Our Man In Haiti, Part V

By Kent Ravenscroft, M.D.

IPI Emeritus Faculty

I was in a narrow muddy rutted road between tents when I saw a green steamroller, or maybe one of those big, bug-like French street sweepers, coming straight at me.  Nowhere to hide.  So I quickly rolled over to the side in a panic.  Then I awoke.  It was 4 am and I had landed in my suitcase!  As my mind locked in, I realized I was feeling ill-prepared for my first clinic in Petite Guinee, a beautiful spot on the edge of the azure Caribbean in perhaps one of the most impoverished destroyed areas in the Petit Goave area. My mind started grinding out the supplies I must take: 5 folding chairs — one each for me, my Haitian general practitioner,  my trusty interpreter, Tessier, and the patient, his mother — a folding work table, my pharmaceuticals, chart materials, and lots of water.  It would be sweltering. Then I realized no little tent for my clinic had arrived.  Making mental notes, I fell back to sleep until 6.

My clinic was supposed to start at 10 am, two hours after the Guinee staff had picked up their meds to go set up and get started.  So I had arranged to meet Tessier and our driver at 9.  Only that morning things went hay wire because of transportation snafu’s, and I hastily had to pull up stakes at 7:30 am, loose ends trailing.  But I liked going out with the team, and chatting with the eager but anxious new volunteers, who were amazed at the extent of the damage this far down the peninsula.  One quoted the most recent CNN commentary, which said the rubble from the Haiti earthquake would fill the entire Washington Mall to the height of the Washington Monument.  My heart caught in my throat as a realized the fresh impact of what we were seeing.  We saw a house totally destroyed, with a slanting rough slab, now taken over by goats standing at the peak.  At least they wouldn’t be eaten at night, unlike the ‘free-range’ chickens with nowhere to hide.  I now had more sympathy for the roosters and realized why they were crowing at random hours.  Packs of hungry dogs roamed, seeking food, given the scarcity of left-overs.

I was privileged to see how they set up the clinic. Tables were put up, and blankets suspended and tied into make shift walls in a semblance of private rooms.  Chairs were at a premium, as were tables, so my nightmare and the list it led to was useful as the clinic began to roll. Waiting on fractured cinder blocks for stools or squatting Haitian style all around the periphery, huddled under a huge, slightly twisted corrugated roof with open sides, were perhaps 75 patients, some mothers breast feeding, others holding sleeping children, all eager but respectfully waiting for a turn. I was given a corner up on a cement dais and we saw our first patient.

Pierre, a shy, taciturn eleven old presented with insomnia.  He couldn’t sleep because he kept hearing the cries of a baby and the voices of dead neighbors.  He had been holding a neighbor’s baby when his house collapsed on him.  His mother could only see the boy’s head when she tried to rescue them.  Pierre tried to protect the baby in his arms, but it was gasping when his mother got them out, and died on the way to the hospital.  Pierre felt horrendously guilty, not helped by the baby’s angry grieving parents, whose house had also collapsed.  His mother explained that they weren’t really angry at him personally, but he felt guilty, even for surviving.  He had had a friend die three years earlier and had heard his voice for a long time, and kept thinking he saw him in groups of children.  I worked with the doctor to do the interview, using the interpreter to get feedback and give guidance, at times even speaking to her, the boy, and the mother in my rusty Creole.  Pierre had made it through the mourning of his previous friend, and we told him he now had more complicated grief work to do, but would do fine.  We reassured him that, as he told us, he really did all he could for the baby.  We emphasized he was a shy boy with a strong conscience, making him self-critical, and he needed to ease off.  We told him and his mother he was doing too much work at night in bad dreams and voices, and that they needed to bring the work into the daylight for more effective work.  We advised his mother to have a little session with him in the morning, gathering him and his thoughts and worries into her mind and arms, and another session before bed to help him clear his mind, reassuring him that she would hold the worries and work on them so he could sleep — like Guatemalan worry dolls.  We felt they would be a good team doing their healthy homework.  So we gave no meds, but scheduled a follow-up. They left encouraged and armed with self-help they could carry with them.

The next woman complained of severe palpitations.  On her way home after the earthquake, she passed many friends in front of their destroyed houses wailing for their dead or missing children, and she rushed to see how her five children had done.  She found four of them alive in front of their collapsed house, ‘Grace a Dieu.’  But her fifth child had not made it home from her school, which had partially collapsed. The woman wanted to rush out to find her, but her children reassured her she would come home, and she waited stoically.  Her daughter did eventually return, full of stories of other kids being hurt or trapped.  Three days later the woman had severe palpitations, in response to some random trigger that reminded her of her stoic vigil.  She was already on medication for high blood pressure, but she had never had this before, except when walking up steep hills. Now she was worried her heart was giving out, and that she was dying.  She let us know she was emotionally fit and able to help many of her grieving friends, and so she was sure that her heart symptom was physical.  We agreed she should see her doctor to get checked out, maybe even have that electrocardiogram, but after taking her blood pressure and taking her pulse rate, and listening to her heart, it did seem that she was physically okay.  She had the strength and intelligence to work this out in time, and in the meantime we gave her simple techniques to restore her trust in her body and in life.

I explained the endocrine fear response to her.  Her scary self-diagnosis was escalating her panic.  Her fast walking on the day of the earthquake would make anyone’s heart beat faster, and the new bursts of heart beats were normal fear responses triggered by thoughts, noises, or tremors.  She needed a couple of techniques to interrupt the beginning palpitations. So we taught her the partial Valsalva maneuver, in which she would hold her breath and bear down as if having a bowel movement. The Valsalva works to stop arrhythmia — and is a competence distraction.  We also showed her how to rebreathe from a paper bag sealed around the mouth.  We also suggested noting down each time she had such an attack, so she could outfox the triggers, and disconnect them with an “I told you so”.  She needed to be a kind doctor to herself, just as she was being a good friend to her friend, and not scare herself.  She got the hang of it, and understood the psychology and physiology of it.  She was a school teacher, and so I suggested she could help teach this to scared symptomatic friends, as she herself got good at it.

One other patient had serious insomnia.  Glassy-eyed and depressed, she showed us a certificate of scholastic accomplishment earned by her 21 year old son, his handsome photograph on the front.  Between sobs she told how he was teaching in Gressier, away from home for a while, and was crushed in his little room there by the earthquake.  We listened with near reverent attention, checked on her friendship and religious network, and noted her blood pressure was elevated.  She was consolable but in deep prolonged, but not arrested, mourning.  But it bordered on depression.  I suggested they give her atenolol, a relaxing, sleep-promoting, and anti-hypertensive agent to help her through this sad, sad passing.  She had other children to live for, but we would follow her up closely next week just to make sure she was doing all right.

We saw other patients today, and as time went on I relied on the Haitian doctor more.  We are hoping to give them increased front line competence, a good sense of basic psychotropic meds, and diagnostic acumen for triage and deciding when to refer for specialist care.  Referral should occur only when absolutely necessary.  There is not much psychiatric care to go around, and most people, even if deeply affected, are able to self-right with simple help and access to their own resilience, provided they have their basics met, that is, shelter, water, food, security, and social connectedness.

When I got back to the Residence office, I had to go with Stephanie, my director, and Peter, my colleague, to a meeting for all mental health leadership, which was boring, but necessary, a key brief encounter with the hospital administrator, from whom we must get approval as a hospital resource for medical and surgical inpatients requiring psychiatric intervention.  Though I love this kind of work, I’m feeling spread a little thin.  I also hear there is a movement to base me at the hospital instead of going out to the individual clinics –bad idea for the Haitian docs and nurses, and for the patients.  I am lobbying for staying clinic-based, and we shall see.  I noticed Stephanie was in a good mood, but had forgotten why.  Then I saw her screen saver again, and there he is, her friend and co-worker in Darfur, the man who was abducted for ransom, like her.  That was back in November.  After all this time, after losing hope, he had just been freed, and she was thanking her lucky stars.  It had been a long hard vigil.

Stephanie is a vegetarian, not really interested in food, and eats at sporadic times.  I cooked lunch Sunday, and I made dinner tonight, linguini with olives, onions, tomato and Prego mushroom spaghetti sauce.  Yum, after my fashion, and, Stephanie liked it.  I clued Crystal the cook in on the fact that we would be moving to consolidate all staff and volunteers, making 7 for dinner each night, with the volunteers used to hotel choices and lots of food.  Her eyes got wide, and she thanked me.  My Creole isn’t too bad in a pinch.

I must admit, though, that from a creature comfort point of view, I will be using Haiti, and this experience, as a litmus test of my materialism.  I may think what I am going through at times here is a near-death experience for me, but it is nothing to what the Haitians have gone through.  We had one other woman patient today who lost a child, an aunt, a house and a business, which was crushed and then robbed, and, a van that was trapped under a concrete wall.  So she is without even a tent and no means of livelihood.  She was depressed, and, I sensed, smoldering with rage.  She had been unable to reconnect with her Pentacostal Church, and she seemed close to needing meds.  We started her with a sleep med and not a heavy duty antidepressant, because antidepressants are costly and needed for a long time, and we sensed she might come around the corner. We will see her right away again next week, just to make sure.  Continuity and taking the mental pulse is the key.  We don’t want her remaining children to suffer a maternal suicide, given everything else.

Thank you all for bearing with me.  This blog is bibliotherapy for me, part of my self-care, something we emphasize around here.  It’s a great team down here.

Our Man in Haiti, Part IV

By Kent Ravenscroft, M.D.

IPI Emeritus Faculty

Saturday came around fast. I had to stand up in front of local Haitian IMC clinic doctors and nurses, and talk for 5 hours about the psychosocial impact of what they and their patients had been through.  As I’ve said, public speaking and lectures are not my favorite thing.  I spent from 4 to 5 am floating on my air mattress, dealing with my anxiety.  Into my mind came the words of Maitress Erzulie Grand Freda, who had told me, as I left Haiti 50 years ago, that I would be successful if I worked hard, that maybe someday I would come back to visit and help her people in Haiti.  Thinking of her words and feeling encouraged by my association with the great IMC staff, I took heart, found my courage, and fell back to sleep, until 5:45, when the cock crowed for me.

I had come out to Petite Goave on the southern peninsula to start up our Haitian psychosocial training program here.  We drove to the Royal Beach Hotel for my first all day workshop, to be on Mass Trauma, Loss, Grieving, Front Line Mental Health Work, Treatment, Triage, Symptoms, and Major Mental Illness.  PTSD, though popular with the press and the world, would be a small part of it, since statistically, surprisingly, it is infrequent in mass disasters, if aid and care are given right.  We would cover the needs of patients with pre-existing conditions epilepsy, mania, severe depressive disorder, and chronic schizophrenia who lost their medicine and psychiatric contact because of the quake, and address new first breaks caused by the tremors and the scarcity of outpatient and inpatient psychiatry.  We hope to leave a legacy of psychosocially competent front line Haitian family practitioners when we leave in two years.

There were 12 Haitian doctors from our 5 clinics, 19 nurses, and others from Notre Dame hospital, and 5 from Croix Rouge with whom we have liaison.  It went fairly well.  I even spoke a little Creole to the group when the translator had trouble with my medical English and concepts. I did a group exercise teaching relaxation and imagery techniques to interrupt cycles of anxiety and repetitive thoughts, and then while in the relaxed state, had them visualize where they were when the earthquake struck, helping them recapture and work on their own inner experience so as to increase their emotional availability to each other and their patients. I stressed cost-effective front line stress reduction group sessions that nurses would lead for people they would identify – groups like the one I was modeling.

I had them form pairs and tell each other about what they had been through, and then used their own thoughts and feelings to illustrate the symptoms and expectable phases of recovery for those without psychiatric diagnoses.  We talked of acute stress symptoms, and how rare chronic serious post-traumatic stress disorder is, and how early intervention on the front line reduces its occurrence drastically.  Without that support in war zones and earthquakes like the one in Haiti, PTSD results from seeing and dealing with dead bodies, and rape, abuse, and violence.

The workers told me that they felt guilty about the long lines ever day and the brevity of their problem-focused encounters with each patient.  I reminded them that their Haitian patients are used to waiting for care.  And in this case they will get care like they had never had before.  Even waiting in the clinic, being near their doctors, and knowing the Clinic is there for them, is helpful.  They deliver care in open tents with all watching, and the word gets out that help is there.  I said that they should never underestimate the importance of using themselves as a powerful part of the healing.  By their presence and their manner of caring, the front-line workers become a transference object of great importance for the camp and village.

I stressed the importance of their presence at the camps and destroyed villages.  I reinforced the impact of their caring, their laying on of hands, their quick but careful exams, their mental health first aid, and triage.  As front line workers, their work and reassurance gives hope and momentum to recovery for this impoverished, yet strong and resilient Haitian people. I reminded them of resilience, and advised them not to over pathologize what they see. I emphasized the need to see their patients’ (and their own) weird thoughts and feelings as normal responses to abnormal experiences, and to set them in the context of the normal, expectable stages of mass disaster recovery.  That’s the way to help their patients not to get stuck and become chronically symptomatic.

Once they felt comfortable with me in discussing the needs of their patients, several nurses and doctors shared their personal experiences of losing family members, seeing their houses destroyed, and living in tents outside their houses.  About a third of them had been affected.  When the topic of tents came up, I noticed two nurses looking down and huddling privately.  I finally asked if they could share what was going on.  With some embarrassment but plucky honesty, one of them confessed she didn’t even have a tent yet and was living outside with family members in one of the camps, grateful the rains hadn’t come yet, and proud she made it to the clinic every day to work, somehow looking clean and kempt.  The clinic was clearly a beacon of hope, care and support for her.  And her own experience gave depth and meaning to her work.  It raises the question:  “Who takes care of the care takers?”

One young doctor came up to me afterward, doubtful about the purpose and usefulness of the group exercise.  When I explained that it had to do with taking care of yourself as well as your patients in times of trauma, his eyes rimmed with tears and he told me about pulling children, some dead, some gravely injured, from under crumbled concrete slabs in the house next to his after he and his kids got out safely, before both houses collapsed.  I’ll be working with him in one of my weekly clinic rotations.   I was deeply moved by my experience wit him and with the group in general. The workshop certainly broke the ice for me, and I hope for them.  Now I am poised to go out and work alongside them.

It seems tents are now in short supply in Haiti and there is still great need.  We have enough tents in our privileged IMC ‘camp’.  We are well taken care of, mostly.  So I have a tent that I am not going to be using.  My extra tent was a gift from a friend who sent me off with a lot of camping stuff, urging me to give it away when I left, bless his soul.  So I plan to give it quietly to this nurse when I go to her clinic, secretly so as not to stir up envy, or a perception of favoritism by IMC.  But that other nurse huddling with her may be in the same plight.  So I have sought a more systematic solution.  I asked Stephanie, my NGO administrator if she can get tents for our clinic workers in need. I don’t want to wait on bureaucracy, but Stephanie seems to make mountains melt for her people.  She’s my kind of NGO person!

My only complaint about Stephanie is that she wouldn’t like me to visit my old field site because of security concerns over the increasing risk of abduction. She said that one abduction can cost an NGO $30,000 to $50,000, and she emphasized that this would mean that hundreds of refugees would have to go without food and care because of the wasted funds.  There was something strange about how she tightened up and how guilty she sounded, and how she used the image of starving refugees to persuade me not to go.  I learned that she had been abducted for 25 terrifying days in Darfur, before negotiators got them to release her.  But all she seems to feel about that, besides wanting to protect us, is terribly guilty about how much she cost IMC for her ransom, and the loss of money for care of the people in Darfur.  She has a lovely amulet she wears every day, given to her in gratitude by her people in Darfur.  I find myself tearing up again as I write this:  I have such admiration for this woman.  Stephanie said she felt she could probably get some tents for my nurses in the next week.

Speaking of Stephanie and tents, just the day before my workshop I had visited a clinic called Beatrice, at the top of a high hill, with a tent city surrounding a small village.  We also visited Petit Guinee, a destitute and now ruined seasoned village, and Trois Soeur, a tent city around a monastery.  Later that day a huge wind came up, and when I got back to the staff residence, I discovered that the big tent covering the Beatrice Clinic had blown down, with everyone in it.  Stephanie was frazzled because she had been called, as usual, to rescue the situation, and had spent the afternoon putting the tent back up with the staff.

After my workshop, I treated myself to a Haitian lobster dinner at the Royal, and two Barbancourt rum and cokes.  I enjoyed the ‘Strict Badou,’ a jazzy, professional Haitian group, with appropriately strong island flavors.  I slept well last night.  Even the roosters failed to rouse me.  Today is a day of rest, and a chance to write.  I made an omelette for me and Stephanie, and gave my novel to Peter who was complaining about nothing to read.   So that’s it for now, except for preparing my materials for my first clinic tomorrow.  I look forward to beginning my clinical teaching and training, though I’ve already begun to worry a little about my lecture in Port-au-Prince at the Mars et Klein Psychiatric Hospital next Saturday, possibly on Adolescence.  I’m all prepared for an Eating Disorder lecture, with slides, but somehow that doesn’t feel quite right for down here.  Anyway, type A is interfering with my day off.   Talk to you later.

Back in Touch Next Week

Our Man In Haiti, Part III

By Kent Ravenscroft, M.D.

IPI Emeritus Faculty

Fifty years ago when I was 20 I did my anthropology fieldwork in Masson, named for the remains of an old French plantation. I would periodically take a break, hop on a brightly colored Tap Tap or small camionette, and head back to Port-au-Prince to join the Richardot family.  Jean Bleyfus Richardot was head of the United Nations Economic Commission to Haiti at the time, and his lovely daughter, Caroline, had caught my wandering eye.  Her gorgeous mother was not far behind.  We’d go up to the grand Petionville Country Club, swimming, attending a posh cocktail party, swarming with the elite, Haitian military brass and politicians, and NGO officials.  The place would be filled with glittering jewels and conversational gems, awash with five-star Barbancout Rum and festooned with Bougainvilleas.  Things were different then.

Today, I awoke early, knowing for whom the cock crowed, and, with heart in throat, traveled up to Petionville, not with the Ricardots but with Dr. Peter Hughes, a fine Irish IMC psychiatrist, and not for leisure, but to visit our mobile clinic, staffed by Haitian nurses and doctors, and our medical and nurse volunteers.  We turned into the familiar gates of the Petionville Country Club, the metal letters of the name dangling from loose screws.  We were confronted with a jungle of military and NGO vehicles, gun-toting marines, blue-scrubbed doctors and nurses, and Haitian vendors all plying their trades.  I looked over at the tennis courts.  One of them was covered by a behemoth tent housing a dozen small tents, a small orphanage compound, and supplies.  Two courts were pock-marked by tire tracks leading to the back tennis courts where army vehicles and supplies were stored.  With apprehension and curiosity, I walked out onto the Club terrace.  I saw cracked columns, and huge jacks holding up cement cross beams, camo partitions and windbreaks obscuring my view.  The NGO’s (non-governmental organizations) including IMG, were gathering on the left, and the army was on right.  The army guys were buff in their camo fatigues, lounging in front of a huge TV watching March Madness.  Zombie-like I walked forward to the edge of the terrace.  I looked over the empty pool at the withering Bougainvillea, bearing faded red flowers.  I could just see, over the brow of the hill, three NGO tents, their names emblazoned on the sides, and a few army vehicles.  With its panoramic view of Port-au-Prince and the mountains shimmering in the mid-day heat, I could still see the Club’s former grandeur.

Peter, Kettie, our superb Haitian psychosocial nurse, and I had a pre-arranged rendezvous with a Canal 24 television reporter and her video cameraman.  We were their entrée into the camp below, and they were possible resources for donations to Haiti Relief.  And long term relief is essential.  We walked together over the brow of the hill.  I caught my breath at the sight of the multi-colored mosaic of a tent city now housing 40,000 Haitians.  Following the contours of hills and ravines in all directions, the city was displayed like a Cubist painting.  Our group clinic is nestled in the middle of this tent city. NGO psychosocial care and health groups are scattered throughout, and others are placed strategically around the periphery.  We threaded our way down into this warren along dirt alleys, zigzagging our way between tents, Haitian blankets spilling out of their tents onto these walkways, kids playing, mothers nursing and cooking, and men and women selling their wares every few feet.  We met with civility and curiosity at every step, and I often stopped to say a brief hello in Creole, and got a smile and polite hello back.  I took a picture of two girls combing the hair of their Barbie-like dolls, and a bunch of boys with kites made of refuse, one flying quite high.  And then there was the long string trailing behind a little boy with a piece of red refuse at its end.  I caught on quick: He had a red puppy on a leash.  I yelled when Peter almost stepped on it, saying, “Watch out for the puppy!”  The boy and his friends cracked up.  The child psychiatrist in me was on the look out for resilience and strength, and not just tragedy.  We spent several hours at the clinic seeing psych patients, teaching the young Haitian psychiatrist and learning from him about front line work.  We were in awe, as we watched the other doctors see 70 to 100 patients each couple of hours.

I kept thinking back to the Petionville Club.  Its transformation was mind boggling.  It stirred confusing emotions in me, sadness, respect, appreciation, and hope mingled with anger at the cost of the earthquake, Haiti’s impoverished condition, and its smoldering future.  If the Haitian government, despite all the help, takes too long to pull itself out of disarray, there will be trouble. The OXFAM people are worried about various scenarios in Haiti, any of which might result in the complete collapse of government authority and a surge of wide-spread, violent civil unrest.  I heard from a young friend who is studying international relations that the consensus is that the situation may well deteriorate quite rapidly over the next month as the country descends into chaos and a violent upheaval takes hold.  Her father wrote to me, “You may have seen the beginning with the kidnapping incidents, but it could get a lot worse.  Do you have a weapon?”

But my time was up in Port-au-Prince.  So I packed up early two days ago.  I am actually beginning to miss my little tent which had come to feel like home, all cozy and organized.  Even a rooster came clucking and crowing behind my tent to wish me goodbye.  I took pictures of Pierre and Carmen and Alice who fed us ‘di ri ak poi rouge’ (rice and red beans), ‘di ri ak jon jon’ (rice with french peas and jon jon flavoring), overcooked chicken, and ‘banan peze’ (flattened fried rounds of Plaintain), among other things.  We spoke Creole together which pleased them.  I said my good byes to staff, and followed my driver to the IMC Rangerover.  I had thought the drive to Petit Goave on the Southern peninsula would take 4 or 5 hours.  He told me 2.  Just driving to the Gressier Clinic the previous day had taken 1 and 1/2 hours.  So, I was dubious.  We wound our way down the mountain past the chaos of UN yellow tee-shirted Haitian conscripts working to clean the debris from the sides of the roads, where everyone had piled the debris of their shattered houses.  There were more bulldozers and dump trucks lumbering about, often ancient Mack trucks from the ’50’s kept alive by canny Haitian mechanics.  We crept through Carrefour intersection, amidst teams of brightly colored tap taps, camionettes, and huge camions, each with their own pictures hailing Jesus and pop stars, with Grace a Dieu, and Jesus Sauve Tous, written on the front.  The good ship Comfort, all white with a red cross, had departed.  The road was flooded and rutted down 12 inches deep.  The Marines who built it in the 30’s would be aghast.  We drove past the mix of standing, tilting, and crushed houses that I had seen when I went to Gressier Mobile Clinic yesterday.  I recalled again the volunteer doctor who had talked of seeing the sparkling azure blue see and waving palms, beyond the few standing houses.  He felt it was all beautiful, until he realized that he was passing a huge graveyard of unearthed bodies on either side.

We got to Gressier in the expected 1 and 1/2 hours, and shoved on.  The road improved, and my driver began to rocket along, careening around curves, even pulling out around tap taps and huge slow moving Camions, barely pulling back in after a kamakazi chicken game with a daredevil coming the other way.  We had had a security meeting the previous night about the abducted volunteers from another organization (I found out that morning they had been returned alive — for a price), and in passing they commented that if our drivers scared us, or took chances, we should ask them to slow down.  I kept quiet, being used to the Haitian driving and wanting to get there fast.  Unwisely, I kept taking off my seatbelt to take pictures on either side, at one point thrown forward as the driver came to a screeching halt in front of a gaping jagged hole, the Zeus mark of the earthquake.

Finally we crossed the Momance River, and my heart pounded in my chest.  We were at Brache, where I used to get off my Camionette to walk toward my field site at Masson on the blue Caribbean.  It was vastly different.  I don’t mean just the fifty years of build up, including Leogane’s encroachment.  When I heard about a guy from Masson collecting money, I had been dubious.   How could mud huts held by wattle be affected by the earthquake?  But when I saw the devastation, I gasped and my eyes welled up.  The driver slowed down to see what was wrong with me.  He had no idea I knew any Haitians, especially way out in the boonies, but there I was, a tear-rimmed shambles.  I let him know everything about the friends who were gone or missing, and then he told me what had happened to his family.  He had lost his aunt and his house.  After our sad sharing we spent several minutes together, leveled by the earthquake. I told him I wanted to visit the families I had studied.  I wanted to bring them photos I had taken of them as children, and of their parents and grandparents, as well as a nice gift of all my camping stuff and clothes I am using, and (though not mentioned to my driver) a big gift of American cash I had brought with me.  And in Haiti, the greenback is still king!  And I must say, I see USAID tents and tarps everywhere, and the military standing tall and beautiful.  Those yellow t-shirts along the way make me smile.

To my surprise, as we crested a hill, the vista of Petit Goave stunned me. From the pass we could see a majestic bay, with large ships, and a few scattered sailboats curving into a harbor, cradled by hills and mountains, still fairly green.  It was breath-taking, a part of Haiti I had forgotten, since I saw it only briefly on my quick trip my last summer.  Once we entered Petit Goave, my smile faded as I saw the crumpled buildings beginning, and the myriad clusters of tents — blue (UN) and white (USAID) — and other hews of the rainbow from other groups, from Tibet, and Japan, and Mexico, and France, and Canada.  The international care and gifting is amazing.  I was just told that over 900 groups are here right now.  And there are these incredibly ramshackle constructions everywhere, makeshift from every salvageable piece of debris, made by the poor not receiving aid.  It seems 3/4 of the population is living outside.  That’s the incredible short of it, though the long is more complex.  People are living outside of their houses because they are destroyed, because they are too dangerous, because they are under reconstruction, AND because the inhabitants are terrified of aftershocks.  In China many villages in quake-prone areas keep deer penned outside the village with a person dedicated to watching them.  Deer are incredibly sensitive to the slightest ground tremor — great for avoiding approaching predator, AND pre-shocks of approaching earthquakes when the tectonic plates begin slight shakes as they build up for the big one.  Well, people here are now as sensitive as deer.  In a second, I’ll give you an example.

We first pulled up to a gated beach side hotel, which looked promising, but then we found out the residence where I was staying was elsewhere! Off we went, down the dirt side- road of the National Highway filled with small or shattered houses at first, then a few larger gated houses, until we reached one with a guard.   The drive had, indeed taken just over 2 hours, though I had my eyes shut for most of the last of it.  Except for taking in the view from time to time. Stephanie, a French Canadian, the cute young director of our IMG unit, greeted me, her cell phone glued to her ear.  She was doing a million things, full of energy and excitement.  Lunch was underway, which was quintessentially Haitian, except for a veggie stew because our young director is vegetarian.  Tom, a Kenyan evaluation guy from Port-au-Prince, Jattu, a black Russian and English speaking clinical assistant, and Joanne, our Psychosocial Haitian assistant were there.  Right away, I discovered the nurse clinician to be appointed for my team had decided not to take the job, and so I was evaluating resumes for that position.   Stephanie asked if I wanted to stay there, or at the Hotel where she had a room for me.  Stupid me, now a tent addict, I said I’d stay there, close to the staff action.  Well, at about 6 o’clock everyone disappeared.  Stephanie went out and the others departed for the hotel.  I deployed myself in a tent 4 times the size of my homey pup dome tent.  Now down at sea level, instead of up on Petionville, it was HOT.

The weather has been perfect, beautiful blue skies since the third day, no rainy season yet.  But hot, and HU-MID!  The exertion of going to bed works up a sweat, and my exercises make me drip, but my back makes me stretch.  One good thing, I have lost a LOT of weight, so much that I can get my knee not just to my chin, but almost to my ear.   But I’ll tell you why.  Lunch was also dinner for me, the one consumer.  When Stephanie returned, she said she had already eaten.  Not exactly a mother hen.  So I ate what I could, the salad having been sitting out all day, BUT with beets in it, which were irresistible to me, though where the hell did they find beets?  When Stephanie stopped gyrating, she told me that another team had just been added for me to teach, and also that there had been another kidnapping of an NGO volunteer, up at the other end of Haiti in Cap Haitian, where Henri Christope the liberator  of Haiti had his chateau Sans Souci, and his Citadelle, with canons that could make the earth shake and carry 20 miles to the bay, should the French return.  So we were in tighter lock down, and I was informed I couldn’t go out alone.  I was feeling trapped.  The ground was shifting under me.  I was worrying about preparing an all day workshop in two days and organizing and implementing their master clinic plan — not good for a type A guy in retirement.

While I was talking to Stephanie, I saw her jump and start to bolt.  “What’s up?” I said.  “Didn’t you feel that?” she said.  “What?”  “That small aftershock!”  Frankly I didn’t feel a thing, but today it was all people could talk about, that some people were eating dinner at the hotel while the other half were leaping up and running out lest the thing continue and the ceiling cave on them.  Some people, I would say, now a little hypervigilant, turned into a bunch of post-shock deer.  But then again, if I had been through what they have been through I would be hypersensitive and out the door.  Anyway, I had awakened early, so I was eager to email my wife Patti, or hopefully reach her on Skype, so I went to the internet only to find out it was down and had been down all day.  Stephanie went out to do a security briefing.  So there I was – left, alone, having to prepare my talk, which was not my favorite thing to do, lonely, cut of from Patti, no real food, no company, and a strange new tent to sleep in.  Well, I frittered around for about an hour, reviewing things, then hit the hay, or, rather, the air mattress, once again feeling swamped and disorganized.  Where was my psychiatric side-kick, Peter, when I needed him?  I gave him a buzz, told him I’d lined up four nurses for us to interview when he arrived, and he said great.

I was amazed how disabled I felt with no internet, but sleep beckoned, except that my friendly roosters were replaced by the late night carousing of radios of some nearby Haitians and NGO workers. And yet, all was music to my tired ears, as I thought about the mission I was on for all my Haitian friends.  I would only have to be in the altruistic humanitarian mess for three more weeks.  I could stand it, and give as best I could.  My time was now here.

Back in Touch Next Week

Our Man in Haiti, Parts I and II

By Kent Ravenscroft MD

IPI Emeritus Faculty

Part 1

Haiti is an amazing country. It is devastated by yet another disaster, yet the strength and spirit of Haitians is stunning.   I know it well.  I spent time there as a young man learning Creole and writing my thesis on possession and its link to dissociation.  Now I’m in Paris living at the other end of the spectrum.  I hear firsthand from friends who still live and work in Haiti that the devastation is ghastly.  They say that International Medical Corps (IMC) is co-ordinating support efforts well, and that as a child psychiatrist I could be useful to distressed families there and to people suffering from post-traumatic stress disorder and psychiatric sequelae of physical trauma.  I am powerfully drawn to help, and with my wife’s blessing, I decide to leave Paris for Haiti.  She tells me that her sister, a nurse, heard from her colleague on the American hospital ship Comfort off the shore of Haiti, that they’ve been swamped with the worst cases.  No-one in Haiti has seen ANYTHING like this.  No war zone compares.  I am about to leave when my wife tells me this, and asks me if I know what I am getting myself into.  My anxiety shoots up and I make her stop telling me.  It is time to go.

With $300 worth of overweight medical supplies and equipment, I fly to Haiti from Paris.  On the flight I meet a team of water-purification and rescue workers and a top manager from WHO.  Within two weeks of the earthquake the man from WHO was co-ordinating 240 humanitarian groups, medical and otherwise.  Now there are more, but some are pulling out now as the acute phase ends.

In the air I feel a sadness, the return of the repressed, depressed feeling of missing the Haiti I had known 50 years ago as an idealistic, enthusiastic young man, because of the destruction and loss on the ground, resonating with the stage I am at in my life, and  because my last summer there had been a hard one.

We are one of the first commercial flights to land in Haiti, and I am one of the first child psychiatrists to arrive.  The airport is as chaotic as ever, entrepreneurial Haitians hawking baggage trolleys for $2 dollars (American), and several eager cabbies grabbing me and my stuff.  At last, Matthew, the International Medical Corp driver, finds me and the other new doctor, Zurob, who is from Russia, Georgia actually, and we set off for the Plaza Hotel.

Matthew drives Zurob and me through streets lined by collapsed houses and rubbles, teeming with busy or displaced Haitians, past huge tent cities.  Lighting is spotty, and the destruction massive but strangely spotty.  The gaily painted buses and vans move at a snail’s place, with traffic jams everywhere.  Images slide by: A nursing school with 200 young souls, crushed to eternity; the once gleaming, white Palace, of Papa Doc fame during my years there, now lop-sided and caved in, too scary for President Preval to work in.   Matthew and I jabber away in Creole and French, while Zurob pores over his tropical medical manual as we jounce over an incredibly pock marked road, now strewn with rubble.

When I arrive at the Plaza Hotel, I find the main rooms filled with cots and mattresses, eager, excited, exhausted young physicians from all over the world, coming back from a day’s work in one of the remaining hospitals or outlying clinics.   Everyone is talking about life and death, the resilience of the Haitians, the malingerers, and those wanting a doctor for old ailments. Triage, compassion, and breathtaking work is in the air.  I feel anxious and out of place, no one at first receiving or orienting me.  Then it is time to eat – at a surprisingly sumptuous buffet.  The other volunteers begin to clue me in about how wonderful the effort and how great the support from the leadership of the IMC is.  Other volunteers show me where to find a spot to sleep, and tell me about cornflakes for breakfast, about lights out at 10, lights on at 6, bus leaving at 7 for the hospital, AND, where to find the WiFi, which is good, and where to exercise.  I eye the pool eagerly.  Security is good in the compound, not as good on the streets, the staff being like mother hens for us chicks.  My fear of losing 40 pounds as I had done that first summer has evaporated.  I have landed in comfort.

This was not to be for long. I meet Nick, a British psychiatrist, the next morning, with our driver, a Haitian electrical technician with a generator, and a translator, a great guy, but oddly for one in his profession, he stutters.  We sit on morning rounds which last all day, with no food at all.  We go to WHO’s PROMES facility, a huge warehouse complex, to get psychiatric meds for a Psychiatric hospital we are to visit beyond the airport.  We run into red tape for three hours, and then the traffic is incredibly bad, but we finally reach an alley behind caved in buildings and banana stands, bumping over cess-filled ditches, which will finally get washed out now the rainy season is beginning, and that will be good until the mud slides began.  This reminds the electrician that, though the stench of bodies decaying and of rats has abated through dessication, the rains might stir things up again.  The electrician is stoic until we pass a collapsed building where a dear friend was buried.  All the while, Nick is leading us onward, and briefing me about our teaching mission for young Haitian professionals and support and consultation in the hospital and the outlying beach-head clinics.  He is wonderfully British, very warm and supportive, wise and caring, and inspiring hope and confidence in me as I try to imagine myself once again working on the front lines in the trenches under such difficult and compassionate circumstances.

Finally we reach a nondescript gate opened by a shotgun-toting guard to reveal a huge open space ringed by caved-in one-storey buildings and walls, a collapsed primitive kitchen, a tent city, a patient with an American flag bandana screaming and gesticulating, two women frozen in bizarre positions, men marching her and there, half naked women leaping around the grounds, goats feeding and prancing about.  Nick is walking with the psychiatrist, doing a needs assessment as I trail behind, saying hello to all the curious patients.  I meet one who speaks English.  He has just won a Port-au-Prince award for his wonderful drawings, and he wants to give me a portrait for helping them.

We deliver the huge supply of meds, my friend the electrician installs the generator for their water supply, and the heavens begin to rain on us.  Some patients tell me they fear that their gleaming white canvas tents from Russia are old stock and might leak.  Two excited patients insist that they have their picture taken — I oblige.

When I get back to the hotel I am told to pack up to come to the residence where the staff of IMC live, to get to know them better.  I would be oriented to clinics the next day, today, in preparation for assuming leadership next Thursday in one of the outlying clinics in Petite Goave.  The last tremor, the Translator told me, in between stutters, happened a week ago, with a huge, cracking, snapping deep groan, and a slight convulsive shake.  Nick tells me that when one of the earlier major aftershocks happened two weeks earlier, everyone moved outside to sleep from then on.  Some of the surgeons and nurses got freaked out and insisted on leaving immediately; others now sleep inside at the residence; and I now sleep in an assigned tent outside.

Today I head in with Nick to work in the Hospital Psych Clinic where I will begin warming up my skills – medical, psychiatric, and linguistic.  I am inspired, daunted, challenged, and glad I am here among impressive groups and dedicated younger people.  I’ll try hard as I put my ancient oar in these troubled waters.  May the good Lord and my ancient friends, the Voodoo gods, look kindly on our efforts.

Part 2

Yesterday, I went with Nick to see the IMC facility at the Haitian University Hospital, mostly under Haitian control.  The IMC triage, outpatient, ICU, and medical units are in tents.  First we visited the ICU to see a 30-something woman with symptoms of periodic rectal bleeding, and paralyzed left arm and both legs.  The paralysis distribution didn’t make sense, nor did the bleeding pattern. She looked good, showing la belle indifference, which came on more recently, after the quake, and this fit with the diagnosis of hysterical conversion reaction.  Thinking more about the intermittent bleeding pattern, I concluded that she might be faking or feigning her symptoms, which fit the diagnosis of Munchhausen Syndrome. She was a nurse and would know what to do to generate these symptoms.  I just didn’t know how.  In cases like this, I always wonder if I might be making a mistake and I fear that I am missing something serious.  We told the nurse and doctor our thoughts, and advised that she should be transferred to the step-down medical unit because she was taking up valuable urgent care space.  Shortly after we left she had a significant bowel movement with bright red blood, though her colonoscopy was negative.  When we came back this morning, we found out that they didn’t transfer her.  They gave her an indwelling venous catheter to give her blood if urgently needed.   I suggested the next time it happened they should compare her own blood type to the blood in the bowel movement.  I was fairly certain it would not be hers, though I could be wrong.  She still had her paralysis.  While she thought that we weren’t looking, we noticed normal hand gestures in the paralyzed hand while she was talking to her sister.  We were encouraged that she would recover.

The next patient had lost his leg below the knee and was recovering from shock and speechlessness.  Next was a woman with a manic reaction, speaking fragmented English and singing American songs at us, demanding to be let out.  This state of mind had been precipitated by seeing her house collapsing in front of her. Next was a woman who had been hearing the voice of a god inside her head beseeching her to be more faithful, and she was getting better on a mild sedative and so that suggested a diagnosis of temporary confusion, not psychosis.  We saw a quietly sad woman with paranoid delusions, who was homeless and had been found walking naked.  She was pulling herself together.  Another woman who had seen her house collapse had been thought to be psychotic.  Today we got a better history from her and diagnosed psychomotor epilepsy complicated by severe anemia. The two Haitian nurses rounding with us, giving the psychiatric meds, and doing the follow-up supportive therapy, were bright, gracious and serious.  I found my Creole wanting in these situations, and had to turn to them and to the translator.  The translator was a great guy, very bright and helpful, but he stuttered.  What is going on here?

We were late to get over to what I mistakenly heard called Calvin Klein hospital where Nick delivered a great lecture to a roomful of fully participating Haitian nurses and doctors, with the hope that we would be able to influence the situation sooner or later.  (How will I do???) The grounds were covered with tents for the displaced, and all during the lecture there was a horrific metallic banging.  I found out it came from the inmates in isolation cells.

At breakfast this morning I am very sleepy, kept up by very disoriented and disturbed roosters who cried out randomly all night.  I got to know their individual cries, their personal signature calls, and I knew where they lived.  I dealt with my irritation by thinking of purchasing them for dinner.

The head of the outreach team, a young woman who has worked in Afghanistan and Iraq, and was one of the first into Haiti, has arrived.  She asks each of why we are here.  She has in mind a triangle of categories and wants to figure out where we fall in it – careerist, adventurer, or tree hugger?  I am moved by each personal response.  I appreciate the IT specialist objecting that tree hugger isn’t fair for idealists who should be respected as people of balance and realism too.  He tells us his own terms:  Mercenaries, missionaries and misfits.  Just as I am feeling more at home, someone comes in to announce that two women from Medicins sans Frontiers have been abducted last night and that the Haitian NGO community is waiting for the ransom requests.  I am now taking security warnings much more seriously.

I just found out from the Director what I will be doing here in Haiti for the next four weeks. She has designed a mental health clinic, to be attached to a small Haitian general hospital now partly run by IMC in the outlying town of Petit Goave, a little way out on the southern peninsula.  This is a new clinic, not yet functioning, with a Haitian social nurse and a translater.  I will be creating and running the clinic, which will treat outpatient referrals from the hospital’s follow-up, OPD, and family practice clinic.  Haitian family practice doctors in three nearby outlying family practice clinics will rotate one day a week into my clinic to see our patients and be supervised by me, or see mental health patients with me, to train the family doctors to incorporate mental health interview and intervention skills into their frontline work. On another day I will rotate through 4 ‘boat’ clinic outposts to do the same thing.  On two out of my four Saturdays, beginning this Saturday, all the clinic Haitian Health Care workers will come in to have an all-day Saturday mental health workshop.  Hearing all this makes me feel a little anxious and overwhelmed, especially since the trainees are all Haitian. So the workshop will be in Haitian Creole. Not that I have to do it in Creole, since I will have a translator.  But, never the less it makes me anxious.  Even in English, preparing and giving lectures is not my favorite thing to do.

I will be moving out to Petite Goave Thursday to do the first Saturday workshop and start the clinic on Monday.  I will have Wifi out there, so I am told.  I will have Sundays off, and Fridays for paperwork and lecture prep.  But even sooo!

A Group Dynamics Approach to Understanding America’s Current “Collapse”

By Charles Ashbach, Ph.D.

In 1921 Sigmund Freud published his famous monograph Group Psychology and the Analysis of the Ego. Driven by the madness, savagery and destruction of the First World War, he set about expanding psychoanalytic principles to explain the dynamics of social cohesion. It’s worthwhile that the original German title of the work was better translated as “Mass” or “Horde” psychology than “Group.”

In a similar way this essay will attempt to apply the principles and understanding developed by both Freud and Bion to help explain the social-psychological processes that have brought the United States to a condition of near “collapse” and economic “crisis.”

Freud combined his study of the libido with the mechanism of identification to explain how a group of separate and heterogeneous individuals combine to form a common emotional bond and construct a cohesive social system capable of a wide range of both creative and destructive acts.

He observed that it was through a process of introjective identification that individuals, sharing a common purpose, need, or function, were able to constitute a psychological group. Each individual internalized the image of the central leadership figure, experienced in the unconscious as a representative of the father. This process of common connection and investment of the leader had the effect of allowing all members of the group to now possess a common love object.

Furthermore, and most importantly, the installation of the leader’s image inside the individual’s super-ego-ideal created a common conscience and experience of morality. The leader, now functioning as the ideal, brought about a revalued narcissistic sense. Ideals and aspirations of the leader, and his ideology, become central to the individual member of the group. A single love object, shared conscience, and unified ideal combine to provide the members of the group a common sense of reality and purpose. Out of the many, the One was formed: E Pluribus Unum.

The common features possessed by each member, create a kind of psychic “gyroscope,” make cohesive social action possible. At the same time the homogenization of the values, beliefs, and ideals of group members leads to a decrease of diversity, complexity, and reality testing. The sense of oneness, which generates feelings of inclusion, connection, and safety works against the freedom of thought, feelings, difference, and doubt.

Once unified under a common banner the group must face the task of dealing with the aggression that is the consequence of human ambivalence. Splitting and projection are the prime mechanisms used to place the dangers of love and hate into the external, non-group environment. In fact, one of the central functions of any group is the discovery or creation of “enemies” in order to define and solidify boundaries and contain threats to the common ideal.

The feeling that a “group” exists, apart from the members who make it up, reveals the massive regression that is the consequence of sharing a common conscience and ideal. The group’s cohesion places demands on the individual members to maintain their sense of identity in the face of its homogenizing force. The pressure to define what is “true” by what is “shared” is intense and on going.

In the 1950’s Wilfred Bion offered a series of important developments in the theory of group formation and dynamics. Rather than locating the central group conflict in the Oedipal complex and family “romance” as Freud did, Bion sought the deeper dynamics of the group in the primitive emotional and phantasy experiences characteristic of the infant’s earliest connection to the mother.

For Bion, this meant the anxieties of attachment and the dangers of annihilation preceded concerns about competition and castration. Specifically, psychotic anxiety and dread were now posited as the core dynamic force that the group had to encounter and resolve.

Bion considered the group-as-a-whole to be the primary object of concern for the members of the group. While the leader provided structure and organization, the group as “mother object” provided the true source of comfort and protection against the dangers and challenges that the members faced.

The group as common object is created by the membership through a process of projective identification, not, as Freud thought, through introjective identification. In essence, each member places varying elements of the self within the group-object and then internalizes that “created” entity.

Leader, group-as-a-whole, and member now are seen to exist in a complex field that is constituted to protect the psyche and emotions of each member through a complex structure where phantasy and reality are continually acted upon, at the deepest levels of unconscious experience, to insure the maintenance of the group’s central illusion or ideology.

Bion then added a crucial concept to group dynamics. Not only is the group formed, but the members are able to use it to create a common phantasy condition, shared, unconsciously and anonymously, by all members of the group. This common “disposition” or attitude followed the group’s need to protect its narcissistic cohesion and sense of shared reality. Bion called this regressive condition the group’s basic assumption.

He felt that embedded in human nature were three organizing paradigms that provided the primary forms that collectives arrange themselves in to function and survive: Dependency, based upon the infant at the breast; Fight/Flight, based upon the paranoid and delusional experience of a threat to the integrity of the group; and Pairing, which had to do with phantasies of the primal scene and the conception of a child who would realize the wish for an omnipotent Messiah.

The basic assumption state is a regressive state, in flight from reality and dedicated to maintaining both a sense of primitive object relating and an experience of narcissistic wholeness and invulnerability. The term ‘basic assumption’ may sound as if it contains rational or conscious considerations, but actually it is an aspect of the depth unconscious, closer to psycho-somatic states, and centered on the most primitive emotional and phantasy elements.

In the basic assumption mode the ego’s function of reality testing is subordinated to the group’s primary task of affirming delusion: we are all good and pure; our leader is all loving and all knowing. Therefore another common state of group experience is required for the members to maintain connection to reality in order to adapt, think, change and grow. This mode of group structure and function Bion calls the work group.

The work group is in constant oscillation with one or more of the basic assumption states as the group deals with the challenges and demands of internal and external reality. Members reclaim their individuality in the work group, and yield it when they become the unthinking agglomeration of the basic assumption group.

The basic assumption state reveals a different definition and understanding of leadership. Rather than the leader imposing his or her idea, ideals, or vision on the members, Bion sees the membership selecting one particular individual because of that person’s susceptibility to carrying out the phantasies and emotions central to the operative basic assumption state.

The Group’s “reaction” to the catastrophe of 9-11

Having presented this overview of group dynamics, it is my contention that we can better think dynamically and symbolically about how the group, the United States, has gotten itself into the terrible set of circumstances it now faces. The problems of the group’s fear of “terror” and the worries about “collapse” and “depression” seem best illuminated by Bion’s paradigm of the basic assumptions.

The psychological effects of the tragedy of 9-11 included the shattering of the nation’s sense of invulnerability and of the absolute sense of safety of the American homeland. Those internal experiences and beliefs evaporated as surely as the steel and concrete of the Towers were immolated in those terrible fires.

As clinicians we’re aware that trauma results when events violently exceed the expectations, boundaries, and experiences of an individual. The fall of the Towers and the shock of the unknown pushed the group toward of state of overwhelming dread and disorientation. The group’s regression into the basic assumption state of Fight/Flight was the defensive adaptation to fend off the fragmenting anxieties and dread generated by these unprecedented events.

The regression was quickly revealed by the country’s stated goal of waging a war “on terror”—not on terrorists, not on para-national groups, but on terror itself. If any therapist had a patient present for treatment with the stated goal of destroying terror, per se, we would be taken aback and suggest that the person consider coming in 3 or 4 times a week to help them through their crisis.

At the national level we started organizing our resources and might to destroy a ghost, demon, or chimera. Billions, no trillions, of dollars and thousands of our soldiers have been sacrificed on the altar of this crusade against “terror.”

The Flight/Flight basic assumption allows for the mobilization of enormous states of aggression in a condition of “innocence.” Further, the normal moral structure that prohibits members from committing violence, “thou shall not kill,” is superseded by the revalued group conscience, “thou must kill.”

The enormity of the trauma caused the group to split itself. We became the “good and innocent” victims and the “terrorists” became the evil perpetrators. So much trauma, anxiety, and guilt was generated that no process of national reflection was possible. Therefore no reflection about the complex geo-political, economic and military circumstances that provided the context for the attacks was possible. The idea of guilt surfaced, but only in the form of accusations by fundamentalist preachers blaming the country for its “sins.”

To this day, no significant discussion of our feelings of guilt and responsibility has occurred, and no thorough process of finding meanings in all of this suffering and chaos has emerged. When the good object is lost, the absence is filled with the presence of the bad object, and doubt becomes persecutory.

Might we unconsciously fear that some angry deity punished our attempts to build our version of the Tower(s) of Babel and this catastrophe was the manifestation of the deity’s ire and dismay?

The group, in its manic movement into Flight/Fight mode, sought and seemingly found the moral high ground that then was used as a platform to engage in any behavior or action we deemed justified by the extent of our trauma. The group reshaped its morals and ideals in light of the trauma and in light of the need for guilt-free vengeance.

Since we sought to destroy internal objects in the guise of external enemies we created a deep sense of confusion and disorientation. To show how “good” and “grateful” we were as members of the basic assumption group, we idealized all those who protected us, and all were called “heroes.” The endorsement of leadership became total. In spite of the obvious and shocking deficiencies of President Bush, the group embraced him and reinforced his power to continue to lead us in our Fight/Flight state.

While many now criticize and lament President Bush’s failed and tragic leadership, we would do well to keep in mind the group’s creation of him to fulfill our basic assumption needs. Bush was our dummy; we, the collective, were the ventriloquist. As we now seek to assign blame, our collective responsibility lies hidden, lurking in the shadows of our indignation.

The absence created by our flight from reality was filled systematically with all forms of distraction, stimulation, and charade. Not the least of which was the creation of a war. War served both the need to attack our actual, external enemies, but, more importantly, to contain the sense of inner badness by projecting it into the enemy. In this phantasy mode, war was also a means of offering up sacrifice to the angry “god” who “punished” us on 9-11. On that altar we destroyed billions from our treasury and thousands of our children. It is no accident that soldiers are described as infant-ry.

The economic bubble that was created can now be seen to contain a manic action that would encourage consumption as an antidote for the grief, guilt, and confusion that has never left the American psyche. We should probably think of all of this manic economic behavior, especially the housing “bubble” and the middle class’s use of credit cards, as a kind of air-bag deployed to protect us from banging into the hard edge of the reality lurking in our collective unconscious.

Certainly the madness of the banks, with their abandonment of economic and fiscal reality, has to be seen in the shadow of the overall flight from the stress, conflict, and suffering that the group was avoiding. The use of the word “depression” seems to be a symbolic means of introducing the group’s real problem, guilt over the injury or destruction of good objects, into the national psyche. As yet we have not been able to approach the depressive position that might allow us to re-claim our responsibility for the madness and destruction we have authored.

Eventually, the group, like manic individuals, ran out of its perverse energy and crashed. The seven plus years of running from the internal threats and demons finally became too much for the group. It seems that the group had literally and figuratively depleted itself. Once we heard the clarion call of Obama’s vision of reality, hope, and justice, we began to contact some of the deeper layers of grief, guilt, confusion, and shame. Though, certainly, the sense of imminent Messianic transformation shows the group shifting from the Fight/Flight to the Pairing basic assumption.

In Pairing basic assumption the group believes that two individuals or forces will come together and create a “messiah” who will come from the future to save us in the present. Of course, the messiah must never be allowed to show up because his, or her, presence would disrupt the hope for magical transformation with the demands for actual work, change and responsibility.

Messiahs are almost always killed before they attempt to fulfill their mission of transforming some basic aspect of human nature. Probably it is better to see the death of the Messiah than to see the death of the dream that humanity can be fundamentally altered by the power or message of one individual. We can easily think of JFK, Martin Luther King, Bobby Kennedy, John Lennon, Malcolm X as representatives of that pattern.

Obama’s ascent seems to mark a recovery of the group out of the basic assumption state and toward the work group. His emphasis on equity, justice, thought, reality and lucid articulation represent the functions of the work group; while at the same time the yearning for Messianic magic seems to be the embodiment of both Dependency and Pairing. Somehow all will be solved for us, and Obama, along with whom (Hillary? Michele?), will produce a miraculous resolution to the 30 years of indifference, corruption, and the “dirty dealing,” from both the left and the right, that has skewed the national agenda away from justice and equality and more toward the rich and super-rich.

The bi-valent approach of Obama, toward more reality on the one hand, and toward manic stimulus on the other, suggests that he’s trying to serve some of the basic assumption needs of the group while attempting to engage the work function. The rabid resistance of the radical right shows the persistence of the Fight/Flight assumption and the seductive paranoid pull toward fantasy—away from reality testing. The lure of ideological psychosis persists in the core of the society, that is, at the center of each of us. Somehow, this position says, we should be able to solve our problems through hate and splitting, or through slavish dependency, without entering into a dialogue with reality.

We will soon see what elements of the group emerge and dominate the national agenda.

Russia Letter

By David E. Scharff, M.D.

October, 2008

Our invitation to Russia came from one of our International Psychotherapy Institute Fellows, Patrizia Pallaro, who returned from teaching in Moscow to inform us that two of our books were being translated. Did we know about that? Several months of discussion later, royalties and permissions arranged in medias res, Lena Spirkina from Moscow contacted us to say she had heard that we were interested in coming to Moscow to teach, and that she would be glad to arrange that. Negotiations about the conditions and time of year followed, and a year later we flew to Moscow for a five day visit with another few days in St. Petersburg as tourists.

Lena Spirkina (next to Jill) and other colleagues at lunch
Lena Spirkina (next to Jill) and other colleagues at lunch

Lena’s daughter-in-law, Anna, met us at the airport after 20 hours of uneventful travel, and drove us to the hotel through rush hour traffic, which exists throughout most of the day and into the late evening. The dense traffic that has mushroomed in the last ten years stayed with us throughout our stay. Moscow is a grey city of 15 million with wide streets and communist architecture that includes 7 nearly identical Stalin Palaces scattered through the city. They hold functions as diverse as a government ministry, Moscow State University, and an apartment building formerly for the elite.

One of the 7 "Stalin Palaces" in center view
One of the 7 "Stalin Palaces" in center view

On our second night Alina Krivstova, a charming, generous young woman whom we had met a few weeks earlier in Washington, took us to the opulent designer jewelry store “Alena Gorchakova,” in which she worked, where Russian-style pieces of designer jewelry, with prices perhaps exceeding any store we had ever entered, were displayed. She then took us to a restaurant in the fashion of the elite communist 1950’s, and on a night tour by car of Moscow. It was the most beautiful view of Moscow we saw during our stay.

Our young friend Alina in the Alena Gorchakova Jewelry Store
Our young friend Alina in the Alena Gorchakova Jewelry Store

By day the same views of the city, although dotted by generous parks and two rivers, were a depressed grey, giving the impression of a traumatized populace who seemed never to look one in the eye. The buildings are grey stone and of a monumental scale that feels humanly diminishing. In all, we spent a total of three days as tourists, in palaces, famous churches and, most stunningly, in the Tretyakov Gallery – featuring an impressive and interesting collection of XI-XX century Russian art that had been given to the country. There are still more galleries we did not see, including the famous Pushkin Gallery, but we went to a wonderful opera concert — first row in an elegant hall — and ate in ethnic restaurants like our favorite, a Ukrainian restaurant decorated as a country inn. Borsht is wonderful everywhere.

Russian cathedral on Red Square
Russian cathedral on Red Square

Lena Spirkina and her colleagues were warm and gracious, helping us recover quickly from our doubts about what we had gotten ourselves into. They have been taught generously by IPA members from the US, including the couple Yulia Aleshina and Pasha Snejnevski who emigrated to Washington and worked with me at the Washington School of Psychiatry while beginning their analytic training more than 15 years ago.

Psychotherapy in Russia began with a group of psychologists that included Yulia and Pasha from Moscow State University. This group also included a seminal teacher who, having no access to Western psychoanalysis, had to make it up for himself and his students. Then a few, like Yulia and Pasha, got training in the West or even in Eastern Europe as it opened up after the Soviet Union dissolved in 1990 and psychoanalysis and analytic therapy were no longer forbidden.

Lena Spirkina, then in her 20’s, was among a small group of people invited to California in the 1980s — none of them as yet trained as psychotherapists — who were given red carpet treatment and a blitz of exposures to widely varying kinds of therapy. On her return, she decided that Russia had to have training, and she has over the years founded and developed the Moscow Institute for Psychoanalytic Psychotherapy. For a long time, the institute brought in teachers from overseas – many from the US, but also Europe, and then from the IPA who used shuttle analysis and seminars in Moscow to train enough people that there are now an IPA Study Group and local training analysts. But Lena is the heart and soul of the psychotherapy training. Although it is rigorously analytic, having evolved from being widely and tentatively eclectic, it has to teach basic academic psychology in order to receive state authentication. She is able to rent space in the state Institute of Psychology, but pays for that, and all the students pay tuition to study in this completely private institution. We developed an immediate and sustained admiration for her, her faculty and the students who sacrifice so much to learn what we, in our relative freedom and economic well-being, take for granted.

But there is really a more compelling case for this group of colleagues: Russia is a traumatized society. This generation of teachers and students come from families that grew up in the most traumatizing uncertainty, with parents under constant threat of being denounced, constantly on guard. Every family was either in fear of being undone or imprisoned, or among those doing the spying – traumatic in both directions. So both the therapists and the patients share this history in their social unconscious. Lena told us something of the dramatic and pervasive trauma to her family, spread through the generations, which I will not describe here because it is her story and I hope she will come to one of our conferences to tell it herself. But it makes clear that Russia itself has centuries of trauma, from the enslavement of the serfs, to the struggle to form a middle class that was abruptly cut off by the 1917 revolution, to the 70 years of fear, imprisonment and the death of 30 million people under Stalin. And then suddenly there was a shift. Nevertheless, while we were there, there were images of Putin on TV on his birthday, felling his karate teacher and marching through the forest bare-chested with a gun. It feels as though Russia is moving rapidly back towards the dictatorship that has been its state since the first unification under the Czars and that continued under communism. But this time there is a wealthy class, and a thriving middle class with education, and a sense of more political freedom to speak — at least privately — than in China.

So psychotherapy is a new boom industry, and Lena’s colleagues are hungry to know. They have formed a Society for Psychoanalytic Psychotherapy that forms the base on which formal analytic training should rest, and which offers to spread psychoanalytic application further than the limited reach that formal psychoanalysis can do by itself. Our brand of object relations theory, with its applications to family, couple and sex therapy – and even child therapy – is relatively new to them, especially in analytic form. So they are eager to learn.

Housed in the same institute building is the publisher of Russian psychoanalytic books, Victor Beloposky. A wiry, energetic white haired man, he bounced from his desk to greet us. Then we had an hour’s meeting trying to determine the best Russian translations of some of the key object relations terms. His editor and a translator are working on the third of our books that they will publish. After one particularly protracted discussion on the concept of psychological holding, the editor suddenly felt she understood and dashed from the room to get it down.

Victor Beloposky, left, with the editor and translator of one of our books
Victor Beloposky, left, with the editor and translator of one of our books

St. Petersburg is a stunning city! Palaces and broad beautiful vistas are surrounded by canals, rivers and the sea everywhere. The battleship Potemkin is now a museum docked on a quay. The buildings are painted bright colors, while the palaces are modeled on the 18th century European ones Peter the Great took as his model. Unlike Moscow, energetic people on the street look you in the eye. The depression lifts and even here, near the Arctic Circle on a chilly, bright October day, everything seems cheerful. The art in the Hermitage – mostly Russian and European – is stunning, although the Impressionist collection is much less extensive than I had imagined. But the palaces in the city and surrounding smaller towns, built by generations of Czars and their families in the 18th and 19th centuries, are magnificent. The Germans occupied the towns approaching St. Petersburg and almost completely destroyed the palaces, but they never made it into the city because of the heroism and persistence of the army and citizens over a three year siege. The palaces have been rebuilt from their gutting by the Germans with private and volunteer efforts and now shine as a tribute to the human spirit.

Palace gardens outside St. Petersburg
Palace gardens outside St. Petersburg
The battleship Potemkin's gun that began the 1917 Revolution
The battleship Potemkin's gun that began the 1917 Revolution

We met more briefly with a group of child analytic clinicians in St. Petersburg. They have been helped with psychotherapy and psychoanalytic training by the same Western and Eastern European teachers as in Moscow, but there are fewer of them in this smaller city. Warm and generous, Misha Yarish and his child therapy colleagues asked us to tell them about the rudiments of applying object relations to family and couple therapy, and concluded with the hope we would some day return to do more.

Misha Yarish (with beard) and child analytic colleagues in St. Petersburg
Misha Yarish (with beard) and child analytic colleagues in St. Petersburg

Russia has a small but rapidly growing number of colleagues who desperately want to know what we know, how we practice, how we work with patients. Like China, it has an enormous, long-standing history of trauma, although very different in detail. The number of informed colleagues may be smaller than in China, but they are better-educated and more organized in passing on and enlarging a foundation for future growth and work. They are eager for more help, making good on every opportunity, and in their resilience, their survival of a hundred years of trauma, they have a great deal to teach us in return.

Faith and Prejudice, Part Two: Identity

By Michael Stadter, Ph.D.

Sunrise from the Summit of Mt. Sinai, Sinai Desert, Egypt
Sunrise from the Summit of Mt. Sinai
Omayyad Mosque in Damascus, Syris
Omayyad Mosque in Damascus, Syris

In my previous posting, I described a remarkable trip that I took a year ago to the Middle East in the company of Christian seminarians of various denominations. The trip stimulated many personal reflections on faith and prejudice and I wrote about some of them. In this blog, I look at the role of faith and prejudice in the formation and maintenance of personal identity.

I will start with the premise that identity is partly defined by 2 perspectives of others. First, identity is defined by who we love and feel are part of our group (family, religion, country, etc.) – THIS IS ME. Second, it’s defined by who we see as different from us and who we might fear or hate – THIS IS NOT ME, REALLY NOT ME. If our view of these not-me people changes, it may dramatically change the way we see ourselves. We see ourselves both from the standpoint of who we are and who we are not.

Let me give a simple hypothetical example. Let’s say I’m prejudiced toward Arab Muslims. I’d maybe see myself and Americans as generally good, Christian, responsible peace-loving people. I’d see Arab Muslims as, perhaps, bad, violent, untrustworthy infidels. But, what if my view of Arab Muslims changes into one that is more positive, nuanced and accurate? Then my view of myself and America may be less self-righteous and positive and I would need to confront more of the negative aspects (e.g., violence, untrustworthiness) in me and in the groups that I affiliate with. That can be very uncomfortable and a powerful force for holding onto prejudice. If my view of my enemy changes, my view of myself changes. (I’ll leave to the reader how this might apply to conflicts between Republicans and Democrats in this election season.)

Here’s a real example. In an NPR interview in 2005, Eyad El-Sarraj, a psychiatrist and President of the Board of the Gaza Community Mental Health Programme, spoke about the effects of the Israeli withdrawal from Gaza on Palestinians. He noted that, while this was a very positive move, it created an identity crisis for them. Now Palestinians would have to shift away from defining themselves through their opposition to the Israeli occupation. The shift would need to be toward coping with the differences among themselves – “Who am I if I do not have my enemy?” Last summer we saw that, tragically, Palestinians in Gaza dealt with it in one way through the definition of enemy being other Palestinians – the Fatah/Hamas civil war.


For all of the enormous benefits of faith, religious identity can and often does lead to prejudice. Of course, this isn’t inevitable but I do think there is serious potential danger here. Consider only a few of the terms used for members of various faiths:

The Chosen People

The Eternal People

The Children of God

The Faithful

The Elect

The Believers

Christian Soldiers

Defenders of the Faith


So, if “we” are the chosen, who are “they”? Here’s what I worry about. Language structures our experience. When “we” refer to ourselves with such terms, it can unconsciously structure our experience of others as not only different from “us” but as not being as good as “us.” I think it can lead to a type of arrogance rather than to a sense of humility. If “we” are that list above, then what does that make “them”? Here are some possibilities:

The Chosen People — (The Not Chosen Ones)

The Eternal People — (The Mortal People)

The Children of God — (The Children of Who?)

The Faithful — (The Unfaithful)

The Elect — (The Rejected)

The Believers — (The Nonbelievers)

Christian Soldiers — (The Infidels, Pagans)

Defenders of the Faith — (Enemies of the Faith)

Saints — (Sinners)

At the extreme, this potential for seeing “us” as good and “them” as not good can transform into “them” as downright bad or evil and worthy of being cleansed, conquered or killed. Here we see how violence and war can be initiated in the name of God.

One of the most outstanding benefits of religious faith is that, in many ways, it can transform the unbearable into the bearable. Perhaps the most unbearable and terrifying experience of human existence is death and the knowledge of it: I will die, everyone I love will die, everyone dies. Religion can make death bearable through faith in God, in salvation, and in the afterlife. From that standpoint alone, the potential for faith to be used (I would say misused or perversely used) to do violence to others is great – the person who kills the enemy will be saved for eternity. In my previous posting, I gave 2 of the many possible quotes by religious leaders throughout history invoking killing of others that will lead to salvation in an afterlife. I’ll repeat them below:

“Now we hope that none of you will be slain but we wish you to know that the Kingdom of Heaven will be given as a reward to those who shall be killed in this war [against Muslims].” (Pope Leo IV, 9th century CE)

“The martyr [referring to suicide bombers], if he meets Allah, is forgiven his first drop of blood; he’s saved from the grave’s confines; he sees his seat in heaven; he’s saved from judgment day; he’s given seventy-two dark-eyed women; he’s an advocate for seventy members of his family.” (Sheikh Isma’il al-Adwan, 2001 CE)

This extreme of violence toward the different other has its beginning with our fear or intolerance of differences in others – our human predisposition to prejudice. It can be frighteningly catastrophic when the power of religion is attached to it.


I’d like to share 2 quotes that are very different from the previous 2. They speak of the struggle toward human connection and against divisiveness — even in the face of violence and trauma. Both are from Henri Parens, a psychoanalyst and Holocaust survivor, who has written extensively on aggression and prejudice. He was also a speaker at the IPI prejudice conference in Salt Lake City and is a co-editor of the book from that conference: The Future of Prejudice: Psychoanalysis and the Prevention of Prejudice (2007).

Parens described the experience of Rami Elhanan, an Israeli whose 14 year old daughter was killed in a suicide bombing in 2005 and whose initial reactions were rage and revenge.

“Then Elhanan met Yitzhak Frankenthal, whose own son had been kidnapped and killed by Hamas. Frankenthal, a founder of Parents Circle — an organization established in 1995 for the purpose of bringing together to meet and to talk Israeli and Palestinian parents who had lost a child to these reciprocal killings — talked Elhanan into attending one of their meetings. Elhanan was profoundly moved on hearing Palestinian mothers express the same grief and rage that he felt; his rage and wish for revenge turned into wanting to foster dialogue among bereft Palestinian and Israeli parents. While on both sides of the conflict there are some who think the Parents Circle is a crazy idea, others – seeing the dire state of life revenge has wrought, and is sure to continue doing, so long as it is the solution deemed most honorable and worthy – assert that we have to see each other as we are, not as we distort each other to be, and that we have to talk together in order to live together.”

Who is “us” and who is “them”?

Parens, wrote the following about the Holocaust and prejudice:

“We must not let it happen to us again.

We must not make it happen to others.

We must not be victims, and

We must not be perpetrators.

We must learn

To live together

With our difference.”

St. Catherine's Monastery, Foot of Mt. Sinai, Egypt
St. Catherine's Monastery, Foot of Mt. Sinai, Egypt (Under the protection of Muhammed who was granted asylum in the monastery from his enemies)
Ruins of Capernaum, Sea of Galilee, Israel
Ruins of Capernaum, Sea of Galilee, Israel

Faith and Prejudice, Part I

By Michael Stadter, Ph.D.

“Now we hope that none of you will be slain but we wish you to know that the Kingdom of Heaven will be given as a reward to those who shall be killed in this war [against Muslims].” (Pope Leo IV, 9th century CE)

“The martyr [referring to suicide bombers], if he meets Allah, is forgiven his first drop of blood; he’s saved from the grave’s confines; he sees his seat in heaven; he’s saved from judgment day; he’s given seventy-two dark-eyed women; he’s an advocate for seventy members of his family.” (Sheikh Isma’il al-Adwan, 2001 CE)

Astonishing statements aren’t they? Or, are they?

I had an opportunity this past summer to take a remarkable trip to the Middle East in the company of a group of Christian seminarians. It was a 3 week seminar led by a university professor to expose the seminarians to the “Holy Lands,” and to the cultures and religions of the region. We traveled through Syria, Jordan, Egypt, Israel, the West Bank and Greece. The trip was remarkable both at the level of the countries and peoples that I met but also at the level of the intensive 3 week contact with devout future ministers of diverse Christian faiths. The experience also brought me to a more personal exploration of prejudice, a topic that was examined at an IPI conference in Salt Lake City and became the subject of a book, The Future of Prejudice: Psychoanalysis and the Prevention of Prejudice (2007). In this blog, I will present my personal reflections and raise some questions that I hope our on-line community will discuss.

In the interests of fair disclosure, my reflections are influenced by my own spiritual orientation. I was raised Catholic, but haven’t been part of organized religion since my 20s.


My fellow travelers’ faith in Jesus Christ was a powerful part of the experience. There are considerable differences among them over whether Jesus was A WAY or THE WAY or THE ONLY WAY. I found the depth and diversity of their faith to be very moving. Faith is central to their lives and to their loving

There were many instances of faith and devotion among other people and other faiths as well. In Damascus we saw numerous Shiite pilgrims. Many had made great sacrifices to come from Iran to the Umayyad Mosque to pray and to affirm their faith. This was especially affecting in the mosque’s shrine to the martyr, Hussein. We also saw the devotion of Muslims in their 5 calls to prayer each day.

Omayyad Mosque in Damascus, Syria
Wailing Wall in Jerusalem, Israel
Muslim Minaret and Christian Steeple in Bethlehem, West Bank

Yet, despite all of the powerful indications of love, faith and piety, the Middle East is such a blood-soaked land: fought over for thousands of years, continuing into today and, certainly, into tomorrow. Much of the violence has been in the name of religion – in the name of faith and love. We can argue that religion has been hijacked in the service of base motivations or that extremists have perverted the Word of God, but the evidence is clear that religion has been a force here (and elsewhere) that supports violence.

Witness the many instances in the world of this disturbing fact: Christian vs. Muslim, Christian vs. Jew, Catholic vs. Protestant, Sunni vs. Shiite, Jew vs. Muslim, Hindu vs. Muslim – to cite a partial list. And, of course we’re all too familiar with the terms Holy War and Jihad.

To put it succinctly, I left the trip being confronted with religion as embodying some of the absolute best and absolute worst of being human. It is a force that brings us together, connects us with the oneness of humanity and helps us care for one another. Also, religion is a force that divides us and promotes prejudice and violence.


1. PREJUDICE IN ITS MOST BASIC FORM IS PRE-JUDGMENT. This is a problem if we confidently keep that judgment in the face of our own ignorance or in the face of conflicting evidence. Carlo Strenger, an Israeli psychoanalyst writes, “prejudice is the maintenance of beliefs about an individual or a group without taking into account available evidence.” A prejudiced person is, as the saying goes, “Frequently wrong but never in doubt.”

2. I’M PREJUDICED, YOU’RE PREJUDICED, EVERYONE IS. Usually, when prejudice is discussed it’s easy for people to passionately agree that other people are prejudiced and “isn’t that just awful?” Then nothing much happens, except we can unite around our prejudice against those bad prejudiced OTHER people! But, if we look at the uncomfortable fact of prejudice in ourselves then that permits us to do something about it. We have a chance to accept the common humanity we share with other prejudiced people and to be open to the possibility of some transformation.

3. WE’RE ALL PREJUDICED BECAUSE IT COMES WITH BEING HUMAN. In normal development, at about 8 months, babies develop Stranger Anxiety. At this age, the infant perceives people outside of the family as DIFFERENT and becomes afraid of them. This is adaptive for a variety of reasons (e.g., emotionally knowing who the safe caregiver is vs. the relatively unsafe non-caregiver) but it also is the precursor of fear of difference. Consider that humans are predisposed to fear differences in others or, put another way, to fear others who are different from us. Also, I would suggest that we OFTEN HATE THOSE WE FEAR.

4. WE’RE ALSO FREQUENTLY PREJUDICED BECAUSE WE’RE TAUGHT TO BE by our parents, teachers and other people we respect (perhaps as a way that they unconsciously manage fear and difference). For example, I was surprised to learn from more than one seminarian that they were taught that Catholics aren’t Christian. Given the obvious denial of history this belief suggests, this is clearly a prejudice. The teaching of prejudice doesn’t have to be very explicit, either. It can be subtle and covert.

Simple prejudice can develop into malignant prejudice –malicious, humiliating violent, and discriminating behavior — through a variety of factors including overwhelming fear, hatred, emotional trauma and neglectful, abusive or otherwise inadequate parenting.


In a subsequent blog, I’ll write about issues of personal identity and the phenomenon of “them vs. us”. I invite you to discuss the following as well as whatever else was stimulated by this blog:

How does your religious/spiritual orientation inform your work as a psychotherapist?

What do you see as the relationship between religion and psychotherapy?

What do you see as the best and worst of religion?

What do you see as the connections between prejudice and faith?

What are your own experiences?

Panic Focused Psychotherapy Study

By David E. Scharff, M.D.

Among the sessions I attended at the Winter Meetings of the American Psychoanalytic Association, one stood out on the findings of a randomized control trial of a new and manualized psychoanalytic treatment for panic disorder, overseen by its principal researcher, Barbara Milrod of Cornell Medical Center in New York City. The presentation was chaired by Stuart Hauser, a leading analytic researcher, and discussed by Peter Fonagy.

I’m writing about it here because it is a hopeful and beautifully done addition to our armamentarium concerning the efficacy of psychoanalytic therapy. It adds to studies being done by Fonagy, Target and their group in London on Mentalization-Based Therapy, and by Otto Kernberg’s group at Cornell, White Plains on Transference Focused Psychotherapy. The studies apparently have a good deal of overlap in their systematic use of transference and basic analytic techniques applied to a brief therapy that is therefore much easier to test for outcome.

In this study, Dr. Milrod and her colleagues treated Panic Disorder – including such symptoms of acute anxiety as intense fear, chest pain, heart palpitations, and shortness of breath — precisely because Panic Disorder has been a focus of CBT and medication outcome studies. Since these studies have been based on 12 weeks of treatment, she designed her Panic Focused Psychotherapy (PFP) study to conform to these parameters so they can be compared. PFP treatment is manualized in a manner similar to Kernberg’s Transference Focused Psychotherapy (TFP), but this is much briefer — 12 weeks of twice-weekly weekly as opposed to a year of therapy for TFP.

(Patients were left on medication if they were already on it at the time they began the study, so that is not in the comparison. Obviously, if they were on medication at the beginning of the study, it was not in itself curing the panic disorder because symptoms of panic attacks had to be present for a subject to qualify for the study.)

Panic Focused Psychotherapy begins with initial evaluation of the symptoms, relating them to the surrounding circumstances and attendant feelings, exploration of the personal meaning of symptoms and episodes. Then the therapist works to identify relevant psychodynamic conflict, focusing commonly on issues of separation, autonomy, and anger. In the first phase, therapy aims for panic relief and reduced agoraphobia.

The second phase of PFP explores panic vulnerability by addressing transference manifestations, and working through the many situations of conflict. In this phase, therapy hopes to result in improved relationships, less conflict and anxiety in the experience of anger, separation and sexuality, and reduced recurrence of panic. Finally, a termination phase permits re-experience of conflict around separation and anger themes in the transference, because a frequent temporary recrudescence of symptoms during termination allows for a review of problems that can again lead to an enhanced ability to manage separation and experience autonomy.

In a paper published in February of 2007 in the American Journal of Psychiatry (164:2 pp 265-272) Dr. Milrod and her colleagues reported on the preliminary study that showed 73% efficacy compared to 39% for Relaxation Therapy. This study prepared the research for later comparison to medication and CBT. But at the presentation in January, Dr. Milrod presented preliminary data on the comparisons going forward with CBT. So far and unofficially, PFP holds up well against CBT and especially shows a better capacity to maintain gains months after the completion of treatment. Although the treatment is “manualized” it is not a rote treatment. The manual offers a guide as to what issues to focus on in evolving phases of therapy. There are compromises with the way we practice analytic therapy that are required to construct such a manualized treatment, but anyone who has read Michael Stadter’s excellent book “Object Relations Brief Therapy” (Jason Aronson, 1996) will recognize the enormous overlap in methodology. Stadter’s model is one of a combined focus on the symptom and the dynamic unconscious structure that underlies it, all treated in the transference using working through and a late focus on termination and loss. Brief analytic treatments can be tested, while it is exponentially more difficult to do so with open-ended, long term therapy. These studies, done in ways that can be compared directly to CBT and medication, offer to give us the ammunition to defend our trade in clear and legitimate ways that have, until recently, been sorely lacking. Peter Fonagy spoke with deep appreciation of Barbara Milrod’s study, particularly noting how arduous and time consuming such studies are, and how thoroughly and rigorously she and her colleagues were in the conduct of this study.

Webb MD’s Denise Mann reported on January 17 that, “The psychodynamic psychotherapy regimen used in the study was so successful that the American Psychiatric Association is in the process of changing its guidelines to reflect the new findings, according to researcher Barbara Milrod.”(Until now the APA has only endorsed CBT and medication as treatments for Panic Disorder.)

This research and the few comparable studies now going on are a cause for hope for our way of thinking and practicing. I look forward to more results from Dr. Milrod and her colleagues.

Psychoanalysis in China, Part Two

By David E. Scharff, M.D.

May 15 and 16, 2007

Wuhan is not known for its sights, and among friends and acquaintances with whom we discussed our trip before coming, only those with experience in international business had spent time here. Others had come to board the cruise down the Yangtze River to the Three Gorges Dam without staying in the city. But we are growing fond of Wuhan. We have been to dinner at General Wu’s house, a grand although now dilapidated mansion, eating spicy long green vegetables and chickens’ feet (and some more palatable food) on the verandah two stories above the street, looking at a sign that read “Endless Midnight: Infinite is Overwhelmed with Emotion” over an abandoned store front. Wu was a powerful South China general early in the 20th century who refused to cede power to the occupying Japanese. So they made him an offer he couldn’t refuse. When he developed a virulent tooth infection, the Japanese insisted he accept the help of their dentist. He died immediately after the dentist’s visit.

Yesterday we tried to come to terms with the difficulty the audience had following our videotapes of an evaluation. The gap in understanding is greater than anyplace we have ever taught. Although we sent transcripts of the interview of the couple ahead for translation so that the audience could follow along, the cultural gap has proved to be too great for the interview to make sense to them without quite a lot of explication. Jill labored bravely to bridge the gap, but only got through eight minutes of this tape. It was dismaying because this has always been our most popular, and most easily understood vehicle for teaching. She changed tactics and had volunteers read the transcript for a kind of scripted role play, but thought that the audience would probably have preferred to do their own unscripted role play! Later we learned that the translation of idioms was part of the problem. For instance, when the woman in the couple begins the interview by telling us, “We have three shrinks between us,” the translation read, “We are three very small people.”

Jill struggled with another discrepancy: Dr. Qijai Shi, our host, had asked us to prepare an advanced curriculum, which we came to feel is what would most suit his interests. But now we can see that most members of the audience have no background in what we are teaching, and need the most basic concepts spelled out clearly.

Jill and I spent the next session consulting jointly to an extremely depressed and frequently suicidal young woman, a hospitalized teacher of Chinese language and literature who had lost her job, she said, because her students objected to her disciplinary methods, and who now only wanted to go home and stay with her parents. A sad situation! Dr. Jun Tong, the head of the Inpatient Unit, reports that this woman is actually much improved after some time in the hospital and several sessions of psychotherapy. Dr. Tong tells us that many of the teachers, themselves with little training in pedagogy, are quite harsh and therefore unpopular. Jill continued her teaching for the rest of the day, including a consultation to a case that was extremely well presented by an experienced therapist, while I was given my day off for a tour or two of the city.

Dr. Wu Xiaojan (who has chosen the English name Rose), a 26 year old woman psychiatrist, is Dr. Shi’s protégée. Graduated from the medical school of Wuhan University two years ago and about to complete her Masters Degree in psychotherapy, she will join Dr. Shi’s staff in July. Her English is excellent. She has been an able translator when Dr. Shi hands over to her, and on this occasion, she was tasked with giving me the tour of the city with a clinic car and driver. We went first to the Guiyuan Temple, an impressive although somewhat shabby sprawling structure that houses 500 painted life sized images of pupils of Buddha, each with a distinctive persona, some serious, some fearsome, some whimsical. In one main hall, a golden image of Guiyuan stands on a heavily decorated alter. A peace garden occupies one corner, and massive reconstruction is still taking place on other parts of the large site. What is most impressive is that this is a working religious operation, with monks teaching and ordinary Chinese coming to pray in various halls in the temple. The whole effect is perhaps marred by a lack of tiptop repair and decoration, but my interest was carried by the fact that I could easily see that despite more than two generations of repression of religion, this place still had day to day meaning for so many people. What we learn as we tour more of China is that the culture has not been dominated by a religious ethic for a long, long time. Although we are used to linking Confucianism and Buddhism with China, the country has been principally secular for perhaps a thousand years. There are active religions, including some Christianity, but the lack of a dominant religious ethic began long before the Communists came to power. Weddings, for instance, take place in restaurants, not churches or temples.

I was not prepared for how impressed I was by the next site, however, because the guide book is dismissive of the Hubei Provincial Museum, saying only that it is dedicated to artifacts excavated from the tomb of Marquis Yi who died in 433 B.C. What an understatement! This is one of the most impressive collections of tomb elements I have ever seen! Three years ago Jill and I saw the newly opened, magnificent “Lord of Sipan” tomb reconstruction in northern Peru when we visited one of our daughters who was working in Lima. This was every bit as impressive: Perfectly preserved bronze serving and drinking vessels, large and small, beautifully preserved arrow and spear heads with crossbows, bamboo spear shafts, full suits of lacquered armor, woven silk, massive group tombs to house those who were required to die with Marquis Yi. The collection of likenesses of animals is stunning, but the elaboration of fanciful animals, of one animal turning into another, of a tree that turns from frog to bird, of graceful antlers arising from the head of a bird is hauntingly beautiful. And most of all, a full orchestra perfectly preserved: a mounted collection of several dozen musical bronze bells, from large to very small along with zithers and wind instruments. Apparently, 2400 years ago, Marquis Yi liked music! The highlight of the visit is the concert. While the ancient instruments are all playable, to preserve the originals, the concert is given on a full replica set playing traditional Chinese music accompanied by fluid, graceful dancers, and a small fillip of modern Western music to show how flexible the orchestra is.

The next day, we woke to a grey rainy sky, an army of umbrellas held over motor scooters, bicycles and pedestrians crossing the huge intersection below our breakfast window. The ebb and flow of humanity rain or shine. We tried to adjust our teaching, to match it more appropriately to the mixture of experience in the audience, focusing on the rudiments of the frame required for therapy, a smattering of attachment theory and the way it could be used through assessment of the patient’s language and narrative, some neuroscience of the frontal lobes as the executive of emotional regulation, and the role of the face and mirror neurons in expression and reading of emotion in development and in psychotherapy.

It is odd to teach about non-verbal communication, when we are feeling that the audience is having such difficulty reading the non-verbal expression of our teaching tapes! On this day, while Jill had her turn to see the monastery and museum I had seen the day before, instead of playing a whole video, I played short segments and told the story of an interview with a couple with sexual difficulty who had delayed their marriage in order to get help. We discussed the role of sexuality in the formation of their bond, and of the trauma each of them had suffered growing up in structuring their relationship and their difficulty. We seem to have hit a better level of understanding for the group – but I didn’t think we managed a really good fit as yet.

Jill returned from seeing the temple and museum to share in conducting an interview of a family of a 17-year-old girl who acts up a good deal and whose declining school performance distressed her and her parents so thoroughly that she ended up in the hospital. It was an entertaining affair. The patient’s English was excellent. The English name she had chosen for herself was Elizabeth (altered here for her privacy), and when I went to ask her to participate in the live, observed interview to which her parents had already consented, she flippantly answered, “No sweat!” and headed down the hall to the interview room. Elizabeth translated (and actually often mistranslated) our comments for her parents, while Dr. Tong then corrected her adolescent attempts to mislead the parents, and we worked for 45 minutes to make an assessment of her ambivalent wishes to satisfy and thwart her parents’ ambitions for her. “All Chinese children are under pressure to live up to their parents’ high hopes for them,” Elizabeth said – and young Dr. Wu confirmed that it is so: places are so scarce in the good schools and the reward for success is so high, that all ambitious families are under enormous pressure. Since 1981, all urban families are held strictly to the one child policy, so that each family has but one precious child who is their hope for the future. (We learned of an exception later in Shanghai where negative population growth has led the government to allow two children.)

What makes things worse for the one child families like Elizabeth’s, is that the parents were usually denied a similar advantage because of the destruction of educational possibilities during the Cultural Revolution when Mao ordered young people to forego education and the children of professional and educated families were sent to the countryside. This happened to the parents of our young guide and translator, Dr. Wu, whose parents have been generously supportive of her growth and education, still paying the now expensive university costs and supporting her in the long slog before she becomes eligible for a salary for the first time later this year. But in the case of Elizabeth, the situation had become sadly complicated. Still, these were dedicated and worried parents who clearly would do whatever they could. And while Elizabeth was flamboyant and provocative, disguising and then flaunting her story of declining performance and erratic behavior over the last three years, she responded to our efforts and steadied down in the interview to show flashes of quite remarkable intelligence and insight. True she fell about on the floor and acted “crazy,” but she responded to limit setting and acted sanely again. At the end, in an oedipal enactment, she told me that she wanted my email (which I did not give) so that she could see me in America in three or four years, and immediately turned to tell Jill that she was beautiful. (Elizabeth had a remarkably young and beautiful mother.) We thought that, despite her hysterical psychosis, she had the potential to make good use of family and individual therapy, perhaps a mild learning disability in math, and a supportive, if baffled, family.

The exhausting day of teaching ended with Dr. Shi treating us and our two young guides to an hour’s foot massage, called “reflexology.” What a comic sight, the five of us lined up in a row in plush armchairs, with four young women and a young man for Jill, kneading, slapping, and massaging our feet, legs and shoulders for an hour until we relaxed thoroughly. Dr. Shi kept worked on a large sheath of papers throughout his foot massage.

May 17, 2007

In the teaching today we tried to make modifications based on the experience of the first three days. Jill began by taking questions, and the discussion therefore was much closer to the level of interest of the group. She had to go over the basic ideas of projective identification and transference, using simplified examples from her practice. Later in the day, we interviewed a middle aged couple while the audience watched by video feed to another floor. The couple was of particular interest because the wife was educated while the husband was not. She used her excellent English to exclude him from direct contact with us. We felt this gave a new version to the dynamic of their marriage in which she had chosen a much less educated husband who she felt was more emotionally available than her strict and controlling parents, only to later reject him because unconsciously he represented her denigrated self. Beginning with the pregnancy that produced their daughter, she had become emotionally provocative and he physically abusive. Later he spent money from his overtime work on prostitutes, resulting in her acquiring a gonorrheal infection. They had settled into a marriage marked by emotional distance and fighting. Both had considered divorce, but neither felt they were likely to find a better partner. Finally a friend of the wife had recommended that they seek psychotherapy. The interview was made immeasurably easier by Dr. Shi’s translation which gave him a role like an additional co-therapist. He and I worked to include the husband on a more equal footing to compensate for the way the wife kept trying to recruit Jill to her point of view. At the end of the interview, Dr. Shi offered to see the couple in marital therapy, and the husband, whom the wife had described as reluctant to come to therapy, seemed willing.

Dr. Shi left our afternoon teaching to meet his German colleague, Wolfgang Senf from the University of Ulm, at the Wuhan Airport. At a grand dinner in a private room in one of several Wuhan restaurants that seats 3000 people and is permanently set up for large weddings, we learned more about the alliance between the German-Chinese Cultural Alliance that has been the guiding hand in the establishment of the Wuhan Hospital for Psychotherapy. Dr. Senf, a psychoanalyst, has had a leading hand in the design of psychotherapy training in Wuhan. He has been coming to China for many years, and to Wuhan several times a year for the last 5 or 6. Bejing is only an enviable mere 9 hours from Frankfurt, so the trip is not more difficult than for us to go to Europe. Dr. Senf has set up psychotherapy training that spans the modalities and models of analysis, cognitive behavioral, and systems therapy, and has come to the conclusion that what is needed is not training in analysis or analytic therapy first and foremost, but basic training in doing all psychotherapy. He has developed a basic curriculum that the first generation of trainees can then implement with his and his colleagues help. In the place of individual personal therapy for the trainees, he offers sessions two or three times a year in “self awareness” in which he consults to their own process of self-examination which should continue in the intervals between his visits. The supervision and personal sessions Dr. Senf gives are augmented by local supervision given individually and in groups by Dr. Shi. The design stems from Dr. Senf’s conclusion that standard training and more intensive therapy and supervision are simply not possible in China at this point in the evolution of dynamic therapy, so that the question is comparable to one Winnicott posed in conceptualizing the provision of therapy to the large numbers of children seeking help — not how much can be done, but how little need be done to get the job done. This design contrasts sharply with the discussion Jill had with Elise Snyder before we came to China. She has been working in China for more than 20 years, and currently has a handful of Chinese professionals in analysis at very low fees in a program in which American analysts donate time and accept these fees. The fees cannot be taken out of China, she told Jill, so these analysts have to come to China to spend the money. The scope of influence seems entirely different.

The more I talked with Dr. Senf, the more I was impressed at the complexity of the problem of jump starting psychotherapy in China. The professional audience is eager and naïve. But they won’t wait the many years it would take to slowly build analytic psychotherapy skills to the level of practice of Europe and the Americas. What will practice and training be like in the wake of this kind of short-cut training? Will the level of practice ever reach even that of our mid-level trainees, or will it become a kind of analytically informed counseling? I felt that I had to withhold conclusion, and perhaps after experience in Shanghai at the conference Dr. Shi had partnered, I might feel I knew more about the problems.

May 19, 2007 Beijing

We have spent the last 2 ½ days touring in Beijing after a morning flight, met by Martin, our guide with Mr Jin, the driver of a Chinese make car rather like a down-market Lincoln Town Car. It was a hard working three days of touring, all the sights of the city including Tiananmen Square, the Forbidden City and the state precious objects, a teeming city now surrounded by six ring roads, construction everywhere in anticipation of the 2008 Olympics, more subway lines, highways, high rise apartment buildings, and ever more cars where there were almost none fifteen years ago. But the pollution is not bad, nothing like Wuhan, perhaps because, as Martin told us, industry has been moved out. The architecture of the years the Russians were building for the Chinese, and even after they left with bad feeling, is extremely . . . well, “pedestrian” would be high praise. It’s ugly and rapidly decaying in the way East Berlin is drab, even the relatively expensive apartments. Prices escalate the closer to the center of town, beginning with the 4th ring road, and by the 3rd ring road, only wealthy foreigners can afford the new apartments being built everywhere. The posh Peninsula Hotel doesn’t have the panache in its management that we have experienced in, say, Sydney, but it’s the best that is available we assume, given that the Kennedy Center Board is also staying there during their visit to Beijing.

The first day we visit the Temple of Heaven, a drum tower with ancient timekeeping drums and cymbals, and a bicycle-rickshaw visit through the part of Old Beijing that is being preserved and spruced up for the Olympics. A 73 year-old woman still lives in one of these ancient, not very attractive houses, not wanting to move. She keeps occupied by serving tea to visitors like us, and tells us about her three children, in their forties, each a high level professional with, of course, only one child apiece. They would never live in this old neighborhood, preferring the new high rise apartments, but they visit her and she them – especially when she took care of their newborns some years ago. I’d guess that in another ten years, this neighborhood will be the object of gentrification like Soho or Georgetown, and prices will skyrocket at the chance to get away from the anonymous new apartments.

Yesterday was the Ming Tombs, wonderful treasures from the Ming rulers, and the Great Wall. We climbed one portion of the 6000 mile national treasure, reconstructed after its destruction several times, most lately by the European assault on China in the 19th century and by the Japanese devastation of so many things from the 1930s until the end of World War II. This is true also of the Forbidden City where the Emperors lived from the beginning of the 15th century in the Ming and Quin dynasties, reconstructed after. But these, like Tiananmen Square, are not beautiful. Covered in grey brick, they are impressive, with rooms of precious objects and thrones, awe inspiring, but not beautiful. But there are wonders: the carvings of jade of all colors and from intricately small to large and towering landscapes, and especially a collection of clocks, mostly from Europe, with the most wonderful detail in all sorts of precious materials – gold, enamel, porcelain – and the most wonderful clockwork: the motions of the solar system, varying musical accompaniments to the hours, and one European looking scribe sitting at a desk who writes Chinese calligraphy of eight characters on fresh sheet of paper when set in motion. The Dowager Empress who reigned at the same time as Queen Victoria, and who is roundly believed to have been a selfish and cruel ruler, had a passion for clocks, and collected Chinese and European clocks that are marvels of the world.

This empress also loved the summer palace an hour’s drive from Beijing. Built around a large and wonderful man-made lake, the woods, the Buddhist pagoda tower, and most of all, the painted covered gallery along the side of the lake with thousands of painted images of myth, animals, birds, and country life are one of the most wonderful sights anywhere. The paintings line the crossbeams, the ceiling, and the outsides of the picture gallery walk, with occasional gazebos with stepped ceilings, all painted brightly. The Summer Palace is a beautiful, relaxing park, soon to be made easily accessible from downtown Beijing when the new subway line is finished for the 2008 Olympics.

Beijing is not itself beautiful. But it is teeming with a large and growing population, many of whom seem increasingly prosperous and middle class, growing numbers of tourists from elsewhere in China and abroad. Mixed in with this phenomenon of a seemingly middle class city, there remains a deference to Chairman Mao, at the same time there is gratitude to Deng Xiao Ping for reversing the destruction of the Cultural Revolution that, from 1966 to 1976 when Mao died, disrupted all intellectual and organized life in China, killed millions, kept people from going to university, and kept a generation from learning anything that would enable them to earn a useful living. Only in the last 15 years, has China opened up to the economic and technological progress that has brought it the rapid economic and intellectual gains, developed its enormous economic potential, and brought it to the world’s attention as an emerging presence on the world stage – and fueled it’s interest in psychotherapy.