An Interview with Valerie Sinason

Jay CROSBY

Jay Crosby: Thank you for speaking today. By way of introduction, I’ll say that I’m interested in the relationship between psychoanalysis and disability both for personal reasons—I grew up with a father with a chronic physical disability and have a son diagnosed with a rare developmental disability—but also for political reasons, in order to further understand and address the elitism and ableism that continue to permeate and limit our field. I’m wondering if you can speak to how you came to develop your work and how you’ve negotiated this problem of ableism in psychoanalysis.

Valerie Sinason: There are some key issues that you’re raising, one of which is that most of the work done on intellectual disability has been done by people who, like you and me, have someone they love in their family with an intellectual disability, which makes sense. But it was shocking to me when I realized that the second group that cares intellectually, clinically, and theoretically is made up of those that, for whatever reason, have had a complicated minority experience themselves.

At the Tavistock clinic, where for over 20 years I either led or co-led what was first called “the subnormality workshop,” then “the mental handicap workshop,” then “the intellectual disability workshop,” there were the first group, then immigrants that knew what it felt like to not be the wanted color, gender, accent, or class. The only exception to that—was pointed, out for example, by my excellent co-chair for several years in the adult department at the Tavistock, John Stokes—were brilliant upper-class white people who had felt at odds being brilliant, or upper class-, because therapy professions are mainly middle class.

It is easy for a middle class professional to end up thinking that there’s middle class, lower middle class, working class, the traumatized, the dispossessed—but can tend to forget that there’s upper class and aristocracy. And, in fact, the first time I ever assessed an upper-class patient with a severe disability, I went into a kind of subordinate mode that I was quite fascinated by. He was speaking with these upper-class manners and accent and I was temporarily unable to believe he was disabled. So I got a very embarrassing personal lesson about social class and therapy. We are only now in the UK paying attention to the traumas of boarding school and separation.

When we first started getting ethnic questionnaires asking, “How many people in your workshop are this background or that background,” I answered that it would be a sign that the status of disability had changed when we don’t have far more minorities represented than any other workshop in the building.

JC: Disability can be so aversive to people.

VS: Disability is a terrifying subject, especially intellectual disability—I think it is part of the Darwinian legacy. If we had some extra thinking power that made us different than other animals, it was unbearable to get near someone whose thinking would not be on the level of the rest of their peer group. There’s a feeling of contagiousness getting near it. It’s a reality that people don’t want to face in their own life, so they don’t want to think of someone else having to live like that.

But it’s Mother Nature. Let’s say that 10% of babies in lucky countries will have some sort of cognitive difference. But if you go to traumatized and poor countries, the percentage will be infinitely higher, because outside of the small group of middle-class or upper-class families where something out of the blue happens, the biggest disability worldwide is mild intellectual disability. And the shock is that it’s nearly all for political reasons in that group. Whilst profound disability related to genetics is spread evenly and in relatively small numbers across all social classes, mild disability is a symptom of trauma. There’s a small number for whom something organic has caused it, but the majority are breathing in toxic environments at the age when the brain is developing. And therefore, given that most therapists have a civil service mentality—go very slowly, carefully, don’t rush in, take our time, do not intrude—the shadow side of that is a fearfulness of reality.

JC: How did you bring psychoanalysis to bear in your work with intellectual disability?

VS: Psychoanalysis lives inside me with whatever I do. Well, I did a Kleinian child training with an independent group analyst, and then an adult psychoanalytic training with a Freudian one. I’m very “mixed race” over my training—child and adult. I couldn’t do without projective identification from Klein, or the power of counter-transference, in disability trauma work, but I think that British Kleinians working with adults, until the last few decades, have been damaging over the status of external reality, and that the delay before sexual abuse was seen as reality—and not an Oedipal fantasy—is still impacting generationally. And somehow, within the independent group, the past Freudian work on abuse was just forgotten. So I think that as disability in itself can be experienced as a trauma and as people with disability are more vulnerable to abuse a psychoanalytically- informed, trauma- informed way of working is crucial.

I have my own apologies to make-both over the time it took me to recognize reality and over my class bias in disability work. Anne Alvarez, a brilliant Kleinian child psychotherapist, was my favorite supervisor. When I qualified, I went straight to her by choice. We both joined the Tavistock as consultant psychotherapists at the same time— her with the autism workshop and me with the mental handicap workshop. And it used to impact on me that the work of the autism workshop gained extra support due to the fact that autism was middle-class in terms of the brave parents who were showing that their child had not had the right treatment and needed something. And from my sort of working-class background, I was concerned about autism only if it went with being learning disabled as well. I thought, “Typical -people caring only about autism when it is middle class.” And that was very arrogant and snobbish of me—reverse snobbery. It was almost half a century ago!

Now I’m much more aware that it’s far more than 10% of any school class with a problem. I’m very grateful to the whole neurodiversity movement for making us aware of things that I never had any training in. I never knew about things like sensory processing disorders. So, I think we do need to properly take on board that everybody is a universe of their own, and whilst we might share a common language, it’s going to have a different meaning for everybody until we’ve interrogated it.

This led me to another Freudian realization: that you have to have curiosity for others. You have to ask a question. Whereas in adult analytic training, certainly in the U.K., you didn’t use to ask questions, with disability it mattered that you did. When we asked questions of people with severe and profound disability, we got answers that changed our lives. For example, for 16 years Baroness Professor Sheila Hollins and I ran a weekly group for men with severe intellectual disabilities and sexual problems. The men were all always talking about “sections”—they only met each other in the group once a week for an hour and a half, and every week it would be all, “My section’s coming up.” And one week Sheila asked, after over a year of weekly therapy, “Do you know, you all often talk about being on a section? What’s a section?” And one of the men said, “It means nobody wants to sit next to me because I smell.”

It makes me feel like crying, remembering it all these years later. So, it’s not just middle-class autism that masks. There’s a way every human being masks, and it’s called “politeness” or “courtesy to the other.” But none of us really know how well we know the people we think we know, if we haven’t asked and heard them. So there’s something about really actively and deeply listening to somebody.

One of my most painful examples of this was a girl in a special unit who had come from an abuse background into a lovely foster home, and was doing really well at school until it came to the end-of-term party and she was offered lemonade. She picked up the glass bottle, smashed it, and it went everywhere. Everyone was terrified. It turned out that she was a victim of organized abuse, and in the abuse, semen was called lemonade. What she was saying was, “I thought it was different here.”

Since 80% of everyone disabled I worked with turned out to have been abused—which is average, we now know 30 years later—I started to become very aware of the assumption that words mean the same thing to everyone, when in fact meaning is dependent upon the experience someone has had. For example, what did a bedroom mean? How could someone sleep in a bedroom if that’s where they’d been hurt? What did a table mean if you’d been beaten over a table? What were the different objects that had different meanings in your mind? Because I’ve always loved words, it’s always been the words and the linguistic meaning I’ve gone for. Each of us as a therapist brings something so totally different than anybody else, whatever our training has been. When you work with severe disability and trauma—because they normally go together— everything you’ve been and known is useful.

My maternal grandmother, who lived with us until she died, was illiterate. And that was always the reason given for what she could and couldn’t do. It was only after my mother died that I was allowed to realize internally that she had a mild intellectual disability through trauma. That was not speakable before. So in my second edition of Mental Handicap and the Human Condition, I put my own bit of blindness in, because I’ve always loved Bowlby’s paper, “On Knowing What You’re Not Supposed to Know and Feeling What You’re Not Supposed to Feel.” The more you work with trauma, the more you realize how everyone dissociates, which is my other main area of work.

My father became a professor of “mental handicap having had to leave school at 14 after the army. When they wanted teachers, he got himself a further education, taught “backward children,” then became a head, and then a professor. He was the first head teacher of a school for disabled children to force his staff to give up the cane, because he saw this as assault very early on. He’s the reason disabled children in England go to school. Until him, they went to hospital because they were “ineducable,” and it was his book, No Child is Ineducable, that transformed things politically. He was the most utterly wonderful, wise, and lovely man.

In 1979, Neville Symington—an Australian analyst—got interested in a man with a mild disability who was unusually referred to him, who could speak well and read to an eight-year-old level. So Neville started a workshop, and four or five analysts at the Tavistock joined, because they loved Neville. I was a trainee child therapist, and the workshop had been going a few months, and I thought, “If I join, am I being Oedipal? “And then, “If I don’t join, I’m also being Oedipal, so I might as well join.” And I found that I knew the work—I’d lived it. That man who Neville treated was just like my Nan, even though I wasn’t naming that then. The moment I joined I felt I’d come home. And Dad was so pleased I had gone into the same area.

But once Neville went to Australia the group stopped, and John Stokes and I built it up again. And we found that the international analytic history was very like what happened at the Tavistock—that a single analyst would, by fluke, get a referral, realize, “My goodness, this person can make use of a talking treatment brilliantly,” write a paper on it, it would get noticed, and then they’d never do another piece of disability work again. I stayed for 20 years running or co-running it, and only leaving the Tavistock to set up my own clinic for dissociative studies. Eventually, following in my family’s footsteps, I came to realize that my job was to go where people had not been given meaning.

JC: Psychoanalysts ideally engage in a form of listening that is predicated upon an openness of being to an other—one that offers safety and to allows the patient to open to painful parts of him or herself. And yet, we have so many ideas around the complexity of clinical listening and clinical process and the position of the analyst in relation to the patient, that leads some analysts and analytic traditions to lose sight of the humility necessary to good analytic work. Given your experiences, I’m wondering about your perspective on the utility of psychoanalytic thinking and training in relation to the hermeneutics of humility.

VS: I think that the hierarchy in analytic training , hopefully mainly in the past has been so severe and powerful that it hasn’t aided that kind of humility which is engendered through working in a rough school or in the back ward of a psychiatric hospital. I think there is a way that when analysis is embedded in a prestigious place or a certain class, and not made available, it doesn’t help itself. But I think you have to go through whatever the training is in order to be able to undo it or tweak it—to know what has been precious and mutative for you, and what has been damaging. I was lucky with both the two main analysts I chose, who compensated for where the actual training structure did not help me.

For example, I was working with a woman with dissociative identity disorder, who was quite brilliant in her main personality. And there was a silence after she said something, and I was thinking—or rather, I thought I was thinking. And after a moment the patient said, “Okay, you’ve gone again, Valerie. Where are you? And don’t give me that analytic crap that you’re thinking that you’re in a couple, and I don’t like you being in a couple, and I’m intruding. You’re stuck, you idiot, aren’t you?” And I was utterly gobsmacked. I realized I was stuck, and she told me exactly why I was stuck, and it was devastating. I’ve always said one patient like that can save you years of analysis. They know you better than almost anybody. In a way, that was a very good illustration. Like lemonade, I would never have thought of that. I could have come with all sorts of theoretical formulations and interpretations in mind, but she had the answer when she was listened to.

Another thought I have about analytic training is rather controversial. I think there is a dissociative listening that many analysts are trained in, which is comfortable, that can be sunk into, thought about. “And I wonder if…” “And could it be that…?” And actually, that’s dissociating from the emotional impact of the other.

There’s a small group of us that have been doing this work for 40 years, and we know our equivalent colleagues all around Europe and the world. We’ve all been saying the same things, all meeting the same subtle responses, “Oh, you work with disabled people! You must be so patient!” Meaning, “What a failure you are if you want to work with people like that.” My father used to talk about the E-stream teachers being given the E-stream. He said, “You want the A-stream teachers for the E-stream! You’ve got to have the best for the people that have suffered the most.” But that’s not what happens. Analytic culture is not kinder, is not more understanding than other aspects of culture, which is rather disappointing.

I think, in a way, we feel our mental health is on the line when we apply for analytic training. It’s as if to be rejected is to be told, “You’re mentally ill.” And then, the thrill at being accepted leads to an idealization of the institution in a way that makes it harder to see all the problems involved. Pearl King, my beautiful supervisor for my work with dissociative patients , once said that the time you have most power as an analyst is the year after you’ve qualified, you’ve gotten rid of your supervision, and you feel free. And when you’ve retired. And she said, “Silence is traumatizing.” Most training is on the joys of silence and the 365 flavors of silence. Not with trauma. Not with disability. Not with dissociation. With those, silence is persecution. When the absent object is the present persecutory one, it’s not helpful to work through it by being that. Not for people that have gone through more hell than we could ever imagine.

JC: What you’re saying, broadly, makes me think about Bruno Bettelheim and the move that he did in the 1940s taking seemingly psychotic or autistic children out of the hospitals and offering them a beautiful home on the Midway in the south side of Chicago, serving meals on ornate china and painting elaborate murals throughout the building. This was part of a remarkable paradigm shift in terms of treating disabled people in a more human way and seeing symbolic expression in behaviors that others wanted to shut down. But then I also find myself thinking about the destructive legacy of Bettelheim in terms of the theory of the refrigerator mother and the subsequent biological and neurological turn in terms of conceptualizing most disability in terms of brains and genes. This pendulum can be dizzying, yet I hear a sensitive movement in what you’re saying about the etiology of disability in terms of trauma, disavowal, marginalization, and not being given a voice.

VS: You’re right, we go from one to the other, and it’s hard to stay holistic. Everybody has a bit of everything, and each generation will have to privilege the bit that was missed out by the last. You go ‘round in different circles until they’ve all been put together. But at some level, we have to ask, “Can we go back to being human, please?” I love the Sylvia Plath poem, “The Applicant”—Are you our sort of person? Do you have a crutch? Do you have a rubber leg? And if not, well, how can we find a place for you?

And we haven’t even started. One thing I did have to humbly learn was that, despite amazing changes in emotional capacity and functioning among people with intellectual disabilities in therapy—even with profound multiple disabilities—IQ did not change. I had to learn that through my own research, because I never believed IQ was something static. Not that it necessarily matters, but it was important to realize. The patients’ free association, their stories, their narratives, their verbal language, all showed change. So we’ve been able to show that talking treatment works, but not in ways measured by IQ.

JC: That’s a remarkable finding, particularly since IQ can have such a dominant influence on the provision of services and in determining what level of education one has access to.

VS: Yes, and most people with intellectual disabilities don’t ever get that chance, although a few are lucky with this part of their environment. Just to have one person, one teacher—you don’t expect all the teachers in your school will be nice to you or like you, but you need one. In some cases, it could make all the difference. Being able to say, “I love you,” and realize someone liked to hear that from you, when you felt they all hated you. Also, a greater awareness of ableism is needed. Like with a child who’s fallen over, gotten their scratch, and scratches it more to make their war wound more impressive, a lot of people with a disability will add on what I call “the secondary handicap.” If you’re going to be looked at for looking or sounding different, you might as well exaggerate yourself to mock the people looking at you. They think they’ve seen you, but you know you can do them one better. To be safe enough to give that up then means you’re just a bit different, which can be much more painful. Like getting a B instead of a B-plus can be harder than getting a C or a D. It’s asking a lot of someone to dare to be themselves.

Contributors

Jay Crosby, Ph.D. is a clinical psychologist and psychoanalyst in private practice in New York.  He is on the faculty at the Columbia University Center for Psychoanalytic Training and Research where he trained as a psychoanalyst, and is a Clinical Assistant Professor in Psychiatry at NYU School of Medicine. He has written, published, and presented papers on a range of topics including early psychosis, the psychodynamics of overstimulation, and messianism and object use. He has a Ph.D. from the Derner Institute at Adelphi University, received additional clinical training from the Melanie Klein Trust and has an A.M. in the History of Religions from the University of Chicago.

Dr Valerie Sinason, is a poet, writer, child and adolescent psychoanalytic psychotherapist (retired), Bowlby Centre attachment-based psychotherapist (retd) and adult psychoanalyst . She has specialised in trauma and disability for over forty years within the public sector at the Tavistock Clinic, St George’s’ Hospital Medical School and schools for disturbed children and has edited, co-edited or written twenty five books, 264 papers, reviews and chapters, and lectures nationally and internationally. Founder and now Patron for the Clinic for Dissociative Studies UK, President of the Institute for Psychotherapy and Disability, she is a Fellow and current board member of the ISSTD and received their 2017 Lifetime Achievement Award , the British Psychoanalytic Council’s Innovation Excellence Award, 2022 and the Swedish life membership of POMS. She is an honorary consultant psychotherapist at the Cape Town Child Guidance Clinic. Her first novel is The Orpheus Project (2022), Sphinx books.

Ben Stephens, photographer, https://www.benstephensphotography.com