Projection Writ Large in American Politics.....

 

Recent events lead me to the conclusion that I should comment on them with the hope of breaking up the current pattern.  I see a lot of “hopes and prayers” commentary and “we need to unite like we did after 911” – but I don’t think that gets us very far.  What might help is recognizing the pattern, what it means, and using that knowledge to move ahead.    

Let’s start with the pattern.  To me it looks something like this. 

1:  Gun extremism for the past 20 years (as previously defined).  This results in no adaptive solutions for the problem for one of the major parties.

2:  Normalization of name-calling, blame, and rage by the President.  I don’t think any footnotes or references are needed at this point.  He posts something on almost a daily basis on his social media platform consistent with these activities. As Robert Jay Lifton said in 2017 commenting on the Trump Presidency as a descent into darkness “With Trump of course malignant normality becomes the rule because he’s President and what a President does tends to normalize potentially bad, evil, or destructive behavior.”

3:  Secondary spread of these patterns of behavior to everyone in his party – reinforced by mandatory compliance with his wishes using direct threats.

4:  Attributing all of the bad behavior to other people and another political party and acting as if that is true. 

In psychiatric parlance, 1 -> 4 above is referred to as projection.  I notice today that it is also used by commentators who are not psychiatric professionals.  A basic definition of projection is: ‘’Feelings and desires are not seen and admitted in oneself, but excluded from one’s experience and attributed to another.” (1)  In dealing with a person who uses that defense – it is common to feel like you are being blamed for something you are not responsible for and experience the associated anger.

But it can get even more complicated.  Kernberg writes:  “In contrast to higher levels of projection characterized by the patient’s attributing to the other an impulse he has repressed in himself, primitive forms of projection, particularly projective identification are characterized by: 1) the tendency to continue to experience the impulse that is simultaneously being projected onto the other person, 2) fear of the other person under that projected impulse, and 3) the need to control the other person under the influence of this mechanism.” (2)  In other words, the accuser in this case may be doing the same behaviors that he is accusing the other person of doing. In the cases I am referring to another party or member of another party is being accussed of radical politics that leads to political violence by a party or member of a party that has advocated and conducted radical and violent politics for years.

Before anyone invokes the Goldwater Rule here – let me say that I am not making any diagnosis of any individual.  I am simply observing patterns.  Observing patterns at a macro level is different from observing them in an individual patient in an intersubjective setting.  That field is profiling and it was invented by Jerrold Post, MD.  Post observes that in the case of paranoia projection distorts reality (3).  More specifically:  “Attempting to discredit Clinton’s popular victory in the 2016 election, he claimed massive voter fraud by illegal aliens.  As the 2018 midterms approached Trump expressed his concerns that the ‘Russians would be fighting very hard for a Clinton victory’.  So in his fevered imagination, there was a real basis for voter fraud.  And this suggests, given his reliance on the defense mechanism of projection that he would consider voter fraud.”  He subsequently refused to consider any polls that did not show him leading and called them fake news. (4).  Given his role in concessions to Putin and uniting China, Russia, and North Korea – the original suggestion of voter fraud was not consistent with reality.           

Sure you can say it’s just entertainment.  You can say like a recent District Court Judge that it is just rhetorical hyperbole that no reasonable person should take seriously.  You can say that Trump is “just joking” and that nobody takes him seriously but that misses two critical points.  First, this pattern of thought had to start somewhere.  Most of us are familiar with it from early to mid-adolescence when it is a developmental stage.  We can recall when it ended and we made a conscious decision to take responsibility rather than blaming other people for our problems.  Second, there are obviously many people who take this pattern of thought seriously and who can blame them?  I have seen trained mental health professionals fooled and reacting to it.

It is at the point where it cannot be ignored.  If you “do your own research” all the facts are out there. The current situation is the result of a decades long process that values gun extremism and political divisiveness – all leveraged by one party.  As long as you are caught up in that process – things will only get worse.  The results of future violence will be predictable and the soonest anyone can hope for change is 3 more years.  Stop the problem now by seeing this for what it is – a pattern of thought and behavior that most people grow out of.

Are there concrete steps you can take?  I suggest the following.  First, recognize what is going on. I am an old man and I have never seen a President behave like Donald Trump before.  All the projection going on needs to be ignored.  When you see news stations and social media sites trying to amplify his rage and name calling – just shut them off or ignore them.  You will not be missing a thing.  Think of the good old days when we had Presidents from both parties that did not demand our constant attention and outrage.  Presidents that acted in good faith for all of the people.  Presidents you could criticize and it would be taken seriously.  The government ran quietly in the background.  It was never perfect but it was a lot better than what we currently have.  Second, recognize that one of the provocative strategies associated with projection is to devalue some and overidealize others.  Civil servants, scientists, military officers, veterans, women, the disabled, low income people, and minorities have all been devalued while Confederate Generals, dictators, and white supremacists and neo-Nazis are praised and idealized.  It is a consistent dynamic over time.  Third, projection is a mechanism for producing bogeymen. One good example is the alleged left-wing organization Antifa.  Whenever I encounter that trope, I typically ask for evidence the organization exists and find none.  The Wikipedia page suggests there have been more hoaxes than action. For comparison, I was in college during the time of the Weather Underground and a collection of other radical underground left wing organizations were responsible for 2,500 domestic bombings in 1971 and 1972 (5).  That included attacks on universities and munitions plants. There is no possible way that any organizations like those exist today.  Fourth, recognize that the mechanisms I am referring to are intertwined with rhetoric and a distorted sense of reality. The best example I can think of is the constant accusation that you must hate a politician because you disagree with them. That is a recent development in the political landscape and it is a direct product of projection. You attribute hate to someone else if you really hate them and (per Kernberg) may experience it at the same time, fear the person you are projecting onto, and feel the need to control that person.  You also don’t have to think about it too long to see that the person(s) doing this has to see themselves as being extraordinarily important in your life.  That is also not consistent with reality.

There has never been a time in my life when ignoring rhetoric and focusing on reality has been more important.  I hope that I have provided a few pointers on how to get there and am confident that most mature adults in the country can do this.  When that happens it will be the unifying factor we are all looking for.  

 

George Dawson, MD, DFAPA

 

 

 

References:

1:  PDM Task Force.  Psychodynamic Diagnostic Manual.  Silver Springs, MD.  Alliance of Psychoanalytic Organizations. 1980:  p. 643.

2:  Kernberg OF.  Severe Personality Disorders: Psychotherapeutic Strategies. Yale University Press, New Haven.  1984: p. 16-17. 

3:  Post JM.  The Psychological Assessment of Political Leaders. University of Michigan Press.  Ann Arbor, MI. 2003: p. 96.

4:  Post JM, Douchette SR.  Dangerous Charisma: The Political Psychology of Donald Trump and His Followers.  Pegasus Books, New York. 2019: p. 222.

5:  Burrough B.  Days of Rage: America’s Radical Underground, The FBI, and the Forgotten Age of revolutionary Violence.  Penguin Press, New York. 2015

6:  Lifton RJ.  The Nazi Doctors.  Basic Books, New York.  1986.

Listening with the Third Ear….

 

I joined a group co-teaching a resident seminar in psychotherapy a few weeks ago.  It is an interesting exercise blending didactics and experience.  The format is an hour of psychodynamic focused didactics followed by an hour-long discussion of a transcript by everyone in attendance including residents and 4 faculty. That is an interesting discussion of the technical aspects of therapy as well as individual differences in interpretation and intervention.

Today’s session was about listening and how listening in therapy may be different from what people consider to be typically focused or unfocused listening.  There was some discussion of how you listen to friends as opposed to strangers.  There was a secondary discussion of the depth of listening with a focus on unconscious determinants.  It led me to reflect on a couple of things during the session.

The first was focus.  Very early in my discussion with patients I was focused on what they were saying.  My focus was the same focus I would have with friends or family even though none of my patients would ever enter that sphere. People knew that I was serious and took them seriously.  As I thought about the way I interacted with people over the years – it was apparent that even though patients are technically not friends within a very short period, I would know more about them than I knew about most of my friends.  In some cases, I was more worried about them and spent more time worrying about them than I ever worried about most of my friends. The difference was in the relationship.  With friends there is a mutual affiliation and expectation of support.  In the case of patients – the relationship is for the benefit of the patient. Apart from payment, the gratification of doing good work,  and the occasional thank you -  the therapist should expect nothing back from the patient. 

The focus in both diagnostic interviews and psychotherapy was meditative to me.  I felt extremely comfortable in that setting.  I looked forward to seeing people.  It was the place in life where I felt the most comfortable. I was not particularly interested in one problem compared with another – just hearing every unique story.  When you get to a certain point in your career you are full of confidence.  You no longer have to worry about running into an issue that you don’t know how to address. You know that most people will leave your office feeling better than when they entered – even if it is an initial evaluation. 

Focus in a psychiatric interview is multifaceted.  It involves hearing both the content of what is being said and whether it makes any sense.  Do all the elements hang together in a cohesive picture or not?  If not, the job is to immediately clarify what is happening.  That always leads me back to think of an Otto Kernberg seminar that I attended 30 years ago.  Kernberg described the process of confrontation as exactly that – an indirect inquiry that would facilitate bringing these seemingly disparate elements together.  An extreme example that I frequently use is from acute care settings.  In those settings, my first task of the day was to interview people who had been admitted on involuntary holds.  They were often very angry to be hospitalized and demanded to be released. Their first words were typically: “I want you to discharge me.  You have no right to hold me in this hospital and I want to be discharged.”  The reality is that I had never seen the patient before.  I had nothing to do with how they came into the hospital or the fact that they were on an involuntary hold. Restating those facts to the patient was the type of confrontation Kernberg discussed and it most frequently led to a more productive reality-based conversation.

The focus for me always has the elements of attention, testing what is being said against my internal knowledge of reality and doing the same with any emotional content, and thinking about underlying theories for what I am seeing. At times I will explicitly ask the patient for their theories about what is happening to them to see if they have any and if they do whether they are plausible.  It is generally important to try to figure out the meaning of certain patterns of thought and behavior including dreams fantasies, and other potential unconscious content.

There is also a focus of kindness toward the patient.  The relationship is one of beneficence.  It always reminds me of Jerry Wiener’s comments about the essence of psychotherapy “Be kind and say something useful to the patient.” When I bring that up – many therapists bristle at the apparent oversimplification.  Kindness does get directly to the point that the therapeutic relationship is different from the patient’s perspective in that they should experience the therapist as unique relative to the common experiences in their life. Some therapists I have encountered over the years have talked about “reality therapy” to mean that the therapist should be reacting to what the patient does just like everybody else.  This misses one of the main advantages of psychotherapy as an opportunity to examine what is really going on in those other relationships and correct it if necessary.        

I addition to attending to the primary problem in sessions the therapist must also have a focus on the relationship and empathic responses to communicate to the patient that he had an adequate understanding of the mental problem that the patient is describing and what all the elements may be.  The relationship aspect may include the stimulus value of the therapist and how that varies with age, sex, physical appearance, and communication style.  To cite age as an example – it is common for early career psychiatrists just out of residency to be greeted with: “You are too young to be a psychiatrist.  I have never seen a psychiatrist as young as you are”. Those statements come with varying degrees of enthusiasm and carry several implications that can be explored.  On the other end of the spectrum I have not had anyone comment on my advanced age directly – but have heard comments that some doctors are so old “they did not know I was in the room.” 

Transference and countertransference are obviously relevant here but I want to stay with the focus in interviews and sessions.  In the seminar today, a paleontology metaphor was described about mining the different layers of the unconscious and how to get there.  That suggests a lot of heavy lifting to me. I see it as a much more dynamic situation.  After all – here I am extremely comfortable and interested listening to people and editing their comments for plausibility, cognitive and emotional content, defensive patterns, and their own theories about what may be happening to them.  Together we are defining what brought them in to see me along with all the relevant cultural, social, biological, and developmental factors.  This is all unfolding in the context of a specially defined relationship.  Throughout that session I am switching between listening mode and an interventional mode that involves supportive, clarificatory, and interpretive remarks.  That switching needs to be dynamic, context based, and is not the same for any two patients.  There is also the practical or real relationship including payment arrangements, appointment times, call instructions, and emergency contact instructions.

There is a check that must happen during or between sessions. Every therapist has to ask if they really understand what this patient is saying and if the patient is being helped.  That check can occur as early as the first interview.  In some cases, the therapist may consider the patient’s problem to be outside of their field of expertise. This can also happen after prolonged therapy where the benefit to the patient is uncertain – but they want to continue the therapy.

The title of this blog post refers to a famous book called Listening with the Third Ear by psychoanalyst Theodor Reik. I purchased the book in 1986 on the recommendation of one of my psychotherapy supervisors.  The subtitle of the book says it all: “the inner experience of the psychoanalyst.”  Reik was one of Freud’s first students.  In the chapter “The Third Ear” he describes attending to various cues of the unconscious life of the patient as well as what may prevent the analyst from perceiving them. He illustrates how the subjective reaction of the analyst to the patient can be one of those clues.

Reflecting on this essay so far – the one dimension that needs additional commentary is the non-linear nature of listening and the interview process. It is easy to think of the process as a matrix dependent on focused attention and a long sequence of questions.  That is the format of a structured interview. In many cases these interviews are algorithmic based on hierarchies and inclusion and exclusion criteria.  In a clinical and psychotherapy setting the focus is more on all aspects of the presenting problem. What the patient brings in to the session and the continuity over multiple sessions is more of a priority. Reik describes a patient who caused him to feel annoyed, two different patients walking by a mirror outside his office and how they react to the mirror, and the way a patient looked at him as well and what that meant for their unconscious life. 

In a subsequent chapter he goes on to describe how the analyst must avoid selective attention to what they might want to hear and how they must attend to everything.  He points out that Freud used the term gleichschweben  that has the connotation of equal distribution and revolving or circling (p. 157).  He suggests the terms freely floating and poised attention.  He adds Freud’s rationale for this type of attention as being two-fold.  First, it avoids exhaustion since it is impossible to attend to anything for an hour.  Secondly, it avoids biasing the interview or session toward a particular aim or goal.  The session after all is directed at what the patient is deciding is relevant.

As I revisited my technique, this captures what I tend to do in interviews and sessions. Since I read this book nearly 40 years ago – I cannot claim to have invented it.  I can add a little to what Reik and Freud have to say especially in diagnostic interviews.  It is possible to incorporate free-floating attention and transition to a more structured interview as necessary. Most psychiatric practices these days require that psychiatrists seen anywhere from 2 to 5 new patients per day.  Most of those patients will not be seen in either psychoanalysis or psychodynamic psychotherapy. But most of those patients will benefit from the listening techniques and interventions that can be attributed to the early analysts. It is also possible to add a psychotherapy component to practically every patient seen by a psychiatrist over time – even in relatively brief appointments.  

 

George Dawson, MD

 

References:

Reik T.  Listening with the Third Ear. Farrar, Strauss, and Giroux. Toronto. 1948: 144-172.

 

Supplementary 1:  Both Drs. Otto Kernberg and Jerry Wiener in the above essay are psychoanalysts with extensive teaching and publication experience. They are both medical doctors.  I left the qualifications out for the sake of brevity. I heard Dr. Wiener’s remarks at one of the Aspen Psychotherapy Conferences organized by Jerald Kay, MD.   

Supplementary 2: According to Reik, The metaphor listening with the third ear was borrowed from Nietzsche -  Beyond Good and Evil, part VIII, p.246.  A partial excerpt follows:

"What a torture are books written in German to a reader who has a THIRD ear! How indignantly he stands beside the slowly turning swamp of sounds without tune and rhythms without dance, which Germans call a "book"! And even the German who READS books! How lazily, how reluctantly, how badly he reads! How many Germans know, and consider it obligatory to know, that there is ART in every good sentence--art which must be divined, if the sentence is to be understood! If there is a misunderstanding about its TEMPO, for instance, the sentence itself is misunderstood!..."