21 Chapters
Medium 9781855755475

CHAPTER SEVEN: The forms and transformations of affect

Garfield, David Karnac Books ePub

Tony's preoccupation with the Mills case was temporarily diffused by his intensifying work with Jack Barnes. Here it was a completely different story. Unlike Amy, who could talk for hours, Tony could barely get Jack to say a word. As recommended by his supervisors, Tony set up specific times for psychotherapy with Jack, when Jack was on the inpatient unit. These times were kept separate from the usual ward rounds, diagnostic testing times, or team treatment meetings. Occasionally, Jack would show up at Tony's office door on time, but as often as not, Jack could be found down the hall or he would show up 5 minutes late. Sometimes, Jack would unexpectedly appear at non therapy times. While in line in the cafeteria, Tony would turn around to find that Jack was right behind him; sometimes, when leaving the hospital, Jack would be standing near the door to the parking lot.

In session, Tony would invariably have to ask a lot of questions. Was something coming of all this?

Potter realized then that Jack's delusions and, possibly, the hallucinations as well, kept him from feeling suicidal. They were a way of “binding” the suicidal feelings. The feelings in his arm, chest, and liver, no doubt, had a certain sensory quality to them. Perhaps, these feelings in his body are sad or despairing feelings. Shot by a guardian at the tomb of the unknown. Whom can you trust?

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CHAPTER TWO: Forms of introduction: The chief complaint

Garfield, David Karnac Books ePub

After a quick lunch with his best friend from college, Tony was musing on how he would institute this new policy–saying “no.” Can you take on this patient? Could we meet to discuss this case? Would you organize the other residents for a journal club? After years of saying “yes,”’ could he learn to say “no”?

The beeper startled him out of his contemplation. The only way to say “no” to that damn thing would be to turn it off. Then if one of the attendings tried to get in touch with you, there'd be real hell to pay. It was the psychiatry emergency room. Coming back to reality, he muttered “Oh, great,” hustled out the locked door of the inpa-tient unit, down the stairs, and into the main lobby.

“Admission,” Doris said. She barely looked up as she tossed the papers toward Tony.

“Is it bad?” he asked.

“How should I know?” she replied.

At least she looked up at him from her desk. Not that he particularly liked Doris, the outpatient secretary, but in some ways it wassuch a solitary job to be a psychiatry resident at Mount Sinai that even a little contact with the secretary was comforting.

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CHAPTER ELEVEN: Putting emotion in perspective

Garfield, David Karnac Books ePub

Three years had passed since Tony Potter graduated from his psychiatry residency at Mount Sinai Hospital in Boston. He continued to work with Amy Mills for two of those years, until Amy had moved down to Manhattan to live with an old friend from high school. Amy had obtained a job behind the ticket window of a small, off-Broadway theatre, and although it barely paid for her rent and utilities, she sounded pretty happy. She wrote to Tony weekly for the first 6 months and he would write her back a brief note, most of the time. After that, he would hear from her every couple of months. It was always good to hear from her.

Tony wondered about the fact that they had not had a “proper” termination to the therapy. He had taken a job at the state hospital affiliated with the medical school, and he had a small private practice. Amy didn't fit into either of those modes and Tony figured that part of her leaving was that she didn't want treatment from him for free or near free. She had, perhaps, re-found her pride, The envy of her sister toward her and the guilt and anger that she felt in return had been dealt with in the course of their four years together andthe immediacy and intensity of those affects had receded. Also, it seemed that she had regained some of her old confidence. He knew that the rekindling of old friendships and her return to be near the theatre were good signs. She was still on the lithium and Tony had arranged for a psychiatrist in Manhattan to be available for her medication every couple of months. Amy wrote about taking classes from a “master” teacher at the theatre. This was an older woman whom Amy respected a great deal and they seemed to have an affinity toward each other. Amy was able to take lessons in exchange for working at the theatre. It was satisfying to Tony that Amy had been able to “enlist” people into her life who would be good to her and for her.

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CHAPTER TWELEVE: Staying out of psychosis

Garfield, David Karnac Books ePub

“It is equally fatal for the mind to have a system and to have none. It will simply have to decide to combine the two.

Von Schlegel

Just three days ago, Tony had received the letter from Amy Mills. Now he was having some trouble concentrating on what Arnie Davis was saying … something about his new cat fighting with the old ones … .

(Here Tony mixes together past events, current events, and the transference—he knows that Arnie's father was a Beast, that he wastaken in as Tony the Tiger, and that Arnie was frustrated now, as his old cats were fighting with the new one he had recently brought home.)

Somehow in the midst of the dialogue, Tony's mind was stuck on the image of Arnie” glass splintering as it hit the wall. He knew that Arnie was doing well. Yes, he was still vulnerable to feeling assaulted and guilty, but the anger was more tempered … the cut was from cleaning up the glass and was an accident-not intentional-the anger/ motor episodes were infrequent; only three over the past year, and no doubt, some sleep deprivation from Arnie's new “child” made things worse. The feeling-toned complex of Beast-father-kitten-child was now much more tied into the usual fabric of Arnie's day-to-day life. Rarely did it overwhelm him.

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Medium 9781782202288

Chapter Four: The Infrastructure of the Vertical Split

Garfield, David; Steinman, Ira Karnac Books ePub

As we saw in the case of Judith, disavowed action can be seen as the patient's way of trying to hold on to a threatened sense of self agency. Behaviors, actions and a variety of different split off states contain vital elements of an unintegrated self. For Judith, the mirroring selfobject experience, as it deepened, allowed for the reintegration of these various psychotic behavioral states. The key concept here is “threatened.” Given Judith's experience with her grandfather, her very psychological existence was at stake.

This chapter, through two clinical vignettes, explores in greater depth Kohut's (1971) concept of the vertical split. Interestingly, Sullivan's (1953) identification of “selective inattention” as a security operation within a self system can be seen to foreshadow Kohut's concept of the vertical split. Stern's (1985) research on the development of agency within the infant and the important role of caretaker attunement to the felt consequences of intended action add to the clinical understanding of disavowed motor acts. Here, faulty selfobject experiences result in the development of an in-depth sector of the psyche that remains conscious, yet disavowed. We clearly saw this in Judith's psychopathology.

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