Book Review: The Rupture of Serenity: External Intrusions and Psychoanalytic Technique

Aisha Abbasi is to be thanked for writing us into the scope of her gifts. The gift that stands out most is her courage, and the ability to let us into her real-time inner life as an analyst—not offering us those polished, oversupervised, too-smooth stones we have all held, but her in-real-time inner life, those rough-looking geodes cracked open. She takes us along as she becomes a better and better analyst. She shares the good and the bad, and joins us in curiously observing them. One has the experience of pulling up a chair at a table across from an extraordinary person who also happens to be an analyst, and listening to her unalloyed accounts of her work with patients. She does not try to control her readers or their perceptions. She treats each of us like a trusted colleague.

The Rupture of Serenity is focused on what Abbasi calls the “external intrusions” from within the analytic process. They are the “uninvited guests” at the psychoanalytic dinner table. She describes her own infertility treatments and pregnancy barging into the dyad; swapping envy with her patients; her vulnerability attending disability or illness. She describes incidents when patients learn something “real” about us—for her, the fact of her own transgender child. Even more intrusively, patients learned about how her family handled the situation. Abbasi ventures into habitats we would rather not look at, such as the waiting room, where we do not control how our patients interact with it or with other patients; or the i-world—how technology intrudes, as when she lent a patient her iPhone after his car broke down and he i-plundered it for videos of her family. She speaks of her own and her patients’ reactions to learning that Osama Bin Laden was found hiding in Abbottabad, Pakistan, where she had spent many years as a child and adolescent. Abbasi lets us in.

To read this book is to listen responsively to how one’s own mind works, as she zooms in and out of different analytic “distances,” touching different analytic depths of field, and pointing precisely as needed. She must be an outstanding teacher. Following are some virtues that resonated with me and my experience in treating patients.

Involving her whole self to “find” a patient. Abassi describes a patient who was tyrannizing the waiting room by coming an hour early for sessions, as if camping, even squatting, in the territory. The patient would tell Abbasi and her other patients of all the comings and goings, as if she were an air traffic controller! The analyst took this exasperating situation and began to work with her, opening to experiences that could not be narrated verbally and that must be shown, not told. She writes:

In the midst of my own “psychic vertigo,” I began now to connect my current experiences with Ms. Smith to my own life history. What I thought about were not new facts, but the feelings connected to these facts came up in a more genuine, powerful, and experience-near way. I thought about the birth of my younger brother, my ambivalent feelings about him, my memories of being displaced, my struggle to feel special in my family, my childhood wishes to scare or annoy my baby brother during those early years, and the major changes that occurred. . . . And I thought of much, much more. Perhaps the most important aspect was that I felt freer to truly think analytically about this issue in a more spontaneous and real way. I also became aware that my earlier comments to her about what she was doing and what it might mean had been somewhat rote, premature, annoyed, and not effectively attuned to her distress because I had not yet linked them, in my own mind, to memories of distressing times in my own life [p. 35].

Zooming out and paying spherical attention. By including the waiting room in the treatment, Abbasi reminds us to zoom out and practice paying attention to the entire experience and enactment, not just to what is said and done during the forty-five-minute session. She counters the notion that we can put giant quotation marks at the threshold of the door when the patient steps in, and another set of quotes once he stands up. Rather, she reminds us of thresholds of all types, including the rush of questions, thoughts, and feelings that can happen only when the session has ended and has been punctuated at the threshold of time—those little geysers of the psyche that require the safety of leaving to erupt, the vulnerable questions or feelings or resentments or endless other communications that otherwise would be unbearable.

Allowing memories to awaken, to make contact with the other. She describes Theodore Jacobs’s idea that the analyst’s memories must be activated and revived in order to make empathic contact with the patient’s experience. She shows how an analysis requires memories to be “in stereo” to resonate and heal. As Jacobs (1991) says, “For the analyst to be truly empathic, his own memories must be available to him. This is one of the most important effects of the analyst’s own analysis. . . . When shifted into a mobile state, these memories are then free to rise up to meet those of the patient” (quoted by Abbasi, p. 35). Empathy is the sound and environment that are created when memories are “in stereo,” when memories can go from being recalled to being rewired. I think here of my mentorship with Leston Havens when I was a resident. He spoke of “bumping around in the dark” until we meet each other, or, as he puts it in Making Contact, our experience of “finding the other” (Havens 1986, p. 11).

Working actively with concepts of procedural memory and neuroplasticity. In her example of the woman coopting the waiting room, Abbasi begins to get at her experience in childhood of being one of many siblings, with an intense need to feel special, in control, and providing information that made her indispensable. This suggests to me an expressive process of procedural memory—the kind of memory that is in our muscles, grooved into our neural pathways, like tying a shoe, riding a bike, or playing a piece of music on the piano that our hands know but our conscious mind has forgotten. Abbasi’s interactive process with the patient is an experience of being with patients, not just listening to them. It is the difference between having dinner with someone, and moving in together—where we “show” and not just “tell” each other, those moments of discovering the cap off the toothpaste, or hearing the sweet morning hum of the other—where parts of who we are emerge that cannot express themselves in words, and where their own voiceless voice can finally manifest itself. Abbasi is sensitive to the myriad verbal ways of showing who we are, as well as the happenings and events and all the ways we communicate beyond, inside, or under the words we speak.

Revealing her own evolution as an analyst. Abbasi, though an experienced psychiatrist and seasoned analyst and supervisor, does not present herself as an expert analyst who has always known and understood everything, one who has always made the fullest use of the session in the moment. Rather, she learns from what the great Shakespearean characters do, a technique I heard the literary critic Harold Bloom speak of when I was an undergraduate: she “overhears” herself and shows the layers of how she learned, and how ten years later she further composted her work experiences into richer soil. She writes of her own process with infertility treatments, and eventually having a baby much to her own surprise and how it affected her work:

I, too, discovered—but only in retrospect—that during the period I was going through infertility treatments, my patients felt a need to hold back feelings of anger or pleasure about my struggles. Though there were some expressions of frustration and anger . . . , there was much greater mention of empathy and concern for me at the time. It was only in the months after the [fertility] treatments had failed, and as I stabilised emotionally, that patients began to talk about the envy they had felt regarding the possibility that I might conceive a baby: their fear that I would be preoccupied with the baby if I had one; the anger that I was already preoccupied with trying to have a baby; their pleasure that I was struggling with something; and finally, their ultimate pleasure and satisfaction that I had failed in what I was trying to accomplish [p. 19].

She goes on to describe what she learned from this experience:

I can understand, only in retrospect, that it was truly not possible, during the period that I was trying so hard—and wanted so much—to conceive a second child, to talk with my patients about their wish for me to not have a child, their rage that I wanted to have a child, and their worry that the child would displace them, while maintaining the same degree of neutrality, genuine curiosity, and compassion I generally had. Discussing their glee about my trials and suffering might have felt impossible then. This is an important reminder that as analysts we can ask all the right questions and say all the right things, but these come from our intellect . . . not from a place of deep emotional empathy within ourselves at that point—and our patients can sense it [p. 21].

She lets us know how she comes to see more over time, like visiting a familiar street corner and noticing more on each visit:

I am also aware, as I write this, of the process of useful change that occurs in an analyst, during the span of her career, as a result of continuous inner work—and experience—of both analysis and life. About ten years after my struggle with infertility, when life brought another major challenge, my ability to deal with it—and to help my patients speak about it freely in their analyses—was much greater [p. 22].

She shows us her need to protect herself, and impressively calls herself out on these moments later on.

Being compassionate toward herself as an analyst. Master analysts tend to present themselves as fully baked, and do not always talk about their steep learning curves. Abbasi is not only tolerant but compassionate regarding her process of growth and learning. She shows what it looks like to empathically understand our limitations as analysts at a given moment in a treatment, which then serves to expand the work. One gets the sense that this compassion is hard earned, much like her family’s coming to terms with her transgendered child. She is a wonderful model for young analysts; it seems clear that her openness has helped her learn and has not hindered her in her career.

Expanding from her outer life and its usefulness. Abbasi is good at detecting and bringing to our attention unspoken rules of our profession: for example, if knowledge of the analyst’s personal life comes to the patient from the outside, it is often something to be rewrapped (not unwrapped). We tend not to write about it, expand on it, or expand the intimacy of what is known about it. (Current writing is admittedly somewhat more inclusive in this regard than was once the norm.)

Abbasi notes that little has been written about what happens in the room when the analyst is confronted with facts the patient has learned about the analyst’s personal life. Her moving example is of her many patients who have brought up encounters in which they learned that her older child was transgendered from female to male and so, for her and her husband, from a daughter to a son. That required some working through. One of these patients learned not only of this, but also of how the family had sweated it out, how it was hard and caused family stress, and how bravely and lovingly it was handled. Abbasi demonstrates how she opened up this subject with the patient rather than shutting him down.

My association to this intrusion is that my husband is the drummer in a well-known rock band. When patients learn of this, they have all kinds of reactions that we explore, for example, “Poor you, he must not be making any money!” or “Wow, I’m such a big fan!” or “How did you guys ever meet?” Their fear of talking about it, their anticipation of a possible negative reaction from me, makes it especially valuable. It can be a rehearsal and then an experience available to them at so many moments when they feel just like that—fearful of rejection and the effect of their own curiosity, the space of simultaneously wanting and not wanting desperately to know.

Giving her readership the ultimate credit. As a reader, I feel Abbasi avoids tightly packaging the material to elicit certain thoughts and feelings from me; I do not feel controlled by her clinical examples. Rather, she gives me free range to have my own experience of her work, room for my imagination, and even my judgments. To use my earlier metaphor, I am with her in the river as she pulls out a fresh stone of each clinical case, each situation with rough edges, that together we can be in awe of or in doubt about, rather than her handing the stone to me indoors once she has obsessively polished it. I feel I can learn from her, just as she has learned from herself.

Identifying with her experiences as a mother and analyst. As a woman, a mother, and an analyst myself who practiced to term while pregnant with twins, I have my own experience of external intrusions in the analytic setting! As the twins at full term weighed almost seven and a half pounds each, can you imagine the protrusion and intrusion of such a body practicing “the work of inner life”? I have spoken about this at conferences, ¹ describing the trompe l’oeil effect of turning sideways to reveal my otherworldly three-foot-long belly profile; how close my babies in utero were in proximity to my patients; and my undeniable physicality that allowed people’s relationships to their own body or mine to come to the surface.

This taps into another often unspoken rule—that the woman’s body, infertility, hormones, and the like are not “analytic material.” I am therefore surprised, delighted, and curious regarding Abbasi’s choice to begin her book with a chapter on the female body. My husband, the drummer, and I often talk about how to choose the first song on an album: Does it widely appeal? Confront us? Make us want to go on? Include or alienate us? Draw us in to listen more? Abbasi chooses to begin with a chapter on forbidden topics—pregnancy and infertility—and then widens her scope to include struggles around analysts’ sharing their disabilities, vulnerabilities, or illnesses.

When I have spoken on panels on these topics, the room has always been filled almost entirely with women (with the exception of the occasional male panelist). Though all of us, regardless of gender, have women patients, and are on some level their companions in the experience of pregnancy, it seems not to translate to us equally, as if it applies only to women analysts. I often wonder if male analysts feel that these talks are not meant for them, or should not include them. I have seen men wander into the room only to get a whiff of the conversation and quickly leave, as if they were intruding (even though the talk is about some experience of being a woman, which would typically relate to more than half of their patients).

So my question is this: Given that Abbasi lets people immediately on to the fact that she is a woman who has struggled with infertility and had treatments (and surprisingly became pregnant naturally after their failure), and presents herself straight off as a woman analyst who is talking about the experience of being a woman, will men wander out of her book the way they wander out of the conference rooms? I hope not. Because they would really be missing out.

Bringing up the question of transparency and psychoanalytic technique. How transparent are we willing to be as analysts? The world has become more and more transparent. Are we to follow? How do issues of self-disclosure brush up against this new level of honesty in our world, where a person like Martine Rothblatt, founder of the biotech company United Therapeutics and the highest-paid female CEO in the country, readily tells her transgender story and discusses her child’s illness, its impact on her business development, her blended family, and her decades-long marriage to the same woman?

This morning I learned that David Bowie died and that his final music video was released two days before his death. There was an image of him on his deathbed, a bandage over his eyes with buttons on the bandage replacing them. There was also a scene of him climbing into a wardrobe, and of him peering under the bed as if to say, “Here I am, world, on my deathbed with all my fears, and I bring you my whole self.” It was extraordinary to be let in on that level. He made the choice to bring his whole life and his whole self into the art up until the end. It is actually beyond his art. He made a choice to share his whole self. It will open up so many conversations about death and our fears around it for the entire world—it already has six million views on YouTube.

We may never go as far in self-exposure as artists during our work with patients, but how far for an analyst is therapeutic? And how much of who we are, and of how we are in our work, are we willing to share with other analysts? Abbasi offers a marvelously thoughtful and humane model for our working and collegial selves.

I think of Martin Buber’s essay “On Contact,” in which he talks about a mentor and a student bringing their “whole beings” to each other.

Contact is the primary word of education. . . . It means that the teacher shall face his pupils not as developed brain before unfinished ones, but as beings before beings. . . . Even Socrates himself exercised his decisive effect not through what he taught but through his life. It is not the instruction that educates but the instructor. . . . The good teacher educates by his speech and by his silence, in the hours of teaching and in the recesses, in casual conversation, through his mere existence, only he must be a really existing man and he must be really present to his pupils; he educates through contact [Buber 1969, p. 102].