#psychobiological processes

[shamanflavio]

Shamanism: A Journey Through the Mind, Body, and Spirit Connection

Shamanism, a spiritual practice that spans across various cultures and epochs, serves as a profound testament to the universality of human psychobiological experiences. Through the lens of Winkelman’s (2002) research, we can understand shamanism not merely as a cultural artifact but as a manifestation of innate brain processes, representational systems, and psychophysiological dynamics inherent…

[compneuropapers]

Interesting Papers for Week 17, 2024

Computational mechanisms underlying latent value updating of unchosen actions. Ben-Artzi, I., Kessler, Y., Nicenboim, B., & Shahar, N. (2023). Science Advances, 9(42).

Associative learning or Bayesian inference? Revisiting backwards blocking reasoning in adults. Benton, D. T., & Rakison, D. H. (2023). Cognition, 241, 105626.

The value of mere completion. Converse, B. A., Tsang, S., & Hennecke, M. (2023). Journal of Experimental Psychology: General, 152(11), 3021–3036.

Stable sound decoding despite modulated sound representation in the auditory cortex. Funamizu, A., Marbach, F., & Zador, A. M. (2023). Current Biology, 33(20), 4470-4483.e7.

Differential attentional costs of encoding specific and gist episodic memory representations. Greene, N. R., & Naveh-Benjamin, M. (2023). Journal of Experimental Psychology: General, 152(11), 3292–3299.

The scaling of mental computation in a sorting task. Haridi, S., Wu, C. M., Dasgupta, I., & Schulz, E. (2023). Cognition, 241, 105605.

Simulations predict differing phase responses to excitation vs. inhibition in theta-resonant pyramidal neurons. Kelley, C., Antic, S. D., Carnevale, N. T., Kubie, J. L., & Lytton, W. W. (2023). Journal of Neurophysiology, 130(4), 910–924.

Attention preserves the selectivity of feature-tuned normalization. Klímová, M., Bloem, I. M., & Ling, S. (2023). Journal of Neurophysiology, 130(4), 990–998.

An approximate representation of objects underlies physical reasoning. Li, Y., Wang, Y., Boger, T., Smith, K. A., Gershman, S. J., & Ullman, T. D. (2023). Journal of Experimental Psychology: General, 152(11), 3074–3086.

Associative and predictive hippocampal codes support memory-guided behaviors. Liu, C., Todorova, R., Tang, W., Oliva, A., & Fernandez-Ruiz, A. (2023). Science, 382(6668).

Same but different: The latency of a shared expectation signal interacts with stimulus attributes. Lowe, B. G., Robinson, J. E., Yamamoto, N., Hogendoorn, H., & Johnston, P. (2023). Cortex, 168, 143–156.

Model-free decision making resists improved instructions and is enhanced by stimulus-response associations. Luna, R., Vadillo, M. A., & Luque, D. (2023). Cortex, 168, 102–113.

Infants’ sex affects neural responses to affective touch in early infancy. Mariani Wigley, I. L. C., Björnsdotter, M., Scheinin, N. M., Merisaari, H., Saunavaara, J., Parkkola, R., … Tuulari, J. J. (2023). Developmental Psychobiology, 65(7), e22419.

Action planning and execution cues influence economic partner choice. McEllin, L., Fiedler, S., & Sebanz, N. (2023). Cognition, 241, 105632.

Parallel processing of value-related information during multi-attribute decisions. Nakahashi, A., & Cisek, P. (2023). Journal of Neurophysiology, 130(4), 967–979.

Extended trajectory of spatial memory errors in typical and atypical development: The role of binding and precision. Peng, M., Lovos, A., Bottrill, K., Hughes, K., Sampsel, M., Lee, N. R., … Edgin, J. (2023). Hippocampus, 33(11), 1171–1188.

Mediodorsal thalamus-projecting anterior cingulate cortex neurons modulate helping behavior in mice. Song, D., Wang, C., Jin, Y., Deng, Y., Yan, Y., Wang, D., … Quan, Z. (2023). Current Biology, 33(20), 4330-4342.e5.

Metacognition and sense of agency. Wen, W., Charles, L., & Haggard, P. (2023). Cognition, 241, 105622.

Sensory deprivation arrests cellular and synaptic development of the night-vision circuitry in the retina. Wisner, S. R., Saha, A., Grimes, W. N., Mizerska, K., Kolarik, H. J., Wallin, J., … Hoon, M. (2023). Current Biology, 33(20), 4415-4429.e3.

The timing of confidence computations in human prefrontal cortex. Xue, K., Zheng, Y., Rafiei, F., & Rahnev, D. (2023). Cortex, 168, 167–175.

[dreaminginthedeepsouth]

Misery for Mariners :: Description Based on an old wives' tale. Crush your eggshells when you are done with them, or witches will make boats of them and terrorize sailors: 'Oh, never leave your eggshells unbroken in the cup,Think of us poor sailor-men and always smash them up,For witches come and find them and sail away to sea,And make a lot of misery for mariners like me.' :: [BreeAnn Veenstra]

* * * *

“When Jung’s patients became overwhelmed with emotions, he sometimes would have them draw a picture of their feelings. Once the feelings were expressed in the form of imagery, the images could be encouraged to speak to one another. As soon as a dialogue could take place, the patient was well embarked on the process of reconciling different aspects of his dissociated psyche.”

Ernest Rossi, The Psychobiology of Mindbody Healing (1993) Norton [page 39]

[nitrosplicer]

Lombroso believed that genius and madness were closely linked, being two sides of the same psychobiological condition. A man of genius was a degenerate, an example of retrograde evolution, in whom madness was a form of biological compensation for excessive intellectual development. ... He asked himself: why not meet Lev Tolstoy, the supreme genius of world literature, in his natural habitat, to scrutinise his features and confirm his theory by seeing Tolstoy’s degenerative features with his own eyes?

.... But Tolstoy remained deaf to all these arguments, “he knit his terrible eyebrows” and hurled against Lombroso menacing flashes of his deep-set and penetrating eyes; finally he erupted exclaiming “All this is nonsense! All punishment is criminal!” According to him, human beings have no right to judge their fellows, and all forms of violence are inadmissible even if exercised with the aim of reparation of crime.

… On the evening of the 27th August, 1897, Tolstoy noted in his diary “Lombroso came. He is an ingenuous and limited old man”. And in January, 1900 he remarked, again in his diary, on the science of Lombroso: “All this is an absolute misery of thought, of concept and of sensitivity”.

…

In the definitive text of Resurrection , Tolstoy added, among other things, a detailed description of the legal processes and punishments current in Russia at the end of the century and the anthropological theories of Lombroso were discussed and roundly rejected as immoral. According to Tolstoy delinquency was not “evidence of degeneration of a delinquent type of monstrosity, as certain obtuse scientists explained them to the government’s advantage”.

Interesting article on how Cesare Lombroso (noted biological determinist and father of scientific racism) was obsessed with proving that Leo Tolstoy was evidence of his “theory of degeneration in geniuses.”

[she-is-ovarit]

to be fair, personality disorders as a whole are in large part caused by trauma. so one could say all personality disorders are trauma disorders.

(In response to this post)

Very true. I hope to expand upon your point.

I did some searching in response to this post and what I found is that some researchers are finding an association with malfunctioning genes and personality disorders. Others are also finding strong associations between the types of childhood trauma and personality disorders based on surveys. I am sure this is difficult to tease apart, because people with personality disorders also sometimes exhibit high rates of pathological lying and placing external blame on other people.

This study in particular is interesting to me, and here is the abstract:

Complex PTSD (cPTSD) was formulated to include, in addition to the core PTSD symptoms, dysregulation in three psychobiological areas: (1) emotion processing, (2) self-organization (including bodily integrity), and (3) relational security. The overlap of diagnostic criteria for cPTSD and borderline personality disorder (BPD) raises questions about the scientific integrity and clinical utility of the cPTSD construct/diagnosis, as well as opportunities to achieve an increasingly nuanced understanding of the role of psychological trauma in BPD. We review clinical and scientific findings regarding comorbidity, clinical phenomenology and neurobiology of BPD, PTSD, and cPTSD, and the role of traumatic victimization (in general and specific to primary caregivers), dissociation, and affect dysregulation. Findings suggest that BPD may involve heterogeneity related to psychological trauma that includes, but extends beyond, comorbidity with PTSD and potentially involves childhood victimization-related dissociation and affect dysregulation consistent with cPTSD. Although BPD and cPTSD overlap substantially, it is unwarranted to conceptualize cPTSD either as a replacement for BPD, or simply as a sub-type of BPD. We conclude with implications for clinical practice and scientific research based on a better differentiated view of cPTSD, BPD and PTSD.

Some further context from another study:

Borderline personality disorder is multi-factorial in etiology. There is a genetic predisposition. Twin studies show over 50% heritability (greater than that for major depression).[5] Twin studies performed in 2000 and 2008 both demonstrated higher concordance of the rate of borderline personality disorder for monozygotic versus dizygotic twins. Environmental factors that have been identified as contributing to the development of borderline personality disorder include primarily childhood maltreatment (physical, sexual, or neglect), found in up to 70% of people with BPD, as well as maternal separation, poor maternal attachment, inappropriate family boundaries, parental substance abuse, and serious parental psychopathology.

(Sci-hub for access, if needed)

[religion-is-a-mental-illness]

Introduction

In the last decade, there has been a rapid increase in the numbers of young people with gender dysphoria (GD youth) presenting to health services (Kaltiala et al., 2020). There has also been a marked change in the treatment approach. The previous “common practice” of providing psychosocial care only to those under 18 or 21 years (Smith et al., 2001) has largely been replaced by the gender affirmative treatment approach (GAT), which for adolescents includes hormonal and surgical interventions (Coleman et al., 2022). However, as a recent review concluded, evidence on the appropriate management of youth with gender incongruence and dysphoria is inconclusive and has major knowledge gaps (Cass, 2022). Previous papers have discussed that the weaknesses of the studies investigating the efficacy of GAT for GD youth mean they are at high risk of bias and confounding and, thus, provide very low certainty evidence (Clayton, 2022a, b; Levine et al., 2022). To date, however, there has been little discussion of the inability of these studies to differentiate specific treatment effects from placebo effects. Of note, the term “placebo effect” is no longer used to just simply refer to the clinical response following inert medication; rather, it describes the beneficial effects attributable to the brain-mind responses evoked by the treatment context rather than the specific intervention (Wager & Atlas, 2015). This Letter argues that the current treatment approach for GD youth presents a perfect storm environment for the placebo effect. This raises complex clinical and research issues that require attention and debate.

A Brief Introduction to the Contemporary Concept of the Placebo Effect

The term “placebo effect” can be used variably by different authors. As recently defined in a consensus statement, placebo (beneficial) and nocebo (deleterious) effects occur in clinical or research contexts and are due to psychobiological mechanisms evoked by the treatment (or research) context rather than any specific effect of the intervention. Importantly, placebo and nocebo effects not only occur during the prescription of placebo (inert) pills, but they can also substantially modulate the efficacy and tolerability of active medical treatments (Evers et al., 2018).

The therapeutic ritual, the encounter between a sick person and a clinician, is a powerful psychosocial event. Clinicians, particularly physicians, are our society’s designated healers and their prestige, status, and authority help engender patients’ trust and expectations of relief from suffering (Benedetti, 2021a). Positive clinician–patient interactions are associated with decreased anxiety and increased hope. Complex neurobiological mechanisms are implicated in the placebo effect, including release of neurotransmitters (e.g., endorphins, cannabinoids, dopamine, and oxytocin) and activation of specific areas of the brain (e.g., the prefrontal cortex, anterior insula, rostral anterior cingulate cortex, and the amygdala) (Colloca & Barsky, 2020; Kaptchuk & Miller, 2015). These changes are associated with an increased sense of well-being. They also impact on cardiovascular, respiratory, immune, and endocrine functioning, all of which may contribute to patients’ clinical improvement (Enck et al., 2013; Wager & Atlas, 2015).

Several unconscious psychological mechanisms, including classical conditioning and social learning, play a role in the placebo effect (Benedetti, 2021a). In clinical trials, where patients communicate with each other, a process of social observational learning may be associated with emotional contagion and, thus, placebo and nocebo effects (Benedetti, 2013). The media and social media may also foster these effects and contribute to the dissemination of symptoms and illness throughout the general population (Colloca & Barsky, 2020).

Expectation of outcome is a principal mechanism of the placebo effect and anything that increases patients’ expectations is potentially capable of boosting placebo effects (Evers et al., 2018). Although research has demonstrated that changes in physiological parameters may occur following placebo administration (Wager & Atlas, 2015), these response expectations have been particularly noted in patient-reported outcomes, such as anxiety, pain, life satisfaction, and mood. Expectations and cognitive readjustment can lead to behavioral changes, such as resuming normal daily activities, which can be observer rated. Physicians’ status, whether through the general position given to them in society or through individual personality factors, may contribute to such expectations of benefit. This type of phenomenon has sometimes been termed prestige suggestion. The “Hawthorne effect” describes the phenomenon where clinical trial patients’ improvements may occur because they are being observed and given special attention. A patient who is part of a study, receiving special attention, and with motivated clinicians, who are invested in the benefits of the treatment under study, is likely to have higher expectations of therapeutic benefits (Benedetti, 2021a).

Placebo-induced improvements are real and can be robust and long lasting (Benedetti, 2021b; Wager & Atlas, 2015). Individual patient factors, such as personality and genetics, may be associated with placebo responsiveness (Benedetti, 2021a). The particular illness is also relevant. For example, although placebo treatment can impact symptoms of cancer, there is no evidence that placebos can shrink tumors (Benedetti, 2021b; Kaptchuk & Miller, 2015). However, there is evidence that placebos can act as long-lasting and effective treatments for depression and various pain conditions, such as migraine and osteoarthritic knee pain (Kam-Hansen et al., 2014; Kirsch, 2019; Previtali et al., 2021). Further, some research suggests adherence to placebo medication, particularly in cardiac disease, may be associated with reduced mortality (Wager & Atlas, 2015).

The Research Setting versus the Clinical Practice Setting

Research into new medical treatments aims to control for placebo effects, and this helps ensure true evaluation of the treatment’s efficacy (Enck et al., 2013). The double-blind randomized controlled trial (DBRCT), although not perfect, is the current gold standard for determining the efficacy and safety of a treatment. The DBRCT study design evolved over several centuries and became widely accepted practice in the mid-twentieth century (Lilienfeld, 1982). Of note, the term “blind” is thought to have originated in eighteenth-century France when blindfolds were used to disprove Anton Mesmer’s “animal magnetism” theory and the mesmerism craze of that era (Kaptchuk, 1998). Well-designed DBRCTs minimize the impact of bias, confounding and placebo effects on findings and are the best type of study for determining whether there is a causal relationship between an intervention and an effect (Enck et al., 2013; Kabisch et al., 2011).

The reader may wonder about this requirement of differentiating placebo effects from the specific effects of an intervention and ask: If the patient improves, does it really matter why? Yes, it does, particularly for treatments that have significant risk of adverse effects. There are also broader problems raised by relying on the placebo effect. Consider prescribing antibiotics for viral infections. The patient may experience clinical benefit through a placebo effect. However, not only may some patients experience serious adverse drug reactions, but the health of the whole population is imperiled by the problem of antibiotic resistance (Llor & Bjerrum, 2014). Furthermore, informed consent is an ethical pillar of modern medicine and requires clinician honesty and transparency. Clinicians deceptively utilizing placebo treatments do not meet this requirement (Barnhill, 2012; Kaldjian & Pilkington, 2021). A medical profession that does little to distinguish placebo effects from specific treatment effects risks becoming little different from pseudoscience and the quackery that dominated medicine of past times, with likely resulting decline in public trust and deterioration in patient outcomes (Benedetti, 2021a).

Ideally, in evidence-based medicine, a new treatment undergoes rigorous research and has reasonable evidence of benefit prior to being introduced as routine treatment (although ongoing further research often continues). Clinicians can then reasonably harness and enhance the placebo effect to improve outcomes (Enck et al., 2013). A placebo effect enhancing clinical setting, in which warm and empathic clinicians provide supportive and attentive health care, creates a “therapeutic bias” in patients, giving them hope and expectation of improvement. This is “legitimate” so long as it is done without deception and in a manner consistent with informed consent, trust, and transparency (Kaptchuk & Miller, 2015).

This ideal of clinical interventions having solid evidence of efficacy before being introduced as routine practice is not always a reality. Sometimes, it is more of a situation where the “cart” of clinical practice precedes the “horse” of rigorous research evidence. Then, this catch-up research may be undertaken in a placebo effect-enhancing clinical environment, rather than a placebo effect-controlled research environment. Such situations, especially when DBRCT are not possible, present the researcher and clinician with complex research and clinical conundrums. Some of these will now be explored using the example of the treatment of youth with gender dysphoria.

A Brief Introduction to the Gender-Affirming Treatment Model for Children and Adolescents with Gender Dysphoria

Gender dysphoria is a term used to describe the distress that is frequently felt by people whose sense of gender is incongruent with their natal sex (these people may also self-identify as transgender) and if the dysphoria is intense and persistent, alongside several other features, a DSM-5 diagnosis of gender dysphoria may be made (American Psychiatric Association, 2013). There has been a sharp rise in the numbers of children and adolescents identifying as transgender and being diagnosed with gender dysphoria (Kaltiala et al., 2020; Tollit et al., 2021; Wood et al., 2013). Many are natal sex females presenting in adolescence, and many have neurodevelopmental and psychiatric disorders (Kaltiala-Heino et al., 2018; Tollit et al., 2021; Zucker, 2019). International guidelines and child and adolescent gender clinics (CAGCs) commonly endorse a gender affirmative treatment approach (GAT) (Coleman et al., 2022; Hembree et al., 2017; Olson-Kennedy et al., 2019; Telfer et al., 2018). Key components of GAT include affirmation of a youth’s stated gender identity, facilitation of early childhood social transition, provision of puberty blockers to prevent the pubertal changes consistent with natal sex, and use of cross-sex hormones (CSH) and surgical interventions to align physical characteristics with gender identity (Ehrensaft, 2017; Rosenthal, 2021). This Letter’s discussion focuses primarily on the medical (puberty blockers and cross-sex hormones) and surgical elements of GAT.

GAT can achieve some of the desired masculine or feminine appearance outcomes, but the main arguments used to support the use of these treatments in GD youth are that they improve short- and long-term mental health and quality-of-life outcomes. However, this claim is only underpinned by low-quality (mostly short-term, uncontrolled, observational) studies, which provide very low certainty evidence, complemented by expert opinion (Clayton, 2022a; Hembree et al., 2017; NICE, 2020a,b; Rosenthal, 2021). No randomized controlled trials (RCTs), including none using the previous treatment approach as a comparative, have been undertaken. This low-quality evidence for the efficacy of GAT is of particular concern given the potential risks associated with GAT.

Risks of Gender-Affirming Medical and Surgical Treatments

Impaired fertility is a risk of cross-sex hormones, and the extent of reversibility of this is unclear (Cheng et al., 2019; Hembree et al., 2017). If puberty blockers are commenced in early puberty and followed by cross-sex hormones, there are no proven methods of fertility preservation (Bangalore Krishna et al., 2019). Surgeries, such as gonadectomies and most genital surgeries, will result in permanent sterility. These impaired fertility and sterility outcomes are important because, firstly, as Cheng et al. (2019) reported, the widespread assumption that many transgender people do not want to have biological children is not supported by several recent studies. Secondly, children as young as ten, who do not have capacity for informed consent, are starting a treatment course that will likely render them infertile or sterile and this raises complex bioethical issues (Baron & Dierckxsens, 2021).

Other adverse effects of GAT are based on a more uncertain evidence base. I provide a brief outline of some of the areas of concern. Cross-sex hormones are associated with cardiovascular health risks, such as thromboembolic, coronary artery, and cerebrovascular diseases (Hembree et al., 2017; Irwig, 2018). Cross-sex hormones may also increase the risk of certain cancers (Hembree et al., 2017; Mueller & Gooren, 2008). Puberty blockers may have negative impact on bone mineral density, which may not be fully reversible, with an associated risk of osteoporosis and fractures (Biggs, 2021; Hembree et al., 2017). Recently, findings from animal studies have increased concerns that puberty blockers may negatively and irreversibly impact brain development due to critical time-windows of brain development. In one study on rams, long-term spatial memory deficits induced by use of puberty blockers in the peripubertal period were found to persist into adulthood (Hough et al., 2017). For those young patients who undertake surgery, there are also the risks of surgical complications (Akhavan et al., 2021). One understudied outcome of mastectomies, for those who later want to and can become pregnant, is the grief about inability to breast feed.

Puberty blockers, cross-sex hormones and genital surgery also pose risks to sexual function, particularly the physiological capacity for arousal and orgasm. It is important to be aware there is a dearth of research studying the impact of GAT on GD youth’s sexual function, but I provide a brief discussion of this important topic. Estrogen use in transwomen is associated with decreased sexual desire and erectile dysfunction and testosterone for transmen may lead to vaginal atrophy and dyspareunia (Hembree et al., 2017). It seems widely assumed that testosterone simply improves transmen’s sexual functioning. However, placebo-controlled studies from the non-transgender population indicate the situation is likely more complex. For example, studies indicate that testosterone may impact female sexual desire in a bell-shape curve manner, and at high levels may have no benefit or even have negative impact on sexual function (Krapf & Simon, 2017; Reed et al., 2016). Also of note, in medical conditions that are associated with high testosterone levels, such as polycystic ovarian syndrome, impaired sexual function (e.g., arousal, lubrication, sexual satisfaction, and orgasm) has been reported (Pastoor et al., 2018).

Recently, surgeon and WPATH president-elect, Marci Bowers, raised concern that puberty blockers given at the earliest stages of puberty to birth sex males, followed by cross-sex hormones and then surgery, might adversely impact orgasm capacity because of the lack of genital tissue development (Ley, 2021). One study has reported that some young adults, who had received puberty blockers, cross-sex hormones and laparoscopic intestinal vaginoplasty, self-reported orgasmic capacity (Bouman et al., 2016). However, this finding does not negate Bower’s concerns, as it did not make any assessment of the correlation between Tanner stage at initiation of puberty blockers with orgasm outcome. Of note, some of the patients in the study were over the age of 18 at start of GAT. Further, its findings do not apply to those undergoing penile skin inversion vaginoplasty. Importantly, Bouman et al. found that 32% of their participants self-reported being sexually inactive and only 52% reported having had neovaginal penetrative sex more than once. A recent literature review on sexual outcomes in adults post-vaginoplasty noted the paucity of high-quality evidence but reported that “up to 29% of patients may be diagnosed with a sexual dysfunction due to associated distress with a sexual function disturbance” (Schardein & Nikolavsky, 2022). Another recent systematic review of vaginoplasty reported an overall 24% post-surgery rate of inability to achieve orgasm (Bustos et al., 2021).

Coleman et al. (2022) claimed that “longitudinal data exists to demonstrate improvement in romantic and sexual satisfaction for adolescents receiving puberty suppression, hormone treatment and surgery.” However, the supporting citation requires scrutiny. Bungener et al. (2020) was a cross-sectional study of 113 young adults, 66% of whom were transmen (most who had undergone mastectomy and gonadectomy, not genital surgery). For its claims of post-surgery increases in sexual experience, it relied on recall of pre-surgical experiences. This means it is at high risk of recall bias, especially given surgery was undertaken up to 5 years (mean 1.5 years) prior to assessment. Further, it focused on sexual experiences, which might naturally be expected to increase as adolescents enter young adulthood, and there was no evaluation of sexual function domains, such as arousal, orgasm, or pain. The study did report current sexual satisfaction but failed to compare this to pre-surgical functioning (or to the Dutch peer comparison group). Thus, it is unable to demonstrate whether sexual satisfaction improved following GAT. On the three questions about sexual satisfaction (frequency, how good sex feels, and sex life in general), 59 to 73% were reportedly moderately to very satisfied. This would appear to mean that 27 to 41% were not satisfied, which is a sizeable minority. Importantly, these sexual satisfaction questions had an approximately 45% missing data rate—an issue not discussed by the authors. This means the authors’ conclusion that the majority was satisfied with their sex life is at high risk of bias. Of additional note, at the post-surgical assessment time these young transgender adults were significantly less sexually experienced than their Dutch peers. Thus, in sum, this study provides little reassurance about the sexual function outcomes of GAT in GD youth.

Lastly, in terms of risks, there are increasing reports of discontinuation of hormone treatments, regret and detransition in young people who have received GAT (Boyd et al., 2022; Hall et al., 2021; Littman, 2021; Vandenbussche, 2022). Two recent studies have relied on pharmaceutical prescription records, both using 2018 as the end date of data collection (Roberts et al., 2022; van der Loos et al., 2022). Their reported rates of discontinuation varied widely. For the US cohort, Roberts et al. (2022) reported, for those who had started CSH treatment before age 18, a 4-year CSH discontinuation rate of 25%. For the Dutch cohort, van der Loos et al. (2022) reported on CSH discontinuation rates in adolescents, evaluated according to the “meticulous” Dutch protocol, who had commenced puberty blockers before age 18. People “assigned female at birth” had a CSH discontinuation rate of 1% at a median of 2.3-years follow-up, and those “assigned male at birth” had a 4% discontinuation rate at median 3.5-years follow-up. Previous research from this Dutch group has indicated that average time to detransition was over 10 years (Wiepjes et al., 2018). Thus, given the van der Loos et al. (2022) study’s short median follow-up time and young follow-up age (median 19.2 for people “assigned female at birth” and 20.2 for “assigned male at birth”), it seems likely that these discontinuation rates will increase over time. It is also concerning to note that 75% of the Dutch youth who discontinued CSH had undergone gonadectomies, but at follow-up they were receiving neither CSH nor sex hormones consistent with their birth sex.

Ongoing Research

Currently, several large long-term observational studies are underway which involve collecting and analyzing data on patients receiving routine GAT at CAGCs (Olson-Kennedy et al., 2019; Tollit et al., 2019). The aims of these studies are to provide the urgently needed rigorous empirical data to bolster the weak evidence base that currently underpins the GAT approach. However, as discussed above, it is critical to note that this type of observational research is prone to bias, confounding, and lacks ability to distinguish treatment effects from placebo effects (Fanaroff et al., 2020; Pocock & Elbourne, 2000). Thus, it is unlikely to provide the rigorous empirical data that can convincingly demonstrate a causal relationship between treatment and outcome.

Further, there seems to be a problematic tension between the research and clinical agendas of CAGCs. GAT is being provided in a clinical environment that maximizes the placebo effect. This is the same environment in which the same clinicians are researching GAT’s efficacy. As previously discussed, while a placebo effect-enhancing environment may be appropriate for a clinical environment, it is far from an ideal treatment efficacy research environment, particularly when DBRCTs are not possible and RCTs are not undertaken. In the next section, I delve more deeply into exploring this issue. First, however, I will take a brief detour with an example that illustrates the risks when expert opinion and low-quality evidence are relied on as a basis for medical interventions.

A Recent Example from Medical History of the Dangers of Medical Advice Based on Weak Evidence: The Iatrogenic Tragedy of Prone Infant Sleep Position and Sudden Infant Death Syndrome

Gender medicine clinicians and researchers have consistently stated that RCTs would be unethical (de Vries et al., 2011; Smith et al., 2001; Tollit et al., 2019). However, as Valenstein (1986) discussed in his study of the history of lobotomy, the ethics of implementing new treatments without a rigorous evidence base also need to be considered. The harm that can be done by well-intentioned, but erroneous medical advice based on prestigious physicians’ clinical judgment without an adequate evidence base can be illustrated by infant sleep position and sudden infant death syndrome (SIDS). Prior to the middle of the twentieth century, it was common practice for mothers to place infants on their backs to sleep (Högberg & Bergström, 2000). The influential pediatrician, Benjamin Spock, was an early advocate of the prone position (front sleeping) for infants. He recommended it in his popular book, Baby and Childcare, from the 1956 edition through until 1985 (Gilbert et al., 2005). This recommendation, that became widespread, was mainly based on clinical wisdom that such a position reduced risk of death from aspiration of vomit and had additional benefits such as decreased crying and reduced head flattening. Early research appeared to support this clinical advice. However, by the 1980s, more rigorous research demonstrated that the prone position increased risk of SIDS. Then medical advice gradually changed to strongly recommending infant supine (back) sleeping. A marked drop in SIDS rates followed. Several biases (e.g., the healthy adopter bias and observer bias) are thought to have contributed to the erroneous clinical belief that prone sleeping position was the safest position. It has been estimated that between the 1950s and the 1990s the infant prone sleeping advice, recommended by well-meaning clinicians and prestigious medical organizations, may have contributed to the deaths of tens of thousands of infants (Gilbert et al., 2005; Sperhake et al., 2018).

Gender-Affirming Treatment for Youth with Gender Dysphoria: A Perfect Storm for Placebo Effect

The reader may ask: Why focus on GAT for GD youth? Is GAT any different from other contemporary medical treatments that also are not underpinned by rigorous evidence? I would reply—indeed, this is an issue in other areas of medicine. For example, the response rate in the placebo groups in antidepressant medication clinical trials is known to be high (Benedetti, 2021a). However, in contrast to GAT, we know this because there have been many RCTs comparing antidepressants to placebos. A recent review, that included placebo in the network meta-analysis, found that all the antidepressants under review were more efficacious than placebo in adults with major depressive disorder (Cipriani et al., 2018). This finding has been challenged by some who argue that the benefits of antidepressants beyond placebo effect seem to be minimal (Jakobsen et al., 2020). However, one of the key points to make is that placebo effect in antidepressant medication response is at least known about and discussed by many researchers, clinicians, and their patients (personal clinical experience), rather than not considered at all, as seems to be the situation to date for GAT for GD youth. Gender medicine clinicians and researchers might take note of a recent meta-analysis of antidepressants in pediatric populations, which recommended that the influence of placebo response needs to be considered in pediatric clinical trial design and implementation (Feeney et al., 2022). Furthermore, it seems particularly vital to consider the potential role of placebo effect in GAT outcomes because the stakes are high. Medical and surgical GAT, being given to vulnerable minors, lead to life-long medicalization and hold the risk of serious irreversible adverse impacts, such as sterility and impaired sexual function. Thus, we need strong evidence that they are as efficacious for critical mental health outcomes as claimed and that there are no less harmful alternatives.

In the field of GD youth medicine, there is a combination of features that seems to create a perfect storm setting for placebo effect. Thus, we have a population of vulnerable youth presenting with a condition, which has no objective diagnostic tests, and that is currently undergoing an unexplained rapid increase in prevalence and marked change in patient demographics. The treatment response is mainly based on patient-reported outcomes (yes, this can be the case for other conditions but remember we are considering the combination of features, not just a feature in isolation). Some clinicians, who may be affiliated with prestigious institutions, enthusiastically promote GAT, including on the media, social media, and alongside celebrity patients. Some make overstated claims about the strength of evidence and the certainty of benefits of GAT, including an emphasis on their “life-saving” qualities, and under-acknowledge the risks. Alternative psychosocial treatment approaches are sometimes denigrated as harmful and unethical conversion practices or as “doing nothing.” This combination of features increases the likelihood that there will be a complex interplay of heightened placebo and nocebo effects in this area of medicine, with significant implications for research and clinical practice. Some examples of these types of issues are now provided.

Overstatement of the Certainty of Benefits and Under-Acknowledgment of Risks

Some professional organizations and leading GAT clinicians, in publicly available communications to GD youth, the public, and policy makers, appear to overstate the certainty of GAT’s benefits and provide inadequate discussions of risks (Clayton, 2022a; Cohen, 2021a, b; Olson-Kennedy, 2015, 2019; Telfer, 2019, 2021). For example, GATs have been described in such communications as “absolutely life-saving” (Olson-Kennedy, 2015) and being underpinned by “robust scientific research” (Telfer, 2019). It is notable that these same clinicians in their peer reviewed publications acknowledge the sparse empirical evidence with critical knowledge gaps (Olson-Kennedy et al., 2019), and the urgent need for more evidence for this relatively new treatment approach (Tollit et al., 2019). Thus, there seems to be a kind of Janus-faced narrative, with a placebo effect-enhancing face of overstated certainty/strong evidence of benefit displayed to GD youth, their families, and policy makers, and the more realistic face of uncertainty/lack of evidence turned toward peer reviewers and the research community. Of note, several publications in the peer review literature that have made overstated claims about GAT have recently required correction (Bränström & Pachankis, 2020; Pang et al., 2021; Zwickl et al., 2021).

The Dangers of an Exaggerated Suicide Narrative

A specific issue that is important to discuss is the repeated claims that GD youth are at high suicide risk and that GAT reduces this risk. Parents report being told by clinicians that their child will suicide if a trans identity is not affirmed (Jude, 2021). Clinicians’ public statements also indicate this message is being given, or at least implied, to parents and young people (Cohen, 2021b; Marchiano, 2017). A recent editorial in The Lancet stated puberty blockers reduce suicidality and to remove access to them was to “deny” life (The Lancet, 2021). However, there is no robust empirical evidence that puberty blockers reduce suicidality or suicide rates (Biggs, 2020; Clayton et al., 2021). The authors of the paper, that was the basis for The Lancet’s claim, subsequently clarified that they were not making any causal claims that puberty blockers decreased suicidality (Rew et al., 2021). Another paper, claiming to have found that barriers to gender-affirming care was associated with suicidality, had to withdraw this claim in a significant correction to their article (Zwickl et al., 2021).

Furthermore, the suicidality of GD youth presenting at CAGCs, while markedly higher than non-referred samples, has been reported to be relatively similar to that of youth referred to generic child and adolescent mental health services (Carmichael, 2017; de Graaf et al., 2022; Levine et al., 2022). A recent study reported that 13.4% of one large gender clinic’s referrals were assessed as high suicide risk (Dahlgren Allen et al., 2021). This is much less than conveyed by the often cited 50% suicide attempt figure for trans youth (Tollit et al., 2019). A recent analysis found that, although higher than population rates, transgender youth suicide (at England’s CAGS) was still rare, at an estimated 0.03% (Biggs, 2022).

Of course, any elevated suicidality and suicide risk is of concern, and any at risk adolescent should be carefully assessed and managed by expert mental health professionals. However, an excessive focus on an exaggerated suicide risk narrative by clinicians and the media may create a damaging nocebo effect (e.g., a “self-fulfilling prophecy” effect) whereby suicidality in these vulnerable youths may be further exacerbated (Biggs, 2022; Carmichael, 2017). This type of risk has been discussed in other similar situations involving youth (Abrutyn et al., 2020; Canetto et al., 2021; Shain & AAP COMMITTEE ON ADOLESCENCE, 2016).

An Excessively Negative Portrayal of the Previous Standard and Current Alternative Treatment Options

Clinicians and groups advocating for GAT tend toward framing any non-affirming treatment approaches as harmful, ineffective, and unethical, and sometimes equate psychotherapeutic approaches with conversion practices (Ashley, 2022). However, others argue that there are a range of contemporary therapeutic approaches which are not “affirmative,” but neither are they conversion practices (D’Angelo et al., 2021). Such approaches can include: Careful assessment and diagnostic formulation, appropriate treatment of co-existing psychological conditions, supportive and educative individual/family psychological care, group therapy, developmentally informed gender exploratory psychotherapy, trauma-informed psychotherapy, and a non-promotion of early childhood social transition (sometimes labeled under the umbrella term of “watchful-waiting,” which should not be interpreted as “doing nothing”) (D’Angelo et al., 2021; de Vries & Cohen-Kettenis, 2012; Hakeem, 2012; Kozlowska et al., 2021; Lemma, 2021).

It is important to note that psychotherapeutic approaches for this group of patients are also based on limited evidence. More research into their efficacy is required. One critical consideration here seems to be that ethical psychological approaches do not hold the same adverse risk profiles as do the hormonal and surgical treatments (Baron & Dierckxsens, 2021).

Recently, two Scandinavian youth gender services have drawn similar conclusions and instigated a more cautious approach to hormonal treatments for GD minors, placing a higher emphasis on psychological care (Kaltiala-Heino, 2022; Socialstyrelsen, 2022). Furthermore, in England, the Cass Review into the country’s youth gender services has released its interim report (Cass, 2022). In response, the National Health Service’s “Interim Service Specification” for GD youth specialist services has specified that the primary intervention for youth will be psychosocial support and psychological interventions. A cautious approach to social transition is recommended and puberty blockers will only be available in the context of a formal research protocol (National Health Service, 2022).

Given all this, it is hard to accept the claims that GAT is prima facie the best treatment model for today’s cohort of GD youth. Furthermore, the unwarranted negative portrayal of contemporary psychotherapeutic approaches likely creates nocebo effects and undermines the possibility of providing such ethical care to GD youth (Kozlowska et al., 2021).

Clinicians’ Media and Social Media Promotion of Gender Affirmative Treatment

There is intense media and social media coverage of “trans youth” issues. Some surgeons are promoting their gender-affirming surgeries on social media platforms that are popular with young adolescents (Ault, 2022). Some clinicians encourage the celebratory media coverage of GAT, stating it may empower young trans people to seek GAT (Pang et al., 2020). They largely dismiss concerns that the identified association between positive media stories and increased referral rates to CAGCs may be indicative of a social contagion phenomenon. This is despite the reports of the sudden emergence of gender dysphoria, especially in adolescence, and its association with social influence (Kaltiala-Heino, 2022; Littman, 2018, 2021; Marchiano, 2017). Gender clinicians also condemn and have attempted to prevent what they consider as excessively negative media coverage of GAT (although others judge it as reasonable and balanced) (Australian Press Council, 2021; Pang et al., 2022). These clinicians are likely correct that critical media coverage of GAT could negatively impact referrals to gender clinics and might upset some patients. However, a deliberate strategy of promoting an unbalanced celebratory GAT narrative through the media and social media could contribute to social contagion and placebo effects.

What is the right balance? The Australian Press Council’s judgment on a clinician’s complaints about what she considered as excessively negative press coverage may, arguably, provide an example of some balance on these matters. Of note, while some of the complaints were upheld, many were not and it was judged that “even medical treatment accepted as appropriate by a specialist part of the medical profession is open to examination and criticism…needs to be debated…and was sufficiently justified in the public interest” (Australian Press Council, 2021).

The Exclusive Promotion of Gender-Affirming Treatments within Child and Adolescent Gender Clinics

There is indication of an unbalanced promotion of a celebratory GAT narrative occurring within CAGCs, where, simultaneously, there is a deep enmeshment of the clinical, advocacy, and research agendas. This has already partly been discussed in the sections above, but one detailed example is provided. The Trans20 study is a prospective cohort study based on children and adolescents seen at Melbourne’s Royal Children’s Hospital Gender Clinic (RCHGC) which provides a GAT model of care (Telfer et al., 2018; Tollit et al., 2019). It is important to highlight that this study’s human research ethics committee (HREC) approval was not for the treatment approach, which was implemented as routine clinical care, rather it was for matters such as collection and storage of data, and longitudinal follow-up of discharged patients.

In 2019, an amended HREC approval was granted, allowing a “newsletter blog” to be sent to patients and families with the aim of improving patient engagement with the study. This change was described as raising no new ethical issues. This “first ever” newsletter asked for help with the Trans20 survey completion (Royal Children’s Hospital, 2019). This research request was placed amid positive accounts of the service and its patients. For example, following attendance at the clinic’s single session assessment triage (SSNac) young people were described as feeling “empowered…and more likely to start living as their preferred gender,” and having improvements in mental health and quality of life. A colorful diagram showed the increased rates of social transition that followed SSNac attendance, and the section concluded “Hopefully the improvements after SSNac are a taste of things to come!” One pro-GAT parent/carer support network, that also fundraises for the RCHGC, was spotlighted. There was a “lived experience” piece in which a well-known transitioned, now young adult, patient was pictured receiving an award. This patient provided a personal testimony of the clinic’s medical director: She “will always be one of my biggest heroes…an incredible person: Intelligent, compassionate and strong.”

This newsletter’s communication raises much to think about. The point I want to make here is that sandwiching the requests for a research survey completion between celebratory accounts of the clinic seems likely to magnify the impact of bias and placebo effect on research outcome findings. For example, consider the likely impact on patient bias (patients wanting to please the clinician by giving positive reports), response bias (patients with positive experiences of the clinic more likely to complete the surveys), social learning/contagion, prestige suggestion, and the Hawthorne phenomenon. Furthermore, consider this newsletter as part of the whole therapeutic ritual, enhancing the psychological and neurobiological placebo mechanisms. Apart from this research impact, we can also wonder whether such a newsletter is ideal clinical practice. In my opinion, there are problems. Think, for example, of the young GD patient who may be hesitant to transition. Where is the celebration of this young person’s choices? Communications from the clinic, such as this newsletter, may contribute to feelings that, unless he/she transitions, he/she lacks courage (having not been “empowered”) and that he/she will never be an award-winning celebrated patient. This may act as a covert form of pressure on patients to transition or, for those who do not, act as a nocebo effect negatively impacting their psychological outcomes.

Where to From Here?

There are no easy solutions to the complex research and clinical issues presented in this Letter. Here, I present a few ideas to stimulate discussion. The first step would seem to be more professional awareness and debate. Independent reviews by expert clinicians and methodologists, not currently involved in clinical practice and research in this area (thus, having some emotional distance and minimizing intellectual conflict risk), could helpfully advise further research and clinical strategies. England’s Cass Review is an example of this type of approach (Cass, 2022).

Clinicians should also make measured and honest statements to patients, families, policy makers, and the public about the evidence for GAT’s benefits. Placebo effects could also be noted in the limitations section of any research papers. In addition, in public discourse, the media and clinicians could present not only celebratory transition stories, but also: Realistic positive stories of those with gender dysphoria who have decided not to transition or have delayed transition until maturity; accounts of patients who have benefitted from ethical psychological approaches; and accounts of those who have had negative transition experiences. Detransition, regret, and harm from transition should be acknowledged and publicized as a significant risk. A recent paper detailing the elements of a comprehensive informed consent process is timely and important (Levine et al., 2022). However, while a comprehensive informed consent process is vital, it does not address the issue of how the whole ethos of a clinic and the media/social media milieu may act to influence young patients and their families and undermine the capacity for true informed consent.

Conclusion

In conclusion, this Letter has noted that although GAT for GD youth lacks a rigorous evidence base, it is undertaken as routine medical treatment in a strongly placebo effect enhancing environment. It is within this environment that research into its effectiveness is being undertaken. One consideration raised by this relates to clinical practice: When does such a strongly placebo effect enhancing environment meet optimal clinical practice standards? When, if at all, does it veer into the territory of unethical practice that involves deception and undue influence? This Letter has also highlighted that such a placebo effect enhancing environment presents grave problems for research (particularly non-DBRCT research). It seems unlikely that the current research being undertaken in this field will be able to untangle benefits that are due to the placebo effect from those due to the interventions’ specific effectiveness. Thus, especially given the adverse risk profile of the hormonal and surgical interventions, it may be that yet again well-intentioned physicians are engaging in medical practices that cause more harm than benefit (Clayton, 2022b). The research and clinical conundrums presented in this Letter have no easy answers. However, as a first step, there is an urgent need for more awareness of the placebo effect and for rigorous and thoughtful debate over how best to proceed in research and clinical practice in this area of medicine.

[koffeevibes]

Fic Idea

So I was sitting in my Psychology class learning about the psychobiological process of stress when an idea for a new fic flew into my head (I really wished I actually listened in that class, but that's a problem for another time.)

So its a long fic following the main story for TWST, but with like a mystery within it that the readers have to work out to 'unlock' extra pieces of the story so you can see other sides of the story which I though might be cool. Especially since I've noticed recently with some of my works on my other accounts not getting much interactions (comment wise).

In this story, the main character Calliope is loosely based of Belle just for a little fun and to pay homage to my younger self who was very much obsessed with Beauty and the Beast.

Anyways I've started writing the prologue and I'm about halfway through that so I have a safety blanket incase I don't have a lot of time to write with how chaotic my life is :')

[rwby-redux]

How is Salem’s faction organized in Redux? I know that for example some rewrites create a grimm-worshipping cult to fix her lack of manpower but what is it like in Redux?

To be fair, one of Salem’s lieutenants in the Redux was an active Grimm-worshipper—Tyrian. He’s not an outlier, either.

Selectively inducting Grimm-worshippers to her ranks is one of her favorite recruitment tactics. Grimm-worshippers (or archotherolatrists, as they’re technically known) are predisposed to following Salem, because they venerate the creatures that she controls. Once Salem makes her existence known, they tend to immediately adjust their reverence to centralize around her instead. After all, if Grimm are worthy of veneration, then what of the woman who is their master?

It's one of the reasons why Ozark outlawed all forms of Grimm-worship after the Great War. It was his way of directly cutting her off from a steady supply of followers.

Salem’s inner circle—much like Ozma’s—tends to be pretty restricted to just a handful of supporters. The difference here is that Ozma chooses to limit the number of people he involves in their conflict. Salem, on the other hand, would love to increase the number of followers she has, but it’s a lot harder for her to do so. Sometimes she literally can’t, and there have been a few critical points over the millennia where Ozma actually managed to cull her inner circle and reduce it to zero. There’s a reason why she has such limited access to followers, but that’s spoiler-territory for now.

Her current roster is identical to the canon. Out of her four lieutenants, Hazel’s been in her service the longest, followed by Watts, then Tyrian, then Cinder. Cinder was the one who recruited Emerald and Mercury (both of them by serendipitous accident), and it was her idea to enlist Roman Torchwick’s gang and Adam Taurus’ cult. Leonardo Lionheart is also a member of her faction, but unlike the canon, he didn’t defect to her out of cowardice. His motives are rooted in nihilism and pragmatic resignation.

Although Salem can’t easily pad out her inner circle, she does have access to a resource that Ozma lacks: the Grimm. And this story treats the Grimm very differently from the canon.

In the Redux, there’s this thing called cognitive metamorphosis. It’s a form of psychobiological growth that senescent Grimm undergo once they’ve survived enough encounters with people. Their behavior is no longer exclusively dictated by a single-minded compulsion to kill. Grimm that successfully undergo this process become smarter, gaining self-preservation instincts, theory of mind, and other traits associated with advanced cognition.

There are several individual Grimm within Salem’s forces that have achieved this state. They functionally serve as generals within her army.

It’s been a very, very long time since Ozma has seen any of them.

He dreads the day that they return.

[boricuacherry-blog]

Dr. Carl Hart, a neuroscientist at Columbia University, released a new book, which makes an unconventional case for drug use. Dr. Hart, 54, is one of the first tenured African-American science professors at Columbia.

In his book, Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear, he confides that he has used heroin regularly for the last four years and describes the time he took morphine daily for three weeks in order to experience withdrawal. Every adult, he says, should have the freedom to do the same.

He used to test pharmaceutical grade drugs on participants for research, funded by the National Institute of Drug Addiction.

After receiving regular research grants totaling more than 6 million from NIDA, Dr. Carl Hart found himself cut off after 2009. Because I'm asking questions that do not focus on pathology, it's harder to get funding.

A spokesperson for the agency said it did not comment on its decision making process for grants.

As he drew criticism from the scientific mainstream, he attracted a new, receptive audience, including private donors for his research.

"For harm reductionists or prison abolitionists, or policing abolitionists, he is a hero," said Dorothy E. Roberts, a law professor and director of the Penn Program on Race, Science & Society at the University of Pennsylvania. "He's been willing to say, with a lot of expertise backing him up, that these policies are harmful."

Unlike past academic advocates for drug use, like Timothy Leary and Baba Ram Dass, who both experimented with LSD at Harvard University, Dr. Hart rejects as "self-serving" the distinction between so-called good drugs, like psychedelics, and more maligned substances, like heroin and methamphetamine. All, he said, have their place.

Some parts of the world may be starting to agree. Oregon has decriminalized possession of small amounts of all drugs. But Dr. Hart objected, saying decriminalization alone does little to make the drugs safe. If people do not know what they are buying, they cannot use it without risking overdose.

A next step, Dr. Hart said, should be setting up testing sites nationwide where users can determine the purity and strength of their drugs - anathema to researchers like Dr. Bertha K. Madras, a professor of psychobiology at Harvard Medical School and director of the Laboratory of Addiction Neurobiology at McLean Hospital in Belmont, Massachusetts. She says that anything that "normalizes" drug use leads to more use by adolescents - but essential to saving lives, Dr. Hart says.

If most drugs users have few or no negative consequences, what is the best way of alleviating the suffering of those who do?

"If people have a co-occurring psychiatric illness, then that's where the focus should be, not on the drug the person is taking."

So began his war on the war on drugs. It turned his career around, moving him away from heavy lab work and toward legal advocacy [after experiments with drugs addicts at Columbia University proved opposite of what he previously believed].

Much of the blame, he says, falls on his own profession. "We in this field are overstating the harmful effects of drugs, and purposely negating the positive."

Every adult, he says, should have the freedom of choice. "The pursuit of happiness and liberty."

Says Dr. Barbara Broers, a professor at the University of Geneva, "[Contrary to popular belief] Heroin is one of the safest drugs."

[vomitnest]

my uncle johnny came to visit my folks recently. it was nice to see him. it isn't very often i get to see him and we don't really keep in touch. i couldn't very well keep up with the conversation he and my parents were having. i'm like that in a lot of situations. i definitely have very bad social anxiety but i also have difficulty tracking. i imagine it is a similar thing with people who have autism or aspergers. hell, for all i know i could be on the spectrum. it makes me very tense and self-conscious and depressed. if asked a question i might seem confused and take an unusually long time to respond. it makes me feel dumb. and to make things worse i often don't outwardly display much personality in social situations like that. and so i struggle with confidence and self-esteem. i hate to feel like an aloof idiot with no personality. the kind of shy guy other people can one-up and run circles around in a casual conversation.

it's really not that big of a deal. but it still seems like it to me. i can't tell my neurotransmitters to behave differently. and yet that is what appears to determine our interpretation of every situation in which we find ourselves. we project our biochemical, neuropsychiatric electrical activity onto the world around us. and the result is that certain things appear to be more important than they really are. or they appear to be a bigger deal than they really are. or conversely we may struggle to appreciate ourselves in proportion to what is actually there. instead of seeing ourselves from a more balanced, intelligent, compassionate perspective we might see only the negative.

i don't believe in mind over matter. if it exists, it does not very well apply to my situation. the positive thinking thing only goes so far. you have to be wary of the tendency to indiscriminately apply this idea to every person's predicament, no matter what it may be. there are complex processes at work, and while thinking positively can sometimes override your emotions and perceptions, and the psychobiological activity in your body and brain, it isn't always going to work. and if it does work, it will often only be a temporary fix and/or it may prevent one from directly engaging the situation through decisive action and personal accountability. this has been referred to as spiritual bypass. in this case positive thinking or mind over matter acts more like a crutch that allows us to avoid the issue and thus miss an opportunity for concrete intervention.

sometimes it is simply our perspective that needs to change, which is easier said than done and can require more complex considerations than chalking everything up to will-power and positive thinking. (that's hypocrisy, imo.) other times it is more than simply our perspective that needs to change. or in other words there are times when opportunities for resolving issues present themselves during which we can ideally come to act differently and express ourselves differently in a given situation. it requires discernment because there are some things which we have the power to change and some things which we do not. there are times in which we ought to act, and there are times in which we ought to refrain or reflect. each of us has unique capacities and limitations as individuals and there is no singular solution which can apply to every person or every situation.

[timothygadson]

Enhancing Student Achievement and Well-being through Teaching Executive Function Skills

In the ever-evolving landscape of education, there is a growing recognition of the importance of executive function skills in shaping students' academic success and overall well-being. Executive function encompasses mental processes that enable individuals to plan, focus attention, remember instructions, and manage time effectively. Research suggests that teaching executive function skills can profoundly impact student achievement and well-being. In this article, we will explore the significance of executive function skills in education and how teaching these skills can lead to improved outcomes for students, supported by real supporting citations and a reference page.

The Importance of Executive Function Skills

Executive function skills are critical for success in school and beyond. These skills enable students to set goals, organize tasks, regulate emotions, solve problems, and adapt to changing situations. Research has shown that individuals with strong executive function skills are better equipped to succeed academically, develop positive social relationships, and navigate life's challenges effectively (Diamond, 2013; Zelazo & Carlson, 2012).

Teaching Executive Function Skills

Educators play a vital role in teaching students executive function skills. By integrating explicit instruction, modeling, and practice into their teaching, educators can help students develop and strengthen their executive function skills. Strategies such as breaking tasks into manageable steps, providing visual aids and reminders, teaching self-monitoring and self-reflection techniques, and fostering a growth mindset can all contribute to developing executive function skills in students (Meltzer, 2011; Blair & Raver, 2015).

Impact on Academic Achievement

Research has shown a strong correlation between executive function skills and academic achievement. Students with strong executive function skills perform better academically, including reading comprehension, math problem-solving, and writing proficiency. These students can better stay focused, follow instructions, manage their time effectively, and persist in facing challenges, leading to improved academic outcomes (Best et al., 2011; Jacob & Parkinson, 2015).

Promoting Social and Emotional Well-being

In addition to academic success, executive function skills are closely linked to students' social and emotional well-being. Students with strong executive function skills are better equipped to regulate their emotions, communicate effectively, resolve conflicts, and establish positive relationships with peers and adults. These skills contribute to greater resilience, self-confidence, and overall well-being, helping students navigate the complexities of school and life more easily (Eisenberg et al., 2010; Blair & Razza, 2007).

Teaching executive function skills is essential for promoting student achievement and well-being in education. By equipping students with the cognitive and emotional tools they need to succeed, educators can empower them to thrive academically, socially, and emotionally. As educators continue to prioritize the development of executive function skills in their teaching practices, they can make a meaningful difference in the lives of their students, laying the foundation for success in school and beyond.

Reference:

Blair, C., & Razza, R. P. (2007). Relating Effortful Control, Executive Function, and False Belief Understanding to Emerging Math and Literacy Ability in Kindergarten. Child Development, 78(2), 647-663.

Blair, C., & Raver, C. C. (2015). School Readiness and Self-Regulation: A Developmental Psychobiological Approach. Annual Review of Psychology, 66, 711-731.

Diamond, A. (2013). Executive Functions. Annual Review of Psychology, 64, 135-168.

Eisenberg, N., Spinrad, T. L., & Eggum, N. D. (2010). Emotion-Related Self-Regulation and Its Relation to Children's Maladjustment. Annual Review of Clinical Psychology, 6, 495-525.

Jacob, R., & Parkinson, J. (2015). The Potential for School-Based Interventions That Target Executive Function to Improve Academic Achievement: A Review. Review of Educational Research, 85(4), 512-552.

Meltzer, L. (2011). Executive Function in Education: From Theory to Practice. New York, NY: Guilford Press.

Zelazo, P. D., & Carlson, S. M. (2012). Hot and Cool Executive Function in Childhood and Adolescence: Development and Plasticity. Child Development Perspectives, 6(4), 354-360.

[psychreviews2]

Case Studies: The ‘Wolfman’ – Sigmund Freud Pt. 3

On the cutting room floor

Being such important case studies, later analysts would unearth from them what Freud could not see in the early 20th century. Patrick Mahony analyzed some of what was missing in The Cries of the Wolf Man based on more current discoveries, just like he did in his huge review of the "Ratman." In those days, again, women were often not emphasized as much as men for their influence on a child's upbringing. "...Freud's paternalistic bias in his understanding of the case and the [minimization] of maternal transference appears in the odd statement that the father was Serge's 'first and most primitive object choice.' Finally, Freud's judgment of aggressive factors was wanting. He underplayed the hostile elements in the transference. Stressing sexual explanations, he neglected the essential connection between narcissism and aggression and the patient's identification with the aggressor; in particular, much of Serge's early [behaviour] was an identification with an aggressor, which is to be explained not merely as a reaction from passivity to activity but rather as a process whereby becoming the aggressor diminishes [low self-opinion], gratifies the self, and regains self-esteem...Sociologically we must be aware that because of the enormous wealth and aristocratic standing of Serge's family and attendantly because of its palatial mansion, it is of the greatest unlikelihood that the boy would have slept in his parents bedroom. We can hardly imagine that this reality was not brought up and discussed during the analysis, and yet Freud suppressed this in his reportage." Freud was also working through his own situation with homosexual libido at around that time with his split with Wilhelm Fliess. In a letter to Sandor Ferenczi Freud wrote that "a piece of homosexual investment has been withdrawn and utilized for the enlargement of my own ego. I have succeeded where the paranoiac fails." It was also known that Sigmund slept in his parents quarters and was more likely to witness his parents having sex rather than his patient.

Mahony further describes the improbability of the primal scene, and that the child with malaria was able to watch the parents having sex for a long period of time, even if he were only in the room once. The angle of seeing the genitals from the cot would also be improbable. "Apart from the fact that the primal scene may be absorbed into screen memories, the question remains as to whether the exposure to primal scenes must necessarily be traumatic or be interpreted as a sadomasochistic experience. The universality of incest taboos and the inevitability of unconscious guilt incurred in witnessing the primal scene and the child's possible rage and narcissistic injury are elements to be taken into account in any future answer. At any rate, Freud's focusing on direct instinctual overstimulation due to a single primal scene overlooked the possible trauma of more important factors: the pathology of earliest object relations; the psychobiological side effects of the nearly fatal pneumonia suffered at the age of three months; life threatening malaria and its sequelae in ego disturbance; and finally, what we now understand as the sensitivity of the rapproachement subphase of separation-individuation when language, secondary process, and gender identification are rapidly evolving and vulnerable." Here the rapproachment subphase he is talking about, is the age when the child has to start to feel comfortable doing some things on his or her own.

Like the mutual admiration society described earlier, prematurely believing in success can fool both the therapist and patient. Mahony adds that "[by bringing] their 'interplay of suggestion and compliance' to bear upon the so-called breakthrough at the end of the case, we see at another level the patient's submission to his insistent analyst, who all the while eagerly and self-deceptively believed that infantile material was being worked through. The forced termination gratified the Wolf Man's passive fantasies related to the primal scene and at the same time further entrenched him in a castration complex. There is a partial truth to the diagnostic account of the Wolf Man 'as having submitted in a feminine manner to Freud and as having produced a child for him - the wolf dream and its analysis - and thereby a cure in part through a misalliance and mutual inappropriate gratification. One might even speak of an '[invention] induced by interpretation whereby the dream, placed at the center of the treatment, became the object of an equal ardor and of reciprocal seduction.' In one sense the patient retreated to a second line of defense; his compliant false self gave Freud what he was looking for, with the result that the patient's infantile grandiosity remained untouched, a false-self maneuver which 'settled several critical dilemmas, and satisfied narcissism at both ends of the couch.'" Ironically, Freud was studying Narcissism at this time but all he saw was genital narcissistic masculinity rebelling against femininity.

A big possible miss comes from the former director of the Sigmund Freud Archives, after Kurt Eissler, Jeffrey Masson, who found unpublished material that could be of use to the case study. In his controversial The Assault on Truth, he was "asked...to go through the unpublished material...concerning the Wolf-Man, one of Freud’s most famous later patients. There I found some notes by Ruth Mack Brunswick for a paper she never published. At Freud’s request, she had re-analyzed the Wolf-Man and was astonished to learn that as a child he had been anally seduced by a member of his family—and that Freud did not know this. She never told him. Why? Did Freud not know because he did not want to know? And did Ruth Mack Brunswick not tell him because she sensed this?" His discovery unfortunately doesn't provide which family member it was and so it remains floating in the possibilities of interpretation. Was it a parent, a sibling, or a caretaker? Freud did acknowledge sexual abuse in childhood, but he focused more on frustrated wishes, precisely because not all victims end up with psychological problems after abuse. A more balanced view that looks at both abuse and frustrated wishes would help, and if Serge had that dealt with in the analysis with Freud, it certainly would have been more insightful.

In the end Mahony found Brunswick's analysis too timid to break with Freud's orthodox analysis. "Brunswick bore some similarity to her patient the Wolf Man, and one may wonder whether the overlap influenced Freud's decision on the referral. To complete this part of the story: during her prolonged stay in Vienna, her health deteriorated, prompting her to follow the dying Freud to London in 1938 to have further analysis with him. Imagine the desperate scene: now a recent widower, the succor-seeking Wolf Man rushing to London to see his analyst, who herself was frail and back in treatment with her own and her patient's former analyst." Mahony speculates that this could have been seen as a rejection to Serge because "in London the Wolf Man obtained relief from Brunswick but tried unsuccessfully to see Freud." Then with Freud's death, his wife's suicide, and Ruth's untimely death, he would eventually have to find others to rely on. By the time Serge was interviewing with Karin Obholzer, he was seeing Kurt Eissler and possibly Dr. Wilhelm Solms. Mahony researched the background to those interviews. "Pankejeff voiced endless resentment of others, including Eissler and Gardiner, who so generously sustained him materially and psychologically; meanwhile he was criticizing Obholzer to Eissler. This backbiting, atypical of the immortal patient, indicates another character change where senility had its say. But it is fitting to ask how much he was influenced by the anti-psychoanalytic interviews, if he spoke for himself, or even more to the point, did he ever speak for himself?"

Life after Freud

Despite the positive overtones of the Psychoanalysts, Psychoanalysis has always been under a lot of criticism, and Serge was the longest living patient of Freud's. He would provide a lot of material to analyze after so many treatments. The last part of Serge's life until his death included continued communication with psychoanalysts and an interview with an agnostic journalist, Karin Obholzer. It was very interesting to see the two sides of the Wolfman case. From the point of view of a psychologically untrained journalist, Karin was able to see Serge without the lens of psychoanalysis and to be able to notice how little he changed for an average person. Any unknown biological sources of pathology would continue to manifest in front of her. Yet, from the point of view of psychoanalysts, they are the ones trained to treat patients and are able to see more depth than Karin was able to. It's very easy when reading these books to get emotional and take sides, because it's a human life in the balance. Karin would not be able to analyze Serge's defenses and break through them. She had to take him at his word. Psychoanalysis would develop into different traditions, including Object-Relations and Self-Psychology. Reviews of later psychoanalysts could see what Freud did right and wrong and add further understanding from more recent clinical observations. After all these years of treatment, how much improvement should Serge have noticed? Also, at his advanced age of 86, how much would he remember for an interview? 

Serge's late views on Freud and Psychoanalysis

Despite all that help from Freud and other Psychoanalysts, Serge remained skeptical at the end of his life. "Freud was a genius, there's no denying it! All those ideas that he combined in a system...Even though much isn't true, it was a splendid achievement." One of the interesting sticking points for Serge was the endless debate about choice and determinism. Even though Freud was mostly of the opinion of determinism, he still talked about choice. "Freud said that when one has gone through psychoanalysis, one can become well. But one must also want to become well. It's like a ticket one buys. The ticket gives one the possibility to travel. But I am not obliged to travel. It depends on...my decision." The difficulty for therapists is how to generate desire in people to change, and certainly Freud and others tried. "He had very serious eyes that looked down to the very bottom of the soul. His whole appearance was very appealing. I felt sympathy for him. That was transference. He had a magnetism or, better, an aura that was very pleasant and positive. When I told him about my various states, he said: 'We have the means to cure what you are suffering from'...He said 'Treatment means that you have to say everything that occurs to you'...He must have thought that the important things are in the subconscious and that they emerge through free association." Freud warned him not to rationalize the material. The patient had to trust the the analyst. "That's how he succeeded in bringing about a total transference to himself. Is that a good thing, do you suppose? That's the question. Too strong a transference ends with your transferring to individuals who replace Freud, as it were, and with your believing them uncritically. And that happened to me, to a degree. So transference is a dangerous thing....Basically [hypnosis and transference] are similar. I can remember Freud saying 'Hypnosis, what do you mean, hypnosis, everything we do is hypnosis too.'"

Serge went on explaining how he "worshiped" Freud and how Freud was a replacement to a disappointing father who preferred his sister instead. When his father died, Freud would be able to use a much stronger transference in therapy, and suggestions would be much easier to be adopted. Serge then talked about the difficulty of affording treatment, and how psychology is much better than it used to be. His big concern about psychotherapy was the false promise of happiness after an analysis, and the unexpected dependence on analysts. "The analyst puts the patient back into his childhood. And he experiences everything as a child. But that doesn't mean that the suffering has to pass. That's the important question: Must it pass when one remembers something? This question has not really been answered...The disciples of psychoanalysis should have not laid hold of me after Freud.

O: You mean they should have left you alone?

W: Yes, because I would have acted more independently...That is the danger of psychoanalysis, that one is dependent on the decisions of others who are not competent and knowledgeable but who believe that they know everything and can guide one just because they are psychoanalysts...Freud was so anti-religious [but] he and all of psychoanalysis are being blamed for the very thing for which he blamed religion, that it's nothing but a faith...But psychoanalysis is complicated. Who can make definitive and official statements? The effect was salutary, in any event. But it was not a complete cure.

O: And do you still believe in psychoanalysis?

W: I no longer believe in anything.

O: Nothing at all?

W: All right, I believe in transference. I am of the opinion, of course, that improvement can be made by transference.

O: Today, they also concern themselves with the family or with the couple if that's what it is.

W: That's the way it should be, of course. [They] must also deal with Therese and not say, that isn't my patient.

[But] I never thought much of dream interpretation, you know...Freud traces everything back to the primal scene which he derives from the dream. But that scene does not occur in the dream...That scene in the dream where the windows open and so on and the wolves are sitting there, and his interpretation, I don't know, those things are miles apart. It's terribly farfetched.

O: But it's true that you did have that dream.

W: Yes, it is...I prefer free association because there, something can occur to you. But that primal scene is no more than a construct...The whole thing is improbable because in Russia, children sleep in the nanny's bedroom, not in their parents'. It's possible, of course, that there was an exception, how do I know? But I have never been able to remember anything of that sort...If one...concludes from effects to cause, it's the same thing as circumstantial evidence in a trial.

O: What about the obsessional neurosis now?

W: I believe you are born with something like that, there's nothing one can do about it.

O: Freud writes that your illness erupted because you got the clap [Gonorrhea].

W: That we have to talk about these unpleasant things!

O: What's so terrible? It can happen to anyone. Perhaps it will console you when I tell you that I had the clap myself.

W: I am amazed you should tell me. You really seem to trust me!...I had a friend, and this friend had an older friend who arranged it. There was a café with three girls in it. And this friend knew that these girls were [waitresses] in that café and that they could also be put to a different use...And they also had a room...

O: How old were you at the time?

W: Seventeen.

O: Was that your first sexual experience?

W: Yes. In any event, we went and I asked the friend - you'll have to excuse my telling you these terrible things - whether one should use a prophylatic or not. And he answered, 'The whore will laugh at you.' So we didn't take any long. And then, by way of a joke, he said that there's a superstition that the name of the first woman with whom one has sexual intercourse will also be the name of the woman one marries. And that was true in our case. Her name was Maria, I remember, and my wife's name was actually Maria Therese. So it was true.

O: The gonorrhea came later?

W: Yes, later. I got it from a peasant girl. That was a year later. I felt confident; I thought, that can't happen in the country. People always said that it was risky to go to prostitutes. And out in the country it is less dangerous. The opposite turned out to be true.

O: And you gave the peasant girl money, or were you in love?

W: No, no, you always gave something, that was a matter of good manners.

O: What did you tell Freud you were suffering from?

W: Well depressions...it was because of Therese...Everyone was against Therese: the doctors, my mother, my relatives. They all said that she was a woman with whom one could not live. Had I decided to go see Therese, things might have been alright without Freud.

O: What was the attitude toward masturbation?

W: Well, my God, people said that one became insane, that it is very dangerous, that it's harmful. And when I saw Freud, he said, 'Well, that's an exaggeration. It isn't that serious.'

O: Did Freud advocate masturbation?

W: No, no, that's putting it too strongly. He viewed it as harmless.

O: [Ruth] writes that you said, 'Of course, I only masturbated regularly on the big holidays.'

W: What she wrote there is stupid. It's absurd.

O: Why? What if you did?

W: When I was seeing her, I was with Therese. I had no need to masturbate.

O: There are people who masturbate nonetheless.

W: But that's primarily young people who haven't had the courage to go to a woman or haven't had the opportunity.

O: One also finds it among couples. It isn't that unusual.

O: Did you ever have real homosexual relations?

W: Of course not, never. But since you bring it up, I happen to remember something. In Russia, the Armenians were known as homosexuals. I was told when one went to a bathhouse in the Caucasus, they asked, do you want a woman or a boy? When I was a student in Odessa, there was an Armenian. His name was Murato. He was a good-looking person but had disquieting eyes. Very strange eyes. That was what was so beautiful about him. There was a small group of us students, and this Murato was one of us. Once, he said to me, 'You know, after the performance, we are all visiting S. P. That was an actor in Odessa who was a known homosexual...Murato said, 'We are all going to see S.P.' I knew right away what he meant. One day, I was at the university to attend a lecture. All the seats were taken except for one next to this Murato. I sat down there. Suddenly, he takes my hand and starts pressing it. That was supposed to be a test. I immediately distanced myself...I had a second experience...I was going to Paris, there was another gentleman in the compartment. I stretched out and fell asleep in the corner by the window. Then he stepped up to the window and placed his foot close to mine. I didn't know what to do, should I push his foot away? So I pretended to sleep. Then he played with my knee, but finally he stopped. He wanted to see how I would react.

O: Freud writes about your homosexual tendencies...

W: Subconscious, of course. For Freud, all relations between men are homosexual.

O: It's probably true that every human being is naturally bisexual.

W: But homosexuals are relatively rare.

O: The educational barriers are very strong...Freud says somewhere that you preferred a certain position during intercourse, the one from behind...that you enjoyed it less in other positions.

W: But that also depends on the woman, how she is built. There are women where it is only possible from the front. That's happened to me. It depends on whether the vagina is more toward the front or toward the rear...With Therese...the first coitus was that she sat on top of me."

O: [Quoting Ernest Jones here]: 'From the age of six he had suffered from obsessive blasphemies against the Almighty, and he initiated the first hour of treatment with the offer to have rectal intercourse with Freud and then to defecate on his head.'

W: For heaven's sake, what nonsense! To write something like that, I don't know, is that fellow crazy or what, writing such nonsense. He explained it to me, he sits at the head end rather than at the foot of the bed because there was a female patient who wanted to seduce him, and she kept raising her skirt...That fellow must have a screw loose."

The quote Obholzer referred to was from Ernest Jones who took the situation too literally. Thankfully Mahony referenced the original letter from Freud writing to Sandor Ferenczi about a transference insult he received from Serge: "A rich young Russian whom I have taken on because of compulsive falling in love, confessed to me, after the first session, the following transference: Jewish swindler, he would like to use me from behind and shit on my head." Whether Serge forgot the transference or it never happened, at his age during the interview it's hard to verify. Certainly it's possible there was an anal obsession with Freud doing the analysis. At this point it's good to bring in more modern understandings of obsession and homosexuality. 

Homosexual OCD

A lot of conflict between people regarding sexuality is based on phobias and compulsive thoughts. When someone looks at someone else, they don't only look, the brain assesses imitatively if it identifies with the pleasure that person looks for. People forget that their desire or distaste is their own. For those who obsess, compulsions can happen just from looking at someone or thinking about content that adds to obsession. Freud in particular is a psychoanalyst that talks a lot about obsession and homosexuality. When obsession goes to an extreme it turns into what modern therapists call Homosexual Obsessive Compulsive Disorder (HOCD). Certainly with so much emphasis on sexuality and sexual orientation in Freud's insights, it's easy for people to obsess about how they dress, how they hold themselves and think "is that unconsciously gay?" Phobias and stereotypes can easily develop if you are constantly looking for signs. The human mind has many parts to it and it's capable of imitating emotions of others, just like you see in TV shows, movies, and even singing Karaoke and singing along in concerts are great examples of mimetics. You can imitate being the singer and it creates some emotions of validation, and identity, but this short-term imitation, that can turn into an obsession, is shallow compared to being the actual person. There are more piano notes to being in a long-term homosexual relationship where you are in love with your partner and desire to have regular sex with them, but where you also have deep intimate conversations and long-term joint projects. People can be confused by imitation, identification and compulsions to act. With OCD, the intrusive thoughts are very powerful. It may seem funny to many people, but it actually affects a lot of people, and if they can't get out of their thoughts/images and into the sensations of their body, they can have doubts about their sexual orientation for long periods of time. 

Monnica Williams did an excellent review of this type of OCD. In general, with OCD..."compulsions are repetitive, ritualized behaviors that the person feels driven to perform to alleviate the anxiety of the obsessions. Depending on the severity of the disorder, the compulsive rituals can occupy many hours each day...A recent study using a broad sample of OCD patients found that 25% experienced sexual obsessions currently or in the past. Sexual obsessions may revolve around a multitude of loci. Common themes include unfaithfulness, incest, pedophilia, unusual behaviors, AIDS, profane thoughts combining religion and sex, and, of course, homosexuality. Since sex carries so much emotional, moral, and religious importance, it easily becomes a magnet for obsessions in people predisposed to OCD....Homosexual anxiety is described here as the obsessive fear of being or becoming homosexual, the experience of intrusive, unwanted mental images of homosexual behavior, and/or the obsessive fear that others may believe one is homosexual. A person may have only one of these facets of the disorder or any combination. Since OCD is characterized by doubt, the person with OCD will contemplate the uncomfortable thoughts or images, agonize over the meaning of the questions that arise, determine possible answers, and then doubt the answers. The person will continually seek evidence to help arrive at a decision, perform compulsive rituals to ward off anxiety, ask others for reassurance, and/or avoid things or situations that worsen the anxiety. At times the person will realize that the fears are extreme but at other times the concerns may seem perfectly rational...People with HOCD may engage in a multitude of checking behaviors and avoidances. They may avoid watching television out of concern that seeing a show with a gay character might trigger the obsessions, causing a 'spike,' or surge of anxious thoughts. Others might look at pornographic images of homosexual couples and repeatedly assess whether they feel aroused, or even compare their responses to when they look at heterosexual images. Many people with homosexuality fears worry about a sudden lack of attraction to others of the opposite sex. They may attempt to have intercourse with their partner or masturbate to pornography just to ensure that they are 'still straight.' This form of checking is particularly destructive because the anxiety from the OCD typically results in decreased sex drive and/or an inability to perform, which the patient then misinterprets as further evidence of homosexuality. People with HOCD will often solicit reassurance from others then feel temporarily relieved, but the doubts always return. No amount of reassurance is ever enough because complete certainty cannot be obtained. Even though the person may be diagnosed with OCD, until they are treated they often will doubt the diagnosis...Homosexuality anxiety is not caused by dislike of homosexuals, but rather a fear that the person will no longer have access to the opposite sex, something they highly value."

An example of how extreme it can get is an OCD patient Monnica describes. "I have been diagnosed with OCD for a while now. The therapist I was seeing told me that I should try to be with a man, and that everybody is bisexual. It really freaked me out, and I was suicidal for five months thanks to what she said. The thoughts grew even stronger. Eventually, I couldn’t be with any person of the same sex alone in the same room, watch TV, read the newspaper, or listen to music with male voices." So this is important for Freudian psychoanalysts who are comfortable with bisexuality, but their patients are not, and also have OCD, especially if they are undiagnosed. Another example is of a 20 year old male masturbating to see which pornography creates the largest pleasure. "I’m struggling with these bloody urges, and I can’t stand it any more. It keeps saying, “You want it,” [obsession] and eventually I say, “Fine,” and I just masturbate to things I hate [compulsion]. It does a little bit for me, but I’m pretty sure that’s the stimulation and not the content. But then as soon as I think of a girl [compulsion], boom, I finish, and I know I am straight. But how am I supposed to get these thoughts out of my head? These urges feel real. I don’t like this. I don’t want to be gay at all. It’s a scary thought that I'd have to spend the rest of my life with a guy [obsession]. I can’t handle that, but something keeps telling me that’s what I want [obsession], even though in reality that’s disgusting to me. OCD is so confusing isn’t it?"

Of course this doesn't only affect men. "This is all started about two years ago, with obsessions about being gay. Over the past several months my thoughts have been insane. I can't do anything without freaking out that it is a sign [obsession]. I am in the medical profession. If I have to do an...exam, and a girl is skinny (and of course I'm jealous), I get visuals that I don't want. If a couple comes in and the husband is ugly, but the wife is pretty and thin, I think, 'Oh my God, I would rather be with the wife than the husband [obsession].' Then I try to picture myself years down the road [compulsion], and I can't see who I am with – a man or a woman. I feel like I have become obsessed with the female body, which could either be due to my horrendous self-esteem or that I'm really gay. I used to be obsessed with the male body and always talking about how hot this guy was or that guy, and now I feel like I can't do that anymore. These thoughts are shifting my entire outlook on who I want to be with. I have been dating someone for the past seven months, and he is aware of what has been going on. He tries to help, but doesn't really know how. It seems like it has gotten progressively worse since I have started dating him. In the beginning, sex was awesome, and now it's all I can do to make it through sex without crying because I feel like I'm going insane. And at times I feel so full of sadness and depression, that I forget how much I love (or think I love) [obsession] my boyfriend."

Like with most OCD, the treatments involve tackling the logic of obsessive thoughts. "I realized that when the phrase 'You're gay' popped into my head I was telling myself the following: (1) You are inferior to other men, (2) You are effeminate, (3) You are a sissy, (4) No woman would be interested in you. When I saw the lies in these statements, I said to myself, 'You know what, even if I am gay this distorted belief system is a problem and needs to be fixed.' Once I saw the lie, it was like a fog lifted, and the horrible depression disappeared instantly. I thought this was really too good to be true so I called my therapist. She told me that, yes, once you realize the distortions in some of your thoughts your mood can change instantly. It was unbelievable."

Fred Penzel, from the International OCD Foundation, provides some tips for resisting checking behaviour. "Not checking your reactions to attractive members of your own sex. Not imagining yourself in sexual situations with same-sex individuals to check on your own reactions. Not behaving sexually with members of the opposite sex just to check your own reactions. Resist reviewing previous situations where you were with members of the same or opposite sex, or where things were ambiguous to see if you did anything questionable. Avoid observing yourself to see if you behaved in a way you imagine a homosexual or member of the opposite sex would." The problem with checking behaviour is that it can become addictive because of the relief. Yet the relief doesn't last because doubts keep returning because it's hard to be absolute about fuzzy areas like sexual orientation, and certainly having other non-professionals suggest your orientation is to give them too much power. One has to develop skepticism of people who rattle off suggestions that "your clothes are gay, your interests are gay, you saw gay pornography, that means you're gay, you had thoughts about being gay, then you're gay." You can reverse it to see how unscientific those suggestions are. "Your clothes are straight, your interests are straight, you saw straight pornography, that means you're straight, you had thoughts about being straight, then you're straight." Another area of healing can come from exposure therapy, where you actually entertain more ideas of homosexuality to face your phobias. Now this isn't a checking obsession, these are actually attempts to learn. Depending on how serious the compulsions are, a patient has to be ready to deal with the anxiety. This includes..."reading books by or about gay persons. Watching videos on gay themes or about gay characters. Visiting gay meetings shops, browsing in gay bookstores, or visiting areas of town that are more predominantly gay. Wearing a T-shirt at home with the word ‘gay’ on it. Wearing clothes in fit, color, or style that could possibly look effeminate for a man or masculine for a woman...[Read] about people who are sexually confused. Reading about people who are transgendered. Looking at pictures of people who are transgendered or are transvestites."

As an aside, on the checking behaviour with pornography, people need to be aware of how much disgust towards any sex is held back in things like pornography. Just like in advertising, all undesirable details are removed, or participants act as if undesirable details are desirable to get the brain to imitate. As long as participants look like they're having a good time, the brain wants to imitate pleasure. This habit can sneak into areas that require more authenticity. Long-term sexual relationships require a lot of love, caring, and concern. Most of these things are missing from pornography. The relationship template the brain is learning from in pornography is based on what's left out. This isn't to bash pornography but much of it leaves out long-term relationships, envy, jealousy, STIs, and relationship skills. Lust also gets boring. What is attractive at the beginning in a relationship can become quite boring after a certain amount of time. Long-term relationships have passion, love and interest that doesn't fizzle as easily. Having gay or lesbian sex without the human connection that goes beyond a sexual connection is too superficial to be full sexual orientation. Pornography is not a good example for people to decide what their sexual orientation is. At most it can help condition an appreciation of the same sex in terms of lust, but it doesn't condition romantic love and relationship skills because those things are absent in most pornography. The piano notes of a loving long-term relationship have a lot more variety than sex addiction, and like any addiction, overemphasizing one note is all about short-term quick relief to regulate the emotions, just like alcohol and other substances. If boredom rules addiction and it requires more novelty and intensity then in the example of relationships, long-term relationships would be boring and partners would have to be exchanged constantly. What people with different sexual orientations are fighting for in claiming equal rights is much more than just sex. 

Outside of sexual orientation, a person has to look beyond needing a response from society or authority figures to bless a relationship, and one has to get to a point as if you and your partner are on your own, making your own decisions, without needing validation from others and to be able to feel relaxed, comfortable and happy. This is actually a difficult thing to do. To look at actual relationships and actual objects for their actual value, without needing validation, and agreement from others is an advanced level of intrinsic motivation. Many people want what they want and demand that everyone agree with them, even if opinions from others are irrelevant. A lot of the high people get is on social validation and it can distort any individual's decision making strategies, and is a huge source of conflict internally and externally. People want you to agree with their religion, philosophy, sexual orientation, and cultural habits. Rewards and punishments constantly steer the mind away from authentic choices. To mind your own business and live your own life actually takes a lot of courage, but the reward is psychological freedom and independence.

Horace Frink & Proto-conversion therapy

Of course this mistake of needing help from authority figures to work out sexual orientation also happened in Freud's time and he was also implicated in those mistakes. Serge wasn't the only one that became a ward of psychoanalysis, and this can happen in any modality where the therapist receives a parental transference respect from the patient. Freud over emphasized unconscious homosexuality in a way that helped but he was too omnipotent to understand how unbending many sexual orientations are. He eventually figured it out, but it didn't start off that way. The Frink Fiasco was almost as bad as what happened with Emma Eckstein. [See: Dreams: https://rumble.com/v1gtf6j-dreams-sigmund-freud.html] Horace Frink was a former analysand of Freud's and he impressed him enough to have Horace selected as Freud representative in America. Frink was having an affair with the banking heiress Angelika Bijur, and Freud suggested that Frink was in love with her and should divorce his wife, which he had two children with. After the divorces and the new marriage to Bijur, Frink's mental health deteriorated with feelings of guilt. His depression and anger increased with accusations that his new wife was ugly and looked like a man or a pig. Freud responded "Your idea Mrs. Bijur had lost part of her beauty may be turned into her having lost part of her money. Your complaint that you cannot grasp your homosexuality implies that you are not yet aware of your fantasy of making me a rich man. Let us change this imaginary gift into a real contribution to the Psychoanalytic Funds." Freud was in the dangerous position that most psychologists face, which is how to make money and follow ethics. The pressure to have famous successful cases pushes people to take short-cuts, and is always an influence therapists have to ignore to protect their patients. Frink himself was now stuck analyzing patients for the needed money, even as he started losing faith in psychoanalysis. His ongoing fights with Angelika resorted to blows and she filed for divorce. Freud was forced into having to dismiss Frink from leadership in America, and it turned into a resentment that Freud had against his followers in the United States. Frink continued to deteriorate, including two suicide attempts, leading to an admission in a sanatorium. Now on Freud's side, he wasn't responsible for Frink's affairs, but psychological suggestions are dangerous, partly because it's actually hard to be a therapist and avoid suggestions, but this is also compounded when important individuals in family relationships are left out of the analysis. Angelika's ex-husband Abraham asserted himself in a letter to Freud that should be an example to all therapists who should think before they offer any suggestions, especially match-making suggestions. "Dr Freud: Two patients presented themselves to you and made it clear that on your judgment depended whether they had a right to marry. The man is bound in honour by the ethics of his profession not to take advantage of his confidential position toward his patients. The woman was his patient. The woman is my wife. How can you know you are just to me: how can you give a judgment that ruins a man's home and happiness, without at least knowing the victim, so as to see if he is worthy of the punishment, or if through him a better solution cannot be found? Great Doctor, are you savant or charlatan?"

This is just as much a problem today as it was then. Going back to the concern of the 'Ratman' Ernst Lanzer, Patrick Mahony said "it was years later [than his analysis] before Freud fully realized that the uncovering of guilt could lead to the negative therapeutic effect of worsening a patient's condition." This is a great example for budding therapists to study before they start the profession. Blame, as is known in the court system, can be accurate, but it also can conflate all the problems that a person has onto a scapegoat and therapists can be scapegoated. Both the therapist and the patient have to take on their own responsibilities for making decisions. Patients need to find second opinions, and if they are capable of agency, they should be doing their own research. The challenge for therapists is to make sure the client knows that psychology is not a magic wand that will make you rich and find the perfect spouse. Psychologists are not experts in every field of life, and suggestions outside of their expertise must be looked at with skepticism. Many things are uncertain, and in a world where people glorify intuition, it can be as dangerous as a random guess. Daniel Kahneman describes when intuition works best "We have seen that reliably skilled intuitions are likely to develop when the individual operates in a high-validity environment and has an opportunity to learn the rules of that environment. These conditions often remain unmet in professional contexts, either because the environment is insufficiently predictable or because of the absence of opportunities to learn its rules." What this basically says is that you can only trust intuition when you know a lot about something. The best attitude to have in therapy is to be skeptical of all intuitions until the patient's family and friends are understood very well. Even then, there will be mistakes, so an emphasis that people have to take responsibility for themselves instead of relying on their psychologist like they are a child dependent and the therapist is a parent, must be communicated to the patient. The patient needs to inform themselves and read different points of view, and if they are capable of learning a lot about reality, and the different scientific disciplines, then they can be independent minded enough to make their own decisions, and hopefully, if their problem is not genetic or biological, they can let go of dependence on a saviour therapist. For most therapists, success is when the patient doesn't need to come back, and the ex-patient now cherishes their own research and decision making skills. 

Why so few talented therapists treat clients with challenging disorders - Marsha Linehan: https://www.youtube.com/watch?v=d5mTLFfCQyY

Bisexual erasure and psychological templates

Jonathan Barrett from the University of Nevada, did a good review of early conversion therapy philosophies in Psychoanalysis and how it's toxicity split off into the United States. Freud eventually learned that “It is not for psychoanalysis to solve the problem of homosexuality...one must remember that in normal sexuality also there is a limitation in the choice of object; in general to undertake to convert a fully developed homosexual into a heterosexual is not much more promising than to do the reverse, only that for good practical reasons the latter is never attempted." Here he suggests that object choices are made early in life and they are very persistent throughout life. By the time someone is an adult and a patient, unless there is some intensity and pleasure with either object choice, a conversion therapist is in the position of trying to make someone straight when there isn't enough pleasure already there to support it, and maybe even disgust towards the opposite sex. Another pitfall is bisexual erasure, where again labels are used to block possible experiences. Labels can be useful, but not if they repress real object choices. The actor Alan Cumming provided a warning that repression can go in many different ways. “I see a worrying trend among LGBT people, that if you identify yourself in just one way, you close yourself off to other experiences. My sexuality has never been black and white; it’s always been gray. I’m with a man, but I haven’t closed myself off to the fact that I’m still sexually attracted to women.” This statement is helpful for people who are in homosexual or heterosexual relationships, because they don't have to pretend they don't have other desires as well. Having those desires also doesn't mean people can't be in a committed relationship with one person. The typical mistake is labeling someone as homosexual or heterosexual when they are concurrently in those kind of relationships, as if they can't carry both desires in their mind at the same time. Accusations of bi-sexuals being greedy or cheaters can also be put to bed. Cheating can happen in any sexual orientation.

Alan Cumming fan page: http://www.alancumming.com/

Mel B and Ginger Spice: https://www.youtube.com/watch?v=Q7rqO-PjxQg

Geri Halliwell Mel B Lesbian affair: https://www.youtube.com/watch?v=aGqhC4tejLA

Like in HOCD or in situations of internalized bigotry against homosexual desire in oneself, the brain can move into self-attacking, and that's what is the pathology. Self-hatred can inhibit at one degree but it can also become more severe with suicidal ideation. Real therapy is to accept desires in oneself without resorting to pathological self-recrimination. Ultimately you are not falling in love with a category, but an individual. More important relationship questions that are not to be overlooked are "am I in the cycle of abuse? Do I have a habitual template to be with abusive people? What is a good relationship?" What a successful relationship looks like, has more to do with relationship skills, and in places like the Gottman Institute, there are so many skills partners have to develop to achieve great long-lasting relationships. Too much focus on sexual orientation may make one miss why you wanted to be in a relationship in the first place. To be with people who are non-abusive and who love and understand you. Ultimately that's what Serge was not doing. He was moving from one influence to another. Religious influences grafted on him, but then in the presence of an atheist he would lose belief. He was moving from doctors to psychoanalysts, and being swept along cultural changes, but was not able to row his own oar. In the end, Serge's template of relationships was more important to analyze than what his sexual orientation might turn out to be. Tragically, he learnt that too late.

The Gottman Institute: https://www.gottman.com/

Luise and the cycle of abuse

Towards the end of Serge's life, his greatest weakness was choosing the wrong relationship template. His last intimate relationship was with a women that Serge called "Luise." This story should trigger a lot of recognition for those who know about the cycle of abuse. 

W: [Luise] is a very impulsive woman...Twenty years ago...we ran into each other on the street. And she said, let's make up. I shouldn't have done that.

My father restricted my inheritance until I reached twenty-eight because he was afraid that I might fall into the hands of...a robber. And I always felt, that's not a danger for me. I never thought that I...would become involved in such an affair with this Luise...This Luise was completely unsuitable. Luise is an oaf. It's through her that I spoiled everything for myself.

Therese died and she wrote in her farewell letter: 'Marry a decent woman and go to Sister...and seek her advice, and don't become attached to some slut because that could be the end of you.' She had understood the important thing.

O: That you feel drawn to sluts?

W: Yes, she understood that that's where the danger lies. When I am friends with a decent woman, I can marry and live in some fashion. But there's nothing to be done with a slut. Because sluts...either they demand money from you all the time or who knows what...Well, and that's what happened, and so I find myself in an awful situation with this friend. 

O: But in what way is she a slut?

W: Isn't it being a slut when the woman gets married and tells me nothing about it...and kept coming to me the whole time? Had she said that she had got married, I would have stopped seeing her. But then she divorced him. All right, slut, what does slut mean? The word isn't attractive. Couldn't we find a better one, one that isn't so offensive? Twice I associated with impossible women, and with the first, things turned out all right. I even wrote about it, I was lucky, I got away from her...And then I got involved with this other one and I can't get away from her because the woman has nothing. She has no pension, no health insurance, and she is ill...There's something wrong with her heart, she has angina pectoris, there is something the matter with her kidneys, with her gallbladder, and she has diabetes. What can you do? And now she says she has cancer. I don't know if it's true, of course. And she constantly tortures me with reproaches and wants me to marry her. One cannot marry this woman, she is a serious psychopath. I don't even know what I should talk to her about. It's always the same thing that interests her. We pass a house and she says, 'I wouldn't mind having a house like that...' She makes demands that are altogether absurd...and I have been her lover for twenty-five years, as it were. I only see her on Sundays...She has had two divorces!

O: And she doesn't get anything from those men?

W: Nothing. She is so clever, when people are standing in line at the movies or the theater for tickets, she simply walks up and says, 'I ordered tickets,' and they give them to her. You'd think she's really clever. She has no interests, nothing. She says she has read a great deal. But when I saw what was on her shelves, it isn't true. She is only interested in material things...Constant reproaches. Everything is my fault. I never had any idea that there are people like that, women who are so impossible in every sense...Eissler writes, 'Let her scold, let her rage, what of it?' It's easy for him to talk...But if that woman is constantly causing scandals like one time...We were quarreling on the street and people were already calling the police - that sort of thing is unacceptable. Perhaps you could give me some advice. Solms once said, 'Men are stupid.'

O: There's only one advice one can give, and that is that you dissociate yourself from that woman.

W: Solms says that 'If it didn't work back then, it won't change now.' There were a few occasions when I could have broken with her. But this idea that Solms expressed, that this is the way it has to remain, prevented me. Instead of doing me some good, psychoanalysis did me harm.

O: What was it that attracted you about that woman? Did she have such a strong sexual attraction for you?

W: She had sexual attraction. And the absurd thing is that the sexual attraction wasn't really all that strong...In the beginning, perhaps, but then it decreased...This woman is always ready to quarrel. That's her element. To slander, to berate others, to feel the victim...that all kinds of injustices were perpetrated against her. And everywhere she goes she must have her way. Even in restaurants: her portion is so small, the person at the next table had a larger one. Then she has a heart ailement and says, 'The air is bad.' Or, 'It smells of mothballs, that coat hanging there, it smells of mothballs.' She can't stand it, the window has to be opened. But the waiter says, 'We can't do that, there are other people here, there's a draft...' There is nothing you can talk to her about...There's nothing you can say to her, she immediately starts threatening...It's forever the same thing: disputes with neighbors, the old Bohemian who doesn't open the windows along the corridor, there's a bad smell there, the air is stale...Her interests are so limited. Nothing but constant demands...I feel a certain obligation, because I have been with this woman for such a long time. And she really is ill, isn't she? But the terrible thing is, one cannot talk to this woman. She wanted to report me to the police. She will make her case public - this injustice, this terrible viciousness, what I did to her because I was so old and she is still so young. The public must hear about this; it must be shown on television...'That should be brought to public notice.' You can't talk to her. I sit there like an idiot and keep my mouth shut. And she says, 'You are having another one of your spells.'

O: What sort of spells?

W: A depression....She has the idea that you must be a fool to have depressions...An entirely primitive idea. Well, and what does Solms say? 'A serious psychopath with paranoid ideas.' Wherever she goes, she feels persecuted. She feels disadvantaged by fate.' She demands money for her health and then she buys clothes. And yet she is sixty years old and hates old women. It seems she feels she's a teenager.

O: She's forever buying clothes?

W: Now she has lost weight. And altering things costs more than buying them new.

O: And you go along with that?

W: As you see, unfortunately. But I don't know how it's all going to end.

O: Can you afford it?

W: I got money from the book.

O: And all the money you got...you spent nothing on yourself, you gave it all to your friend?

W: Only she benefited, really. I was so restless at home, and so I gave her the money. I did make that mistake.

O: But she is never satisfied?

W: No, never. And now it's always the same thing: 'What am I going to do when you die?' And I console her. Eissler sends me small amounts of money for her.

O: He sends you money? For what?

W: For that woman.

O: He helps you for humanitarian reasons, or did you give him something for the archive?

W: I gave him quite a few paintings.

O: And the archive pays for them, or does Eissler pay out of his own pocket?

W: The archive.

O: Regularly?

W: Yes.

O: So you actually get a kind of pension from the Freud archive.

W: ...which does me no good, it's for the woman. If they sent it to me, and I kept it, I could live quite well...You can see that everything is full of conflict. And that also influences how I feel.

O: And Luise knows about this?

W: She knows about the archive. I haven't told her anything about the book. But begging isn't pleasant either. And it is not a pleasant feeling that they send me something because they feel compassion for the woman.

O: Will she get something after your death?

W: I'm uncertain. At times, Eissler says one thing, at others another. So a dependence on Eissler has arisen, and so it drags on. And I receive free treatment. A whole number of dependencies arise, and that's harmful, of course. It harms the ego I'd say....

O: In other words you have no talent for making life pleasant for yourself...I would not have taken that much from anyone.

W: That's it: I put up with too much.

O: I find your behaviour odd. If something is proposed to me, I ask myself, what do I want?

W: Yes, yes, I believe the ego is damaged somehow.

W: Eissler wants to keep track of the case that has become so famous - Freud's most famous case - and see how it ends....Eissler has one opinion, Solms another, and Gardiner a third...One becomes involved in a labyrinth of dependencies that contradict each other...According to the theory, one would have to be completely free, uninfluenced...Psychoanalysis should really enable one to live without a father figure. But what actually happens is that one goes on living with the father figure... Sometimes, when I think about all those things, it seems the only way out...Should one kill oneself? I have gas.

O: Gas, you know, is not what it was in 1938. Today, it's practically impossible to kill yourself with gas. The gas is detoxified.

W: Thank you for having told me about the gas.

O: Had you seriously considered it?

W: Yes, but now its out of the question."

Serge did continue on living and enjoyed the company of Karin, and the reader can witness the pleasure that he enjoyed of someone just listening, mirroring and validating him, even if it the interview was about an exposé of psychoanalysis.

"If I were younger, one could at least try it, make an attempt but...You would really be the right woman for me. I get along with you. I don't get along with the other one, and she clings to me. Because you said that you also had gonorrhea, you caused a profound change in me."  Unfortunately for Serge, it was too late to make changes and he had a circulatory collapse. "In early July, the Wolf-Man had received his pension for two months, the monthly check and vacation money. Luise supposedly appeared abruptly at his door, he admitted her, and the meeting ended in a loud row. Finally, she simply snatched 10,000 schillings from his hand and ran off. [He] was terribly upset...During the afternoon of this very hot day, as he was coming back from the tobacco shop, he collapsed."

Serge deteriorated and Karin detailed his last days in the Vienna Psychiatric Hospital: "The Wolf-Man takes a postcard from the open drawer of his nightstand and hands it to me. Here's what Luise writes to a deathly ill, ninety-year-old man who, confined to his bed, is constantly fighting for his breath.

'My dear Serge, I have heard that you are already feeling much better, that your appetite is good and that you can already wash yourself. I am pleased. As you are eating with such a hearty appetite, aren't you thinking of me, that I go hungry, that I am about to be evicted if I cannot pay the rent, that the gas and electricity will be cut off if I can't pay? How can you do that to a person with whom you have spent forty years? I would like to see you, talk to you. I was already there a few times, but the attendants always tell me that that young girl is visiting you again, so I didn't want to disturb you. You must be very much in love if you ordered two flannel suits for 4,500 schillings each and pay all that money for her housekeeping expenses as you told me. Unfortunately, I have no money for stamps or letter paper. So far, I have received nothing of the royalties for August from your book The Wolf-Man by the Wolf-Man. They say you gave it to the professor so he would pass it on to me, but he demands that I pick it up at his place, which is absurd, my lawyer says, and I have it from you in writing that I would get money from Gardiner even after you die.'

[After a brief moment he mumbled,] 'The woman is crazy.'"

As Luise faded into the background during the last two years of his life, Serge had that feeling that so many people feel at the end of their lives. "Life was in vain, everything was pointless, we must build something, something new, begin at the beginning once more...Give me some advice!" His strength faded and his last gesture to Karin was a heartfelt kiss on the hand and a feeble wave before he died the next day.

Amber Heard and Johnny Depp: https://www.youtube.com/watch?v=aca0KWoHtqQ&t=331s

Modern psychoanalysis

"Take what you can from your dreams, make them as real as anything." - Dave Matthews

Like with many other case studies of Freud, so many disorders have genetic and early life challenges as their source. Is it OCD, Borderline and Narcissistic personality disorders, or a severe masochistic co-dependency? Or is a mixture of all of them? Using the metaphor of the childhood "lucky caul," Serge was stuck inside the veil or caul of dreams and specialness to the end, and so were his therapists who sought to make a name for themselves. By not seeing how the sense of specialness and entitlement would interfere with reality testing, the dreams and desires Serge had would fail to find realistic outlets with independent and assertive decision making, especially with choices of partners. The healthy way to attach importance to specialness is to effort. Special effort, not entitlement. The metaphorical veil or caul is ruminating about possibilities and dreaming about changing the past. Being stuck in painful thoughts while remaining inactive leads to a habit of inhibition.

Serge's past may have looked like a heaven with beautiful estates, servant women, and a sense of entitlement to a great future. It could easily add to the sense of specialness. But when you are at the end of your life, the memories of what actually happened can bring up the question "what if?" He attempted to get his fortune away from Russia, but the inflationary pressures of war diminished it. With his sister's and his wife's suicides, and possibly his father's, the mind could easily think "what if I did this or said that? Maybe they wouldn't have taken their lives." Once the past can't be changed, and in the end, depression never left completely, all that was left for Serge was the hope to "begin at the beginning once more." What motivations would he have needed to make difference choices when he was younger? Most importantly, what was so pathogenic that he couldn't have made better choices?

Nicolas Abraham and Maria Torok, in The Wolf Man's Magic Words: A Cryptonymy, engaged in an abstract word analysis of all the players in the Serge's psychoanalysis, and interpreted the wolf dream as the father having incest with his daughter Anna, and Serge being a witness. The English Governess is told by Serge what had happened and she uses it as blackmail to torture Serge and his family. Serge then oscillated between desiring Anna and imitating her, which would be desiring the father in the latter. He would also have knowledge that could hurt both his parents. This theory, and it's only a theory, brings up a lot of questions. If his father committed suicide, was it because he abused his daughter? Was it because of the political changes he saw in Russia? Was it because he had manic depression? Or is it a combination? Also if instead, Masson and Brunswick were right about Serge being sexually abused, and possibly groomed to desire anal stimulation [anally seduced], both cases could lead Serge to imitate a passive sexual choice. If Serge felt shame about those impulses, then his lack of self-worth and need for repression would continue. A false self that is beyond shame would have to be developed as a protection against a pathogenic secret. The pathogen could be an array of possibilities supported by these theories. For example, shame over wanting to be like Anna, shame over wanting Anna, shame over wanting his father, shame over wanting to be his mother, and shame over wanting to give or receive anal sex. In the end, whatever combination, it would lead ultimately to shame over socially unacceptable sexual desires. Since this "crypt" of a false self in Serge's mind is hiding a body of pathogenic shame, and most importantly, it's somehow unconscious, then he did not recover because his pathogenic secret remained a secret, even to himself. The coffin remains shut and the Russian Iistina, or hidden truth, remains hidden. If on the other hand, this secret was conscious all along, but he did not want to share the information for obvious reasons, he would have to take what he learned from Freud's work and heal himself, if he didn't trust anyone else.

For example, if he read and understood Remembering, repeating and working-through, and if he could see his sexual appetite as a worthy foundation that could go beyond a sister template, then maybe that knowledge could help him identify with different relationship choices and he could avoid choices like being with "Luise." To grow better crops, so to say. In his interviews with Obholzer, he clearly identifies his sister as an object choice, identifies Karin as a good example and even admits that if he were younger he would pursue her. Though this could appear insulting because his template includes an aggressive sister, women with less power, prostitutes and "Luise." Yet reading those interviews with Karin, even if she's aggressive with trying to land an exposé, one gets the impression that she was desired by Serge because he enjoyed being with a woman who listened and accepted him. She accepted his having gonorrhea and his masturbation as normal. That made him feel better. Feeling better, meaning less stress. The stress was caused by some pathogenic desire that he was ashamed of, whether it was a desire for his sister or desires from one of the theories above or else something he never communicated. Shame, we have to remember is a fear of rejection from important social contacts.

Too much shame means you accept bad people in your life you think you deserve, which stops further development. The low self-esteem made him desperate enough to choose mostly one-night-stands, women who had little in common with him, women with less power and prostitutes. He also chose Therese when she really needed his help financially, after the condolence letter reintroduced them to each other. Therese, despite being suicidal, ended up being the best woman for him and even warned against another improper choice, which he ended up choosing. Self-esteem becomes a necessity so you can choose people who care about you, and of course you have to do the same for them, so that as a couple the individuals have permission to improve themselves. Obholzer pointed out before that Serge lacked the assertiveness to ask for what is good for him. If he wanted to look for further methods from Freud, if he read about his letter to Ferenczi, about how he was able to increase his ego by dropping homosexual friendship with Fliess, it happened naturally with disenchantment. Fliess did malpractice on Emma Eckstein's face and Freud distanced himself from him. Serge would have to be disenchanted with his toxic relationship template before he could find a replacement. Since so many women he was involved with didn't want to improve themselves, he would have to be disenchanted by them and move on, while also developing himself. There's really no reason, even for a criminal, to not improve themselves if they believe they have a foundation for different choices. Regardless of dream therapy and it's value, one has to accept oneself and be disenchanted with people who don't allow that. Who's supporting your goals for self-improvement, and who's not? Either your biology prevents improvement, in which case you must accept, or it's just the ideas about yourself that need to change. People have to experiment with their choices to see what's possible for them and not rely on beliefs.

With scandals of people thinking their parents sexually abused them because of Freudian analysis, with some cases being true, but others not, how accurate of a method is it for courts? Like Mahony says about Abraham and Torok's theory of father and sister incest, "coherence is not proof." If some people are capable of passing a lie detector test, and the results are not admitted in all court systems, then certainly dreams could be open to lies and manipulation by so many people. At best dream analysis can help the patient if convincing memories return. They may get a relief where they are able accept what happened, grieve and move on with their life. Phenomenology can only be accessed through the subjective, but unless there is concrete evidence that is objectively available, the whole process moves back onto patient and only they can benefit, since only they can experience their memories. The reader can choose to believe, or leave a question mark for these dream analyses. The memories of the patient must resonate clearly with no skepticism, otherwise it becomes a form of brainwashing where the patient has to believe. 

The biggest question is that if bringing something up into consciousness is supposed to create relief, that may not be the case. Many abuses are not in the unconscious and the patient is very aware of what happened. They don't talk about it because of possible stigma. For example, if the accusations from Brunswick and Masson were true, and the abuse was conscious, who would want to talk about how their anus was groomed to enjoy sexuality and now impulses are being fought over with repression? Anal flashbacks that are conditioned to repeat impulses and desire for anal pleasure, that are also conscious, would continue to cause stress if the patient ruminates on it and what it means in an obsessive way. When something is conscious, guilt and rumination cause their own problems. Serge was aware of his desire for his sister, but it still influenced him even when conscious. Some people go through horrendous abuse that is unconscionable, but they are still able to thrive. Others go through no abuse, or less abuse, and are psychologically compromised very easily. There could be genetic factors with that. And finally, anybody going through two World Wars, family suicides, and a loss of a fortune, are going to be consciously traumatized. No therapy will bring those people back.

Another area that only René Girard tackled in a major way, is what happens if you remove your transference to God, or imitation of Jesus? His warning is that we can just imitate the people around us and that's exactly what happened to Serge. From an atheistic perspective, if Serge wanted to be independent of a father figure, then he would have to consciously not worship a God, another human being, or himself. Now that is a difficult meditation practice! In reality most people have a hope for a loving God, even if it's not aimed at a particular religion, and many people have role models for success. That means social exchanges of trust. Those social exchanges have to be done carefully to avoid exploitation. Like Karin pointed out, if people are making suggestions for you, you have to ask "what do I really want?" Without the ability to negotiate, predators can take everything away from you.

I like Mahony's description of how challenging a patient like this would be for any therapist, in any modality. "The total profile of the Wolf Man's analyses constituted a muddled picture. True, a marriage replaced the flight from woman, and the defective capacity to work gave way to the successful [completion] of a doctor's degree in law and employment for over thirty years in an insurance position. There will surely be those who will criticize psychoanalysis for its technical limitations because of the psychic distress and disorder that stayed on with the Wolf Man: though the depression, guilt, ambivalence, compulsive doubt, and narcissistic demands were abated variously at times, their overall force remained considerable. Whatever shortcomings obtained in the analyses conducted by Freud and Brunswick...I do not think that the best-directed therapy could have sufficiently rehabilitated the severely defective psychic organization and narcissistic structure of the Wolf Man or compensated for the lack of early parental care. He is one of those tragic individuals who remain forever inside a gaping wound and whose hopes grow mostly in lonely dreams." 

Manchester by the sea - "I can't beat it": https://www.youtube.com/watch?v=kAcYyreYFyk

Resources:

The Wolfman and other cases - Sigmund Freud: https://www.isbns.net/isbn/9780142437452/

The Wolf Man by the Wolf Man - Sergei Pankejeff, Ruth Mack Brunswick, Muriel Gardiner, Anna Freud: https://www.isbns.net/isbn/9780465091973/

The Wolf Man: 60 years later - Karin Obholzer: https://www.isbns.net/isbn/9780710093547/

The Cries of the Wolf Man - Patrick J. Mahony: https://www.isbns.net/isbn/9780823610907/

Freud Standard Edition Vol 12: https://www.isbns.net/isbn/9780701205256/

The Correspondence of Sigmund Freud and Sándor Ferenczi, Volume 1: https://www.isbns.net/isbn/9780674174184/

The Assault on Truth - Jeffrey Masson: https://www.isbns.net/isbn/9780345452795/

The Wolf Man's Magic Words: A Cryptonymy - Nicolas Abraham & Maria Torok: https://www.isbns.net/isbn/9780816648580/

Freud and the Rat Man - Patrick J. Mahony: https://www.isbns.net/isbn/9780300036947/

Violent Origins: Ritual Killing and Cultural Formation - Walter Burkert, Jonathan Z. Smith, René Girard, Robert G. Hammerton-Kelly, Renato Rosaldo, Burton Mack: https://www.isbns.net/isbn/9780804715188/

The War that ended Peace - Margaret MacMillan: https://www.isbns.net/isbn/9780143173601/

The First World War - John Keegan: https://www.isbns.net/isbn/9780676972245/

The Origins of the War of 1914 - Luigi Albertini: https://www.isbns.net/isbn/9781929631261/

Lothane, H. Z. (2018). Freud Bashers: Facts, Fictions, and Fallacies. Journal of the American Psychoanalytic Association, 66(5), 953–969.

Homosexuality Anxiety: A Misunderstood Form of OCD - Monnica Williams: https://www.psychologytoday.com/sites/default/files/attachments/72634/williamshocd2008.pdf

Misusing Freud: Psychoanalysis and the Rise of Homosexual Misusing Freud: Psychoanalysis and the Rise of Homosexual Conversion Therapy - Jonathan Barrett: https://digitalscholarship.unlv.edu/cgi/viewcontent.cgi?article=1027&context=psi_sigma_siren

How do I know I'm really not gay? Fred Penzel: https://iocdf.org/expert-opinions/homosexual-obsessions/

Sigmund Freud urged his disciple to divorce: https://www.latimes.com/archives/la-xpm-1987-11-12-vw-20532-story.html

The Master's mad move: https://www.theguardian.com/books/1999/jan/30/sigmundfreud

Conditions for intuitive expertise: a failure to disagree. Daniel Kahneman, Gary Klein Am Psychol. 2009 Sep; 64(6): 515–526

Alan Cumming Is Bisexual — And You Might Be Too: https://www.advocate.com/bisexuality/2015/03/30/alan-cumming-bisexual-and-you-might-be-too

Alan Cumming Sounds Off On Being Bisexual And Being Married To A Man: https://www.huffpost.com/entry/alan-cumming-bisexual-_n_4460070

Psychology: http://psychreviews.org/category/psychology01/

[dreaminginthedeepsouth]

illustration

* * * * *

Ernest Rossi, The Psychobiology of Mindbody Healing (1993) Norton [page 39]:

“When Jung’s patients became overwhelmed with emotions, he sometimes would have them draw a picture of their feelings.  Once the feelings were expressed in the form of imagery, the images could be encouraged to speak to one another.  As soon as a dialogue could take place, the patient was well embarked on the process of reconciling different aspects of his dissociated psyche.”

[nikkichen04]

Weekly Reflection

Right now, I am doing all right. I am somewhat stressed because I currently have a lot of commitments and coursework. I think that physically, I am doing well. Last quarter, I started going to the gym regularly, about three times a week. At the gym I usually walked on the treadmill for thirty minutes. Then, I would either do exercises on a yoga mat, such as plank, sit ups, russian twists, and leg lifts, or do exercises with the machines. In my classes, I am keeping up with my work and I like the classes I am taking right now. Socially, I think that I am doing well and recently I have met a lot of new people. In life right now, I am going to college. Recently, I decided to switch my major from mathematics and economic to psychobiology, but I still have to do the formal process of switching my major. Right now, I am taking three classes: biology, chemistry, and a writing two course. I also work right now at the student store. I work for about eight hours a week for three shifts a week. My biggest goal for this quarter is to do well academically while also balancing my social life. I think that my goal is attainable as long as I maintain strong study habits. Another goal I have right now is to drink more water. I think that I forget to drink water until I am very thirsty. My goal is to drink water throughout the day and not just when I am thirsty. An upcoming goal that I have is to do well on my chemistry midterm. I am somewhat concerned for my midterm because the material is very conceptual and I do not know what to expect for the test.

[muqingt]

Love is Reflection -- Eternal Sunshine of the Spotless Mind

At the beginning of the semester, I viewed love as a reflection. The discovery of different types of love and different ways to love and be loved make this emotion mysterious. But if we take a step back, things are indeed straightforward. We love something that mirrors a part of us, reminding us and projecting what we actually want as different individuals. Although loving someone is a selfless process in that we put someone else in an important position, the person we love, and the way we love them, still reflect who we are. 

In the film Eternal Sunshine of the Spotless Mind, the main characters, Joel and Clementine, both deleted their memories about each other after they broke up to avoid living in the pain of losing each other from their lives. However, the day that Joel removed his memory, they meet and fall in love with each other again. They fall in love in a completely different setting than their first encounter: they meet on a train instead of at a party at the beach, and they started dating naturally. Without any memory and context, Joel and Clementine find each other again, which is reasonable for us to believe it is something about themselves that make them fall in love with each other.  

The film is about the struggle between enduring the pain of breakups and maintaining the memories when they were dating. And the pain also has this reflecting nature. According to Tiffany Field’s paper, “Romantic Breakups, Heartbreak, and Bereavement,” the potential mechanisms behind the heartbreak syndrome after romantic breakups are the loss of social regulator and loss of psychobiological attunement when you lose your partner. To be more specific, your and your partner’s psychological and physiological equilibrium will adjust and match each other when you are in an intimate relationship with them, and this will reflect on your personal daily patterns and arousal level. You and your partner are actually “reflecting” each other’s habits, diet, sleep, mood, excitement, stress, and other major and minor parts of your daily life. Once you break up, the reflecting surface is gone, and you cannot see yourself from the mirror, which will lead to the painful feeling of losing a part of yourself. And there is no doubt that we feel the pain because we’ve lost something that’s important to us, which further suggests that the lost love is a loss of a reflective surface of ourselves. 

To Joel and Clementine, even though they have very different lifestyles that lead to endless conflicts between them when they are in a relationship, they still blend into each other’s lives and project certain characteristics on each other. Clementine’s passion for every event in life, her braveness to approach Joel, and her unique personality that is shown by her hair colors all reflect the hidden desire of freedom that Joel has. In the opposite, Joel reflects the desire of stability and security that Clementine hides behind her optimistic life. Their love is a reflection of each other’s inner wants and needs, and this mutual reflection explains their inseparable bond. However, there is still no guarantee that they will always and only reflect the good parts of each other. In the end of the film, the film explicitly displays the bad words that Joel and Clementine say about each other, revealing their significant other’s ugliest side, and displaying their own defects. They blame each other because time makes it possible to reflect more of themselves, taking away the love that is supposed to reflect the most. 

It is also worth noting that, according to Tiffany Field, the brain releases similar chemicals when a person is experiencing a painful heartbreak after a romantic breakup and during a long-term love relationship. This suggests that the reflection is not selective. Just like a mirror has no choice but to reflect whatever is projected in front of it, the reflection of love might also be blind. We find similarities from our loved ones, and we also find our flaws doubled on the reflected surface. But we can never lie when reflecting, which also means that we can never lie about our feelings and love. Because what we love is a reflection of ourselves. We love a certain lifestyle that we can only achieve with that specific person we love; we love someone who makes us feel accepted, understood, and familiar.

Joel and Clementine go back to each other because even though the memories are removed, they are the same, and the other person will still be “the one” that will reflect themselves, forming this bond of love. No matter how long time has passed, and things have changed, once their memories are removed, they start looking for that projection of themselves again among the countless people in their lives, repeatedly falling in love with their identical counterparts. And during the process of clearing Joel’s memories with Clementine, he witnesses all the wonderful moments that were reflected in their shared time and realizes that the reflecting process of his love should not be covered by an external force even though there are pains involved.

Lacuna can allow you to break a reflective surface, avoiding the person that will reflect various parts of yourself. But it can never stop your journey to finding the perfect reflection of yourself. Additionally, the nature of two people in love is also like placing two mirrors in front of each other, creating the condition of infinite reflections that extends closer and deeper to the center of the mirror. Love is a reflection that makes us better observe ourselves, for both the good and bad. We cannot change what is being reflected, but we always have the flexibility to adjust ourselves and make a direct impact on what is reflected. If Joel and Clementine make a difference in the way they behave and treat each other, their love will be reflected differently than before, and there is a possibility for their love to continue in the future. Love is a reflection that is such straightforward that all we can do is be honest and face whatever we see from ourselves and our loved ones.