I wish to present my work with a patient who discovered she had developmental prosopagnosia(facial blindness) after several years of psychoanalysis. Though as much as 2% of the population may have this, there is little if anything in the psychoanalytic literature about this condition, or it’s effects on development or treatment. I wish to highlight that many patients are unaware they have this condition or their therapist, including myself, don’t consider it.
Facial blindness or developmental prosopagnosia (DP), was considered extremely rare in my training and as recently as the 2003 review by Kress and Daum (1). Since then there has been a surge in research findings that have greatly expanded our understanding. It is now estimated that 1.5 to 2% of the population is affected. An example is a 2008 study with Hong Kong medical students by Kennerknecht and Wong(2), showing a 1.9% distribution, demonstrating the universality of this condition.
Numerous publications in the popular press have appeared. Several prominent people have reported to suffer from it, Oliver Sachs (3), Brad Pitt, and the artist Chuck Close, to name a few. Jane Goodall, the famous chimpanzee researcher, describes her own experience as follows: I used to think it was due to some mental laziness, and I tried desperately to memorize the faces of people I met so that, if I saw them the next day, I would recognize them. I had no trouble with those who had obvious physical characteristics—unusual bone structure, beaky nose, extreme beauty or the opposite. But with other faces I failed, miserably. Sometimes I knew that people were upset when I did not immediately recognize them—certainly I was. And because I was embarrassed, I kept it to myself. (Goodall and Berman1999).
相关的书籍报道大量出现。一些杰出人士也报告说他们遭遇此类疾病，例如奥利弗·萨克斯，布拉德·皮特和艺术家查克·克洛斯。Jane Goodall， 一位著名的黑猩猩研究者，就描述过她的亲身经历：我曾经以为这是心智惰性导致的，我试图拼命地记住我曾经遇到过的人的脸，这样我下次再见到他们时就可以认出他们。对于那些有明显生理特征的人——比如有不同寻常的骨结构，鹰钩鼻，特别漂亮或非常丑的人我是可以记住的。但可悲的是，对于其他脸我就完全不记得了。有时候我知道那些我没能马上认出的人是不高兴的——对此我也不高兴。我因此而感到尴尬，因此只能把这件事当做一个我自己的秘密。
The author Heather Sellers has written a well-received book “You Don’t Look Like Anyone I Know: A True Story of Family, Face Blindness, and Forgiveness” describing her own experiences. The observed effects on children’s behavior is described and well expressed in the title of Dalrymple and Duchaine’s paper (4)“A room full of strangers every day”.
Facial recognition is a complex phenomena, that apparently involves several cortical areas. Some recent work suggests the defect in DP involves reduced connections between the occipital and visual areas. It appears to run in families and involve multiple genes. I defer to those better qualified in understanding this complex and now extensively studied area of cognitive research. See a current review by Bates and Tree(5).
I want to present a patient, who discovered she had DP in the course of a long standing analysis, surprising us both, and forcing some new understanding of our work together.
The pt. L is African American single professional woman in her late 50’s. She has been in some form of ongoing therapy most of her adult life. I remember my first impression of her as she came for her initial session. She was referred to me by another analyst, who was relocating out of state. She was a tall, awkward woman with masculine gestures yet still attractive, with a shy smile like a little girl trapped inside, her manish gestures and bearing. Her presenting symptoms were depression, difficulty in relationships, sexual preference, and episodes of transient dissociation described as “spacing out”.
Her psychiatric history included several hospitalizations in her early 20’s for suicide attempts and alcohol abuse. After being required to sign a contract not to commit suicide by her inpatient psychologist, she responded by burning down 2 buildings and being kicked out of the hospital. She did continue as an outpatient with a bearded social worker she was comfortable with. A gifted student and athlete, she finally finished her degree and moved to my city where she obtained a PhD. Her previous analyst, a woman, felt she had stabilized somewhat with multiple sessions weekly because she had object constancy problems. L initially was concerned about my capacity as a male to be helpful, but we did quickly connect. She has an excellent sense of humor and loves to banter about sports. I thought I could see glimpses of a positive brother transference emerging. I noticed a concreteness about her thinking in patches, a tendency to forget contents of sessions, and external events, that looked like dissociation. I made a conscious choice to be as interactive as possible, giving considerable here and now feed back as to my experience of her and what I was thinking. My thought was to deepen the engagement, counter the negative paternal projections, and present myself as much as possible as a real object in the hope of facilitating better object constancy.
She described a most unusual childhood. Her parents, both college graduates, were dairy farmers in a rural area. L. was the 4th child with 2 elder brothers and a sister 2 ½ years older. The family dynamics centered around L’s sister, who was developmentally delayed. L experienced almost constant intrusion and absence of boundaries with her sister. She was mostly ignored, and not allowed to complain. The father was deeply attached to the sister with nothing positive towards him experienced by L. In all my years of seeing L, she could never retrieve a single positive feeling towards her dad. She always remembers herself as seeing the world only as an observer of others not a participant. She learned by observing and imitating others. She felt closer to the calves than her family in many ways, naming them and touching them daily(notice the parallel with Jane Goodall and her chimpanzees). She attended a one-room school-house till grade 7 having no playmates in her isolated rural neighborhood. Her memories of father are of a cold stern man with his gloved hand artificially inseminating restrained bleating cows, or callously shipping off her beloved calves for sale. The mother and sister stayed in the house, while L worked outside doing chores with her Dad and brothers, modeling herself after them. The mother was a needy and helpless person. L. took pleasure in caring for her mother but expected little in return. She convinced herself that she would eventually grow into a boy like her brothers and was devastated with the onset of menses. This also coincided with L’s changing schools, becoming lost in a group of strangers all of whom knew each other. A gifted athlete and student she organized herself around these activities. She developed some difficulty with absenteeism and drugs as a junior in High School leading to her first seeing a bearded counselor with marked improvement in her behavior. She described him as the first person to ever listen to her, She developed the idea that he could always see her, which was both gratifying and scary. Going away to university led to her first psychiatric admission when the chaos seemed just too much. I was to be another in the line of bearded therapist for her.
她向我讲述了一个非常不同寻常的童年。她的父母都念过大学，是乡下的牧场主。L在家排行第四，上面有两个哥哥和一个大她2岁半的姐姐。L的姐姐有发育迟缓问题，整个家庭的动力以她为中心展开。L的生活总是不断地被姐姐闯入而且和姐姐之间缺乏边界。她总是被忽视，并且不得对此有任何抱怨。父亲和姐姐的联系紧密，L感受不到任何与父亲有关的积极体验。在她的记忆中她之于这个世界总是一个观察者而不是一个参与者。她从观察和模仿他人中学习。她觉得，她对小牛犊都比对家人在许多方面亲近得多，每天给它们起名字，并且抚摸它们（请注意，这恰好与Jane Goodall和她的黑猩猩之间的关系一样）。她在一个只有一间教室的乡村小学念书，直到7年级之前她在与世隔绝的乡下都没有玩伴。她记忆中的父亲是一个冷漠 严厉的男人，总带着手套在给咩咩叫的奶牛人工授精，或者冷酷地把她心爱的小牛运走卖掉。母亲和姐姐通常就待在屋里，L则学着父兄的样子跟着一起干活。母亲是一个高需求又无助的人。L乐于照顾母亲但很少期待回报。她说服自己终有一天她会长成像她哥哥那样的男孩子，但是例假的到来摧毁了这一幻想。这一点与L的转学也很一致， 她在一个别人都互相认识的陌生群体里感到迷失。起初她在活动中把自己塑造成一个有天赋的运动健将和好学生的形象。到了高中一年级她逃学和吸毒，为此她开始去见那个长胡子的咨询师，之后她的行为有了显著改善。在她的描述中，这是第一个倾听她的人，她以为他能一直见她，这既让她满意又让她害怕。上大学后她第一次被精神科收治，因为当时的麻烦实在太大了。我成为了下一个与她工作的大胡子治疗师。
I decided to see L 4x’s weekly sitting up. I felt this would help with her clear problems with object constancy and attachment. I also decided to be more interactive with her, building on a bearded therapist, big-brother transference that seemed pre-formed. The biggest difficulty developed in the second year when she developed a violent negative transference rising at times to almost delusional quality, whenever she saw me with another pt. This paralleled the developing positive transference, as she started expressing rage directed towards me or any other patient who might be waiting to see me, or if I was literally one minute late. In this state, she would be delusional and paranoid. I was setting her up, deliberately making her think she was important only to take pleasure in her humiliation. She called these her “rants,” which initially lasted days and were associated with severe suicidal ideation.
There was no looseness of thought process during these times, rather more like rigid delusional ideas. These could usually be dealt with by empathically talking her down in the following sessions, wondering with her about her amnesia for her good feelings towards me, how could I remember her last session and her history if I had truly forgotten her. She would insist that she knew I no longer had memory of her when I looked at the next patient. In these moments, I often felt a chilling sense of not being seen, becoming a thing in her mind while she raged at me. I tried a number of parameters. I shifted her to the last pt. of the day and scheduling a 5 minute buffer before her instead of my usual back to back schedule. Inevitably, a pt. might be in the restroom or talking on a cell phone outside the office and set off a rage, however they became less frequent, and over a long time less intense. The pt. experienced these as ego-dystonic and felt increasing frustration at the uncontrollable nature of them. I got a good bit of interpretive traction by connecting the intruders to the experience of her mentally disabled sister. The sister was 2 ½ years older, with the family focused exclusively on her needs. L described constantly being intruded upon by her sister. L’s clothes, mail, were all things the sister felt free to take with no limits being set. L’s considerable athletic and academic talents were never acknowledged. In contrast, she was always admonished to not make her sister feel badly by comparison, whenever she had success. The father was very involved with the sister who was very attached to him. Several parameters and the repeated interpretations as other patients’ intrusion into her space turned them into her sister were eventually helpful, but only after the explosion had begun to subside. Indeed many of my colleagues would see this as becoming intensive psychotherapy rather than analysis. My focus was on what was helpful and worked.
Over time, she was increasingly successful at work and beginning to form a social network for the first time as she began playing an instrument in a local orchestra. She became a full professor, a licensed instrument rated pilot, and scuba instructor. Then while driving with a new friend M, they passed an attractive man in another car. L was astonished that her friend could describe his face in such detail when she had none. We had previously explored how differently our minds worked, in that I filed stories with faces and she did not. This time, she searched the internet, and discovered a trove of information about facial blindness. This information led her to take the Cambridge facial recognition test online scoring in the 40’s consistent with prosopagnosia. Suddenly our psychodynamic formulations had to be sharply altered to include this new information. I struggled to catch up with the new findings myself. In one session, I brought in a mirror from the waiting room. She was unable to see the mirror image as herself. “It’s like someone looking at me through a mirror,” she said. She experienced great discomfort in moving her arms and seeing them in the wrong place. This was amplified when I stood behind her so we were both visible. “I can’t see you and me at the same time. It’s too uncomfortable, if I concentrate hard, I can see us both but it’s too tiring to keep up very long. It’s like straining to focus on a difficult abstraction in math.
Let me describe some recent session material:
She comes into the session sits down, and begins to tell me of her dinner with M. her new friend. She describes the evening by describing the sequence of events, the positioning of M’s hand bag, How she ordered straight vodka on the rocks, not being familiar with M’s drink selection. A description of the meal ensued interrupted only by my teasing her about ordering her filet well done. I threatened in jest to have her leave my office because beef should be at least pink. The ensuing banter reveals her real issue is with blood, which she associates with animal skin, dirt and feces like the renderings on the farm growing up. She assured me she was vigilant about overcooking and drying out good beef. We both reminisced about the bland diet of her childhood. Specifically she recalled the boiled beef tongue and white rice with the only seasoning available, being ketchup. “ I appreciate how my world has changed,” she says. I point out that while she has described in detail the sequence of events, there are no details about M’s facial expressions or how she looked etc. “ It’s the facial thing again,” she says, “it’s the sequence that holds it all together. I did notice an uneasy feeling when we left, a queasy unsettled feeling.” You had a pleasant evening with a friend you say, did you feel sad after the connection ended I ask? “I’m not sure I know what that feels like she says, like when you leave I feel anxious or angry so I know I act as if I miss you or at least the way other people do when they say they are missing someone.”
“There is something different now, that feeling I had with M. In the past I would have said it was sadness because you or someone else called it that. I would observe the behavior and use the words trying to be like everyone else and not so different. This is different, it’s hard to explain, it’s more coming from inside me. I can disagree with you now not because of logic but because it comes from a sensation in me. You’ve really created a problem here for us because you have given me language, I am aware of something coming from inside of me now that I am trying to describe with my own words. It’s complicated I know, but it is something I’ve never been able to do before.”
The next session begins, “last night I had a dream about you, but I don’t know if I can talk about it.” This is a great rarity and there is a hint of a blush. I figure there is something erotic about it, so using the light bantering style we have evolved over the years I say “Was it good for me too?” She laughs the tension gone, and says, ”Actually we kissed on the lips. I wouldn’t let it go any further even in my dreams. What was different was I felt a tenderness and vulnerability nothing like I’ve ever experienced with a man. Maybe I had glimpses of the wish with D(a colleague she briefly dated but he moved away), never with my father. It was a mutual thing like you’ve talked about, something I could never imagine.”. “Yes she says, something has changed, but now I’m afraid of how vulnerable I feel. I’m afraid a rant is coming!” she says. I say,“ I’ll tread lightly for a bit.”
I am wrestling with how to understand how facial blindness affects the way she experiences herself as a self that is like or different from me. How does one feel attached in the full sense of the world without being able to put a face upon it. When I ask her she responds that it is all context. I say “I’ve teased you about whether you would miss me in the past around vacations and separations. You always say no but then act as if that were the case. I’ve never been clear if it was too shameful to admit or that you were unaware.”
She responds, “What I miss is the context, this place, the sound of your voice, the colors, the lighting. This is the you I miss, not a face. Your face fades in a day or so. That’s why context is so important. I expect certain people to be in certain contexts based on probability, I can remember their names that way, but not by a face. I say how hard it is for me to conceptualize that, for me faces are like a folder on a computer desktop, with all the narrative story and memories contained. ”
She brightens, “ I can see that, like a folder with a name for a group of things, I can visualize a folder on my Mac desktop like that. I can see that as a cognitive abstraction, but not at a feeling level.”
“When I was a junior in high school, I started smoking pot and missing a lot of classes. I was about to be suspended but I was referred to counseling instead. My Dad was president of the school board, probably because of his involvement with my sister. He never said anything to me, but I suspect I didn’t get suspended because they were afraid to, rather than anything he said or did. I don’t think he cared that much. I saw this social worker with a beard at the counseling center. He was the first man or person I felt was listening to me. I’m embarrassed to tell you this, it sounds crazy I know, but I started feeling like he was watching me all the time, like he had a periscope or something. I would drive by his house and think he could see me. ” I have fleeting concern these might have been ideas of reference, but instead I say “Perhaps it’s like when you look in the mirror and it feels like someone else.” She says, “Yeah being seen or listened to I can’t feel me and them at the same time. Like I have to look away here so one of us doesn’t disappear. It felt good and scary that he was always there. Anyway I decided if I was going to college I needed to buckle down. My grades had stayed pretty good but I didn’t miss any more class.” I say, “Since you can’t remember my face I must just be another beard in your life like him!” We both laugh.
Another session: We are discussing the Sachs and Chuck Close podcast. www.radiolab.org/story/91967-strangers-in-the-mirror/). She says “Close is the artist describing working with small individual detail working up to the whole which makes a portrait even though he has facial blindness. That really spoke to me, I can remember the photograph of my mother I carry in my wallet even though I can’t remember her face. Same with my dad, I can remember the 2 dimensional representation in a photo but not the 3 dimensional face, which is never quite the same as you look at it.”
A later session: She encounters a tardy previous pt. female, well dressed leaving my office. There is the usual explosive reaction. She sits in another chair, no eye contact. The familiar fixed litany follows, how she feels set up, can’t compete, she is always on time, why do they feel entitled to stay, obviously I prefer her. Feels I deliberately set her up, thought she could trust me then I do this!. I make sister interpretations. Eventually she takes chair feeling disgusted with herself. “I guess I still can’t control my feelings.” I explore whether she can recall any feelings of connection with me. Says she doesn’t give a flip, and can’t remember any. I wonder if same thing happened with dad, turning her rage against the part of herself that wants any connection. I prompt her with the recent kissing dream session. She describes a sensation like feeling a glass partition between herself, myself, and others. She can’t bear attachment because of this reaction. I say for me it’s like watching an Iraq war vet throwing self on floor every time a car backfires in street outside. I say I feel it is important to talk about this because this reaction is in part why she has no long-term relationships. I wonder if this wouldn’t happen with anyone that she cares deeply about who has other relationships. This seems more about envy of my having a perceived connection with, or attachment to, someone that she feels too defective to be able to experience herself. We both feel there is something unique about her rage reaction that has to do with her facial blindness more than just the developmental psychological trauma. It is as if there is something organic that we cannot yet discern with certainty. We both continue to struggle to understand this.
It is an ongoing challenge for me to try to understand someone whose mind operates in such a very different way. I feel the following observations are specific to L’s DP and not environmental. 1) L. can’t recognize her mirror image. She conceptualizes it as another person looking through the mirror at her. It is confusing to see moving her right arm is reflected on the left in the mirror. 2) She has almost no memories of looking in the mirror seeing herself as a whole just parts hair, arms even as a child. (3 She has great difficulty in maintaining eye contact with me. “I can’t see you and feel myself at the same time”. (4 She has always experienced herself as an observer. All she learned about people is by observation and imitation until her analysis. (5 Even in her dreams about the encounters with me and a previous patient, she is in my place looking at the other, no third party perspective. (6 As she says, context is everything. Her description of only being able to remember her mother’s photograph of her face does not include her ability to remember the activities, smells and the sound of her mother’s voice in her daily activities. She remembers people by context, color of hair, the way they walk, what they are wearing and where she sees them.
I found the following parameters to be useful with this pt. It was important to be active and interactive. Frequently describing what is going on in my mind in the moment. Displaying curiosity about the differentness in the way our minds work. My pt. was fascinated by my description of people’s stories or narratives, I store away under faces. “ You mean faces for you are like file folders on a Mac desktop?” My relative openness to describing my experience in the moment forced her to confront her fantasies and preconceptions about men. This was interconnected with her own developing curiosity about her own emotions leading to the dramatic development of increased mentalization. “I now have a language for myself words not just feelings.” This has led to a more stable sense of self, even if evolving in a different context.
L. has been able to use analysis successfully. From beginning as a severely disturbed young woman, she has achieved a lot. She is a successful professional, a full professor at a major university. She is an instrument rated pilot with her own plane and a scuba instructor. She plays a musical instrument in a prestigious local organization. She has developed an increasing circle of friends. Internally she has developed a remarkable capacity for mentalization and self-reflection. Her episodes of depression and suicidality have essentially disappeared. She is able to modulate and manage her emotional life in a dramatically better way. She has achieved a more stable self-representation and in her unique way, object constancy with me. In concluding I wish to encourage anyone working with patients exhibiting an apparent object instability, transient episodes of dissociation, together with social isolation and intimacy problems, to rule out unrecognized facial blindness or DP and adjust technique accordingly if present. I hope describing my experience may be useful to others.
1. Developmental prosopagnosia: A review Thomas Kress and Irene Daum∗ Behavioural Neurology 14 (2003) 109–121 1092.
2. Kennerknecht, I., Yee-Ho, N., & Wong, V. C. N. (2008). Prevalence of hereditary prosopagnosia (HPA) in Hong Kong Chinese population. American Journal of Medical Genetics Part A, 146A, 2863–2870. doi: 10.1002/ajmg.a.32552
3. A Neurologist’s Notebook AUGUST 30, 2010 ISSUE New Yorker Magazine Face-Blind Why are some of us terrible at recognizing faces?
4 “A room full of strangers every day”: The psychosocial impact of developmental prosopagnosia on children and their familiesKirsten A. Dalrymple 1, , Kimberley Fletcher1, Sherryse Corrow, Roshan das Nair, Jason J.S. Barton, Albert Yonas, Brad DuchaineThe Journal of Psychosomatic Research ,August 2014 Volume 77, Issue 2, Pages 144–150
5. The definition and diagnosis of developmental prosopagnosiaThe Quarterly Journal of Experimental PsychologySarah Bate & Jeremy J. TreePage 1-8 | Received 19 May 2016, Accepted 20 May 2016, Accepted author version posted online: 02 Jun 2016, Published online: 20 Jun 2016
6. Childhood Adversity Is Associated with Adult Theory of Mind and Social Affiliation, but Not Face ProcessingLaura Germine1,2,3,4*, Erin C. Dunn1,2,3, Katie A. McLaughlin5, Jordan W PLOS ONE | DOI:10.1371/journal.pone.0129612 June 12, 2015
7. “You Don’t Look Like Anyone I Know: A True Story of Family, Face Blindness, and Forgiveness” Riverhead Books; First Edition edition (October 14, 2010).