THE USE OF THE DIGITAL CAMERA IN PSYCHOTHERAPY

Victor Bloom MD

Jane came into therapy with me eight years ago. At that time the understanding was that she was part of a marital couple that needed a lot of work. Her husband, Don, a Yale MBA ended up hospitalized for suicidal preoccupation after ten years of supportive therapy and multiple medications by another psychiatrist. A thorough evaluation at a university center led to a recommendation of intensive, insight-oriented psychotherapy for both partners. My wife, a clinical psychologist, undertook treatment of the husband while I undertook to help the wife.

Jane's initial concern was about the suicidality of her husband--- what shouldn't she say or do to keep him from committing suicide. Taking on the worst-case-scenario I told her that if a person is intent on committing suicide, it cannot always be prevented, and if a person commits suicide, it is not necessarily anyone's fault. My intuition was on the right track, as Jane worried that she was responsible for her husband's depression and his difficulties at work. When they first had a baby, she was always anxious and fearful and would call her husband at work, begging him to come and help her. His inability to work long hours and his worry about his wife and child did in fact impact his work record.

While Don was being treated by my wife, I began uncovering therapy with Jane. She would come three times a week and I encouraged her to free-associate face-to-face in the interpersonal mode. She relaxed as it was becoming clear that with her husband's more intensive and insight-oriented approach, his depression was lifting and he was no longer suicidal. She took the opportunity to stop worrying about him and start taking care of herself. The past ten years she was trying to carry on raising two young boys and dealing her husband's chronic psychiatric condition. He was taking various anti-depressives and tranquilizers and suffering the usual side-effects of drowsiness, weight gain and sexual dysfunction. Her role, as she saw it at the time, was to be the strong one, the consistent breadwinner and the dominant parent. Otherwise, Don was a good father to their two sons, despite worrying about his job and feeling bad about his under-achieving in a sub-culture in which financial success was highly prized.

Meanwhile Jane was getting into deep and thorny material. She felt evil and incapable of love. She was 'trouble' and always at fault and to blame for whatever went wrong. It was her fault that her husband was depressed and suicidal and had trouble keeping a job or getting promotions. It was her fault that her sons had problems. She was wrong for wearing a black armband during her college graduation, for being against the war in Vietnam. Her family was rigidly Catholic and conservative and any deviation from that norm was strongly criticized. Jane took criticism hard and felt it deeply. She worried about being angry, because anger was a sin. She tried to be a good girl and no trouble. She tried to see her family as ideal, like the public relations image of the Kennedy family. Like the Kennedys, her family was 'old money' and often in the newspapers and portrayed as philanthropists and pillars of the community.

There was a part of Jane that was proud of her family name and tradition, but her associations brought up many memories of marital conflict and family dysfunction. In the family history were numerous cases of depression, suicide, fatal accidents and alcoholism. These were family secrets. When Jane told her mother that she was worried about her drinking and depression, and asked her doctor what to do, her mother raged at her for telling tales and breaking a confidence.

The first few years of therapy Jane was in my analytic group as well, and she felt dumb and inferior to the other members. She thought they considered her a spoiled brat and not too bright, even though they all thought she was very intelligent and keenly insightful. However Jane became the fragile member of the group. Any time there was intense emotion expressed, she would shudder and shake and become confused. When she was asked about this, she never could say why, except that she didn't like loud voices--- they reminded her of her parents fighting. In time she saw herself as the group problem patient, and sure enough, the other patients got well and terminated and she was left and the group disbanded. She always thought it was her fault and she wished the group could have stayed together because in spite of everything, she felt she was learning a lot. And she did get a lot of positive feedback for her value as a person, something she never experienced before. And she really could see eventually that the others were no smarter than she was.

In both group and individual therapy she manifested occasional lapses of attention, which she associated to a childhood diagnosis of petit mal epilepsy. She had been put on medication for it and her siblings instructed to watch out for her in case she would have a lapse while crossing the street. She thought the anti-convulsant medication made her somewhat drowsy and she felt drugged during several years of her childhood. Later she thought she really didn't have petit mal, but was merely preoccupied at times. Maybe her parents wanted her drugged so that she wouldn't tell family secrets or would be believed if she did tell. When she complained of anything she was told that she was exaggerating or making up stories or just wanting attention. She was branded the sick one and that was how she started to be 'trouble.' Around the age of eight she was a compulsive hand-washer and her hands were chapped and dry, cracked and bleeding, but she received no dermatologic or psychiatric attention. The nuns were strict in parochial school and she got grief for not doing well in her schoolwork. She had trouble reading, she felt she had to read and re-read to be sure she read every word, but then had difficulty remembering what she just read. Or she would stare at her book for periods of time without being able to read. In later years she would often have to check to see if she locked the door or whether any appliances or the stove was left on.

I naturally questioned her about these symptoms. At first she had no idea, but then she took to interpretations about Catholic doctrine causing guilt and feelings of being sinful. It was a sin to be angry. I suggested that she was probably also taught that sexual feelings were sinful. She agreed and at first nothing came of that. She didn't masturbate as a child as far as she could remember, but she did recall tickling and wrestling games with her father. And that he would sometimes spank her bare bottom. When she was ten or eleven he said she was getting too big for that and the practice stopped. Her associations included recent instances of her father commenting on her female shape and feeling uncomfortable with that. She recalls feeling closer to her father than her mother and her mother resenting that fact. She said she felt like a whore on many occasions, because of the way her mother looked at her when she was close to her father. She had suicidal fantasies and once stepped on a nail and punctured her foot.

A whole Pandora's Box was in process of opening up. Although she frequently had sex relations with her husband, and said they were mutually enjoyable, in time she reported feeling detached and uninvolved, incapable of love. She said her heart was locked away or that she had no heart. A part of her was involved with her husband and a part of her was not. Then it became other parts and more parts. There was 'little me' and puppets, more and more puppets protecting and confusing the 'little me.' When she felt under stress she would wave and flutter her hands over her head and say she was confused. I interpreted her confusion as avoidance and obfuscation of something traumatic. She said her whole childhood was traumatic, her family a 'war zone.' Soon after she saw a British movie called "The War Zone" with a frank depiction of father-daughter incest and she became interested in the movement to uncover and help women who were traumatized by incestuous molestation. She began to wonder if anything happened between herself and her father.

She wanted her father to know that her psychotherapy was leading to memories that she might have been traumatized in some way, and wanted some financial help to pay for more intensive psychotherapy. She wanted him to come and meet me to get a better understanding of our work and who I was, and I consented to his coming in for one joint session with her present. He was a tall, impressive-looking man who acted friendly, and interestingly, when she said she might have been sexually molested by someone in her family, he asked in an apparent nonchalant, matter-of-fact manner, "was it me?" At the time we let that pass, but later that revelation took on greater importance. He refused further financial support of her psychotherapy, claiming the he didn't believe in it.

She saw other movies about sexual abuse. In "The General's Daughter," the father implored the daughter to keep it a secret that she was gang-raped by a company of soldiers. It wouldn't look good for the Army or for his reputation as an esteemed five star general. In the movie the daughter re-enacted the gang-rape and eventually got her therapist to go re-enact the scene and go all the way with her. She eventually killed herself and the Army therapist committed suicide. This plot gave her a good idea of the meaning of 'repetition-compulsion,' and she felt that she was compelled to repeat with me whatever happened to her. As time went by she reported uncomfortable vaginal sensations which made her very nervous, worried and guilty, feelings which she couldn't understand. I suggested they were fragments of memories. Our further work was in the paradigm of recovering traumatic memories, probably of a sexual nature, but I was careful not to be suggestive and related the fact that these were merely tentative hypotheses, that whatever we piece together of the fragments were valid only insofar as they were consistent and reinforced by other stable memories.

Another movie which captured her attention was "Little Girl Fly Away," which was about a woman with a split-off memory of childhood molestation. I suggested she also view "The Three Faces of Eve," and "Sybil," both of which she found fascinating and personally impactful. I shared with her a New Yorker short story which was about how a young father in India gradually induced his young daughter into a sexual relationship with him. This story was so detailed and vivid that several professionals I showed it to were convinced it was not fiction and one, a victim herself, considered it pornographic. Jane said she could see how it could happen, and she believed something like that happened to her, but she had no such memories. Then there was an impasse, and so we increased the intensity of sessions to three double sessions a week, and then five double sessions a week.

This work led to more and more fragments of recollections that suggested there were repeated molestations and by family members beyond her father, two uncles who were cousins to each other and teenagers at the time. The latter are now both dead, one of suicide and the other an accidental drowning, falling through the ice in a lake. Jane's mother was a chronic alcoholic and given her angry and rejecting attitude, she wondered if her mother were molested as a child too. The mother was very intense about keeping family secrets, and very suspicious of the relationship of her husband and daughter.

After another couple of years the intensive psychotherapy was proving to be too burdensome economically and the husband's wish prevailed that she should cut it down. For a time, in deference to his feelings and worries and not understanding the need for such intensive in-depth work, we reduced it to one double session a week, but that proved stultifying to the analytic work. Jane became more assertive and sold some of her stock and demanded to resume the more intensive work, which was reinstated at two double sessions a week, which continues until the present time. She also thought it would help to take a week off work to have all day sessions. We settled on three hour sessions several days in a row, and they did produce more vivid re-enactments and memory fragments.

Her associations were getting repetitive and she could recover no more memories but she was getting into fugue states during the session and seemed to be dumbly re-enacting what appeared to be traumatic events. She would close her eyes and open her mouth and throw her head back and clutch at her groin and moan. Sometimes she would throw herself on the floor and draw up her knees and cover her head, as if protecting herself. Visualizing this I imagined Jonbenet Ramsey being killed, only Jane was not killed; she survived what I thought was an attempt to kill her, so that she could not tell the tale of what happened. I suggested that she was intimidated not to tell about whatever took place, that she was told it was a secret and not to talk about it or something very bad would happen. She thought this was right. I wondered if she could show me what happened if she couldn't remember in words and tell me. And so she would get into these states and I would describe them to her and ask her about the details. At the time she would be emotional and tearful, realizing these bad things happened to her as a little girl, but she later bacame detached and unemotional about them, referring to herself like a case. She would say her feelings were locked up.

I knew she was interested in photography, and early in the therapy she had bought a certain framed photograph at an art show which was intriguing to her and which was one of the clues to sexual molestation. It was a beautiful nude woman, somewhat seductively displayed, but the whole lower half of her body appeared to be buried in the ground. My interpretation was that that was her, and the lower half of the body contained her genitals, and for some reason they need to be buried and hidden.

During the therapy she started doing more of her own photography, getting new cameras, including a digital, and quickly learned Photoshop and PowerPoint. I had meanwhile obtained a digital camera and quickly realized its potential. I suggested to her that since she was emotionally detached from her re-enactions in therapy, if she could see herself seemingly being violated and physically attacked, she would connect with the fact that that was herself and not some split-off part, and that maybe she could get more emotionally reconnected with these events, which I still felt were fragments of memories being physically enacted but for some reason without an emotional connection or words.

So for several months this year (spring of 2001) I took 20-30 digital photos of her during these 90 minute sessions, of selected portions of her behavior each session and emailed them to her, usually later that day or the next day. She would then look at them on her computer screen or print them out with some written reactions, which she would bring to the sessions and that we would discuss. During most of the therapy she also kept extensive notes of her thoughts and feelings relating to therapy, and sometimes she would read them to me in an effort not to overlook anything. Even so for a time she remained cut off from the emotional connection, but after a while, with my further personal involvement*, she could see and feel that that was her and she had been truly and severely traumatized, both sexually and physically, as if she were beaten with a warning never to tell.

As I write this at the end of November, six weeks before my presentation in New York City, my patient is selecting transparencies for me to show for this talk. Of course I had to get her permission to present this, with the knowledge that it is highly unlikely that her face would be recognized by a handfull of Academy analysts, and even so, the professional ethic of confidential and privileged information would prevail. Furthermore, the patient wants to be of possible service to other therapists and patients if this method proves helpful. At this point the patient is clinically much better and highly functional in her work and family. But she wants to finish reintegrating herself, getting her heart and 'little girl' back together with her adult self.

*There was an occasion when I shared with her my old family photographs of grandparents, aunts, uncles and cousins who were murdered in the Holocaust, in which I became tearful.

Victor Bloom MD

1007 Three Mile Drive

Grosse Pointe MI 48230

313.882.8640 phone

313.882.8641 fax

vbloom@comcast.net

Clinical Associate Professor of Psychiatry

Wayne State University

School of Medicine