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Intra-staff Openness; "What's a nice girl like you doing ina place like this?"1

Abstract: At the 1986 Chestnut Lodge Symposium, Diane LaVia reada presentation written by a group of five female members of the Chestnut Lodge medical staff, reporting on our study group, whichhad been meeting for the prior three years. The membership included Drs. Lea Goldberg, Diane LaVia, Laurice McAfee, Vega Zagier and myself. Like many of the symposium presentations, it was not published. The presentation conveyed the importance of staff members learning aspects of each other’s histories. I believe that the notion of the “blank screen” has been perverselyused to maintain our own schizoid defenses: “It’s nobody’s business but my analyst’s” serves to keep us as strangers from the others with whom we may work side-by-side for years or decades. If we only learn about our colleagues at their funerals, we are left with the poignancy of lost opportunity. This opportunity probably has clinical implications as well as interpersonal, as patients observe our interactions with our peers. With their heightened acuity regarding trustworthiness, they take the measure of our own defensiveness, our own hyper-reliance on a professional veneer.

Keywords: professionalism, communication, psychosis, interpersonal, schizoid

1 This paper was first presented at the ISPS-Israel conference, “Psychosis and Psychoanalysis in the Institutional Culture, December 28-29, 2011, at the Maiersdorf Conference Center of The Hebrew University

Author: Ann-Louise S. Silver. M.D.

4966 Reedy Brook Lane

Columbia, MD 21044410-997-1751fax: 410-730-0507www.mdpsychotherapy.comasilver632@gmail.com

This paper draws heavily from a Chestnut Lodge

Symposium talk read by Diane LaVia, MD in 1986. It

summarized the work of a study group that began in 1983. The

presentation was crafted by the group, about thirty years

ago. The report was never published. One of the five

participants in the project has died, Lea Goldberg, Chestnut

Lodge has closed and all its buildings are gone with the

exception of the Bullard family's home and Frieda Fromm-

Reichmann's cottage and office. So why am I reporting on

this study group? I believe it taught something important

that is still relevant, perhaps more important now than it

was then, given the general decrease in interest in

psychodynamics in the mental health care community, at least

in The United States, and the loss of many therapeutic

communities. I hope that when the pendulum swings back to

more humanistic approaches to psychosis, future clinicians

may profit from the lessons we had learned.

Five of the women on the medical staff— Lea Goldberg,

Diane LaVia, Laurie McAfee, Vega Zagier Roberts. and myself

decided to meet together to study the personal process of

becoming a psychotherapist of patients suffering from

schizophrenia. Immediately, some of the male staff members

became curious and even suspicious. They teased us, calling

us a "gaggle of geese." Our come-hack, not entirely joking,

was, "You're just jealous." A senior staff member, Samuel

(Tommy) Thompson playfully knocked on the door during one

meeting asking if he could join us. We told him what we were

up to, and he silently stayed for that meeting while we

talked about our childhoods, and he never came back. We

enjoyed the men's curiosity; this pleasure formed the

initial glue for our group.

Our first task was to become better acquainted. We had

chatted at lunch, had heard each other's case presentations

and our various comments in response to others'

presentations, and had a sense of each other's styles, but

knew next to nothing about each other's life stories. We

spent so much time learning our patients' stories and those

of their family members, and yet at this analytic hospital,

there seemed to be an unspoken rule that our histories were

the business of us and our analysts only. We learned basic

biographic facts only at deceased staff members' funerals if

then. We thereby were merely colleagues to each other, and

this created a professional loneliness. I think we formed our

group because we wanted to be friends, and to do this, we

began by introducing ourselves to each other. We were meeting

for just a half hour on Fridays at lunchtime, and each of us

took a meeting to tell our personal story of how we came to

choose this profession of working psychoanalytically with

hospitalized patients struggling with chronic and severe

mental illness.

The senior member of the group, Lea Goldberg, had

noticed a gradual change in her theoretical and technical

thinking during her years at the Lodge, and thought she was

seeing a similar course of professional development

occurring in the younger members. She hoped we would

articulate the dynamics of this process. Was there a common

psychological developmental process in the therapist working

there? Another member thought we might find dynamic

similarities in terms of an early organization of a self

concept in relation to others.

We soon saw we needed to give more time to this

project, and added monthly Sunday brunches, rotating the

hosting functions. Thus we got to meet for two hours in each

of our homes, and a certain competition developed regarding

who could feed the group the most and the best. Sitting

around each other's dining room tables gave us great

satisfaction dissipating the loneliness inherent in having

only a collegial relationship. We had gotten invited to play

at a friend's house, and our friends had all come over to

our house. This happiness provided the safety and trust

needed to then explore and demonstrate our aggression towards

each other, and to more fundamentally grapple with aggression.

We never did devolve into the full chaos of a family blow-up.

Our biographies highlighted our personal story,

educational history, and the process of professional

decisions such as specialty training and the decision to

apply for. work at the Lodge. They were quite different — our

sibship patterns showed no trend; our family’s social

positions differed; our heritages and religious faiths

(although 3 out of 5 were Jewish, in a country where Jews are

about 2% of the population), the sort of work each of our

parents pursued, the features of mobility and immigration,

all showed scatter.

The unifying feature was the great emphasis we gave to

our mothers and their stories, and out of this came our

recognition of their depressions, and the variations these

depressions had taken. One mother worked with people all day,

coming home with stories of the fascinating things she had

learned, often saying with amazement, "Imagine - people

actually pay me for this!"2 She had been suicidal during her

2 Throughout this paper, quotes appear, without citation. These are quotationsfrom the unpublished paper presented by Diane LaVia at the 1986 Chestnut Lodge

younger years and she talked about the toll immigration had

taken on some people who had suicided when failing to

establish themselves in a new culture. She had noted that

doctors seemed the most able to maintain a viable self image.

Being useful to others became a haven from feelings of

loneliness and from potentially fatal despair. Her daughter,

now a group member, had chosen medicine as a necessary

discipline for survival, and she saw psychiatry as a

privileged branch of that profession.

Another focused on her mother's family as

paternalistic: the sons' efforts were rewarded and supported

while the efforts of the daughters were used to further

support the sons. This mother had excelled in high school

but the family did not encourage a college education for

her, and this mother then adamantly encouraged and even fed

her daughter's academic ambitions. A photo of the daughter

as a four-year-old, playing with her father's stethoscope

was held up as proof that she "always wanted to be a

doctor." Another member was reticent about sharing personal

details.

An emerging trend was our emphasis on our mothers,

their frustrations, discouragement, sorrows and distrusts.

Our fathers were important to us but drew far less verbal

attention. When it came to discussion of our choices of Symposium.

profession, we disagreed on the relative roles of each of

our parents and of other influences independent of family

issues. This area of disagreement was one of the earliest

areas of conflict in the study. As Diane LaVia said in her

report to the Chestnut Lodge Symposium in 1986, “This

struggle can be viewed as reflecting the almost over-

powering input from one or another of our mothers into the

study group process. Through the group process, a powerful

female force had become operative for all of us."

And what about other family members' contributions to

our decisions? One member suspected that her grandfather had

committed suicide as his health and finances deteriorated.

Her family ran a funeral home, so themes of death and

combatting it influenced her choice of medicine as a career.

The reticent member of our group felt that her father's

emotional distress and frustration were the primary

contributors to her career choices. Thus, there was complete

consensus that the distresses of one or the other of our

parents and their tragic life frustrations were crucial in

our career choices, even if that frustration and turmoil

lasted only a brief period. Quoting LaVia, "A parent's

potential patienthood seemed to be a unifying infantile

motivating drive among the group members. This reminds us

that some {I'd add, or perhaps all} schizophrenic patients

are profoundly dedicated to curing their therapist (Searles,

1979/1975) and seemed impelled to sacrifice their life for

the therapist's betterment. Such motivation, whether in our

patients or in ourselves, is not necessarily altruistic, but

can involve a profound rejection of the less than omnipotent

parent/therapist."

We then moved to reflecting on our choosing to work with

potentially violent patients. Only two of the five members had

experienced explicit family violence. We were unable to

grapple with this topic until later in the development of our

group, and this only after “increasing experience of

aggression within the study group.”

Most of us had one or more siblings who “in some way had

been chronically in need of special attention, either due to

illness or to some other area of specialness. ” We had seen

ourselves as the stronger one in relation to another family

member, and saw this as resonating in our treatment

relationships at the Lodge. “We questioned if this position

of relative strength in childhood had resulted in our being

relatively neglected, and if so, had this encouraged a

pseudo-independence. Had we too prematurely-- in childhood --

set ourselves up as independent healers.” . We saw this as a

turning point in our group, as we developed a major theme --

the theme of dependency. “Issues of dependency began to

dominate our thinking about ourselves as therapists." and

became our major theme. We agreed that in our childhoods, we

tried to understand something that seemed incomprehensible,

the misery or psychic distress (then current or past) in one

of our parents. We saw our current therapeutic strivings as a

repetition with roots in seeking a solution for earlier

family lunacy. Bringing order out of chaos had become a

Iife's mission we each shared. LaVia commented, -The therapy

might also be of value to the patient.”

Another thread in the history of our group could be the

quilting bees so popular in the U.S. in its pioneering days

and its first century. Women got together and quilted

bedspreads. They rotated ownership: one person chose the

pattern, the group sewed the quilt together, and that person

got that quilt, then they began the next quilt. One person

would be the reader each meeting, and the group decided on

the book -- sometimes a novel, sometimes a study of history

or philosophy. The aspect that few are aware of is that this

was in an era of patriarchy. Ben Franklin, for example,

warned men not to let their wives read too much if at all,

since it would distract them from their God-given tasks of

caring for the household and raising the children. The

quilting bees became a bit of organized rebellion in which

the women held seminars, disguised as efforts to warm the

marital bed. We needed no such disguise, but our chatting

paved the way to our studying the roots of the therapist's

motivation. We discovered the perplexed and horrified child

within each of us, who needed a more secure mother, and

dreaded the loss of the mother she had. In these times of

distress we had been catapulted into prematurely developed

ego states. Our therapeutic strivings were a continuation of

those childhood attempts, and our resentments towards our

mothers echoed in our countertransference towards one

patient after another.

In this context, we discussed vignettes from our daily

work with potentially assaultive patients. We worked to link

our personal motivations to our clinical role, returning to

focus on the aggressive aspects of work with patients

suffering from schizophrenia, some of whom are overtly

aggressive and assaultive. It [was] not unusual for the

therapist and other staff members to sustain physical

attacks over the course of work at Chestnut Lodge. Actual

physical attack [could be] minimized by our increasing

experience and proficiency. However, an increased potential for

aggressive behavior in the dyad always remain[ed] in our

awareness... One [derivative effect on the therapist could

be] the recognition and mastery of an excessive degree of

fear within ourselves. By acknowledging this effect, we

became aware of another aspect of our shared motivation for

work with psychotic patients, i.e., a need in ourselves to

develop our capacities to manage interpersonal aggression.”

A nicely illustrative vignette was presented. I was not the

therapist here, and thus cannot add illustrative detail.

Ken is a 24 year old schizophrenic patient who had beenill, with multiple hospitalizations, since age 16. During his first two years at the Lodge, he was seen incold wet sheet pack during his therapy hours due to hisassaultive rages. In the therapy, Ken repeatedly deniedany feelings of anger or assaultive urges, but he displayed dissociated episodes of rage and contempt at the therapist. Gradually, he was able to move out of cold wet sheet pack during his sessions, and, over another year's time, progressed to meeting with the therapist in her office. However, he maintained a more subtle assaultive tendency, which took the form of bullying the therapist by flexing his muscles and showing his physical strength. This intimidated the therapist and kept her from asserting her normal level of interpretations.

The therapist began to examine her own fear and discomfort with this patient, and came to recognize thatmuch of her discomfort was not based on the patient's potential for assaultiveness, but, in fact, reflected her own rage at having felt bullied and threatened by the patient during the early years of treatment.

Once the therapist's own aggressive feelings (as well as her experience of fear) in relation to the patient were realized, she was able to confront him about his bullying behavior—including asking him to leave the office when he made threatening gestures (and the patient would leave quite calmly). The therapist recognized and contained her own rage at the patient's aggression, and was then able to work more effectively with him. The patient subsequently became able to put

into words the aggressive feelings towards the therapist that had previously been denied,

Concurrent with our discussing our work with our

various potentially violent patients, a period of intense

aggressive struggle emerged within the study group. This

disruptive behavior could easily have destroyed the study.

In this time of increased transference within the group,

we experienced one or another group member as a

controlling maternal influence. Meanwhile, we experienced

a mutual dependency on one another as we worked to

accomplish the group's task. “It seemed that autonomous

urges and dependent needs came into dramatic conflict in

the group. and this conflict was given, at times,

intensely aggressive expression.” (We never actually came

to blows, however.) We felt that this aspect of ourselves

in the study group again reflected the linkage between our

personal motivations and our clinical work, i.e., it

reflected our need for a greater comprehension of

interpersonal aggression and of dependency. The study of

this relationship had a long tradition at Chestnut Lodge,

and is featured in the writings of Frieda Fromm-Reichmann.

For example, in her Academic Lecture to the American

Psychiatric Association, she said. (Bullard, p. l98)

"Schizophrenics suffer, as all people in our culture do,

even though to a much lesser degree, from the tension

between dependent needs and longing for freedom, between

tendencies of clinging dependence and those of

hostility….The degree of the schizophrenic's need for

dependency, the extent to which he simultaneously recoils

from it, and the color and degree of his hostile tendencies

and fantasies toward himself and others are much more

intense than in other people. As a result, the general

tension engendered by the clash of these powerful emotional

elements becomes completely overwhelming."

We felt then that “in a given psychotherapy situation

with an aggressive patient, there can be a gradual reduction

of fear of aggression within the dyad—first this reduction

of fear occurs in the therapist and then eventually in the

patient, whose paranoid processing of the relationship

begins to diminish." As I read this transcript some thirty years later, I now think this illustrates a certain

grandiosity and naivité in us. The diminishing or fear was

probably mutual, resonating one unconscious with the

other, communicated somatically through facial expression,

respiration rates, and general motoric activity, as each

member of the duo gradually relaxed into the work. As we

noted, “Such patients are extremely fearful of life (i.e.,

of autonomy) and therefore may utilize aggressive action

to maintain regression and dependency and to protest any

movement away from that position. We came, over the course

of the study, to view aggression in psychosis as

predominantly related to issues of dependency (and

helplessness). We also began to comprehend some of our

motivation for aligning ourselves with the internal

struggle of the aggressive patient and began to recognize

our own aggressive struggle with unresolved dependencies."

This awareness marked the start of the study's final

phase, in which we highlighted the interrelationship of

dependency in the therapist and the patient. We had

recognized how our personal backgrounds, varied as they were,

"had fostered in all of us a significant degree of conflict

in relation to dependency. Also, our intense involvement with

professional goals had enabled us to delay confronting the

degree to which we had not sufficiently become aware of, or

resolved, our personal dependency." In the psychotherapy

situation, unresolved dependency will unduly prolong a

regressive patient/therapist attachment and handicap the

process of therapy. (Searles, 1979/1967) Therapeutic change

will demand -- of both patient and therapist -- an ability to

accept increasing autonomy within the dyad.” It was as we

struggled with organizing our ideas in written form that our

exploration of the dependency theme became clearest. "In the

group process there was a utilizing of each other's mind to

get our own minds to function

11

better. This was one of the predominant ways in which

dependency was expressed in the group." We struggled

"between dependence and independence of thought and

communication. This was sometimes expressed by raising

doubts about the value of the study or about our ability to

organize the material sufficiently to make a contribution to

the literature. We felt uncomfortable with each other's

writing style and way of conceptualizing the material. This

led to a number of heated struggles for individual autonomy

and control in relation to the project. "Both in the study

group and in psychotherapy, conflict between dependency and

autonomy is often expressed as a struggle in interpersonal

communication."

"The regressed schizophrenic is inadequate at verbal

communication, and responds by withdrawal, aggression, or

bizarre forms of expression. Psychotherapy offers the

chronic patient an opportunity to move from profound

dependency to greater autonomy in relation to the therapist

within a context of increasingly coherent self-expression.

However, unrecognized dependencies in the therapist become

countertransference factors and stifle the patient's wish

for autonomy or interfere with our ability to foster

developmental urges in the patient." A second vignette

illustrated that the therapist had failed to recognize the

extent to which her patient had become independent of the

hospital, but still was not discharged. The patient had to

threaten to abandon therapy, for her therapist to see that

it was she herself who had become an obstacle. Once she

acknowledged this, the patient was greatly relieved.

Discharge was arranged and the therapy continued,

"In summary, during this final phase of our study we

consolidated an awareness of the role of our own unconscious

dependency in our clinical work, and how that

dependency intersects with the more profound, disorganizing

dependencies of severely disturbed patients. We more clearly

understood how unresolved dependency in the therapist can

negatively influence the dyad and operate as a contributing

factor to chronicity in the psychotherapy of schizophrenic

patients. And we were "able to begin to observe and to

understand with greater scientific detachment the very

personal struggle that often seemed to overtake us, especially

during the first few years of our work at the Lodge. We also

came to understand the personal and professional change that

has been stimulated in us by work with chronic patients."

We all felt that working at the Lodge was changing us

in similar ways, both professionally and personally. We

talked a lot about regression, which we felt was intrinsic

to our involvement in this setting involving both chronicity

and dynamic movement. Our propensity for regression at times

facilitated and at times disrupted the progress of our

study.

Where does this study group fit in the history of

psychoanalytic ideas? I don't think we ever mentioned Sándor

Ferenczi in the course of our discussions, but as I reflect

on the group and on its setting within the Chestnut Lodge

community, and the Lodge's place in the larger history of

treatment efforts for those suffering severe mental illness,

I (of course) find Frieda Fromm-Reichmann to have been the

vector infecting us with Ferenczi's and Groddeck's

orientation. Ferenczi has been called the first

intersubjectivist (by Imre Szecsödy). Fromm-Reichmann had a

special interest in empathy and intuition, a direct

continuation of her years with Groddeck, and summers

including Ferenczi. And as l researched on the PEP

(Psychoanalytic Electronic Publishing, www.p-e-p.org) looking

for papers in which "analyst's childhood" and "analyst's

mother" appeared anywhere in the text. I found only about 25

references for each category. When I researched Ferenczi in

the title line, and "my mother-“ in the paragraph line, I

found 56 hits, predominantly from Ferenczi's letters to

Freud, a few of them in Freud's letters to Ferenczi. These

letters were Ferenczi's attempts to continue his brief

analysis with Freud. Most quoted was Ferenczi's remark to

Freud about the damaging effect of his mother saying to him,

“You are my murderer."

I would like to return to the question of what led to

the group's disbanding, without completing the final phase

of the project, taking it to publication. We had managed to

agree on a text that was presented to a very appreciative

and large audience. We pulled together our bibliography

(which I now cannot locate) but then the majority of the

group did not want to submit it for publication. One member

said she would publish whenever she had something to say

that was not derivative. Of course, all our ideas are

derivative; we all are members of our culture.

A few years earlier, I had participated in a panel at

the American Psychiatric Association, on transference and

countertransference when the therapist is pregnant. In this

instance, after the successful panel, as we all reviewed the

event, the chair, Tom McGlashan called for a volunteer who

would coordinate getting the papers submitted to a journal

for a possible special issue. Nobody volunteered, and Torn

looked over to my husband with a puzzled expression and

shrugged his shoulders. We had become girls demurely waiting

for him to choose whom he wanted to ask to dance. I think

any one of us would have accepted the responsibility had he,

instead of shrugging about these silly women, had said to

any one of the four of us, Ann, or Susan, or Ingrid — would

you take this task on? And so, the papers were not

published. These would have been the first on that topic.

And in a third instance, I was in a large study group

made up of twelve women, on the topic, "Psychoanalysis and

Women." Again, after having worked together for perhaps

five years, we felt ready to create a conference. We each

presented a fifteen minute paper, on related topics, at the

Washington School of Psychiatry and a wonderfully fruitful

discussion evolved among the fifty attendees. The editor of

the School's journal, Psychiatry: Interpersonal and

Biological Processes (which had been founded by Harry Stack

Sullivan) invited us to submit the articles for a guest-

edited issue of the journal. Yet again, the overwhelming

majority of participants wanted not to publish their

papers. They coalesced around the notion that the editor

was a male chauvinist, and refused to deal with such a

person, none of them having met him. I had worked with him

and had found him very collaborative and unbiased, but my

reassurance was dismissed as somehow irrelevant.

I come back to the informal title our Chestnut Lodge

group had chosen, "What's a nice girl like you doing in a

place like this?" At whatever age we are, and with whatever

our personality style, women may all have an introjected

"nice girl" weighing in on their decision making, even after

their experiences of personal analysis. She isn't "too"

pushy or forward: she is reluctant to step to the microphone

at conferences, less so if she is asking a respectful

question of a presenter. Since the Women's Lib movement of

the 1970s we have seen a growing proportion of journal

articles authored by women, but I contend that for every

published paper there may be ten not published because of

inhibitions in the potential author.

My speculation is that we draw back from our mother's

rule that it is nobody's business what goes on inside our

home. People gossip. Don't discuss what happens here.

People love to make trouble. Be a nice girl. Make our

family proud of you. I believe it is part of "normal"

dissociation to compartmentalize such early rules, but

they stay with us, inhibiting us. I assume that many

women go through their personal analyses without ever

bringing such childhood rules into our analyses, and thus

keeping that rule actively in mind in our preconscious,

inhibiting our progress as forcefully as does a red

traffic signal.

Relerences

Bullard. D., ed. (1959) Psychoanalysis and Psychotherapy : Selected Papers of Frieda Fromm-Reichmann. Chapter 15. "Psychotherapy of schizophrenia," Academic Lecture. pp. 194-209. University of Chicago Press, Chicago.

Searles, H. (1979/1975) "The patient as therapist to his analyst," Chapter 19 in Countertransference and Related Subjects: Selected Papers. International Universities Press, New York. pp. 380-459. and in Tactics and Techniquesin Psychoanalytic Therapy. Volume II: Countertransference, ed. P. Giovacchini, Jason Aronson, New York, pp. 95-151.

Searles. H. (1979/1967) "The 'dedicated physician' in the field of psychotherapy and psychoanalysis." Chapter 5 in Countertransference and Related Subjects: Selected Papers. International Universities Press, New York. pp. 71-88. and in Crosscurrents in Psychiatry and Psychoanalysis. ed. R. Gibson, J. B. Lippincott, Philadelphia, pp. 128-143.

Silver, A.-L. (1993) "Countertransference, Ferenczi and Washington. D.C." Journal of the American Academy of Psychoanalysis: 21: 637-654.

Szecsödy, I. (2007) "Sándor Ferenczi: The first intersubjectivist.” Scandinavian Psychoanalytic Review.30:31-41.