Book Excerpt: Pages 141 to 147
Relationships: A psychiatrist's narrative
Relationships: A psychiatrist's narrative
This essay analyzes the relationships and interactions between the observing narrator and the people he observed, as described in two stories of this collection: In a cloud of smoke and The melody. After reviewing the characteristics of those relationships, we will uncover the implied model used during the interactions between observer and observed. We will draw the implication that this model has for the practice of psychotherapy and psychiatry, especially when using narratives as a therapeutic tool.
The narrator of In a cloud of smoke, along with other staff members, participates in a symbolic burial ceremony at the end of a program at the National Center for Post-Traumatic Stress Disorder (PTSD) at West Haven VA Hospital in 1992. This ceremony occurs towards the end of a hospitalization of a group of Vietnam War veterans who were treated there together for several weeks. During their hospitalization, each veteran would process the specific traumatic events that affected them. Each Veteran had told his own story, which had been shared with the other members of the group. They received support from each other and from their families while expressing their personal narrative. In preparation for the ceremony, which was well attended by their families or loved ones, the veterans were asked to write a list of the fallen soldiers they were mourning. This ceremony was meant to help the veterans to have closure for their losses. The ritual has been described by David R. Johnson, who was directing that program at the time.
The narrative of In a cloud of smoke is written from the point of view of a psychiatrist who had just joined that program participated initially as a newcomer and a stranger, and in the chorus of treatment staff in the mourning ceremony. During that ceremony, as in another ceremony (the “crossing over” ceremony commemorating the program’s completion), the staff chorus repeats comforting lines intended to heal the veterans from their trauma and foster the connection and integration with their families and communities. With words like “we let you down” or “this is war,” the chorus tries to repair the feeling of abandonment that the veterans experienced when they returned from war. The input of the staff chorus in this ritual was also supposed to alleviate the veterans’ burden of guilt for having survived their fellow soldiers in this brutal war involving dangerous enemies and innocent civilians. Ultimately, at the end of the mourning ceremony, the staff chorus, acting as a moral court, authorizes the veterans to release the spirits of the fallen soldiers they were holding onto and that prevented the veterans from moving back into civilian life.
The ritual created by Johnson, the Master of Ceremonies in this story, has an implied religious overtone, using Christian symbols, such as the crown of thorns worn by Christ, and the Hindu ritual of cremation. These Christian and Hindu rituals are foreign to the narrator’s tradition and contribute to his discomfort and sense of distance. Bilu and Witztum, respectively an anthropologist and a psychiatrist in Israel, describe several interesting uses of religious-like rituals in psychiatric practice, in a more culturally competent approach for their Orthodox Jewish patients [2]. It is obviously more difficult to be culturally specific in a more multicultural group setting, such as in our story. Johnson describes previous homecoming rituals inspired by Native American rituals, adapted for Vietnam veterans [1]. Those rituals did not match the cultural perspective of most veterans and therefore Johnson advocated the use of different, “more secular” rituals. However, in his ritual, which is called the Ceremony for the Dead as described in our story, spirituality and religion are still very present, even if only implied.
In In a cloud of smoke, when the psychiatrist is exposed to this intense mourning ritual, he confronts his own past and his own narrative. The broken narrative of the veterans and the healing narrative of the chorus sometime clash with the psychiatrist’s own narrative. At a certain point, the psychiatrist became aware that his narrative interferes with his experience of the ceremony. The psychiatrist views the list of the names of fallen soldiers as a sacred writing. Its burning is perceived as sacrilegious, like the burning of a Torah scroll during the Roman persecutions, or like the burning of Jews and others in the crematorium at Auschwitz. The psychiatrist then sees for a brief instant the burning spirits detaching from each name of the fallen soldiers’ list, flying off in a cloud of smoke. This almost hallucinatory experience dramatically expresses the narrator’s discomfort. On one hand, he feels connected to the veteran’s narrative involving the spirits of the fallen soldiers. On the other hand, he also connects with the ancient and disturbing Talmudic story of a rabbi wrapped in a Torah scroll and burned alive by the Romans. In that narrative, the Talmud reports that the rabbi said before dying: “I see the parchment being consumed but the letters are flying off and they remain. [3]”
Ultimately, the narrator overcomes his discomfort and accepts the ceremony rituals when he sees the veterans’ intense concentration and emotions. For them, the burning of the sheet carrying the names of their lost comrades is not a religious sacrilege, but is full of meaning. In the Hasidic Tales of the Holocaust [4], the Grand Rabbi of Bluzhov was able to light the first flame of a makeshift Hanukkah candleholder while imprisoned in the Bergen-Belsen concentration camp. After reciting the first two traditional blessings, the Rabbi doubted if he could continue with the third blessing thanking God “who made us live to reach this time” [5] while hundreds of dead Jewish bodies were lying literally within the shadow of the Hanukkah lights. Then he noticed the attention of the simple Jews who, despite death lurking in every corner, expressed their faith and devotion as they participated in this ritual. The Rabbi then could recite that third blessing, thanking God for witnessing a people with such faith and fervor. Here too, at the Vietnam Veteran Memorial, the intense emotions of the veterans overcome the problematic burning of the names and make it acceptable to the psychiatrist, considering the circumstances. This connection between the simple devotion of the surviving concentration camp inmates, and the intense suffering of the survivors of the Vietnam War, helps the narrator to empathize and deeply relate to the veterans.
This mourning ritual elicited strong reactions from the narrator and reactivated his grief related to the Holocaust. Because the narrator psychiatrist becomes aware of his own feelings and of his own narrative, he can better relate to and absorb the narrative of the hospitalized Veterans.
Narratives have been used in therapy to help patients deconstruct their problem-saturated stories and create an alternate, empowering story. The therapist acts as a catalyst in this process. Gardner and Poole describe narrative therapy as follow:
“A postmodern approach to the practice and theory of therapeutic counseling, narrative therapy is a collaborative process predicated on the belief that identity is cocreated in social, cultural, and political contexts and revealed through stories and narratives. Narrative therapy involves unearthing dominant or ‘problem’ stories in people’s lives (i.e., ‘the addiction story’), understanding them, and retelling them in alternative and more empowering ways.” [6]
Narratives have also been used in order to try to master and ultimately alleviate traumatic memories [7]. Some have criticized this approach and said that the therapist’s own narrative may interfere in this process [8]. In order to avoid that pitfall, therapists have to articulate their own narrative, as in this story, while eliciting a therapeutic narrative from a patient.
In The melody, as in In a cloud of smoke, the narrator attempts initially to be an impartial participant and observer in a religious or semi-religious ritual. However, in The melody this attempt clearly fails and the narrator, in observing the outside reality, end up changing it. The narrator comes as an observer (or even a “voyeur”) and finishes by being himself observed by the Hasidim and in turn, affecting them. This description corresponds to a postmodernist approach to relationships, far from the positivist approach in which there is clear separation between the observer and the reality being observed. Wolff-Michael Roth, while discussing the postmodern use of autobiography in auto-ethnography, summarizes this postmodernist approach:
“The idea of an independence of the observer (and therefore his/her knowledge) and the world observed has been seriously questioned both in the natural and the social sciences. In the natural sciences, relativity theory and quantum mechanics both suggest that the status of the observer codetermines what and how it is observed. (…) The observer and the observed cannot be separated, and if what and how the observer perceives is determined by the current state of the organism that has its history. (…) In human terms, this requires us a better understanding of the autobiography of the individual observer.” [9] Assuming this interdependence between observer and observed, the analysis of the interaction between the therapist and the patient becomes an essential treatment tool for certain schools of psychotherapy such as Relational Psychoanalysis [10] , Transference Focused Psychotherapy [11], and Intersubjectivity Therapy:
"Intersubjectivity theory is based on the premise that both the client and the therapist bring something of themselves and of their respective past emotional experience to the therapeutic relationship. This theoretical orientation is very attentive to the dynamics in the therapy room, especially of the relationship between therapist and client. It attends to how the client and the psychotherapist interact with each other, as well as how they feel about each other, consciously and subconsciously. " [12]
During psychotherapy, the patient can interact even unconsciously with the therapist. The observation and awareness of the relationship between the therapist and the patient is necessary in order to maintain appropriate boundaries between them, while helping therapists understand the inner feeling of their patients. Sometimes a therapist is able to experience her patient’s emotions, when the patient uses the defense mechanism of projective identification [13]. For example, the patient could project his own feeling of incompetence onto his therapist and may unconsciously try to make her feel incompetent instead of him. By understanding this process, the therapist can determine the patient’s real feelings about himself despite his superior and devaluating demeanor. Therapists need to understand their own defense mechanism in order to sort out whether their feelings come from their own issues or if those feelings are imposed on them by the patient. This is one reason why psychoanalysts are required to undergo psychoanalysis prior to providing therapy.
We saw how the psychiatrist developed his own narrative when observing the collaborative narrative of veterans and staff. As illustrated in the two stories, we too can apply more broadly the model of interactive narratives between the observer and the observed. Narrative therapists need to take this model into account, to be conscious of our own personal narratives and to be aware of how they may interact with and relate to the narrative of their patients.
NOTES for Relationships: A psychiatrist’s narrative [1] Johnson, D.R., Feldman, S.C,. Lubin. H. and Southwick, S.M. (1995). The therapeutic use of ritual and ceremony in the treatment of post-traumatic stress disorder. Journal of Traumatic Stress. Apr;8(2):283–98. [2] Bilu, Y. and Witztum, E. (1993). Working with Jewish ultra-orthodox patients: guidelines for a culturally sensitive therapy. Culture, Medicine, and Psychiatry. 1993 Jun;17(2):197–233. [3] Babylonian Talmud, Avodah Zarah, 18a. [4] Eliach, Y. (ed.) (1982). Hasidic Tales of the Holocaust. New York: Oxford University Press, pp. 13–15 [5] The shehecheyanu blessing in Hebrew. [6] Gardner, P. and Poole, J. (2009). One story at a time: narrative therapy, older adults, and addictions.” Journal of Applied Gerontology. 28: 600–620. [7] Schauer, M., Neuner, F., and Elbert, T. (2011). Narrative Exposure therapy: A Short-term Treatment for Traumatic Stress Disorders (2nd revised and expanded edition). Cambridge, MA: Hogrefe Publishing. [8] Meier, S. T. (2012). Language and Narratives in Counseling and Psychotherapy. Springer Publishing Company, p. 93. [9] Roth, W-M. (2005). Auto/biography and Auto/ethnography: finding the generalized other in the self. In: Auto/Biography and Auto/Ethnography: Praxis of Research Method, Wolff-Michael Roth (ed.) Sense Publishers. [10] Aron, L. (1991). The patient’s experience of the analyst’s subjectivity. In: S. Mitchell and L. Aron (eds.), Relational Psychoanalysis: The Emergence of a Tradition. 1999: Hillsdale, NJ: Analytic Press, pp. 243–268. [11] Kernberg, O.F.; Yeomans, F.E.; Clarkin, J.F. and Levy, K.N. (2008). Transference focused psychotherapy: Overview and update. International Journal of Psycho-Analysis 89:601–620 [12] Larson, J, S. (2005). Relational Aspects of Intersubjectivity Therapy and Gestalt Therapy: A Theoretical Integration. (Doctoral dissertation, Pacific University, p. 3.) Retrieved from: http://commons.pacificu.edu/spp/4 [13] Ogden, H. P. (1979). On projective identification. International Journal of Psycho-Analysis, 60: 267–268. Retrieved from: https://pdfs.semanticscholar.org/303e/20a9ec17de0b6f7d49ed466faca9090d4e13.pdf
The narrator of In a cloud of smoke, along with other staff members, participates in a symbolic burial ceremony at the end of a program at the National Center for Post-Traumatic Stress Disorder (PTSD) at West Haven VA Hospital in 1992. This ceremony occurs towards the end of a hospitalization of a group of Vietnam War veterans who were treated there together for several weeks. During their hospitalization, each veteran would process the specific traumatic events that affected them. Each Veteran had told his own story, which had been shared with the other members of the group. They received support from each other and from their families while expressing their personal narrative. In preparation for the ceremony, which was well attended by their families or loved ones, the veterans were asked to write a list of the fallen soldiers they were mourning. This ceremony was meant to help the veterans to have closure for their losses. The ritual has been described by David R. Johnson, who was directing that program at the time.
The narrative of In a cloud of smoke is written from the point of view of a psychiatrist who had just joined that program participated initially as a newcomer and a stranger, and in the chorus of treatment staff in the mourning ceremony. During that ceremony, as in another ceremony (the “crossing over” ceremony commemorating the program’s completion), the staff chorus repeats comforting lines intended to heal the veterans from their trauma and foster the connection and integration with their families and communities. With words like “we let you down” or “this is war,” the chorus tries to repair the feeling of abandonment that the veterans experienced when they returned from war. The input of the staff chorus in this ritual was also supposed to alleviate the veterans’ burden of guilt for having survived their fellow soldiers in this brutal war involving dangerous enemies and innocent civilians. Ultimately, at the end of the mourning ceremony, the staff chorus, acting as a moral court, authorizes the veterans to release the spirits of the fallen soldiers they were holding onto and that prevented the veterans from moving back into civilian life.
The ritual created by Johnson, the Master of Ceremonies in this story, has an implied religious overtone, using Christian symbols, such as the crown of thorns worn by Christ, and the Hindu ritual of cremation. These Christian and Hindu rituals are foreign to the narrator’s tradition and contribute to his discomfort and sense of distance. Bilu and Witztum, respectively an anthropologist and a psychiatrist in Israel, describe several interesting uses of religious-like rituals in psychiatric practice, in a more culturally competent approach for their Orthodox Jewish patients [2]. It is obviously more difficult to be culturally specific in a more multicultural group setting, such as in our story. Johnson describes previous homecoming rituals inspired by Native American rituals, adapted for Vietnam veterans [1]. Those rituals did not match the cultural perspective of most veterans and therefore Johnson advocated the use of different, “more secular” rituals. However, in his ritual, which is called the Ceremony for the Dead as described in our story, spirituality and religion are still very present, even if only implied.
In In a cloud of smoke, when the psychiatrist is exposed to this intense mourning ritual, he confronts his own past and his own narrative. The broken narrative of the veterans and the healing narrative of the chorus sometime clash with the psychiatrist’s own narrative. At a certain point, the psychiatrist became aware that his narrative interferes with his experience of the ceremony. The psychiatrist views the list of the names of fallen soldiers as a sacred writing. Its burning is perceived as sacrilegious, like the burning of a Torah scroll during the Roman persecutions, or like the burning of Jews and others in the crematorium at Auschwitz. The psychiatrist then sees for a brief instant the burning spirits detaching from each name of the fallen soldiers’ list, flying off in a cloud of smoke. This almost hallucinatory experience dramatically expresses the narrator’s discomfort. On one hand, he feels connected to the veteran’s narrative involving the spirits of the fallen soldiers. On the other hand, he also connects with the ancient and disturbing Talmudic story of a rabbi wrapped in a Torah scroll and burned alive by the Romans. In that narrative, the Talmud reports that the rabbi said before dying: “I see the parchment being consumed but the letters are flying off and they remain. [3]”
Ultimately, the narrator overcomes his discomfort and accepts the ceremony rituals when he sees the veterans’ intense concentration and emotions. For them, the burning of the sheet carrying the names of their lost comrades is not a religious sacrilege, but is full of meaning. In the Hasidic Tales of the Holocaust [4], the Grand Rabbi of Bluzhov was able to light the first flame of a makeshift Hanukkah candleholder while imprisoned in the Bergen-Belsen concentration camp. After reciting the first two traditional blessings, the Rabbi doubted if he could continue with the third blessing thanking God “who made us live to reach this time” [5] while hundreds of dead Jewish bodies were lying literally within the shadow of the Hanukkah lights. Then he noticed the attention of the simple Jews who, despite death lurking in every corner, expressed their faith and devotion as they participated in this ritual. The Rabbi then could recite that third blessing, thanking God for witnessing a people with such faith and fervor. Here too, at the Vietnam Veteran Memorial, the intense emotions of the veterans overcome the problematic burning of the names and make it acceptable to the psychiatrist, considering the circumstances. This connection between the simple devotion of the surviving concentration camp inmates, and the intense suffering of the survivors of the Vietnam War, helps the narrator to empathize and deeply relate to the veterans.
This mourning ritual elicited strong reactions from the narrator and reactivated his grief related to the Holocaust. Because the narrator psychiatrist becomes aware of his own feelings and of his own narrative, he can better relate to and absorb the narrative of the hospitalized Veterans.
Narratives have been used in therapy to help patients deconstruct their problem-saturated stories and create an alternate, empowering story. The therapist acts as a catalyst in this process. Gardner and Poole describe narrative therapy as follow:
“A postmodern approach to the practice and theory of therapeutic counseling, narrative therapy is a collaborative process predicated on the belief that identity is cocreated in social, cultural, and political contexts and revealed through stories and narratives. Narrative therapy involves unearthing dominant or ‘problem’ stories in people’s lives (i.e., ‘the addiction story’), understanding them, and retelling them in alternative and more empowering ways.” [6]
Narratives have also been used in order to try to master and ultimately alleviate traumatic memories [7]. Some have criticized this approach and said that the therapist’s own narrative may interfere in this process [8]. In order to avoid that pitfall, therapists have to articulate their own narrative, as in this story, while eliciting a therapeutic narrative from a patient.
In The melody, as in In a cloud of smoke, the narrator attempts initially to be an impartial participant and observer in a religious or semi-religious ritual. However, in The melody this attempt clearly fails and the narrator, in observing the outside reality, end up changing it. The narrator comes as an observer (or even a “voyeur”) and finishes by being himself observed by the Hasidim and in turn, affecting them. This description corresponds to a postmodernist approach to relationships, far from the positivist approach in which there is clear separation between the observer and the reality being observed. Wolff-Michael Roth, while discussing the postmodern use of autobiography in auto-ethnography, summarizes this postmodernist approach:
“The idea of an independence of the observer (and therefore his/her knowledge) and the world observed has been seriously questioned both in the natural and the social sciences. In the natural sciences, relativity theory and quantum mechanics both suggest that the status of the observer codetermines what and how it is observed. (…) The observer and the observed cannot be separated, and if what and how the observer perceives is determined by the current state of the organism that has its history. (…) In human terms, this requires us a better understanding of the autobiography of the individual observer.” [9] Assuming this interdependence between observer and observed, the analysis of the interaction between the therapist and the patient becomes an essential treatment tool for certain schools of psychotherapy such as Relational Psychoanalysis [10] , Transference Focused Psychotherapy [11], and Intersubjectivity Therapy:
"Intersubjectivity theory is based on the premise that both the client and the therapist bring something of themselves and of their respective past emotional experience to the therapeutic relationship. This theoretical orientation is very attentive to the dynamics in the therapy room, especially of the relationship between therapist and client. It attends to how the client and the psychotherapist interact with each other, as well as how they feel about each other, consciously and subconsciously. " [12]
During psychotherapy, the patient can interact even unconsciously with the therapist. The observation and awareness of the relationship between the therapist and the patient is necessary in order to maintain appropriate boundaries between them, while helping therapists understand the inner feeling of their patients. Sometimes a therapist is able to experience her patient’s emotions, when the patient uses the defense mechanism of projective identification [13]. For example, the patient could project his own feeling of incompetence onto his therapist and may unconsciously try to make her feel incompetent instead of him. By understanding this process, the therapist can determine the patient’s real feelings about himself despite his superior and devaluating demeanor. Therapists need to understand their own defense mechanism in order to sort out whether their feelings come from their own issues or if those feelings are imposed on them by the patient. This is one reason why psychoanalysts are required to undergo psychoanalysis prior to providing therapy.
We saw how the psychiatrist developed his own narrative when observing the collaborative narrative of veterans and staff. As illustrated in the two stories, we too can apply more broadly the model of interactive narratives between the observer and the observed. Narrative therapists need to take this model into account, to be conscious of our own personal narratives and to be aware of how they may interact with and relate to the narrative of their patients.
NOTES for Relationships: A psychiatrist’s narrative [1] Johnson, D.R., Feldman, S.C,. Lubin. H. and Southwick, S.M. (1995). The therapeutic use of ritual and ceremony in the treatment of post-traumatic stress disorder. Journal of Traumatic Stress. Apr;8(2):283–98. [2] Bilu, Y. and Witztum, E. (1993). Working with Jewish ultra-orthodox patients: guidelines for a culturally sensitive therapy. Culture, Medicine, and Psychiatry. 1993 Jun;17(2):197–233. [3] Babylonian Talmud, Avodah Zarah, 18a. [4] Eliach, Y. (ed.) (1982). Hasidic Tales of the Holocaust. New York: Oxford University Press, pp. 13–15 [5] The shehecheyanu blessing in Hebrew. [6] Gardner, P. and Poole, J. (2009). One story at a time: narrative therapy, older adults, and addictions.” Journal of Applied Gerontology. 28: 600–620. [7] Schauer, M., Neuner, F., and Elbert, T. (2011). Narrative Exposure therapy: A Short-term Treatment for Traumatic Stress Disorders (2nd revised and expanded edition). Cambridge, MA: Hogrefe Publishing. [8] Meier, S. T. (2012). Language and Narratives in Counseling and Psychotherapy. Springer Publishing Company, p. 93. [9] Roth, W-M. (2005). Auto/biography and Auto/ethnography: finding the generalized other in the self. In: Auto/Biography and Auto/Ethnography: Praxis of Research Method, Wolff-Michael Roth (ed.) Sense Publishers. [10] Aron, L. (1991). The patient’s experience of the analyst’s subjectivity. In: S. Mitchell and L. Aron (eds.), Relational Psychoanalysis: The Emergence of a Tradition. 1999: Hillsdale, NJ: Analytic Press, pp. 243–268. [11] Kernberg, O.F.; Yeomans, F.E.; Clarkin, J.F. and Levy, K.N. (2008). Transference focused psychotherapy: Overview and update. International Journal of Psycho-Analysis 89:601–620 [12] Larson, J, S. (2005). Relational Aspects of Intersubjectivity Therapy and Gestalt Therapy: A Theoretical Integration. (Doctoral dissertation, Pacific University, p. 3.) Retrieved from: http://commons.pacificu.edu/spp/4 [13] Ogden, H. P. (1979). On projective identification. International Journal of Psycho-Analysis, 60: 267–268. Retrieved from: https://pdfs.semanticscholar.org/303e/20a9ec17de0b6f7d49ed466faca9090d4e13.pdf
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