A new way of doing tele-analysis by Samuele Filomena

What I am presenting is something completely new in the tele-therapy world of analysis and in describing that, I think, the best is convey you how I got there.

The main difference is that the patient is connecting to my office in London from my office in South Italy, where he physically can go there and find all the equipments (internet connection, a sofa, a computer).

This idea came from  my necessity to do my own analysis when I am in Italy and for this reason I set up first a studio for myself and after I thought why not offer this service to local people that can benefit of that.

I have been seeing a patient now for an year and half, and I did some consultations online and in person, and when I am there I see my patient in person.

Equipments

I choose for the connection a Chrome OS computer that starts in 10 seconds and instead a programm like Vsee or Skype (thatdo not run on Chrome OS) I create a room on Tawk.com, a canadian start-up that runs this server using EasyRTC.

This technology is a browser to browser connection and the set up is very easy.

At the beginning when you enter in the website of my room, in this case www.tawk.com/psicote the programm will ask to set up the microphone and web cam and when this is done I receive the call on my webpage open. The patient cannot see if I am online like Skype or Vsee.

Of course to be in contact with the patient I use Whatapp, for instant message in case of difficulties.

The web page program runs on any machine  (Window, Mac, Linux) with Firefox, Chrome or Opera browsers.

For the moment I am doing this in one way from Italy to London, and I did some trials from Lodnon to Italy, where my English patient can go in my office in London when I am in Puglia and it works.

I am establishing now some entry door systems that can allow me to open the door of my office from remotely. I am using DoorBird at the moment in my office in Italy and it works, also I am exploring the possibility to instal some domotika accessories, for example swichting on the light and the clima, etc.

What are the advantages of this system?

There is a physical place where people can go and it can be implemented in remote areas.

Possible application and development.

There are different possible application of this way of working in tele-therapy.

The first that comes to my mind is the implementation of a virtual clinic. A building with rooms and entry codes equipped with the computer and internet connection where people can go and access therapist all over the world.

The possibility for a colleague to set up a room in his/her office if there are some requirements (language, approach, interest, a specific pathology).

Improve the access to people where there are no therapist.

Creating consulting room in cyties and places where it is difficult to find a therapist, that are most the time available in big cities and the possibilities to acces that in rural places.

The house and the car

I spent last two years with a child in therapy for him be able to build his own house and to play with it. Also he built a car inside himself that allows him to leave the house and go around and move around. What these two elements represent in his mind?

The house is the place where to be and feeling safe and where he can go to shelter himself, Winnicott calls it the pure female element.

The car is the movement from the house to explore the outside world, it is linked with the walking and talking, it is the pure male element.

The use of these two pure elements simultaneously creates the wave of the mind, we can represent the function of the mind with a wave, like the hart wave.

But the mind’s wave is made of two components and when we are in the session with a patient or in a interaction with another human being we are able to detect it.

But as analyst our task is to recognize and identifie these two pure elements and own they are in relation to each other.

A much more emphasis was given to the male element in the development of the psychoanalytic theory and very few attention has been given to the female pure element, the psycho-sensorial in Gaddini terms.

This bias is due to the fact that psychoanalysis as science of the development went in the opposite direction to discover the secret of the mind and the paycho-oral, or male element is the last one coming.

The focus was mainly on introjections and projections and very few attention was given to the imitation process.

The mind is coming from the body, imitating the body’s functions and to register the wave we need a mind able to tune on in this very primitive process where no words are available.

At the beginning of life after birth the configuration of the two waves is as stated by Freud in a letter to Marie Bonaparte. All the aggression is outward and all the libido is inward, and the decathexis of the aggression allow the cathexis of libido, not the contrary.

It is the mother at the beginning that supplies to shelter to the baby and in this way is able to incorporate a safe place where to be inside. From the mother slowly a father comes out, at the beginning as a duplicate of the mother and after as an extraneous and external object and his role is to take the child out from the mother to explore the external world. The interaction and interweaving of these two pure elements allows a mature interaction with others, identification.

As institute we need a premises where we can feel safe and also we need a car to go around and explore new opportunity. The training allows me for example to set up a new way of working where I set up two offices and I can see people in person in each of them of my patients can go in one of them when I am in the other one. This modality could be useful to set up a virtual clinic for our institute. I consider this innovative and I understand people having concern, but this is what came out from my training, the interaction between my personality and this journey. It took me three years to convince you to move from telephone to video conference and probably it will take me another three year to set up the clinic and the next thirty to explain to the scientific community this revolutionary metha-psychology.

The last remark, psychoanalysis like all the other sciences was born in the Hellenistic period in the third century before Christ and on the same period appear the nuclear family and other modernity.

Dead ends by Samuele Filomena

“After all, we assume that in the course of man’s development from a primitive state to a

civilized one his aggressiveness undergoes a very considerable degree of

internalization or turning inwards; if so, his internal conflicts would certainly be

the proper equivalent for the external struggles which have then ceased.” Freud, S. (1937). Analysis Terminable and Interminable.

(Freud made some further remarks on the destructive instinct in a letter written shortly after this paper to Princess Marie Bonaparte. An extract from it appears in the Editor’s Introduction to Civilization and its Discontents.)

I came up with this title of my paper looking a sign on the street here that indicates that the road does not have exit, and we find ourselves a lot of time in working with patients that experience a therapeutic negative reaction or a general acting out.

The impasse also is in our personal and professional development, in our personal analysis and in the supervision of clinical cases.

But the cul de sac is also a potential resource to restore our vitality and go back to the main road and carry on the journey of life.

Facing the termination phase of the training program, the lost of the colleagues and teachers is a difficult moment, but also an opportunity to find my own way of working that was stretch in different way during the recent time.

Developmentally dead ends with the psychological birth that occurs at 6 – 8 months with the process of separation individuation of the baby from the caregiver (m-other).

This is an ongoing process through our all life, and if things were well at that point, though we end it up in a dead end we have the ability to come out from it.

Things are more complicated if things were not have been going well at that time and in this case we need for our patient to experience ex-novo the process.

In this statements is implied that at the beginning of life there is any libidinal force or any object, and this puts me in a different perspective from Fairbairn or Klein.

If you read my previous papers you can see how many times I underline this difference and you are more familiar with the model that I create to describe and explain that.

The difference can be better elucidated with the analogy of making food and the implication on the tecniche. When I cook a meal normally a start from the dessert, and I go back to the second course, and to the first one, and to the appetizer, and when you start you have already ready.

The same is in psychoanalysis, what you present to the patient is the inverse of the work that you do inside yourself. Then the model that I am presenting is not a libidinal model but a model based on the aggression, it is not the investment of the object, but the disinvestment of the aggression and his internalization that allowed the possibility to looking for an object.

I know that you can feel confused because this is a completely different paradigm, but for my point of view more fruitful, and also we are just starting to understand this matter and a lot need to be done. This is my journey, and I am coming out from the dead end where I end it up, and I am starting again the trip to explore the internal world in my own way, sometimes solitary in this journey, other times with the hope that other will follow me, or I can come across to others interested in the unknown. I recommend the reading of Eugenio Gaddini and his wife Renata De Benedetti Gaddini, there is a bunch of articles collected in English A Psychoanalytic Theory of Infantile Experience  Conceptual and clinical reflections where one of the most famous concept is the imitation and the distinction between psycho-sensorial and psycho-oral way of functioning of the mind. This is my contribution to this institute and I want to express the gratitude to you in allowing me to explore and manage this concepts in a deep and profound way in the clinic with my patients.

Play with words by Samuele Filomena

Recently I have been thinking about words. For example the word mortgage, for an english speaker is just a word, for me is a composite word by mort and gage, and the meaning of mort id dead in italain.

I’ll give you another example, ball in italian is palla and also it is a composite word by pa, hat is the sound of hitting the ball and la (there) where the ball goes.

Words describe actions, movements and discourses are narrated, spoken.

Lets carry on this game and focus on two basic emotions and the correspondent actions.

At the beginning of life there is not any solid food, just liquid and the baby does not have any tooth. The emotion that I associate with this state of life is sadness and normally it is express by tiers.

The word thirsty is very similar to the word triste (sad in italian), also in South italy we use tristu to connote a child that is restless. We know that in childhood the depression can be expressed with movement.

At 6 – 8 months with the separation-individuation and the appearance on the mouth of the teeth, the child with the weaning process starts to intake solid food. I associate an important emotion to this state and it is the anger and the correspondent work in English for starving is hangry.

The child is now able to express his anger and byte.

As Freud stated to Marie Bonapart in a letter on the 1937 May 27

I will try to answer your question [about aggression]. The whole topic has not yet been treated carefully, and what I had to say about it in earlier writing was so premature and casual as hardly to deserve consideration.

The turning inwards of the aggressive impulse is naturally the counterpart of turning outwards of the libiido when it passes over from the ego to the objects. One could imagine a pretty scheatic idea of all libido being at the beginning of life directed inwards and all aggression outwards, and that this gradually changes in the course of life. But perhaps that is not correct.

I don’t know if you remember my diagram based on what Freud said.

On Cartesian axis I put on the vertical aggression (high) and libido (low) and on the horizontal the time, a liquid time till 6-8 month and a solid and liquid onward.

If things go well and there is someone looking after the baby the aggression goes down and the libido up. An internal object is built inside from the bad object intorjected and the libido is projected on the good object outise.

At 6 – 8 months these two curves cross and for the first time in life the aggression is down the libido.

If I divided this space in four square at the intersection of the two lines and I name them with the four basic algebra operation +, -, *, /

Now lets take the word italian condivisione that is a composite word con (with) and division. In English can be translate with share. But the meaning is much more complex, there are two operations implicated a division, separation of the child from the mother at 6-8 month and not before, and the addiction of the baby with the mother with the investment of libido in her.

Now I let you imagine how many of these we can create with just four simbols.

Another example could be procreation in this case the two operations are * creation and pro +

 

Words with Play by Samuele Filomena

What I would like to address in this paper is the difference between two forms of autism and an important development maturational process that leads to walking, crawling.

For my point of view at the beginning of life there is a symbiotic relationship between the baby and the mother and there is no difference between them. I agree with Fairbairn that the child is object sicking but this is from the adult point of view. From the child point of you the outside world, included the mother, is just dangerous and he displays all the possible aggression to protect from it, and if the adult is able to supply some stable and reliable condition, the child can start to disinvest the aggression from outside.

The autistic child looses the connection with the object and this state is exactly the opposite to the symbiotic stage at the beginning, the prognosis for this type of autism is not good especially with the progression of the age.

If an early intervention is applied in order to re-establish the symbiotic relationship that helps the child to trust again the outside world and then to disinvest the aggression from it and able to invest the object, then it is possible to restore completely the maturational process of the child.

I would like to use the analogy of walking to explain that, in normally development the crawling comes before the walking and a child that was able to crawl has more facility to walk.

At the end of the day walk and talking is a way to take some distance from the mother and able to have a distant relationship, that before was made by contact.

When the child arrives in therapy that is not playing and talking, what comes before is the play and after the child is able to put some words, sounds, songs to that play.

And what is the play? Re-establish the symbiotic relationship with the child, that can allow the child to crawl away and to talk and walk, when before he was running so far away lost in the dark space, falling for ever without landing anywhere on the ground, without the possibility to develop roots.

How you can see my interest is on the relationship and been able to be in it, and able to communicate these raw experiences to colleagues in order for them to experience it.  

 

Two two­pages paper

Part B: Philogenesis: The origin of the species

The references for this paper can be found in Ferenczi Thalassa and in Lucio Russo The

forgotten Revolution and in doing that I will follow the history of my own town Carovigno from

the greek word Karpene (A lot of fruits) a greek colony from the VIII century bC of Athens, but

probably it was there before, and I suspect that we colonize Greece and not the contrary in more

ancient times.

The town is on the Adriatic Sea in the South East of Italy in the Apulia region.

During the Hellenistic period around the III century bC the town was a centre of commerce for

olive oil and other important materials, wine, fruits, almond and ceramics (I suggest to visit the

room 73 of the British Museum where there are the Egnatia Vase).

During this period the families were nuclear, like today, the people had a lot of scientific

knowledge, included psychoanalysis, as well documented, and there were state schools.

But with the conqueror of roman with the second Punic war all these knowledge spread over the

Mediterranean Sea went away on the East, far east, till China and India.

I want to remember you that these people were aware that the sun was at the centre of the Solar

system, the human being were coming from apes and the conscious is a small part of the mind

under the unconscious processes. (See Freud Interpretation of dream part 2 footnote)

The knowledge of physics, mathematics, chemistry were invented on that time and last till now.

A lt of people were made slaves and brought to Rome as tutor for their children and they were

architects, engineering, medical doctors, astronomer, and for this reason after a century we had

some flourish of science and arts in Rome.

But these knowledge were lost, though used for a while, and we ended it up in the medieval era

(a kind of latency for the human beings)

We need to wait for the Renaissance to have back with the fall of Costantinopoli all the books

that were kept there to come back to Italy and Leonardo, o Piero della Francesca and many more

artist and scientist. I want just to remember you that Padua is the first University in the world.

(Galileo Galilei)

If we had an industrial revolution and another Emperor, this time British instead of Roman,

based on navigation and notions of astronomy and bolts and screws, it is thankful to the

hellenistic thinkers that imitate the human body studied in details.

They were aware of the difference between sensory and motor neurons. The eye had a specific

book written by Erofilo, who also knew about dreams and their interpretations.

I suggest you to read some paper of Francis Bacon where there are flights machines and people

exploring the North Pole.

You can ask what this is to do with psychoanalysis and my reply is that psychoanalysis is the

queen of the science (see Abraham and Torok) and this is part of our recent past, just 80

generations away from us. If you think the second war world was just 3 generations ago.

And what is the difference between the Hellenistic period and the Egyptians or Babylonians,

mainly they were collecting data, the river Nile went out this year, ect.

With science we have a model of reality and we can intervene on it and modified it, with an

enormous advantage. The job that before needs 10 men now can be done by 1.

Alexandria of Egypt was built ex novo by Alexander the Greater during that time and the Faro

was able to illuminate at 50 Km of distance, and the Rhodi colossus was similar to the statue of

liberty.

Archimede used glasses convesse to burn the roman ships, Euclid invented the geometry.

Aristarco of Samo the heliocentric theory.

Two two-page papers

Part A: Ontogeny, the development of an individual from conception to adulthood.

In this first paper I will describe my view on the development of a human being from a psychological point of view. My main reference is Eugenio Gaddini and his wife Renata De Benedetti Gaddini.

At birth the individual goes to some importants changes (Physical), the respiration is from the lungs and the intake of food from the mouth, and the environment is not anymore stable as before.

The role of the mother is to keep this transition as smooth as possible and in this sense during the first eight weeks there is no difference with the intrauterine situation (from a psychological point of view).

The mericism or infantile rumination is the first psychosomatic dated illness and cannot occur before that time and the presence of this illness shows to us that at that point an important process starts: the imitation. The baby is able to use his own body to perceive the environment though the sensations and operates a detachment from it.

Only at 6-8 months the true perceptions start to operate , now with the separation from the mother, the baby is able to perceive the internal and external environments with his own senses (five).

The psychosomatic dated illness at this time is the dermatitis. The mother is a not-me object, there is an internal and an external and the skin delimitations them.

From this time on the baby starts to recognize the father as a separate object from the mother, at the beginning as a meiotic process that we are able to see in the clinic with the primal scene fantasies and after the first year of life as a distinct object. We are not any more in the range of sensations and perceptions but the thoughts and emotions play an important role in dealing with the loss.

The psychosomatic dated illness at this time is the asthma. Breathing, walking and talking are strict linked, and in a way it makes sense because the child can now distance himself in space and time.

This view is very similar to Fairbairn, he made a distinction between a mouth without teeth and a mouth with teeth, and we can see how with the feeding and the respiration the mouth is involved.

These two way of functioning operate at the same time for the rest of the life of an individual and what we are able to observe in session is the combination of these two ways of functioning.

Winnicott called them pure female and male elements, Gaddini psico-sensorial and psico-oral.

I made a model following a letter that Freud wrote to Marie Bonaparte on the aggression on 1937 in Jones Vol .

The two components are aggression and libido and at the beginning of life the libido is low and the aggression is high and this makes sense because the baby needs to protect himself and if there is someone that is taking care of him can de-cathected the aggression because the object is not bad and can cathected the libido to the object.  Only at six month the libido will cross the aggression.

Of course this is a model and I use this model in assessment and therapy all the time to see the two different components, the amount of them and the interaction. And though this model I can make change on the reality.

Psicoterapia Breve

Seguendo un approccio psicoanalitico è possibile utilizzare la psicoterapia breve per ottenere dei risultati in solo quattro sedute. Naturalmente queste sedute possono essere anche viste come una consultazione iniziale per una terapia a lugo termine, e nello stesso tempo dipende dalle risorse disponibili nel paziente.

Dopo il primo incontro preliminare le tre sedutesuccessive sonon volte alla individuazione degli oggetti interni e della loro espressione.
Stabilire il rapporto di fiducia è essenziale per poter facilitare l’espressione dei possibili conflitti interiori e l’emersione di una fiducia di base in se stessi e negli altri.
Il ritrovamento dell’oggetto buono e rassicurante nel paziente se presente nella propria storia personale permete il riequilibrio interiore.
Certo non tutti hanno un oggetto interno buono e rassicurante e questo permette una fase diagnostica dove è possibile intravedere un possibile percorso più lungo che permetta la creazione del suddetto oggeto interno.
E’ uno strumento diagnostico quindi e curativo allo stesso tempo e questo in genere informa tutte le psicoterapie dove vi sono omenti di sviluppo e allo stesso tempo momenti di valutazione.
Per poter operare questa tecnica il requisito del terapeuta è quello di avere una vasta esperienza e poter riconoscere da subito le necessità e i bisogni dei pazienti.
Sperimentare intense emozioni nella stanza di terapia, riconoscerle e nominarle permette al paziente e al terapeuta di creare uno spazio di lavoro essenziale per il raggiungimento di un equilibrio psico-fisico.

Il duale: la formazione del bambino nel primo anno di vita

Lo sviluppo della mente individuale deriva da una relazione duale tra il bambino e la madre e porta alla creazione di due oggetti interni nella mente infantile nel corso dello sviluppo durante i primi anni di vita.

Alla nascita le sole funzioni corporee vengono attivate e nel giro di pochi mesi una prima modalità di funzionamento emerge, dove non vi è distinzione tra il soggetto e l’oggetto, una funzione altamente imitativa della mente delle funzioni corporee.
È solo con il processo di individuazione-separazione dalla madre intorno ai sei otto mesi che l’oggetto viene riconosciuto differente da Se’ ed iniziano a funzionare dei meccanismi più evoluti di introiezione e proiezione. Un primo oggetto interno inizia ad insediarsi nel Se’ infantile.
Prima di questo periodo le cure materne hanno permesso al Se’ di illudersi e di creare uno spazio interno distinto da quello sterno da una barriera dove il primo oggetto si insedia. Ma l’oggetto madre viene dal di dentro, la madre diventa prima estranea e poi esterna al bambino con la catastrofe della separazione.
Con lo sviluppo del linguaggio e del camminare, strettamente connessi al respirare, il bambino inizia a diventare più autonomo intorno al primo anno di vita.
Qui inizia a fare la comparsa sulla scena del padre che è il primo oggetto esterno. All’inizio egli è un duplicato della madre, e a questo periodo sono connessi i vissuti della scena primaria, dove i due oggetti sono sovrapposti.
Un oggetto che all’inizio si duplica per poi sdoppiarsi
Questo permette l’insediarsi nella mente del bambino del secondo oggetto e questo processo occupa tutto il secondo anno di vita.
Tra il secondo ed il terzo anno un’altra funzione viene rappresentata nella mente infantile, quella della riproduzione, del rapporto dei due oggetti che gli hanno dato vita. È solo in questo momento che inizia il Complesso di Edipo che nel giro di un anno si dissolverà per fare posto nella mente del bambino della ricerca di un oggetto esterno, ma tutto questo verrà congelato dal periodo di latenza ed è solo durante l’adolescenza che questa ricerca potrà avere inizio.
Come possiamo vedere ci sono due modalità di funzionamento della mente. Una di tipo aggressivo rivolta verso l’esterno ed una di tipo libidico rivolta all’interno. E’ solo con le cure materne che quella aggressiva diminuisce che permette alle cariche libidiche di essere investite fuori sull’oggetto.
Questo modello presuppone due tipi di interventi, uno di tipo interpretativo ed uno di tipo contenitivo durante il corso del trattamento.

G. and my first tool box

A four year old child in care and in adoption. I prepare for him the first toy’s box and I started to see him in the Family Centre three times per week. I brought the clinical case in discussion with other colleagues for the entire length of therapy. Still I remember vividly the ending of the work from me and for him a drawing of tears.
The face of this child remembered me a clown, with a pronounced smile, but fix, stuck, sometimes muscular. He behaved in a way to pleased me in order for me to take care of him, to accept him, to not be refused I offered him a space to play and he started to use the game from the box and he built a farm and he kept separated wild and domestic animals.
He used massively drawings.
This case remember me another case that I treated in this country, a four year old boy, with a single mother and a distractive behavior at school and home.
At the beginning he putted just colors on the paper without any shape, something abstract and terrifying. Slowly he started to differentiate the colors and to represent objects (house, tree) and person on the drawings.
R. was another clown, a facial expression of a dwarf in a circus, behaving and looking as an adult. When he asked to me to bring at home his drawings that he did in the sessions I said to him that he could make them at home. In this case the therapy was in a school, an institution with teachers, social workers and Senco involved.
I work in a therapeutic community setting with severe mental health adults. We are in between an hospital and a flat. They come from hospitals and like to get independent.
But, I think, the most important experience was my personal life. I grew up with and in the home of my grandparents. For personal reasons my parents left me there and I felt that my family was to my grandparents and I belonged to them.
When my parents took me back in a certain way I felt adopted or fostered by them and for long time I questioned myself “Why?” Just recently I started to remember and understand these feelings and in this way I have a privilege route these children and they experiences.
The needs to be protect, to put together two different families, to enrich themselves instead to feel deprived.
I think that it is difficult to work in this field for the amount of emotions, but at the same time, it is a good opportunity for me to use my personal and professional knowledge to help them.
I had in therapy a child and I went to visit his father who was in a therapeutic community for drug users. What I remember of this case is the diffidence of the grandparents.