had developed a variety of anti-depressants, mood stabilizers, anti-psychotics. In my private practice in La Jolla I had used the milder versions but sparingly. It is of note that in my previous capacities at Fort Knox, St. Elizabeth’s and Hanbleceya I was in a special position of authority. Here I positioned myself as an apprentice staff psychiatrist, to test the persuasiveness and effectiveness of my methods per se. Dr. German accepted my theses about therapeutic community, but he was the one in charge. The chief nurse, expecting a situation that would further patients’ spontaneous interaction and lead to agitation, even assault, looked askance when I proposed having the Ward meet, patients and personnel, to figure out our daily problems. She held

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that the newly waxed floor would be marred, and was reluctant to call the meeting. Shades of One Flew Over the Cuckoo’s Nest! A rehabilitation therapist of Dr. German’s and my treatment team valorously called a meeting, placing the chairs in a circle. She ran the meeting, calling on me to say my peace, in turn. Nevertheless, the patients joined in, in time mobilizing their messianism, as in Hanbleceya, Howard Hall, and Fort Knox. Once the therapeutic community was started securely, I opened my door to the patients and personnel, for collaboration on ongoing problems. With many patients, this turned into regular, several times per week, therapy. I conceived of a subgroup of the more willing participants titled “Living In Reality.” Twelve to 14 in number, the members worked in a manner comparable to that of Alcoholics Anonymous, confronting each other helpfully. This group was able to settle down and then list a series of paranoid and disturbed patients and launch them on courses of advised self-change. This culminated in work with an especially dangerous and violent patient who was handed down from ward to ward as those units became incapable of dealing with him. In this “Living In Reality” group he settled down to assume a leadership role, transferring that to his participation in the larger therapeutic community group Important in the therapeutic community of this unit was my participation with the music therapist in assemblage and furtherance of volunteer dancing and singing. Then the patients taught me the lyrics to “Hotel California.” A patient from Somalia engaged me in a vibrant dance, returning him from an alienated stance. Of special note was my research into the interior dynamics of this ailing population with special attention to the healing processes. In my book on Howard Hall, This Way Out, I went into those data in some detail and I chose two patients for special scrutiny: one particularly sick and disorganized and the other a highly paranoid and coherent personality disorder. However, in the one on Atascadero State Hospital, A Study in Institutional Transformation: Therapeutic Community at Atascadero State Hospital, there are detailed accounts on work with a severely disordered individual and later a highly organized, deeply resistive, paranoid individual. Especially important there with the former was the attainment of therapeutic alliance. This rendered his coherence and readiness for court appearance all the more startling. This patient and I eventually learned to transmute his assaultive tendencies into a playful game that drew us together. The members of the psychiatric staff, 32 in number, sought me out to become the chair of the department of psychiatry. I ran its meetings but especially its retreats. There my previous experience with a psychoanalytic retreat and the professional identity group analysis at St. Elizabeth’s was brought to bear. This led me to propose that I initiate a psychoanalytic seminar, to discuss forensic issues in the light of psychoanalytic theory and prac-

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tice. I presented my experience hitherto with forensic issues in the Army and at St. Elizabeth’s. I emphasized the role of messianism in recovery from alienation from self and others. We spent considerable time listening to a tape on malignant narcissism done by the psychoanalyst Otto Kernberg. The members presented cases in their experience and their theory. In collaboration with the director, Dr. David Saunders, I initiated a series of colloquia attended by psychiatrists, social workers, psychologists and nurses, on the range of rehabilitation therapy there. We discussed therapeutic community in a series of presentations including the exceptionally violent patient who had responded to therapeutic community. As was my usual mode I accumulated notes, detailing the course of my sessions, group and individual and of the colloquia, retreats, and the seminars. In addition, I had been appointed as chair of a treatment improvement project by Robert Behan, the then acting medical director. I assembled a team consisting of the various disciplines to inquire into the state of treatment at the Atascadero State Hospital. We published all minutes and a number of documents stemming from that inquiry. We concluded that a training program in group therapy was necessary for the further progress of Atascadero State Hospital. As at St. Elizabeth’s, nursing took the lead in this positive development. However, it was not to be. The department of mental health in Sacramento had determined that the hospital needed to take the lead among its five state hospitals in self transformation in accordance with the model pioneered by W. Edwards Deming, who had remarkably transformed Japanese industry. I was struck by the similarity of his group process to that of my psychoanalytic group process and, bowing to reality, decided to join ranks in the transformation of this state hospital from top to bottom, bottom to top and middle to both ends. The object was achievement of the state of mutual confidence continuously operating toward improvement of the quality of performance. As I had with the treatment improvement project, I published my experience and inferences throughout. I was delighted with the enthusiasm leant the enterprise by the nurses, psych techs, teaching and administrative personnel. Looking back, the only flies in the ointment were that of the participation by the Executive Director and several top administrators. He, in a top level study group, earnestly stated he wanted input from everybody. I replied “Do you mean collaboration with everybody?” He blushed, and I knew that I had touched on a problematic area. He later exemplified his retention of the authoritarian mode that was in contradistinction and to the distinction advocated by Deming. Deming had, through his charisma and what I take to be his messianism, been able to convert Japanese authoritarian personnel into the Democratic mode.

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WARD 24 The hospital administration decided to let me try my therapeutic community on my own unit and offered me Ward 24 to that end. The nursing personnel and psychiatric technicians were chosen for their willingness to collaborate. Ward 24 became a model therapeutic community. In addition to the triweekly therapeutic community meetings, “Living In Reality” group, I initiated a problem solving group, and a meditation and relaxation group. The music therapist collaborated with me in the last. The treatment team meetings at Ward 10 had taken on a psychoanalytic cast, but those of Ward 24 were notable for their depth psychologic inquiry. The task in treatment on Ward 10 centered around recovery in patients of their capacity to appear on the witness stand in court, but here it extended to recovery from a chronic illness and state of psychopathic alienation. This entailed a third roaring review of life course and emergence into reconciliation with reality that extended to their families, occupation and education. Of special note was the therapeutic course of a deeply paranoid sex psychopath (detailed in the volume An Adventure in Self Transformation) whom I chose to represent the many on this unit who engaged seriously in recovery from their psychosis and psychopathy. This patient was deeply immersed in antisocial activity and leadership of the actively anti-social segment on his various wards during 8 years of hospitalization. He did manage at times to be chosen by the ward administrators to keep order on the ward and during passage through the halls to the mess hall. This reflected an underlying competency and capacity to live in reality, which was soon submerged. He was chosen to participate in therapeutic community because of these episodes of promise. He soon emerged as a leader, both in the anti-social and pro-social factions of the population on Ward 24, gradually settling as a prosocial member. He began knocking on my door for appointments, asking for an opportunity to put the broken pieces of his life together. He displayed considerable sad affect and related periods of wild abandoned rage, originally directed at his parents, then his foster parents, and the various institutions to which he had been relegated. He accounted for his episodes of anti-social and paranoid behavior at Atascadero State Hospital as manifestation of a sick, disorganized character. He became a leader at self-disclosure and constructive relationships in the therapeutic community “Living in Reality,” and meditation and relaxation groups. He served as ward captain and participant in colloquia devoted to therapeutic community. He was able to assume a responsible job at the hospital canteen and work through difficulties with the director of it, who for this account happened to have been the outspoken rehabilitation therapist on Ward 10.

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Along the way, he began reconciliation with his siblings, who began visiting him. The hospital administration began negotiations for this patient’s transfer to a less secure facility. There was one period of regression, psychopathic in nature, in which in the manner of hijinks, he led several of his fellows in the production of an alcoholic beverage from orange juice, slowing his progress but leading to greater frankness in identifying underlying anti-social psychic trends. The psychoanalytic relevance of this account was manifested by this man’s ability to enter into a durable relationship with me, eventually manifesting in transference aspects in which he experienced me as family figures, correlating them with dream material and manifesting appropriate affect. As with the patient on Ward 10 in this volume, also with the patients in previous institutional groups, this man was loathe to leave behind his psychopathic and paranoid defenses and manifested entrance anxiety on attaining his own and common reality. AN EPISODE OF ASSAULT ON MY PERSON It is ironic that following a promising session of a work group devoted to the problem of assaults at the hospital, I was assaulted as I traversed the hall of the ward of a colleague whose authoritarian treatment of a paranoid psychopath had roused him to assault a member of the staff—myself. After an extension to his sentence had been added in Superior Court, during an encounter with me in the hallway subsequently, smiling, he extended his hand in a friendly manner, stating “No offense Doctor; I had to get a doctor.” This brought to mind the incident at the beginning of my career, in which the psychopathic leader of a riot at Fort Knox had answered my query as to why he had got himself shot; he replied, dying, “Captain, I had to.” The patient at the Atascadero State Hospital similarly quoted he had to. I had not won his doctor over to the cause of therapeutic community, nor had I the executive director. REMARKS I had become a member of the staff at Atascadero State Hospital to test the validity of my approach to the utilization of institutions in the treatment of psychosis and psychopathy in the light of changes in psychiatry and society. Also central to my motivation was intensive research into the intra-psychic aspects of psychopathy, which I had begun at Fort Knox. Atascadero State Hospital was the most modern of maximum security treatment facilities. As a psychoanalyst I was interested and invested in determining what were my blind spots in the treatment of a psychopath at Hanbleceya. I had been in a

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way complicit in his larceny of my credit card, by not keeping it in mind when I was momentarily absent from my office during an interview. I had in reality exposed myself to danger in my office and on Wards 10 and 24 by trusting the patient during our interviews in my office. I was protected there, to my ken, by our original contract of messianic sort. The patient who assaulted me had not entered such a contract. The inference I would draw would be that I had mistakenly estimated that the Hanbleceya patient and I were tied together by the messianic mutuality that I had achieved with other Hanbleceya patients, as manifested in the account of my leadership of its multi-family group. At best I was aware of wanting to test whether the psychopathic patient in question believed in me as did the schizophrenic ones. My blind spot consisted in a lapse in testing whether that therapeutic alliance was continuously operative. The period that followed my work at Atascadero State Hospital may be considered one of resumption of my original interrupted sabbatical, but also one of testing my hypotheses about messianism and alienation with a dozen or so cases that I treated until full retirement, seen in a partial schedule, the rest in reflection and the writing of a series of books. I experienced difficulty in turning down patients who called for interviews, but finally retired, except for two cases. My retirement was occasioned then not by an act of will on my part, but when my insurance company discontinued its business in the state of California, but for covering what was called my “tail coverage,” the responsibilities I had for work which I had done. My assault was followed by a period of post-traumatic depression which hardly responded to the then current anti-depressant medication administered by a colleague at ASH. In pain due to insomnia and night sweats, I consulted with a psychoanalyst in the San Francisco Area, Luis Weinshel. I had three appointments of remarkable nature with him, each lasting an hour and a half. From the beginning I sensed him to be deeply acceptant, if not messianic in his orientation and attitude. I was inchoately sad and full of rage, hardly making sense, a performance polar to that with my first three analysts. His response was that of empathy and hardly verbal. I gradually became more coherent and appreciative of this opportunity to unburden myself so fully and began a review of why I had tried so hard all these years. I began filling him in on my relations and position in my family of origin and by the end of the third session had reached a point of exposition of my messianism and my relationship with my mother. There was no fourth session since he suffered an incapacitating stroke, and I was informed of such by Dr. Wallerstein, a close friend of his. I accepted the reality of the loss of this sole analyst who I really trusted fully, but felt no initiative at searching for a replacement beyond that of Wallerstein himself, who demurred assumption of the task. Looking back, my esti-

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mate is that Wallerstein had a personality similar to my third analyst and analysis with him would have ended in an incomplete result. It is of note that following the assault, my dream life changed markedly towards scarcity and elusiveness. I hardly remembered dreams upon awakening and they have only recently returned with their original clarity and pointedness. Remarkable there has been the appearance of a dynamically pertinent introject, similar to that of the patient I reported who experienced in a series of dreams the return from the dead of her grandmother. I had long suspected a similar constellation, that of the tie of my mother to her mother, in which she was in effect swallowed by the introject. It is of note that my work with psychopaths at Fort Knox and psychotic individuals in Howard Hall was effective without the use of medication. A corollary consideration on retrospect was my belief in the capacity of the body and soul to heal itself. I was oriented towards the view that the prisoner and patient can seek and attain their reality, psychic and physical. However when organic interventions came along in the early fifties in the form of insulin shock and electroshock, I availed myself of their use with frankly psychotic patients, finding them in one case life-saving. Impressed by the success by physical intervention, I began employment of Thorazine in 1954. First, I tried it on myself in the form of a 5mg dose, miniscule in comparison with the usual dosage which can be as high as 2g/day. I found it to result in a subjective sensation of clouding of consciousness and deep relaxation. It was if a curtain had been drawn over my cognitive eyes. An inference I drew was that something similar happened with the patients whom I medicated later, resulting in a somewhat somnolent state, with drooping of head and eyes. I found them responsive to my voice, gaining alertness and comprehension as we continued our dialogue. It was as if the veil I had experienced had been lifted from these patient’s cognition and employment of their egos. Early that time a colleague expostulated candidly, his philosophy and practice, “Give what it takes to kill the bad!” In my mind, he was advancing an animistic philosophy of medication. In my private practice prior to work at Atascadero State Hospital I gingerly essayed into employment of antipsychotics, antidepressants, and mood stabilizers, keeping the dosage minimal. I also attempted to have periods that were drug free. Overall, I found medication to be a useful adjunct to my psychoanalytic investigation and in no way contradicted. The medical culture at Atascadero Hospital dictated standard employment of medications, to which I generally acceded, finding that the individual and group therapy enabled the patient to transcend the cognitively downgrading effect of the medications. However the literature of the last decade would indicate the biological destructive side-effects of those medication, of worst import of the voluntary tremors that I noted in my patients, and which resulted in my cessation of their use.

Chapter Six

Post Retirement–1996 to Present Six Iconic Cases and a Revealing Colloquy

I retired from Atascadero State Hospital in 1996, after a short period of psychoanalytic treatment by a senior psychoanalyst in San Francisco. In three sessions I obtained relief from a post-traumatic stress disorder manifested chiefly by a depression that had not yielded to medication. Dream analysis did not play a part, chiefly intuitive connection and emotional ventilation. I had not experienced that connection with my previous three analysts, despite their and my efforts. Recuperating, I opened my office for a limited practice, and prepared to scrutinize the research protocols of six decades. Instead, poetry came to mind. The chief was a dramatic autobiographical one, and I conceived of publication of them, alongside dreams of dramatic import, selected from accumulated hundreds. It was during this period that my wife inquired concerning my career and motivations. We engaged in a lengthy colloquy. There I attempted to explain the nature of the practice I had been developing the previous six decades. The conversation was held in 2010. It serves in this volume as a general yet at times specific review of my practice, revealing its relationship to my marriage and other factors.

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A COLLOQUY ON AN EXTENDED PRACTICE OF PSYCHOANALYSIS AND ICONIC CASE NUMBER SIX: MESSIAH IN THE HELICOPTER Joe: This piece follows one on the same subject I had previously produced. It was an attempt to clarify this matter and its relation to what I had come to consider clinical material of a central nature. The aim in analysis is for the individual to be able to live with himself and conduct his business of living in accordance with his own enlightened self-interest, to be responsible to self and others. That is exercised in the encounter with me through a transaction of real nature in which language is the central feature. The spoken language is one aspect of the language involved. Elisabeth: Is this how you sit with the patient? Joe: Yes, I sit alongside the patient, somewhat behind, out of direct sight, convenient for the patient, to turn one’s head and speak to me. The patient is encouraged to consult with self on one situation and state of being and to honor and report the images, words and feelings that appear to consciousness. For the most part, the patient is in the best position to commune with self. Those items would be manifestations of one’s grasp of one’s experience and grasp of one’s reality. The exchange of language is crucial here. Elisabeth: Would you elaborate on the issue of language. Joe: There is the language we communicate through speech, through the states and movement of our bodies, and then there is a largely unexplored language through the essential aspect, that of our personalities that we designate as soul. Freud at first called the ego/self, the seele. That is the German word for soul. Elisabeth: That seems to me where the analyst comes in. If somebody would just be talking to themselves and made sure they were just playing out what goes through their head, the analyst would be less important. Joe: Eventually, as the individual becomes more competent at self-exploration and expression, the analyst becomes less important. Elisabeth: If it were just the spoken language that was important, then the interaction would be less important. Surely, it’s the interaction that affects the body language. The body language and the soul language of the patient interact, and that is what is important.

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Joe: What I am trying to say is that yes that is important, as in a vehicle to enable the individual to have the internal dialogue. At the root of his life difficulty is self-alienation, a basic disjunction. Through the dialogue, external and internal, this disjunction is worked through and there is reconciliation with self. One then lives in authenticity. Elisabeth: The focus there is on the internal dialogue, the internal dialogue that anybody has with himself. Joe: This differs from the religious thesis, in which the individual is asked to dialogue with an hypothesized external god/self for communion and guidance. Elisabeth: That has no relevance with the issue of an extended practice, the subject of this query. Joe: It ultimately does. The issue when the patient comes to the analyst is ascertainment both patient and analyst of the reality of the situation. Reality is manifested by the occurrence of events and that, in turn, by the actions and enactment of the intentions of individuals. Elisabeth: Would you call the enactment between you and the patient an event? Joe: Yes, the event is a happening. Elisabeth: Would calling it an event give it more richness? Joe: We focus on events as occurrences in human history. Events occur in a transaction between humans in the present. We make history as we go along. In this, we experience ties to the past which cause us to resist being in the present. Psychoanalysis attempts to deal with alterations in those ties and those resistances. Elisabeth: I would like to get back to what psychoanalysis is. I thought psychoanalysis was the bringing into consciousness, unconscious material, in order to find out what was unconsciously motivating the individual. Joe: That is inherent in my definition, portending what goes on in the individual and the resistance to the interpersonal reality. Elisabeth: I am very sorry but I did not hear a word of that or even the concept.

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Joe: That is because I couched it in interpersonal terms. What is being resisted is the happening between analyst and subject. I defined it in terms of an encounter between human beings, in which there is resistance to that unique formation. The individual holds back from his potential for full living in the present with others, a defense against which the individual holds that he is going to remain in the autonomy he is used to, the autonomy of the past you wanted to have happened. This resistance is generally unconscious. The other resistance also unconscious is one of acknowledging the aspects of the past which keeps the individual from experiencing the present. These aspects from the past are called transferences, hangovers from the past. These transferences have to do first with issues that pertain to early family life. The analyst and the patient get into family issues, first relative to nurturance, and then to self-control. I had a patient who regularly dreamed about toilets, and she enacted aspects of toilet training, held back from coming out with relevant material. She was not aware that she had this problem until it showed up in her dreams. Then, she recognized she is withholding in the hour. She gradually let south little pieces of it and is just like being on the toilet, with a mother. I was the mother pro tem, in this instance. This is a transference situation. All she is aware of when she came to analysis is that she is trying to cooperate and finish the damn thing. This transference was gradually enacted, and on enactment was recognized. On recognition, the personality assimilated and worked through the problem inevitably when the stage was set properly. This is pertinent to the issue of the extended practice of analysis. This person could not be analyzed at first were it not for group therapy. This patient was a highly intellectual young woman who had a super brain for working in business, at thinking data with her bosses. She was an effective sidekick, got in with men, and went to bed with them. There she was potent in their service. Somehow, there was an impediment to courtship that would result in marriage and children. She could get along with her female contemporaries when she was young. She got to her 30s and realized that something terrible was happening and needed someone to do something about it. After a failure in handling of her monies, she was out there, self-caring, and humble enough to ask for analytic help. She had come to me first as part of a situation where she was with her boyfriend. The boyfriend had problems with his former wife and family. I held family sessions to deal with the various problems that had emerged, anomalous ones. The boyfriend had had previous analysis, which hadn’t taken. I helped straighten the family things out and she

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participated in it. As a result of this experience, she gained confidence in me. She was able to seek analytic help, and when she got it, she encountered a terrible depression that she did not know existed except for an incident in the past, when she went to boarding high school. She survived it and went on. At this point in her therapy with me, she was very depressed about herself, and wanted to commit suicide. I became alarmed and put her in my group for support. The group offered our contact, dealing with the loneliness. She would hang on from one group to the other. I was seeing her four times a week. The group acted to keep her depression within bounds so she could proceed with her analysis. The analysis revealed material having to do with her mother. It revealed that her mother had a terrible depression. She got hung up in the mother’s problem, eventually obviating her to capacity to envision becoming a mother herself. The whole thing had become submerged in favor of her father’s stance in reality, so she could function in the world. Elisabeth: What I don’t see is that you say that it was in the transference that she was helped. Joe: We had to get through the resistance to the transference first. But what I did not say is that part of the problem was that when she was away from the analytic couch, she doubted the validity of the analysis and the further she progressed with the analysis the more she felt she was betraying something deep within her pertaining to reality. This turned out to be her father’s reality. He believed that a table was a table and a chair was a chair and you did not look underneath that reality for meaning in life. This was a very realistic view of reality, and in her reaction analysis peculiar things were emerging that had to do with dead people. She had a dream in which her mother’s heart and hers were hanging in a sack outside her chest. Two hearts were beating together there. Elisabeth: In other words, what I call unconscious motivation was coming through to the surface. When she started to look at it, it destroyed her hold on reality as she had known it. Joe: When she got back to reality as she had known it, she realized that she was betraying something that was very dear and near. It also brought her to this state where she wanted to kill herself and where she lost all capacity to function. She stopped being able to work in business and in school and was a basket case. She would’ve opted out of therapy if it were not for the group therapy.

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Elisabeth: I am still not sure, and you say that the group helped her in her therapy. I am not quite sure how the group operated and what they did specifically to enable her to continue with the analysis. Joe: Two things: the group had real people in it and they were transacting in an analytic mode, brought in daydreams, which she participated in analyzing with them. She could see that I was not the malevolent, Machiavellian creature of her apprehensions. She there had contact with other human beings so that she could see her passage from one day to the other, and had the group to look forward to. Elisabeth: That I still can’t follow. Are you saying that her hold on reality was through her father’s way, and then when she came into the transference, she lost out and had to deny the validity of what she was experiencing? And that her participation in the group helped her work through that dilemma? Joe: Yes. Reality told her that in recognition of what was coming out she was vaguely betraying all that was dear and purposeful: life, a relation with a father who helped her survive a catastrophe with her mother. In that past catastrophe she had lost all her capacity to function, to be with her husband and work in school. She would have opted out of therapy were it not for the group. Elisabeth: Is there anything else that the group helped her with? Joe: She had a basic difficulty in living with people, unless she was working on a business project with a man. She had a basic self-concept as a low creature, a pariah, a leper. The group accepted her as a valid person. She could not believe this at first, and resisted it. Elisabeth: Is that the key? Is that a basic characteristic of the extended practice of the psychoanalysis? Joe: In my practice I wear a number of hats, and they are exemplified in the psychoanalytic group. I would say that this woman was reached in the group analysis, through intuitive connectedness with the members and myself. Her resistance was too great in our individual sessions. Elisabeth: The issue here is how this woman, so alienated from herself, was reached in the extended practice of psychoanalysis. There are a number of things that the extended practice of psychoanalysis offers. Whether they are offered as group therapy, or as psychoanalysis.

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Joe: She was too resistive in the individual sessions. The issue was one of reaching through the distortion, the resistance. Freud was aware of this, I think, when he resorted to taking walks with certain patients, in an attempt to reach them. Elisabeth: So the extended practice did not depend solely on an analytic group. Joe: In walking with the patient, I think Freud was aware of the need to change the context of the relationship, to bring the patient into common reality. Elisabeth: And what is unique to the extended practice? Joe: It is unique in its openness, its extension to this particular factor, its openness to flexibility in reaching other realities than the one engaged in the standard psychoanalytic method. As an example, a patient who had been in psychotherapy previously was considered too contaminated to be brought into standard psychoanalysis. The analysis had to be a fresh one, with a different analyst. For a time, there was a prohibition against reading in psychoanalysis. One was not supposed to significantly alter one’s relations, through changes such as marriage. There were a number of rules adhered to in a different Draconian, authoritarian way and people would get kicked out when they violated them. This was a Stalinist phase, from 1932 to 1955. So I considered extended practice to get to basic aspects of what Freud was really doing, instead of what he and some of his followers said one should do. Gradually, psychoanalysts have reached into analyzing conditions previously thought unanalyzable, such as narcissistic and psychotic individuals, very perverse people. The worse off, the more unanalyzable. The only one analyzable was someone whose mental health gave them a good grip on reality. Elisabeth: You are saying that in extended practice you can analyze these other conditions. Joe: Yes, you can, with the use of these other modalities, bring them eventually into psychoanalysis. Elisabeth: Why does it work, as with this woman in your illustration? She was able to make it to a position from her reality to the common reality through the analytic group therapy? What about the psychotic, the individual who Freud said could not be reached by analysis?

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Joe: Freud held that the psychotic individual could not get the transference. I happen to agree with Freud that the psychotic individual is too wrapped up in himself and is unable to tolerate the transference. They accept human mutuality and mutual dependency. The woman in the illustration was alienated from her humanness in considering herself a leper. She felt beneath consideration. The members of the group who suffered from analogous alienation were able to help her with this and to achieve intuitive mutuality. This was done on the feeling level, largely unspoken. When she reached that point, she was able to utilize her marvelous mind in comprehending what was going on in her femininity, her relationship with the other members of the group, and ultimately her mother. Another patient whose analysis was saved by the employment of an analytic group had fallen deeply in love with me at the inception of treatment. Her preoccupation with that was not so much erotic as it was a fusion of souls, in which we would be pioneering in a new ideal way of living, demonstrating it to the world. She resisted my remonstration and interpretation, holding that I would come to my senses. She convinced a psychiatrist in Hawaii that I was in love with her. He communicated such to my colleagues in San Diego. They began to shun me and I had difficulty in restoring the situation. It looks like transference, since she had bought a strong positive relationship in which she very much believed in the therapy. Actually, it was a defense against a relationship in reality which could ultimately lead to the transference. At my insistence, she accepted membership in my analytic therapy group and there disclosed the details of her course with me. She traversed intense humiliation and then realization of her messianism, her devout belief in an idealistic role and capacity for herself in conjunction with an ideal Christ-like man. Within that compass she had stayed in her previous marriage, bearing five children. In the group and in her hours she began experiencing an underlying depression, first manifested by frigidity in which she felt she was freezing. Her teeth chattered and her lips became blue. She felt that she was no longer the resurrected paradigm for humanity and was a human being, however distressed, with her fellow humans. She then started to experience me and other members of the group in a family way. Elisabeth: What do you mean by the family way? Joe: She identified members of the group who acted like her sister, also like her mother. She became feisty and argumentative. She had previous-

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ly thought of herself as the most wonderful person, who never fought with anybody. Now she was a stubborn person. Elisabeth: She became very human. Joe: Yes, no longer a mess. Elisabeth: In this extended practice, you sought to bring them into human status and to what you call your psychoanalysis, and through that to their underlying problems with self and others. Joe: And through working through the transference, discover their blocks to effective living. Elisabeth: Where does the counter transference fit in here? Joe: The counter transference is the involvement of the analyst in the process, analogous to that of the patient. I had a certain amount of residual messianism left in my functioning which the patient saw, linking it to her messianic investment. The group as a whole saw me in a more realistic light and enabled her to work through the troubled messianic self she manifested in her family of origin, and then the family she made, basing it on devotion and altruism stemming from her messianism. The members recognized their own transference as they worked through hers. They found themselves able to live with people more in the here and now, with a sense of integrity. Elisabeth: What forms of extended practice are there? Joe: Family therapy, multi-family therapy, and group analytic therapy, plus therapeutic community. Elisabeth: How many patients do you have? Joe: Generally, twenty. Elisabeth: A patient of yours with whom I have become acquainted does not use the couch and sits at your feet. Joe: This patient is almost a paradigm of the extended practice. She presented the problem of an individual who had regressed in her morale to nadir. That is the lowest state at which one can exist. She had no self and sought death as her salvation. She lived in another world in which her dead father there was kept alive by a salvationous figure. This delusional figure piloted a helicopter to her father’s place of residence. It was a sort

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of a haven in which they would live forever. There also would be a visionary population there which consisted of her dead mother, and other helpers. She spent much of her nighttime and a good part of her daytime in communication with her salvanionist figure. All of this was in her mind’s eye. In between the psychotic loads of existence, the patient could talk realistically with you. At the inception of the therapy, at the end her first session with me, held in my office, she told of the death of her father, crying disconsolately. In doing so she was acknowledging that he was dead. She had a negative reaction to her breach of fealty to him. She would therefore be training her father’s ego ideal. “In our family we do not cry.” She would then be subject to obliquy. In atonement, she became severely anorexic. The aim was to kill herself. She could then join father. In her previous analysis in a distant city, she had revealed to her analyst that she possessed a revolver and naively intended to take him out and then have Dave take him, the patient, and her brother to this heavenly spot. Since she stopped eating and drinking I had to hospitalize her, and I did so at Mesa Vista hospital. There, I had to alter the hospital procedure, to further this patient’s analytic experience. The admission was done in collaboration with Dr. Charles Gabel, who had admitting privileges there. Then, Dr. Gabel lost privileges at Mesa Vista and I had to make arrangements with a Dr. Fidelio who was non-analytic in orientation, if not opposed to it. My job was to spend enough time with this patient and work out the state of mutuality and mutual confidence with the personnel, so the patient would not opt out of the hospitalization. This called for consultation with the day shift and the night shift so they could be attuned with her special problems. I was more successful with the night shift. Her husband played a part in all of this and I reestablished contact with her brother and sister-in-law. They had become alienated because an overt threat to kill them as part of her delusional scheme. They had broken fealty to her father, and because of that, they deserved death. We held analytic family sessions in the hospital, enabling them to reconcile. In the concept of extended practice, I spent time with the night and day personnel, orienting them and attuning them to the patient’s problems in

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depth. The night personnel and I formed a little therapeutic community around the patient community. Elisabeth: I did realize that you were instrumental in that way. What did you intent to do with her therapy, from that point? Joe: I realized that this patient had a lusty hold onto her delusional world, and it onto her, and that we were in for a struggle. Central there was my commitment and her confidence in me. Her confidence came and went, attended by lapses into delusion. In previous experience I realized that relinquishment of a delusional state would be attended by depression. This depression had at least three aspects to it: (1) loss of her father; (2) previous loss of her mother; (3) loss of the delusional Dave, her principal delusional Savior. Accession to her human self, as differentiated from the autistic, superhuman one was attended by transference from her young adult and earlier developmental eras. The aspects of self in which she had been alienated were aspects which she could not stand being. Prominent there was her feminine identity which she called Jennet. Her middle name was Francis Jennet. She had cut away from Jennet when she was a little more than a year old, according to her story. Jennet was a part of her personality that was all walled off. She was no longer a girl, but was a boy. With amusement she would point to her pen as her penis. Elisabeth: This pen is my penis. Joe: She had great facility in writing. She was a feminine self, but was in essence a boy. If she could have had an operation, she would have. A transsexual operation. Elisabeth: She obviously started to eat again and came out of the hospital. Joe: I had a hell of a time with her along the way. Elisabeth: What were the steps in her recovery, her steps in progress back into reality, and toward her self-identity.? Joe: I found out about a private therapeutic community, called Hanbleceya and made arrangements. Let us switch our attention to the present. She is now able to drive her motor scooter out to Hanbleceya and is usefully employed by the city library in book repair. She is quite entrepreneurial. Working in books for shut-ins. She is attending classes, so she can be with normal people and learn to get along with them again.

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She is also seeking out psychotic people, so she can get herself to stand being with them. Before that, she could not stand being with psychotic people, who she felt drove her crazy. They were devils. Elisabeth: I’m sorry, but let’s get back to the steps. Joe: I recognize her salvationist figure was my adversary, and that he was operating in good faith at her service. I also wanted to cooperate with him. She then reported that she was thinking of fighting him in a coming visit. There was a problem of the furniture in the hospital, and Francis was quite capable of throwing furniture during a prospective fight. So I tried to get the furniture out of the room and the hospital people objected. The hospital personnel on hearing that I was rearranging furniture, want to arrange me out of the hospital. As a result, in the logic of the drama, Francis had to choose between her Salvationist figure and me. The important item there was that she accepted me as an equal to him. I gradually displaced him. The important item here was that I took this matter seriously. I used all sorts of perjorative designations relative to Dave, such as the Mickey Mouse Dave. She remonstrated with me, but gradually gave them up. Elisabeth: If you had not taken her systems seriously, she would never have accepted you. Joe: Yes. Pertinent to this transaction, I would like to mention what Robert Linder has written about in his book, the 50-minute Hour. There, a patient escaped from his reality through residence in deep space. Linda joined this individual there, and eventually on the thesis that both cannot live there together, the patient returned to Earth. John Rosen used direct analysis in a similar way. Both Linda and Rosen consider themselves to be analysts, but were not accepted in the analytic circles, yet I find their ideas to be operationally pertinent. Another who was accepted as a valid analyst, Rudolph Eckstein, situated himself with a delinquent boy in a car outside a store that they in their minds robbed, making their getaway. I accepted her as she was, and in our person-to-person interchange between the transactions, I cited to her that I was a psychoanalyst and was interested in her dream life alongside of all the dreamy characters. I had learned to act in that acceptant mode in previous work at St. Elizabeth’s hospital. An example was a grandiose patient who proclaimed that he owned the hospital and all the fields around it, and all the cattle thereon. He would wax biblical and I entered that field of existence temporarily, person to person. I then switched over to my analytic mode, hypothesizing as to the life circumstance that led to his assumption of a messianic

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defense. He replied that it had to do with his wife’s infidelity and grew extremely sad. I knew that my investment of time and purpose was paying off. He was recognizing that he was a sick, humble black man, stranded in this vast mental hospital, and very much in need of help. I recognized that Francis, at the inception of her illness, with her father’s death, had regressed deeply into herself, and was in the throes of a messianic alter ego. I was faced with the fact that this was a medical necessity. More, what was called for here was extraordinarily patient psychological intervention on an animistic messianism, meaning a messianism that derived from animistic origins. That messianism happens to be a core aspect of the professional identity of the doctor and of the analyst. In my functioning, I need to balance that consideration with the usual aspects of the therapeutic alliance, marshalling resources to both ends. There is balancing in taking care of the patient and oneself at the same time and marshaling resources to facilitate the process. By that token, it would be of crucial importance for the analyst to analyze the messianism, so that he can be free to take care of himself. It is important to remember that messianism requires alienation of oneself, at core. Elisabeth: Yet extended practice requires the messianic mode. Joe: Yes, the analyst uses his messianism and professional advice, relinquishing it gradually, to the patient’s tolerance. Elisabeth: To return to the steps, you are at the point of her thinking of relinquishing her identity with her Salvationist figure, and struggling with her loyalty to him, reverting to him when you failed her. Joe: I understood the pain felt in letting go of him, as I understood the pain that the alcoholic individual experiences on letting go of the bottle, one’s friend. Elisabeth: Back to the steps. We are now on the step of letting go of the Salvationist figure. Joe: She formed a relationship at a young age at Mesa Vista with the son of an analyst up in Los Angeles. She also became friendly with some of the night nurses. Dave wanted her to stay away from everybody, and she began breaking away from him. I potentiated this development by talking with these people. Also, she would come to my office to process these experiences with me and her relatives, of course including her husband.

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Then came the messianic mutuality with Moira, the Director of Hanbleceya, which was deeply intuitive, far beyond my capacity. Francis would stand next to Moira. She conceived that she was inside Moira. Moira has written on a symbolic realization of this sort and she would become comfortable with the arrangement of Francis living within her symbolically. At this point, when Francis was outside of Hanbleceya, she was beset by all her problems stemming from an identity as a separate person. In that context, she was able to transact with the people at Hanbleceya with relative safety. She acted as more of an assistant and associate, answering the phone. That part of her personality which was hysterical can’t assume roles and act on them. She assumed the role of the normal person when she answered the phone, normal as blueberry pie. Then, while there, underwent the procedure. When it was estimated that the patient could tolerate it, they were ready for the procedure. On the way to that, they observed it in its effect on others. On their consent, she would individually be approached by three or four personnel who raised them, in this case Francis, above their heads and held her high; they then lowered her to Moira’s breast. She lay there face flushed, as if recently fed. She then opened her eyes and could look at people, including myself. Ordinarily, she was not able to look at me. Here, she was reborn as a person, in accordance with the dictum of Hanbleceya. This faded after several hours, as her nightmare in existence returned. Elisabeth: What happened to her Salvationist figure during her residence at Hanbleceya? Joe: Moira would stray from the strictures of the situation, and he would return to Francis’s consciousness, to be replaced again when Francis reinvested in Moira and the community. Moira gradually eased the patient out of the symbolic connectedness. She did participate with Francis in a ceremony in which they buried part of her father’s ashes in a military cemetery. Also, Francis killed her Salvationist figure in a ceremony. Elisabeth: Francis was there about a year. Joe: Yes. It took a long while, with regressions along the way. Then her Salvationist figure was replaced by a construction the patient called the special forces. I failed to mention another entity in her experience called Rock. Another was a mother figure. She would sit there and never open her mouth.

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Three months after she came to Hanbleceya, Francis started to dream but she hated to bring the dreams to me. They were all connected to death. Then gradually she started to come out with awareness and aspects of her feminine identity. Then came sexual stuff. She turned eager to bring in her dreams. In one of the dreams, she had been on an elevator and a group of people then came to a stop and walked off. She did not know what she was saying goodbye to. She had one dream of obvious sexual import, which she at first denied vehemently. She came in time to ask for it and complained about the untidiness of the files I keep. She went on to establish full relations with her brother and sister-in-law, and eventually moved to a residence in a distant city. Her husband became quite successful as a consultant in hospital matters. At this instant, they corresponded systematically concerning the world that they built around them. Elisabeth: You have played an essential role in monitoring and affecting this patient’s transition from a desperately sick patient, through her residence at Hanbleceya. Joe: During her office visits here, I encountered her and her family, as she came and went. Then came the transition to her residence in a distant city and occasional visits here as a friend. I realize that I have not finished the analysis of this patient, and she has not sought further analysis in the distant city. There is still a state of discrepancy between her and her husband which both transcend psychically. The reality is that she is a grown woman, in love with her husband. There is a discrepancy there and they are in the long process of working that out. In their marriage she was scared to death of a child, and her capacity to care for it properly. She still had a deeply disturbed relationship with men and shuned physical contact with them. When she made a step toward solution of the problem, she became panicky. Then she had to call me, to make sure that I am okay. It was because the panic had to do with her mother; her internalized mother was not there to support to her. One of the problems not mentioned was the onset during the latter part of her life in San Diego of neurologic disorder, a mild form of Lou Gherig’s disease that interfered with her walking, but that otherwise left her mobile by use of a wheelchair. Elisabeth: Instead of her mother’s support, she had you, as you are, in part, a Messiah. Joe: You have played the role of the doctor’s wife in maintaining confidence of the patients. The fact that I have been engaged in this professional activity with your support is an important item in this extended prac-

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tice. You have to have sufficient knowledge of the practice to have confidence in its integrity and effectiveness. Elisabeth: I sensed Francis’s need for access to you by telephone during the therapy. I saw healing, and I saw a mystical component. There was some unspoken reason why Francis, when she first came to see you, was able to burst into tears. She had to recognize that she was in mourning for her father. Joe: This was my intuitometer. Elisabeth: You can label it what you will. You can tell me that it exists 3 inches above or below the navel, and so define it, but I call it mysticism, not something very scientific. Joe: I hold that it needs to be studied scientifically. But there is a mystical component to it. Elisabeth: I’m glad we have the tape recorder on. This admission is sensational! In traversal of the dialogue between myself and my wife Elisabeth, we visited material cited in the course of this volume, redundant perhaps but rendered in vivid form. I hold that the spiritual, which includes the mystical, experienced there is an essential aspect of the phenomenon of my intuitive connectedness, or intuitometer. My wife and I still argue on the role of mysticism in therapy of the severe disorders, and I still hold to the necessity of analysis and the phenomenon of mysticism. On retirement from Atascadero State Hospital I opened a limited practice, home-based. Averaging four individuals, mostly couch borne, it was essentially identical to those in Washington and La Jolla, with one decompensation, calling for family analysis and leading to working with a key member who was tied to the introject in a parapsychologic manner, accessible through dream analysis. Messianism played a large part in rendering the family members accessible. Another, a mental health professional, was highly defended, rendered accessible in a long analysis, through messianism, largely disavowed, and dream analysis. These two patients constituted my last iconic cases and their story will be published in the future. A distinctive feature of that publication will be the collaboration of both in the telling of the story.

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SUMMARY In this volume’s search for the events and concomitant inferences in my life’s careers, the data which I factored into my apperception of reality have taken me to my earliest years and those of my forebears. Before my careers in medicine, psychiatry and psychoanalysis, I was intent on that of historian, an intention in retrospect pervading in the construction of this entire volume. I must mention other careers, such as politics and also ventures into architecture, landscape design, painting and sculpture. At core to these careers, the exercise of epistemology became central in my life purposes. This volume is replete with relevant data, but in summary I shall call and collate them into their significant patterning and its underlayment of inferences. In the earliest event to my memory I searched intently at a plume of steam coming from my mother’s kettle, reaching out and pulling it down for closer scrutiny. The result was a scar on my chest and a lasting memory. Was I striving or driven? Did I simply want to know or did I have to? In striving I would be simply myself and curious, on the way to an identity as a scientist or perhaps a novelist connecting meanings in life. I would have a wider range of options then in the compulsively driven state. I would be relatively free from outside interests, to whom I would at least in part belong. I was cognizant of the issue of effective autonomy, of being my own person not long after that incident when I charmed the trolley man to take me to the end of the line, the Hartford zoo. That independence of mind and enterprising spirit would be a natural extension of the original curiosity. The following events, deemed significant, have been extracted from the text of this volume, in the course of which we shall re-traverse its most important elements. It is followed by the story of my discoveries in psychoanalytic theory. Then I paint a picture of prospects for expansion of psychoanalysis and its applications based on innovations depicted in the text. Finally I present leads to further research, with particular reference to neuroscience. I have related events in the text which, from the earliest to recent, comprise the history of my career. Intertwined are inferences themselves achieved during the writing of this book. In fact, the last two were arrived at during the cogitations attending this summary. Out of the complex of factors contributing to my success in treating psychopaths were two: a sense and state of transcendence in which I was impervious to danger, physical and emotional, that is. In my lifetime self-analysis I had discerned its origin that stemmed from my earliest years. Messianism accounts for the emotional component and disassociation from pain the rest. My inquiring mind, protected from anxiety and pain through its capacity for transcendence served me in good stead in assumption of a superordinate role as my mother’s helper. It was not until I had assumed a position of

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considerable responsibility as a psychoanalytic reoriented therapist in an Army rehabilitation center that I realized the core identity to that helpful role was as my mother’s Savior. My inquisitiveness, a marked characteristic of both of my parents, may be more than happenstance. My mother had received a severe drubbing from her father for having inquisitively disassembled his cuckoo clock. My father set about as an immigrant learning about this great country on foot as a peddler. I have a proto-memory of wide-eyed astonishment, held in my father’s arms as he sat on his motorcycle speeding through the Texas countryside. Later I repeated that experience with my younger brother on my bicycle. Seated alphabetically in front of the class, I transposed my relationship with my mother to that with my mentors, excelling. I imagined my way through careers as a cowboy, ballet dancer, Indian fighter, and frontiersman, pushing ever westward, secretly exulting in my Texas origins. Then came science, history and serious literature. My inquisitiveness and quick mastery of that material resulted in close working relationships with my mentors. Towards the end of high school I chose history, receiving a scholarship to a major university, Cornell. Leaving home then would have been attended by severe guilt on my part, to be discerned later as survivor’s guilt. Since my mother was mired in a severe depression at that time, I instead chose medicine as my profession, on reading the novel Arrowsmith by Sinclair Lewis. Like him, I was set on conquering epidemics. Instead of quelling epidemics, I was surprised to find that the psychotic and psychopathic patients I was assigned to interview for my sophomore psychiatry class responded willingly to my untutored interviewing attempts. My presentation in class of those experiences was touted by the members still at class reunions. Alongside my medical staff training as an intern, 1939-1941, I engaged in the extensive and intensive study of the rise of fascism in Europe, the far East, and also the United States. This project was to be based on a collection of data consisting of the pictures of events, in this case a massive volume of clippings from the New York Times. An underlying identity as a warrior, having to do with an ancient Jewish tribal role as a caaen, the priestly warrior class in ancient Israel, emerged first when I joined the Army at the end of my internship. I found myself to be a capable administrator and leader of a medical detachment of a tank destroyer Battalion. As important was my role as a trainer of my men in their version of the profession of military medicine. Training them in my stead were I to become a casualty brought about the mastery of the leadership required, both organizational and individual that prepared me for my next wartime challenge. I was to have full exercise of the emotional component of my new profession of military medicine when I was assigned to the group therapy at the

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rehabilitation center for military prisoners. Instead of dealing with injury and illness of the 1200+ men of a combat battalion, my task was leading an equal number of alienated rehabilitees. At this point in the summary I wish to pause to note what I conceived to be the major crisis in my personal and professional development. I have a clear memory of my malign intentions towards my brother, conceivably an early manifestation of psychopathy. It went underground, beyond the reach of messianism, reinforced by my mother’s approbation and need. This underlying tendency surfaced as an epiphany when I stood, transacting with a boisterous group of young psychopaths, as an affiliate of sentiment and the thought, “these are my people.” Earlier, in my juvenile phase I had wished to become a member of the Cherry Street gang in the Lower East Side of Manhattan for their expression of youthful exuberance and manhood but not to join them in antisocial acts. It is my thesis that my intent was influenced by a favorable experience with a psychopath at the Atlanta penitentiary as a medical student. The strength and clarity of that intention, coupled with a well-developed plan leads me to believe now that this malign, even Satanic aspect of my early personality was at least equal to the manifest benign, messianic aspects. My original malign profession toward my younger brother was replaced by that of psychoanalyst, on a curative mission. The training I had received from my parents, teachers, contemporaries and on my own was now being directed toward the war effort in quelling a monstrous threat from abroad and in advancing the democracy my parents and I had learned to love and to live for. The Fort Knox venture prepared me for that at Howard Hall in St. Elizabeth’s in Washington D.C., the nation’s capital. I had experienced what I came to call my intuitometer, and learned to trust it as a scientific instrument through asked conceptualization and experimentation. The same went for the profound transformative experience of the rehabilitees and the reality of their successful embarkation on pro-social courses. I was fortunate to have a commanding officer at Fort Knox and superintendent and clinical associates at St. Elizabeth’s who were consonant in values and action, resulting in transformation of alienated populations through a combined psychoanalytic approach. A significant segment of the clinical staff, composed of a broad array of allied mental health disciplines backed by a progressive and farseeing superintendent, Dr. Oberholzer, took initiative toward a combined multidisciplinary group work training program. At core here the chief nurse, Lavonne Fry, and I conducted for a decade a multidisciplinary professional identity analysis group, essentially psychoanalytic in nature, which gave its members the opportunity to sort through current and past experience, discerning genetic determinants. The result was an analytically-based practice in matters of

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the members’ ego ideals and that of their subjects. There was frequent traversal of traumatic experience analogous to that which I had encountered in my professional development. A basic research interest at Fort Knox had been the population that was intent on alienation. An exemplar had courted this in assertion of such. As he lay, pieta-like in my arms, dying of a gunshot wound that he had invited, he stated to me on my inquiry as to why he had got himself shot, “Captain, I had to.” Exploration of profound alienation became a central focus in my work subsequently, a centerpiece in a research endeavor reported in my book Maternal Dependency and Schizophrenia. The mothers and daughters there, at first completely alienated from one another and from themselves, yet inexorably linked and enabled by the group process, made significant movement toward reconciliation with themselves and one another. I later inferred that the tie was that of survivor’s guilt, and that the core element to the group process was messianism. A bone of contention in my psychoanalytic training at the Washington Psychoanalytic Institute had been my tendency to treat schizophrenics in groups, in contradistinction to the dictum of Frieda Fromm-Reichman, a centrally significant mentor. She subsequently attested to the validity of the work by visitation to my mother-daughter group. In my practice, I became group proficient in leadership of troubled couples and families. I learned to focus on the ego ideals of the members and their vicissitudes as they traversed their marital careers. This pattern which constantly appeared, that of mutual creation of a mythically relevant ideal, soon to be replaced by disillusionment, was itself replaced by renegotiation of more realistic and mature nature. A series of cases, couch-borne, revealed an internal encounter, exemplified and attested by an active dream life. There a tie to an introjected forebear, impervious to reality and of imperative nature, yielded to the analytic experience. These patients had achieved a messianic transference to me, which allayed anxiety that would have been of overwhelming nature. I discerned a similar systematic pattern, in which the experience was heralded by what I came to call the advent phenomenon. The first patient in this series had a dream in which her dead grandmother, whom she had idealized and strangely had not mourned, appeared as a hooded figure on the crest of a hill, then halfway down the hill, then confronting her, revealing her face in death, entering her psychically and presumptively left. Mortified, the patient in horror began to cry, initiating a flood of tears. This was a screen memory in fact, for the death of her mother before she could remember her. Culminating this series was the analysis of a middle-aged patient whose father appeared as a ghost following his funeral. In time, and after much resistance, this patient experienced his father as a rotting corpse within him. Then, separated by compulsive flight, he revisited himself, through analysis

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and the analytic couch, entering deep mourning. Jumbled together there, yet increasingly clear, were elements in his forebears that resulted in his construction of a personal myth of transcendence of what would otherwise be a mundane and meaningless existence. He was aware of a “hole in his soul” previously occupied by an introject, that of his parents, entwined and not yet alienated. Discovery of this conundrum was the answer I had sought since transacting with the dying prisoner at Fort Knox. It is my inference that this patient’s act of courage and perseverance, enabling him to face tremendous guilt and absolute terror, enabled my unconscious to do likewise. At this point in my professional development, I myself, a decade after completion of my second analysis, apparently grasped the nettle in a dream of death in the coffin. Were I to not accept this psychic death as a fact, it would through psychosomatic process, become fully organic and result in my physical death. Analysis of this and a series of dreams of death and restitution revealed cognizance of my tie to my mother, who had been tied in a messianic manner to her mother. My association train also led me via cognizance of my messianism to further study of the myth of narcissists and the man-God relationship. I had already embraced a comprehensive view of myth beyond Freud’s Oedipus. I employed myth and legend in typifying the characters in a piece I presented at the American Psychoanalytic Association meeting of 1957, on group and individual psychoanalysis. It and its inferences were rejected by official psychoanalysis. Identifying with Freud, who had found himself alone for a considerable period, I persisted in my researches, accumulating detailed histories, and I sought a hiatus in my practice, to assemble my data and inferences towards publication. I had chosen the locus of a sabbatical, California, but marital difficulties placed this out of my reach. Instead, I reconceived it as a testing ground for the validity of several ideas under development. I considered my work so far to be basically psychoanalytic, in the spirit of the Freud who had written group psychology and analysis of the ego and who had pioneered in views on the nature and destiny of man. The Washington Institute of Psychoanalysis had asked me to teach advanced students my theory and method in the utilization of groups toward fitting the patient for standard analysis. On that basis I joined with nine other founding fathers to start the San Diego Psychoanalytic Foundation, of which I was secretary, then the San Diego Psychoanalytic Institute and Society. Central there was transaction with psychoanalytic colleagues in the establishment of a new Institute. It turned out that the need to adopt Orthodox positions was dominant and, unlike the conflict in Washington, I was not able to reconcile my frame of reference with theirs, except for their utilization of my group expertise in traversal of a potential split. My workshop method had

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been adopted by the Washington Institute to avoid several tendencies towards a split. My method of combining individual and group psychoanalysis, analytic treatment of troubled individuals, couples, and families, also intervention in a private and public mental hospital, conform to the patterning experience in the Washington phase of my career. Review of Theory Development I had begun my career as a psychoanalyst in an unusual manner. I had by now achieved competency and recognition in the psychoanalytic, theoryoriented treatment of two conditions considered impossible to treat with psychoanalysis: psychopathy and schizophrenia. I had already received initial training in the disciplines of history, biology, and modern physics. I experienced myself as possessing an intensely individual frame of mind, yet willing to subject it to Freud’s associative process and his dream analysis. His defense analysis and engagement in myth and data from anthropology, history, and folklore made sense to me. Formulation of my own theory began with my assumption of professional responsibility in charge of group therapy at the Fort Knox rehabilitation center. I had noted that as the groups progressed they also underwent Freudian regression systematically. Leadership-followship patterns were in exemplification of inherent issues. Polarization about those issues followed a pattern of thesis and method, and synthesis was manifested by arrival at deeper levels of inquiry. In this polarization, a dialectic appeared regarding the nature of experienced reality. Along the way, I noted the experience of intuitive connectedness, between me and the members of the group, and they with one another. Discussion of these phenomena with my team and our commanding officer resulted in consensus on these important matters. Further, they accepted my concept of messianism for each enabling character. In his Group Psychology and Analysis of the Ego Freud had not dealt with this small group formation. Yet fears arose concerning the investment of large group leaders with royal and religious qualities, matters that he related to the ego ideal. Loss of that connectedness would result in disorganization and loss of meaning. One could infer a relationship between this social phenomenon and that of the individual psyche. At Knox we made that connection in more definitive terms. When the members relinquished their psychopathic stances and defenses, they regressed in disrepair through states of depression, psychosomatic states, and borderline psychosis. This was transitory to entrance into consensual reality and they became cooperative and collaborative in the real matters of their lives.

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We theorized that they had, through some unspecified trauma, transcended that state through assumption of psychopathic stances and defenses, into a centralized world of psychopathy. This they had appeared to idealize, and adhere to through a code of perverse loyalty. From it they had looked down on our world of reality. We had known then of the legend of the criminals on their crosses, placed alongside the Christ on his. It was only later, in collaboration with pastoral associates, that appreciation of that conundrum was reached. It was that the psychopath was inherently affiliated with the Messiah without and within. This would explain their ready crossing over in our groups. I had found along the way that discussion of these spiritual matters was stoutly resisted by my psychoanalytic colleagues. But they admit that Freud originally called the ego by the German word seele, for soul. My study of soul phenomena became to be innate in my career. It began with my dream of death in the coffin, and thenceforth inherent was the urge to call my soul my own. I conceived of its existence at the core of my personality, and its nature to be both simple and simply complex. In the latter category, I would include its qualities of good and evil, base and sublime. It could create and destroy worlds. There was an inherent drive toward humaneness. I conceived this soul to exist at the core of the ego ideal, yet at times to encompass the entire personality. This would occur at times of spiritual crisis. In my study of intuitive connectedness, reported in the psychoanalytic review, I conceived of transaction of souls through the intuitometer phenomenon. SUMMARY OF MY EXPERIENCE WITH THE ICONIC CASES To repeat the previous data on this crucial subject, I intend to collate then correlate the phenomena attendant on the vitally significant mourning process in my iconic cases, when they freed themselves from their narcissism thrall in which they belonged to the introject. The patient of my first iconic case lost her mother due to death in childbirth and subsequently formed a symbiosis with her grandmother that resulted in incorporation of the essential aspects of the grandmother’s character. The intrapsychic transaction was exemplified in the dream sequence in which a ghostly figure appeared on the horizon, then back halfway down the hill, then confronting the patient, then revealing her face, throwing off the bird, to be that of her dead grandmother. The ghostly presence then approached and entered into the being of the patient. Then followed separation from it and the inception of crying on the part of the patient as she related this dream sequence. I have theorized that the appearance of the ghost presages the mourning process.

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The turning point in iconic case number two occurred in a most dramatic fashion on the floor on the isolation room at George Washington University Hospital. There the patient hallucinated his father’s image as a face in front of him as he stared straight ahead, the Dr. seated on the floor by his side. He had been placed in the isolation room by personnel as a precaution for his safety, as he was in an agitated depression and could have harmed himself. The patient pointed and stared at the image and was thereupon plunged into grief manifested by convulsive sobbing. Consequent to the mourning he became coherent. Iconic case number three can be characterized by the occurrence of a wisp of the ghost of her mother behind the door. The patient was situated on the Dr.’s couch, engaging in a rehabilitative enterprise with him, subsequent to discharge from Chestnut Lodge for a psychosis in which she engaged incessantly in utterance of gibberish. She reported awareness of an entity just behind the open door to an adjoining room. The doctor looked for it and reported nothing there. She insisted that she had seen it peering at her. She thereupon plunged into profuse tears. The gibberish ceased, with assumption of clarity of consciousness and a capacity to live in reality. In iconic case number four, the young physician had experienced a ghostly presence of his father clad in his burial suit, on the back-seat of his car as he drove from his father’s funeral. Thereupon ensued a state of insomnia and anxiety which resulted in a career of addiction, led to by the use of medication. The patient was obtusely resistant to psychoanalytic intervention until hospitalization in a therapeutic community engagement. There the patient’s messianism invested in an encounter in caring for an older man who resembled his father which led to an experience of the image in sleep of that father as a rotting corpse within him. Awareness of this internalized object was attended by massive affect and self-revulsion. He compulsively fled from himself propelling out of bed, injuring his knee in the process. After a period of restitution, he was recounting this dream. On reaching the awareness of incorporated father he began the morning in profuse manner, after which he recovered and became a very sober citizen. This patient had striven mightily with two previous analysts to deal with his inability to mourn. It turned out that the problem here as with the previous iconic cases was a disjunction within the psyche of massive proportions, amounting to splitting, in which the locus of identity of the patient conjoined with the introject in a manner in which separation would result in survivors guilt. In iconic case five, characterized by mother’s and daughter’s conjointly beating hearts, the female patient sought therapy for a depression which interfered with her relationship with a daughter who was just beginning to become a person on her own. As in iconic case number one, long analysis of characterologic resistances resulted in data from her unconscious through dreams, relative to a relationship with an introjected mother and the mourn-

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ing of this mother’s death. Here however, the mother was experienced as a part in a sack that contained both patient’s and mother’s beating hearts. Such experience resulted in the patient’s reaching her own heart which had been exterior. Awareness of her alienation from herself and accepting the death of her mother and consequent mourning followed. She then recovered from her depression. The advent phenomenon central to iconic case number six took the form of adjoint hallucination/delusion of a messenger who was in command of a helicopter which would bring the patient to the place of safety on the mountain where her dead father, still alive, resided. She had had therapy with an analyst previously, deciding to kill him so that he could then go in the helicopter with her father and help out. She recognized inappropriateness of this and exceeded to her husband’s remonstration that a change of geographic locations was necessary for that analyst’s safety. In accounting for her situation at the inception of her work with me she inadvertently cried of her father’s death. This sent her into a semi-panic and the inception of anorexia, with subsequent hospitalization for it. I was fortunate to have the collaboration of a therapeutic community, spiritually based, in which the patient was able to invest in reality. A messianic director of that community was capable of entering into comprehension of the patient’s internal psychic drama, and struggled with her concepts in the perception of her internalized father and the savior figure she had created. Patient then gradually yielded to investment of such in both the director, the therapeutic community, and the Dr. She accepted, and mourned the loss of her father and to a certain extent revealed nightmare like transactions with her mother. We did not achieve the iconic transaction with the introject, as in the other cases, but the patient did achieve a platform in reality, on a compromise basis. This survey had led me to the following, through its systematics. Regarding the nature of the introject concept involving conjunction of souls, the essential nature of our parents in ourselves is central. Hamlet sensed his father’s soul torment and experienced his command as imperative, and in accordance with the relation of fealty between the generations. In earlier phases of civilization the individual belonged, body-and-soul, to the group as an ideal, and to God and God’s representative, the Emperor and later the Pope. In plying their troth, people falling in love transact in this mode. In such authoritarian mode Hamlet belonged to his father in body-and-soul and had no choice but to vindicate him. Were he to violate this he would then be told listing existential guilt and subject to immolation by society or self. I apply this paradigm to the tie in transaction between the individual and introjected parents, first mother then transferred to father, of the theist and then neonate. Central there is a presence of an incorporated memory of phases of symbiosis and personal nurturance, with its inherent reciprocity. Experience of mutual confidence is an important fact. With that as the infra-

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structure to the intra-psychic, personal, and interpersonal relationships, the individuals involved can embark further on their developmental careers. In this version of attachment theory the patient would experience threat to its very existence when it attains its separate entity that is akin to that of the survivor of the concentration camp. A corollary state of guilt was posited by Melanie Klein, then her daughter Melitta Schmideberg, in reference to the attainment of a separate state of orality with potential harm to the nipple by a frustrated infant. In the annotated bibliography to this volume, I have included much material on the spiritual and existential guilt pertinent to the tie to the introject, extending the work of Melanie Klein in her pioneering conception of the early genesis of guilt in the human constitution. FUTURE PRACTICE OF PSYCHOANALYSIS AND EXTENSION OF THE PSYCHOANALYTIC METHOD TO ALLIED FIELDS Psychoanalysis is changing rapidly in the direction of my career, with the employment of family analysis, couples’ therapy, and conferences/workshops towards reform of societies and institutes. Had I remained in the Washington area, I would have followed through the invitation of Dr. Alexander Halperin to institute group psychoanalysis at the Washington Psychoanalytic Institute. Since then that Institute has been transmuted into a Center, progressive beyond my vision at the time. It is but a further step to the development of a comprehensive employment there of group analysis in various aspects of the training and functioning of the center. An associate of Freud, August Eichorn, who had engaged in a form of group analysis of delinquents published as Wayward Youth, was an educator who became a prominent member of the Vienna Psychoanalytic Society before, during, and after World War II. Farseeing and far-reaching, he might well have applied his method to the professional identity of young educated students in a Viennese University. Under the thesis that mobilization and refinement of the underlying ideals of the young professional should be an inherent exercise at the initiation of professional training, I engaged in the pilot course reported in this text. While in Washington I made initial moves toward such a course in an engineering school in that area. Such a course would be advantageous in the fields of business, law, and government. I have noted in this text work done in the professional identity of the politician and political activist. Beyond that there is the issue of the development of politics itself as a true profession. That would involve systematic training of the aspiring professional in their professional identity, reaching into its personal aspects. Along with this would come training in group and analytic dynamics, and relevant anthropology and sociology.

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In the course of my work at Atascadero state hospital, a forensic institution, I received training in the continuous quality improvement methodology, an outgrowth of the work of an American statistician, C. Edwards Demming. Demming’s work was both educational and transformational, centering on the formation of transactional groups termed quality circles. Although highly structured in inquiry, the basic transaction was centered around brainstorming, a free associative method most likely stemming from Freud’s work. To a certain extent, I succeeded in transacting psychoanalytically in the Demming type of group work. Further Research It appeared to me from the first work at Fort Knox that there was profound change in the rehabilitees as they traversed the therapeutic experience. That change was undoubtedly accompanied by changes in the central nervous system, now accessible through imaging. My long experience with intuitive connectedness convinces me that we will find systematic central nervous system changes again, as the patient and therapist traverse significant psychoanalytic sequences. The role of psychic death in the sequences could well be pursued, along with relating it to the known chemistry of death. My book, Maternal Dependency and Schizophrenia, was in the mid-’60s subjected to factor analysis of the Stephenson variety. Significant statistical changes were found in the mothers and daughters as they traversed the therapeutic experience. This gives a link between the test of therapy and other aspects, such as intuitive connectedness, brainwave changes, and imaging. Summary Conclusions From a jointly personal and professional platform, sociological and psychoanalytic in nature, I have experienced a seven decades plus career, combining private and institutional practice, research, and educational ventures. Pioneering from the first, based on genetic, familial and cultural determinants, this career has been marked by systematic crises, accompanied by discoveries of psychoanalytic and sociological import. These crises have been inherently transformative, first in work with psychopaths, then schizophrenics, resulting in inadequate training in treatment of multidisciplinary nature that in turn brought me closer to its essentially professional mission. Embodied there was a small group function, termed professional identity group analysis, a form of career psychoanalysis. Occasioned there was the identification and working through of developmental arrests brought about by psychic trauma. I found this forum of career analysis useful in work with troubled couples and families, also the lesser morbidity of neurotic patients.

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Wherever possible, the group analytic experience was combined with standard psychoanalysis of the individual. Phenomena consisted of intuitive connectedness of major import, multi-generational ties via the introject, messianism, and a variety of forms of disassociation, culminating in alienation. Finally, I engaged in self-analysis life- and career-long, preceding and following that of my patient population. In sum, I led and was led, into a state of reconciliation, from self-alienation. Along the way, I encountered a genuine surprise, the appearance of the spiritual, along with the scientific.

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Messianism and the Essential Nature of Psychoanalysis A Talk by Joseph Abrahams, M.D.

A CLUE AT THE BEGINNING: FREUD’S SEELE Psychoanalysis is a scientific discipline devoted to the study of the human being per se, with emphasis on interior life, and its relationship to reality, social and physical. Derived from direct and consensual observation, its theoretic constructs have undergone progressive and increasingly rapid change in its more than a century of development. Clamorous, competing theories abound. Psychoanalysis has centered its inquiry into that which was consensually known, but more so, consciously unknown to the individual and his groups. This has been done through a method of self-disclosure termed free association, also systematic examination of the content of altered states of consciousness such as dreaming life. To ensure a stable, consensual platform for scientific observation, it has structured the studied transaction to control distortion and an inevitable psychic regression. In the modal process, analyst and analysand are on the alert for evidence of data carried over or transferred from the past. That admission to consciousness paves the way for intra-psychic and interpersonal reconciliation. A working relationship is developed, termed the therapeutic alliance, with components analogous to apprenticeship elsewhere in human endeavor—medicine, the arts, politics, education, religion, industry and the physical sciences. Given the complexity of the data and differences in the observers, collecting data and developing hypotheses for a science of man has been difficult. 249

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In initiating his new science, Freud attempted to be exact in word and concept, limiting practitioners to only those most trustworthy of temperament and accountability. Nevertheless, schisms resembling those in religion soon ensued. The core problem may have been exemplified by his use of the word, seele, to designate the word ego, central to his new lexicon. Seele is the German word for soul. Freud accepted his translator Strachey’s designation of ego for seele, ostensibly as more scientific. Had the scientific study of the human soul been the central task of psychoanalysis, it could be that alienation in the ranks of the early analysts might have been avoided, and the soul of the matter, a spiritual core to the discipline, have undergone collective scrutiny, the generation of hypotheses and their testing. Such an hypothesis is that of messianism, the saving principle for resolution of problematic aspects of the human condition. Related to the Freudian eros and the original thesis of the seele, or soul, it is linked to the Freudian mental mechanism of sublimation, and to orders of complexity experienced in multiple worlds within reality. Conceptualization is similar there to that of quantum theory of physics, which led mankind into the wonderland of particles and their ostensibly bizarre properties. Freud essayed into this then alien aspect of reality in his queries on parapsychology. My thesis is that Freud had a way with words and instinctively and naturally used seele to designate the soul of the matter, the ego or self. He evidently found spirituality alien to analytic inquiry, despite an encompassing interest in mythic experience. SEELE AND INTUITIVE CONNECTEDNESS This author encountered the phenomenon of messianism, a step away from study of the soul, early in his career, in the course of World War II group treatment of delinquent young adults. The Army’s experimental treatment prison was led by an Army Colonel, George Miller, an educator and graduate of the Army War College, who had studied and followed the work of an associate of Freud, August Aichorn. Aichorn had pioneered in the postWorld War I group treatment of delinquent youth. I was associated with Lloyd McCorkle, a sociologist trained by Clifford Shaw, himself a pioneer in community intervention in Chicago. Mobilized to self-expression and leadership by the wartime emergency, and without overt action on my part, I experienced identification with the psychopathic group members on the basis of “These are my people!” At the same time, the prisoners in the groups grew poignant, intuitively connected with one another and me. They then yielded their rebellious ways, appeared contemplative and cooperative. They had left their psychopathic reality for ours. Remarkably and concomitantly, I experienced the intuitive connected-

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ness in my chest, under my sternum. They had left psychopathic reality, entering ours. I had a glimpse into my psychopathy. Something essential in the relationship was the variable in the puzzle, and it occurred to me and my associates that a spiritual component was active. “Scratch a psychopath and find a messianist” entered our parlance. We began study of this phenomenon in our practice, the conditions, intrapsychic and interpersonal, of its emergence, and its consequences. It appeared to be related to, yet independent of the religious belief systems of the practitioner and subject. None of us was religious. It appeared more related to character formation and alienation from self. The most alienated and malign of our subjects was also the most motivated, assuming leadership of a wartime riot in a military setting, sacrificing his life for psychopathic ideals. He motivated me to longtime study of his character malformation, the satanic side of messianism. He was the very soul of hatred and alienation, who at the same time was salvationist to his fellow rioters. MESSIANISM AS RESISTANCE IN ANALYTIC TRAINING My subsequent mentors in psychoanalysis resisted recognition of the phenomenon of messianism, except as a manifestation of a narcissism that was strangely resistant to analysis. I accepted that it was a core component of my personality, but also, failing its analysis in my formal training, relied on it in subsequent work with psychotic and psychopathic populations, carefully recording my findings in my practice and self-study. The latter centered on a dream diary, inspired by Freud’s dream book. All the mental mechanisms I studied in my apprenticeship made sense to me, especially sublimation, a higher order of altruism, which came close to the messianic hypothesis my men and I had developed. I located my messianic impulsion in the Freudian ego ideal. In time, I conceived of the ego ideal as resident in a core seele. Concomitant to analytic training, I pursued work that in large part attempted to replicate the momentous wartime advances. Having experienced the clinical value of therapeutic community, I consciously pioneered in a number of group modalities—family, couples, group therapy, professional identity group analysis. The use of the group in treatment brought me into conflict with my mentors, then my fellow faculty members. Throughout, I pursued what I conceive to be the self-determined course of Freud, following the lead of the data that presented themselves, as he enabled his subjects to free associate, dream, and figure out and alter reality with him. Five years of training analysis by two analysts failed to make a dent in my messianism, followed similarly by five with another to cope with a mid-life depression. Then, at age 50, a series of death dreams opened the door to

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mourning regarding tragedy in my family of origin and the one I had made, which had ended in divorce. It became evident to me that I had undergone psychic death early in life, and that my abundant energy and altruistic initiative were resurrective. The first of the death dreams was instructive. I was in a coffin, dead. The lid was on, and were I to fight it, I would really die. So I decided to study the situation. Free association yielded the question, how long I had been thusly dead. The answer from my innards was, all my conscious life. What had killed me? My mother’s identification with her mother who had died of cholera in Europe when I was 2. She overcame her depression by willing a daily resurrection. I did likewise, within my character. I asked myself, If I was so good, what about my evil impulses, such as fratricide and patricide? Answer: Like in the Savior myth, my personality was linked to that of psychopathic criminals, who were martyred alongside on a mythic cross, seemingly abandoned by their Deity. God and Satan, messiah and the evil one went hand in hand. It took years of self-analysis to work through these spiritual issues. My messianism had enabled me to form mutative relationships first with the wartime psychopathic population noted earlier (reported 60 years later in Turning Lives Around: Wartime Treatment of Military Prisoners, AuthorHouse, 2006); attainment of a therapeutic relationship with a group of mothers and their schizophrenic daughters (Maternal Dependency and Schizophrenia: Mothers and Daughters in a Therapeutic Group, International Universities Press, 1953); then initiation of a therapeutic community at a maximum security hospital (This Way Out: A Narrative of Therapy With Psychotic and Sexual Offenders, University Press of America, 2009); treatment of depressive and schizoid disorders in private practice utilizing modified individual analysis, group analysis, couples therapy, and family analysis (Report of a Panel on Group and Individual Psychoanalysis, American Psychoanalytic Association, J Am Psa, 1957). Joint clinical work with Rev. Charles Jaekle and associates of the Pastoral Counseling and Consultation Centers of Greater Washington brought me into open discussion of the existence and clinical significance of the soul. An initial essay into the study of messianism resulted in the volume, The Messianic Imperative: Scourge or Savior, XLibris, 2007. Further study resulted in another work, A Passionate Psychoanalyst: Poems and Dreams, XLibris, 2007. My clinical work and self-analysis has led me to recognition of the centrality of Freud’s death instinct, except as the phenomenon of a death experience. In a grand scheme, Freud combined death, Thanatos, with its dialectic opposite, Eros. Clinical experience does that with a depressive-mania duality. In my hypothesis the individual, early in life, intrauterine and subsequent, undergoes severe privation to the point of psychic death, then resur-

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rection. In mythology, itself a manifestation of underlying psychic genes, this story is told again and again. Freud formulated the death instinct late in the psychoanalytic day. It is of moment to review the struggles of generations of psychoanalysts to conceive of the nature of the autonomous human entity, the ego or self, that Freud first designated as the seele, following alienation from the spiritually relevant concept of soul. Contributors there have been Hartman, but more so, Erikson with his schematic of a lifetime identity concept, within which the individual and his group pursued careers. Seminal to dream analysis has been Erikson’s Dream Specimen paper, in which he carries the reader through a deep epistemologic exercise in true Freudian manner. Other contributors to the psychosocial concepts were Berne with the beginnings of role and transactional theory, and Sullivan with an interpersonal construct. The Freudian enunciated concept of transference and countertransference dealt with the core issues of intergenerational transaction. Klein addressed herself to the role of the underlying maternal-infant transaction, and the generation of oral guilt, an earlier version of Freudian oedipal guilt to which I have linked the soul issues of the messianic hypothesis. My clinical work has pointed to the ubiquity of a character-determining introject, leading to construct by the individual of a personal myth. Within that paradigm there is a degree of messianism, inherently both reconciling and alienating. Shakespeare saw into that conundrum: Hamlet’s life is obviated in the course of fealty to the haunt of an introjected father, experienced in an altered, dreamlike state of consciousness. We all face our forebears, for autonomy’s sake.

My Contribution to the Psychoanalytic Literature

My contributions to the literature of psychoanalysis began with a study of the dynamics of a group of mothers and their schizophrenic daughters, Maternal Dependency and Schizophrenia: Mothers and Daughters in a Therapeutic Group, International Universities Press, 1953. The altruistic drive of the mothers rendered them emotionally unavailable to their already altruistic daughters. Both had saved themselves, messianically. The next analytic exercise was in recapitulating the work done at Knox to a civilian institution. There we were able to employ patients in each other’s treatment, in an exercise of mutual messianism. This was published six decades later as This Way Out: A Narrative of Therapy With Psychotic and Sexual Offenders, University Press of America, 2009. A report to a panel on group and individual analysis, at the American Psychoanalytic Association of 1957 featured the treatment of neurotic women, from the perspective of analysis of their personal myths and dream life. The field of group therapy of severe disorders was the subject of a chapter in Scher’s book in 1964. An analytic concept and practice, that of Professional Identity Group Analysis, was employed in the training of medical students and also an array of disciplines in a mental hospital. Psychoanalysis was applied to mobilizing and energizing political formations in Democracy From The Grassroots: A Guide to Creative Politics, XLibris, 2005. The poems and dreams of the author were reported, in the context of his life course, in A Passionate Psychoanalyst: Poems and Dreams, XLibris, 2006. A general cultural presentation of the messianic hypothesis can be found in The Messianic Imperative: Curse or Savior? XLibris, 2007. The role of intuition throughout these works is presented in 255

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My Intuitometer: Evidence and Inference, Psychoanalytic Review, April 2005.

The Professional Identity of Medical Students

In sum, my experience with the prisoners at Fort Knox, and the hardened psychotic criminals in Howard Hall had demonstrated the presence of idealism underneath their perversions. Then, the regular, systematic opening up of their very souls of the 30 some-odd participants in the professional identity group of the group work training program at St. Elizabeth’s convinced me of the role of idealism in professional careers such as a professional thief, murderer, or doctor. This led to the professional identity analysis group described in the following pages. I presented a two years’ experience in A Pilot Course On the Professional Identity of the Medical Student. Experience in the course recapitulated the previous work in training groups, in which the group process eventuated in an intensive encounter centering about problems in personal aspects of professional identity. The rapidly growing literature in the field of problems in the education of the medical student was discussed. I hold that the group experience not only increased the adaptive capacity of the medical students, aiding in traversal of their course, but gave the indication of aid in dealing with elements in their professional identity which resulted too frequently in morbidity. Medicine is changing swiftly and profoundly, and the physician, himself changing, finds his identity as a professional tried as never before. The institutions of medicine built around his autonomy and authoritarian control of his “case” had now given way under the impact of democratizing social changes and of advances through research and technology. The physician is paradoxically coming to work with the patient as a whole person and the subject of a complex of specialties. He is more of a member of a team of equal and necessary disciplines. 257

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As the physician and his institutions change, they face the task of reformulation of old and evolution of new ways, while preserving their idealism and high traditions. This is difficult enough for the graduate physician, let alone for the neophyte, without the preceptors of old to guide. The changes are often attended by a sense of loss and isolation, frequently outrage, except when the persons involved participate directly in them. While most sensitive to this state and to defects in the ideals and performance of his models, the beginning physician is himself bearer and initiator of changes in the field. Dealing with the hazards and challenges of this interface, of simultaneous negotiation with the old, and nurturance of the new, calls for systematic close-in work with the young doctor. The central task in such work involves a consciously guided learning experience whose focus is on the core aspect of the problem, the identity of the medical student as a professional. The transition to professional status is a complex process involving a deep and meaningful negotiation, a mutual and reciprocal investment by the training institution and its faculty. There is a centrally important renegotiation within the components of the student’s personality. The training consists in part of retraining of the set of role expectations the student transfers to the training situation. There is relinquishment of inappropriate role expectations and introduction and affirmation of appropriate ones. The outcome is development by the student and faculty of a sense of identity, a sharing of versions of common ideals, sentiments and self-concepts. Traditionally, the work involved in these transactions has been informal and unsystematic. Specifically, the arenas of learning have been the loci of confrontation with the patient—ward rounds, examination room, operating table, increasingly rare house and ambulance calls— prepared for and assimilated in classroom, conference, bull-session and solitary study and counsel. There is increasing recognition of the tasks of student and faculty in this necessary process, of what the sociologists call the occupational aspect of adult socialization, and the formulation of specific enabling experiences. The author presented their findings with one approach to the subject—a seminar with a group of students on their personal concerns in their professional training. In this presentation, first the concepts found useful in approaching the subject and working with the group were traced through the literature. A few pertinent reports of similar training ventures were presented. Inherent in a study of this sort was the question of the enormous stress and morbidity suffered by physicians in their medical careers, and the responsibility of the faculty and students in coping with the problem.

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BACKGROUND CONSIDERATIONS AND A REVIEW OF THE LITERATURE For the purpose of this study, the recent literature is divided into four categories: 1) The nature of the profession of medicine; 2) The concepts of identity and professional identity; 3) The process of medical education; 4) Innovations in training. The Nature of the Profession of Medicine Sociologists and physicians contributing formal studies to the literature on this subject, Flexner, Carr-Saunders, Sigerist, Parsons, Merton, Bloom, and Moore, generally have agreed on the characteristics of the profession of which they hold medicine to be a prime example. These may be summarized as (1) prolonged specialized training in a body of abstract and applied knowledge; (2) service orientation; (3) self-governance and autonomy of members in practice; (3) superordinate responsibility for decisions on the nature of the problem and solutions. In regard to the latter, Parsons emphasized the importance of ascribed and primitively determined values such as savant to the physician, noting that the achieved aspects of the role needed to be brought to the fore in modern medicine, modulated by the profession as a scientific enterprise. Bloom, in a comprehensive text, A Doctor and His Patient, pointed out that the essential aspects of the medical profession in modern times can be discerned in primitive medicine and as an institution, definable like others in society. This institution deals with important aspects of life, morbidity, death and healing. In primitive times it dealt with object intrusion, breech of taboo, and witchcraft, the medicine man being the primitive, but equally responsible counterpart of the modern doctor. Bloom traced the evolution of medicine from the autonomous traveling prognostician and market place entrepreneur and craftsman of ancient Greece. He was concerned with the patient as a whole and was trained through apprenticeship, or in schools, named after prominent innovative physicians. Under Roman society, the physician was more often a slave attached to a household. In the Middle Ages, medicine underwent institutionalization similar to the rest of society. Training schools were developed at universities and professional associations were formed which protected and governed its members, brought about medical legislation, and elevated their social status. Bloom cited that under the social mandate of that era, the doctor was limited to rote study and practice until the great changes of the modern era— scientific and social—freed the physician’s mind and capacity to autonomously exercise his investigative and healing function. At the same time, this brought into play what Flexner called “unequal responsibility,” a condition

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of ultimate personal and social responsibility as the main mark of a profession, especially in reference to medicine. Bloom noted that these same forces were at work in other social organizations moving toward professional status, and with whom the physician must increasingly work in teams. Thus, the medical team is subject to the powerful evolutionary (and revolutionary) dynamic which has impelled, and still impels, the physician and which plays a large role in the stress, internal and social, the physician encounters in his career. Bloom brought to the profession the clearest exposition of a transactional (or higher level of integration) system for examination of its role and the relationship of the doctor and the patient. Alongside of this, Bloom posited the study of the doctor and the patient in the context of their principal reference groups, the doctor in his profession and the patient in his family. These reference groups, in his model, were each embedded in their own subcultural reference groups. In turn, those groups were positioned in the context of a dominant sociocultural matrix. The Concept of Identity and Professional Identity In the concept identity, Erickson, among others (Spitz and Hartman), has contributed an essential tool for the study of the development and functioning of the doctor in the course of his career. In Erickson’s scheme, basic to the scheme was an epigenetic, or built-in personal developmental course. Like epigenetic differentiation in biology, this course was dependent on a differentiating psychological “organizer” whose existence is hypothesized and whose nature is as yet undiscerned. It acts in stages and orders, moving through levels, in a context of a unique life cycle. The concept of ego identity relates to a changing self which synthesizes abandoned and anticipated selves. Erickson emphasized the reciprocal and interlocking relation of the developing individual and his co-developing human environment; mutual recognition is essential at each stage of development. The professional is especially concerned with the ideological issues in human development, cited by Erickson as essential achievement of the individual and his society in passage through developmental crises involving trust, autonomy, initiative, industry, identity itself, intimacy, generativity, and integrity. Erickson conceived that professional ideology is made up of methodological, practical, and ethical factors; the ways of the physician and the needs of the patient in distress thus dovetail through interaction about the ideologies of both. For such to happen consistently, the physician needs to have traversed the crises in the development of his career. Also important in the conceptualization of the inner workings of the ego is the treatise, Aspects of Internalization by Schafer, in which he identified the phenomenon which he called the primary process presences, concretely fantasied representations of important figures and factors in the life of the individual encountered in his

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daily life and especially in critical situations when psychologic aggression is apt to occur. Szasz and Hollander categorize the role tasks of the physician from the point of view of the autonomous capability of the patient. A polar state is that called Activity-Passivity, in which the patient is helpless and the physician acts similarly to a parent, who does something to him. In the median, is the state called Guidance-Cooperation, in which the doctor directs a compliant patient, as with a child or adolescent, who, though ill, is capable of following directions and exercising some judgment. At the other pole, is Mutual-Participation, in which the doctor as an adult-to-adult, helps the patient to help himself. Valliant, Sobowale and McArthur cited suggestive findings on the emotional vulnerability of physicians (suicide, alcoholism, divorce) whose careers involved direct care of patients, with the implication that “Some physicians may elect to assume direct care of patients to give others the care they did not receive in their own childhood,” as evidenced in the study by data on statistically significant unstable early development courses. The Process of Medical Education The sociologists Merton, Reader, and Kendall have considered the criteria of adult socialization, transmitted by the medical school subculture to successive generations of students. They emphasize that the autonomy of the socially certified physician is granted as long as he discharges his function responsibly, in accordance with a body of shared and transmitted ideas, values and standards, through norms and codes of technically and morally allowable patterns of behavior. The student goes through a process of learning from role models and by precept. This is in the context of striving for the ideal, in the care of people who, in their suffering, place extraordinary demands on the professional. Fox characterized the core element of the education of the physician as “training for uncertainty,” citing that the medical student is confronted by a vast amount of knowledge, and the fact of death, both of which he cannot control, leading to doubt and uncertainty. By the end of the preclinical years, he has learned to master some of this uncertainty, and to be a little more sure of himself. He learns this through personal experience, through interaction with the faculty, and especially his fellow students. In the clinical years he adopts a “manner of certitude,” learning to “act like a savant.” Popper noted an overall trend toward equal status for the social scientists as designers of health care. He emphasized that the physician needs to be trained to work together with allied health professionals in the context of the medical student as part of a school of higher learning in the health sciences, looking forward to the health team of the future. Tyler attempted to define the problems of medical education in terms of a comprehensive model of student learning embedded in the program of

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complex learning which is the medical school and of the students’ need for role models which he can observe repeatedly to increase perception of learning tasks. He notes the isolation of the student from frequent contact with equal examples of the profession as a whole and in its parts. He criticizes vagueness and conflict in definition by the faculty of the essential character of their roles, inadequacy of formulation of educational objectives, and lack of properly sequential learning experiences. He proposes a limited sort of guidance of students in carrying on complicated behavior patterns, with students acting as junior colleagues in the pursuit of medicine, and (mutual) evaluation in planning and conducting educational programs. Innovations in Training The method of small group training, new at the time to teaching, was the subject of a pamphlet put forth by the Group for the Advancement of Psychiatry, titled Small Group Teaching in Psychiatry for Medical Students. In the pamphlet instructors are told to deal with relatively normal ways of adjustment, rather than engaging in therapy of the students. The aim is toward increasing empathy toward the patients, fostering emotional maturation of students and awareness of the student’s own problems, not as ends in themselves, but as means of opening the way for acquisition of skills and knowledge. It considers efforts at group psychotherapy for the student aimed at “professional development of his subjective self,” as “ill-advised,” a position diametrically opposite to that presented in this pilot course. Balint, in a cogent and important work, The Doctor, The Patient and The Illness, asserted that the general direction of training and practice in medicine is clear to him in that the general practitioner needs to remain in charge of the patient and stay autonomous and equal to specialists in medicine. This ideal is impeded by a “collusion of anonymity” (in which the practitioner undergoes self-effacement, acting as a pupil of the specialist). At the same time, the physician acts in a grandiose, magical-religious fashion with the patient, which Balint calls apostolic. There, according to Balint, the doctor has a sacred duty to zealously convert to his faith all ignorant and unbelieving among his patients, in which his individual solutions are held to be the best and most sensible, and enjoining the patient to take them as his model. Balint holds that the doctor needs to relieve suffering, a furor theradeuticus. The doctor also trains the patient, educating him to a normative response to his illness. He must give something to the patient, the patient returning something to him, in a “mutual investment company.” Balint noted that in the course of the relationship the doctor and patient get to know one another and gain one another’s confidence, attempting to convert each other to the other’s belief. In this he acknowledged what the authors of this present study consid-

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ered to be a centrally important ideological struggle inherent in their relationship. Balint conducted his work with physicians through small group discussions, a form of weekly case conference in which the doctors’ counter-transference is characterized as the way he uses his personality and exhibits automatic reaction patterns to the patient were brought under scrutiny in the group. The aim was to enable the physician to be more sensitive to what was going on and help him achieve considerable change in his personality, necessary for what Balint conceived to be the new skills of psychotherapy called for in general practice. Balint found that the members of the group traversed depressions caused by realization of their shortcomings, achieving the “courage of one’s stupidity.” The doctor became free to be himself with the patient, to use all of his past experiences and present skills without much inhibition. The group leader allowed everybody to be themselves, to have their say in their own way and time, watching for proper cues. Balint avoided a one-to-one therapeutic relationship with the group and used the “brotherhood instead of fatherhood” group approach. Kline reported the experience of a discussion group of eight graduate psychoanalysts. Having formed by mutual selection under the impetus of feelings of isolation in the practice, they found the task to center around unresolved character problems which had become indurated as professional character pathology, described as a close-mouthed, guarded approach with attitudes of a combination of “mother superior” or “tin god” and “tough in-fighter.” The members at first demonstrated an inability to simultaneously experience and understand the group process. In the group they explored what turned out to be a combined maternal transference and masochistic attitude, and a tendency to ask for mothering. Rosenberg (20) reported a successful program at the University of Minnesota Medical School of discussion groups for medical students. Starting as a venture in research, the program, consisting of elective discussion groups of fifteen at the beginning and end of the school year, overcame faculty resistance to demonstrate its usefulness to students and faculty and to become a total class group program. The work of the groups each year centered about role interpretation, with sharing of experiences relative to competence, dependency and sexual concerns. In the last two years, the students delved more deeply, with the eventual uncovering of the relationships to their mothers as the chief determining force in the course of their medical careers. The groups were acknowledged to aid the students in adapting to their school environment and to assume leadership positions in their class. The authors cited in the foregoing review generally adhere to the view that the role of the physician calls for acceptance of an identity in patient physician relationship of an extraordinary nature, because of the adherent

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confrontation of patient and physician with uncertainty, death and disease, as well as health and growth. To this end the physician needs to enact a role attributed to him by the patient and society hitherto relegated to the charismatic, magical-religious sphere. Parsons called the latter assumption an ascribed one, and instead advanced the concept of achieved status, attained by the physicians through discipline and technical ability. Only such attainment gave him responsible entre to a role of intimacy with the patient’s person and life. Balint, Kline and Fox characterized the imbued role assumption as “apostolic,” “tin god,” and “mother superior.” Balint and Kline called for analysis to rid the imbued assumption of its compulsive quality. The authors of the current study propose a term they consider generic to the nature and the order of the phenomena of the imbued role assumption, namely myth role assumption. Myth in this instance is an anthropologic term concerned with largely dramatized manifestations of the deeper aspects of the meaning and nature of the universe and man. By this definition, an apostle is an enactor of a mythic, God-relevant role, as a follower of a savior, dealing with a central life issue of helplessness. Erikson’s epigenetic theory with its place for the concept of personal and cultural progression and regression from and to former developmental considerations, together with Bloom’s sociological and transactional frame, provide us with a context for analysis of the doctor-patient relationship! The authors of the current study wish to make explicit a consideration implicit in Bloom’s and Erikson’s work, that in the course of the medical transaction both doctor and patient necessarily regress in part of their egos. They do this to deal with the business of belief, trust, and the core aspects of their orientation to one another. They maintain contact through more primitive belief systems and mechanisms, guiding one another as they traverse the period of illness and accomplish the work performed with the rest of their egos (diagnosis and treatment on the doctor’s part, and corresponding functions on the patient’s part). The changes in medicine and medical education cited by Popper and Tyler and of the participation of the patient advanced by Szasz, all work towards an active co-autonomous functioning of faculty and student, patient and physician. At this point in history, such changes have increased rather than lessened the stress experienced by all concerned, making imperative psychologic growth on the part of the doctor and his institutions. The new ways advanced by the Group for the Advancement of Psychiatry, Balint, Kline, and Rosenberg all involve active group learning experiences. These centered about the role and identity of the physician, pre and postgraduate, in what turned out to be a form of team work, itself enabling the members to relate to others on a more equal, peer basis. What formerly was a hardly noticed incident in the preclinical years of a medical student is now studied as a valid emotional state, that of depression and disillusionment, calling for support, guidance, and treatment when

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needed. That this occurs too regularly later in the career of the physician is established by Valiant et al, who attributed it to altruism based on a sense of deprivation occasioned in early personal development. Prior versions of those findings are those of Kline and Balint on miscarriages of altruistic role assumption which interfere with the autonomous functioning of the doctor. A picture emerges of a literature which begins to provide the conceptual frame for study of careers in medicine and of approaches to training in the ideological and mythic aspects of the physician’s role assumption. Increasing attention is being paid to the genesis and morbid processes in such careers. THE FORMATION OF THE PILOT COURSE The initiative for this course stems from the work of one of us during several decades of conducting staff groups which evolved into seminars on the identity of the professional. This work was done in the context of organizing group work training programs in clinic and hospital. In these, the members first engaged in work groups devoted to mutual support and assimilation of their experience in traversing the group work training course. Almost uniformly, the members turned to discussion of what they were doing in the training group itself. Their aims and goals for the group experience came next into focus and play. Concomitantly, they seemed to invest deeply in the group. This was manifested by enunciation of an array of concepts of what they conceived to be the ideal training group, mixed with past and current disappointments in that regard. Roles were assumed in bringing those idealized concepts into being. The group at this stage formed itself into a separate small society, a social entity, manifesting the politics of utopian and messianic communities. Once the group established itself as an entity, members related to it and to its leaders in dependent modes. They experienced what appeared to be trusting regression and resistance. They revealed states of immediate and past loss in their own and other’s life courses and situations, and the relation of such to the personal motivations and impulsions in their professional lives. They took roles relative to what appeared to be the authentic situations of helplessness, alienation and isolation in which they found themselves in their current situation as students in the training group. When the self-observing and analytic capacity of the group developed and came into significant play, they began experiencing themselves in a manner analogous to that found in analytic group therapy, made different by the limited responsibility of their training experience. In these experiences, the members regularly dealt with a number of sectors and layers of their professional functioning, in which these were simultaneously revealed and altered through the group process. Specifically, they

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experienced the depressive and aggressive elements which lay behind their original and current drive toward a professional career, and beginning revelations of the self (the internal and external object), avoided personally and yet encountered in the professional mission. These enactments occurred in an intensely emotional experience over the course of what usually was a year’s basic training in group work. It seemed appropriate to apply this experience to the situation of the medical school, which each year calls for sounder and deeper grounding in an informed self-reliance, coupled with the capacity for significant meshing with others in the group designated as the professional team. Extensive discussions on an administrative level resulted in the decision to attempt a pilot group to explore the nature of the problem, with a view toward perhaps working out a program to deal with the developmental aspects of the entire medical school career of the student. The decision was made to initiate the venture with students who were in the sophomore year, to facilitate the critical transition from laboratory to classroom to clinic and ward. The format chosen was an elective quarter, to meet once per week for an hour and one-half, limited to eight students. The prospectus cited simply that the class was to be devoted to group discussion of the identity of the medical student as a professional. There was no study made of the composition and nature of the class as a whole to ascertain the characteristics of this segment of the class. The members communicated in the sessions and informally to the effect that they were biased in favor of dynamic considerations even prior to attending school. They were not considered exceptional in their interest but still the rest of the class was contented to struggle through without examining their motivations and situation. In accordance with the aim of formation of a group large enough to have the variety of response and initiative to deal with most blocks, impasses and ambiguity which were expected to arise, and to provide room for retreat for the individual within the group, yet small enough to enable ready focus on him, the size of the group was restricted to eight, plus two faculty members. The latter were paired at this phase of the project to compare notes, match and correct biases and to train personnel for extension of the program. It was projected that later, a composite of psychiatrists and internists plus perhaps other divisions in the ranks of medicine would be tried, representing new trends in collaboration on normal aspects of medicine. The group met weekly at first for a quarter, extended to a second at the request of the members. Prior to the experience, the members were subjected to individual interview by one of us to determine suitability. All but one of the group were in the upper one-third of their class and seemed to have good standing with their peers; one was the Class President. All came from the upper middle class of society, but were otherwise heterogeneous in social, ethnic and intellectual background, objectives, and motivations. Five were

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from professional families, four of which were medical, and stated that they were expected to follow a medical career. The merchant parents of two others were extremely proud of their sons’ independent decision for medicine. Three had come from the West Coast, the rest were local. Two had background activities which would place them far from the conforming to stereotype—one raced speed boats and the other played for years in a rock band. All but one had continuous and successful scholastic careers, generally with emphasis on biology, punctuated by summer work as orderlies. One assisted his physician father. They apparently related well to their teachers, giving evidence in initial interviews of looking for an inspirational learning experience. In temperament the members were mostly introverted; they would sit quietly waiting for the instructors and other group members to initiate discussions and interaction. Two were actively intuitive, easily bored, contemptuous of pedantry, and conformity to institutions. One openly identified with a messianic ideal, the others with general altruism. In their attitude toward the student role, important in which was the capacity for submission and mastery of an enormous amount of didactic material, one was “fanatic; loved it for the rest of my life.” Two resisted, one matter-of-factly, and the others were “struggling through.” The Development of the Class Groups The work took place over a period of two years, involving two pilot classes, each lasting two quarters. As noted earlier, the groups met weekly for one and one-half hours; two longer sessions, termed mini-marathons, lasting four and six hours, were held with the first group. Notes were taken of the sessions by one of the leaders. These were transcribed and one was processed to arrive at a history of the group, which in turn was used to formulate a composite developmental picture. The methods which were used in such processing and formulations are described in Powdermaker and Frank and by Abrahams and Varon. They consisted, in brief, of scrutiny of events in the reported group experience for critical turning points, then denotation of patterning of antecedent and subsequent events. From the aggregate of sessions a social or natural history of the group was sketched. Inferences were drawn as to the group dynamics evidenced in the several stages of processing of the data. Space does not permit more than an outline of the results of this formal analysis, plus summaries of sessions, to indicate the specific nature of the groups at the various stages of their development.

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Outline of the Natural History of the Groups Introductory Sessions I–V: Self-Definition as a Group The members in the first five sessions addressed themselves to what brought them into medicine. They stated their motivations to be altruism, avoidance of a military career, a healing mission, and pursuit of respect and status. They moved in their discussion to the background of such, consisting of advancement beyond their parents’ occupational achievements and realization of their families’ expectation. Next, they discussed the “feminist motivations” in medicine of a female classmate. This led to an intense discussion of what they considered to be a task in their medical career of integration within themselves of what they designated as masculine masterfulness and feminine sympathy. Stating that they were tired of discussing identity, the members still continued pursuing the subject. Q alluded to the influence of his mother on this score through “whispering” in his ear when he went to sleep. The members moved through mention of short and long-term goals, to their need to surmount difficult situations this year and the role “others’ eyes” played in their medical careers. The discussion went on to values. The members enunciated adherence to both modern liberal and uncompromising fundamentalist values, culminating in exposition by one member that one’s identity is “known as one is about to die, complete with all paradoxes, a summation of all you are.” Another cited his feelings of identity as a palpable driving force within him. Another then asked the members to respond concerning their feelings of self-esteem and whatever dis-esteem of him they experienced. They replied by going into the difficulties they had in living up to their ideals. One member reported a voice inside himself commenting on who he was. (This member asked for individual consultation shortly after, concerning what turned out was a state of identity confusion. He was in conflict on pursuing his medical school versus a rock band career and suffered periods of apathy and alienation from self. He resolved his conflict in favor of continuing his medical school career, in two interviews). The members generally seemed depressed about their current motivation in medicine. One stated poignantly that he wanted to give himself to the patient; his dad had died of a heart attack. A second, with great sincerity, stated that a good doctor has to give a lot, gets back rewards, but not those of the rose garden. In general, the group had developed in this short time as a discussion group to the point where the members could usefully conceive of who they were in this aspect of their life situation, and share their conceptions and perceptions. They then began exchanges on their life’s goals and referred to the presence in their daily life of their parents’ influence. The

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appearance of the parental “presences,” termed primary process presences by Schafer marked successful regression in trust by the members to a position and situation where what they were carrying into medicine that was governing their motivations became apparent to them, a phenomenon analogous to the transference of psychoanalysis. They felt more at home in the group than in large classes, with non-M.D. faculty members who insisted on the “scientific” aspects of medicine. They went on to cite the aura of the position in the lives of others they were beginning to hold as physicians at home, among their friends, and soon on the wards. In these five sessions, members may be conceived to have taken counsel in their peer group’s subsystem, stubbornly and in their own way manfully pursuing a mission in concert with their medical school class of declaring independence from the older generation. They had negotiated a position that they considered valid for their discussion group in their school community. It also held particular promise in their eyes. Sessions VI–X: Self-Definition by the Group In the next five sessions, the student members denoted their independence from the older generation (the faculty) by standing for marijuana and educational democracy, moving on to express their wish for freedom from definition of themselves by others. They confided to one another, after showing enthusiasm and belief in the validity of their group feelings of need and guilt behind their altruistic motivation, manifested at the moment in lonely, alienated feelings. The members continued to grope toward the core aspect of their role in medicine, which would yield highest job satisfaction, culminating in a statement by one member, “If I didn’t choose a field where I would be helping, I would feel guilty.” The group began with a statement by a member who felt alienated from his healing aspirations, asking the others if they felt similarly. The members stated that they were looking for inspiration now, in this course. One reported that he felt close to it when in the situation of near death. Others reported that the “lonely” and alienated feelings they had were alleviated in the group and when talking with close friends. They were “searching for a concept and capacity to feel things through when no one was that way”. One told of a fear that he would “turn into one of them.” Touching on the search for good models to identify with, the members reported what they perceived to be the “dehumanized” treatment in the clinics of patients as bodies and their overempathizing with them. Coincident with this development, the group exhibited interaction between members in which they directly commented on one another. They reported they felt safe in the group, “not jeered at”. One member stated that he formerly “took it from the professors as God,” saying, “thank you though.”

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The state of loneliness and alienation of the members had by now become accepted and consensualized. Also accepted was a separate task of attending to one’s state of identity and development. This is reminiscent of Freud’s statement in reference to his own identity of “the willingness to live in opposition to the majority.” Finally, the train of associations arrived at the fear of losing one’s identity to an external land, possibly internal) object, a patient, the object of the profession’s endeavors. It had also become safe enough to express and enact ambivalence, to become themselves in the group, and be free enough to meaningfully examine their altruistic and alternative career goals. Sessions XII–XVI: Depressive Phase For five sessions they continued the expression of feelings of disillusionment, alienation and abasement, chiefly in reaction to the faculty, then the group itself. Members who had been most active in initiating interaction absented themselves for several sessions ostensibly because the group was not reciprocating their altruistic initiative. The group then broke through into a directly relevant investigation of their ideals for themselves in medicine versus other occupations. Having attained a situation where the members could talk directly, they revealed their disappointment in their own group. This marked a state of object-relatedness in which the initial leaders and followers altered their relative positions, the former coming back to the group after modification of their concept of it as an instrument of an exalted belief system and hope in medicine. With the realignment in their ideas for the group—and within their own professional ego ideal—came the possibility of exchange with one another and the leaders on the same level. The “above it,” omnipotent, messianic role-position, turned apostolic by Balint was relinquished for increasing periods in the group process. Sessions XVII–XXI: Assumption of Counseling and Familial Group Roles They moved in the next five sessions into their daily struggle in earning their way to self-worth, and eventually to the part their parents’ ideals played in the maintenance of their self-esteem. Session XVIII: Mini-Marathon Four Hours The members plunged right in, citing the crisis that led them to medicine—in one instance, the death of a parent, in general a feeling of inappropriateness and difference from others in the life context of the crisis. Members reported a feeling of bizarre depression—“no feeling, no roots.” The thought of medicine “gave the balance, otherwise, I’d blow my mind.” One reported that he was in medical school out of fealty to his (medical) father. “I couldn’t slap

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him in the face. He dies an old man. You die an old man; that’s all there is to life.” The theme was picked up with an avowal by another member of his being driven by a life purpose which he had to finish. Another member stated that his was marked by fear of failure in (regular) society. Medicine supplied something altruistic to hide behind unlike other vocations (grocery, cab driving). The members grappled with the question of whether it was a more “intense” experience to tell relatives a patient will die of cancer, than drive a cab in heavy traffic, out-foxing other cabs. The members returned to the feeling of inappropriateness they had touched on earlier, when without roots there is no freedom. “I go crazy and lose all feelings of adequacy.” … “People become blocks of stone.” They all agreed that they had difficulty maintaining a relaxed and homeostic state, having to be active and striving. They turned to the imperative they felt to be independent of their parents, at the same time their liability to guilt if not acting constructively. One stated, “You are as free as you define yourself to be.” Finally, the group discussed the part money played in their career expectations, whether they were defending against acquisitiveness through their altruism. In this session members took counsel with one another on a peer group level concerning the developmental crisis that led them to medicine. There was little, if any, evidence of transference in the sense of investment in the group and one another, with ascription or experience of object relatedness pertinent to the traumatic experiences discussed. Instead the work consisted of identification and consensualization of aspects of the strands and patterns of the emotional net, obviously compulsive in nature, members had been caught in which led to their “calling” of medicine. The core experience involved object loss. In this instance what emerged, since the focus was on the crisis that led to the career choice, was something which took place relatively late in their personality development. The depression and identity confusion and violence which attended the loss had apparently been dealt with by massive altruistic reaction formation, with identification with the ideals, or ascribed ideals, of the lost object. It may be inferred that had Q. chosen something other than medicine, he would in his own mind be humiliating and mortifying his father. The posited eventual unrequited death of father and son, rendered so by son’s dereliction, called for son to renounce this core aspect of his autonomy and identify and live out his father’s ideals. Stated in identity terms, the arrest of initiative involved was more than a submission to an Oedipal father. It involved loss of autonomy and invasion by doubt. Such was evidenced next in the associations of the group, in which the members alternated in looking at the selfdoubt and guilt behind their altruistic drives and role assumptions, which they sensed to be a basic defect in their feeling for themselves.

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Sessions XXII–XXV: Exemplification and Personification of Issues In the next four sessions they brought up issues in their training, their vulnerability to needful and dominating women and a sense of alienation from themselves. They became constructively involved with one another in identifying and considering problems they were encountering with self-destructive patients and family members. They moved the inquiry to their old selfdestructive tendencies, relating it to hopelessness and apathy, guilt towards the disadvantaged, intolerance of rejection by patients, difficulty with separation from them, and need for the messianic role. Summary Session XXVI: Last Session The group expressed affilliative sentiments, and how the experience had been useful to them in discussion and exploration of their identity as physicians and how it had prepared them for the challenging clinical year ahead. The members cited their gain in motivation, especially in traversing the chores of learning didactic material, and the disillusion and helplessness in the clinical setting they experienced in their sophomore year. They discussed their personal difficulty in finding appropriate models to look up to in the faculty and within themselves. They commented on their distrust of one another, their cut-throat competitiveness, and their difficulty in sharing. They discussed this in terms of levels, reporting that they lived on a higher, illusory (Ben Casey) level, and that the “experience of seven to eight days pressing in on you was useful.” One stated, “Everybody needs to lay themselves open and receive reflection from others, discussing their problems in trusting one another.” The core difficulty they reported had to do with doubts on the durability and extent of their rapport with their patients, and their naivete. They exchanged, at the end, on their love for their new profession. The members had engaged in what amounted to an ongoing study of the emotional aspects of the course of their sophomore year’s experience. Central to this was a close-in scrutiny of their values and ideals. In the course of the year’s class, they had formed their own psychological entity, their discussion group, through which they received reflections of themselves. In this experience, they had formed a training alliance analogous to the therapeutic alliance of psychoanalysis. The group developed trust and mutuality on the basis of successfully traversed work, rather than on charismatic or idealistic assumptions. In the inceptive phase, the group was invested with such meaning, which the instructors accepted as necessary to the dynamic of the encounter. In time, that mode of investment itself was breached, and the group moved into position to reveal what became apparent as the core problem, a defective state of ego functioning, or identity, in which homeostasis and proper self-regard were attendant on achievement of ideals and goals (in

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some instances, of mythic nature), themselves determined by unduly predominant and still present parental influences. In a follow-up meeting a year later, we found the members to recognize the value of being involved in similar groups in their future areas of the practice of medicine, of being able to share thoughts, feelings, their experiences and anxieties with other colleagues to avoid and prevent isolation, alienation and depression, and at the same time enhance their medical knowledge. They did not express a strong desire to bring the same group together, indicating a successful resolution of the group process. The concensus was that through their experiences in the groups, they had developed awareness of intricacies and nuances of interpersonal relationships. Summary The dynamics of the groups in this pilot course may be considered similar to those cited by the authors in the groups with other professionals and those reported by Kline, Balint and Rosenberg. In each there was an encounter, guided by what may be characterized as an alliance of the members and leaders. This encounter resulted in formation of a group entity when the members yielded inappropriately held autonomy, based on isolative positions and mythic role assumption. In the altered setting which resulted, the members developed interdependent relationships based on achieved experience, followed by development of more appropriately held autonomy and value systems. Kline and Rosenberg traced the genesis of the problems encountered in their groups to mothering stances derived from unresolved identification with the maternal figure in early childhood. In this study, because of the different focus cited earlier in this paper, such configuration was found in relation to the paternal figure at a later period of development. The authors consider that acceptance by the physician of the parental and mythic role and its various manifestations to be necessary when the patient is helpless and is so constituted that he needs to believe in a primitive magico-religious or mythic manner. As Szasz and Bloom have pointed out, when the physician exhibits an incapacity to relinquish such role assumption in organic as well as functional illnesses, he hampers improvement and attainment of a well, autonomous state. The authors hold that when the physician resists the parental and mythic role and considers himself solely a medical technician, he may block an underlying dynamic in the medical treatment essential to even the most sophisticated patient. The members of the group reported on here were helped to relate as persons in a group, a step towards doing so with other professions and subprofessions.

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Conclusions In conclusion, the authors consider that the pilot course demonstrated: 1. Discussion groups properly constituted and devoted to this aspect of the training of the professional are feasible, and that their experiences are similar to those reported in the literature. 2. The tasks of such training at this stage of development may be stated to consist of (a) strengthening the adaptive capacities of the young professional; (b) enabling him to traverse the medical school course with less morbidity; (c) training of physician and taking counsel with self and others, with special reference to his identity within his professional situation. In doing so, the young professional is taught to deal constructively with his encounter with maladaptive self-concepts and role assumptions and the genetic determinants thereof. The pilot course provided further evidence of what is increasingly recognized as a nexal concern in the original training and lifetime learning of professionals and of their emotional health—the developmentally arrested and skewed aspects of their professional identity.

Psycho-Social Rehabilitation PSR

At ASH, a report was rendered with a plan for implementation to the treatment project steering committee with the psychosocial rehabilitation model that was to be used to maximize our treatment effectiveness. The focus was to be an enhanced recognition of where the patients were going and what barriers to their ultimate placement could be identified. These barriers were often the result of a lack of specific coping skills required within the treatment setting. The committee’s goal was not to develop a cookbook process but to develop a self-correcting system for treatment delivery. The steering committee met regularly beginning in early May. It conducted an assessment of the organizational realities, historical structures and basic assumptions that serve as the environment in which we are presently providing services. This process resulted in a clear need to restructure the patient placement/treatment delivery system along the lines which have as their focus this positional outcome as the prime determinant. The committee completed its task with the following assumptions: 1. Fundamental treatment modalities such as pharmacology, longer range detoxification, medical diagnosis and stabilization, and appropriate nutrition, continue to be foremost. 2. PSR is an organized system by which social behaviors and skills can be taught and attained in order to expand and strengthen their positional possibilities. 3. Learning via the PSR model takes a variety of forms, but its objective by pre-imposed measurements is ultimately validated by successful positional placement. 275

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AN OPERATIONAL DEFINITION OF THERAPY Therapy may be defined as a systematic intervention in a situation of psychological disorder or defect which enables an individual or group to achieve the intra-psychic, interpersonal, and social changes necessary for an adaptive, autonomous outcome. In the treatment process, the patient and therapist engage in degrees of investment called the treatment alliance. Psychoanalysis centers the treatment on and during intra-psychic changes, effected through this alliance. Psychotherapy, utilizing similar mechanisms, emphasizes adaptive interpersonal changes. Counseling, a therapeutic experience, enables the individual to perceive of self in one’s life situation with a view toward making choices. In guidance, the emphasis is on traversal of life situations and courses. The applied therapies—art, music, recreational, occupational, educational, psychodrama, movement, and rehabilitation—attempt to change the individual supervision of a neighboring experience by means of their particular activity. Therapeutic community is a group approach which utilizes all the forms of therapy, enlisting the collaboration of patients and personnel towards a series of changes in an egalitarian yet structured partnership within an institutional setting. DEFINITION OF PSYCHOSOCIAL REHABILITATION Psychosocial rehabilitation is a set of theories and methods by which carefully designed training is provided. Properly understood, it is not therapy as defined above but is an approach to dysfunction which can be applied usefully either with or without therapy as such. It becomes included in the therapeutic task. It is effective by the use of skill training segments of a relatively concrete nature that are generally more readily assimilated. These segments form a lesson plan that turns into learning models. When appropriately motivated, patients who participate in these models can acquire the coping skills and adaptive behaviors—domains of emotional, physical, cognitive, social and life skills—called for in an independent lifestyle. The substantial body of knowledge obtained through research strongly indicates that this approach enhances coping skills that serve as an inoculation against recidivism. Further, the PSR model stresses that we must provide to the patient, following assessment, that which the patient needs, not that which we may enjoy providing. Finally, PSR places emphasis on outcomes studied, by means of behaviorally oriented internal and external tabulation of what the patient has learned. PSR is one of the directions in which mental health treatment in California state hospitals has been moving for the past decade. The documentation system and the planned schedule treatment concepts have been developed

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with PSR as a fundamental concept, although not always incorporated by name. PSR has a communication system wherein channels of communication and relationship are essential to the treatment process. With its emphasis on goal-directed behavior and accountability, PSR makes a contribution to that communication and relationship. It emphasizes the by-directional transactions between all elements—patients, professionals, and administration. Assessment of ongoing treatment and treatment outcome is linked by feedback to the learning models. Within the treatment plan itself, PSR goaldirected formation of treatment objectives, appropriate alliance of the team members and the patient, and coordination of their efforts, lead to constructive, creative, and critical thinking. PSR can be conceptualized as a system of communication between the various entities involved in treatment. The term aspect will be used to indicate an element of the PSR complex. This term was selected to be as broad and inclusive as possible. In some ways, it is analogous to the axis term in the DSM III, but applied to the PSR system. Aspects include such things as the patient, the problem list, the various treatment disciplines, con rep agencies and physical health problems. PSR is, in the sense of this section, a system of by-directional communication links between the aspects. The purpose of the communication links is the coordination of all components in aspects of care to maximize and optimize the process of progression toward the goals of psychosocial rehabilitation. The fundamental communication link is that which measures the ultimate effectiveness of the entire treatment in improving the adaptation of the patient after discharge. Information from the field—parole, con rep, recidivism statistics, patient questionnaires, re-hospitalizations—can provide information not only about whether treatment was effective, but also about what components of treatment were effective in specific patient population, symptom complexes, and post-discharge setting. This information gathering must be carefully designed, and the data rigorously analyzed on an ongoing basis, in order to provide long-term guidance for the hospital treatment. The information should be able to assist us in defining exit criteria, demonstrate which skills require what minimum levels of functioning to give reasonable assurance of the patient’s ability to cope and what specific type of setting. From these validated exit criteria, individualized to patient and to discharge setting, measures of progress can be established. Treatment programs and modalities can be evaluated by the extent to which a given patient problem is affected by specific treatment. This communication loop between the exit criteria, the patient status relative to the exit criteria, and the demonstrated effectiveness of a given treatment for a particular problem facilitates reasonable preparation of a treatment plan. This process assisted the treatment team in keeping the treatment goal—psychosocial rehabilitation—in

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mind when making treatment planning decisions. This can be called the treatment planning loop. The treatment plan is one of the more important communication channels, and the treatment planning process, the interdisciplinary contributions of all team members, the coordination and therapeutic alliance with the patient, and the preparation of the team conference report required clear, PSR goaloriented formations of treatment objectives and constructive, creative, and critical thinking. In addition to testing the effectiveness of present modes of treatment, information from the outer loop and the treatment planning loop must be collected and integrated to determine if there is a treatment need which is not currently being met. Such unmet needs must be identified in order to develop and implement treatment for them. This process is essential if the PSR system is to change with changing patient population and needs. New treatments should not be initiated without a demonstrated need for them, and new treatments for existing defined needs should have their effectiveness evaluated in carefully assigned pilot projects prior to the widespread acceptance. Those treatments which are demonstrably effective in assisting progress toward exit goals must be evaluated by careful study of the treatment itself, not the therapeutic description of the treatment. This may be doubly true of those treatments which do not demonstrate effectiveness. OVERVIEW OF THE TREATMENT IMPROVEMENT PROJECT MODEL The first phase of the treatment model begins in the admission program where individual patient needs are prioritized according to clinical status, the forensic context, estimated time for hospitalization, and most probable placement on discharge. A decision tree is used to place each patient into a treatment unit or program that best meets their needs. The second phase involves a comprehensive assessment by the receiving interdisciplinary team that focuses on diagnoses, treatment, and specific skills and behavioral changes that are required to attain and maintain the next level of care subsequent to discharge from the hospital. Critical to this phase is the recognition that while appropriate specific treatment of psychosis or other brain disease continues, treatment is inadequate unless it also specifically addresses those behavioral and performance deficits which accompany such illness. In other words, while medication for psychosis is appropriate and necessary, it cannot remediate the serious deficits which have occurred in the course of the illness. Recognition of such deficits is a major focus in the PSR model.

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The third phase encompasses developing the patient’s ability to accept and cooperate with treatment, and improvement of skills or behavioral repertoires. The predominant treatment philosophy to accomplish the acquisition of required skills is a psychosocial rehabilitation model—PSR. It is based on scientifically derived principles of social learning theory. Other treatment modalities continue to be necessary to prepare the patient for the next level of care. However specific goals related to patient needs require outcome measurement to assess the efficacy of all treatment interventions. At times, indirect measures such as assessment of motivational changes to attendance records will be required. Each treatment process program is responsible for developing the PSR activities necessary to assist patients in attaining the skills required for successful discharge placement. Most treatments can be provided by the residential units. However, some treatment such as didactic substance classes, vocational instruction, disability screening, and education services can be delivered more efficiently through central program services. Six major skill domains were chosen which best seem to summarize a complete picture of successful patient functioning in each particular setting. These skill domains included symptom management, responsible decisionmaking, interpersonal relationships, daily living activities, vocational/educational needs, and skills related to effectively coping with forensic issues. Symptom Management Domain: Medication self-management—the ability to recognize the need for medication, appreciate the effects of medication, and make a commitment to taking medication voluntarily on a routine basis. Symptom self-management: the ability to recognize signs of relapse, identify and manage stresses, cope with hallucinations and delusions, and know how and when to seek help. Prevention of dangerous behaviors/appropriate expression of emotion—The ability to cope with a range of emotions both internally and in relationship to others, without allowing strong feelings to place either the individual or others in a dangerous situation. Avoiding alcohol/substance abuse—The ability to know and understand the effects of alcohol and other drugs and emotional states which trigger alcohol/other drug use, and the ability to abstain from using substances when consequences of use would impair social, physical or mental functioning. Responsible Decision-Making Domain: Effective decision-making/impulse control—This skill accomplishes the ability to recognize problems, weigh alternative solutions, decide which course of action is needed, implement the decision, and evaluate the effect of its implementation. Impulse control is an aspect of this skill, such that when the thinking process is slow and deliberate, acting out behaviors may be prevented. Empathy training/victim awareness: The ability to readily

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comprehend and understand others’ feelings, thoughts and activities— particularly those of the victim of the patient’s crime. When appropriate, this also includes the ability to deal effectively with situations in court or in the community where the patient may encounter the victim or their relatives face-to-face. Effective time management: The ability to plan, implement, and monitor a productive daily schedule which promotes personal and social development and allows flexibility when changes are necessary. This includes the capacity to follow a daily plan consistently and responsibly. Interpersonal Relationships Domain: Developing social skills and social supports: The ability to meaningfully participate in conversations and social situations and the capacity to develop and maintain positive relationships with others. This also includes the ability to seek out and utilize social supports and to offer support to others without prompting. Family communication skills: This skill is an extension of social skills. It focuses on familiar relationships and the ability to communicate effectively with family members in the therapy process and in the home environment. Daily living activities domain/self-care and hygiene: The ability to achieve and maintain a clean appearance, including personal clothing, at a level commensurate with good physical and psychological health. Money management/shopping/banking: The capacity to plan, implement and monitor a realistic and comprehensive personal budget with attention to future financial needs. Food preparation: The ability to prepare balanced daily meals safely and efficiently without supervision or prompting. Recreation/leisure time use: The ability to purposefully seek out and consistently participate in recreational activities offered in the community or institutional setting. Health maintenance/nutritional wellness: The ability to obtain and assimilate knowledge about disease and medical conditions affected by diet and nutrition and to apply this knowledge to a personal health plan. PROFESSIONALISM AND MANAGEMENT IN MENTAL HEALTH FACILITIES Doctors and bureaucrats make uneasy bedfellows. They do not co-exist comfortably. They may ostensibly share the same purposes and goals, especially if those purposes and goals are stated in sufficiently idealistic and vague terms, but the reality is that their values, attitudes, and procedures are essentially at odds with each other. Ancient Egyptian and Greek traditions, codified by Hippocrates and others, indicate that for many centuries physicians

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have set high ethical and altruistic standards for themselves. During the twentieth century, they have also come to value medical technology, and especially in the United States they have achieved remarkable economic success and social prestige. In consequence, American doctors have great zeal for altruism, technology, and self-interest. Organizational managers have other priorities. Although they may subscribe to the virtues of altruism and the benefits of technology, they are necessarily preoccupied with matters of organizational efficiency, and with reality constraints imposed by finite resources. They are also, of course, impelled by their own self-interests. Those basic problems have been compounded in recent years by a rapidly increasing complexity of both sides of the interaction. Medical knowledge and practice require specialization and sub-specialization. There has been an evolution of a whole range of “ancillary” professions. At the same time, the sociology and economics of health care and treatment have become dauntingly complex, resulting in an array of public and private organizations, all of which must somehow be managed in order to be continued. The focus of this document is on some issues which become especially visible in public mental health hospitals. In such settings, doctors are in professional roles, but they are also employees and thus subject to organizational management. The issues tend to overlap and become confusing. Perhaps sorting them out will make it possible to present a coherent point of view. Several arenas of conflict are identifiable. The importance of each of them is underscored by the intensity of the struggles, the investment of much energy and money, the resort to expertise and protracted legal action, and the voluminous coverage in the publications of health care, management, and professional organizations. Issue 1: Medical Staffs vs. Governing Bodies Hospitals and health care systems on the one hand, and medical staffs on the other, have both been declared to be legally responsible for the provision of quality diagnostic and treatment services and care, although in reality both may actually have ambiguous authority and autonomy. Medical staffs typically regard provision of extensive diagnostic and treatment services as a clinical and ethical mandate. They resist organizational constrictions, and they are likely to oppose any attempt by a governing body to limit, control, or monitor physicians’ practice. Governing bodies, on the other hand, are impelled by fiscal limitations, and by necessities of risk management. They regard limits and controls as indispensable.

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Issue 2: Psychiatrists vs Psychologists The traditional preeminence of psychiatry as the authoritative profession in mental health is being challenged. Other professions are rising and establishing themselves, especially in public mental health organizations where psychiatrists are scarce. Clinical psychologists lead the way, asserting their ability and right to function as fully qualified to provide diagnostic and treatment services. Issue 3: Joint Commission on Accreditation of Healthcare Organization vs. Mental Health Organizations The Joint Commission on Accreditation of Healthcare Organizations, having spread a wide net, finds itself with two sets of accreditation standards, both of which evoke strong objections from some national agencies and professional organizations. Issue 4: Professional Practitioners vs. Mental Health Employer professionals, especially physicians, whose attitudes and values have been shaped by autonomous private practice, are not prepared to recognize or accept the different conditions that exist when a professional is an employee of a mental health organization; nor are organizational managers inclined to recognize the crucial importance of self-determining and selfaffirming professions. All of these struggles are related, in one way or another, to the essential issue of professionalism. Thus it may be useful to state the characteristics which identify a profession as such, distinguishing it from an occupation or job. 1. A profession is an occupation. It differs from other occupations in that the choice of a profession reflects individual interests and objectives which are expected to be long-lasting and to become an important aspect of the fundamental identity of the professional person. 2. A profession has a well-defined body of organized knowledge. This knowledge is transmitted by systematic training and experience to selected students, apprentices, or disciples. Such a training system results in verifiable competence, which is typically validated by a written credential. Thus, the profession takes upon itself the explicit responsibility of setting standards of training and competence, and of continuing professional development. 3. A profession has both fiduciary and altruistic purposes and goals. Although the practice of the profession may bring economic rewards to the practitioner, it is not simply a business or trade which is owned

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and operated for profit. It is ethically prohibited from being solely proprietary since it must also direct itself to the needs and best interests of its patients or clients. The practitioner is explicitly mandated to merit trust, to enter into a covenant, and to apply the best available skill and knowledge to the benefit of the recipient, whether or not such action is profitable to the practitioner in each instance. The profession also necessarily exerts itself toward the wider benefit of the society in which it functions. 4. A profession has defined ethical standards and discipline. It recognizes that, as a profession, it has a duty to protect individuals and society from those who are incompetent or unscrupulous in their professional activities. 5. A profession emphasizes the importance of acuity, skill and judgment rather than standardized formulas and procedures. 6. A profession, in order to maintain itself and further its own standards and goals, necessarily organizes and maintains guild rites and functions which are actively supported and financed by its members. No profession exemplifies these characteristics perfectly, but each profession is likely to be at its best when it is able to function with a relatively high level of autonomy. The American medical profession, highly organized and functioning as a component of a capitalist society, is a remarkable example. The evolution of the structure and function of the medical staff of a typical American hospital has proceeded in such a way that it has seemed to approach the ideal pattern by which a collection of highly autonomous individual professional entrepreneurs can produce optimum benefits for themselves, their patients, and American society as a whole. TEAMWORK AS A SOLUTION TO THREATS TO PROFESSIONALISM The core of the matter is that good contemporary creditable mental health diagnosis and treatment and complex care are best provided by teams of professionals. Good patient care requires recognition of the broad range of professional services required for long-range treatment of chronic and recurrent conditions. The professions share concerns and tasks such as: therapy of many kinds, suicide prevention, ethical issues, staffing standards, quality assurance, documentation, and abuse responsibilities, coordination and liaison between organizations, pre-hospital evaluations and post-hospital followup, care and treatment in correctional facilities, rehabilitation, family relationships, recidivism, etc.

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In order for a team to function it must first be made clear that a team is not a committee, nor is it a democracy. It must have recognized the necessary role of authority in leadership, and it must have understood patterns which define at least some of its roles and tasks. Experience indicates that such a team is likely to function best when the psychiatrist is defined as the designated team leader. The psychiatrist typically has the broadest clinical training, has well-defined medical and legal responsibility and has authority. However, a designated leadership role is not the same as an operational leadership function. Because the psychiatrist may be relatively inexperienced, or unskilled in teamwork, or have personality characteristics which interfere with effective leadership, the operational vigor and direction of the team may come from one or more of the other members. If the team works its way to an operational consensus that such leadership is acceptable, even if not explicitly stated, the work can proceed well. THE ROLE OF PROFESSIONAL IDENTITY GROUP ANALYSIS IN PROFESSIONAL DEVELOPMENT The Renegotiation of the Professions at ASH as to Their Professional Identity Two previous experiences informed my work at Atascadero State Hospital in the area of professional identity. The first was at the beginning of the organization of the group work training program at St. Elizabeth’s, where we were faced with the issue of rivalry, ambiguity relative to competence, and attainment of the intimacy necessary for development of true confidence in one another. With the nurses at St. Elizabeth’s Hospital, I attempted to transition them from being the doctor’s handmaiden, the traditional professional role, to one where they were collaborators in relative equity. The second was my work in staff development at Fort Knox Rehabilitation Center, where I engaged in conferring with my fellow staff members on who they were about in their performance of their professional roles, an exploration of their natural history, and then the envisioning of their prospects. Success there led to an agreement on formation of a multidisciplinary, group professional identity analysis experience at Atascadero State Hospital. Along the way, we collaborated on mounting a hospital-wide group work program. I had assembled the heads of the professional departments of psychiatry, psychology, social work, dance therapy, educational therapy, occupational therapy, and the pastoral counseling segments—catholic and protestant. There we exchanged on the challenge of the new group work venture and the roles and capacities of the members. The result was an agreement to restructure an annual training program for thirty-four trainees. The program centered around a year-long group experi-

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ence to foster competency in membership of a human group. Attained there was a collaboration in which the members, diverse as they were, formed their own small society under the guidance of myself and Levonne Frey, the chief nurse. Its task was exploration of the personal and professional identity of its members, from inception, to the present, projected into the future. The dynamics of this small society were analogous to that of a psychoanalytic group therapy. Emotions were raw and immediate, illustrative of resistance to the transference and the transference itself. Generally, management of this formation was accomplished by the group itself. Much of my activity was empathic identification as they traversed the memoires of their initial motivation to join their professions. This was most vivid in the case of the pastoral candidates, when they reported hearing God’s voice calling on them to be ministers. Others reported analogous inspiration of less dramatic nature. My empathic identification catalyzed others in the group to do likewise and the transaction became generalized.

Atascadero State Hospital’s CQI Experience

Close to four decades after its inception under Dr. Rood, Atascadero State Hospital had reached the point of challenge presented by the therapeutic community approach he had begun. I gladly accepted chairmanship of the ad hoc committee for treatment improvement started in 1991 by Dr. Robert Behan, the acting Chief of Staff. He had formulated it as a multidisciplinary endeavor to assess the contribution of each discipline to the treatment of the individual patient towards changing the Hospital along thoroughgoing community lines. I led the groups in the manner that I had at St. Elizabeth’s, and listing their collaboration in a dynamic, analytic mode. As at St. Elizabeth’s, the disciplines collaborated, and in time arrived at a determination to begin a multidisciplinary training program in group work. Each discipline would contribute candidates, to be trained in a professional identity group analysis mode, also in didactics pertinent to the disadvantage disciplines and in group therapy. They would be supervised in group therapy and group work, attending a mutual supervisory group. On attainment of competence after a year of the program, they would be advanced to advanced students status, eventually receiving certification. This plan was set aside by the hospital in favor of one advanced by administration at Sacramento, centering on reformation based on continuous quality improvement which had been pioneered by Edwards Deming, a group procedure centering on a new way of collaboration on the part of hospital management. It appeared to me that its use of group dynamics, down to techniques of brainstorming, was analogous to that of group therapy. Its approach was the opposite of traditional authoritarianism, toward democratization of staff function. I envisioned that continuous quality improvement 287

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and the treatment improvement initiative would in time collaborate to bring about a sounder therapeutic community. In addition, I anticipated that the security forces would join in a treatment triad. Continuous quality improvement methods have traditionally held that change in the system would bring about change in the individual. I had noted in my previous writing the concomitants of those changes. Alongside, it had become apparent to me that without such change towards collaboration, the administrators would find himself at odds with therapeutic community. At Fort Knox the chief administrator, Col. George Miller was temperamentally able to support an analytic discussion group therapy, alongside a tight security system in which he had confidence. Similarly, and in an even more security-bound setting, Dr. Frank Tartaglino and Dr. Bernard Cruvant provided support to the group therapy at St. Elizabeth’s, while maintaining maximum security. Dr. Winfred Overholser of St. Elizabeth’s countenanced the transmutation of this authoritarian institution into a therapeutic community that supported its members every step of the way. The Executive Director at Atascadero State Hospital was capable of joint democratic and authoritarian transaction with the Central Patients’ Counsel, but reached an impasse in transacting in such a manner with personnel in the course of the continuous quality improvement program. When it came to sharing power with the highest level of the continuous quality improvement group, his reply relative to collaboration was that he would accept their representation as input, but unfortunately there was a block to the essential collaboration that was needed. I was left with the inference that a proper role for me as consultant, ad hoc or otherwise, was to support this top administrator in his collaborate function. An analogous formation in my practice would have been to have met with the parent in a problematic family, during his or her crisis in their developmental role. MANAGEMENT ANALYSIS A word about the management functions experienced in continuous quality improvement is essential to the exposition of its instruments employed in managing their analytic ventures. These consisted of the communication and assimilation of the techniques known as fade cycle, fishtail diagram, plus statistical analysis. These techniques of analysis of problems by management were impressive, but they lacked the approach of psychoanalysis toward selfanalysis by the administrator to identify the developmentally relevant; and to be aware of the distortion known to psychoanalysis as the transference. Also lacking was the concept of regression in the course of development of a situation, and the causes thereof. I attempted to inject my knowledge and experience on those matters as my training group traversed its developmental

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course. The problems they tackled involved arranging a more efficient system of transmittal of charts, passage through the corridors of the patient population on the way to lunch, the luncheon experience per se, and return to the wards. At the end of my work in that regard was participation in a conference on analysis of the factors relative to violence in various settings in the hospital. There we were engaged in exposition of the various scenarios of violence, and the analysis of the factors involved. Ironically, I became the subject of one of those scenarios, as I passed through the ward of a doctor who ruled by repressive medication. I became emotionally disabled and this was eventually relieved by psychoanalytic intervention. I recognized that the hospital was making progress towards the triad of therapeutic community, continuous quality improvement, and collaboration with security personnel and I volunteered to continue on as consultant, as I had at St. Elizabeth’s. Unfortunately, my offer was declined. MATRIX MANAGEMENT Mental Health organizations tend to be unbalanced. Where professionalism is weak, managers make the necessary decisions, but as professionalism gains strength it is necessary to pay attention to the interaction between the professions and the management of programs. This can only be done by crafting a matrix of shared authority and responsibility. Without such a matrix there can only be a perpetual competition for power and dominance. No matter which way the scales are tipped at any particular time, there will be losses. The fact is that managers cannot produce good program results without strong professionalism, nor can professionals do well without effectual management of resources and organizational necessities. The solution is to build a system of understanding and practices which give managers clear authority in all matters which bear directly upon resources and upon necessary requirements for employees as employees per se. The professions must have equally clear responsibility and authority in matters of professional training, credentials, competence, ethics, and quality of professional performance. Inevitably, a large grey area will remain in which no absolute responsibility and authority can be assigned. It soon becomes observable that both managers and professionals will repeatedly try to deal with the grey areas by establishing rules and regulations. Such efforts usually fail, since most grey area issues can actually be dealt with satisfactorily only by use of flexibility and judgment. Thus, both managers and professionals must come to the explicit understanding that the successfully functioning matrix can only be sustained by a constant balancing of complex and changing vectors. Such a dynamic balance depends upon continuous planned communication and good will.

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The term “executive,” as used here, includes the Executive Director or Superintendent, the Medical Director, Clinical Director, and their staffs. The final critical component is executive support of both professionalism and management. This is not immediately obvious. There is a strong built-in tendency in mental health organizations to polarize the executive level. Program managers will do their best to enlist executive support in order to exert control over the professions in the service of their defined program goals. Professionals will also do their best to capture the executive. They will often insist that a professional—preferably a psychiatrist, must be at the head of the organization. Since today’s executive is likely to have arrived at his position by working his way upward through managerial ranks, he is likely to ally himself with the managers. In such a situation, the professionals will perceive him as an adversary. His life will be difficult in many ways. Conversely, the executive who has been captured by the professionals will encounter organizational dysfunctions, perhaps even sabotage, from managers. He will need great executive skill and power in order to preserve the structure and function of the organization. The executive, in order to achieve and maintain the necessary balance, must establish and empower both the manager and the professional. Most public systems have well-defined organizational and program management, but they tend to lack adequate professional organizational development. Even if the organization has a well-organized and functional medical staff, that staff often lacks adequate provision for the necessary self-definition and integration of the other mental health professions. Under such circumstances, it is necessary for the executive to provide opportunity and authority for each professional discipline to have its own operational leadership and participation in the organizational matrix. The executive must also make provision for all the professional disciplines to come together in a comprehensive professional staff. Since there will continue to be matrix difficulties, there will be a continuing tendency for managers as a group, and professionals as a group, to see themselves as oppositional. That tendency can only be overcome by action of the executive to establish and maintain a forum which should meets regularly and includes all of the established professional leaders and program managers. This forum should meet without a defined chair. Although it would function under executive auspices, it would not be chaired by the executive, since under an executive chair it almost inevitably becomes a cabinet with various members vying for executive support and power. The forum is to be understood as a vital component of the organizational matrix, since its crucial function would provide a setting for progressive development of interpersonal communication, understanding, and relationships, thus preventing the de-

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structive polarization which otherwise inevitably impedes organizational effectiveness. People who meet regularly for informal discussion and planning with sharing of problems, ideas, and attitudes, become incapable of dogmatic and defensive polarization. The executive must recognize the necessity to orchestrate the dynamic balance of a living matrix. Conflicts then become resolvable. What results is a three-way balance which is not unlike the system which the Founders of this country devised. Each major component of the Federal government—legislative, executive, and judicial—is constitutionally defined. Each acts both as a support and as a constraint to the others. The support must not become one-sided, and the constraint must not become adversarial. Having established such a balance, each of the three components of a mental health organization is able to function well. Managers maintain organizational integrity and effective use of resources. Professionals bring knowledge, skills, continuing development, competence, and ethics. The executive supports both, and deals with necessary external forces such as governmental sources of funds, legal and societal systems, licensure and accreditation agencies, political forces, etc. It is possible for all to contribute, and all to benefit. SUMMARY Issues arise in public mental health systems and hospitals as a result of tension between necessary management patterns and necessary characteristics of professionalism. Organizational effectiveness results when management and professions are integrated into a dynamic matrix with unambiguous executive support of both components.

My Intuitometer Presentation Peruvian Psychoanalytic Society, January 25, 2011

BY DR. PATRICIA CHECA, SCIENTIFIC SECRETARY OF THE PERUVIAN PSYCHOANALYTIC SOCIETY, PRESIDED; DR. AUGUSTO ESCRIBENS ACTED AS TRANSLATOR MY REMARKS I am overwhelmed by the reception, and the seriousness of your purpose in psychoanalysis. I inferred such from your demeanor, and hope to match it in my performance. I have been in psychoanalysis, both in practice and as a subjective agent, for some 60 years. I have a lot to report, and at the end of my career, I have been churning out these books, to try to figure out what actually happened. I want your help. This paper is in the service of analysis of one portion of my experience. My career started very early. I was trying to figure things out from the first, with my kind of mind. When I came to Freud as a teenager, I felt, “This is for me!” I was born in Texas, but we moved to New England and New York, after just three years. But in that short interval I took on the Texas spirit in its positive aspect, “deep in my heart.” The move was disastrous. My family all loved Texas, but my mother, losing her mother to cholera in Europe, had to be back with her family, back East. My father became alienated for the rest of their marriage.

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This set up a situation for me to study. On the surface, life went on. Our family was the prime one in the group of families, we were a supposed model, but I was miserable. The bloodline went back to ancient Israel, to the caaens, the priestly warrior class. My father was proud of that, his family, the bus line he worked for, and his new country, as was my mother. Both believed in being happy. But then there was the underlying alienation. It took me long to understand and unravel the contradictions. As my mother’s mainstay, I had developed a case of messianism, not uncommon in good Jewish boys. That afforded me great strength in my new profession of medicine. Then it played a great part, when I was called on, during the Second World War, to function as a psychiatrist, in a treatment prison, The Fort Knox Rehabilitation Center for Military Prisoners. I learned therapy of psychopaths from a sociologist, who learned from an analytic group therapist, Alexander Wolf. The Commandant was Colonel George Miller, an educator who had read August Aichorn’s Wayward Youth. Aichorn was an associate of Freud, taking over the leadership of psychoanalysis in Vienna, after Freud left for England. The lines of understanding and practice there go back to basic analytic beginnings, and I took to them naturally. The rehabilitees took to me, as they had to my sergeant, Lloyd McCorkle, and before that to Captain Wolf, before that to Miller, and Aichorn. Something was happening there, and that is the burden of this paper. I have invented a word, intuitometer, to characterize the seminal, central action of my psychoanalytic work. In it are combined the detection, and its correlate, of the phenomenon of intuition, and discernment of its qualities and their measurement. I present the paper concerning this approach, as an avenue to the experiential relationship of the psychic and somatic, individual and group, in space and time, in a manner that can conceivably be rendered mathematical and subject to inference of higher psychologic order. It is an instrument of measuring what is going on in me, my intuition, in making connection to the other person. In its course, you and I become one psychologic unit, for that moment. The subjects in the work at Fort Knox were characteristically raucous young psychopaths. They had offended through misuse of alcohol, assault, absence without leave, sexual offenses, etc., could not sit still, listen, talk appropriately or discuss their problems coherently. In their natural state there was a high decibel level, hence the term, raucous. The story goes that Eleanor Roosevelt conceived of saving the more eligible of them through a special reeducation that had just been emerging in social work circles. Without it, a considerable amount of manpower would have been lost to the war effort, at a time of shortages of young, able-bodied males. Nine centers were established. Aichorn had done this sort of work in Vienna, after the First World War. Our Commandant found in Alexander

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Wolf someone who could systematically talk with these people. But Alexander Wolf was a liberal, and they were fascistic and anti-semitic. They found out who he was, and eventually he was in danger of assault, needing a guard during sessions. Sergeant McCorkle, Irish, tough talking, became the leader. Since I was a captain, and a Texan in character, I had to get on the horse and ride! Are any of you impatient for me to get to the point? You are. My wife, Elisabeth is. Those guys would be a hundred times as impatient as you, and would let us know it! You, Captain, you Sergeant, you’re full of shit! That would induce dialectic of expression in members who saw virtue in McCorkle and myself. There would ensue a loud argument, basically for leadership of the group. As a result of Alexander Wolf’s and the Colonel’s prior work, the outcome of that dialectic surprised us. They quieted down and became contemplative and cooperative. The military training, hard labor, and education they were receiving in the program, and the nascent hope of becoming a soldier again, impacted on the therapy and it on the rest of the program. My prior experience in the matter of toughness also impacted the therapy. My family landed on the Lower East Side of New York, after we left Texas, in New England. Toughened psychologically by that experience, I found myself, a good Jewish boy, wanting to be a member of a gang of Irish toughs, several blocks down Gouveneur Street, on Cherry Street. In the Fort Knox Center, the Army was placing me as the leader of a gang of toughs. It helped that I had an athletic, fighting stance. In the midst of a melee, I found myself thinking, “These are my people!” So it is no wonder they accepted me, despite my very Jewish name and background. I liked their forthright ways and expression. I think Aichorn had the same reaction to his delinquent boys. I had six therapists, including McCorkle in my detachment, and we had regular conferences. We tried to figure out what was going on, why alienation was giving way to reconciliation, why the antisocial leadership was replaced by pro-social readiness to talk about themselves, pose and solve problems in living. I found myself contributing the observation that I experienced something subjective just prior to the periodic communion, a sense of poignant expectancy in my chest, centering behind my sternum. My men and I recognized that something momentous was going on. The Colonel also felt it. These psychopathically inclined persons had systematically left the world of alienation to rejoin consensual reality. I found myself teaching, but they taught me as well. I termed the process, “From gripe to group.” I did not give the intuitive connectedness with its psychosomatic chest marker a name until later. It appeared grounded in empathy and I reserved it for later psychoanalytic study. I felt it in my body, and others did so, and it appeared linked to a capacity for purposeful inquiry. That work became famous at the time, and the Federal Prison Service wanted

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to gingerly adopt it for its younger populations. But I had not received formal training in psychiatry, much less psychoanalysis. I had no residency. At this point, Dr. Escribens stated that he felt empathy for this situation, since the Peru group went through a similar experience at first. I went on to cite that I insisted on taking a residency, at St. Elizabeth’s, before I went further into my psychiatric career. The Superintendent, Dr. Overholser, gave me great leeway, and I worked for a while with Ezra Pound, the poet. He was a group of one, running a little empire on the West Side Service, amid droves of visitors from all over the world, permitting me to interview him. Also on West Side Service was Howard Hall, a maximum security section, for the detention and treatment of violent offenders. It had a 35-foot concrete periphery, entered through a medieval passage and thick iron gate. It had a reputation, of “behave or else!” These turned out to be my people, as at Fort Knox. I had embarked on a mission to discern why the men we failed with at Fort Knox were so durably committed to their alienation. An event at Knox set that quest in motion. A consummately violent prisoner, whom I had been interviewing about his career in violence, led a riot on VJ Day, provoking a mortal wound. Awaiting the ambulance, I held him in my arms and asked him why he did it when he knew he would be shot. He replied, “I had to, Captain.” That reply haunted me. I had to find out why he “had to.” Howard Hall was full of opportunities for further inquiry into an ongoing research project, that of the motivation and career of the maximally alienated. The circumstances had a great deal to do with my subsequent motivations. In the course of researching why we had failed with 60%, I had selected him as the most motivated member of that cohort. I had talked with him as I am doing here, person-to-person. He stated, “You can’t do anything with me, Doc. Why don’t you do something with my buddy here. He needs it.” When the riot started, the prisoners freed him and his associates, to dramatically honor them in the mess hall. They were finally lined up, by dint of a massive influx of troops. Last in line, he broke ranks, lunged for a guard’s rapid-fire gun, receiving a blast to his liver, a wound visible as he lay in my arms. As I relate this, I realize an affective connection with that man, with activation of my intuitometer. In Howard Hall, the staff and I mounted what became a sophisticated treatment program, similar to the one at Fort Knox. I became known in that hospital of 6,700, and the Chief of the Afro-American unit called on me for consultation. One of his wards had become completely mute, started losing weight, and he was alarmed. Could I make connection, as I evidently had in Howard Hall? Instead of the usual hub-bub of schizophrenic sound, his patients lay still, many under the benches. I sat with him, receptive, my intuitometer on the ready, for a full twenty minutes. Then I felt the substernal stirring. Nothing

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was going on, but I felt it. Then a patient under a bench cleared his throat, using an animal noise. He announced then that he was the Christ, come to save. Another patient, off somewhere else, called out, “You’re full of shit!” A third called out, “Hallelujah!” This was followed by ejaculations all over the room. Dr. Escribens called attention to the fact that there might be a sexual meaning to ejaculation. I went on to cite that the Service Chief was gratified that his ward was back to “normal.” I left, curious about the significance of communication with a patient who was silent and out of sight, but was more than ever convinced of the meaningfulness of the experience of a somatic marker of awareness of connectedness, and passage from alienation to reconciliation with reality. The attestation that he was the Christ was another dimension of the messianism I had suspected in work with the prisoners. I had entered training in the Washington Psychoanalytic Institute. In my training analysis, I had already identified messianism, a tendency to rescue and save. I must insert here that my mother was built that way. She had to be back with her family, could not stand apartness, when her mother died. She spent the rest of her life mourning her mother, while vigorously going about raising a family. I recognized messianism as one of my personal problems that was at the same time an asset at the core of my professional identity. It became increasingly apparent to me that a degree of messianism in my character has given me the strength to succeed in work with psychopaths, then with criminal psychotics, and now with “normal” schizophrenics. I had the opportunity to examine that phenomenon with pastoral colleagues, where we took up the issue of intuitive cogency and connection. It made sense to them, and encouraged, I found myself calling the phenomenon of intuitive connection and its measurement my “intuitometer,” and continued doing so. It stuck! I was going my own way in psychoanalysis. I had done so at the inception of my training, when I organized a study group to make sure we learned classical analysis versus the teachings of Harry Stack Sullivan prevalent in our Institute. I utilized my new group analytic skills in several workshops mounted in Washington and later San Diego dealing with schizmatic crises. Dr. Escribens noted analogous social and political dynamics in recent Peru, the co-existence and working through of orthodox and heterodox. My close associates in our study group did not want to hear anything about my new intuitometer. I went my way, concentrating on research in my private practice. In my process notes, I cited the intuitometer stirring as SF when it was sad, PF when it was poignant, EF when the feeling was elated. In several dramatic examples, the intuitometer phenomenon had announced the experience of an internal transaction with the object one female patient experienced inside herself, or introjected. The transaction was announced by a dream. This was followed by an experience of mourning, and

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recovery. The associations of this woman, in midlife crisis, had become extremely scanty for some sessions, when I experienced a substernal stirring. She then related a dream, which came in a series, of the approach of a hooded figure that turned out to be her dead grandmother, who had become her surrogate mother. Her mother had died second year. Traversal of mourning for both, previously arrested and deeply repressed, enabled her to complete her analysis. In another instance, a deeply dysfunctional family had reconciled from its alienation through the tears and complaint, a call for mother and father to love one another, of a five-year-old daughter. This had been preceded in a family analysis session by long silent communion and activation of my intuitometer. By that time, I had developed comprehension and practice to the point of perception of intensity and psychoanalytically relevant associations. In this case, the associations were to a previous action by the mother, in which she had fled tearfully from her role as mother, to residence in her daughter’s playhouse. When I noted this, the whole family burst into tears, to reconcile, on the way to working together to traverse the crisis. Another illustration of alienation, reconciliation and the role of the intuitometer occurred in the case of schizoid depression in a young woman. In the initial interview in my office, she mentioned that her father had died several years previously, and on my inquiry, also mentioned that she had not mourned him. I detected a trace of depressive affect with my intuitometer. On return home, she became mute and anorectic. When this became profound and dragged on, hospitalization became imperative. Our admitting interview took place in the Intensive Care Unit, with the patient positioned under a blanket, mute. I sat down alongside the tented figure, and noted my presence and wish to talk with her. I then waited, in a state of silent communion, intuitometer on the ready. It took a full twenty minutes until I experienced the substernal cogency. She stirred underneath the blanket, and spoke in a whisper, saying she wished to talk with me, but did not know about what. I had associated to my intuitometer reading, in which I had come across the depressive affect she had touched on in our initial interview. I noted that previously she had been somewhat sad about her father’s death. She sat bolt upright, discarded the blanket, and looked me in the eyes, gazing through me far away, into another world. It turned out to be an autistic one, in which she traveled in her mind by helicopter to keep alive a father ill from the cancer that had actually killed him. Therapeutic community and a devoted husband played a large part in the task of relinquishment of autistic identities and hysteric mechanisms through which she had defended herself against mourning. Finally, after relinquishing an idealized father, she mourned his actual death. She also came to terms with a deeply depressed and rejecting mother. Throughout, the intuitometer phenomenon was basic to connection of the disparate pieces of

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the puzzle and furtherance of the therapeutic alliance, to deal with transference elements. A therapeutic community participated in her treatment in a singular manner, through what they called “the procedure.” There she participated in a silent encounter, in which five personnel and the female director attempted to gently make eye contact. After about twenty minutes, she appeared to yield somewhat, displaying depressive affect. They then raised her above their heads, and she broke into silent tears. They lowered her to the director’s breast, and she cried openly, at which point I experienced my intuitometer, and felt sad, noting that the others were so moved. She then flushed and fell asleep, moving her mouth as though she had been fed. Dr. Escribens opened the floor for discussion. A member asked a question concerning the relation of the substernal experience to projective identification. I noted that it announces the advent of the projective identification. She went on to ask how that communication comes to me. I noted that in my character I have, in part messianically, derived from my mother and father, a particular sensitivity to the other. In trusting regression within myself, I join in regression with the analytic other. We arrive at the patient’s material. I am ready for it. At the same time, I free-associate to the experience, and find my way. My executive functions are operative and I correlate the core material with that previous experience with other patients, in the ongoing research project that is my psychoanalytic career. Alongside is my lifetime personal analysis. Interventions are made in the context of estimation of clinical data. I keep clinical notes throughout. The discussion moved to the issue of ineffability. I noted that we were now into the issue of parapsychology, which I had encountered in my paper. Freud had been interested in the subject, and at this point in my life it seemed to me that answers to its issues lay in what at first seems ineffable. Attempting to penetrate that, I noted the critical nature of this trip to South America, and reported that I was working on two recent dreams. One involved a patient of four decades previously. This man developed a depression after his father died. Hamlet-like, he saw his father’s ghost in the back of his car, as he drove from the funeral. He couldn’t stand to dream further, became insomniac. As a physician, he took to medication and addiction to morphine. In a psychoanalytic hospital in Washington, D.C., Chestnut Lodge, he found himself aping his father’s furious style of boxing, pummeling what turned out to be the wall of his isolation room. His father had killed an opponent during a career in amateur boxing. He became my patient, and I mobilized all assets to make significant contact with the insides of this furious man, who was intent on destroying himself through morphine and suicide. I finally achieved it when he affiliated with a patient in a therapeutic community I had just begun at George Washington University Hospital. He adopted and cared for this man, again mes-

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sianically, a man who resembled his father. My patient became peaceful and therapeutically purposeful. At home again, he dreamed his father’s rotting corpse was within him, and convulsively leaped from his bed, to jump out of his very skin. Talking about projective identification, he projected his dead father outside and away from himself. He returned to therapy, to mourn, profoundly, his father and all of his life, recovering in the process. To return to the issue of analysis of the ineffable, I report that on this trip, amidst my exuberance, I have found myself sobbing, depressed. I had a dream, in which this patient appeared. In the dream, I was amnesic for the dread experience regarding his father that he had gone through. It appeared in the dream as an empty space in his abdomen, the locus of the apparition of his father’s corpse. My inference was that I had analogous unfinished business. I hypothesize that Freud had much, in his self-induced death, to do in his lifetime analysis. Dr. Escribens asked if I had talked with colleagues about the substernal experience. I answered that it was universal. We all, to a varying degree, have an intuitive sense. We also feel it in our heads. Most analysts say, “Yes,” but then shuffle it off. They have established their own systems. Dr. Escribens asked a question concerning its relationship to poetry. I answered that the poetic state was always incipient in me and I felt on the verge now. It was dialectic to my scientific mind. The intuitometer has to do with the whole body, bringing much together. After Dr. Checa gave concluding remarks, Dr. Escribens cited that I was a maverick. I agreed with that designation, but added that I honored tradition, as manifested by my devotion to the Freudian endeavor. But I do like to ride wild horses. It is important to me to have a mind of my own, and to trust my associations. They lead me to further questions. I presented this paper in Buenos Aires and one of the important questions that arose was my doubt of my intuitometer. The questioner was sure I had said I did, and had evidence in the text that I did. We searched, and she found the item. I had written there, “it stuck,” after arriving at the formulation in scientific language. I explained that its meaningfulness as such had not changed. I do not think she changed her mind, so fixed was it, that I had abandoned belief in my intuitometer, and consequently it had lost its, what to her was misguided, power. What I did doubt was my messianism. Not its presence, but whether I wanted to be messianic. Mother Teresa was messianic, as was Eva Peron, and I have striven to free myself from whatever spell is involved. But those in need believe in such help in that religious spell, and I have recognized the need to carry them through that phase. In time, I have come to an awareness of a basic, organic capacity to care, to be committed to one’s fellow human beings. Sullivan said, “We are all much more simply human than otherwise.”

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But then, that can become pathologic. He cited this truism in the context of his very human limitations. The hour becoming late, Dr. Checa thanked me for the presentation. I reciprocated, citing their evident attentiveness as my reward.

Glossary of Terms

Advent phenomenon: This is a term I have taken the liberty to coin, because of what I consider to be its significance. Literally, it heralds the coming or advent of an encounter of psychological significance, premonitory of illness or recovery. My first awareness of this phenomenon came with the report by a patient of a series of dreams that preceded mourning for a dead grandmother. In the first, a hooded figure appeared on the horizon of a hill. In the second, this figure was half-way down the hill. In the third, the figure entered the room, followed quickly by one in which the visage of the grandmother appeared as she lifted the hood. At first terrified, the patient began deep mourning. I described the second clinical instance in the text of this presentation, of the appearance of a ghostly image of this patient’s father as herald to the onset of his psychosis, and of that father’s rotting corpse within him, heralding deep grief, followed by recovery from a psychosis. In another, a patient saw a ghostly presence at the edge of an open door in my office, which she identified as her dead mother’s ghost. This was followed by mourning, and recovery from an intractable psychosis. Further discussion of the advent phenomenon in my series of iconic cases is presented in the summary chapter of this volume. Alienation: The core meaning here refers to estrangement and the state of being a stranger; interpersonal withdrawal or separation, including affections; and intrapsychic separation or splitting. Alienation from self is a central factor in my hypotheses of mental and emotional disorder, resulting in rupture of relationships with others and regression and fixation at earlier developmental levels and states of deficit which result in secondary phenomena such as hallucinations and delusions. In its massiveness and earlier formation, it is differentiated from repression, a Freudian mechanism of render303

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ing thoughts and affects unavailable to consciousness, in the context of an already operative superego, or internally guiding and governing agency. I hypothesize to the effect that there is an organic basis to psychological alienation, stemming from injury to the nervous system and its development, altering it towards flight to higher and lower centers, and consequent alteration of the essential functioning, or soul. Animistic: This would be an early stage in the development of religion. My thesis is that the surfer experiences the God of the Curling Wave, and that we all experience our own version of animistic religion. In our rationalism we are superstitious, avoiding black cats, pavement cracks, etc. Deeper than that, we experience all of mankind’s religious past, including a version of the Aztecs’ appeasement of the Sun God by sacrifice of youth, demonstrating the palpitating heart of the youth to the first rays of sun. Apoptosis: Cell death is a supposedly normal phenomenon in the growing embryo as new structures arise and old ones fall away. Embryology recapitulates phylogeny, namely the profound changes evidenced in evolution. In addition to these normal changes, there are those that occur due to the toxicity and trauma experienced during the normal pregnancy. I posit that the embryo is infinitely sensitive to toxic influence on the part of the maternal object, resulting in impairment and even death. I correlate this phenomenon with a recurrent experience of the embryo with death and resurrection, and a premordial memory of such transmitted through subsequent dream life. Apparition: This would be that which appears, from another reality. Apparitions are ghosts, from a mere trace to a life-like state. Freud writes of the Revenant, or that which returns from the dead. Hamelet’s ghost was such. The apparition, or Revenant, in this volume populates my accounts of the iconic cases, having to do with the mourning process. Autism: I am here concerned with a disorder of the self, a product of alienation from that self, manifested by absorption in self-centered, subjective intra-psychic functioning attendant on an incomplete or complete break with reality. It results in existence in separate worlds. Autonomy: We no longer belong to God utterly, except in cults, having a right to our religious and even secular autonomy. This has been a long time in development, involving struggle with ourselves and our souls. Sabbatai Sevi, in my volume, The Messianic Imperative, took a step towards that autonomy when he turned to Nathan for help with his misery, but in Nathan’s culturally determined incapacity to depart from his role as acolyte, Nathan doomed Sabbatai to his eventual martyrdom to this messianism. Another

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example of the failure of individuals to take the choice to autonomy was that of Hamlet and Ophelia, in which had he not immolated himself in favor of his father’s request that he avenge him, he might have taken a longboat to America, as many Danes did in centuries to follow. Bipolar Disorder: My estimate is that Sabbatai Sevi suffered from bipolar disorder. His moods went on a roller coaster, with some plateaus, in which he plunged from heights of activity, religious capacity (of savioristic sort) and euphoric feelings into the depths of self-derogation and incapacity. The experience of heaven and hell was prominent. Another example in my practice of bipolar disorder was that of the young doctor whose father’s ghost appeared in the back seat of his car on the way from his father’s funeral. Career: This social psychological term is of great moment in the designation, and integration, of data concerning their progression and regression of the ego as it proceeds in its development. The individual assumes roles, based on his identity in that capacity, going through phases of development in coordination with others. It may be conceived that the infant engages in a career relative to nurturance, mastering the seeking of and sucking at the breast and indicating to the mother its satisfaction, at first with unknowing incorporation of the milk, but subsequently awareness of its full belly. As it goes through this mastery and role integration, it is launched on this career as a member of the family, achieving confidence in expectation of the role integration. That success leads to further successes in careers in grasping, kindly when held, eventually crawling, and then walking. Career Theory: This concept is important in the study of the career of the messianic individual; also, generally in careers and professionalism, even in careers in crime. In ontogeny, or the study of the development of the individual, we conceptualize the career of the new-born child in engaging in self nourishment through suckling. If the child is not motivated to suck, as in the marasmus one sees in orphanages, where there is not a motivated nurturing one, then the career is impeded. Suffice it to say here, the messianic individual would have formed a unity with his mother, and learned how to transact there and later in a role reversal, become the caring one with her and then others. The young physician who reverted from his professional career into that of one of a career as a drug addict applied himself to the second career with the termination and assiduity he had shown in his original one. Complexity Theory: This theory stems from physics in explanation of transitions of states of matter, with chaos as an intermediary state. Stemming from my experience at Fort Knox, with the dramatic change of the rehabilitees from psychopathic to prosocial, gripe to group, and the chaotic intermediate

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state where representative individuals would decompensate into mesmerian fits and speaking in tongues, it appears to me that we are dealing with states of complexity and simplexity, as described by Cohen and Stewart in Collapse of Chaos (1994). The notion of simplexity is intriguing, having to do with a different, simple level of organization of matter and function, analogous in the human being to that of soul. In one’s ego ideal one enters into superordinate states of organization of transcendent nature, which at the same time reflects the functioning of both the whole and the parts of the psyche. Condensation: The bringing together of disparate elements into one coincident formulation, imagistic or ideational. This is an important aspect of dreaming and its analysis. Confidentiality: This critical aspect of the patient-doctor relationship is rendered even more so by that I would simultaneously see the patient in a group therapy and family therapy setting after finding that I was ineffective in my individual therapy because of the patient’s resistances and alienation. Inherent to that complexity was the fact that whatever the patient told me was of moment to the group or family, and yet private. How to bridge that hiatus became a challenge. I searched to the essential aspect of the conundrum and found it to be resident in the even more essential imperative of confidence on the part of the patient in me, self, group and family. Growth of that state of being, of confidence, would be central to the therapeutic experience and its ongoing maintenance in good faith nurtured by both patient and doctor. An example of this was experienced in the iconic case of the doctor who felt his father’s rotting corpse within him. His very soul had kept this datum confidential both from himself and the analyst and he would not yield it to me until he had formed a tie of therapeutic nature with a father figure in the therapeutic group community situation. That tie brought the matter into reality, having given him the confidence he lacked in the faith of his allegiance to his introjected father. That enabling tie was of messianic nature, matching that of therapist and patient. Counter Transference: This phenomenon involves the correlate of transference in the analyst. It served a signal-marker in the analyst of the existence of the transference through an underlying experience. However, there is another obtrusive aspect to counter transference, stemming from unresolved problems on the part of the analyst, leading to impasse with the patient. Such was present in the iconic case number one when the patient arrogantly confronted the analyst, leading to confusion and a borderline sense of futility. Here the help of the supervisor in this case was of inestimable value.

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Death: I first came across this crucial consideration with the observation that, following their lively display of energy and oppositional motivation, the psychopaths at the Fort Knox Rehabilitation Center became depressed. When they came to life again, they were capable of living in common reality. I hypothesized that they had gone through a psychic death-experience, followed by resurrection. Subsequently, I learned of Freud’s death instinct, which he hypothesized as empathetically to that of Eros. Subsequent clinical experience led to the observation of the prevalence of a death experience in my patients and then in a dream of my death, which I describe elsewhere in this volume. Dementia Praecox: Meaning early dementia, it was a diagnostic classification in which the adolescent or early adult individual would inexplicably fall into what turned out to be permanent mental illness manifested by cognitive decline and profound apathy. Prior, the young person showed great intellectual, artistic, and spiritual promise, which appeared to be turned off, as by light switch. Theory as to its genesis was central to a meaningful psychiatry, and I have adduced the phenomena of psychic death and resurrection, with an organic underlayment. Elements of the dementia praecox syndrome could be detected in my patient population, as well as in the story of Sabbatai Sevi in my book, The Messianic Imperative. Displacement: Along with condensation, displacement is an essential mechanism in the formation of dreams. It denotes the placement of an idea or affect from one locus of being to another. Energic Hypothesis: It is but natural to conceive of energy as motivator of the psyche and soma, since we see its effect in lighting bulbs, driving machines, and heating houses. But we know that we move our arms secondary to a signal sent over one’s nerves to muscles, which contract because of chemicals. In that energetic action, energy does not flow, a signal does. Likewise, the nervous system switches signals in profusion, and there is thrust and soul to that machine, stemming from its higher order of existence, perhaps someday explainable by complexity theory. But, again, it is not due to hydraulic or other transmission of energy. It just feels that way, after we get on a head of steam, and blow our tops. Freud, when confronted by this conundrum, conceived of a form of energy he called libido. It was a love energy that he later separated into sexual and ego aspects. This energy on investiture of an object was cathected. The course of transmittal of energy became extremely complicated, full of contradictions. My thesis is that he attempted to invest this conundrum too soon, in what 19th century physical science was about in its energic inquiries. I find the concepts of myth and its transmission more gemutlich than Freudian libido and his viscissitudes.

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Ego Ideal: This aspect of the ego functioning of the individual is centrally important, and I consider it to be the terra incognita of psychoanalysis. It is especially important when it comes to the spiritual life of the individual. I consider that each of the following entities are stacked inside the other, as with Russian dolls: self, identity, ego ideal, soul. The ego ideal would be at the core of the individual’s identity, which is core to the operative self or ego. The core to the ego ideal would be the soul. Freud had it that the superego watches the ego for how it measures up to its ideals, the self as the self would really like to be. He later evolved the superego into a measurement enforcement-instrument, culminating into conceiving of a separate ego ideal. The ego-ideal was later conceived to be the repository (through identification by introjection) of idealized parental figures and aspired toward careers and states. Freud held that the ego ideal was formed late in adolescence when the individual forsakes childhood issues, turning to adult concerns, forming individual life aspirations and self-guiding values and concepts. But throughout, he had the two, superego and ego-ideal, bound together. He was graphic in denoting the ego-ideal as central in the constitution of human groups, which would include the group of two. It would account for amorous fascination, subordination to a hypnotist, and submission to leaders, put one and the same object in the place of their ego ideal and have consequently identified themselves with one another in their ego. It would appear that the ego ideal, in its centrality concerning life aspirations and positioning in larger reality, would be the mediator on issues of reality itself. Otherwise stated, it would be through the ego-ideal that we ascertain our sense of reality and position in regard to it. The ego ideal would by that token be the repository and effector of the course of life and sense of destiny, of hope and doom. Those scenarios are centra1 to the Biblical versions of Genesis, Days of Our Years, and the End of Days. In a systematic study of the ego-ideal, The Ego Ideal—A Psychoanalytic Essay on the Malady of the Ideal, Janine Chasseguet-Smirgel extends Freud’s thesis that malady stems from the child’s helplessness leading to compulsive fusion with the mothering one. The incestuous implications there lead to the necessity to side with the genital father, as hope in dealing with the primary fusion. Beyond that, in a sense of a wondrous past, when we were our own idea1, lies the hope for the future. This is a formulation whose thought structure is similar to the Genesis story, of oneness with self within God, and the subsequent estrangement or alienation. This course of life and civilization, encapsulated in the ego ideal was a core consideration for Freud in his Totem and Taboo, and is of relevance to this study. There he reached further into the God-man equation, citing that in his primary narcissism, man, in an animistic phase of development, thought himself omnipotent (Freud stopped short of designating that as a God-state);

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then in a religious phase, in which Gods are separate and omnipotent; then a scientific phase, in which man is small and resigned to death. What is missing there is the concept of an ego autonomous from the first, if only primordially, as developed by Hartman, in his formulations in ego psychology. This I hold to have suffered an experience of alienation to be followed by Chasseguet-Smirgel’s helplessness and ultimate fusion with mother. Ego Integrity: I have made reference in my clinical examples to a patient who experienced classical alienation from his sense of integrity, yet was the soul of integrity in his medical practice. In a dramatic crisis in his analysis, he experienced his father’s rotting corpse within him, as an advent phenomenon. He then mourned him, then gained the capacity to relinquish his compulsiveness and engage in the analytic process. He transacted productively in his analytic therapy group and his analytic family group. He had previously compulsively fantasized of intercourse with his mother and had been haunted by his father. Epigenesis: This concept is important for its formulation of a built-in developmental course, an unfolding of previously latent characteristics, or differentiation of previously undifferentiated ones. Freud outlined the development of the individual in accordance with inherent instincts, revolving about problems in nurturance and training. Erikson enlarged and deepened this to include factors in socialization. Epiphany: This refers to appearance, coming to light, and has to do with the appearance of deity incarnate, or essential soul-ness. It is a core aspect of the messianic experience. Eschatology: This term refers to the ultimate destiny or purpose of man. The assumption here is that man has latent such formulations, made manifest by the messianic individual, who, in evidencing this, assumes a place of leadership. In the volume, The Messianic Imperative, Scholem cites that Sabbatai Sevi reflected the longings of 18th Century diaspora for a return to the homeland, and so became the messiah they expected to appear. Falsifiability: Karl Popper has pioneered in the philosophy of science in a most specific and effective manner in bringing up the issue, dialectic in nature, of the role of falsity in determination of truth. I agree that in theorizing one needs to have an open mind, both to these issues and to their processes in determining the nature of reality. The existence of my intuitometer throughout this volume and of the psychic changes I first noted at Fort Knox and subsequently, were very real to me and my collaborators. Their falsifiability of their attendant has been a matter of utmost concern.

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Fealty: I use this term, in contradistinction to loyalty, to indicate the earlier historical form of loyalty, involving the very soul in a temporally extended contract. Hamlet was not just a loyal son, he was bound to his father in fealty. Feral: I use this term, which has to do with a state of wildness, to indicate the biologically inherent (phylogenetic) nature of man, to which he regresses. One sees clear evidence of such in the psychopathic state, in the anima-like capacity of such individuals for movement and feats of great strength. Generations of God: The evolution of the Godhead, personal and societal, is here conceived to be in a multi-generational manner, most clearly shown in the coherent Greek theogony, starting with Chaos, up to Prometheus. One can trace this through growth of the ego. This is in contrast to the disjunctive course of the Semitic godheads, of Astarte to Jehovah. Jehovah himself underwent development, as the Hebrews changed over the centuries, evidenced by the steadily-more merciful prophets. God: Starting with the definition of God as the supreme or ultimate reality, one moves into conceptions and attributions that are personalistic, with the qualities of human existence (creation, sustenance, judgment, redemption, righteousness, etc.). Study of the anthropology of God reveals thousands of deities, as evidence of the plasticity of the experience, also its universality. The inference can be drawn that the experience of God is inherent to the human psyche, and is a man-made aspect of nature. That nature is evidently systematic, but we clearly impute purpose there. Hamlet: In my theorizing, Hamlet, a literary figure, looms large, secondary to his evident existential dilemma, so similar to that of Narcissus, and to his fatedness. Id: Freud posited an aspect of the human personality in which was resident humanities past myth, down to a primordial Ur. I understand that he derived the It from Georg Groddeck, The Book of the It. In this interesting volume, Groddeck presents his view of the inner psychology of the individual, of frankly mythic nature, down to mythic trolls. Groddeck considered the It to be an agency of ultimate intelligence, perspicacious and integrative. Freud gives the impression of the It as chaotic and deeply regressive. Identity: In the text I go into Erikson’s identity concept, with its tracing of the issues humans traverse and resolve in maturation from birth through senescence. Yet the word identity relates to the sameness of organization and experience throughout this course, concomitant to the uniqueness of the indi-

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vidual. At core to this is the identity or essential sameness with the rest of humanity. I consider the Freudian ego ideal to underlie this identity, and the soul to manifest an overall and essential organizing capacity. Later in the glossary I deal with the concept of professional identity, a central feature of this volume. Incorporated Object or Introject: The thesis here is that when we identify with another in our relationships, we take in or incorporate a representation or image/experience of that person. When we are impaired in our ego functioning, that incorporated entity takes over, and we become fixated at that level of development. In the course of the experience of the iconic patient’s loss of his father to death he first came upon his father’s haunt, a ghost, then inability to mourn, attended by insomnia and great anxiety, then profession of deviant sort, addiction. Then came his analytic experience and visitation there of an infantile erotic relationship with his mother. Midnight fugues followed, manifested by assumption of father’s fighting stance in life in an attempt to break through the essential relationship there. This was then followed by perception of his father within him as a rotting corpse. It may be conjectured that the rot had followed his father’s demise. The realization of such incorporation was attended by the horror I have reported in the first iconic case presented in this volume and a precipative flight from that juncture. I posit that operative there was survivor’s guilt, itself related to a messianic tie with the introject. Infra-ordinate: This relates to a concept of organization of the nervous system, and an accompanying psychological phenomenon of worlds. The idea here is that the original neural centers and their connections, prior to the trauma incident to anxiety and illness in the mother, are susceptible to injury and limitation of function. Their original state of organization and function would be considered as ordinal, a higher one, supra-ordinal, and lower, infraordinal. Each ordinal level would be accompanied by the psychological phenomenon of worlds. All this is of great moment in the study of the complex of phenomena of messianism and the godhead. People like Sabbatai Sevi, as an example of the messianic experience, lived in worlds apart, of super-ordinate status, anticipating his advent to the godhead itself. The physician who experienced his father as a rotting corpse within was on one hand a highly professional and scrupulous physician and on the other the meanest of addicts, a Jeckyll-Hyde phenomenon. Iconography: I have included this word in this glossary, to represent the icon-fraught nature of the experience of the messianist and his followers, where symbolism and thrall richly imbued all of life. I conceive that at the

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inception of the work in Howard Hall at Saint Elizabeth’s Hospital, the leadership of the patient population were the most antisocial and morally regressed there. By the end of the work there they had turned into their dialectical opposite, icons of probity and collaboration. Intuitometer: I have devised this word to indicate the experience and diagnostic instrument I have described in the text. The experience of intuitometer is accompanied by associations akin to those I employ in dream analysis that furnish leads to deeper analysis of the data that are cognitively manifest. I posit that it is related to the epiphanic experience and a manifestation of the operation of the soul. Jekyll-Hyde: The dynamic conjunction of good and evil was dramatized in the fictional character by that name, and was exemplified in the patient I described, who Hamlet-like, was tied to his father’s very soul described in the text. Libido Theory: Freud hypothesized the transmission of energy, intra-psychically from the subject to the object, with an investiture of libido in the latter. Fundamentally, the libido sprang from instincts, which Freud held to be initially sexual, later adding those coming from the ego, of non-sexual nature. Interferences with this flow, and consequent damming, resulted in aberrations such as hypochondria. Light: I first came upon the phenomenon of the perception of light in my work with the severe disorders (psychopathic and psychotic). They would experience states of illumination (and darkness) when epiphanic, and in dreaming. In time I associated the light with resurrection, then death. Matriarchal: This concept and phenomenon is coupled with patriarchal, in a dialectic. In arriving at a synthesis, their authoritarian worlds are giving way to our current democratic world. The God systems of both have been mankind’s and womankind’s glory and bane. Mesmer: Mesmer was an Austrian physician of the latter 18th and early 19th Century who had a profound effect on European and world medicine through introduction of animal magnetism and a method of hypnotism, for the treatment of psychosomatic disorders. I take the anima of animal to be a phenomenon of the anima or soul. His healing groups or banque were marked by manic fits similar to those experienced by the psychopaths in my work at Fort Knox, noted in this text and a previous volume, This Way Out: A Narrative of Therapy with Psychotic and Sexual Offenders.

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Messianism: The components of messianism involve a deity who intervenes in human destiny by causing the advent of an individual endowed with charisma (anointed and divinely and spiritually gifted, favored). The deity and messiah were conceived in terms of kings and over-lordship, and the outcome of the intervention is to be redemption and a golden era. The Greek word for messiah was Christ. Prophecies by Isaiah and Micah foretold the advent of a messiah from the House of Joseph who would die in Jerusalem in the course of uniting the twelve tribes and combating their enemies. The final redemption would occur with a messiah from the House of David, a claim attributed to Jesus. The expectation of a savior-king sent by God was present in the Zoroastrian religion, Islam (the mahdi), and the North American Native Americans (wovoka). Many authors have found the messianic role and experience to be ubiquitous in civilization. My observation corresponds to this finding, with the messianic expectation and presentation to be present either in their form, or as part of the personality of each person. An inference to be drawn from that observation is that in prior history it was even more prominent, as witnessed by regularly occurring gatherings in expectation of the momentary arrival of a messiah. A corollary speculation is that there were numbers of messiahs at the time of the destruction of the temple and the diaspora, and since. Sacrifice of self for the common good was present in other religions, in the form of the Greek Narcissus and also in the Aztec sacrifice of children to keep the sun going. This component of the human personality is at the core of the healing initiative and is central to my epistemologic adventure in Terra Incognita. Morale: This term, social psychological in nature, pertains to the purposivess, confidence, and adherence of the individual and the group. It is based on idealistic factors and their reciprocity. I learned the importance of this first in my work with psychopaths in a treatment prison, then at St. Elizabeth’s hospital. The state of morale of the mother and daughters in the motherdaughter group depended on their belief in the Dr. and his confidence in himself. Thereafter I found the morale of the troubled couples I met in my practice and my sensitivity to it to be crucial for their progress in further investment in the venture of helping one another through their crisis. Mourning: Messianism and mourning are deeply related. In an eschatologic formulation, God is moved to redeem mankind, with a view towards a blissful reunion and a harmonious nature. The original rift stemmed from a sinful state, variously attributed to the eating of the apple of knowledge, or birth through the passage through a woman’s birth canal. The thesis of woman as evil is inherent here. That thesis would stem from banishment of the female

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goddesses from the Semitic pantheon by the male God, Jehovah, an attribution of evil thereto, and association with Satan, the other side of God. Woman, then, would naturally be in mourning for that loss, and in the position of being subversive. Her son, caught up in that mourning, would in my formulation be damaged in the ante-natal and/or post-natal stage of development, resulting in messianic and satanic states of transcendence. Identification with his mother’s sorrow at her loss, would result in turning against his own gender identity and his father. All of these losses would result in a complex state of mourning that reached back to the original ideal state of consonance with the complex godhead which would include male and female. The efforts of the kabbalists at discernment of female elements in their original El Souf, or the Original Godhead, reflect their discernment of this dilemma. The paradigm of my work with messianically afflicted individuals was demonstrated in the mourning experienced by the individua1 who dreamed of his father’s rotting corpse within him, causing him, in horror, to jump out of his skin. The mourning that followed, when the individual became consonant with himself, in the messianically stabilized therapeutic alliance (as differentiated from his self-alienation) was for both his introjected father, his own lost and beleaguered life, and the losses experienced by his family because of his illness and malfeasance. This is a concept of mourning derived from Freud’s Mourning and Melancholia, in which, through identification with the parental figure in the ego ideal, the individual turns from self. Myths: The word stems from the Greek mythos, or tale, speech; related to Gothic maudjan, to remind, Old Irish smuainim, I think; Old Slavic mysli, or thought; Lithuanian mausti, to desire ardently. Involved is deeply emotional cogitation, pertaining to human aspiration and experience. Use of the concept myth has been bedeviled by attributions of non-verifiability, a quality of uncritical acceptance and veiled allusiveness. But myth has been generally accepted as an underlying mode of psychic functioning which shapes personal and social reality. Mythopoetic: This term is of utmost importance in the formulations of this work. It refers to the junction of the nervous system and the personality in the creation of new myths, which when matched to reality, results in new knowledge. In the Genesis story, when Adam ate the apple, he became able to acquire knowledge, and was akin to God, who jealously had difficulty in sharing that larger reality. Mythopoesis is central to scientific inquiry, in that, stemming from the new cogitation, man could test his universe and gain greater comprehension. Narcissus was caught up in old myth, looking for the new, which would result in his death, according to Tiresias, the Seer.

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Nadirhood: To be at one’s nadir is to be at the lowest state of moral and selfconcept. The members of the mother-daughter group cited in this volume were at bottom, along with the iconic cases at certain points in their journey. Narcissism: This is a basic Freudian construct, relating to man’s capacity for self-love. In this inquiry we are concentrating on the narcissistic condition as a malady in which the individual is alienated or split away from self, concomitant to a regression to earlier states of being, the locus of the psyche elsewhere, in what I describe as other worlds. The self-concept is at once megalomanic and diminutive. The narcissist is by that token incapable of love for others, or even self. I hold that the interpretation of the myth of Narcissus as loving self and self-image is delusionary. Neonate: Important to this study is the hypothesized psyche of the newborn, how much of a tabla rasa it is, and whether there is a primordial ego organization, with special reference to the ego ideal. This ties in with the concept of an idealized state intra-utero in which mother and child are one, conceptualized as a paradise. Neutralized Energy: This pertains to a derivation of the energic hypothesis in which the psychic energy is conceivably rendered, to my mind, to belong to itself rather than cathected or invested in an object or inherent in the original object. I cannot conceive of such neutrality relative to an energic concept, except in Freud’s thanatos, or death instinct. Normalization: Recognizing that norms differ widely, I would define normalization for behavioral purposes, to be attainment of a state of mutuality, relatively respectful, in the here and now. Oedipal Anxiety: Here we address ourselves to the patient’s anxieties over the hierarchic aspect of management of one’s family, and ultimately of self. Freud chose the Oedipal myth to exemplify the uncertain course of attainment of primacy in one’s family. Oedipus had killed his father in an almost accidental altercation. Further, he courted a woman who turned out to be his mother, and like Narcissus later in life through an act of de-repression learned the truth. Freud found the human psyche to be built on shifting sand such as that. Ontogenesis: This refers to the course of development of the individual organism. A maxim in ontogeny is that in the embryonic and fetal stages, it recapitulates phylogeny, or evolutionary development.

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Oral Guilt: This formulation of the prominent British psycho-analyist Melanie Klein pertained to an early situation between mother and child, in which the child dependent on the mother for nurturance, experiences aggressive, hurtful feelings, for which it is simultaneously guilty. In my iconic cases, I have discerned a deeper existential source of the guilt. The survivor’s guilt of the concentration camp population would be a manifestation of this period. The survivor here would have no right to further existence. Oral and Anal Components: In his search for biological aspects of the infant’s psychic development, Freud came across the oral, anal, and genital phases in transaction with the mothering one. He might well have added the important transaction of being held by her. In the oral phase, the hungry infant seeks nourishment and is guided by the mother to the nipple and by its responses forms an integration or transaction with her that is encrypted in its memory banks and acts as a guide for the satisfaction of future hunger. Dealing with the product that the other end of the digestive tract then becomes a matter of transaction. While genital arousal is present from the first, it apparently goes underground and becomes latent, engaged through hormonal action in adolescence. However, it is clear that such engagement on the part of the mothering one occurs earlier. Ordinal: This word, referring to order, is in contradistinction to superordinate and infraordinate, aspects of different grades of the function and structure of the nervous system occasioned by the hypothesized trauma to the nervous system of the developing embryo and fetus, and reached by the restitutive mechanism I call resurrective. The ordinal would be the state of the function prior to the trauma, and to which the organism would return, after relinquishing the resurrected state of messianism. Parapsychological: The altered states involved in the messianic experience are marked by para-psychological phenomena, like telepathy, clairvoyance, visionary experience, and telekinesis. The author experienced depth into parapsychology when he intuitively made contact with a catatonic patient situated out of sight under a bench. Parameters: Deviation from the core method of psychoanalysis, a joint inquiry into the coexistence of analyst and patient, devoted to facilitation of the emergence of dissociative aspects of self and functioning has been designated as a parameter. This action and event is usually subject further to joint inquiry. Patriarchal: Related antithetically to matriarch, the patriarch is the founder of the race or clan, with the backing of a male god. In Mediterranean cul-

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tures, the patriarch and matriarch are simultaneously empowered; the female the authority of the house, the male the overall authority. Personal Myth: A case can be made for Freud’s goldener ziggie as an example of a personal myth, having to do with his destiny towards greatness, induced in him by his mother (and perhaps his father), plus added to by others’ expectations, with its core his own version of the myth of Narcissus. I have noted elements of that constellation in my messianism. Premorbid: I include this term to denote signs pointing to dementia praecox, in which the young man, eyes shining with promise and talents, is brittle in personality and living out ideals of central moment to his family. Similarly rigid personality characteristics may be present in a woman approaching menopause, or in a woman who conforms utterly to the ideals of motherhood and family building. Both have great difficulty in making the transition to the nest stage of life, and enter a state of helplessness and decompensation. Presences: Freud has posited return of the repressed. In this volume that which has been disassociated through repression or splitting is represented in many forms. Of particular relevance in this volume are those that take form of specific emergence, in the iconic cases of gross, hallucinated representation of faces, a mere whisper of a presence, a rotting corpse, a beating heart in a sack outside the patient’s body, a vivid, still alive father in a hideaway on a mountain, or a fluttering bird. This return from the repressed marked the onset of reintegration of the psyche, so that it was positioned to accomplish the task of mourning. An example in literature which I hold to be very pertinent is the presence in Hamlet’s life of his father’s ghost early in the play. I have described the dynamics of that encounter elsewhere in this volume. Freud has noted, significantly, another occurrence of the presences in what he called Revenant, or return from the dead. Prometheus: Prometheus was a Titan who foresaw the defeat of his kind by the Olympians, and was spared by Zeus. He thereupon fashioned man out of clay and water, and saved him from a great flood. He was chained to a mountain, suffering his vitals to be eaten by birds. Mankind was then plagued by Pandora and her box of evils. The thesis here is that this was a god that reached out to man, both creating him, encouraging him, and was resident within him, subject to a jealous god. Provident God: I have included this designation to emphasize the importance of the concept of a provident god. The Jews in the Sabbatai Sevi story believed that God through this messiah would bring them back to Israel. The French believe in a provident God who died in World War I, at Verdun. The

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Germans regressed to earlier, Nordic warrior gods, who would carry them to ascendancy, with Hitler as their savior. Psychopathy: In the clinical vignette earlier in this volume, concerning the treatment of psychopathic individuals during World War II, I have described the process whereby the members of the group went through dramatic conversion from an alienated, intrapsychic position to a messianic one through which there was human relinkage with self and others. At core I have found the psychopath to be suffering from a severe personality disorder as disabling as schizophrenia and depression. Its intrapsychic severity is attested to by the major mental illness experienced in the course of recovery from the psychopathic state. Also, at core, I have come to the hypothesis that the disorder is one of the soul of the individual, and approachable through transacting in that arena. Reality: Rea1ity is an ardous construction by humanity, and becomes what man is searching for. His leads there stem from his capacity for new cogitation, or mythopoesis. By this token, mythopoesis would be at the root of the scientific method. An important thesis I have encountered is that the ego ideal is the personality’s instrument of the sense of reality and positioning in the human and material universe. Reconciliation: Reconciliation is the other sìde of alienation, and is the critical stage on the way to reconstitution of relationships. In issue is whether that reconstitution would be a new order of reality, as in the synthesis of the dialectical process. Repression: This core psychoanalytic concept pertains to the consignment of ideas and feelings to the unconscious by the operant self of the individual. While it differs from suppression, it maintains in the author’s mind some of that quality, as differentiating from the act of disassociation, or separation of the ideas and affects from awareness. That dissassociative process is manifested most openly in the process of splitting, or total disassociation. Recovery from splitting would then go through a state of repression, then of derepression, and then admission to consciousness. Resurrection: This is a key underlying concept in the development of my thought about narcissism. It would seem that after the psychic death or near death of the developing organism, in response to trauma, there is a rebirth through assumption of the junction at higher or lower centers that is experienced as resurrective.

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Restitution: The resurrective experience would be restorative function, and the organism could achieve homeostasis in an adhered reality. However, the restitution, as in depth therapy, would call for retracing the path of the pathology, relinquishment of the resurrective (or superordinative) way of the functioning, then the death, allowing the organism to re-achieve functioning on the ordinal level. Role theory: Role reversal is an important mechanism in the genesis and perpetuation of the messianic position. Understanding there comes from grasping the basic social theory that our individuality operates in the context of group life, starting with the group of two. The members of that social entity transact reciprocally and as a unit. That social unity has its own history, mode of relating, and is related in turn to the rest of society. In the role reversal in question, the child is parent to the parent, an anomalous situation readily identified in pathologic families. When born, the messianic individual unwittingly receives career training in savior-hood (except in families which a priori give a son to the Church, or in the case of the Dalai Lama). We have touched on the subject of career training earlier. Schizophrenia: The profession which undertook the care of schizophrenic individuals was first called alienist, most likely in recognition of what I take to be the central feature of the disorder, alienation from self. Though I hold that alienation underlies mental disorder and psychopathy, schizophrenia is acknowledged to be the most intractable and deepest of all. It is as varied in its manifestation across the globe as are human beings. Screen Identification: This is a depth-psychologic term in which the individual assumes a role and capacity, or identification which acts as a screen in reality super-ceding an underlying one for dynamic purposes. In iconic case one, the patient treated herself and the world in the manner of her grandmother in a both benevolent and peremptory fashion. I identified that behavior as such which the patient recognized then discarded to arrive at her underlying state of loss of her mother. Soul: At humanity’s current level of comprehension, we conceive and perceive the existence of entity in the world and its essential meaning and structure as soul. Death follows departure of that coherent animation, that soul. As living creatures we tend to experience that life as present in the future, and therefore immortalize the soul. We conceive of a career for that soul, postulating in myth stories of genesis and ultimate outcomes. It would appear that religionists and philosophers first conceived of the essential and the ideal aspects of its governance of self as soul. However, there are anlage in myth of that development elsewhere in society, such as the career in Greek

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mythology of Prometheus, who broke with the Gods, and the development of democratic ways on the part of northern European tribes, eventuating in democracy in England, France, and America. That would lead one to think that humanity would have come to the conception and perception of the essential self and other were Abraham not to have heard the voice of a conjointly universal and personal God setting him on a mission in selfhood for his tribe. Along the way God’s design for the entity and dignity of the human being was revealed in abstinence from human sacrifice, then in the cultivations of the prophets, and the evolution of the soul of Israel as an example for the world. My thinking about the soul is an extension of Erikson’s formulation on identity. He had it both as a process and product. Through that combined junction and psychic structure, he expressed the manifold aspects of the ideals and aspirations, linkages and affiliations to others and their ways, how the individual enduringly identified self in time, space, personal and social reality. The soul would be such on both a higher and deeper order. The soul would have wings as well as heart, indicating representation of psyche and soma in an essential way. The soul would be reflected in the dream life of the individual, as with the appearance of the rotting corpse in one of my clinical examples, and in Hamlet’s father’s mission on the parapet. We experience the souls of the living and the dead as presences in our daily life, and especially in crises. Our lives pass before our eyes in severe crises. We experience evidence of our soul-connectedness with others in our chests and heads, as in my intuitometer. We experience essence of self in our chests and heads as internal or external auras. Then there is the terra incognita of parapsychology, where we have the task of separating fact from fancy, but where there are more things in heaven and earth than are dreamt in your philosophy. We look for evidence of the essentially organizing soul comparable to that of the ultimate directing genes. Superego: Again, a formulation of Freud to designate the governing aspect of the personality, as differentiated from the ego and the id. It is largely out of consciousness, and is reflective of the governance of others. It is held by some to be of a piece with the ego ideal. Sabbatai Sevi was subject to the superego judgments of the orthodox rabbis, and through inspiration experienced in his ego ideal, adhered what was prohibited and permitted in ritual. Survivors Guilt: I hold this to be a seminal concept. It came to the fore in thought concerning the intractable mourning of concentration camp survivors. The theory here was that they suffered guilt for not having perished with the others. I relate that to my theory about the role reversal of the

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messianic individual and the mothering one. An example: the patient who could not mourn the father resident within as a rotting corpse. Secondary Revision: This pertains to the alteration of data from the unconscious by the conscious mind to bring it in conformity to reality experienced by the conscious mind. In the literature it pertains mostly to dream processes. The Severe Disorders: The severe disorders would be schizophrenia, depressive disorder, bipolar disorder, narcissism, and psychopathy. In all I have found significant alienation from self, and admixtures of the other disorders, leading to the concept of spectrums of disorder, down to the disorder of the soul of the contemporaneously healthy individual. It is of spiritual nature, inherent, stemming from man’s emancipation from the godhead. Beneath in a provident deity has veined with the enormous loss of life in the First World War. In his Christianity Must Change or Die, Bishop Spong challenges his fellow believers along this line. The Therapeutic Despair: This is a state of being on the part of the psychoanalyst in which there is a loss of meaning and purposiveness in the therapeutic enterprise occasioned by defensiveness on the part of the patient, itself occasioned by encounter in the unconscious with such analogous loss. This phenomenon was first reported by Dr. Lewis Hill, of the Baltimore Psychoanalytic Society. Rather than a negative occurrence in the analysis, he took it to be indicative of an avenue for further depth analysis. I have found it to be so. My first iconic case reported in this volume would get up from the couch stating that the procedure had no meaning and that she was not going to lend herself to it anymore. This preceded analysis of screen identifications, in this case that of her dead grandmother. Transaction: This social psychological concept denotes a unity of interacting entities. It has been popularized by a psychoanalyst, Eric Berne, in a simplistic formulation of the child and adult within the psyche. I find it essential in conceptualizing and contextualizing our human situation. The psychopaths at Fort Knox who fell in mesmerian fits were regressing in psychological and soul unity. Psychoanalysis currently is entertaining the concept of transaction as intersubjectivity. Transcendence: I invoke this concept to explain the other-worldly nature of the messianic experience. I noted it in the capacity of the psychopath to endure punitive privation and separation from their fellows, as in solitary confinement. It occurred to me early that the psychopath lived in another world. The issue of worlds of existence was very evident in the case of schizophrenics, especially with paranoid and hebephrenic individuals. What

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was being transcended and the role of alienation came later. It appears that humankind has less and less need for transcendence into other worlds, as reality become more bearable, in the womb and afterwards. Transference: This psychoanalytic concept was developed by Freud in an attempt to investigate the penetration and obviation of current reality by that of the past. When the individual in treatment transacts in a trusting relationship there is a regression in the ego and the discernment of aspects of the past as differentiated from current reality, along with the intra-psychic and interpersonal factors which keep the individual tied to the past. Identification of the transference and its resolution is the work of analysis. Verdun: I employ the horrific experience of the French and German forces in WWI, in which a million men were killed and wounded in a year-long battle, to dramatize the turn in humanity’s concept from provident to abstinent deity. For many intellectuals God died there. Before, the young man of Europe had marched joyfully, in their blind narcissism, to the coming battle. Fort Duamont changed hands many times, each time with the sacrifice often of thousands. The result was disillusionment, down to the very soul, resulting in Poilus who in contrast to their previous lusty manhood bleated like sheep, which was an expression of their human condition. They then mutinied. World: This term might more properly be worlds. It denotes an aspect of consciousness and existence especially important to understanding the messianic experience. In my work The Messianic Imperative, Sabbatai Sevi lived in a number of worlds which themselves contained worlds. Each world would save its own population, ways, and relationship to the other worlds. Most importantly, he was able to communicate his visualization and actualization to the multitude and individua1 through his charisma, so as to impel them to their promised land.

Annotated Bibliography

Abrahams, J. and McCorkle, L.W. 1946. Group Psychotherapy of Military Offenders, Am. J. Sociol. 51:455. Abrahams, J. and McCorkle, L.W. 1947. Group Psychotherapy at an Army Rehabilitation Center, Dis. Nerv. Sys. 8:3. Abrahams, J. and McCorkle, L.W. 1947. Analysis of a Prison Disturbance, Jour. Abn. and Soc. Psych. 42:330. My associate, the sociologist Lloyd W. McCorkle, and I here report our adventure in treating psychopathically inclined youth during the momentous days of World War II. Narrative in form, these accounts were intended to set the stage for further research and development. He went on to initiate Highfields, a halfway house for delinquent youth; then became Principal Keeper of the New Jersey State Prison; Commissioner of the New Jersey Department of Institutions and Agencies; Professor John Jay College; and author, with David Korn, of Modern Penology. The advances we report on, and continue for a decade were lost subsequently. Abrahams, J. 1947. Group Psychotherapy: Remarks on its Basis and Application. Med. Annals of D.C. 16:612. ———. 1948. Preliminary Report of an Experience in the Group Psychotherapy of Schizophrenics. Am. J. Psychiatry. 104:613. This is a preliminary report of the work in Howard Hall, leading in time to the establishment of a multidisciplinary training program in group work at St. Elizabeth’s Hospital. ———.1948. Group Psychotherapy: Preliminary Remarks on its Use in Correctional Institutions. Bull. Correctional Service Assoc. 1:12. This Bulletin of the Correctional Service Associates marks the high water mark in a movement within the Federal Prison Service towards establishment of rehabilitation there on the Fort Knox model, also a National Institute for Research in Crime. ———. Group Psychotherapy: Implications for Direction and Supervision of Mentally Ill Patients, in Theresa Muller’s Mental Health in Nursing. Washington, Catholic Univ. Press, 1950, pp. 77–83. ———. 1953 The Large Group, Chapter in: Powdermaker, Dr. Florence, and Frank, Jerome D., Group Psychotherapy, Cambridge: The Harvard Press. Jerome Frank and Florence Powdermaker, along with Daniel Blain, Chief of Psychiatry of the Veterans Administration early post war initiated a research group, which in turn organized a group treatment project at the Perry Point Veterans Administration Hospital. Following the evident feasibility of extremely large groups, later called therapeutic community groups, we established a group of 87 patients, therapists and personnel. The Chapter reports on that rewarding experience.

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Abrahams, J. with Varon, Edith. 1953. Maternal Dependency and Schizophrenia, A Group Analytic Study. New York, International Univ. Press. Foulkes, Rev. S. H., Intl. J. Psa, 1955. 36:358; Jordan, A. M. Q., 1955, 24:300–302. This group on a chronic ward at St. Elizabeth’s Hospital consisted of 6 mother-daughter pairs, a social worker recorder, and myself, meeting weekly for 2 years. The alienated tie of mother and daughter was subjected to analytic scrutiny, and yielded to cycles of alienation reconciliation. Abrahams, J. 1956. Some Views on Group Psychotherapy in the Mental Hospital. J. Neurophsychiat., 4:39. Abrahams, J. and Stanton, Alfred H. 1958. (Report) A comparison of individual and group psychology. (Panel: Am. Psychoanal. Assoc., Chicago, May 1956), J. Am. Psa. Assn. 6:121–130. This paper is a report of combined individual and group psychoanalysis of a group of 10 private patients, their courses towards recovery, and my inferences. Alfred Stanton summarizes the work, which is still unpublished. The character analysis initiated in the group was a mainstay in the members’ individual analyses. A remarkable feature was the insight afforded by delineating the role of myth in the life courses of the women. Abrahams, J. 1960. (Ed.) Group Methods in the Treatment of Schizophrenic Outpatients, Scher, Sam C. and Davis, Howard R, (Eds.), The Outpatient Treatment of Schizophrenia, New York, Grune and Stratton. This is a broad gauged essay into the theory and practice of group methods in the treatment of schizophrenic outpatients, occasioned by the initial efforts towards their treatment in community clinics. ———. 1962. (Ed.) Group Work in the Mental Hospital: A Manual, The St. Elizabeth’s Hospital Group Work Training Program, Washington, D.C. The work in Howard Hall, Perry Point VA, and elsewhere at St. Elizabeth’s led to a Hospital-Wide Group Work Training Program. The faculty, consisting of the chairs or representative of the departments of the hospital—nursing, psychology, psychiatry, pastoral, educational, dance, occupational therapy, and psychodrama—learned to be members of and to lead groups, through training groups. Eventually, a large faculty (35) was established, along with 200 groups, hospital wide. ———. 2006. Turning Lives Around: Wartime Treatment of Military Prisoners, AuthorHouse, Bloomington. The illustrative cartoons in this volume were a psycho-educational feature of the large groups in the rehabilitation program at Fort Knox, Kentucky, during World War II. Drawn by a rehabilitee who understood psychopathy, they deepened the reach of the groups into the character disorders of the rehabilitees. There are narrative accounts of sessions, and presentation of a theory of alienation. Abse, D. Wilfred. 1974. Clinical Notes on Group-Analytic Psychotherapy, Charlottesville: The University Press of Virginia. This rich and masterful presentation of group analysis and therapeutic community, product of an original mind, is a far cry from Slavson’s early work on the subject. Abse has coined a designation for the activity of interpretation in group therapy, learning alliance, in which the preconscious of the leader is joined with that of the group, to monitor consciousness, guiding the members in a state of de-repression. He also comes out with condenser phenomena, in which associated ideas are pooled, to result in sudden discharge of deep and primitive feelings and ideas. He suspects that the group judgment engaged in problem solving at this primitive level. He notes the advantages offered in analytic groups of character analysis, and mobilization of “totemistic” transference. Elsewhere he mentions motive analysis, in the context of a profound discussion of anomie, suicide, and social integration and disintegration. Altizer, Thomas J.J et al (1982) Deconstruction and Theology. New York, Crossroad. The book starts with the definition of deconstruction theology as the epitaph of God put in writing. Death of meaning plays a prominent part here, in a semantic world, pulling the semantic achievement down toward that which was repressed by the fact of representational origination. It appears to me that there is potential for mythopoesis in the following: the new

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speak that it disseminates is usually a metaphor language that finds its footing in the semantic realm because the foot placed in the semantically indeterminate realm can never be sure of itself. Heidigger is quoted as saying that this is carried out under the guidance of Being. In the final essay, Whither Religious Thinking, the search is for a new method, intuitive in pattern. My interest in the spiritual aspects of the ego ideal led to the study of this volume. Altman, L. L. (1975). The Dream in Psychoanalysis. Intl Universities Press Inc. In this clear exposition Altman summarizes and furthers the work on the adaptive aspect of dreams and their furtherance of the mutative aspect of psychoanalysis. Adler, A. (2002) The Collected Clinical Works of Alfred Adler, Volume I: The Neurotic Character. The Classical Adlerian Translation Project. A member of the Freudian early circle in Vienna, this pioneer German psychoanalyst strayed from the then prevalent pursuit of analysis of defenses to an aspect of ego psychology that can be characterized as striving for power and purview which this author conceives to be a then prominent aspect of the German personality. He parted company with standard psychoanalysis developing his individual psychology, moving to America and attaining prominence there. Aichhorn, A. (1949). Some Remarks on the Psychic Structure and Social Care of a Certain Type of Female Juvenile Delinquents. Psychoanalytic Study of the Child, 4:439–448. In this publication on the subject of delinquency, Aichhorn does a mostly social psychologically presentation of a study of delinquent girls in the immediately post-war period in Vienna. He categorizes them in terms of maturity, coherence of behavior, and intelligence. The more mature appear to have made a precocious object choice to which they are evidently “faithful.” Then come girls who are caught in what Aichhorn estimates to be prepubertal crisis when, breaking away from their families and pairing with a more dominant girl, aggregate in predeliquent groups at locales such as music halls. Aichhorn has it that the breakthrough into sexuality from latency results in eruption of frank sexual deviance and also holds that intelligence is a dominant variable. He has it that the more feeble minded cannot be reached. He attempts to apply psychoanalytic developmental theory to the problem, starting with the eruption from the unconscious of instinctual drive, also the issue of maturity of the ego, but his theorizing falls short, in comparison to that in wayward youth. He has recommendations on the management of this complex program through formation of appropriate institutions and training of mentors. Psychoanalysis would play a large part in that training. I wish to note that Aichhorn cites that this report is only preliminary. Aichhorn, A. (1968) Wayward Youth, New York: The Viking Press. This remarkable book has played a central part in the philosophy and practice of the Ft. Knox Rehabilitation Center especially through its influence on Col. George L. Miller, its Commandant. For that reason, and to discern the philosophy and practice of its author, August Aichhorn, I give a close reading here. The editors of the book also scrutinize Aichhorn’s life and practice for clues to what gave him his extraordinary capacity to reach the delinquent, create institutions for their treatment, and influence his contemporary society to accept them. These are issues still very much alive now. First, Aichhorn’s family tradition was that of the independent burgher, from artisan, official, to bank president, inventive yet conservative. His father was unusually capable in surmounting business difficulties, and closely trained his son in such. Young Aichhorn had to make the bakery deliveries early, for efficiency of the apprentices, who in turn befriended the master’s son, resulting in a capacity on young August’s part to reach people as such. Aichhorn next showed civic concern and capacity for intimacy with others in the choice of teaching as a profession, extending it to work with troubled youth. He demonstrated his father’s capacity for leadership in the founding of the supplementary day school for children with learning difficulties, then a residential institution. He recognized the value of psychoanalysis as a method of reaching the inner life of his charges, and soon was recognized by his fellow analysts for his remarkable intuitive capacity and success with the delinquents, hitherto considered untreatable. In a foreword, Sigmund Freud cogently sites Aichhorn’s “… Warm sympathy for the faith of those unfortunates… rightly guided by his intuitive understanding of the psychic

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needs.” Freud goes on to admit that psychoanalysis could teach Aichhorn little more than a theory for his practice and a platform to teach further. And that is what Aichhorn did, lecturing at the Psychoanalytic Institute and establishing climes in Vienna. The couch did not figure in his teaching; he engaged in dialogue with delinquent and family, winning them from alienation to reality through a positive psychoanalytic transference, adapted to the special need and pedagogy of the problem child. In the introduction, Aichhorn attributes difficulty on the part of the developing child, in moving from a natural asocial to a social state, to problems in emotional development. Failure of repudiation of earliest instinctual tendencies result in “latent delinquency” and “susceptibility.” Treatment is through education and development of an acquired capacity to deal with cultural reality. There is an inherent capacity, phylogenetic and also ontogenetic, that is expanded through education and experience. Aichhorn accepted Freud’s notion of an unconscious, to explain man’s unknowingness, secondary to repression or disassociation of “emotion too great for assimilation.” The task of the remedial educator becomes that of devining and bringing to consciousness that repressed emotion, then engaging in reeducation. In chapter 2, “The Analysis of a Symptom,” Aichhorn, in a lucid account, details of inquiry into the ambivalent motivations and family situation of the boy who stole his sister’s money for vengeance, ran away from home from home in his father’s manner, in like kind aggravating his mother. At the same time, he intended to treat his mother with cherries of his father’s tree far off in the woods. Aichhorn, with clinical meticulousness, traces the drama to a critical point where the boy, and his course of alienation, sees cherry pits on the windowsill, and decides to favor his mother, as well as punish her per se and for favoring his sister. Along the way, Aichhorn engages in ameliorative family therapy, through a benignly abstinent manner, then letting the mother in on her child’s loving side. The reformatory was averted. In chapter 3, “Some Causes of Delinquency,” Aichhorn begins with a truant 16-year-old boy who suffered the loss of his father, became his mother’s keeper, then loses her to an accident in which she was a mangled. Mourning was released on interviews, and reeducation on a farm freed him for productive engagement. A second case was of a girl who also had suffered loss of her parents, was void of feelings, bad tempered, deceitful, and extremely resistive to participating in the family of her adoptive uncle, resulting in corporal punishment by her vexed aunt and they complained of child abuse by her teacher. Through an intuitive connectedness, Aichhorn elicited that she was haunted by her parent’s death, particularly by a dream in which she saw the deathbeds over and over again. Her tuberculous father had died dramatically while she cared for him, and mother had committed suicide despite the child’s best efforts. Thereafter, the child yielded to a world of fantasy about the past. In school, she was well-adjusted, confided in her classmates about the beating at home, at which her teacher lodged a complaint of abuse. Aichhorn made the judgment that the aunt could not be brought to understanding of this untoward child, so he transferred her to institution in which she was cared for by a trained and understanding teacher, as well as a therapeutic milieu with other children, with recovery. A 15-year-old girl had been expelled from school, and was still obstinate and rebellious in the institutional group. She opened up to Aichhorn with violent tears and revelations of a repeated, frightening dream of the dead mother attempting to choke her to death. Encouraged by a friend, she had stolen some of her mother’s clothes while her mother was dying. Her teacher’s affection had opened her to the memory, and the girl was afraid of rejection. She admitted her guilt to the teacher, and settled into an identification with her, with relief of her symptomatic behavior. In another case, a 12-year-old girl compulsively tried to terrify other girls with red garments and objects. Aichhorn elicited that in the first grade she had been terrified by a Santa Claus who had switched her and chased her under a bed. Earlier, at four years of age, the mother had assaulted a red-haired sexual rival, on separation of her parents, leaving her face bloodied, framed by her red hair. Again bringing this inner material to light in developing a relationship in the process resulted in relief from the compulsion. In chapter 4, Aichhorn delves more deeply into the “abnormal accumulation of affect,” in the case of an 18-year-old boy who had difficulty making the transition into manhood, acting younger than his age and violently towards his siblings in assertion of a dominant

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position in the family. Aichhorn found the key to the situation in the boy’s problem with masculinity, secondary to his father’s death when he was 14. Aichhorn stood psychically in for the missing father, intervening in the family dynamic to afford the boy relief from his alienation from him and his alienation from the family over the issue of his job career and religious orientation. Gaining the confidence of the mother and the boy on the possibility of a positive outcome, tension was released. Aichhorn intervened to have an apprentice in carpentering career resumed, the boys freedom to pursue his own religious beliefs, and a gradual reconciliation between members of the family. In chapter 5, entitled “Underlying Causes of Delinquency,” Aichhorn goes more deeply into reasons for alienation, citing the case of a 17-year-old boy who, carpenter’s helper to his father, turned on him by stealing alcohol and lumber, to fund gifts for his new stepmother. Aichhorn elicits data from the woman, who had been his mother’s friend, about the existence of an adolescent crush, developed several years prior to the death of his mother. Aichhorn pointed to the underlying dynamic as genetic to the boy’s alienation. He goes on to cite the case of a 17-year-old shoemaker’s apprentice who, formally corporatist, had become thoroughly alienated from his father, stepmother, and siblings. From the boy’s continent and grown-up manner, he instituted that he was holding something deep secret. Aichhorn paradoxically reached the boy by offering to make a deal in which he did not have to tell what he did not want to reveal. Following his intuition, he elicited that the boy wanted to commit suicide, over the alienation from his father and rivalry with an older brother. Aichhorn then effected a reconciliation between the boy and his father, with deep effect on the part of both, indicative of the depth of their time. But further individual analysis with the boy was necessary, dealing with a feminine identification that had its origin in his relation with his deceased mother, transferred to his stepmother. Aichhorn logically traces to the failure of the adolescent’s life plan, to the point where symbolic suicide was the way out. These deeper considerations are summarized in chapter 6, on The Transference. Aichhorn mounts a thesis that the reality of contemporary relationship is built on or transferred from relationships in the past. It becomes transmuted as the personality develops. He stresses disturbance in love of libidinal attachments, either from too much love or too little. He identifies both with inner conflict, or neurosis, and differentiates them from those in open conflict with the world, in defense of original libidinal desires. They differ markedly in the possibility for a transference relationship. Untruthfulness is a marker of alienation and is similar to how we hide our real selves, in normal parlance. Aichhorn describes how he builds his relationship with alienated youth. He first studies the person intuitively, “feeling out” the situation. This is followed by a struggle for mastery, indicating from the first that Aichhorn had the necessary power, but withheld it in favor of giving the other options, on the way to a cooperative relationship. Aichhorn then makes contact via topics of interest to the child, other than the delinquency, to the point where trust is established as a precondition to investment in the analyst to the point of transference of parental affects. He describes a case where he broke through the defenses of a very selfsufficient boy, by provoking into one array from the institution. The resulting hiatus gave him the opportunity to realize his incipient tie and dependence, and breakthrough of that realization. Aichhorn utilized his intuition as guide throughout his unorthodox regimen. In chapter 7, “The Training School,” Aichhorn describes his “practical psychology of reconciliation,” an attitude which brings the child into contact with reality, conforming to actual social community, which significantly belongs to the children. Aichhorn tells of how he arrived pragmatically in grouping people with similar problems together, reflective of underlying personal and social dynamics. A feminine influence helps with younger children, and the mood of the counselor is carefully monitored, for outgoing cheerfulness and capacity for emotional investment on the part of the children. Aichhorn illustrates this with a 16year-old boy who stole and was aggressive, fantasizing being the leader of a gang. He was of limited intelligence and found his place as a gardener, displaying strength, digging in the ground. A 17-year-old homosexual boy was employed in a tailor shop, channeling his feelings into superior skills, resulting in self-esteem and stability. In his institution, Hollanbrun, Aichhorn utilized critical situations, such occasions of stealing within the institution, for cathartic discussion with the miscreant, on the basis of mobilization of the field when

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trust developed through the transference. Aichhorn gives a vivid account of an instance in which he confronts a boy who stole from his fellows. The account reads much like those that were grist for the mill in the groups at Fort Knox. In chapter 8, “The Aggressive Group,” Aichhorn goes further into his philosophy and practice. He allows as much freedom as possible, “let the boys alone.” Fights were intervened to avoid injury. Aichhorn goes on to cite the dynamic behind alienated aggressions: the delinquent tests limits to affirm his life attitude, for effect. He describes what happened in the early stages of his work, when he and his personnel abstained from reacting in an authoritarian manner. They then systematically proceeded to destroy the quarters and its furniture. At its height, one of the boys threatened to slit the throat of another, and when Aichhorn did not respond, the boy dropped the knife, was rageful, then burst into tears. In time, Aichhorn sensed and elicited those tears in each of the 12 members of the aggressive group he cites in his chapter. In the process, an emotional bond developed with the personnel, cemented by a Christmas celebration. One over, normal boys dynamics followed, yet more sensitive and intense than expected in normal boys. Aichhorn then yielded leadership of the group to a psychologist, who began making emotional couch demands on the 12 boys, who became “dependent charges.” Aichhorn quotes Freud’s Group Psychology and Analysis of the Ego to the effect that “an emotional tie to the worker develops after the period of greatest aggression.” We noted this crucial dynamic in our groups at Knox, when we drew them out in the course of the sessions. When, as with Aichhorn, we did not respond in an authoritarian, repressive manner, their leadership acted powerful and at the height of their display of hate and alienation, they decompensated, at times falling to the floor and fits. Older than the boys at Hollanbrun they did not weep, but they did experienced depressive mourning for their former alienated way of life, and also psychosomatic disorders. Aichhorn finishes this important chapter with a meticulous account of the alienation and re-conciliation of a member of the group, Luis. In chapter 9, “The Reality Principle,” Aichhorn adapts Freud’s theory of how the child is civilized, formulated for the “normal” neurotic adults, two issues of delinquency. It amounts to the thesis that the parents live in other realities and do not assist in helping the child renounce immediate gratification of pleasure (the pleasure principle), through love, to life in mutually achieved reality. The child is over gratified or over deprived, remains arrested in earlier developmental eras, to which it regresses. Treatment involves discernment of the situation, intuitively guided enlistment of the child and parents in corrective engagement, to result in renunciation of pleasure positions in pleasure in new realities. In chapter 10, “On the Ego Ideal and Behavior,” Aichhorn cites it as the inner voice, the categorical imperative that differentiates the rest of us from the delinquent. Aichhorn does not go into the nature of the ego ideal in alienation. The inner voice, whatever its nature, is combined with a critical ego that guides both conforming and nonconforming behavior. He asks if this voice and guide comes from the mind, soul, or body, and concludes that it is all three. He fails to approach the issue of the role of the soul and moral development and treatment. Perhaps the spiritual played a part in the pivotal turn his aggressive group took, when a Christmas celebration was entered into enthusiastically by the boys, followed by reconciliation from a state of obdurate alienation. At Knox, I pointed out to my therapists that Christ was flanked by criminals in the crucifixion. I would say to them that one had to but “scratch a psychopath to find a Messiah.” I would infer that it is the ego ideal that is the central factor in Aichhorn’s approach and through which he so adroitly reaches the delinquent in his plentiful clinical material. It is the phenomenon behind the weeping he cited in the aggressive group of chapter 8 and the character change he seeks in treatment. In sum, this honest presentation by a master educator, detailing his pioneering experience makes clear why Col. Miller at the Fort Knox rehabilitation center chose to adapt Aichhorn’s method 20 years later, during World War II. Alexander, F. (1925). Dreams in Pairs and Series. International Journal of Psychoanalysis. Franz Alexander pioneered in variations of the psychoanalytic method, while adhering to Freud’s original approach. Here he addresses himself through the linkages between dreams, a matter of some moment to this author.

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Andrewes, Anthony (1978) The Greeks. New York and London, Norton. From Oxford, Professor of Ancient History, Professor Andrewes gives this cogent exposition of the civilization of the Hellenes, or Greeks, who scraped a good living from their relatively barren land and build a remarkable civilization which characterized itself as free, capable of general speculation, uninhibited by past myth or authority, distinguishing itself from the barbarian or ridiculously servile Persian neighbors. The Greeks conceived of an individual soul, whose rational aspect organized passions and spirit. Hesiod organized the polytheistic dynasty of Greek Gods in his Theogony, with its generations of gods, down to Prometheus and man. The gods were creatures in the human mold, and Homer had them interrelating with man and intervening in his destiny. The Greeks expected to live only in the memory of their successors, leading to the cult of the family. The after-life was populated by ghosts, however, who were laid to rest through ritual. States were under the influence and protection of specific deities, as in the case of Athens and Pallas Athena, whose characteristics can be detected to this date in the character of dominant women. On the other hand, Pythia was an important oracle (a priest who imparted the response of a god to the human questioner). On the wall of the central temple at Delphi was inscribed Know thyself which I hold to be at the core of the Narcissus story. Sacrifice was also centra1 to divination, or asking for the favor and intervention of the Gods. Assmann, Jan (1997) Moses the Egyptian. Cambridge, Harvard University Press. This tremendous work relates Freud’s thesis that Moses, who drew the line between paganism and monotheism, was an Egyptian. Assmann reports that Freud was obsessed with Moses and Egypt, having started a historical novel on the subject, and made three attempts at it prior to Moses and Monotheism. One of the titles was Moses the Man. The thesis here is that the Egyptians in the spread of their empire, in the Athenian religion, developed concepts of terrestrial and celestial monarchy. Freud’s idea was that the death of the pharaoh Akhenaten and the subsequent reaction to orthodoxy prompted Moses to leave Egypt, adopting the people of Yahweh as his own. Freud then constructed an intergenerational drama, as he had in Totem and Taboo, in which Moses was slain, then his undiluted monotheism was encrypted, reaffirming an obsessive devotion to his deity. I have noted this incorporative then imperative behavior in the severe disorders I have reported earlier in the study, the Messianic Imperative, Abrahams, J. (2007) The Messianic Imperative: Scourge or Savior. Xlibris Corporation. Armstrong, Karen (1993) A Hìstory of God. New York: Ballantine Books. An important work by a former nun, who characterizes herself as a freelance monotheist after a period of atheism. She has found the study of the great religions to lead her to both an essential spirituality and humanness. Balint, Michael (1968) The Basic Fault. London, Tavistock. In a search for the basic fault behind the most difficult patients, Balint cites their uncanny capacity for understanding, verging on telepathy and clairvoyance, with a background of sensing evil in the environment. He searches for the primary narcissistic state, arriving at the concept of primary love, a state of harmony within, in the context of one without, as a state of harmonious interpenetrating mix-up. Aggression would be secondary. He quotes Takeo Doi, a Japanese analyst on the Japanese amae, a basic wish or expectation of a unity of mutua1 love. Hatred would follow perpetuation of unconditiona1 dependence on primary love. The basic fault would be in the arena of primary love and its vicissitudes, treated by therapeutic regression and interpretation by an analyst capable of experiencing that state without untoward defenses. It would seem to me that this corresponds to my thesis of messianism, and the mutual messianism necessary to the treatment of the severe disorders. Berman, L. H. (1996). The Psychoanalyst Working in a Community Mental Health Center. Journal of the American Academy of Psychoanalysis 24:649–660. Berman, L. H. (1089). Comments on “Correspondence and Thought-Transference during Psychoanalysis,” by Samuel Silverman, M.D. Journal of the American Academy of Psychoanalysis 17:531. Dr. Berman was chosen for erudition to present the theoretical aspects of the integration of group and individual psychoanalysis at the 1957 annual meeting of the American Psychoanalytic Association. I have summarized his presentation elsewhere in this volume. I make

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special notation of his openness to discussion of parapsychological phenomena as evidence in his review of “Correspondence and Thought-Transference during Psychoanalysis.” Berne, E. 1963. The Structure and Dynamics of Organizations and Groups, Philadelphia: Lippincott. The ambitious title stems from a wide consultancy and practice of transactional analysis, a variant of psychoanalysis. Berne applied the valuable social psychological concept of transaction—a unity of interacting entities—to the unit of psychoanalysis, which in time created that of inter-subjectivity. His ego psychological role analysis, done in parent and child terms, and ego defense analysis of “the games people play,” plus their inherent scripts proved interesting in popularizing psychoanalysis, but of limited usefulness. Bettelheim, Bruno. 1983. Freud and Man’s Soul: An Important Re-Interpretation of Freudian Theory. New York: Random House. Himself stemming from the Vienna psychoanalytic fold, psychologist Dr. Bettelheim has contributed to the inquiry into malign aspects of the relation of mother and child, but to this author’s mind essential insights into Freud’s scientific mind. Bettelheim describes a Freud conflicted between Naturwissenschaft and Geisteswissenschaft (natural sciences and sciences of the spirit), the latter would include comprehensive mythology, philosophy, and the classics. To my mind Bettelheim makes his case, though is polemic at times. My take on the issue of man’s soul is that Freud might very well have defined his work as the scientific study of the human soul, eschewing premature attempts to “scientize” his data by engaging in hypothesis relative to the instincts, chemistry and physics as applied to the human situation. He was on firmer territory when he attempted to discern human data in mythic terms. Bettelheim also worked with the analysis of children in the context of a creation of his, the orthogenic school. There, depth counseling, guidance, and supportive living were the mode of treatment. I contrast this with the approach of another psychoanalytic pioneer, August Aichorn in Vienna in the 1920s, in which the analyst ran a therapeutic community style group, obtaining close communion with his charges. Bion, W.R. 1959. Experiences In Groups, New York: Basic Books. Wilfred Bion and Maxwell Jones developed their group approaches under wartime emergency, and their work warrants closer and comparative inquiry. We gain greatly through their candor. Along the way they both underwent psychoanalytic training, and inevitably and uniquely let us into their situation. It turns out that Bion resists being a member of the group, while Jones glories in the experience. In this presentation we shall extensively inquire into Bion’s experience. Citing group work performed wartime with neurotic soldiers at London’s Tavistock Clinic, psychoanalyst Bion lays the groundwork for operational statement of his experience postwar with large and small groups, and his inferences. Like Freud early in his Group Psychology, he regards the phenomena, group and individual, to be the same, regarded from different standpoints. Early in Experiences, he cites psychoanalysis to be a pairing, or dyadic group, centered on the Oedipal situation, and when examined as a group per se, centered on the myth of the Sphinx, related to problems of knowledge and the scientific method. The relation to the Sphinx is as enigmatic as the Sphinx itself. But such enigmas stud Experiences, midst largely pellucid language. This work, published early in the development of analytic group therapy is classic. In it Bion cites what he and the group members said and did, and gives a running account of his feelings, with essays into his intrapsychic workings, as illustrative of what may be going on in the members. Such an effort calls for reciprocation by others, for equally frank sharing of parallel experiences. The session reports referred to is rendered in Chapters 1 and 2, in which he presents specific behavioral sequences, apparently from a vivid memory. In succeeding chapters he goes on to build a group science with postulates of group mentality, group culture, basic assumption group, and work group. Following the thesis that the Devil is in the details, I would like to review his report on a group, in the manner I cite as microanalysis in the volume This Way Out: A Narrative of Therapy of Sexual and Psychotic Offenders, Abrahams, J. Maryland: University Press. To lend perspective, I shall insert into the account a running commentary:

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Microanalysis of Bion’s Experiences in Groups, Chapters 1 and 2 1) Bion begins the account with how he got to “take on” the group in question. He had been asked by the Professional Committee of the Tavistock Committee to “take” therapeutic groups, utilizing his technique, which apparently had become famous by this time. 2) He then cites his discomfort with the request, not knowing what they had in mind. He had persuaded the groups he led in the military to study their tensions. He could do that again, but he had found out that the Committee expected cure, something different from Bion’s expectation. 3) He then reports that he expected the groups to cure him of a symptom, his “belief that groups might take kindly to my efforts.” This mordant statement was of great importance, to my mind. I would infer that the symptom is of a malady, related to an analogous belief prominent at that stage in my career, of messianic nature. In subsequent extensive efforts at self-analysis, I attempted to cure myself of it. It plays a critical role in this account. 4) Then Bion prefaces description of a session itself by noting that a run of them had both patients and personnel, leading to a “peculiar quandary.” Implicit here was that the patients and personnel would have different expectations, significantly regarding the issue of cure, in the case of the patients. 5) Then he presents a session with mixed patients and others: Members gradually gather at the appointed time, engaging in desultory conversation, interrupted by silence, recommencing, then silence. I make much of pregnant silences in my groups at Fort Knox and Howard Hall. Pragmatically, they were followed, as with Bion’s group, by something other than desultory conversation, but deep, cogent emotion. In the Howard Hall and Fort Knox groups the group atmosphere changed markedly, in the manner described by Bion. But I am getting ahead of the story. In anxiety, Bion interrupted the silence, confiding his sentiments. 6) Bion next reports that he “confided” his anxiety to the members concerning meeting the group’s expectations. He later reveals that he “blurted” this confidence. I got to know Bion later in his life, during his residence in the United States in Brentwood, as a man who kept himself and his privacy under great control. He appeared to be in personality elevated above others. Blurting would be out of character, and I would infer that, under the anxiety of this new situation in the group, he had regressed inwardly at this point in an experience of great consequence to his career as a psychoanalyst and the new discipline of group therapy. He had already revealed that he was conflicted by an impulse to “cure.” By my token, were he to assume that stance, and the groups take kindly to it, he would be in the messianic position. One of my therapists at Knox made a practice of disclosure of his discomfiture per se, in a manner so engaging that the members reassured him, without pursuing him further. Dr. Whitaker, a psychologist group therapist, and noted pioneer, as an initiatory act at this stage of the development of his group, lay himself down on the floor in front of the group, as if in a swoon, presenting himself as the subject for discussion. Monitoring the interaction, he later related to them what they had said and done, affirming their capacity for autonomous interaction. Both my therapist and Whitaker maintained their leadership role and position, engaging the group in the counseling stage of therapy. I had found such maneuvers not necessary, waiting out the silence, while attuned to my and the members’ phenomena. I became aware of how cogent and full of content the silences were. An associate, McCorkle, described a 40-minute silence with a group of young psychopaths, who responded to his strong authoritarian leadership by “staying with him” in communion. 7) Bion reports that his self-revelation was met by mixed “indignation” and “friendliness.” He had not abandoned the leadership position, perhaps maintaining hope through previous success with his Army groups, when the inherent group dynamic led to polarization of those with and those against collaboration. Remember his previous mention of groups that “might take kindly” to his efforts.

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8) Bion then averred that he sensed that the indignant members were expressing an underlying sense of entitlement. He has regained his intuitive capacity, and is recovering from the anxiety that led him to blurt. 9) Allied with the “friendly” members who, trusting, gave him credit for knowing what he was doing, Bion engaged the group as a whole in free association to what they sensed as his motivations and presence. He wondered what their expectations were and what aroused them. They informed him: most were told he would “take” the group; some that he had a reputation of knowing a lot about groups; some that he would lecture. That enactment was later termed brainstorming in the group dynamics movement, a guided evocation of data. It is apparent from his report that he volunteered as a democratic participant in the group, while maintaining his authority and position as psychoanalyst. He thereby provided leadership to the members in taking counsel with self and others on the role and capacity of leader and members. 10) He replies that their positions regarding him are based on “hearsay,” and senses that the members feel he was denying his “eminence as a ‘taker’ of groups.” He is here saying that the members got his mission wrong, hearing what they wanted to hear, coupled in the same sentence with Bion’s attribution to the group that he was denying whatever he means by eminence, and again, he brings up the phrase “taker of group” attributed first to the Committee. He earlier equates it with cure. 11) Bion cites the arrival of the vocal members to the position that the good expectations about him are disappointingly not true, and that his behavior is provocative, and that he chooses to be spiteful. The realization that the members are disappointed in him is sinking in, moreover, that he is alienated to the point of being spiteful. I get the impression here that he is using this transaction to study this quirk of his personality. 12) He points out that it is hard for the group to accept that this is his way of taking groups, or that he should be allowed to, in such a way. He would not let himself get away with it! 13) Bion goes on to discuss with us his rationale for his now admittedly provocative and evocative behavior, whether he or the group was forced, then brings up the issue of psychoanalytic processes, through mention of group transference and interpretation. He now admits that he was subjected to anxiety sufficient to cause him to blurt earlier. Moreover, he suspects he did so, somehow feeling persecuted. I would infer that the issue of being forced had to do with compulsiveness of this personality trait. Also, the inference that, believing in Melanie Klein’s theories of regression to depressive and paranoid positions, he was regressing to the paranoid, under the stress of assumption of the role of group leader with the new task of “cure,” with all the ambiguity he describes. 14) Returning to the group account, he notes for the reader an improvement in the atmosphere of the group. Certainly his introspection at this point would be accompanied by a lessening of the assertiveness with which he criticized them as subject to hearsay. He had then “taken” their criticism. It had traversed the initial formative stage he had experienced in his work with the Army groups, and he could possibly relax and guide its further development. But this civilian group would not let him hide behind the position of authority he had held successfully in the Army. The members instinctively searched more deeply. In my Army experience at the Fort Knox Rehabilitation Center, my therapists and I had noted this expectation to be one of saviorist nature. When resisted, the group lost meaning to the members. It did not need acknowledgement in words, but in readiness to receive communication on that level and in that mode. I sensed it to be messianic, and they agreed to that formulation. I came up with the formula, “Scratch a psychopath, and find a messianist!” 15) Bion digresses, to admit in part that he provoked the focus on his personality, and purposive as interpretation of psychoanalytic transference, arrived at spontaneously. Remember that he blurted out in the context of the deeply evocative silence at the inception of the group. I would estimate that he was engaged there in resistance to the act of transference, on the way to analysis of that quirk of his character. He indirectly admits at this point to feeling paranoid.

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16) A leader of a subgroup, Mr. X, takes “helpful” initiative for the group, focusing on “elements in the group destructive of morale and good fellowship,” identifies Bion’s leadership as the problem. From the “eminence” of leadership of the subgroup he interviews Bion as to his internal difficulty, which Bion cites as his object, why Bion cannot give a straightforward explanation of his motives. In reply, Bion apologizes, and offers the group testimony as to the motivation he had in prior work in the Army, “to study group tensions.” He either dissembles here, or has disassociated from awareness of the issue of cure and his state of inadequacy, either in individual psychoanalysis (involving the Oedipus myth), or group analysis (involving the Sphinx myth, both momentous and novel courses of inquiry. 17) The leader of the subgroup, Mr. X, queries others on their ideas regarding Bion’s difficulty. He runs into resistance, and Bion picks up that they lean towards acceptance of the thesis that the Committee “must have some purpose in saying that I was to take the group,” also that the group was of value per se. Members give testimony regarding their origins and possible value to a group which studies itself scientifically. Bion is evidently monitoring this phase of self-propelled group activity. 18) Another subgroup forms, vaguely discontented with the position arrived at so far. Bion senses this, interpreting that it is dissatisfied with his revelation regarding his motives and presence. The members reject this and enter a state he states he has experienced in every group. He cites that his “fitness for the role I am expected to fill is in question.” The group enters a deep existential crisis, with threatened dissolution of the group situation. He anticipates reporting such to the Committee, and attributes such gloom to the members. He reports an inner transaction of memories of being excluded from other groups because of his personality. Were he to relinquish what I take to be the self-justified aspect, if not arrogance, of that personality, he would also experience the gloom he attributes to the members and be on the way to analysis of his character. 19) Another group leader emerges, Mr. Q, spokesman for the group’s autonomy. He stated that logical argument would not get the data sought, and it was up to the group to experience the nature of its phenomena for itself, and I must have good reason to take my line. There were three elements extant and accomplished here, the issue of logic versus its opposite, affirmation of Bion’s reason, and the group’s capacity to identify and explore its nature. 20) Bion notes a change of course in the group, a change he also notes as an improvement in “atmosphere.” It is accompanied by Bion’s second thoughts on his resistive personality. I would infer that he notices a lifting of the sense of silent challenge he reported at the inception of the account. In the emergent acceptant setting, he begins to work in private on the resistance that has caused him so much trouble in the past, in his work with groups. 21) Bion reports awareness of a former lower opinion of the group, and a personal bias against self-revelation, which he reconsiders. This would call for inner self scrutiny of analytic nature, and my growing thesis here is that he is resisting awareness of his arrogance and messianism. 22) Almost simultaneously, the members return to the former position of wanting him to lead in the manner he had resisted. Bion intrapsychically allows as how the members are with justice annoyed at him for his resistance. Paradoxically his mind alights on the issue of a past sense of gain groups have experienced at this point, his attempts on his own to discern why that was so, and also to ask others, in vain. He finishes this introspection with the determination “to present a broader view of the situation.” I would infer here that he is determined to be more open, “broadly,” to data about his personality. 23) Bion intrapsychically speculates, through ascribing such to the members of the group, that his internal resistances are also present in the transactions in the mental life of the group. He alludes to the mobilization of resistances going on in the group, to the possibility that the members are coming to the conclusion “that the label on the box is a good description of its contents.” Realizing such, they logically would become alienated, and leave, as members have in past groups. He states then to the reader that the group is in crisis. He senses that the members are making ready to infer that his internal mental contents match his resistive position, further that the group is in a real crisis and ready to break up.

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24) He then reviews past history in a most peculiar manner, employing double negatives: that at first the group was unwilling to think it had not satisfied itself regarding hearsay about Bion. One would infer that he pictured the group as satisfied regarding the hearsay, but with the profusion of negatives, simultaneously not so. 25) Bion alleges to the reader that he is but another member of the group, with specialized knowledge. He goes on to state that the Clinic has “given the seal of authority to a myth of unknown dimensions.” Next he states that the group’s tensions call for a God “fully responsible for all that takes place.” We are next door in awareness to a possible messianic identity for Bion, arrived at after the assertion he was just another member of the group, with specialized knowledge. 26) Members then assert that Bion had knowledge of what he was about, which Bion interprets as its insistence on its will. He later alludes to members speaking different languages. If my hypothesis is correct that Bion was edging up on awareness of his messianic identity, although sensed as god-like, rather than messianic per se, the cognizance by the members that he knows what he was about would be the match of his internal cognitive process. Otherwise, he was ascribing to the members his own willfulness. He previously alluded to spitefulness, a state allied to willfulness. Denying his “eminence,” he cites “the objective fact that he is only a member of the group possessing specialized knowledge.” But it does bring up the question of the leader as a member of the group, and subject to the powerful forces he notes at this point. The metaphor of different languages refers to states of alienation. 27) The members turn to a self-effacing member for leadership. Bion senses that the members chose a leader representative of a self-effacing mood. 28) Bion communicates the “bright idea” that the members are searching for a leader to give them orders, or for survival, or to deal with emergencies. He goes on to speculate on such wish to be an archaism, stemming from what would seem as inappropriate fear of emotional, or some other emotional situation. This swing is consonant with the dialectic established in the group, of swinging from one ego position to the other. In his speculation about archaism and threat in the group, he is edging into conceiving the transference. However, he is out of touch with those considerations, through his transcendent intellectual defenses. He does not go further in report of this group, but it is apparent that he is the chief obstacle to inquiry, by himself and others, into what the members suffer from, and its correlate, himself as a healing agent. He has alluded to this conundrum in stating they wish him to be God, his approach to the subject of messianism. 29) He then reports further work with groups, and a pattern in which he discerns how members give away an aspect of their internal psychology by their seeking or aversive behavior in the group. Discernment of this aspect of their internal psychology, by projective identification, is a great contribution by Bion to group psychoanalysis, linking it with Klein’s work with individuals. 30) He then cites how the curiosity of the group in his personality slackens after two or three sessions, to be transferred to other members. I would infer that he here intuits that there is cogency in that interest, a cogency my group therapists and I at Fort Knox noted in the silences, and identified as related to messianic expectations. We noted that traversal of this phase of the group development resulted in change from psychopathic behavior to that consonant with reality, or normal. In regard to this potentially momentous change, Bion earlier noted that “the group atmosphere changed for the better.” 31) He reports that he interprets the interest in others besides himself is related ultimately to him. He gathers evidence of this he thinks will convince the group, and presents it as such. He terms it evidence of “transition.” Again, he intuits that the members are still after him to enact an aspect of his role and responsibility (I take to be messianic) before they will unburden themselves of the information about themselves he is seeking. 32) Bion brings up the issue of wisdom versus doubts. I relate this reference to doubt and wisdom to the issue of the members’ doubts regarding his wisdom as leader. Throughout his assiduous and detailed exposition, Bion reiterates appreciation of the powerful emotional

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currents traversing the group and himself. His lucid and at times baffling prose has made him a touchstone in the treatment of the severe disorders, illuminating patients and self as persons in life dilemmas, momentous in nature, in a struggle for freedom hampered by their personality limitations. An exposition, not as detailed, is found in the group report of another psychoanalyst, August Aichorn, in his seminal work, Wayward Youth, found in this Annotated Bibliography. While I am at it, I would like to cite the report of psychoanalytic experience, similarly conversational in tone, rendered by George Groddeck, in his Book Of The It, reported elsewhere in this Bibliography. Brabender, V. and Fallon, A. 1993. Models of Inpatient Group Psychotherapy, Washington, D.C. American Psychological Association. Early in this massive work, the authors seek to make explicit the assumptions about psychopathology and the processes effecting its alteration, goals and interventions that purportedly accomplish them. They pose delineation of models as the context of events and systematic intervention. They quote Yalom on the advisability of the consequent cognitive framework. They describe seven models. The first is educative (Maxmen), in which the subject, using information furnished by a leader and the analysis of the situation in the group, learns to think clinically and behave therapeutically towards others. Meetings are held without staff. The second is the interpersonal model, using Sullivan’s principles of social learning, Yalom’s relatively unstructured version, and use of data from the here-and-now for interpersonal learning, the go-around potentiation of group process, and agenda-setting for ego potentiation. Yalom also advocated focus groups for lower functioning members. The third is the object relations/systems model, reflective of the organization of the patients’ inner lives. Residency on the unit is advisable. Attention is paid to the relationship to inner schemata, or images, treated as objects, and their generation in experience with the external objects or family members. Attention is paid to early ego formation, and the phenomenon of splitting. The course in treatment of Vince Jordan is an example of the object relations approach. The fourth model is the developmental, based on the developmental stages of psychotherapy groups. The group is conceived of as a social system, developing its unique structure. The development of the large group in the Powdermaker and Frank’s Group Psychotherapy is a case in point. A great deal of attention is paid to development of the groups in This Way Out. The fourth model is the cognitive-behavioral. While the patient’s cognition is a primary concern in many of the psychodynamic therapies, the cognitive-behavior approach is a systematic therapy of its own. The patient is turned into a behavioral scientist, ferreting out data from the personal environment leading to incorrect, distorting, and self-defeating theories about self, dysfunctional schemas. The therapist is a co-scientist and instructor, and the patient instructs self. The groups here are small, 4–12. The authors provide session protocols and examples of cognitive distortions. The fifth is the problem-solving model. Its centerpiece is skills training, taught by the leader. S/he poses the method, and modes of reframing of the problems presented in the sessions. Aids such as posters, slides, and films are employed, as in the work in Howard Hall. The sixth is the behavioral/social skills model. Empiric in basis, and begun in opposition to introspection, it sought phenomena that were subject to consensual validation, that which was observable. In practice, it centers on correction of untoward or defective behavior, phenomena present in inpatient settings. The empiric validity of an intervention with dilapidated patients was their change towards more normal and acceptable behavior patterns. It emphasized action and was ahistorical. Goal setting, skills training, and exercises are features of the practice. The seventh model is social skills training per se. Base on stimulus-stimulus connection, or classical conditioning, or stimulus-response, and particular outcome, or operant conditioning. In addition there are vicarious or observational experiences, or reciprocal interactions, or “reciprocal determinism.”

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The authors discuss the increasing commonalities among the models, developed pragmatically in inpatient group psychotherapy, as the realities and complexity of the treatment situation evolve. “One true path does not exist” (Lazarus, Beutler, and Norcross 1992). That was the experience of This Way Out, though based on psychoanalysis. Blain, Daniel. “The Presidential Address: ‘Novalescence,’” The American Journal of Psychiatry 122 (July 1965):1–12. Blain, Daniel, and Ralph M. Chambers. The Study of Standards for Inpatient Care for the New York City Mental Health Board. Washington, 1957. These two publications are insufficient evidence of this man’s progressive influence in American psychiatry and psychoanalysis, post-war and for decades following. He was a moving force in the change from asylum to modern mental hospital. My employer for a scant four months in 1946 at the Veteran’s Administrations, he inspired me with his vision and active participation at central headquarters and in the field. I must mention his close association with Florence Powdermaker and Karl Menninger. Blitzsten, N.L., Eissler, R.S. and Eissler, K.R. (1950). Emergence of Hidden Ego Tendencies During Dream Analysis. International Journal of Psychoanalysis. 31:12–17. This trio of psychoanalytic investigators in this seminal article posit a number of paths into then unchartered aspects of dream analysis. In doing so, they essay into the then new field of ego structure. Of particular value is their operational inquiry of writing down dreams on awakening and its relationship to purported resistances. Baring, Anne, and Cashford (1991) The Myth of the Godless. London, Viking Press. This meticulously researched and Jungian oriented work aims for a new mythology of the universe by retracing the steps in the evolution of the Godhead from an hypothesized original complementary relationship of masculine and feminine. Yet the primary thesis here is that the original image of life was the Mother, as evidenced by Paleolithic evidence (giving birth, offering nourishment from the breast, and receiving the dead back into the womb for rebirth). The masculine God separated from the original androgynous Goddess to stand as the Creator, causing the feminine God to go underground, certainly in doctrine, if not completely in image. New Science, as Noetics, pictures the universe as a living whole which can only be understood as a unity. Baring and Cashford hold that guilt is not for sin, but the tragedy with roots in the very structure of existence itself. This is close to the thesis of alienation and a multi-generational drama. M. Bowen, Family Psychotherapy with Schizophrenia in the Hospital and Private Practice, in I. Boszormanyi-Nagy and J. Framo (eds.), Intensive Family Therapy, New York: Harper and Row, 1965 M. Bowen, Principles and Techniques of Multiple Family Therapy, in P.J.Guerin, (ed.) Family Therapy, Theory and Practice, New York, Gardner Press, 1976 Bowlby, E. (1982) Attachment and Loss Trilogy. New York, Basic Books. In this trilogy, Bowlby eschewed classic analytic, libidinal-based theory of attachment for empiric studies itself based on evolutionary theory. The child and caregiver attach themselves to each other to equip the child towards autonomous development. Bowlby’s pioneering efforts were followed by research by psychoanalytic investigators, with great profit. The mothers and daughters in my study appeared to be immutably attached to one another while thoroughly alienated. There they exemplified the dialectical nature of attachment and alienation, a central conundrum to which I have addressed this volume. Branston, Brian (1957) The Lost Gods of England. London, Thames and Hudson. In a search for the mythology of England’s Indo-European forefathers, Branston finds a linguistic unity until about 4000 BC, when a split occurred into satem and kentum speech. The focus of the book then turns to the Northwest European peoples. The Norse divinities worshipped were Woden, Thunor, Tiw, and Frig, in temples, sacred groves, by holy trees and wells. Oaths were sworn on a golden ring, a bowl caught the blood of sacrificed animals, and sprigs for sprinkling blood over worshippers, who were devout heathens and believed their very lives depended on their devotion to the gods of the sky and weather. Those gods were a family, as differentiated from the Hebrew one transcendent God. The goddess Nerthus, known as Ishtar further south had a consort called Lord or Baal. The god

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Frey had a sister named Freya, their father Niord, the family group Vanir. Balder is the bleeding God of vegetation who returns to his lover, Earth. Branston traces the myth of Balder, or Lord from the Greek Adonis (the Hebrew adonoi is related), hidden in a chest by Aphrodite, and given to Persephone for safe-keeping. Persephone, because of his beauty, would not return him, and Zeus decreed he should spend parts of the year between the goddesses. He encounters a bull along the way each year, and bleeds profusely from wounds. Branston has fertility associated with such passages, and cites the myth’s appearance in Norse myth associated with Balder. The myth of Narcissus appears to be related. Odin, assisted by Thor, is engaged in a continua1 struggle against the giants, the forces of evil. The road to heaven is up, hell is down, the world between. In a chapter, “Balder into Christ,” Branston masterfully sketches the subjective nature of the pagan Old English in their observation of natural phenomena as thou rather than it. Divine and demonic powers were immanent. The God of the Hebrews was pure being, unqua1ified and ineffable. Jesus was experienced as immanent, related to the Indo-European culture of father and his authority, versus the Mediterranean mother and hers. Branston goes on to assert the superiority of the woman throughout remote history, with their subjugation a recent matter of our civilization. Like Bishop Spong, he claims, in this intriguingly wellresearched work, that organized Christianity is dying a lingering death, smothered under an accretion of man-made dogma and doctrine. Bolen, J.S. (1989) Gods in Everyman. San Franscisco, Harper and Row. A Jungian analyst investigates and catalogs the Greek gods as they can be identified in the formation and the functioning of the modern male personality. She had already looked into that of the female. In holding that we are creatures of mythology, Bolen’s thesis of a systematic inquiry into that mythology is consonant with my writings, but there is no mention of the Judeo-Christian godhead, or its antecedents. Boothby, Richard (1991) Death and Desire. New York, Routledge. This is an important treatise on Jacques Lacan’s formulation of the death instinct as central to his and Freud’s theories. Boothby cites Lacan to the effect that we are alienated from an underlying unity, manifested by a mirroring in the personality, hailed by a death drive that is the dark engine of transformation at the heart of the human being. Boothby interprets Lacan to the effect that the death drive is the mutative effects on psychic structure exerted by energies that remain foreign to its organization. This results in bifurcation of the ego and id, and a dialectic between the death drive and the real or life force extant in the body, with the submission of the psychological individual to death. This in turn results in no total psychic representation of the reality of the anima subject (characterized by an ineffable body) which is beyond the imaginative powers. I have discerned this state of impossibility in the patients I have described in the body of this work, who were faced with the task of relinquishing their narcissistic defense structure, experience psychic death and survivor’s guilt, and come through to their underlying Lacanian unity. Lacan dips into the mystical, on the edge of messianic experience, with his concepts of jouišsance, signijìcance, and coming. This important author attempts to arrive at a theory and clinical usefulness of the manifest dream per se, systematically relating it to the contemporaneously experiential, down through historical ego-relevant data. Brenneis, C. B. (1975) Theoretical Notes on the Manifest Dream. International Journal of Psychoanalysis 56:197–206. This serious inquiry into the inherent language and dynamic structure of the manifest dream combines the work of a host of investigators in a central concern of psychoanalysis if not its core a scientific venture. While I hold to his thesis on the necessity to approach the manifest dream as an entity, in practice I venture with Freud and his followers into discerning its latent underpinnings. I recommend study of the bibliography of this seminal piece, for its wit and depth. Brown, Norman O. (1959) Life Against Death, The Psychoanalytical Meaning of History. Weslayan University. Holding that Freud’s death instinct is explanatory of man’s diseased state, along with a general cultural trend, itself tending towards stereotypy and sterility, Brown examines Freud’s thesis of the universality of neurosis. He holds that desire, stemming from the

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unconscious, the subdued and indestructible element of the human soul impels man to a deep-rooted, passionate striving for a positive fulfillment of happiness. Man is a prisoner of his past, in an archaic heritage in which religion is the heart of the mystery, and in which original sin, according to Brown, is the centerpiece of inquiry. He quotes Joyce to the effect that history is a nightmare from which he is trying to awaken. To that I apply the lesson I learned from my patient whose life was a living nightmare, that passage through the terror of mourning his father freed him to live his own life, laying aside a Faustian dilemma. Brown, while rejecting the path of sublimation, yet accepting Freud’s death instinct, advocates overcoming it through the life instinct. Narcissism and erotic exuberance would be the basis of life. He reconciles with the death instinct in an eschatology in which one’s body is freed to have no unlived lines and is willing to die, joining in an eternity. Wilhelm Reich followed such resurrective and emancipatory reasoning in his advocacy of erotic liberation from repression. I found useful the concept of the death experience instead of couching it in terms of the death instinct. Budge, E. Wallis (1960) The Book of the Dead. New York, Random House. The dynastic Egyptians went to great lengths to preserve the physical and spiritual integrity of the dead against human evils, as the dead proceeded to the Kingdom of Osiris. Ra, the Sun god was under continua1 threat from Aspep, a monster which could swallow the sun disc. The Book of the Dead is the mass of texts the theologians of ancient Egypt created to protect the dead in their passage. On reaching Osiris, the conqueror of death, the souls were born again. An inference is that The Book of the Dead, clearly a messianic text, is a precursor of the Hebrew Bible. Bushman, Richard L. (1969) The Great Awakening. Chapel Hill, The University of North Carolina Press. Not only did the Awakening have a profound effect on religious life, but it contributed greatly to the sense of self of the American nation that was to be born shortly. At its heart was The New Birth, and the churches were not only invigorated but more responsive to its practitioners. I find study of this closely documented work reflective of that done for the Sabbatian movement by Gershom Scholem in Sabbatai Sevi, also in the establishment of the therapeutic community in the various stages of my career, psychoanalytic and politician. Cahill, T. (1998) The Gifts of the Jews. New York, Anchor Books Doubleday. A historian’s view of the progressivism of the Judeo-Christìan religious experience, attributing to it the fructification of Western Civilization. Campbell, Joseph (1974) The Mythic Image. Princeton, Princeton University Press. Rendered more powerful through its images, this remarkable work details the embeddedness of the individual and world culture in their myriad myths. Campbell takes the reader from dream to myth, from the non-literate to literate civilizations, culminating in the modern religions. Clebsch, William A. and Jaekle, Charles R. (1964) Pastoral Care in Historical Perspective. Englewood Cliffs, Prentice-Hall. Clebsch and Jaekle have been pioneers in effecting the transmutation of pastoral care into a pastora1 pattern which embodied the new awareness of man initiated by seminal thinkers like Freud. Pastoral care had been relegated to junior partner to the helping professions, prominently psychoanalysis, social work and psychology, which engaged the autonomously conceived individua1 in the process. To the functions of healing, sustaining, guiding, and reconciling troubled souls was added that of collaborative analysis of one’s spiritual life and its norms in great and small decisions. Clebsch and Jaekle usefully trace the evolution of pastoral care from the Primitive Church to the present, noting its enormous contribution in guidance and education of peoples towards the conception of the individual as such, in its striving towards both an inherent righteousness and that of its messiah. In my Washington years I participated in the Pastoral Institute of Greater Washington, a progenitor of the counseling and consultation centers, initiated by Charles R. Jaekle. It was a fruitful collaboration. In its acceptant atmosphere I expanded my concept of the self to utilization of the word soul. In addition, I taught my concept of messianism, and it was accepted there in more contrast to my efforts in that regard with my psychoanalytic colleagues. Cleckley, H. 1976. The Mask of Sanity, St. Louis: Mosby.

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In this pioneering study of psychopathy, still pertinent, Cleckley, in anecdotal fashion lays out his experience with psychopaths, leading to the inference that they suffered a deep alteration in their capacity to live in their and our reality sufficient to be described as psychotic. Cohen, J. and Stewart, I. The Collapse of Chaos. New York, Viking-Penguin. An intriguing essay into complexity theory, with the formulation of a concept they call simplexity, which to my mind is one step away from the concept of soul. D’Amore, A. R. (1981). Psychoanalysis in America: 1930–1939. Psychoanalytic Quarterly. Dr. D’Amore was a member of a psychoanalytic study group we formed at the Washington Psychoanalytic Institute to validate our psychoanalytic comprehension versus the Sullivanian approach. He published relative to the development of psychoanalysis. A member of the faculty of Howard University, he extended the reach of psychoanalysis there. J.M. Cunningham and K.L. Matthews, Impact of Multiple Family Approach on a Parallel Latency-Age\Parent Group, Int. J. Group Psychotherapy—32(1), Jan.1982. These authors indicate the usefulness of guidance and role modeling in the multifamily of latency aged children. Dement, W. and Fischer, C. (1963) Studies on the psychopathology of sleep and dreams. American Journal of Psychiatry, 119, 1160–1168. Starting with studies in the physiology of sleep and its stages, these pioneer investigators extended into comprehension of the dreams encountered there. They laid the foundation for modern sleep research. Durkin, H. E. 1954. Group Therapy for Mothers of Disturbed Children, Springfield: Charles C Thomas. Utilizing relationship therapy, an application of psychoanalysis, Durkin set to inquiring into the unconscious needs and emotions of mothers and the behavior of their children. Over a period of 15 years and 100 groups of meetings of mothers, once weekly, she found that the interference of the mothers in the treatment of their children was eliminated. Moreover, the neurotic pressure of the children in the family was removed, and character change in the mothers effected. This was done through collaboration of the mothers in analysis of the transferences they brought to the group. Eissler, K.R. 1949. Searchlights on Delinquency: New Psychoanalytic Studies, New York: International Universities Press. This is a commemorative volume dedicated to Professor August Aichorn, a teacher and psychoanalytic pioneer, on his 70th birthday. His work in rehabilitation apparently started with an interest in the causes and treatment of delinquency, then a ten year crusade, as educator, against a military settlement for boys, in Vienna. With the fall of the monarchy at the end of World War I, he was given the opportunity to organize a new school, at Oberhallanbrun, adapting a psychoanalytic approach to treatment. In a Biographical Outline, Eissler informs us at some length of Aichorn’s personality, seminal to his success. He lauds his non egoistic passion, intuition, capacity for life in the other, alienated countries of crime and schizophrenia. It would appear that Aichorn provides us with the complementary side of Freud that, if pursued systematically, would open psychopathy and schizophrenia to psychoanalysis. Oscar Pfister, the pioneer pastoral psychoanalyst, has a chapter on Aichorn’s therapeutic approach and his ethics. He addresses the locus and core of idealism he and Aichorn term love. Failures in the arena of parent-child love result in waywardness. He personifies noble and sublimated love, which Pfister equates with Christian. Pfister describes the mission of the therapist as like that of the Son of Man, “come to seek and save that which is lost,” a pivotal mechanism of his corrective education. This love transference is cultivated, acknowledged, and employed as reward to the delinquent in compensation for the rigors experienced in the process of self-change. Aichorn expects his charges to lead useful lives, and expects to take pride in them, in a transference that does not end. Relapses are dealt with in a manner similar to that of Jesus. Pfister calls for the creation of a new ego ideal. He cites that Aichorn permitted wild boys to abreact their rage, leading them subsequently to find, through his super-ordinative care, that they were heaping “coals of fire on their own heads” (Proverbs, 25, 22). This was

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followed by tears of rage, emotional instability, then acceptable behavior. An essential element in the “cure” was Aichorn’s ready engagement with his charges in discussion of daily life in which they poured out their troubles. There they discovered his strength. This became the core element in their new ego ideal. In a footnote at the end of his piece, Pfister introduces the word messianic, in reference to a misguided aspect of science, independent of ethics. It does not offer “the faintest protection against the diabolical destruction of the highest human values, but rather it constitutes the most terrible danger unless the development of human, social-ethical attitudes keep pace with it.” One can infer that in his Jesus-like approach, to Pfister, Aichorn was messianic. Eissler’s and Pfister laud and analyze Aichorn in Searchlights on Delinquency, but the volume is a treasure trove of work done by Melitta Schmideberg, Edward Glover, Anna Freud, and Margaret Mahler. The last presents a report of work done with children of analysts, whom she calls, enfants terrible, for their arrogance and alienation. Eckstein, Rudolf (1971) The Challenge: Despair and Hope in the Conquest of lnner Space. New York, Brunner/Mazel. A pioneer of treatment of the severely disordered child, Eckstein illustrates his capacity to engage with the mythic inner world in a chapter, “Working Alliance With Angels, Good Spirits, Deities.” He holds that the interpersonal and intrapsychic cannot be differentiated in the psychotic and dreamer, as illustrated by the Moebius strip, a one sided surface, where outer is continuous with inner. Clark, John Ruskin (1977) The Great Living System. Pacific Grove, The Boxwood Press. Ruskin engages in an exercise in epistemology, defined as the theory of the method and grounds of belief and knowledge. He acknowledges the death of the supernatural God, but not the being of ultimate significance. He sees virtue in the freedom from religious control and closed metaphysical world view, and the transformation of religion along with the transformation of knowledge. He posits the earth as a great living system in which we are embedded and creatively articulated. Man is unfinished, a little lower than the angels, in search for hidden reality, his morality system sensitive. He deals with the breaking of myths and the mythopoetic change in religious rituals from orthodoxy. Dean, Thomas (1975) Post-Theistic Thinking—The Marxist-Christian Dialogue in Radical Perspective. Philadelphia, Temple University Press. Following the humanist aspects of Marxian thinking, the author, himself searching for meaning after his death of God experience, attempts to discern a humanism of the whole man, which would include the subjective and transcendent. He takes one through existentialism, and its cosmologic implications and a new eschatology. He goes back to Marx’s early works, in which he identifies heaven as a manifestation of self-alienation on the part of man, an inverted consciousness of the world. He cites that Marx then addressed himself to man’s a1ienation from himself and his human world, and atheism as a negation of what he held to be the alienating negation, God. Dean has him starting anew with what I hold is close to a definition of the soul experience, calling only for the inclusion of capacity of man for transcendence and entity, a sensuous perception, theoretically and practically, of man and nature as essential beings, positive self-consciousness. At core, Marx attends to the issue of alienation of man from self. In his economic theory he focuses on the alienation of man from his product of his labors by the capitalist system. Thus he rids man of that dilemma by abolishing the class which is entrepreneurial. I hold that the entrepreneurial initiative and the mythology that it exemplifies is an essential element of societal functioning and of man’s intra-psychic and interpersonal existence. Thus, psychoanalysis has a role to play in conceptualizing man’s alienation from self and the process of reconciliation. I approach this seminal issue in my book, Democracy from the Grassroots. Eggan, D. W. (1952). The Manifest Content of Dreams: A Challenge to Social Science. American Anthropologist, vol. 54, pp. 469–485. This author pioneered in the recognition of the role of dreaming in the anthropologic subject, focusing her efforts on the Hopi Indians. She and Gardener Murphy challenged their profession to awaken to the universality of dreaming as a cultural phenomenon.

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Erikson, E.H. (1954). The Dream Specimen of Psychoanalysis. Journal of the American Psychoanalytic Association. I placed this article into iconic status in my teaching, basic and advanced, of dream analysis. In it, Erikson advances the thesis of a model structure and dynamic sequence of dreams experienced in psychoanalysis. He posits that the dreaming ego proceeds in stages from manifest, to latent, to exposition and inquiry into infantile conflicts. Alongside that he gives a brilliant exposition of brief, highly symbolic dreaming. Erikson, Erik H. (1 974) Dimensions of a New Identity. New York, Norton. Erickson here has Jefferson as the prototypica1 American, born and developing in a new consciousness of self, rooted in identity, ever freer and realized. He describes how Jefferson sought to arrive at his own version of Jesus, as core to his life’s purposes. Erikson, Erik H. (1982) Report of Psychoanalytic Seminar, San Francisco Psychoanalytic Institute, January 9, 1982, furnished by Gary A. Levinson, M.D. In this important seminar, unfortunately not published, Erikson deepened his inquiry into identity by citing the I that is at its core: 1) A luminosity with a concomitant tranquility; 2) A sense of being active; 3) sense of feeling central, whole, and continuous as he would be a chosen indispensable coherent person at the center of you; 4) This is closely related to religion and a cosmic higher being. Levinson reports that Erikson emphasized that these elements are highly important in old age, when a universal need for an outside concept of God exists. Faith, whose genesis stemmed from the earliest I, Erikson defined as a particular world image that has an inclusive ideology that hangs together. It would appear to me that Erikson here is moving in the direction of the concept of soul. Fonagy, P., Kächele, H., Leuzinger-Bohleber, M., Taylor, D. (eds.) (2012) Review of The Significance of Dreams. London, UK, Karnac Books. This rich, important contribution to the literature on dream analysis stems largely from the 12th Joseph Sandler Research Conference in March 2011. The editor cited as analogously bringing dream analysis from the Newtonian to the modern area of physics. This volume covers clinical research on dreams, extra-clinical research on dreams and conceptual integrations including dreams in modern literature. Fox, Hugh (1981) Gods of the Cataclysm. New York, Dorset Press. Fox started this book to look at the world through the eyes of the Indian. He journeyed long in Indian culture of North and South America, in detailed inquiry into their myths, and came up with a revolutionary thesis on migration of a world culture, proto-Indo-Mediterranean-Amerindian. This was devastated by a cataclysm of extraterrestrial origin, with the ascent of patrilineal gods, reflective of the privation and disorder of the cataclysm. This mythic formulation pertains to the end of the world experience of my psychotic population, institutional and in my private practice. Grotjahn, Martin. 1993. The Art and Technique of Analytic Group Therapy, Northvale: Aronson. Another analyst who worked with large groups in the crucible of creativity that was World War II, Grotjahn in simple language attempts here to tell how he and his groups work. He defines his approach as analysis by the group, as differentiated from Alexander Wolf’s analysis of the individual in the group, or J. L. Moreno’s analysis of the group. He holds that all psychoanalysis is group therapy, but faults individual therapy for inducing regression into a transference neurosis that “swallow(s) the analyst.” The group is a “theater in the round” for the projection of the entire mind. Grotjahn gives a vivid picture of not only his work with groups, but of his internal life therein. Chasseguet-Smirgel, Janine. 1985. The Ego Ideal: A Psychoanalytic Essay of the Malady of the Ideal, New York: W.W. Norton. Chasseguet-Smirgel reviews the literature on the ego ideal, especially Freud’s contribution. However, she first details her own theses. She holds for the existence of an agency within the ego, its conscience, that has its origin in the earliest developmental period. She conceives the infant as precociously driven by inordinate ambitions that stem from an illusion of symbiosis with the mothering one. The infant seeks to reify the consequent ideal ego.

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The issues inherent to this conundrum are central to the self-analyses of the patients in my previous book, This Way Out and in the current one. They begin under the thrall of ideal, delusional states that are matched with their opposites, as with Vince Jordan and John Jefferson. These turn out to have developed during epiphanic states in their illnesses, that followed dementia praecox-like crises. Prior, it appeared that they were in narcissistic states, derivative of illusions of symbioses with parental figures, principally the mother. From later work, I have inferred that there was a sacrifice of identity in favor of the maternal object, accompanied by a state of psychic death. Freud identified that ubiquitous death as an instinctual state. Farber, L. H. (1958) The Therapeutic Despair. Psychiatry. 1:7–20. I have found this obscure piece in a journal considered secondary in the psychoanalytic firmament to be of central moment in the analysis of blocks in the treatment of obdurate narcissists. There the analyst encountered subjective despair, repugnance and aversiveness to further inquire into both the patient’s and into the analyst’s dynamic processes. Flugel, J. C. (1950). The Psychoanalytic Study of the Family. London: Hogarth Press. It is of note that this psychoanalytic pioneer extended his researches beyond the usual intra-psychic sphere to that of the human family. Frankl, Viktor (1975). The Unconscious God. New York, Simon and Schuster. Frankl vividly relates his experience of a God within and in each human being. He goes further, creating an analytic method he calls existential analysis, or logotherapy. He does not discard the concept of mental illness, but does identify existential despair and spiritual distress for treatment by his approach. I find my work in messianism to be essentially related to Frankl’s experience of the godhead within and to his logotherapy. French, T.M. (1954). The Integration of Behavior Volume I and II. Chicago, University of Chicago Press. A member of the second generation of American born psychoanalyst and a leader in the Chicago Institute, Dr. French in this groundbreaking work, still true to libido theory, to my view contributes to the study of the ego ideal, though not avowedly so. He attends to ego psychology, normative and pathologic, and its formulation of life plans and purposes, relating them to infantile identifications. Freud, S. 1900. The Interpretation of Dreams, S.E. IV and V, London: The Hogarth Press The patients in Howard Hall reported that they experienced their psychoses as dreamlike states. Their references in the record to their dreams were sparse, compared to those in patients in my later practice, extra-institutional and institutional. I infer that further training and experience on my part made the difference. However, Freud’s instruction in dream analysis was central in the transaction with the patients in Howard Hall, involving suspension of disbelief, acceptance of the emergent material within and without the therapist, while maintaining one’s capacity to correlate and estimate it. This did not induce further regression into psychosis of the patients, as was feared, because of its grounding in the capacity to “figure it out” emphasized in the therapeutic enterprise. ———. 1921. Group Psychology and the Analysis of the Ego, S.E., XVIII, London: The Hogarth Press. In this seminal work Freud intimately relates the character of the group and the individual, through the concept of ego ideal. In the formation of the group, members invest both the leader and members with their ego ideal, regressing in the process. Freud also correlates this process with the intrapsychic process that occurs in mania, where he holds that there the ego and ego ideal become as one. Vince Jordan and William Cohen in This Way Out traversed manic episodes, regressing into megalomanic states. Recovery involved relinquishment of that delusion, experiencing antecedent narcissism, which in turn yielded to analysis, with data pointing to psychic symbiosis with the maternal object. Although Freud refers to the group structure of the state, church, and army, this volume is principally devoted to his definition of ego psychology. He asserts that one cannot separate individual from membership in a group but goes on to attempt such definition per se. Since Freud, psychoanalysis has moved from the analysis of the ego to the self-analysis, advanced by Kohut and his followers.

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Freud, S. (1914) On Narcissism: An Introduction. In: The Standard Edition of Psychological Works of Sigmund Freud, Volume XIV (1914–1916): On the History of the Psycho-Analytic Movement, Papers on Metapsychology and Other Works, 14:67–102. In this tremendous piece, Freud attempted to get to the core of man’s disorder, of his departure from truly loving himself, versus a perversion of that love. He chose the myth of Narcissus to illustrate that dilemma, a myth in which Narcissus appeared to love his image, but in which getting to know himself in that inquiry would result in his death. I found in my work at Fort Knox with psychopaths that their perverse self-love yielded in the therapeutic process, with the appearance of depression and psychosis, which then gave way to contact with reality. I infer that they got to know themselves, died a psychic death and came back to themselves. That hypothesis was confirmed with schizophrenics and narcissistic individuals. This set me at odds with Freud’s libido theory. I am however deeply indebted to Freud’s masterful presentation on Narcisism. Freud, Sigmund (1913–1914) Totem and Taboo and Other Works. Standard Edition. Voi. XIII. London, The Hogarth Press and the Institute of Psychoanalysis. It is of note that in An Autobiographical Study, Standard Edition Vol. XX, Freud relates that he engaged in the Bible as soon as he learned to read. In Freud’s seminal essay into the origins of religion, he bases totem worship and religion in general on mourning of the departed and venerated dead, and the construction of an illusory belief system. Freud constructs a scientific myth, centering about what is now termed survivors guilt, in which patricide is followed by worship. Freud, Sigmund (1920–1922) Beyond the Pleasure Principle, Group Psychology and Other Works. Standard Edition. Vol. XVIII. London, The Hogarth Press and The Institute of Psychoanalysis. Important in the study of messianism is the relationship of the charismatic leader and his group. Freud pioneered in denoting the role of identification in the ego ideal in that essential process. Freud, Sigmund (1937–1938) Moses and Monotheism, An Outline of Psychoanalysis and Other Works. Standard Edition. Vol. XXIII. London, The Hogarth Press and the Institute of Psychoanalysis. Freud herein holds that Moses, the Great Lawgiver, was himself an alien to the people whom he served, and moreover, was murdered by them, as in the patricial myth in Totem and Taboo. Friedman, Maurice (1985) The Healing Dialogue. New York, Jason Aronson. Following Martin Buber’s thesis of the between as the locus and focus of the healing experience, and the intimacy of the Thou, Friedman in this important work, messianically cogent, surveys the fields of psychotherapy. He traces the confirmation that repairs the disconfirmation that results in mental illness. Of particular moment is the discussion of guilt and what Friedman calls touchstones, an approach to transcendence of subjectivity, on the way to transactional unity, engaging the essentially assertive energy within. From, Erich (1941). Escape from Freedom. New York: Farrar & Rinehart. I have found this former spouse of one of my mentor’s, Frieda Fromm-Reichman, to be of seminal importance in affirmation of social and psychic theory I developed in my Fort Knox years. Fromm, Erich (1955) The Dogma of Christ. New York, Holt, Rinehart and Winston. From the beginning of this book, in which Fromm asserts that the history of religion reflects man’s spiritual evolution, to its end, where he cites messianic time as the state of man’s peace with nature (Isaiah’s wolf coexisting with the lamb, etc). Along the way he has the messiah as the symbol of man’s own achievement, of the development in order to be truly human, no longer alienated from self, others, and nature itself. In my lexicon man needs to go one step further, emancipation from messianism, to become truly human. Fromm, Erich (1966) You Shall Be As Gods. New York, Hoh Rinehart and Winston. In this closely reasoned work, the psychoanalyst Fromm traces the God experience of man, holding that we should be asking, not whether the God of the God-experience is dead, but whether, in his alienation, man is dead. My thesis is that man has finally arrived at realization of an inner state of self-alienation and death, which I denote in my interpretation

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of the Narcissus myth. The object of therapy and life itself would involve traversal of that death, and reconciliation with self, without resort to a transcendent messianism. Gibbard, Graham S., Harperman, John J., and Mann, Richard D. Eds. 1974. Analysis of Groups: Contributions to Theory, Research, and Practice, San Francisco: Bossey-Bass. This classic has material on observation of groups, group process and development, the individual and the group, collective fantasy and myth in group formation, and authority and leadership. Much attention is given to data collection and analysis, integrating psychoanalytic (Bion, French, Foulkes) and social science approaches (Bales, Murray). Of particular note is the detailed presentation of training group protocols. Giovacchini, P.L. (1967). The Frozen Introject. International Journal of Psychoanalysis. 48:61–67. I have found a concomitance of dream analysis and characterologic defense analysis to be central in the iconic cases presented in this volume. Giovacchini touches on the importance of analysis of the ego ideal and a focus on transactions with the introject as central in the cases he presents in a wide spectrum of brilliant articles. Glover, E. 1960. The Roots of Crime, New York: International Universities Press. In this large work, Dr. Glover, a pioneer psychoanalyst, centers his inquiry about a superego defect. He cites the normal infant as “completely egocentric, greedy, dirty, violent in temper, destructive in habit, profoundly sexual in purpose, aggrandizing in attitude, devoid of all but the most primitive reality sense, without conscience or moral feeling, whose attitudes towards society (as represented by the family) is opportunistic, inconsiderate, domineering, and sadistic.” He quotes a lady magistrate’s remark, “But, doctor, the dear babies! How could you say such awful things about them?” Perhaps the answer to that conundrum is that she saw the messianic and he the satanic side of the baby, itself in an earliest state of alienation from self. The closest Glover comes to the phenomenon of alienation from self is in a mention of Franz Alexander’s concept of the Neurotic Character as driven by demonic compulsion, with overpowering of the ego by an Id that produces tendencies alien to the ego. The inference is that the Id tendency would be alien in itself, locating the seat of alienation in the Id. Glover goes on to cite Wilhelm Reich’s ‘triebhafter’ character, taken over by instincts. Glover goes on to cite his “neurotic characters” and there a change in the libidinal milieu, repetitive in nature. He goes further to cite that the “psychotic character” might be more appropriate. Glover has the personality of the psychopath as within normal bounds, overcome by abreactive periods of psychopathic tension, revealing an underlying mental abnormality “almost as grave as that of an insane person, and absence of reality feeling or judgment, and frequent senselessness and peculiarity of behavior.” A strong lead in research is the concept of unconscious guilt, in which the individual induces punishment due to repressed infantile wishes. Certainly the patients in Howard Hall had strong moral tendencies early, chiefly as requirements for the adults in their family. Greenblatt, M., Levinson, D., and Williams, R. Eds. 1957. The Patient and the Mental Hospital: Contributions of Research in the Science of Human Behavior, The Free Press. This important study reports on the papers and discussion of the Conference on Socioenvironmental Aspects of Patient Treatment in Mental Hospitals. The Conference was rendered immediate by the deterioration of care in the state hospitals of the period, and the need for establishment of the therapeutic milieu, or community newly emerging on the medical scene. Participants were the leading lights in the state hospital, NIMH, and university (Harvard and Michigan) scenes. Added in this volume to the professions extant in the mental hospitals of the day (nurse, social worker, recreationist, occupational therapist, clinical psychologist, and chaplain) were the sociologist, social psychologist, and social anthropologist, to study the institution itself, in an ongoing manner. The Conference on Socio-environmental Aspects followed a Symposium on the Mental Hospital as a Small Society, with social science playing a central part. The Patient and the Mental Hospital is the distillation of 60 investigators, of diverse theoretical and empirical approaches. That distillation is of seminal importance to the understanding of This Way Out, and is embodied in Dr. Harry Solomon’s concluding chapter, entitled “The Mental Hospital as a Research Setting: A Critical Approach.” There he cites

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the critical ideas raised by the investigators: “social structure, formal and informal organization, culture, social position and role, transactional processes, group dynamics, ideology, identity, the social patterning of authority and the individual’s relation to authority, unconscious conflict and ego defense.” They are of moment sufficient for inclusion in this Bibliography. Dr. Solomon goes on to cite the value of the naturalistic approach to research, for its “initial exploration of complex social and psychological processes and in the search for significant concepts and hypotheses.” He goes on further to cite its limitation, as a single case study, insufficient formulation of variables, deficiencies in research design. These considerations were very much in mind of my volumes, and reflected in its initial approach, running commentary, and inferences. In a section, entitled Role Dilemmas of the Mental Hospital Investigator, Dr. Solomon examines the issue of choice of problem, achieving a tenable position and role within the hospital, and interpreting, writing and publishing the research. All of these deeply cogent considerations were encountered in the text of volumes. Finally, Dr. Solomon argues for a field research role for the social scientist. This of course applies even more so to the psychiatrist and psychoanalyst. Greenblatt, M., Sharaf, M. R., and Stone, E. M. 1971. Dynamics of Institutional Change, Pittsburgh: University of Pittsburgh Press. This volume is of great importance to This Way Out, Atascadero State Hospital: An Adventure in Institutional Change, and now Terra Incognita for its problem in bringing about basic institutional change, as a platform of the therapeutic community. Greenblatt cites at length how he came to the concept of unitization, or decentralization. What he had in mind was in advance of the work in industry of centering organization about tasks. He recreated Boston State Hospital into four units, serving different localities, emphasizing autonomy and local responsibility, in a larger unity that was responsible to them, and of course, the community. He worked to re-orient the personnel, administrative and professional. All this is what happened in Howard Hall, and to an extent, a task at Darrell state hospital, started therapeutically from the grassroots. Groddeck, Georg 1935, The Book of the It. London: C.W. Daniel Company In this seminal work, Groddeck spells out what psychoanalysis was about in its early years, through letters to an imaginary woman. This is the Groddeck who had established a psychiatric retreat in Baden-Baden, Germany, which Ferenczi and Freud visited. At the same time, Groddeck communed with trolls in a lair he constructed up the hill, nearby. He has one of them, Patrick Troll, sign his letter and chapters. One can conjecture a personality configuration similar to that of Wilhelm Reich, who contributed greatly to psychoanalysis, regressing later in life to experiencing reality in a religious manner. All this is in turn relevant to the issue of messianism in their makeup. Groddeck’s spiritual side is reflected in his conception of the unconscious, which he called the It. Freud importantly changed the designation to Id. A Morris Robb provides the Introduction. He employs lyrical language, seeing Groddeck as reverential, feeling from the heart, contemplating the mystery of life, its wonder and paradox. Complexity is reduced by symbolism, dealing with the soul and its cycles. Reduced are high/low, narrow/broad, discord/harmony, confusion/clarity. He saw Groddeck as sharing, fellow friend, genius, with strange ideas that somehow became part of one’s life, breaking from terror, awakening that which has been asleep, outgrowing one’s traditions and former sexual ways. The inference I would draw from this introduction is that Robb senses that Goddeck addresses what we now would consider issues in the ego ideal, as would a dream analyst. The text of the book calls for translation from that of an informal letter to a friend. He starts with a confession. I believe Groddeck cites that he was raised like Joseph above his brothers, by his father’s offer of a profession, based on his capacity for empathy. He had sensed that his sister would be smothering her doll with excessive clothing. Along with that existed murder, based on envy of her. He goes on to examine the components and dynamics of his professional identity, eschewing, in identification with her gentleness, the blood of the surgeon and poisons of the physician, for massage and mental treatment.

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He goes on to inquire into his relationship to science as a discipline. He starts by citing how his identity as a researcher stemmed from a fixation on his sister’s cardiac condition. He attests to impatience with the acute, versus chronic. That impatience would interfere with looking at the affection systematically, a hallmark of science. He cites his father’s heretical and doubting attitude towards science, his scoffing at the theory that bacteria as causative of disease, and sutistic esteem for the curative value of bouillon. He also had an aversion towards science, because both his sister’s friend and school were associated with Alma and Mater. He goes on to his experience with this mother, her need for a nursemaid because of atrophied breasts, and a hypothesized deprivation when he was a sucking babe. He then went on to cite a woman who had been deprived early in the suckling stage, and developed a lifelong enmity to her mother: “As thou to me, so I to thee.” This woman’s gait is that of a pregnant woman, her breasts swell when she sees a suckling babe, and abdomen enlarges when her friends conceive. A yearning cry for the unattainable. He goes on to posit the truth of another child symbiosis, sealed in the nursing experience. From that truth, one escapes into the kingdom of fantasy, a fantasy similar to that of science. This amalgam of science and fantasy, tied together through intuition, marks the rest of the book. In the second chapter he goes on to assert that man is governed by an unknown force, an It. It is present as the underlay of life, and we are cut away from it by our infantile amnesia. Yet we revert to it, and to manifestation of our parents, and of the It they bequeath. He attributes his strange ideas to Professor Freud. He goes on to speak of the ubiquity of ambivalence, mother love and mother hate, and its manifold assaults on the expected child and numerous psychosomatic abdominal disorders. “It only disappears when one succeeds in tracking down and purifying the filthy swarm in the recesses of the soul, the poisonous swarm which corrupts the unconscious.” Thus Groddeck paints a picture of a sentient self at the core of the personality of the larger aspect as the organization was telling the guy in the individual, which he terms the soul. It is an intelligence that operates on mythic terms, not a region of unknowing chaotic forces of mythic nature, that reach into ultimate developmental errors. Suitably situated in a constructive stance through their messianism, the patients of Howard Hall and those in Terra Incognita severely disordered were able to read and translate their Its in a manner similar to that of Groddeck and his trolls. Hartmann, Heinz (1960) Psychoanalysis and Moral Values. New York, International Universities Press. Beginning with an evaluation of Freud’s work as reflecting the realization that the highest and lowest in man have common origins, Hartmann cites that man has rooted in his personality in the form of the ego ideal and superego, moral imperatives—the good and the ought and ought not. He goes on to trace the transvaluation of values in the individual, the teaching afforded one in knowing oneself and the genetic aspect of one’s morality. Mankind is gradually accepting the imperatives resident in the id, citing Freud to the effect that man is not only less, but more moral than he knows. In analysis, one considers, first of all, the genesis, dynamics, the economics of the patient’s imperative and ideals, and the structure of his moral codes. This also applies to the analyst, in the counter-transference. He goes on to describe, in analysis, the relativity of value systems, and the need for what he calls death ethics. He closes with an inquiry into analysis and the meaning of one’s life, the good as well as the evil, the existence of not only God but also the devil—all psychologically real aspects of our inner world. Hawkins, D. R. [2011(1966)]. A review of psychoanalytic dream theory in the light of recent psycho-physiological studies of sleep and dreaming. Bri. J. Med. Psychol. (1966), 39, 85. This seminal thinker sets us on the path of consideration of the adaptive, problem-solving functions of dreams. He differed from Freud on the issue of the dream of protector of sleep, emphasizing its mutative function. Hillman, James (1996) The Soul’s Code. New York, Random House. A Jungian psychologist, Hillman delves into the unique, essential quality of soul, to find an inner Godhead, the deus absconditus or concealed god, to be spoken only in images, metaphors, and paradoxical conundrums. One such is the soul as acorn, endowed by a daimon with a unique entity and fate.

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Johnson, Luke Timothy (1998) Living Jesus, Learning the Heart of the Gospel. San Francisco, Harper. This is Johnson’s answer to the Jesus Seminar revisionists who are attempting discernment of the original Jesus from the accretions of the centuries, towards finding one’s inner spiritual life, sui generis. Johnson centers his exposition on the verities of Jesus as the accomplishment by God for man, in the light of his present and continuing power as an act of love for the enhancement of the other’s life. In this closed, transcendent system of sacrifice one prays that God shape us into saints. It appears to me that Johnson is thereby calling on humanity to transcend its humanness, thereby continuing its alienation from self. This formulation was of central moment in the iconic case histories in Terra Incognita. Hatch, Nathan O. (1989) The Democratization of Amerìcan Christianity. New Haven, Yale University Press. Important in detailing the effect of the democratic spirit on the American larger community, when the democratic challenge shattered the professional monopoly, medicine, and the church. Individuals alienated otherwise, responding to the call of God, became preachers, and the camp meeting, with its mass regressive displays, replaced and supplemented the established churches. The result has been energizing and affirmative, despite resultant atomization and pluralism. Gershom Scholem inferred that a certain amount of democratization occurred in the course of Sabbatai Sevis’ messianic tenure. I encountered a mass display of grassroots in my psychopathic treatment-groups, in which individuals fell into religiously relevant fits, and engaged in both satanic and devout preachments. In the treatment of the more severe disorders in Terra Incognita this co-presence of God and Devil was clearly exemplified. Holt, R. R. (1967). The Development of the Primary Process: A Structural View. In R. R. Holt (Ed.), Motives and thought: Psychoanalytic Essays in Honor of David Rappaport. Psychological Issue, 5 (Monograph No. 18/19), 345–383. This important author furthers understanding of the primary process and its mythopoetic function. Jones, E. (1953) The Life and Work of Sigmund Freud. New York: Basic Books. This British psychiatrist discovered the seminal work of Sigmund Freud and thereafter was steady in their adherence and professional collaboration. This volume is a faithful rendition of Freud’s personal and professional life and a seminal contribution to psychoanalysis as a science and art. Jones, M. 1953. The Therapeutic Community. New York: Basic Books. Describing the social structure of an industrial unit in a hospital, itself integrated closely with the surrounding community, Jones goes on to cite how local industries were employed in the treatment of the patients, plus the use of a large group conference to deal with emerging problems. The fortuitous designation, therapeutic community came into wide usage, as well as its underlying logic, of the answerability of the parts to the whole, and vice versa. ———. 1968. Beyond the Community: Social Learning and Social Psychiatry, New Haven: Yale. In addition to advocating leveling of hierarchy in the organization of the mental hospital, Jones espouses what he calls multiple leadership, or the assumption of leadership initiative on the part of its components. He acknowledges the pioneering work done by Laing and associates at Kingsley Hall. There they had “ordinary” people living with schizophrenics, who were allowed to regress to infantile levels, followed by reintegration. Howard Hall had regression, of controlled sort, modulated by both patients and personnel, in the context of therapeutic problem solving, as illustrated with William Bostic and Vince Jordan. Jones foresaw a great future for therapeutic community and social psychiatry. ———. 1991. The Therapeutic Community: Dialogues With Maxwell Jones, M.D. Interviewed by Dennie Briggs. Special Collections, The Library, University of California San Francisco. In this important volume Dennie Briggs, a longtime associate, if not informal partner with Maxwell Jones in the development of therapeutic community, interviews Jones over a period of 21 years, most of it at Jones’ insistence. This is the distillation of notes and recordings, aiming to render understandable the phenomena attending therapeutic community in the

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groups and its leadership. Briggs cites that Jones created democracy within autocracy. Both Jones and Briggs underwent psychoanalysis in the course of their careers, Jones with Melanie Klein. He refers to his three years on the couch as ultimately burdensome, devoted to biography, reductive to earlier memories. It is my inference that the messianism, the God, mystical, and spiritual experience he reports at the end of his career was present as an underlayment earlier. Wilhelm Reich, a psychoanalytic pioneer was similarly motivated towards personal and social change, and displayed his spiritual side floridly towards the end. Maxwell Jones may have fled the couch when his messianism brought him into rivalry and conflict with his analyst, Melanie Klein. In his account of his career, Jones first cites the atmosphere he was able to establish (in his groups), then the failure of psychoanalysis to deal with his problematic emotions, the immense relief he experiences in his group work, but at the end of his career, still the drive towards what he calls “transformation.” He associates to that as spiritual or transpersonal. He retrospectively recognizes that he sensed the presence of God during prolonged silences in groups. He realizes that he needed to inquire further into what was going on there. In my work, the groups at Fort Knox, Howard Hall and the Atascadero State Hospital developed the atmosphere Jones refers to, and a core component was messianic, saving. For the rest, the members related to one another on the simple human level described by Harry Stack Sullivan. They formed an existential unity, a transaction in the present, marked by the dialectic—thesis, antithesis, synthesis—described by Jones and Briggs. It proved be as powerful and pervasive, producing change in the individuals, the personal learning that was at the same time social. In this review of Briggs’s interviews, I shall traverse the notes I took of the fascinating dialogue. Dennie and Max talked, over the decades, in England, the Continent, America, and Canada. Briggs began by citing a remark by Jones that “therapeutic community happens when the total resources of patient and the institution are pooled.” Jones developed the original concept in work occasioned by the social dislocation of post-War London. He noted that, during the War, there was a common enemy, plenty of work, outstanding leadership, and high morale. Then, with peace, the problem subjects exhibited low intelligence, unemployment, alcohol, drugs, vague illness, deliberate idleness, hard-core unemployment. Society transcended mental hospital and prison, through development of experimental rehabilitation centers, versus mental hospital and prison. I would infer that Jones came upon the practice of therapeutic community when the groups of 100 he conducted as classes on effort syndrome during the war developed a life and initiative of their own. He then applied that group initiative to work with the ex-POW’s who were alienated from themselves and others, then conceiving and enunciating the concept of therapeutic community. Then Jones segued to his training in organic psychiatry in America prior to WW II, moving over to Maudsley in England, and a team with insulin and shock therapy. Then came the crucial war work with effort syndrome at Mill Hill, for 5 years. The teams found effort syndrome to be psychosomatic. The team decided to educate the soldiers regarding their condition as functional, not organic, through classes, in large groups. Attractive young women conscriptees were involved then, participating in classes of 100, with the appearance of curiosity on the part of the soldiers, evocation of contributing factors, future concerns, and then family concerns. The therapeutic method evolved of its own momentum, according to Jones. Smaller groups were conducted by the nurses, and discussions on a human level evolved. A Nervy Ned manikin appeared, also skits devised by personnel and patients. Prior patients educated later ones. The staff pulled back as the groups took over, on their own. Jones and associates engaged in theorizing and notation of systematic patterns in the groups. They noted self-love versus self-hate, the binding of opposites, oscillations in the groups, with peaks, destructive periods followed by constructive ones. A soldier created and published a journal of the lecture-discussion, and addressed the issue of causes, functional versus organic. The skits evolved into systematic psychodramas, with dramatization of the core histories of members, and appearance of the voice of conscience.

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This use of dramatic material was an inherent part of the work at Fort Knox and Howard Hall, though not through organized skits. We used media more, as well as audio-visual material illustrative of life courses. Mill Hill went through behavioral crises, occasioned when the soldiers received pay, went off to drink, came back rowdy. Jones referred them to the groups to work through their issues, and got into “hot water” with the hierarchical nurses, by letting the offenders “get away with it.” He was backed by his superiors, though. The theme became “Don’t destroy Poor Max!” Unexpected positive leadership emerged in the groups and personnel. His fame spread, occasioning supportive visits by outside leaders. In Howard Hall we went through similar crises with the nursing personnel. Then came the work with returning Prisoners of War, who lost their sense of identity, suffered from alienation from self, family, and friends. Jones assembled a staff of 59, for a unit of 300. The course was 6–8 weeks, of community meetings. The ex-prisoners expected authoritarian rule, but were engaged in psychodrama, intuitive connectedness, part time employment, making their own destiny, and emergence of their latent abilities. Then came the publication of a newspaper, The Grapevine, and improvement of the food. It was a democracy within basically an authoritarian military situation, with emphasis on coequality. Jones gave an example of a disturbed member who hid the Thorazine that staff believed had dispelled his symptoms, as evidence of the deeply curative value of the group process. He and Briggs formulated it as a result of a dialectical process, social and intrapsychic: thesis-antithesis-synthesis. They had learned to depend on it in the group process to bring about changes in the individual. They described the 8:30 Group. It met at that time in the morning, composed of 100 patients. It was followed by staff post-mortems. Doctors held groups then. Then lunch. Then a ½ hour meeting on the ward, conducted by the nurse, followed by work groups. There was a departure group, family groups. Though successful, Jones and Briggs held that the authorities, including the Anglican Church were opposed to its deviant ways, and they ended, leaving “prophets without honor.” Designation of themselves as prophets who expected some special honor is significant, attended by depression cyclically in their careers. Despite their notoriety and fame, they were acutely conscious of their minority status in the professions, and of its missionary character. Jones then segued again to his career development. He cited himself as a lifelong rebel. His father, himself a mercenary soldier during the Boer Uprising died soon after it, when Jones was 5. Mother was an idealist and moralist. Maxwell, slight of stature, excelled at team sports, convinced life-long of the transcendent centrality of morale in effecting victory. He dreamt of becoming a coffee planter, choosing a medical career instead because of political factors. He was enthralled by James’ Varieties of Religious Experience. He cited John Kennedy on looking into one’s own soul for courage. He continued with exposition of work he did in education, in the introduction of peer counseling. But first he engaged in an exposition of what he calls social learning, the transformative acquisition of new ways of thought and behavior, and ostensibly unlearning of old. This occurred in the dialectical transaction in the group. He cited the hope induced in the process, and how children would not let lessons stop. One taught oneself, and Jones extended it to peer teaching. He quoted Shakespeare on “learning what sadness is made of.” In a telling exchange he confronted Briggs on the charismatic quality of Briggs’ leadership, and they went into Briggs’ work in prisons and his leadership. Briggs freed guards to advance to counselor status, shedding their uniforms. The leader’s role diminished as the therapeutic community matured. They evoked the innate therapeutic capacity and sense of integrity of their social therapists. They then arrived at the term “affective integrity” that was formulated by Harry Wilmer, who pioneered therapeutic community in the US Navy. Relative to affect integrity, they hinted that they were exercising such when they left their respective analysts, “Leaving the couch is when the learning began.” In the work at Fort Knox and Howard Hall the members systematically arrived at the past which interfered with capacity to live in the present, the history that was the psychoanalytic transference. Dealing with it was transformative. Briggs and Jones, denying psychoanalysis as useful, encountered this phenomenon and designated it as social learning.

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As an example of such learning, Jones described a situation when Diggs called on him to consult in an emergency with a potentially violent psychotic patient at Dingleton Hospital. He cited as background that he had in mind his initial encounter at San Francisco State University and the formation of a lifelong partnership with Briggs. He noted Briggs’ idealism, then his depression following defeats and losses in his initial mission to change the educational establishment. Jones induced Briggs to work with him at Dingleton, and he did so, after rousing and “strengthening” experiences with idealistic left-wing students in Europe and England. Briggs was given his own ward, and took to eating with the patients. Briggs had identified with their plight in the work detail, the dirty cutlery, and the iniquity of being subject to foul cleaning fluid, also of being relegated to separate recreational space. Representations about the dirty silverware went nowhere, and the final straw was the fact that the patients had less rashers or sausages for breakfast. He then sat with the patients at meals. He sensed a fellow prophet, willing to be martyred for the cause, the “truth.” In the dialog with Jones, Briggs equated that act of rebellion with standing for the “whole truth,” alleging that therapeutic community was being used there to control “spontaneity and freedom.” Jones sadly acknowledged he had been living there in an “illusionary world,” to the effect that what was of moment on the level Briggs occupied had not reached his executive level. Had it done so, Jones would have subjected it to “social learning.” It would overcome the “errors of family, school, and other formative influences that tend to produce a stereotype, the so-called normal person.” At the end of their careers, they were ready for analysis of its messianic components. Jones mentions the social learning he would have undergone, if he had descended from his illusionary height, at Briggs’ instance. He would have associated to, in psychoanalytic manner, the lifelong mission he had pursued in addressing the morale of his athletic groups towards winning. The compulsive rebellion against authority and unfinished rivalry with authority, father figures would have come into view, etc. He might have encountered the contents of a recurrent depression which he managed to transcend by plunging himself into new challenges. Jones went on to cite the problem with administering discipline, the problem Briggs experienced on his ward with the potentially violent patient. Jones advocated spontaneity and taking risks, and in the social dialectic, the surfacing of parts of the personality previously hidden. He went on to trace the development of the group identity formed at Mill Hill, to that in the ex-POW center, then Henderson. He had abandoned his training in psychotherapy, to admission to the patients that “we don’t know how to treat you.” He described the new method as “eye-ball to eye-ball” in a circle, one speaking at a time, not too long, group setting its rules, and each patient a participant in decision making. I would infer here that the free interpersonal association and the formation of a transactional unity resulted in a new unity and separation from the past one. Briggs and Jones agreed that faith, trust in the process, objectivity of the facilitator, representation of all, in equity, were essential. Result: new learning, new decisions. Next in the dialog was a letter from Jones to Briggs from Nova Scotia, July 25, 1987, in which to Jones the foggy countryside was experienced as “a transcendental infinity, construed as an invisible reality.” He went on to cite that he was “enveloped in the mystery of life if (one) cease to exist separately.” He maybe “understands the meaning of pantheism and the divinity of the whole.” God is not present in his conscious mind, but still part of the universe. Jones is “all or nothing.” “Dialogue is creativity.” I would infer that the unity, the cessation of separate existence, was accomplished through merging with the divine. In their dialog, Jones and Briggs then bemoaned the regression into stereotypy in the worlds of therapeutic community. Jones immersed himself in work at Stanford University and the San Mateo Program in 1959, also work with character disorders in prison work with Doug Grant at Chino. Briggs had initiated New Careers for the Helping Professions and the forestry camps in Southern California. Jones then went on to work in the Virgin Islands, which ended with disillusionment with the hierarchic white and black cultures, and the rigidity of the National Institutes of Mental Health. Both Jones and Briggs

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lauded Thomas Szasz for his opposition to medical domination and advocacy of life as that what was meant to be lived. They now came to sum up. Jones cited the paradigm of open systems, but found that they were inherently self-reifying. Jones stated that he has been accused as manipulative. But Briggs and Jones knew that multiple leadership was valuable and self-correcting, leading to superordinate freedom of thought. There was transcendence and realization of inner self, and one became in touch with a higher being. Jung’s universal unconscious was applicable. Jones then noted that he was in a crisis, after 50 years in the minority, after attack by the medical profession, itself pathetic. It was a test of the integrity of the group approach as a whole, and in his case an instance of metanoia (fundamental transformation of the mind). Jones cited that he respected women more than men, despite their dominance. Children learn from each other. One needs to submit to learning about oneself. Myths do outlive one. There was a change from war to peace, on a condition of soul, Christ-like. The enemy was oneself. He has been a leader of the transformative movements. He cited his despondence, and his “pain, for the while.” There was always the inspiration of taking up another task, for the while. There was the inspiration, between waking and sleeping, awake dreaming, becoming and awakener. Krishnamurti dissolved the barriers of time and space. Dennie then cited Max’s life changes, from charismatic leader, to awakener, and guru. Jones did not like the thought of being charismatic. Dennie noted the shift to power involved. They discussed Robert Bly, who Jones found exhilarating. They took satisfaction with the creation of hundreds of drug recovery communities, stemming from Jones’ “hope.” They lauded women’s liberation, and groups of all kinds. There was a contemporary discontent with bigness, concern for integrity. A new society was being born, and education prominent there. Here was peace through peer action, and learning the inherent order in things. Learning was through social process, and feedback, listening responsibly, getting to know the person and the group. One recycled oneself, stepped back to move forward, into a new wholeness, new identity, insecurity giving way to challenge, learning from becoming. Jones then again revealed that he terminated analysis after three years on the couch, finding the process burdensome. He had lived life in the company of deviants. He noted that creative psychopaths have been contributive, citing Gandhi and Jesus. There was psychological contagion, intuition, linking with the supernatural and metaphysical, networking. There were 15 million in futurist, citizens movements, enveloping them, revolutionary. The human brain has been fully developed for 15,000 years; the Savage Man was present, in evolution and revolution. With early problem-solving by children, one could expect the disappearance of mental illness. Jones quoted Buber on the determination to engage in dedicated listening and dialog, following giving up on religion per se, after the suicide of a student he had ignored because of Buber’s immersion in religious experience. Jones cited that major problems can be, not solved, but outgrown, through an ego-less, spiritual phase. He and Briggs went into the phenomenon of silence in the group, a living silence in the group, that attended deep change. Jones went on to equate psychoanalytic with obsessive attention to biography, reducing the process to restoration of memories. This ego-less, spiritual phase would be central to the social learning itself central to their group process. Jones addressed the attainment of a state of grace in human experience, and the presence of God. Briggs returned to the role of silence in the treatment of prisoners, sailors, and psychiatric patients, linking it with assembling in a circle. Jones and Briggs agree that therapeutic community goes only as far as the staff allows. Finally, Jones returned to his growing experience of spiritual, mystic growth. He has struggled to overcome his psychoanalytic training, through transformation and spirituality. Both Jones and Briggs stated that the passion for democracy was contagious, spreading all over the world. Briggs included at the end of his volume a transcript of a large group, described by Jones as “ghastly,” of student and teacher participants in a peer teaching experiment, led by Jones, that struggled to establish its separate identity, but never quite accomplished it.

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This failure was ostensibly because it needed guidance at its agreed on task, a critique of a film on peer teaching, and was waylaid by Jones, himself, into self-scrutiny, resisted stoutly by the members, except for one of the peer teachers, Alice. Recurrently, Briggs and Jones brought up the failures of the Jonestown religious community and that of Synanon, an at first promising drug treatment community. They noted their authoritarian character as contributive, but did not go into it further. Throughout the volume they took satisfaction with the spread of the democratic ethos and practice in society, and Jones designated himself as a social ecologist, abandoning the designation of psychiatrist, especially psychoanalyst. But then he returned to his conflict with his analyst and his quitting of the couch, and the “social learning” he developed instead. My thesis is that psychoanalysis did not have within itself the instrumentality or theory of religion to enable his analyst, Melanie Klein, to analyze that transference resistance, of his rivalry with her of transcendent messianic nature. The reader is referred to the author’s experience with that problem, in (2007) The Messianic Imperative, Philadelphia, Xlibris. Jung, Carl G. (1933) Modern Man in Search of a Soul. London, Routledge. Jung is positing that modern man is immersed in a “mystique,” an all-embracing pristine unconsciousness, the metaphysical certainties of his medieval brother, which claim the bulk of mankind almost entirely. When he reaches modernity, he is at the edge of the world, standing before a void out of which all things may grow. Jung cites that man lives in sin, stemming from emancipation from the bounds of tradition, haunted by ghosts. He seeks from the depths of his psyche a spiritual form, sensing that, like Eastern religious experience, it is the mysterious truth that spirit is the living body seen from within, and the body the outer manifestation of the living spirit. He goes on to quote the poet Holderlin, danger itself fosters the rescuing power, and that his (Jung’s) ideas are a subjective confession. It would appear to me that these notions and experiences are close to my theses, stripped of mysticism, on the situation of the soul of modem man, as he emancipates himself from the past, and searches his very soul for existential meaning and a Godhead within. The iconic cases in my volume Terra Incognita were haunted by Ghosts to those cited by Jung. Kanas, N. 1996. Group Therapy for Schizophrenic Patients, Washington, D.C.: American Psychiatric Press. Kanas espouses what he calls an integrative group therapy model. He initiated an insight fostering one in 1975, in a military teaching hospital. He had found it to worsen psychotic patients, and in 1977 in a Veterans Administration Hospital developed a supportive, homogeneous model that focused on ways to cope with psychotic symptoms and improve interpersonal relationships. Katan, M. (1960). Dream and Psychosis: Their Relationship to Hallucinatory Processes. International Journal of Psychoanalysis. This intrepid pioneer in the second generation of European psychoanalysts ventured deeply into the borderline fields of psychosis and deviancy. In vivid prose he cites the dynamic role of dreaming in psychosis, its morphology and analytic relevance. Kerenyi, C. (1982) The Gods of the Greeks. London, Thames and Hudson. In this evocative and authentic account, commissioned by the publishers, Kerenyi writes a mythology for adults who are interested in their origins as human beings. He begins by quoting Thomas Mann that psychology contains within itself an interest in myth, for the childhood of the individual soul, the origins of religion and morals. Mythology is a fundamental activity of the psyche. He ends with an elliptic mention of a mysterious child, laughing in Baubos womb, after noting that the divine child was hailed at the Eleusian Mysteries with epiphanic shouts of Iakchos that content of the Mysteries might not be, and could not be spoken of. Kernberg, OF (1984) Severe Personality Disorders. New Haven, CT: Yale University Press. Along with Heinz Kohut, Otto Kerberg ranks foremost as pioneer in exploration of the narcissistic states. Kernberg adhered more closely to Freud’s libidinal hypothesis and Kohut to a break with Freud, postulating existential states. Of Kernberg’s work, most applicable to my volumes is his theory of malignant narcissism. There he depicted core narcissistic states, along with antisocial features and a fairly well organized personality that enables the indi-

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vidual to largely integrate self in social organizations. Kernberg’s treatise was central to the work I conducted at Atascadero State Hospital in its psychiatrist study group. Kierkegaard, Soren (1980) The Concept of Anxiety—A Simple Psychologically Orienting Deliberation on the Dogmatic Issue of Hereditary Sin. Princeton, Princeton University Press. Kierkegaard was critical of Descarte’s cogito ergo sum in favor of ergo sum, as reflective of the whole man as the explorer of the existence of man and his problematic existence, knowing oneself. In a semi-free associative, revelatory, yet exploratory manner, he finds that man is a synthesis (temporal and eterna1) of psyche and body, constituted and sustained by spirit, a state of dreaming. This spirit projects its own actua1ity, seen outside of self. Anxiety is inherent to that dreaming spirit, related to a state of individual and hereditary sin, occasioned in the context of innocence, itself consequent to ignorance. Spiritlessness is a profound state of loss of spirit, minus feeling of anxiety, shown in the haunting of ghosts and meaningless merriment. The demonic stems from failure through evasion in the pursuit of the devout. I find Kierkegaard suggestive of the state of the person who sets aside dogmatism concerning God and man’s spiritua1 life, and about to mourn. The advent phenomenon I have noted in my researches then comes into play, announcing the historic losses, personal and cultural. Kierkegaard, Soren (1983) Fear and Trembling. Princeton, Princeton University Press. Calling it Dialectical Lyric and Repetition by Johannes de Silentio, Kierkegaard examines the responsibilities of Abraham when commanded by his God, with faith as the highest passion, then through letters of a young man, the anguish and ordea1 of Job. For Kierkegaard, Christianity involves the sacrifice of lsaac, versus Judaism, which has the experience as an ordeal, attendant on the spiritual growth of God. In the book Repetition, he examines the metaphysics and psychology of consciousness as springing from the collision of ideality and reality, itself in the context of a repetition that itself is absent in the present, because reality is only in the moment. The inference I draw from this and the preceding work of Kierkegaard is that he was an early explorer of survivor’s guilt. Kirsch, Jonathan (1998) Moses—A Life. New York, Ballantine. Kirsch cites Moses (whose name stemmed from an Egyptian suffix of Egyptian kings, mose) as a very human character, but haunted, a facially disfigured, masked man, who regressed into magic, blood ritual, and bloody purges, whom God tried to kill in the course of their arguments, and whose historicity is an open question. Kirsch cites Freud’s thesis on Moses’ mission, in which, comparing Moses to Oedipus, and abandoned by his father, a pauper is raised as a prince, whose destiny was to cultivate the seeds of monotheism in an enslaved people. Kirsch holds Moses, a transcendent yet very human man, to be caught between God systems, meeting a tragic end that is symbolic for our tumultuous times. Kirsch, Jonathan (2000) King David. New York, Ballantine. Kirsch delineates the flesh-and-blood Biblical King David (whose name means beloved) as a prototypic human being, at once sacred and profane, the precursor and direct ancestor of the redemptive Messiah. Kirsch cites the Bible (in its multiple authorship) as an anticipation, then celebration of David and the subsequent Kings of lsrael. On reflection, it becomes apparent that that, but for the changes in society, has brought us democracy, and our political figures are Davidian in their failings. Klapman, J. W. 1946. Group Psychotherapy: Theory and Practice, New York: Grune and Stratton. An early exposition on the value of group psychotherapy, with valuable discussion of its origins, also the place of psychodrama, this volume advocates it for its usefulness in “affective re-education.” Klein, Melanie. Love, Guilt and Reparation: And Other Works 1921–1945, The Psychoanalysis of Children, Envy and Gratitude, Narrative of a Child Analysis. London: Hogarth Press. This woman rose from tragic and lowly status in middle Europe, through analytic training to become a leading figure alongside Freud in psychoanalysis. Independently minded, she was nevertheless tied to Freud in his larger theorizing, such as that pertaining to the death instinct. It played a prominent part in her intra-psychic and interpersonal theory leading to

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concepts such as the depressive and paranoid positions in the early infant. She and Anna Freud pioneered in the treatment of children, as individuals. I have been influenced by her and found myself independently able to identify parallel phenomena in my individual work. However, I differ strongly in reference to the death instinct which I have encountered as the death experience, which itself proved to be analyzable. Kohut, Heinz (1977) The Restoration of the Self. New York, International Universities Press. Kohut here calls on psychoana1ysis to change in accordance with new insights on the problem of narcissism if it wants to stay alive. The challenge is couched in a manner similar to that of Bishop Spong towards Christianity. Kohut is concerned with man’s self-alienation, which he exemplifies in Kafka’s cockroach-man, then in ONeill’s The Great GodBrown. Man is born broken. He lives by mending. The grace of God is glue. Kohut posits a primary and tragic defect in the self, a state of inner deadness and depression, with overcompensation through hyper-vitality. The essence of that self is not knowable. He alludes to gods, in citing that ideals are not gods, and if they become gods, they stifle creativeness, impede the activities of the human spirit that points most meaningfully into the future. Behind the defect is a dread of disintegration, dread of the loss of the self, estrangement from body and mind in space, the breakup of the sense of continuity in time. This in contrast with the child’s hypothesized merger with the empathic omnipotent idealized self-object. Self-objects, as differentiated from real objects, are empathic, and as necessary as oxygen for the newborn child, including the child in its own psychological organization. I find that thesis to be tenable, one consonant with the transactional hypothesis, in which the child forms a psychological entity with the mother. My problem is with the normative aspect of his formulation, when he has the mother in the unity as omnipotent. That state would be in itself transcendent, and therefore out of grounding reality. Such a state of discrepancy would call for the neonate to likewise be transcendent. In my version, this occurs earlier, in utero, and when transcendence occurs, narcissistic pathology is already present. Another important point in Kohut’s formulation is his claim that aggression is initially absent in the baby, if responded to with empathy from the start. This would have implications for a theory of evil, in holding that the baby is born good. Korn, Richard R. and McCorkle, Lloyd W. (1963) Criminology and Penology. New York, Holt. Korn and McCorkle have given us this major work on institutional aspects of corrections, leading the way to more enlightened penology. Korn went further, developing concepts of institutional transformation centering on the individual as a participating citizen. He then went on to charismatically engage with society—politicians, forensic personal, and general citizens, through workshops that went as far as experiences in incarceration, to enable society to understand the situation of the prisoner, and the alienating aspects of modern incarceration. Krippner, Stanley and Welch, Patrick (1992) Spiritual Dimensions of Healing—From Native Shamanism to Contemporary Health Care. New York, Irvington Publishers. An earlier version of this book, was Between Heaven and Earth, published in German, indicating its scope. In mostly popular vein, the authors trace through the history of spiritual healing, from shaman through witch, to current acceptance of the spiritual in healing groups such as Alcoholics Anonymous and mainstream medicine. My work in spirituality is an exemplification of the author’s thesis. Larsen, Stephen (1990) The Mythic Imagination. New York, Bantam Books. Following Joseph Campbell and Carl Jung, Larsen details how myth undergirds the personality and culture, and goes on with a thesis of personal myth, an integration of myth necessary to everyday existence. Personal myth plays a large part in my formulation regarding the messianic career. Lampl-de-Groot, Jeanne (1962) Ego Ideal and Superego, The Psychoanalytic Study of the Child, Vol. XVII, pp. 94–106. A path finding piece, tracing the development and distinctive nature of the ego ideal, itself of central importance to this study. The closest she comes to the spiritual aspects of the ego

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ideal are in the omnipotence attributed to ideal and almighty parents experienced in the earliest phases of development, especially in response to distress and anxiety. Liff, Zanvel A, Ed. 1975. The Leader in the Group, New York: Jason Aronson. A celebration of 35 years of leadership in analytic group psychotherapy by Alexander Wolf, this engaging work has chapters by Wolf, Schwartz, Liff, Foulkes, Glatzer, Aronson, Mendell, and Kosseff. Wolf inveighs against authoritarian leadership, emphasizing informality. In his practice he had his groups meet in alternate sessions without a therapist. It is of note that Wolf started the group therapy at Ft. Knox, and was transferred overseas because a problem arose over an insurrection on the part of the rehabilitees related to his lack of control. Of particular note in this volume is a presentation by Harriett Strachem of couples and family group therapy. Lorand, S. (1957). Dream Interpretation in the Talmud—(Babylonian and Graeco-Roman Period). International Journal of Psychoanalysis 38:92–97. In a closely packed compendium, psychoanalyst Sandor Lorand examines the books of the Talmud for can be gleaned of use to the modern psychoanalyst. He merely introduces the subject which includes dreams, early and late in the sleep cycle, dreams in sickness and health, dreams and temperament, dreams and cultural influences, dreams and the day residue, etc. We obtain entry into the influences of Babylonian, Graeco-Roman, Egyptian, Canaanite and other cultural practices during the long period of Israel as existence as a nation and in captivity. Psychology then was immersed in religion and its theory building and practices. It is amazing that Freud merely glanced in this direction in his monumental initiative in the study of dreams. Mack, J. E. (1969). Dreams and Psychosis. Journal of the American Psychoanalytic Association. 17: 206–221. This is a faithful report of a panel on dreaming and psychosis at the American Psychoanalytic Association, evidencing a far-ranging discussion, which to this author would indicate significant interest on the part of psychoanalysis in the analysis of psychotic individual. Its relationship to the analysis of neurotics is broached throughout. MacNamara, E.J. and McCorkle, L. Eds. 1982. Crime, Criminals, and Corrections, New York: John Jay Press. The chief contribution of note in this work is its chapter, “Contemporary Trends in Corrections,” and within that, a detailed presentation of the Highfields Experiment conducted by Lloyd McCorkle. Within that is an absorbing account of sessions of its centerpiece, guided group interaction. The aim there was to support the adolescent, 16 years of age, in traversal of his difficulties with the law, his normalization, and alteration of his untoward behavior. Within that frame was a certain amount of character change and attainment of insight, but the theme and thesis of treatment in depth of the work at Fort Knox and Howard Hall was eschewed. Nevertheless, Highfields claimed to cut the recidivism rate by half, over a comparable population that chose a roughly similar institution, but for its guided group interaction. Maharaj, Rabi R. (1977) Death of a Guru. Eugene, Oregon, Harvest House Publishers. An instinctive account of a conversion encounter between a Hindu and Christian, illustrative of the personal nature of Christ to this man, and the stages of the experience, all of moment in our study of messianism. McCorkle, L. W., Elias, A., and Bixby, F. L. 1958. The Highfields Story: A Unique Experiment in the Treatment of Juvenile Delinquents. New York: Henry Holt. Credit for this experiment goes to Lowell Bixby, a criminologist in the State of New Jersey, who conceived of a home for 16 year olds, with minimal personnel, and a short term, intensive stay centered about group counseling, led by a responsible professional, here, Lloyd W. McCorkle. An equal cohort was assigned to a regular reformatory. Built into the design was study of the sessions, termed guided group interaction, and the outcomes. The residents learned to achieve self-control, through identification with the program, the director, and the group. There was improvement of relationship with a probation officer (67%); relationship with family (72%); attitude towards self (73%); work adjustment (57%); overall adjustment (59%). There was no in-depth inquiry, as in Howard Hall.

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Based on the Highfields experiment, in response to a wave of teenage offenses, the author led a citizens-committee halfway house in Fairfax County, Virginia. McKay, M. and Paleg, K. Eds. 1992. Focal Group Psychotherapy, Oakland: New Harbinger Press. This relatively recent work is indicative of the widespread employment of group therapy for specific areas of concern, ranging from shyness, through agoraphobia, anger, eating disorders, rape survivor, domestic violence, incest offenders, to addiction. The language is clear and the protocols are useful in setting up psycho-educational groups in institutions. Meissner, W.W. (1986) Psychoanalysis and Religious Experience. New Haven and London, Yale University Press. A remarkable work, in which the author, a psychoanalyst and Jesuit, attempts to reconcile psychoanalysis and religious life. In the course of this endeavor, he penetrates to the religious aspects of Freud’s personality. Meissner noted that Freud, in his correspondence with his minister Oscar Pfister, conceded the humans right (and by implication that of Freud) to the universal experience of irrational religious belief. Meissner, on the other hand asserts that there is no room in psychoanalysis for a positive impulse for freedom, one of the characteristics of the experience of soul I have noted in this work. But then again, he calls for a theological anthropology dependent on psychoanalytic input. A scientific study of the human soul by both would be a proper project for religion and psychoanalysis. Meissner, W.W. (2000) Freud and Psychoanalysis. Notre Dame, University of Notre Dame Press. In this magisterial work, Meissner attains a synoptic view of psychoanalysis from Freud on. Important for our purposes, his social theory as evidenced in works such as Totem and Taboo and Civilization and Its Discontents is sidelined in favor of the clinical. The editor begins with a poem to Freud for his reunion of the severed psyche. He goes on to cite Freud’s resistance to the incarnational and humanizing task of integration of mind and body, spirit and matter as a response to humanity’s wish for something whole and ready-made. The editor cites that the challenge is to embrace the earth of our humanity. He then quotes Merton to the effect that Freud was basica1ly hopeless rather than pessimistic, and deploring that man’s society impedes his learning to love in mature manner. Meloy, J. Reid. 1988. The Psychopathic Mind: Origins, Dynamic, and Treatment, Northvale CT: Aronson. In this important thesis on the psychopathic individual, Meloy integrates the psychoanalytic approach with his considerable experience in the field as a psychologist. He essays into mythic and religious motivation in the psychopath. In Chapter 4, entitled “Affective Life and Death,” he postulates the existence of a regressive reptilian state (with its evolutionary configuration of the limbic system), complete with an alienated stare, or way of looking. This is combined with a malche movis, or evil eye (which I have noted earlier in this work, in reference to my version of my mother’s emotional constitution), and messianism in the victim perceived as threatening to the psychopath’s masculinity. In his discussion of the incapacity of the psychopath to mourn, and experience depression, he quotes Melanie Klein (1935, p. 290) in a manner suggestive of my notion of messianism, citing an attempt to save the love-object. This serious and significant work on psychopathy, from a psychoanalytic point of view is of special moment when it comes to treatment. This becomes even more important in a forensic hospital or prison, where individuals with varying degrees of psychopathy are incarcerated. Meloy starts his section on treatment by noting the “heart and soul” it takes to undertake such a venture. I would infer that he is edging there into the messianism that is entailed and that I consider an initial essential to the therapeutic alliance with the severe disorders. Meloy further emphasizes that he assumes initially that the subject will deceive him. It is possible and necessary to hold both ego positions. In the chapter on treatment Meloy goes into the internal operations of the psychopath inquired into by the psychoanalysts Edith Jacobson and Otto Kernberg. A search for the role of messianism as an avenue to treatment is fruitless. Yochelson spoke of conversion of the psychopath as an essential step in treatment. In the work at St. Elizabeth’s, Ft. Knox, and Howard Hall, abandonment of psychopathy was attended by transient psychosis and neurosis, an indication of a psychotic base to character disorder. Meloy does arrive at that position

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in a chapter on structure and dynamics. In the volume Terra Incognita we encounter aspects of psychopathy in work with troubled couples, were members subvert their own and their partners ideals. Nacht, S. (1962). The Curative Factors in Psycho-Analysis. International Journal of Psychoanalysis 43:206–211. I have found this author’s term rapproche, not too close not too far, to be important in intra-psychic, interpersonal, and social distancing in the therapeutic process. Along the way I have found his wide ranging interests and expositions useful. Nelson, Marie C., and Eigen, Michael (Eds.) (1984) Evil—Self and Culture. New York, Human Sciences Press. This important volume is the product of a dialog between cultural historians, clinical practitioners and theologians concerning the burgeoning evil preoccupying the civilized world on the turn of the twentieth century. Focus is on the nature of evil and the role of compassionate therapeutic attitudes after three centuries of subservience to medieval dogma and reification of evil. Recognition of a state of innocence and trust, with synthesis and reconstruction of the personality, is advanced as a bridge between the theological and scientific. Along with that goes mourning for the rupture and lost integrity of antecedent developmental structures embedded in the mother-infant relationship which symbolized comfort, innocence, and omnipotence. Such recognition is involved in the capacity to repudiate cultural ascription of evil, and consequent forgery of the soul (Grotstein, in a particularly lucid chapter). Evil would be a malady of the soul, a transference from the past, that would be subject to analysis, by my token, with the aid of messianism, (a component of Kohut’s notion of empathy) which itself would need to be outgrown. Noble, D. (1964). The Clinical Use of Dreams: By Walter Bonime, M.D. New York: Basic Books, Inc., 1962. Dr. Noble, an important colleague of this author, ranged widely in his work with dreams, reviews of other authors. Noy, P. (1969). A Revision of the Psychoanalytic Theory of the Primary Process. International Journal of Psychoanalysis 50:155–178. The reader is referred to my somewhat extensive review of this extremely important revision of Freud’s introduction to the primary process. Pagels, Elaine (1996) The Origin of Satan. New York, Random House. In this intriguing book, Pagels, a professor of religion at Princeton, depicts Satan as a son of God who undergoes development over the centuries and incarnation as demons in the enemies of the Christian version of God’s coming kingdom. She describes the conversion of Justin, an early Christian, to a divine power in an encounter analogous to that of Sabbatai and Nathan, with consequent exorcism of Satan. He then could live beyond nature, and from this new level of integrity, could then see the natural gods as social and personal transferences from the past. She traces the growth of the Christian identity (and the transformation from the profoundly human view that otherness is evil) to the role of Christ as a divine reconciliator. This had direct pertinence to my analysis of messianism in self and my patients. In my work at Atascadero State Hospital I collaborated with the Catholic minister in a non-ritualistic excorcism which consisted of colloquy with a patient who had cried out for days that he was Satan. Through our spiritually relevant rational conversation, he became reconciled to his human status without further ado. Person, Ethel S (Ed.) (1997) On Freud’s A Child’s Being Beaten. New Haven, Ya1e University Press. Of the panelists who discuss this important paper on masochism, or sought suffering, Shengold, alongside the standard psychoanalytic theses, reaches into spiritual considerations, citing regression to evil and an incestuous union with the parent as God. He points out that at the end of the paper, Freud refers to the burdens of evil bequeathed to us by our parents, as exemplified in Hamlet and Oedipus. Apparently in illustration, he closes his discussion with a dream of Anna Freud, in which her father is returned from the dead, calling on her to renounce her progress in favor of a reciprocation of a tenderness that had been largely lacking in their life together.

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Person, Ethel S. (Ed.) (2001) On Freud’s Group Psychology and the Analysis of the Ego. Hillsdale, N.J., The Analytic Press. A number of thinkers and practitioners discuss Freud’s classic, of moment to this volume because of the central role of Freud’s thinking to the ego ideal in the psychic life of the individual and the group. Caper refers to Bion’s designation of the Messianic hope, which aims towards the Nirvana of discharge of all of the unpleasure of Freud’s pleasure principle, all mythic concepts that call for discussion as such. Poani, A. (2010). Animal Homosexuality: A Biosocial Perspective. Cambridge University Press. This important study in evolutionary biology evidences both behavioral and genetic data, ostensibly establishing animal homosexuality in its theory. Pope, Marvin H. (1965) Job (The Anchor Bible). New York, Doubleday. Setting his study in the context of the ancient literatures of Egypt, Mesopotamia, Syria, and Anatolia, Pope cites earlier Mesopotamian texts of similar nature, going back to the Third Dynasty of Ur. Raising doubt on its Israelite authorship, and with its Satan possibly of Persian origin, Pope goes on to cite an Akkadian poem of very similar construction and thrust, reflective of the Mesopotamian view that evil is an integral part of the cosmic order. More than implicit in the story is an assembly of gods, including Satan. A similar Akkadian text, known as the Babylonian Ecclesiastes, is even more polytheistic. Pope also reflects on the Promethean myth of the Greeks. He considers that evaluation of Job’s situation needs to be in the context of a systematic scrutiny of the dynamics of the generations of God, and of the God-man relationship. In this construct each step along the way towards autonomy, God and man, is attended by very human jealousy and rebellion, tests for malfeasance on the part of the other, alongside nutritive concern and care. This would be understandable, if one accepts that the experience and idea of God are those of man, therefore man-made. During the past year with the onset of my macular degenerative blindness, I experienced Jobian despair and a drive toward self-destruction, bringing home the crucial issue of belief in the deity and man’s purpose in life, bringing forth the issue of the core aspect of the author’s Ego Ideal pertaining to his profession. Restitution of the capacity to master texts and dictate, via modern technology solved this problem! Popper, K. (1935) Logik der Forschung. Vienna: Julius Springer Verlag. This Austrian philosopher considered to be the leading figure in the philosophy of science has constructed a stringently posited process of theoretic verification, called falsifiability. A theory would have to be capable of being proven false to be scientific. I take this counterintuitive stance to indicate the necessity of openness on the part of the investigator to alternate data, theoretic and empiric. My study of this concern began with the myth of narcissus who knew only what the Gods on mount Olympus held to be reality. I held that Narcissus was determining for himself the nature of reality when he looked into the pool of waters, and experienced darkness and psychic death when he strayed from the cognition of the Gods. He then had the possibility of having his own concept and experience. Mankind has come a long way from Mount Olympus in his cognition of reality. Powell, John Walker. 1950. Group Reading in Mental Hospitals, Psychiatry: Journal for the Study of Interpersonal Processes, 13:2, May. Dr. Powell extended his practice of reading discussion groups from libraries in San Francisco to Chestnut Lodge Sanitarium and Howard Hall. It was an extension of the adult education movement (late 1940 to 1960) of Professor Alexander Meikeljohn, of the University of Wisconsin. Meiklejohn held that a great task of democracy was the further education of adults. Powell applied his theory and practice through reaching alienated populations. In Howard Hall, utilizing group leadership similar to mine, he was able to engage with the members, white and black, in discussion of America’s founding tracts, such as the Declaration of Independence. Trained in critical thought, members further contributed to the Howard Hall Journal and to their recovery. Rachman, A. W. 1975. Identity Group Therapy With Adolescents, Springfield: Charles C Thomas. Based on Erik Ericson’s concept of identity formation and development, Rachman’s group sees group therapy as the treatment of choice with adolescents. The crises inherent in

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development are gone into in detail and related to group phenomena. This work is of moment for its similarity to the Fort Knox and Howard Hall experiences, whose sessions were marked by traversal of developmental crises. Rachman describes marathon sessions that in essence resemble the experience reported with Wilfred Bostic. Richardson, G. A. and Moore, R. A. (1963). On the Manifest Dream in Schizophrenia. Journal of the American Psychoanalytic Association. I employ this article, rich in illustrative material, to adumbrate my argument on the usefulness of the manifest dream, both with schizophrenics and neurotics. Roche, P.Q. (1958) The Criminal Mind. New York, Farrar, Straus. Roche emphasizes the religious aspect of the trial of the criminal and the presence still of demonologic conceptions of the motivation leading to crime. Rosen, John (1953) Direct Analysis. New York, Grune and Stratton. This is a casebook of a pioneer in the psychologic treatment of schizophrenics. From direct observation of his work and discussion with Dr. Rosen, it seems to me that his messianism was the chief factor in his successes. He does admit in the text that alongside playing the foster-parent he was an omnipotent protector. I can here report his reply to my query as to what his therapeutic work with the schizophrenic individual was, “Here Joe, have this piece of cake!” Rosenbaum, M. and Snadowsky, A. 1957. The Intensive Group Experience, New York: The Free Press. The authors and contributors cast a wide net, encompassing group dynamics, group encounter, institutional group work, psychodrama, Alcoholics Anonymous, intentional communities, millennial communities, etc. attempting to identify that which is “intensive” and effective in accomplishing change. The review of work in prisons is valuable, for its exposition of difficulties presented by the prison situation. Rosenblatt, A. D. and Thickstun, J. T. (1977). Energy, Information, and Motivation: A Revision of Psychoanalytic Theory. Journal of the American Psychoanalytic Association 25:537–558. I consider that the theses of Rosenblatt and Thickstun, colleagues of mine at the San Diego Psychoanalytic Institute, are an important epistemologic step between biology and myth. Rubenfeld, S. 1965. Family of Outcasts: A New Theory of Delinquency, New York: The Free Press. Rubenfeld centers his theory on oppressive ideals imposed by ‘sure’ parents, resulting in massive reaction formation on the part of youth who are pursuing deviant personal values of their own that amount to a culture of their own. Alienation from self and other is systemic, fixating developed patterns. The way out of that dilemma lies in negotiation of new values and redefinition of selves. Rubenfeld inquires into the economically and other culturally advantaged groups, identifying enthrallment to celebrating the ego, personal power, individual competence in work, play, and sex games. All of this analysis is done in eloquent, vivid style, in a chapter entitled, “National values, Neurosis, and Delinquency.” Rubenfeld’s exposition of his theory of delinquency begins with the proposition of eunomie, or normative collaboration, itself a reciprocal relation within a culture between end state attainment and social synergy. Integrative failure there results in “outness,” self-destructive roles, and “hardening.” He cites opportunity theory and role preparation in a career in crime. These constructs underlay the work at Knox and Howard Hall, in search for causes and courses in recovery. They were prominent in the methodology at Fort Knox, taught prewar to McCorkle by the sociologist Clifford Shaw at the Chicago Area Project, a successful counter-delinquency venture and later work in Howard Hall and Atascadero State Hospital. Sagan, Carl (1977) The Dragon of Eden—Speculations on the Origin of Human Intelligence. New York, Random House. An early treatise on man’s relation to his universe, with emphasis on neuroscience. He holds that the cataclysmic emotional and religious aspects of our lives to be localized in the limbic system and shared with our non-primate mammalian forebears (and perhaps the birds). He cites the Platonic dialog Phaedrus, in which Socrates likened the human soul to a chariot drawn in two different directions by a weak charioteer. The neuroscience analogy

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ascribes oppositional motivational thrust to the aforementioned limbic system and an earlier, reptilian one. Out of the oppositional or dialectical transaction, held over by the neocortex comes the vector of the human soul. He goes on to the issue of the eschatologically relevant expulsion from Eden which happened coincident with the growth of the neocortex and the rea1ization of death as man’s destiny. To that I adduce my notion of the experience of death of the earlier biologic system resident within the evolving brain and the phenomenon of apoptosis, or pre-programmed cell death. Saul, L. and Sheppard, E. (1956). An attempt to Quantify Emotional Forces Using Manifest Dreams; A Preliminary Study. Journal of the American Psychoanalytic Association 4:486–502. In this classic piece the authors essay into the fertile field of dream analysis through a study in the psychosomatics of hypertension. They report their effort pertinently and remarkably come up with a scale of quantification of hostility in manifest dreams. This author questions certain cultural factors in their report, namely an attempt to have equity in the presence of black members in the hypertensive and normatensive population. However this study points the way toward the need for further quantitative analysis of the subject. Schmideberg, Melitta. This eloquent psychoanalyst received her start in the field by being the daughter of Melanie Klein, who afforded her child reportedly one of the first psychoanalyses. She became a physician, married a fellow physician who became a member of Freud’s inner circle. Subsequently they moved to Britain, became involved in the controversies initiated by her mother, who pioneered in child analyses and more importantly intra-psychic dynamics and transaction there with the introject. In this course she was analyzed by Edward Glover, a leading British psychoanalyst. She then became allied with in controversy with her mother, both relative to theory and practice. I find much of her work to be clearly expressed and valuable from the point of view of the requirements of a professional in training self and conducting that craft. Central there, I would say, is her concept of the professional as a human being regarding the subject of ministration in that light. Important there would be abstinence from rote, cant and above all fanaticism. Her concept of the human entity appears to be analogous to that of Harry Stack Sullivan who stated forthrightly “We are all much more simply human than otherwise.” She also had the courage and conviction to inquiry into delinquency and antisocial behavior psychoanalytically. She published in the journal of orthopsychiatry in 1953 on delinquency, citing that it was induced by social and personal factors, resulting in the surfacing of underlying what I take to be alienation. This analytic pioneer appears to me to be closest, in her approach to her craft, to my approach. Along the way, she was highly critical of her fellow psychoanalysts for their tendency toward enmeshment of the patient in saviorist expectation of psychoanalysis. While I hold that that saviorist transaction is inherent and necessary, especially in the severe disorders, in my practice I have engaged in the abstinence that Schmideberg advocates at the earliest possible moment, and subsequent analysis. Of the messianic transference, I have differentiated such transference from the actual transference that Freud discovered. Scholem, G. (1973) Sabbatai Sevi, the Mystical Messiah. Princeton, Princeton Press. This seminal work forms a centerpiece of my inquiry into the life history of a messianist. In its 1000 pages, Scholem details Sabbatai’s life and his times, and further, that of the movement Sabbatai initiated and continued. Shengold, Leonard (1993) The Boy Will Come To Nothing! Freud’s Ego Ideal and Freud as Ego Ideal. New Haven, Yale University Press. In this profound and eloquent work, Shengold focuses on Freud’s central concept of the ego ideal. With attention to the phenomenon of the “revenant,” or return from death, he details Freud’s identifications with the biblical Joseph and Moses. His deeply ambivalent relationship with Fliess and Jung was marked in the latter by fainting spells, from one of which he awoke stating, “How sweet it must be to die!” Shengold cites that the figure of the devil or the demon was a recurrent metaphor for Freud. In his relationship with Jung, who like Fliess manifested paranoid tendencies, Freud entered a symbiosis with a messianic underlayment, in which Jung would carry forth for his father creator, Freud.

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Shengold, Leonard (1991). Soul Murder: The Effects of Childhood Abuse and Deprivation, New York: Ballantine Books. In a volume that calls for wide and deep study, professor Shengold cites the abuse of children, resulting in the veritable murder of their souls, with concomitant bondage to the perpetrators. I find his thesis to have been exemplified in the material I have gathered at Fort Knox, Howard Hall, Atascadero State Hospital, and in my practice. Slavson, S. R. Ed. 1956. The Fields of Group Psychotherapy, New York: International Universities Press. Slavson’s authors cover the fields of mental hospitals, psychosomatic disorders, addiction, alcoholism, stuttering, allergies, geriatrics, mothering, delinquents, child guidance, family services, private practice, community mental health, industry, training and research—all indicative of how rapidly and widespread group therapy had become. ———. 1964. A Textbook in Analytic Group Psychotherapy, New York: International Universities Press. This is a massive compilation of half a century of work by Slavson, a social worker who was one of the initiators of group psychotherapy. Done in a forthright manner, he starts by citing how he discovered the process, in searching why he and his colleagues were successful in a recreational project, finding that the group per se was the operant variable. He later discerned Freudian mechanisms. He has concluded that limitation of group size to eight is necessary for results, a notion at odds with the work at Knox and Howard Hall. Smith, Homer W. (1952) Man and His Gods. Boston, Little Brown. With a Foreword by Albert Einstein on the mythic, authoritatively anchored forces which can be denoted as religious, Smith, a physiologist, tracks through both ancient and modern worlds, in search of the beliefs of man, and denoting their atavisms. A free thinker, he despairs because science is shut outside of man’s search for self-realization (and happiness) by ancient mores and a gentleman’s agreement that keeps them from changing society’s basic beliefs, man’s gods. After demolishing current myth as reality, he ends pessimistically on the note of the abyss to which nature led. There is a particularly penetrating chapter on Satan, and another in which he details his career as an epistemologist, in the study of knowledge itself. Spiro, Howard M., Cumen, Mary G, and Wandel, Lee P., Eds. (1996) Facing Death. New Haven, Yale University. A compilation of chapters on the increasingly recognized need for an art (and science) of dying, the most pertinent to the issue of the place of messianism in that experience is a cogent discussion of the history of concepts of the soul in the process (Wandel) and a presentation of the fulfilled life. What I found missing in the cogent discussions was that of the death within life through our defense of transcendence that interferes with fulfillment. In this volume I inquire into the place of death in the life of man. Spong, John Shelby (1998) Why Christianity Must Change Or Die. San Francisco, Harper. This seminal work, with its vision and hope, was the impetus for my volume on messianism, The Messianic Imperative. Spotnitz, Hyman. 1961. The Couch and the Circle, New York: Alfred Knopf. Spotnitz was an analyst, consultant to Slavson’s domain, the Jewish Board of Guardians, who started a group with “untreatable” patients whose treatment in turn seemed to be at a standstill. At first surprised at the ease they experienced in adjusting to one another, he came to rely on their capacity to bring out latent resources for problem solving and expansion of each other’s horizons. He called analytic group therapy the third psychiatric revolution, and espoused small groups as the modality of intervention. Stanton, Alfred H. and Schwartz, Morris S. 1954. The Mental Hospital: A Study of Institutional Participation in Psychiatric Illness and Treatment, New York: Basic Books. This seminal work, a socio-psychiatric report of a 3-year study of Chestnut Lodge, a psychoanalytic mental hospital, is of moment in understanding the structure and functioning of Howard Hall. Stanton and Schwartz, “living on the wards” found that there were too many people making decisions, they were emotionally skewed, and there was insufficient feedback. Their reports resulted in concomitant centralization, federalization, systematic conferences, and separation of administration from therapy. Applying those theses to Ho-

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ward Hall, one may cite that the attendants “in the line of fire” decided too much, there was deficient consensual upper and mid-level authority, no systematic feedback by conferences. Emotional skewing by attendants was rife. Both institutions in time worked towards the therapeutic community model, with differences in individual therapy in Chestnut Lodge and group therapy in Howard Hall. Both called for increased competency on the part of patients, and answerability on the part of therapists. Stephenson, W. (1953). The study of behavior: Q-technique and its methodology. Chicago: University of Chicago Press. This psychologist devised a method of content analysis, in which he discerned key words and their assemblage, ascribing values to their repetitive occurrence. He was able to discern thereby changes, intrapsychic and intrapersonal. He did this in analysis of the protocols in the book, Maternal Dependency and Schizophrenia. Stone, Merlin (1976) When God Was A Woman. New York, Harvest HBJ. Going back to prehistoric and early historic times, even to the early Paleolithic age, the author describes the worship of the Great Goddess. Subject to persecution and repression, from the female Goddess worship came the creation myth of Adam and Eve and the loss of Paradise, with the blame going to woman. In a closely documented text, Stone hints at the descent of Abraham from Brahmin priests, and the Levites from the Indo-European Luvians. Sullivan, Harry Stack. 1953. The Collected Works of Harry Stack Sullivan, New York: W. W. Norton and Company. Sullivan held that “we are all much more human than otherwise” and evidenced capability of talking with his patients in a simply human fashion, empathically reaching them. He is widely accounted as a pioneer in the treatment of the severe disorders. In this volume he sets forth his interpersonal theory and practice. His prior experience was at St. Elizabeth’s, Sheppard and Enoch Pratt Hospital, and Chestnut Lodge, where he adapted psychoanalysis through his focused interview technique. He also evolved an ego psychology based on a self-system that was altered through anxiety and what he called “parapraxis.” Anxiety was central to the disturbance of maternal-infant relationship in early childhood. Another contribution was in the concept of malevolent transformation, a process in mid-childhood of transformation of the self towards the malevolence of psychopathy. He founded the journal Psychiatry in which he welcomed an operational statement of psychiatry that included the ally disciplines; also due regard for cultural factors. Swinburne, Richard (1991) The Existence of God. Oxford, Oxford University Press. Starting with the observation that scientists reach justified conclusions about reality beyond immediate experience, such as subatomic particles and the big bang, Swinburne reaches into recent developments in inductive logic, called confirmation theory to bring out the close similarities between religious theories and scientific logic. He claims that the existence and operation of man (and his consciousness) are not ultimately scientifically explicable and offers a theistic explanation. He goes on to the behaviorist and mind-brain identity hypotheses, the difficulties inherent in correlative and probabilistic theorizing. He advances a personalist explanation of mind-body correlations, then gets into the increasing complexity of organisms, moving to that the existence of conscious beings could not come about by norma1 physica1 processes. He invokes God as explanatory at this point. It would seem to me that complexity theory needs to be called into play. He goes on to the question of a good God creating evil, which Christianity deals with through redemptive reincarnation, and I see as evidence of man’s creation of God, and recreation, in his image. Swinburne cites the God-experience of man in the form of wise men, prophets, and great leaders, plus religious experience itself as God’s intimate presence on earth. He concludes that the probability of theism on scientific evidence is very low, but that the testimony of man makes the evidence of theism over all probable. In the continuously pertinent issue of the place of god in the life of men, Swinburne’s internal struggle attains a crucial place. L.S.Szymanski, and W.E. Kiernan, Multiple Family Group Therapy with Developmentally Disabled Adolescents and Young Adults, Int. J. Group Psychother. 33(4) Oct.1983

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These authors affirm and convey the general experience with multifamily therapy in which its inherent mechanisms enable the families’ and individual members to emerge as autonomous expressors in the problem-solving mode. Thorpe, J. J. and Smith, B. 1952. Operational Sequences in Group Therapy with Young Offenders. The International Journal of Group Psychotherapy, Vol. II, (p.24–33). Thorpe and Smith describe operational sequences in interaction with young offenders at the National Training School for Boys, in the course of development of the program there. Thorpe and Smith cite the need to integrate the group therapy into the program. They go on to pose the problems related to security and the need to “sell” the program. Certainly, that issue was made clear by the attendants in Howard Hall, in the course of the Integrated Group, when they challenged me relative to the validity of the group therapy, and its attendant “disorder.” Trembath, Kem T. (1991) Divine Revelation. New York, Oxford University Press. Holding that human beings are constituted as moral beings sui generis, and that sin was a disruption of that original state in consonance with God, Tremblath closely reasons his way through God as an experience of man and vice versa, from the point of view of what is revealed in the journey. He searches for the linkage between the trinitarian Christian god (self-transcending knowledge, love, and hope) and humanity through revelation in which God and man speak and disclose, in the context of a foundational groundedness. I find his reasoning close to my experience in a scientific study of the human soul, in analogous, if scientific, terms. Tyson, Phyllis; Tyson, Robert L. Narcissism and superego development. Journal of the American Psychoanalytic Association, Vol 32(1), 1984, 75–98. A valuable work, in which the authors focus on the intra-psychic dynamics relative to the formation of the ego ideal and its transactions with the introject, a matter of central import in my work with the iconic cases in this volume. Roland, A. (1971). The Context and Unique Function of Dream in Psychoanalysis in Psychoanalytic Therapy: Clinical Approach. International Journal of Psychoanalysis. 52: 431–439. With clarity and economy this author presents the controversy in psychoanalysis relative to the unique place of the dream in psychoanalytic theory and technique. He quotes a number of authors along the way, to specific effect. I recommend close scrutiny of this important piece. Ward, Ivan (ed.) (1993) Is Psychoanalysis Another Religion? Freud Museum Publications. Six analysts join ranks to examine this question. Neville Symington comes to the conclusion that it indeed is one, and goes on to explain. It is a natural religion, as opposed to a cultic one, since through pursuit of inner truth we shall gain health and happiness. I find myself differing from this thesis, in that the truth I seek is scientific, foremost, and religious as an adjunct. The myth of Narcissus is case in point: Narcissus passes through a shadow of death, to regain his own light and state of integrity. Weeks, H. A. 1958. Youthful Offenders at Highfields: An Evaluation of Effects of Short-Term Treatment of Delinquent Boys, Ann Arbor: University of Michigan Press. A group of authorities, academic and forensic, examine an application by McCorkle of the work done at Fort Knox. It came about as a response to judges who balked from assignment of adolescents to reformatories and training schools for youth they held redeemable. It was held on the former estate of Colonel Lindberg, and the youth stayed generally for three months, working in a nearby state hospital, attending the hour-long group sessions five days per week. It was designed to have a generalized constructive impact rather than an individualized treatment result, differing significantly from the work at Knox and Howard Hall. Weigert, E. 1970. The Courage to Love: Selected Papers of Edith Weigert. New Haven. Yale Univ. Press. My first analyst, Dr. Weigert, in her career displayed a wide range of interests, chiefly psychoanalytic. These included a piece on folie atrois, the signs of the zodiac, the termination of analysis, criminality, and issues in technique, including the counter transference. After five years of work with me, she transferred me to Dr. Rex Buxton. Both failed to adequately identify and attempt to analyze my narcissism, which finally gave way in my

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middle years with depressive counter-transference with several of my iconic cases. I infer that Dr. Weigert was edging towards comprehension of the counter-transference problem. Weiner, M. F. 1984. Techniques of Group Psychotherapy, Washington, D.C.: American Psychiatric Press. Dr. Weiner here presents a pragmatic approach to group therapy, ranging from advice and counseling, to evocative, insight oriented treatment. A chapter is devoted to a history and overview of a wide range of the group therapies, that includes Recovery, Inc., Synanon, also teaching and training aids. Whitaker, Dorothy S. and Lieberman, Morton A. 1964. Psychotherapy through the Group Process, New York: Atherton Press. In this valuable work Whitaker and Lieberman, starting with the psychoanalyst Thomas French’s focal conflict theory, approach group process in the microanalytic mode featured in This Way Out. Like Powdermaker and Frank they identify basic themes, “under progressively expanding cultural conditions.” They fail to identify the crises and resolution inherent to the cultural change. An important feature of this work, in its effort to arrive at a way of inquiring into group process, is a comprehensive and critical review of others, such as Bion, Ezriel, Powdermaker and Frank, Foulkes, Corsini, and a host of others. Wilmer, H. A. 1958. Social Psychiatry In Action: A Therapeutic Community, Springfield: Charles C Thomas. Wilmer patterned his meetings with the admission ward community at the Psychiatric Treatment Center at the Oakland Naval Hospital on those of Maxwell Jones, T. P. Rees, and T. F. Main, in England. The experiment went on for 10 months (July 1955 to April 1956). He cites its humanitarian utility, as well as usefulness to the staff, in the betterment of the patients. The patients were in flux, varied in number and capacity for collaboration. Personnel were trained by attendance at the meetings, which are described as humanizing. Wilmer cites his motives as stemming from a rescue situation in a mental hospital, and determination to counter the brutality of its personnel. His meetings were attended by large numbers of personnel, also visitors by naval officers, including Admiral Nimitz himself. Dr. Wilmer had larger aims to “humanize” Navy personnel practices, to alter the toll of psychiatric illness. He was assiduous in the study of his experience, dictating a note after each session, recording a number of them by film and tape, and devoting time to their study. Wolf, A. and Schwartz, E. K. 1962. Psychoanalysis in Groups, New York: Grune and Stratton. Alexander Wolf was the initiator of the group psychotherapy at Knox, its large and small groups, and its psychoanalytic bent. Under his leadership, the groups worked through its issues, leading to inquiry into the deeper issues of the individual, itself leading to character changes. But insufficient authoritarian aspects of his character led to difficulty with the prisoners leading to impasses, near riot, then his replacement. Lloyd McCorkle, who followed him in charge initiated what he termed guided group interaction, in which he exerted what he held was the necessary authority, in guiding the members to conform to the norms of group therapy, including issuing military commands. Somehow, the members found my interventions appropriately authoritative, engaging in the dynamics initiated by Wolf, down to working through to the individual dynamic mechanisms. Psychoanalysis in Groups is an exposition of Wolf’s theory and practice in treatment of individuals in his practice prior to and after his military service. First, he emphasizes the equality between therapist and person afforded by the group. Then he notes its advantage in reality testing. Not only that, but the group stimulates interpersonal communication as well as the intra-psychic communication of psychoanalysis. Moreover, he has his groups meet without him, for testing, exploring, and consolidating. It is cited as a specific for isolation and socialization. He sees the psychoanalyst of the future as giving up his isolation, eschewing the intra-psychic as “mystical abstractions,” and embracing the group dynamic in his practice. Yalom, I.D. 1983. Inpatient Group Psychotherapy, New York: Basic Books; (1985) The Theory and Practice of Group Psychotherapy, New York: Basic Books. This psychiatrist has contributed seminally to the field of group psychotherapy in inpatient and outpatient settings. His approach is active and interpersonal, with emphasis on guided inquiry into the here-and-now as demonstrated in the group dynamic, also carefully struc-

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tured feedback. Lower-functioning patients are placed in groups of non-exploratory or supportive nature. He generally also structures groups towards support and problem solving, avoiding psychoanalytic regression and decompensation. Yochelson, Samuel, and Samenow, Stanton. 1976. The Criminal Personality: Profile for Change, New York: Aronson. Yochelson and Samenow report on 15 years of research in the criminal personality at St. Elizabeth’s Hospital. They arrive at the thesis that inquiry on the part of the criminal into cause results in perpetuation of the disorder. Instead they focus on inducing the abandonment of the personality traits that lead to crime. This reeducation occurred in a conversion process “reluctant converts,” proceeding to systematic reeducation. The last was done outside the hospital, because of administrative problems with personnel. This is reminiscent of the problems with the attendants in the work in Howard Hall reported in This Way Out. In his groups the criminal presented his 24-hour phenomenologic report, and the inquiry extended to his thoughts as well as actions, in “microscopic attention,” leading to the person’s view of life. They cite the view of life as abstract, but it was an abstraction that was at the core of the individual’s problem with alienation. They assured the criminal that following their method would lead to the building of a meaningful life. This sounds similar to the implicit contract made in This Way Out. “Impeccable functioning” differed from later emphasis on responsible arrival at decisions more than the decision itself. Families were separately consulted for data, as privileged communication. It grows apparent that this work grew to resemble that reported in This Way Out, but it also differed markedly. Both strove to arrive at conceiving of the person’s life purposes, collaboratively, engaged through mutually arrived at idealism and state of mutual responsibility. The context of the work in time was separated from the hospital, because of failure to arrive at a state of mutual confidence. Eschewing insight led to handicap in the long term. And, despite the need for a certain degree of authoritarianism in a security bound situation, there appeared to be an excess here. That criminality is exposed and destroyed by rationality, and logic appears to be a delusion and snare. Unacknowledged messianism would more rationally be behind the project’s success.

Index

Abrahams, Elisabeth (wife), 220–234 Abrahams, father of, 2, 3, 144, 236, 293–294 Abrahams, mother of, 2, 4, 144, 235–236, 236, 293–294, 297 addiction: alcoholics, 188; in father’s rotting corpse case, 105, 108 Adonis, 149 advent phenomenon, 128, 141; in father’s rotting corpse case, 105; patients and, 238; troubled couples and, 197 Agnes-Bruce-Greig School, 93 Aichhorn, August, 9, 10, 91, 250, 294 alcoholics, 188 Alexander, Franz, 114 alienated individuals, 5; in couples, 203 alienation: of delinquents, 146; in father’s rotting corpse case, 110, 111, 112; Fort Knox rehabilitation center and, 238, 295, 296. See also self-alienation; specific cases alienation hypothesis, 159; individual psychotherapy and, 46; self, 5–6 Altman, L. L., 169 American Prison Association, 95; Congress of Correction, 96 American Psychoanalytic Association, 46, 64, 65, 89, 255; Board of Professional Standards and, 132; Dreams and Psychosis panel, 116; splits in, 208–209

analysis: self, 246. See also dream analysis; group analysis; psychoanalysis analyst: narcissism and training, 209. See also psychoanalyst analyst and patient, as couple. See troubled couples, category 3 analytic dream theory, 174 analytic group: in father’s rotting corpse case, 108–109. See also group analytic training: messianism as resistance in, 251–253. See also training Andrews family, 157–158 Antigone, 73, 152–153 Aphrodite, 149 Apollo, 149 Army, 236 ASH. See Atascadero State Hospital assault, at Atascadero State Hospital, 216, 217 Atascadero State Hospital (ASH), 100; assault, 216, 217; “Living in Reality” group, 213, 215; medications at, 218; overview (1990-1995), 211–212, 245; professional identity and professions at, 284–285; professional identity group analysis at, 284; remarks, 216–218; retirement from, 234; sex psychopaths at, 211, 215–216; therapeutic community, 215–216; Ward 10, 212–214; Ward 24, 215–216. See also 367

368

Index

psychosocial rehabilitation Atascadero State Hospital, A Study in Institutional Transformation: Therapeutic Community at Atascadero State Hospital, 213 Atascadero State Hospital, CQI experience: management analysis, 288–289; matrix management, 289–291; overview, 287–288, 291 autism: consultation on normalization of autistic children, 93; couples and autistic love, 201 Balint, Michael, 262–263, 264, 265, 273 Barr, Helen, 17, 139 Barrett, Edith, 28 Behan, Robert, 214, 287 Berl, Mildred-Elliot, 93 Berman, Leo, 65 Berne, Eric, 147, 253 Bethesda Naval Hospital consultation, 91 Bible, and dreams, 163, 164 Bill (patient), 177–179, 211 bipolar disorder, 105, 177, 178 Blain, Daniel, 211, 212 Blitzsten, N. L., 167 Bloom, S. W., 259–260, 264, 273 Board of Professional Standards (BOPS), 132, 209 borderland initiatives, 100 Bowen, Murray, 182–183, 183 California: mental health treatment in, 276; sabbatical, 141–144, 157, 239 career: career psychoanalysis, 245; early development, 2–6, 199; midlife career and crisis (1971-1989), 141–209; overview, 235, 245, 293; post retirement (1996 to present), 219–246 cases: reputation for impossible, 104. See also iconic cases; specific cases Charles D. Thomas publishers, 97 Chase, Mariane, 29 Checa, Patricia, 300 Cherry Street gang, 9 children: childhood messianism, 294; child-savior, 154; disturbed, 24–25, 93; dreams of, 166; early childhood, 2–4, 295; flower, 149; newborn and mother,

154; normalization of autistic, 93. See also family Chinese: Tiananmen Square, democracy and, 207–208; UCSD students and faculty, 207–208 Christ, Jesus, 153 cognitive processes: in dreams, 165, 170, 175, 176; Noy on, 171, 175; primary, 161, 162, 164, 165, 170, 171, 173, 176; secondary, 161, 164, 170, 171, 175 college, 4; psychiatric interviews during, 4–5 colloquy: on extended practice and iconic case 6, 220–234; Institute Round Table Colloquium, 132, 133–134, 134, 135 Columbia University, 13 commitment procedures, 25–26 community, therapeutic. See therapeutic community community of families: overview, 185. See also family community group community relationship workshop. See St. Elizabeth’s Hospital, community relationship workshop conferences. See psychoanalysis conferences Congress of Correction, 96 conjointly beating hearts, iconic case 5: depression in, 123; dreams in, 123, 124–126; marriage counseling in, 123–124; maternal introject in, 125, 126; overview, 123–126, 189 consultation: Bethesda Naval Hospital, 91; borderland initiatives, 100; Demonstration Counseling Program at national training school, 92; Durrell at NIMH, 91–92; Fairfax House, 93; Federal Prison Service project, 90–91; foreign professionals training, 99; hardened delinquents workshop, 94–98; on normalization of autistic and disturbed children, 93; overview, 90, 91; Pastoral Care Movement, 98–99; psychodramatic, 99 continuous quality improvement (CQI): methods, 288; overview, 287. See also Atascadero State Hospital, CQI experience

Index Convention Conference Forum, 132, 132–133 corpse, father’s rotting. See father’s rotting corpse, iconic case 4 Correctional Service Associates, 95, 97 correctional therapeutic community, 181 correctional treatment, of delinquents, 146 Council of Clubs, 205, 206–207 counseling, 276 counter transference, 253; messianism and, 227; overview, 227 couples: alienated individuals in, 203; autistic love of, 201. See also marriage couples group therapy, 182; troubled couples and, 192, 198, 238 couples therapy: weekend marathon, 196, 202. See also troubled couples The Courage to Love (Weigert), 144 cowboys, 4 CQI. See continuous quality improvement Cronus, 148, 149, 152 Cruvant, Bernard, 288 Cutter, Fred, 212 death: dreams, 251–252; Freud on, 153, 252–253; instinct, 252–253; in life of man, 153–155. See also psychic death deity. See gods delinquents: alienation of, 146; correctional treatment of, 146; hardened delinquents workshop, 94–98; World War II, 250. See also Fairfax House Del Mar Fair, 207 Dement, W., 116 Deming, W. Edwards, 214, 245, 287 democracy, 150; Tiananmen Square and, 207–208; workshop, 205–207 Democracy from the Grassroots: a Guide to Creative Politics (Abrahams), 143, 255 Demonstration Counseling Program consultation, 92 depression: in conjointly beating hearts case, 123; in father’s rotting corpse case, 106; phase of pilot course class group session, 270 despair, therapeutic, 128 developmental crisis, 237, 245

369

“The Development of Primary Process: A Structural View” (Holt), 170 diagnostic entities, and dreams, 168 discrepant situations, 192 discussion groups, psychoanalysis conference, 132, 133, 134, 135, 136, 137 disturbed children: consultation on normalization of, 93; facilities discussion in community relationship workshop, 24–25 doctor: social contract between patient and, 65–66. See also physician; therapist The Doctor, The Patient and The Illness (Balint), 262 A Doctor and His Patient (Bloom), 259–260 dream analysis, 156, 299; importance of, 160–164; manifest dream, 172–174; overview, 159–164; of patients, 160, 172–174; primary process cognition and, 173, 176 dreams, 143, 219; Alexander on, 114; Bible and, 163, 164; of children, 166; cognitive processes in, 165, 170, 175, 176; in conjointly beating hearts case, 123, 124–126; death, 251–252; Dement and Fischer on schizophrenia and, 116; diagnostic entities and, 168; divination, 159–160; ego and, 114, 115, 116, 117, 118–119, 120, 126–127; ego psychological theory and, 161, 162, 171, 176; Erikson and, 167, 175, 253; in father’s rotting corpse case, 106, 108; forgotten, 165; Freud and, 3, 113–114, 127, 159, 161, 162, 163, 164–167; gender and, 168; in iconic cases, 112; latent, 164, 166, 173, 175, 176; Noble on, 114; overview, 113–116; as problem-solving activity, 171; prodomal or precursory, 119; of psychic death, 239; Richardson and Moore on schizophrenia and, 115, 168; secondary revision of, 165–166, 176; sexual orientation and, 168; Talmud and, 163, 164; unconscious and, 161, 162, 164, 166; as wish fulfillment, 165. See also manifest dream

370

Index

dreams and psychosis: clinical aspects of, 113–116; dream study group, 122–123; ego in, 114, 115, 116, 117, 118–119, 120, 126–127; Freud on, 113–114; Jung on, 114; Katan on, 115; overview, 113; psychoanalysis and, 113; psychotic crisis, 119–121; study of natural history of, 116–117; summary and inferences, 126–127; survey of patients’, 116–119 dreams and psychosis, life course patterns: overview, 119; parents in, 120; psychotic crisis, 119–121 Dreams and Psychosis panel, 116 The Dream Specimen of Psychoanalysis (Erikson), 114, 160, 167, 253 dream study group: January 11, 1969, 122–123; overview, 122 dream theory, 162, 172, 175; analytic, 174; manifest dream and, 175, 176. See also dreams drive discharge hypothesis, 151 Drummond, Alan, 123 Dunavan, Craig, 207 Durrell, Jack, 91–92 dyad of psychoanalysis. See psychoanalytic dyad early separation trauma, iconic case 1: course in treatment, 50–60; overview, 46–50; recapitulation and formulation, 60–62; summary, 62–63 Echo, 145, 150, 153 education: college, 4, 236; early, 3, 4. See also medical education Eggan, Dorothy, 168 ego: dreams and, 114, 115, 116, 117, 118–119, 120, 126–127; Erikson on, 73, 75; Freud on, 153, 250, 253; in psychoanalytic therapeutic groups, 66; seele and, 250, 251, 253; in social contract, 65 ego ideal, 145; narcissism and, 145; resistive patients and, 147–148 ego psychological theory, 161; dreams and, 161, 162, 171, 176 Eichorn, August, 244 Eickstein, Rudolph, 230 Eissler, K. R., 167 Eissler, R. S., 167

Emmy Von N, 164 Emory Medical School, 4 Enneis, James, 99 entities: dreams and diagnostic, 168; psychologic, 195; transaction as unity of intersecting, 195 epiphany, inspired by prisoner, 5, 12, 14 Erikson, Erik H., 73, 75, 264; dreams and, 167, 175, 253; The Dream Specimen of Psychoanalysis of, 114, 160, 167, 253; on identity, 260 Escribens, Augusto, 295, 296, 297, 299, 300 executives, 290–291 extended practice: colloquy on, 220–234; forms of, 227; uniqueness of, 225 Fairfax House consultation: hardened delinquents workshop, 94–98; overview, 93 family: Flugel on, 181; Freud on Primal Horde, 180–181; oedipal family system, 181; psychoanalysis of, 181. See also children; parents; troubled families family community group, 185; crises of, 180; example, 184; at Hanbleceya, 179, 184; NIMH, 182; overview, 179–180, 182, 188–189; psychoanalytic dyad and, 179; session 52, 185–187; session 59, 187–189. See also multiple family therapy family group: roles in pilot course class group session, 270. See also family community group family group therapy, 204. See also family community group; multiple family therapy family therapy, 227; in father’s rotting corpse case, 227; messianism in, 234 fantasy life, 3 Farber, Les, 128 fascism, 236 fascist personality, 155 father: of Abrahams, 2, 3, 144, 236, 293–294; Hamlet’s, 147, 195; Primal Father, 148, 149; transference, 147 father’s ghostly face case, iconic case 2, 63–64, 202

Index father’s rotting corpse, iconic case 4: addiction in, 105, 108; advent phenomenon, 105; alienation in, 110, 111, 112; analytic group in, 108–109; bipolar disorder in, 105; conclusions, 112; depression in, 106; discussion, 111–112; dreams in, 106, 108; family therapy in, 109; father’s death in, 105, 106, 108, 109; marriage counseling in, 107, 108, 109; narcissism in, 108, 109; overview, 104, 105–110, 194–195, 238–239, 299; psychopathology in, 105; suicide in, 105, 106, 107, 112; summary of treatment, 110–111; therapeutic alliance in, 107, 111; therapeutic community and, 107, 111; transference in, 108, 110; wife in, 106–107 Federal Prison Service, 95, 97; project, 90–91 “Figure It Out” film strip series, 11 Fischer, C., 116 Fitzpatrick, Moira, 189, 232 flower children, 149 Flugel, J. C., 181 foreign professionals training, 99 Fort Knox rehabilitation center, 94, 100, 200, 252, 284, 288; alienation and, 238, 295, 296; epiphany inspired by prisoner at, 5, 12, 14; Federal Prison Service project, 90–91; “Figure It Out” film strip series, 11; as group therapist at, 8–10, 10–11; as individual therapist at, 10; intuitive connectedness and, 250; McCorkle and, 8, 42, 138, 142, 250, 294, 295; overview, 236–237, 237, 238, 245, 250–251, 294–295; psychopaths’ treatment at, 1, 9–10, 10–11, 11, 12, 13–14, 200, 294; seminal work at, 8–11, 12, 12–13; in This Way Out, 213, 255; troubled couples and, 128; VJ day riot, 12, 296; World War II duty at, 8–13 Francis. See Messiah in helicopter, iconic case 6 Frank, Jerome, 28, 29 French, T. M., 114 Freud, Sigmund, 9, 14, 20–21, 89, 239, 251, 294, 299; on death, 153, 252–253;

371

dreams and, 3, 113–114, 127, 159, 161, 162, 163, 164–167; drive discharge hypothesis of, 151; early circle of, 131; on ego, 153, 250, 253; Group Psychology and Analysis of the Ego of, 127, 144; The Interpretation of Dreams of, 113, 159, 161, 162, 163, 164, 165, 166; manifest dream and, 164, 166, 167; messianism and, 250; metapsychology of, 151; Oedipal myth and, 152; on Primal Father, 148, 149; on Primal Horde, 180–181; on psychosis and dreams, 113–114; on psychotics, 225–226; on seele, 249, 250, 253; soul and, 153, 220, 249, 250, 253 Freudian transference, 143. See also transference Frey, Lavonne, 17, 139 Fromm, Erich, 171 Fromm-Reichmann, Frieda, 14, 35, 46, 156, 238 Fry, Lavonne, 237 Galvin, John, 94 gender, and dreams, 168 George Washington University Hospital of Psychiatry, 201 George Washington University Medical School, 139 German, Michael, 212 Germany, and Nazism, 155 ghost of mother, iconic case 3, 104 Giovacchini, P. L., 170 Goddess of Democracy, 207 gods: man and, 239; Narcissus myth as sacrifice to, 148; Primal Father as, 149. See also specific gods Greek democracy, 150 Greek myths: about ideal youths’ deaths, 148; Narcissus myth and, 148. See also specific Greek myth gods Greek Symposium, 133 Gregorian, Haikaz, 138, 139 group: life and individual, 144; modalities, 251. See also specific groups group, class. See pilot course, class groups group analysis: professional identity, 245, 284–285. See also group therapy

372

Index

group analytic therapy, 147, 227. See also group therapy group and individual psychoanalysis combined, 240; analysis of session 50, 85–88; comment, 74–75; effectiveness of, 222, 223–224, 224–225, 226–227; group course, 75–89; group members, 66–75; initial phase, sessions 1-8, 75–80; overview, 64–65, 246; part I, 65–66; phase of beginning transferences, sessions 8-40, 80–82; research design, 89–90; session 50, 84–88; summary, 88–89; working through relationship cycles, sessions 40-49, 82–83 Group for the Advancement of Psychiatry, 262, 264 group psychoanalysis, 104; therapist’s approach in, 65–66; Washington Psychoanalytic Institute and, 244. See also group and individual psychoanalysis combined Group Psychology and Analysis of the Ego (Freud), 127, 144 group psychotherapy. See group psychoanalysis group psychotherapy research project. See VA group psychotherapy research project group therapist: at Fort Knox rehabilitation center, 8–10, 10–11; at Warner Springs Rehabilitation Hospital, 8 group therapy, 142; as authority in, 14; couples, 182, 192, 198, 238; group analytic therapy, 147. See also group treatment group treatment, 1, 251; of schizophrenics, 156, 238. See also group therapy group work training program, St. Elizabeth’s Hospital, 16, 20, 22, 142, 147 guilt, oral, 127 Hadley, Ernest, 141, 160 Hall, Howard, 213 Halperin, Alexander, 14, 244 Hamlet’s father, 147, 195 Hanbleceya, 143, 159, 232, 233; community of families, 185; overview,

184, 189–190; patient Bill, 177–179, 211. See also family community group hardened delinquents workshop: opening remarks, 94–98; overview, 94 Hawkins, D. R., 174 hearts, conjointly beating. See conjointly beating hearts, iconic case 5 Hebrew lessons, 3 Helperin, Alexander, 200 Hera, 150 historical regression, 154 history: interest in, 3, 42–43; psychic death and, 155; of revolutions, 3, 42–43 Hitler, Adolf, 155 Holt, Robert, 170 Howard Hall, 15, 99, 100, 142, 156, 199, 237, 296; overview, 237. See also St. Elizabeth’s Hospital Hyacinthus, 149 iconic cases: conjointly beating hearts (case 5), 123–126, 189; dreams in, 112; early separation trauma (case 1), 46–63; father’s ghostly face (case 2), 63–64, 202; father’s rotting corpse (case 4), 104, 105–112, 194–195, 238–239, 299; ghost of mother (case 3), 104; last, 234; Messiah in helicopter (case 6), 158–159, 227–234; overview, 241–244; troubled couples, 128–129 idealism, 146 identity: Erikson on, 260; literature review of concept of, 260–261. See also professional identity Ikeda, Yoshiko, 99 individual: alienated, 5, 203; group life and, 144; psychoanalysis and, 130. See also self individual psychoanalysis, 104. See also group and individual psychoanalysis combined; individual psychotherapy; specific cases individual psychotherapy: alienation, reconciliation, messianism and transference hypotheses and, 46; category 2 troubled couples and, 197–198. See also individual psychoanalysis

Index individual therapist, at Fort Knox rehabilitation center, 10 individual treatment study, 1–2 Institute Round Table Colloquium, 132, 133–134, 134, 135 The Integration of Behavior, Vol. II (French), 114 Integration of Personality (Jung), 114 internal dialogue, 221 International Journal of Psychoanalysis, 171, 175 international psychoanalytic organization, 209 The Interpretation of Dreams (Freud), 113, 159, 161, 162, 163, 164, 165, 166 intimacy: category 3 troubled couples, natural history and, 198–204; of transaction, 199 introject: theory of introjection, 205. See also maternal introject introject drama, iconic case 6. See Messiah in helicopter, iconic case 6 intuition, 300; intuitometer and, 294 intuitive connectedness, 245, 246; Fort Knox rehabilitation center and, 250; seele and, 250–251 intuitometer, 234, 237; intuition and, 294; overview, 294, 297, 297–298; presentation, 293–300 Jaekle, Charles, 98, 99, 252 Joan of Arc, 153 Johnson, Lyndon, 92 Joint Commission on Accreditation of Healthcare Organization, 282 Journal of American Psychoanalytic Association, 65 Journal of Medical Education, 138 Jung, Carl G.: on dreams and psychosis, 114; Integration of Personality of, 114 Kassof, Arthur, 92, 95 Katan, M., 115 Kernberg, Otto, 214 Kiernan, W. E., 183 king’s reality, 149 Klein, George, 171, 253 Kris Study Group, 115, 169 Kushner, Edward, 129

373

Laboratory Symposium Lecture, Classroom, 132, 135–136 La Jolla: Democratic Club, 205; midlife career and crisis (1971-1989), 141–209; practice, 141, 143, 144, 157; Republican Club, 205 language, in psychoanalysis, 220 “The Large Group in Group Psychotherapy” project: commentary on, 44; discussions with thematic continuity, meetings 12-15, 40–41; meetings 16 to final, 41–42; overview, 29–30, 37; sessions 1-5, 37–38; sessions 6-11, 38–40 latent dream, 164, 166, 173, 175, 176 life: myth and, 154. See also death Linder, Robert, 230 literature: contribution to psychoanalytic, 255; multiple family therapy review of, 179–184; professional identity of medical students, review of, 259–265 “Living in Reality” group, 213, 215 Lorand, Sandor, 163 man: death in life of, 153–155; gods and, 239 management: ASH CQI experience and, 288–291; executives, professionalism and, 290–291; mental health facilities’ professionalism and, 280–283, 289–290 manifest dream, 165, 167; Altman on, 169; analysis, 172–174; dream theory and, 175, 176; Erikson and, 167; Freud on, 164, 166, 167; Giovacchini on, 170; Kris Study Group on, 169; “On the Manifest Dream in Schizophrenia”, 115; overview, 161, 162–163, 177; studies of, 168, 168–170, 171–172 marathon, weekend, 196, 202 marriage, 192; as real, 202. See also couples marriage counseling: in conjointly beating hearts case, 123–124; in father’s rotting corpse case, 107, 108, 109. See also troubled couples seminar Mary Magdalene, 71 Maternal Dependency and Schizophrenia: Mothers and Daughters in an Analytic Group, 29, 182, 238, 245, 255. See also

374

Index

VA group psychotherapy research project maternal introject, 127; conjointly beating hearts case and, 125, 126 McCorkle, Lloyd W., 43, 89, 93; Fort Knox rehabilitation center and, 8, 42, 138, 142, 250, 294, 295; National Training School and, 96, 98 medical detachment leadership, 7–8 medical education: changes in, 264; literature review of process of, 260–261 medical schools: Emory, 4; George Washington University, 139; San Diego, 156; UCSD, 156, 207, 208. See also psychoanalytic institutes medical staffs, vs. governing bodies, 281 medical students. See professional identity of medical students medications: at Atascadero State Hospital, 218; usage, 218 medicine: literature on nature of profession of, 259–260; military, 236; physician and changes in, 141 mental health: facilities’ professionalism and management, 280–283, 289–290; society and field of, 130; treatment in California, 276 mental health organizations, 282; professionals vs., 282–283; as unbalanced, 289 mentors, 236; Washington Psychoanalytic Institute, 200 Messiah in helicopter, iconic case 6, 158–159, 227–234 The Messianic Imperative: Curse or Savior? (Abrahams), 255 messianism, 43, 122, 138, 142, 147, 203, 239, 297, 300; childhood, 294; counter transference and, 227; in family therapy, 234; Freud and, 250; hypothesis and individual psychotherapy, 46; in Messiah in helicopter, iconic case 6, 231, 233; messianic mutuality, 232; mutative relationships and, 252; narcissism and, 251; overview, 250; of physician professional identity, 204; psychoanalysis’ essential nature and, 249–253; of psychopath, 11; as

resistance in analytic training, 251–253; in self-alienation hypothesis, 6; soul and, 250; transference and, 238; troubled couples and, 128. See also specific cases metapsychology: of Freud, 151; psychoanalysis and, 151 Meza, Cesar, 99 military medicine, 236 Miller, George L., 9, 10, 11, 91, 96, 250, 288, 294 Minerva, 69 Moore, R. A., 115, 118, 168 Moreno, Jacob, 99 mother: of Abrahams, 2, 4, 144, 235–236, 236, 293–294, 297; newborn child and, 154 mother ghost case. See ghost of mother, iconic case 3 mothers and schizophrenic daughters group, 252; commentary, 34–37; mother-daughter couplings, 31–34; naming of participants, 31; overview, 29, 30–31, 146, 182, 238 multifamily group. See family community group multiple family therapy, 227; Bowen and, 182–183, 183; overview, 204, 238; review of literature of, 179–184 multiple family therapy community. See family community group mutuality: messianic, 232; pseudomutuality, 196, 201 mysticism, 234 myth: life and, 154; Oedipal, 152; overview, 152, 239; personality and, 149; psychic development and, 148; role assumption, 264; science and, 152, 153; soul and, 153; theory and, 151, 152. See also Narcissus myth; specific characters of myth narcissism, 142, 203; ego ideal and, 145; in father’s rotting corpse case, 108, 109; malignant, 214; messianism and, 251; Narcissus myth and, 145, 148; theory, 149; training analyst and, 209; transference and, 147

Index Narcissus myth: Echo in, 145, 150, 153; Greek myths about ideal youths’ deaths and, 148; narcissism and, 145, 148; Oedipus and, 145, 152–153; overview, 145–153, 239; reality and, 149; as sacrifice to gods, 148; scientists and, 151; self and, 145, 146, 148, 149, 149–150, 151; soul in, 153; Tiresias the Seer in, 149, 150 National Institute of Mental Health (NIMH): consultation with Durrell, 91–92; family community group, 182 National Psychoanalytic Association, 209 National Training School for Boys: Demonstration Counseling Program consultation, 92; hardened delinquents workshop and, 94–98; McCorkle and, 96, 97 natural history: category 3 troubled couples, intimate ties and, 198–204; of dreams and psychosis study, 116–117; of pilot course class groups, 268–274 Nazism, 155 newborn child, and mother, 154 New York City College, 4 NIMH. See National Institute of Mental Health Noble, Douglass, 114, 117, 118, 122 nosology, 168 Noy, Pinchas, 161; on cognitive processes, 171, 175 Oberholzer, Dr., 237 oedipal family system, 181 Oedipal myth, 152; Freud and, 152 oedipal struggle, 180 Oedipus, 145, 153; Narcissus myth and, 145, 152–153 Oedipus complex, 152 “On the Manifest Dream in Schizophrenia” (Richardson and Moore), 115 oral guilt, 127 Overholster, Winfred, 15, 288 Panel on Combined Individual and Group Psychoanalysis, 64. See also group and individual psychoanalysis combined parapsychology, 299

375

parents: in dreams and psychosis life course patterns, 120. See also family A Passionate Psychoanalyst: Poems and Dreams (Abrahams), 255 Pastoral Care Movement consultation, 98–99 Pastoral Counseling and Consultation Centers of Greater Washington, 98, 252 patient and analyst, as couple. See troubled couples, category 3 patients: advent phenomenon and, 238; Bill, 177–179, 211; care discussion in community relationship workshop, 22–23, 24; dream analysis of, 160, 172–174; early private practice patient population, 45–46; ego ideal and resistive, 147–148; personal identification with, 43–44; sitting with, 220; social contract between doctor and, 65–66; toilet dreaming, 222–225; with writer’s block, 128, 193. See also cases patients’ dreams and psychosis survey: comment, 118–119; overview, 116–118 Pauloff, Michael, 28 penology, 12–13 Perry Point Veterans Administration Hospital, 37, 43 Persephone, 149 personality: fascist, 155; malign, 237; myth and, 149 Peruvian Psychoanalytic Society, intuitometer presentation, 293–300 physician: changes in medicine and, 141; messianism of professional identity of, 204. See also doctor; therapist pilot course, class groups: development of, 267; natural history outline of, 268–274; summary, 273 pilot course, class group sessions: Assumption of Counseling and Familial Group Roles (XVII-XXI), 270; Depressive Phase (XII-XVI), 270; Exemplification and Personification of Issues (XXII-XXV), 272; Last Session (XXVI), 272–273; Mini-Marathon Four Hours (XVIII), 270–271; SelfDefinition as Group (I-V), 268–269; Self-Definition by Group (VI-X),

376

Index

269–270 pilot course on professional identity of medical students: formation of, 265–267; overview, 138–140, 141; summary, 274. See also pilot course, class groups “A Plenary Workshop”, 129–131 poetry, 219 politics, 143–144, 156; Council of Clubs, 205, 206–207; democratic workshop, 205–207; overview, 205–207, 244; professional identity training, 206, 244 Popper, Karl, 261, 264 Powdermaker, Florence, 13, 28, 29, 30 Powell, John Walker, 16 practice. See psychoanalytic practice precursory dream, 119 Primal Father, 148, 149 Primal Horde, 180–181 primary process cognition, 161, 162, 164, 165, 176; dream analysis and, 173, 176; Holt on, 170; Noy on, 171, 175 private practice: early (1950-1960), 15–100, 103; La Jolla, 141, 143, 144, 157; later (1960-1970), 100, 103–140; patient population of early, 45–46; post Atascadero, 234. See also psychoanalytic practice; Washington practice “The Problem of Ego Identity” (Erikson), 73, 75 prodomal dream, 119 profession: ASH professional identity and, 284–285; compared to occupation or job, 282–283 professional: mental health organizations vs., 282–283; staff training at St. Elizabeth’s Hospital, 17–18, 139, 142, 284; training of foreign, 99 professional identity: ASH professions and, 284–285; group at St. Elizabeth’s Hospital, 16, 17, 17–20, 237–238; literature review of concept of, 260–261; messianism of physician, 204; training of politicians, 206, 244 professional identity group analysis, 245, 255; at Atascadero State Hospital, 284; in professional development, 284–285

professional identity of medical students: background considerations, 259–265; overview, 257–258. See also pilot course on professional identity of medical students professional identity of medical students, literature review categories: concept of identity and professional identity, 260–261; innovations in training, 262–265; nature of profession of medicine, 259–260; overview, 259; process of medical education, 261–262 professionalism: executives, management and, 290–291; mental health facilities’ management and, 280–283, 289–290; teamwork as solution to threats to, 283–284 Prometheus, 152 pseudo-mutuality, 196, 201 PSR. See psychosocial rehabilitation psychiatric interviews, during college, 4–5 psychiatrists: psychologists vs., 282; during World War II, 7 psychiatrist training: discussion in community relationship workshop, 23–24; after World War II, 13–14 psychic death, 154, 155, 245, 252; dream of, 239; history and, 155 psychic development, and myths, 148 psychic evidence, 6 psychoanalysis: career psychoanalysis, 245; dreams, psychosis and, 113; as event, 221; of family, 181; growth crisis in, 144–145; individual and, 130; internal dialogue and, 221; language in, 220; messianism and essential nature of, 249–253; metapsychology and, 151; method applied to allied fields, 244; overview, 1, 180, 201, 221–222, 249, 276; San Francisco, 219; schism and splits in, 208–209; soul and, 250; standard, 46, 141; training after World War II, 13–14; with Weigert, 144, 156; with Weinshel, 217. See also group psychoanalysis; psychotherapy; individual psychoanalysis psychoanalysis conferences: appropriate planning, 137; Convention Conference Forum, 132, 132–133, 135; co-

Index responsibility principle for, 136–137; discussion groups, 132, 133, 134, 135, 136, 137; diversity of, 132; elements of successful, 136–137; Institute Round Table Colloquium, 132, 133–134, 134, 135; Laboratory Symposium Lecture, Classroom, 132, 135–136; lecture groups, 132, 135–136; overview, 132, 136–137; respect for autonomy of, 136; review on dynamics of, 132–138; society and, 132; symposiums, 132, 134, 136; Workshop Panel Discussion Seminar, 132, 133, 134, 136, 137; workshops, 132, 133, 134, 135, 137, 138 psychoanalyst: society and, 129–132. See also analyst psychoanalytic career. See career psychoanalytic dyad: family community group and, 179. See also therapeutic dyad psychoanalytic institutes: schism over teaching, 208. See also San Diego Psychoanalytic Institute; Washington Psychoanalytic Institute psychoanalytic literature, contribution to, 255 psychoanalytic organization, international, 209. See also psychoanalytic institutes psychoanalytic practice, 1; future of, 244–245. See also extended practice; private practice; Washington practice psychoanalytic retreat (1987), 208–209 The Psychoanalytic Study of the Family (Flugel), 181 psychoanalytic theory, 145, 148, 180; overview, 249. See also psychological theory psychoanalytic therapeutic groups, and ego, 66 psychodramatic consultation, 99 psychological theory: ego psychological theory, 161, 162, 171, 176. See also psychoanalytic theory psychologic entity, 195 psychologists, vs. psychiatrists, 282 psychology: metapsychology, 151; parapsychology, 299; soul and, 153

377

psychopathology, in father’s rotting corpse case, 105 psychopaths, 143, 211; Atascadero State Hospital and sex, 211, 215–216; messianism of, 11 psychopaths treatment, 235; at Fort Knox rehabilitation center, 1, 9–10, 10–11, 11, 12, 13–14, 200, 294; Roosevelt and, 294 psychosis: Freud on, 225–226; transference and, 226. See also dreams and psychosis psychosocial rehabilitation (PSR): definition, 276–278; overview, 275; treatment improvement project model, 278–280 psychotherapy: overview, 276. See also psychoanalysis; individual psychotherapy reality: of king, 149; Narcissus myth and, 149 reconciliation: hypothesis and individual psychotherapy, 46; overview, 5 Redle, Fritz, 94 regression, historical, 154 rehabilitation: discussion in community relationship workshop, 26; transformative process and, 10. See also Fort Knox rehabilitation center; psychosocial rehabilitation resistance: analytic training and messianism as, 251–253; to transference, 196, 222, 223 revolutions, history, 3, 42–43 Richardson, G. A., 115, 118, 168 Ritter, Sand, 212 Roland, A., 174, 175 Rood, Dr., 211–212, 287 Roosevelt, Eleanor, 294 Rosen, John, 43, 230 Rosenblatt, A. D., 175 Rubenfeld, S., 96, 97, 98 Russia, 145 sabbatical, California, 141–144, 157, 239 San Diego: Central Democratic Committee, 206; Council of Clubs, 205, 206–207; medical school, 156

378

Index

San Diego Psychoanalytic Foundation, 239 San Diego Psychoanalytic Institute, 141, 143, 206, 239; overview, 156–157; psychoanalytic retreat (1987), 208–209 San Diego Psychoanalytic Society, 208, 239 Saul, Leon, 168 Saunders, David, 214 savior, child, 154 schizophrenia, 200; Dement and Fischer on dreams and, 116; group treatment, 156, 238; “The Large Group in Group Psychotherapy” project and, 29–30, 37–42; mothers and schizophrenic daughters group, 29, 30–37, 146, 182, 238; Richardson and Moore on dreams and, 115, 168 Schultz, Clarence G., 123 science: myth and, 152, 153; Narcissus myth and, 151 screen identifications, 47 Searles, Harold, 28 secondary process cognition, 161, 164, 170, 171, 175 secondary revision, of dreams, 165–166, 176 seele (soul): ego and, 250, 251, 253; Freud on, 249, 250, 253; intuitive connectedness and, 250–251. See also soul self: Narcissus myth and, 145, 146, 148, 149, 149–150, 151. See also individual self-alienation, 3 self-alienation hypothesis: messianism in, 6; overview, 5–6; reconciliation corollary, 5; transference in, 6. See also alienation hypothesis self-amelioration, 5 self-analysis, 246 self-definition: as group, 268–269; by group, 269–270 separation. See early separation trauma, iconic case 1 sex: orientation and dreams, 168; psychopaths at Atascadero State Hospital, 211, 215–216 Shaw, Clifford, 8, 250 Small Group Teaching in Psychiatry for Medical Students, 262

social contract: between doctor and patient, 65–66; ego in, 65 society: mental health field and, 130; psychoanalysis conferences and, 132; psychoanalyst and, 129–132 sociology training, after World War II, 13, 14 soul, 252; Freud and, 153, 220, 249, 250, 253; messianism and, 250; myth and, 153; in Narcissus myth, 153; psychoanalysis and, 250; psychology and, 153. See also seele spirituality, 234, 250, 251 staff: governing bodies vs. medical, 281; St. Elizabeth’s Hospital’s training of professional, 17–18, 139, 142, 284 Stalin, Joseph, 145 Stanton, Alfred, 65 St. Elizabeth’s Hospital, 13, 99, 100, 181, 182, 288; groups, 16; group work training program, 16, 20, 22, 142, 147; Howard Hall, 15, 99, 100, 142, 156, 199, 237, 296; overview, 15–16, 296; professional identity group, 16, 17, 17–20, 237–238; therapeutic community, 16; training of professional staff, 17–18, 139, 142, 284; workshop observations on professional identity group, 18–20 St. Elizabeth’s Hospital, community relationship workshop: commitment procedures discussion, 25–26; conclusions, 28; disturbed children facilities discussion, 24–25; further patient care discussion, 24; group discussion, 26–27; overview, 21–22; patient care discussion, 22–23; psychiatrist training discussion, 23–24; rehabilitation discussion, 26; summary, 27–28 students: UCSD Chinese, 207–208. See also professional identity of medical students sublimation, 251 suicide, in father’s rotting corpse case, 105, 106, 107, 112 Sullivan, Harry Stack, 14, 21, 46, 122, 189, 200, 206, 253, 297, 300

Index symposiums: Greek Symposium, 133; psychoanalysis conference, 132, 134, 136 Szasz, Thomas, 261, 264, 273 Szymanski, L. S., 183 Talmud, and dreams, 163, 164 Tartaglino, Frank, 288 teamwork, and professionalism, 283–284 teenage years, 3 theory: building, 150, 151; development review, 240–241; introjection, 205; myth and, 151, 152; narcissism, 149. See also dream theory; psychoanalytic theory therapeutic alliance, in father’s rotting corpse case, 107, 111 therapeutic community, 227, 251; Atascadero State Hospital, 215–216; correctional, 181; father’s rotting corpse case and, 107, 111; George Washington University Hospital of Psychiatry, 201; overview, 276; Ward 10, 212–214. See also Hanbleceya therapeutic despair, 128 therapeutic dyad, 195. See also psychoanalytic dyad therapeutic groups: ego and psychoanalytic, 66. See also group therapy therapist: approach in group, 65–66. See also group therapist; individual therapist therapy: mysticism in, 234; operational definition, 276. See also family therapy; group therapy; psychotherapy; specific therapy topics Thickstun, J. T., 175 This Way Out: A Narrative of Therapy With Psychotic and Sexual Offenders (Abrahams), 213, 255 Thorazine, 218 Thorpe, James, 92, 94, 95 3000 Connecticut, 15 Tiananmen Square, 207–208 Tiresias the Seer, 149, 150 training: analysts and narcissism, 209; foreign professionals, 99; literature review of innovations in, 262–265;

379

messianism as resistance in analytic, 251–253; politician professional identity, 206, 244; post World War II sociology, 13, 14; St. Elizabeth’s Hospital group work training program, 16, 20, 22, 142, 147; St. Elizabeth’s Hospital professional staff, 17–18, 139, 142, 284; treatment programs and, 138; at Washington Psychoanalytic Institute, 20–21, 44–45, 297. See also National Training School for Boys; psychiatrist training; psychosocial rehabilitation transaction: Berne and, 147, 253; closed, 201; Deming and, 245; intimacy of, 199; as unity of intersecting entities, 195 transference, 21, 64, 66, 68, 80–82, 122, 253; counter, 227; father, 147; in father’s rotting corpse case, 108, 110; Freudian, 143; hypothesis and individual psychotherapy, 46; messianism and, 238; narcissism and, 147; overview, 196, 222; psychosis and, 226; resistance to, 196, 222, 223; in self-alienation hypothesis, 6; troubled couples and, 196. See also specific cases transformative process, and rehabilitation, 10 treatment: California mental health, 276; delinquents’ correctional, 146; group, 1; of impossible cases, 104; individual treatment study, 1–2; programs and training, 138; untreatables, 1. See also psychopaths treatment; specific cases and treatment topics troubled couples, 104; advent phenomenon and, 197; couples group therapy and, 192, 198, 238; Fort Knox rehabilitation center and, 128; iconic cases, 128–129; messianism and, 128; overview, 190–191, 204–205; pseudo-mutuality, 196, 201; record keeping, 191; transference and, 196; weekend marathon, 196, 202 troubled couples, category 1: illustrative history of, 191–197; overview, 191 troubled couples, category 2: individual psychotherapy and, 197–198; overview,

380

Index

191; per se treatment of, 197–198 troubled couples, category 3: natural history, intimate ties, 198–204; overview, 191 troubled couples seminar: commentary, 129; overview, 128–129. See also marriage counseling troubled families, 104; Andrews family, 157–158 Twain, David, 97 UCSD. See University of California, San Diego unconscious, and dreams, 161, 162, 164, 166 University of California, San Diego (UCSD): Chinese students and faculty of, 207–208; Del Mar Fair, 207; Goddess of Democracy, 207; medical school, 156, 207, 208 untreatables, 1 VA. See Veterans Administration VA group psychotherapy research project: commentary on, 42–45; “The Large Group in Group Psychotherapy” project, 29–30, 37–42; mothers and schizophrenic daughters group, 29, 30–37, 146, 182, 238; overview, 28–30 Varon, Edith, 29 Veterans Administration (VA), 13, 14. See also VA group psychotherapy research project Veterans Administration Hospital, Perry Point, 37, 43 Vision Quest therapeutic community, 143 VJ day riot, 12, 296 Wallerstein, Dr., 217–218 war: neurosis, 8; World War I, 155. See also World War II Ward 10, 212–214 Ward 24, 215–216 Warner Springs Rehabilitation Hospital, 8 Warren, Earl, 211

Washington Center for Psychoanalysis, 132 Washington practice, 1, 2, 45, 142; early (1950-1960), 15–100, 103 Washington Psychoanalytic Institute, 14, 15, 46, 103, 129, 209, 238, 239; conflict between conservative and liberal members, 103; group psychoanalysis and, 244; “A Plenary Workshop” on problems of, 129–131; training at, 20–21, 44–45, 297; trouble to mentors at, 200; Washington Center for Psychoanalysis and, 132; workshop method and, 239–240 Washington School of Psychiatry, 14, 15 Wayward Youth (Aichhorn), 9, 10, 91, 294 weekend marathon, 196, 202 Weigert, Edith, 14; The Courage to Love, 144; psychoanalysis with, 144, 156 Weinshel, Luis, 217 Wineshel, Lewis, 200 Winne, Lyman, 196, 201 Wolf, Alexander, 8, 94, 199, 294 workshop: democratic, 205–207; hardened delinquents workshop, 94–98; method and Washington Psychoanalytic Institute, 239–240; “A Plenary Workshop”, 129–131; psychoanalysis conference, 132, 133, 134, 135, 137, 138. See also St. Elizabeth’s Hospital, community relationship workshop Workshop Panel Discussion Seminar, 132, 133, 134, 136, 137 World War I, 155 World War II, 155, 181; delinquents, 250; duty at Fort Knox rehabilitation center during, 8–13; medical detachment leadership, 7–8; postwar training, 13–14; psychiatrist, 7 writer’s block patient, 128, 193 Yokelson, Leon, 15, 201 Young, W. W., 42 Zeus, 148, 149, 150