On the Mechanisms of Addiction

We conceptualize addiction in terms of what we call “addictive trigger mechanisms,” or “ATMs”. We define an ATM as any substance (e.g., alcohol, drugs, or food), behavior (e.g., compulsive eating or gambling), or person with whom one is obsessively attached. An ATM functions as an archaic selfobject and produces a dissociative alteration of self-experience involving the unconscious organization of subjective awareness by archaic narcissistic fantasies and moods of narcissistic bliss. In other words, from our selfpsychological perspective, we view the addict as addicted to a selfobject experience of fantasy and mood triggered biochemically, physiologically, or psychologically by an ATM.

On Trauma and Pathogenesis

Parents who repeatedly rebuff the child's primary selfobject needs are usually not able to provide attuned responsiveness to the child's emotional reactions. The child perceives his painful reactive feelings are unwelcome or damaging to the caregiver and must be defensively sequestered in order to preserve the needed bond. Under such circumstances these walled off painful feelings become a source of lifelong inner conflict and vulnerability to traumatic states, and in analysis their re exposure to the analyst tends to be strenuously resisted.

The "Double Injury" of Childhood Trauma

In Confusion of Tongues (1932), Ferenczi describes trauma of child sexual abuse as a *double injury*: first, the child is overwhelmed by the intrusion of adult sexuality; second, and even more damaging, the child’s reality is betrayed when their protest or suffering is denied, dismissed, or punished. This second wound forces the child to disown their own experience and often to identify with the aggressor, leaving lasting psychological scars.

My Approach to Psychotherapy and Psychoanalysis

Although I was originally trained in classical psychoanalysis, I have found that contemporary approaches are more effective. In particular, I draw on Heinz Kohut's Self Psychology and its evolution into Intersubjective Self Psychology, as developed by thinkers such as Robert Stolorow, Bernard Branchaft, George Atwood, Peter Zimmermann, as well as the contributions of Thomas Ogden, Stephen Mitchell, Owen Renik, and Christopher Bollas. When integrated with mindfulness practices insights from neuroscience, this framework is profoundly effective.

On Depression

"Endogenous depression is a myth, a psychiatric fantasy - not a reality. Every depression is caused by something depressing that has happened, with no exceptions. Sometimes though people don’t know what it is, or don’t want to know what is causing them to feel so bad. It is a paradox that human beings will plummet into deadly moods and all the while be avoiding or unable to look at what it is that has brought them there. Naive observers examine someone’s life and see none of the standard precipitants in the advent of depression – loss, disappointment, failure - and then - crudely, stupidly - draw the conclusion that it has arisen “from within,” endogenously, by which they usually mean from within the neurochemical environment of the person’s brain. Strangely enough, the patient will often cling to such an explanation, because the depression was actually experienced as “coming from nowhere,” as having no connection to the person’s present or past circumstances. What that means though is that the depression has been somehow stripped of its context – of depressing things happening – and the first step in helping such a person will be to restore the gloom that has enveloped him or her to its formative setting, its human context. There will be a story there, perhaps never before told, and one has to discover that story. Chemically numbing someone’s painful mood states would be the opposite of what would make sense in most instances."

On Therapeutic Change

"All we can do, and it's a great deal, is set the stage for change. To repeat, my therapeutic algorithm consists of a fixed and contained frame, a deconstructive inquiry which potentiates defenses and leads to a much augmented version of the patient's operations in the relationship with the therapist. It is there that the working-through takes place, for me not a simple clarification of dynamics, but a very complex, analogic experience which we can comment on, but never fully grasp conceptually"

Stressed Out? Talk to yourself in the second person.

"When we use the word “you,” it is almost exclusively to refer to other people, Dr. Kross said. But when you use it on yourself, it’s a tactic known as distanced self-talk, which can be a powerful way to regulate negative emotions.

In a 2017 study, Dr. Kross and his colleagues found that people who used distanced self-talk to regulate their feelings showed signs of feeling better within seconds.

So instead of saying “I’m stressed out,” which may cause your heart to race, tell yourself “you’re stressed out,” he said. This casts you in the role of “someone else,” and may help you feel more compassion and empathy.

“This slightly weird, seemingly tiny linguistic shift is consequential,” he writes."

On Your Story and the Cycle of Events

There is an old Chinese parable about a man who lost his horse. When his neighbors heard the news, they went to console him but they found him unperturbed. “We'll see how it turns out.” is all he said. A few days later, the horse returned, bringing two wild horses with it. Now he had three horses. When his neighbors heard the news, they went to congratulate them, but they found him disinterested. “We'll see” is all he said. Later that month, the man broke his leg when he went riding on one of the horses. When his neighbors heard the news, they went to sympathize with him, but they found him calm. “We'll see how it turns out,” he said. A week later, the emperor conscripted all able-bodied men in the village to fight in a new war on the frontier, but because the man had an injured leg he was spared. When his neighbors heard the news, they went to commiserate with him, but they found him calm. “We'll see how it turns out,” he said. The point of the parable is that life is a continuous cycle of good and bad. Whether we've experienced a setback or a stroke of luck largely depends on when we decide to stop narrating. And since this decision is entirely within our domain of control, we have a surprising amount of influence over the story of our lives. For better or worse, no matter what you're going through, things will be different before too long. Act and feel accordingly. Remember the phrases "This too shall pass" and "Bad luck brings good luck, and good luck brings bad luck."

On Love and Desire

"Perhaps the most striking feature of Freud's clinical observation was that the condition most likely to interfere with complete potency, a full experience of desire, was love itself. Freud's patients could love, and they could desire, but they could not experience both love and desire with the same person at the same time. 'Where they love, they have no desire,' Freud noted; 'where they desire, they cannot love.'"

On Love

Philosophers often describe love from the outside, but she could provide an inside account. Her experience had prompted her to reinterpret a famous speech, in the Symposium, in which Socrates, whom she considers her role model, argues that the highest kind of love is not for people but for ideals. She was troubled by Socrates’ unerotic and detached view of love, and she proposed that he was actually describing how two lovers aspire to embody ideals together. True lovers, she explained, don’t really want to be loved for who they are; they want to be loved because neither of them is happy with who he or she is. “One of the things I said very early on to my beloved was this: ‘I could completely change now,’ ” she recounted. “Radical change, becoming a wholly other person, is not out of the question. There is suddenly room for massive aspiration.

On Loneliness

Agnes, who was diagnosed with autism in her thirties, felt that she and Arnold were trying to navigate the problem of loneliness—not the kind that occurred when each of them was in a room alone but the sort of loneliness that they felt in the presence of another person. Most couples struggle with a version of this problem, but it often feels like a private burden. For Agnes, it was philosophical work, a way of sorting out “what one human can be to another human.” It seemed to her that Arnold had come to her with a question: Is it possible to eliminate the loneliness that is intrinsic to any relationship, to be together in a way that makes full use of another person’s mind?

On Excess

"We might say, then, that excessive behaviour reveals a failure of authority; that only children with weak parents are excessive. From a psychoanalytic point of view we might even say - in support of the law-andorder lobby - that when young people are being excessive they are unconsciously - without realizing it - trying to find strong, containing parents. Unruly adolescents, for example, can be thought of as needing to find out just how reliable, just how robust and impressive, the authorities really are. And even though this is an often useful account - that children are only as powerful as their parents let them be, and that there is nothing the child is more frightened of than being too powerful - there is something in this view that we need to notice."

On Knowing Someone in a Relationship

"...certain forms of knowing strive to fix the fluidity and multiplicity of the other into a predictable pattern. This form of knowing kills romantic passion, and this is a kind of knowing that is very prevalent in long-term relationships. It has a strong appeal. It seems to be security enhancing. But it is coercive and illusory.

On the Vulnerability of Children

"But the hearts of small children are delicate organs. A cruel beginning in this world can twist them into curious shapes. The heart of a hurt child can shrink so that forever afterward it is hard and pitted as the seed of a peach. Or again, the heart of such a child may fester and swell until it is a misery to carry within the body, easily chafed and hurt by the most ordinary things."

When Is a Gourmet Meal Not a Gourment Meal?

"A gourmet meal is a gourmet meal only if one is prepared to enjoy it in a relatively conflict-free manner, which means that one is not maintaining the conviction that one does not deserve it, is too greedy, is spending too much, is being exploited by the restaurant, etc. One may eat many such meals and still end up unfed."

On Trauma

"If we are to be an understanding relational home for a traumatized person, we must tolerate, even draw upon, our own existential vulnerabilities so that we can dwell unflinchingly with his or her unbearable and recurring emotional pain. When we dwell with others’ unendurable pain, their shattered emotional worlds are enabled to shine with a kind of sacredness that calls forth an understanding and caring engagement within which traumatized states can be gradually transformed into bearable painful feelings."

On Clinical Work, Psychoanalytic Technique, and Being Surprised

"One of us remembers being told by a supervisor years ago that with long experience one would no longer be surprised by patients, that the incapacity for further surprise was the mark of a mature clinician. What a loss! So many possibilities of experience for patient, analyst, and analytic couple are foreclosed by devaluing surprise and new experience. Making a routine procedure out of the analytic couch, for example, ignores the developmental importance of mutual gaze regulation and other forms of facial affective communication in forming possibilities of relatedness. We must, instead, retain a thoroughly exploratory attitude toward everything we do and create together in a psychoanalysis, and relentlessly seek the meanings, both individual and cocreated."

Mental Pain and Breakdown

"All people who are having breakdowns, whether it's psychotic breakdowns or non-psychotic breakdowns, have that look of utter bewilderment on their face. It's the first visual indication of a person being in really deep trouble."

Beauty and the Two Selves

In The House of Mirth, Lily Bart’s mother also teaches her daughter that society’s regard is everything. That “a beauty needs more tact than the possessor of an average set of features.” That she must manipulate and manage both her gifts and society’s esteem to get what she needs, to be safe. It makes sense that Lily is always looking in mirrors; she knows very well that the specular self is the social self, the one on which her life depends.
But there are two Lilys: the one ravenous for approval and security, who believes entirely in “the great gilt cage in which they were all huddled,” and another, more private one. When she disobeys society’s rules, the rules of her mother, in that grace period before the other inhabitants of the cage begin to punish her for her transgressions, she can feel it, “one drawing deep breaths of freedom and exhilaration, the other gasping for air in a little black prison-house of fears.”