The Body Speaks : Body Image Delusions and Hypochondria 9781782413257, 9781782201694

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THE BODY SPEAKS

THE BODY SPEAKS Body Image Delusions and Hypochondria

David Rosenfeld Translated by Susan Rogers and Sylvine G. Campbell Foreword by Maria Rhode

First published in 2014 by Karnac Books Ltd 118 Finchley Road London NW3 5HT Copyright © 2014 by David Rosenfeld The right of David Rosenfeld to be identified as the author of this work has been asserted in accordance with §§ 77 and 78 of the Copyright Design and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. British Library Cataloguing in Publication Data A C.I.P. for this book is available from the British Library ISBN-13: 978-1-78220-169-4 Typeset by V Publishing Solutions Pvt Ltd., Chennai, India Printed in Great Britain www.karnacbooks.com

Ezequiel and Tamara, my grandchildren and Maria Rhode, Maître à Penseur, the person who helps me to think about psychoanalysis

CONTENTS

ABOUT THE AUTHOR

ix

FOREWORD Maria Rhode

xi

INTRODUCTION

xiii

CHAPTER ONE Body image models and theories

1

CHAPTER TWO Pierre

5

CHAPTER THREE Philippe and countertransference

9

CHAPTER FOUR Katherine: body image transformations

45

CHAPTER FIVE The boy who said that bats were flying out of his cheeks

59

vii

viii

CONTENTS

CHAPTER SIX Inés: bleeding lips and tongue when separation occurs

63

CHAPTER SEVEN Somatic delusion: Hugo and Pablo

69

CHAPTER EIGHT Luis: half of his body and brain are missing—in collaboration with Teresita Milán

79

REFERENCES

85

INDEX

89

ABOUT THE AUTHOR

David Rosenfeld was trained in Buenos Aires, Argentina. He has lived and studied in Paris and London, and also in the United States. He is a consultant professor at Buenos Aires University, Faculty of Medicine in the Department of Mental Health and Psychiatry, a training analyst of the Buenos Aires Psychoanalytic Society, and an ex-vice president of the International Psychoanalytic Association (IPA). His professional accolades include the President Jefferson Award from Virginia University for exceptional achievements in the field of psychoanalysis (1993), the Mary S. Sigourney Award for outstanding contribution to psychoanalysis (1996), and the Hayman Prize awarded to the best paper at the Berlin International Psychoanalytical Congress (2007).

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FOREWORD

Maria Rhode

It is an honour to introduce David Rosenfeld’s book, The Body Speaks. Rosenfeld is one of the handful of psychoanalysts who have successfully treated both children with autism and psychotic adults. His books and papers illustrate his understanding of mental processes that can seem puzzling and bizarre, and his courage and endurance when faced with these. Most of all, perhaps, they illustrate the humanity that is expressed in his rapport with patients for whom living in the world of shared reality is so difficult. He speaks to them simply and straightforwardly, and in a way that links their idiosyncratic preoccupations to the concerns of every human being. The case histories in this book are about patients who expressed themselves through the language of the body. As Rosenfeld writes in his Introduction, he focuses on experiences in very early childhood that they had not been able to encompass. Philippe, the subject of the longest chapter, was a young man with a somatic delusion concerning damage to his skin, who threatened to avenge himself on his dermatologist by killing her and her family. Rosenfeld’s systematic monitoring of his countertransference response throughout an analysis punctuated by the patient’s violence and hospitalisations at length led him to conceptualise Philippe’s delusions in terms xi

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FOREWORD

of a psychotic episode in childhood: of nightmares from which one part of him had never woken up. This original conclusion is one of many theoretical contributions. Running through all the clinical accounts is Rosenfeld’s model of the primitive psychotic body image. At this level, the body is felt to consist only of blood-related fluid, sometimes contained within the fragile walls of arteries and veins. Thinking in terms of this model allows Rosenfeld to chart the progress of patients in analysis, who increasingly experience their body as solid rather than as liquid. It also provides a link between his adult patients with somatic delusions, hypochondria, or psychosomatic symptoms on the one hand, and children with autism on the other. These children, as Frances Tustin has described, experience separation as a tearing away in which they lose part of their own mouth; Ines, a woman whose treatment Rosenfeld supervised, actually bled from her mouth during her therapist’s holidays. This book deals with fundamental experiences involved in establishing a sense of self. It will be essential reading for clinicians working with serious disturbance and bodily symptoms, but also for anyone concerned with human development.

INTRODUCTION

In this book I show the work of a psychoanalyst with severely disturbed patients. My intention is to show what it means to work and think as a psychoanalyst about transference and the internal world of a psychotic patient (example, Philippe), with all the difficulties involved in continuing to be a psychoanalyst even with such severely ill patients. To be a psychoanalyst is to think about transference, the patient’s internal world, and projective identifications onto the therapist and onto persons in the external world. And if we sometimes get an interpretation right and we understand the patient, so much the better. I write in particular about patients who express their mental state through fantasies about their body image. For example, the fantasy of an emptying of the self is discussed in the patient Pierre, when he asserts that he has no more blood or liquids in his body. Also, the fantasies of the young man who says that bats are flying out of his cheeks express his first months of life through his body. And the patient Inés who, with every separation from her analyst, expresses with her body that when the nipple withdraws, it rips off part of her lips and tongue, so that she starts to bleed. xiii

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INTRODUCTION

For the treatment of severely disturbed patients, it is useful and also indispensable to supervise these clinical cases. Psychoanalysts are only human beings who receive powerful projections on a psychotic level from these patients. What I specially search within are the first months and years in the life of these patients. We can only write papers about countertransference once we have been able to put into words and decode what the patients have inoculated with these projections. If not, the psychoanalyst becomes ensnared in powerful projections and is then unable to decode what the patients oblige us to “feel” happened to them at a time when they had no language to express it in words. I was able to write this book because I had the good fortune to have in my life the great teachers of psychoanalysis, when I was living and studying in Paris, when I supervised in London for sixteen years, and also when I was studying with the great teachers of psychoanalysis in the United States. I also emphasise how important it is in an analyst’s personal life to always have the closeness of the family, who provide emotional containment. For this reason I wish to thank my family: Estela, Karin, Debora, Daniel, Rolando, Eugenia, and my translator, Susan Rogers, and Aracelli Luis always helping with corrections and editing of this book. David Rosenfeld

CHAPTER ONE

Body image models and theories

I

n psychoanalytic practice one may sometimes find examples like those I present, and that is why the primitive psychotic body image is a useful explanatory model for a variety of clinical cases. There may be different explanatory models, but for the time being I find the primitive psychotic body scheme the most useful and comprehensive, in so far as it is perfectly suited to many of the clinical phenomena I observe. It helps me to incorporate into a single model developmental genetic and transference concepts, both with schizophrenic and with psychosomatic patients. When we construct a model, we find it useful first for one particular patient but then often for other patients as well. To this we might add, provided it is consistent, a developmental genetic theory of infantile bonds that must be empirically demonstrated in the transference with the psychoanalyst. The primitive psychotic body image is a non-observable entity, but when we construct the model it becomes powerful from the explanatory point of view. This does not mean that the model represents the ultimate truth, as is the case with theology, but only that is a useful model for the time being. Atomic physicists see the effects of atoms, not the atoms themselves; in the case of psychoanalysis and the primitive 1

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psychotic body image, we can observe the effects of the model on various types of patients. Science is the capacity to discover facts beyond observation (for example, atomic theory). The power of science (Klimovsky, 1980) lies in the theoretical models of what is beyond observation, and how those models may be observed in the empirical basis. And of the atom, I say that it is something that cannot be observed directly and about which we know a number of things through indirect inference. These are models of non-observable entities but of great explanatory power as regards what is being observed. The specific explanation of what happens in each case is legitimate and undeniable: each phenomenon seeks its explanation.

Body image definition The concept of the primitive psychotic body image is a theoretical one, based on clinical work with psychotic patients going through acute crises. By primitive psychotic body image I mean the most primitive notion of the body image to be observed in certain patients with whom work begins while they are already regressed or who regress during their treatment. In my view, the extreme notion of what can be conceived of as primitive psychotic body image is the thought that the body contains only liquid, or vital liquid, one or another derivative of blood, and sometimes it is coated by an arterial or venous wall or walls (not always). There is only a vague notion of a wall that contains blood or vital liquids. In turn, as can be seen mainly in crises associated with acute psychosis, this membrane containing the blood may be perceived to have broken or to have been otherwise damaged and to result in a loss of bodily contents, leaving the body empty, without either internal or external containment and/or support (Rosenfeld, D., 2006a).

B O DY I M AG E M O D E L S A N D T H E O R I E S

3

I always work in the transference researching patients’ object relations in the internal world, especially in the first years of life. These are the clinical cases I will present in this book: • Pierre, who believes he has no blood. • Katherine, who has suffered a traumatic event, a car accident, which has changed her fantasy about her body image. • Philippe, who experiences a psychotic hypochondriac delusion. • The young man who said that bats are flying out of his cheeks.

CHAPTER TWO

Pierre

T

he following fragments of clinical material pertain to Pierre, at a time three years earlier. In it, we are able to observe the way in which I intervene and interpret the transference in a post-operatory psychosis rooted mainly in fantasies about the primitive psychotic body image. It is worth pointing out that the tumour for which he was operated turned out to be encapsulated and benign—a glioma—and it was entirely removed. It is my intention to show the analyst’s role in the transference, and also to highlight a rich and clear material on the fantasies that the patient Pierre reveals to us regarding the image and fantasies about his body, especially those referring to his body fluids to which we refer as the primitive body scheme or psychotic body image. The first unexpected incident, which startled neurologists, surgeons, and me, was a post-surgical psychotic episode—a delirium in which the patient affirmed with conviction that liquids were being extracted from his body. These included the encephalic/spinal fluid, blood, semen, and urine as vital fluids. The third night after the operation, Pierre sought to verify that he had not been completely drained of liquids; for this 5

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purpose, he had sexual intercourse with his girlfriend, who was with him at the time. His intention, according to his own words, was “to see if any liquid came out …” One can imagine the expression on the faces of doctors and nurses when the patient, with the bandage on his head awry, said what he had done. An example of his primitive psychotic body image during his delusional episode after the removal of the (benign) brain tumour is shown in this fragment. pierre:

therapist:

I’m afraid of having leukemia … I have begun to despair … to worry because of the destruction of the red cells by the tumour. As if I were afraid of becoming empty … emptied of blood … as if I were soft all over … Soft?

(What a coincidence with Freud’s description of the Schreber case. He said: “… that he had softening of the brain …” (Freud, 1911c)). pierre: Yes, everything soft … like a sack full of blood … I’m afraid of having a haemorrhage, and that everything … will come out … The accuracy with which he expressed his fantasies concerning his body image is remarkable. The conception of the body as a sack full of vital fluids or blood (primitive psychotic body image) is clearly formulated here by the patient on a verbal level. I will now reproduce parts of the material corresponding to the first weeks after the operation. These fragments underscore fantasies regarding Pierre’s bodily image or body scheme and show the way in which I intervene in connection with the delusional or psychotic transference.

PIERRE

pierre:

7

(in muddled language and stuttering) … yes … I’m afraid to urinate, I’m afraid to bleed … to have blood come out, you know? … that when urinating blood might rush out and I could bleed to death … I’m afraid that the tumour is lodged in the bladder, prostate gland, testicles … I think I have bone marrow metastases.

In this material it becomes increasingly clear that the patient is convinced of the following: first, that the tumour was not removed; second, that he has malign metastases; third, that he is his father with myeloma; fourth, he had no fluids. I began here to intervene in the transference. I must make clear that the transference with me increased every time that encephalic/spinal fluid was extracted from him for studies. I became someone who hurt him or took his vital fluids (Rosenfeld, D., 2006a).

CHAPTER THREE

Philippe and countertransference

D

efinition: hypochondria, traditionally described as a constant preoccupation with one’s own health, with self observation of organs that are thought to be diseased, may be regarded as varyingly severe, ranging from chronic hypochondria, which is closer to psychosis, to transient hypochondriac states. This also includes neurotic, confusional, and psychotic elements. Body image is a fantasy about the body. It is not the real organic body. Hypochondria also has a defensive function at the onset of paranoid and psychotic pictures. For Melanie Klein (1957), hypochondria is more the fear relating to persecution within body attacks by internalised persecuting objects. For Herbert Rosenfeld more important are the confusional anxieties projected into the body. Confusional anxieties appear to be caused by a failure of the normal splitting or differentiation between good and bad objects and also in the self. In hypochondria and the psychosomatic diseases, the confusional anxieties are split off into the body, a process which

9

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probably starts in early infancy. These confusional anxieties are projected into external objects and reintrojected into the body (Rosenfeld, H., 1965, 1987).

First interview A family asked to come for an interview with their son, who at that time was twenty years old and had a severe clinical picture of violence and hypochondria localised in his face. He broke objects and furniture in his home and threatened that he wanted to kill the female doctor who had treated him for facial acne. The patient said that this doctor is ignorant, that she applied acid to him and that she ruined his face. The father, the mother, and the patient came to my office and we had a first interview that lasted ninety minutes. The patient, six feet four, was in the midst of a psychotic crisis organised delusionally. He said that the badly cured pimples on his face have left scars. The patient, Philippe, explained that since this scarring will never go away, in revenge, he was going to kill the doctor and her son. He told me all this in shouts that resounded in my office in a very violent way. He stood near me and I was afraid he would hit me. When I told him that we would find out what scar it is that he has in his mind, besides on his face, the patient became even more violent. He continued with his unshakable delusion that the scarring will never go away because he reads medical studies from universities all over the world on the internet which say that this is incurable. I tried to tell him that perhaps what bothered him more than the scar on his face was the scar that existed in his mind. I told him that a young man was not going to commit suicide because of a pimple or a scar on his face. It must be a scar on his soul or in his head; it is hate because they didn’t take care of him, they didn’t give him the right remedy, or because his family didn’t accompany him to the skin doctor, since they let

PHILIPPE AND COUNTERTRANSFERENCE

11

him choose the specialist on his own. But Philippe insisted and repeated the same threat. While I was interviewing him, I was thinking about the most important works on hypochondria and body image that I had studied, especially those by Herbert Rosenfeld (1965), Clifford Scott (1980), and in Schreber’s case (Freud, 1911c). And I quote how Schreber is said to use the same words as Philippe: “He asserted that his body was being handled in all kind of revolting ways …” The patient repeated exactly the same sentence over and over again: that they didn’t take good care of him, that they treated him badly, and that he was going to kill the skin doctor and her son. I thought that this was a hypochondria that was becoming a systematised somatic delusion (Rosenfeld, D., 1992). My definition of a somatic delusion is when it includes external persons and relations. For example, becoming isolated (see patient Paul) or like Philippe, who says that since he has a scar on his face, nobody is going to love him and that the treatment he is undergoing is not going to work; also when he avoids contact with other people. My countertransference concern deepened in the course of the interviews, as I began to perceive the rigidity of the hypochondriac delusion. At the end of the interview, I asked him if he would accept hospitalisation for a few days so that he could be taken care of and medicated. To my astonishment, the patient agreed. The next morning, his mother phoned me to say that Philippe had kicked the furniture and broken objects at home in spite of being medicated, and had said he was going to commit suicide. I ordered her to hospitalise him immediately. He was hospitalised for two weeks during which doses of antipsychotic medications were increased. I remembered at this very moment Freud’s paper and what a coincidence there was with the Schreber case. Freud

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wrote: “He expressed more hypochondriacal ideas … On the other hand, they tortured him to such a degree that he longed for death …” (1911c).

After hospitalisation Usually, when patients are released from hospital I ask them to tell me and even to write down their experiences there, what patients they talked to, what they did, and how they felt. I asked Philippe for details of how he felt during his hospitalisation, how he experienced those days, how he got along with the medication they were giving him, etc. He explained that at first he felt well but that after two days he began to get frightened because there was a severely ill addict, another schizophrenic, and a girl who had had a car accident with brain damage. When I see a psychotic patient following psychiatric hospitalisation, I usually prescribe two sessions per day, as I did in the treatment of the patient Abelard, or one session per day, seven days per week, as I did with the drug addict patient, George, described in my book (Rosenfeld, D., 2006a). However, it was not possible with this family. This was the first time, after the hospitalisation, that Philippe did not shout or threaten to hit me, but the day before he had broken objects at home. I told him that every time he left the session he became violent because he wants to hit me, because I tell him things that he cannot stop thinking about. He calmed down and then spent the rest of the hour listening. I tried not to interpret too much until he was able to listen. I told him that hormones, at the age of twenty, often provoke pimples in boys. philippe:

No, what I’ve got is a scar.

Then he said that he looks at himself in the mirror for several hours a day. And if he goes for a swim, he looks at himself in

PHILIPPE AND COUNTERTRANSFERENCE

13

the mirror in the gym. The only time he doesn’t look at his face is when he is playing soccer. I asked him if he recognises himself in the mirror or if he believes that it’s someone else that he sees reflected there. He answered that he knows that it’s himself and that he recognises himself. During Philippe’s treatment, I often worried about the possibility described by authors such as Avenburg (1998), who emphasised that “Hypochondria covers a wide range of different situations … but it also appears at the start of schizophrenic clinical pictures … and preoccupation with the classical sign of the mirror …” When the patient looked at himself in the mirror, I remembered the teachings of Henri Wallon in Paris (Wallon & Lurc¸at, 1962), who created the theory of the mirror. According to his theory, the reflection of the image in the mirror is what helps the construction and reconstruction of the body’s image. His works on the creation of the body’s image through the mirror were the basis of many other theories linked to the reflection of an image in the mirror, especially in France and in London (Bick, 1968). I told him to try to remember his dreams, that I was interested in listening to them. The only dream that he told is one in which he wanted to be the owner of the hotdog stand near his home. In the dream he was the owner and there were very long, very big hotdogs. I asked him if they were wieners or were his long penis, which he believed was deformed, like the scars on his face that he believed deforms his face. therapist:

Do you believe that you have a face like the long hotdog, or a face with pimples and scars and nobody loves you?

He got up and I was afraid he would hit me. The week before, he had punched the door when he left, breaking the lock of my office and I had to run after him down the stairs and catch hold of him.

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When he arrived home, he went out to the balcony to throw himself off and we decided to hospitalise him again. This time, with the psychiatrist who always works with me, we decided he should go home with an increase in medication, because the patient had threatened that if we admitted him again, as soon as he left, he was going to throw himself off the roof of the building. We offered to send a psychologist to accompany him, but his mother said she didn’t have money for that. It was very hard for me to persuade the mother to allow me one or two weeks for treatment. I asked her to give me this time, but she insisted on hospitalising him because he broke objects in the house (Rosenfeld, D., 2002). In another session I tried to find out whether the famous scar had any relation to the birth of his sister when he was four years old. t: It seems to me that you’re very jealous of your sister, Betty, because she has the best grades in her class, she doesn’t have pimples on her face, and she took away the exclusive attention of your parents. Maybe that’s the scar you have, in your mind. Philippe insisted that his sister’s birth didn’t affect him much. However, his papa, when he came to an interview with the patient, confirmed that he had had many years of severe insomnia after the birth of his sister, until he was seven. The patient answered, p:

t:

p:

I was afraid that monsters under my bed would pursue me, and I looked for them and wanted to kill them. That lasted until I was seven. Tell me, Philippe, do you believe that I’m a moster or a bad doctor that can hurt you like that skin doctor? Do you think that’s the only problem? Tell me, Rosenfeld, asshole, stupid asshole … It’s with the doctor and the

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sister, do you think that jealousy of my sister is the only problem? Long silence. Then he laughed, instead of shouting at me, and I was still afraid he’d hit me. I told him to tell me his dreams. He answered that he doesn’t remember, he erases them, that he doesn’t sleep well. I asked him what memories he has of his first years of life and he answered that they’re only about some outings in the pushchair or on his tricycle with his grandmother. Then I asked if he authorised me to call her in for an interview, and his mother answered that her mother was a depressive hypochondriac. The subliminal message was that I shouldn’t call her. I asked the grandmother to come in for an interview anyway, since she is the only infantile memory the patient had told me about. The grandmother turned out to be very nice and pleasant, and was not the complaining hypochondriac the mother had described. She was a cheerful and enthusiastic woman who loved her favourite grandchild. She told me that they had sent him to daycare when he was still in nappies, even though she could have taken care of him. She said that his mother was jealous of her. The grandmother told me not only about the mother’s jealousy of the close and tender relationship between Philippe and his grandmother, but also about how she used to make up songs for outings and others to help him fall asleep as she rocked him. Then, she started to sing, grandmother:

Philippe … Philippe … my little boy … we’re going to play …

As she sang, she got up and showed how she used to take the patient’s hands and how they danced around in a circle. I never saw Philippe with such a big smile, his eyes moist with emotion. I asked what she sang to help him fall asleep.

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grandmother: I used to invent words to go with the melody of the French song that says, “Frere Jacques, dormez–vous … sonnez les matines …” I would sing, “Philippe, dormez–vous …” The patient, both hands in his grandmother’s, was smiling, moved, with tears in his eyes. At that moment, I thought that Philippe had, hidden in a corner of his mind, very healthy aspects of his infancy and that we had to rescue these healthy relationships that must be encapsulated. I thought of Freud’s famous sentence: “Even in a state so far removed from reality as hallucinatory confusion … that at one time in some corner of their mind there was a normal person hidden” (1940a). During the treatment and the interviews with the parents, another part of the personality of this grandmother, on the mother’s side, was discovered: a personality only shown at home. It was a severe case of hypochondria, which made her go to the doctor every week due to depressive states. Nevertheless, in the session at my office, she revealed herself as an active and very agreeable grandmother showing another part of her personality which is not habitual when she is at home. The grandmother had stated that they had sent Philippe, as a little boy still in nappies, to kindergarten; and the parents, on the other hand, told me he went to nursery school, on the same street as their home, while they were building two extra bedrooms in their home, and only for a few weeks. As for the medication, they gave him doses five times higher than before. That did not stop the violence and lack of selfcontrol.

Dreams: hate and sexuality—the setting is created The patient insisted that he doesn’t have dreams. I asked him if it might be because of the pills and if he sleeps for many hours.

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17

t: What about nightmares? p: I think so, I had a dream. Somebody was killing my dad and mama. t: Well, we can finally see that you want to kill them because they caused the terrible scar when you stopped being the favourite of the house. In another session, he told me about the sex programmes he watches on the internet and I said, t:

You may possibly get hot sexually and instead of masturbating and having sex … when you’re sexually excited and can’t have a discharge … you’re inhibited by the great sexual repression there is in your family and also the religiousness of your family … you go around breaking things. You discharge violence because of contained sexuality.

Only then did he tell me that he had sexual relations twice with a girl from the church club a year ago. At another moment, we talked about his childhood nightmares and he commented on what his father told him. I said to him, t:

At five, six, seven, you were looking for monsters under the bed to kill them because they stole everything you had. You were right; they stole you being the favourite of the house with the birth of your sister.

The patient said, no, that the only problem is the skin doctor and the scar. I tried to say something about the transference, Tell me Philippe, maybe when you break things at home it’s because you’re mad at me or you think I’m a monster that can damage your little head? p: You’re an asshole, Rosenfeld, you think everything is about you. No. It’s only that doctor, asshole! t:

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(His mama, when she came with the patient once, told me that she had also had night terrors and looked for orang-utans under the bed. I asked why hadn’t she told her son about this before.)

Laser treatment of the skin In another session he spoke about the scar and accepted laser treatment on his cheek. He seemed to be calmer and more serene with the psychiatric medication. It had been important to hear that his dad in an interview said that he had been a young man with sexual repressions just like him, because of the religious education at his parochial school. In the following sessions the rigidity of the delusion returned. For months, the patient mechanically repeated the same thing every time I asked him what he had thought about after the previous session. He untiringly repeated that he had just read on the computer about treatments for scars and that his skin problem had no cure. I again asked him what he did besides that, what he had thought about, how he felt, and he answered that he only thought about what he read on the internet, that the scar was never going to be cured, and that he was going to kill the doctor and her son. t: How do you know she has a son? p: I got into the page of the dermatology medical society and took out the data; I hacked the doctor’s Facebook and found out about all the family she has. I’m going to kill her because she didn’t cure me well. t: Maybe you want to kill people that didn’t care for you before you even met that doctor. Mama, dad, the sister that makes you so jealous … p: I’m only interested in knowing that the scar is not curable and that I’m going to commit suicide.

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This went on for weeks and weeks. I’m aware that I can’t communicate in words my countertransference experiences from listening to a patient repeating the same words week after week. All that occurs to me is to quote the poet Jorge Luis Borges (2005): “I now arrive at the center of my tale and my despair as a writer begins. All language is an alphabet of symbols whose exercise presupposes a past shared by the interlocutors. How can I communicate the infinite to others, something my fearful memory barely grasps?” To overcome the rigidity of his answers about the medical reports he read about scars, I tried to get him to tell me in detail about the sexual scenes he viewed online. When I was able to get him to talk about sex, to tell me about other things, who he thought about when he masturbated, etc., I sometimes managed to get him to stop talking about the scar on his face.

Technical use of the countertransference I continued to interpret and the patient always answered the same: “The problem is the scar on my cheek.” t:

You’re a cement wall; it’s like talking to the wall. I talk to you and you reject everything; as if I were running into a cement wall, nothing I say gets through. Maybe that’s the origin of the hate. The hate because they don’t take good enough care of you. Maybe it means that mama doesn’t listen to you. You talk and she doesn’t listen. Look what happened in the interview the other day when your mama came. I was talking to her and she kept on talking as fast as she could, but didn’t listen to me. And you do the same thing to me that your mama does to you. It seems that the theme is not the scar; it’s anger because they didn’t take better care of you, they didn’t listen to you. The anger at them not taking better care of you, you call that a scar.

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This is why it occurred to me, in order to change the rigidity of the theme of the scars, for him to tell me more about the sex videos he watches, and that way I managed to get him away from the rigid theme of talking for an hour about scars and treatments. After the patient shouted he had researched on the internet that scars are never cured, I answered him that data appearing on the internet are not always true, that anyone can falsify medical data. The patient answered shouting that he had found out the truth on the internet, through university papers. As it was the end of the appointment, I proposed that instead of shouting, what did he think if we became friends again and greeted with a kiss, as young people do, here in Buenos Aires and in the south of France? In the session the mother came to, I asked her to always greet Philippe with a kiss on each cheek as they do in the south of France, and that the psychiatrist and I were going to do the same. I never kiss my patients, but in this case, kissing him meant that Philippe is not a monster and doesn’t have a deformed face. The notion of beauty is given by the family and by the other, in this case, me. This occurred to me because in the middle of a session I remembered the saying: “Beauty is in the eye of the beholder.” If I kiss him on the cheek, it means that I consider it something normal and not, as he believes, something disagreeable because of his scar. This fact of kissing him on each cheek produced a great effect in the patient’s mind. That week he started the laser treatment for his scar. p: I don’t believe you, the problem is the scar and that is never cured. t: Well, but you started the treatment. p: The treatment is going to turn out badly, the problem is the scar. t: You’ve got pimples on your face like most adolescents and young people.

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p: No, it’s only a scar that won’t go away. They’ve damaged me, they didn’t take care of me. .

This very rigid dialogue was repeated for weeks. Imagine my countertransference. t: Maybe today a dormant volcano will explode, one that has been building up pressure for the sixteen years since the birth of your sister. p: No, it’s because of the doctor’s scar. I’m going to kill the doctor, and her son I also plan to kill. (Freud, 1909d, 1915a, 1937c; Rosenfeld, D., 1992).

Change of medication The psychiatrist and I thought about hospitalising him again, because he also kicked furniture to pieces at home. We needed to change his medication again. The next night he came in with the effects of Clozapine. He was able to talk for an hour without delusions and repetitions of the same phrase. The new medication was effective although it produced some dizziness. In the following session, for the first time he had a more serene dialogue with me. I explained how women in the post partum are treated so that they make contact with their babies. I asked him, when they breastfeed a baby, where does the baby lie? He answered, on its cheek (the patient touched his cheek with his hand). I suggested that this was the origin of the relationship with his mama, through contact between his mama’s skin and his cheek, and that perhaps this is the key to what happens to him with his cheek now. This was the first time he lay down on the couch. It was the most fantastic proof that he is starting to trust me. For the first time he said that at the end of the year, when he has the last session of the laser treatment on the skin, we’re

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going to see whether he got better or not. He didn’t start with his delusion as he always had, that it was going to turn out badly, that it wasn’t worth it to do it if he was going to commit suicide anyway. His father came to a session and Philippe was lying on the couch with the dad sitting next to me. The dad spoke quietly: he is shy and it was hard for him to talk about his sexuality. I told the patient to realise that his dad had problems talking about sexual relations. Only then did his dad find out that Philippe had had sexual relations. t: Just now you told your dad that you had had sexual relations, but your dad never asked you about it either. In this interview I told the father to go for a walk alone with his son, and he spoke to Philippe in a very affectionate way, telling him how much he loved him. I asked him if he feared feeling shame if they discovered his crazy part might be called “scar” and he said, no.

Childhood history and transference During the treatment, when I showed him aspects of his early infancy (concerning daycare, his sister’s birth, etc.), running away from the transference issues of the day, I knew the psychoanalytic technique was not “politically” correct because I was going far back in his personal history and there was no present time in the transference. However, I could not find the way through the concrete wall, since I always got the same answer for months and months. Added to this was his conviction that he would commit suicide if they did not remove the scar with the new laser technique. I felt fear that this would become a systematised chronic delusion, something that is usually not curable.

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I interpreted that perhaps he was afraid of me as a doctor, afraid I was a monster that could cause him damage and scars in his head. The patient grew angry and screamed insults at me. p:

You’re an asshole. You believe it’s got to do with you and it hasn’t, it’s got to do with that dermatologist.

Words are not enough to explain my great countertransference concern at those moments.

The scar condenses the hate for not having been taken care of better However, a small door opened before me when Philippe’s mother told me that she had confiscated the computer (without discussing this with me or the psychiatrist), because he spent ten hours a day reading on the internet: medical reports of treatments of scars and pimples on the face and also skin treatments with laser. I did not mention this phone call to the patient and waited for him to bring up the subject of the confiscation of the computer. Only after a week had gone by did he tell me about it, and then I told him that for a week he had been hiding his anger and hate for his mother having taken away his computer, which he was just now showing. I interpreted, t: They took away your computer and you didn’t tell them not to take it away from you. Not until the next day, a day later, you were angry and you break the walls, the dishes, and you can’t talk, you can’t put into words what you feel. If they take your computer away, you need to say: I don’t want you to take it away. Instead of keeping it inside for a day and a half and breaking things, which people don’t understand.

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Here I’m showing you how you hide things and explode a week later. You’re like volcanos, dormant for years and they explode sixteen years later. In the same way that you keep the hate hidden because they took away your computer for a week and the volcano explodes full of hate only a week later, you also kept in your mind, for many years, the hate because of all the ways they didn’t take care of you. For example, that nobody went with you to the skin doctor or that you felt abandoned when your sister was born or when they sent you to daycare still in nappies. Even if he were at the nursery school near his home for only two hours, a very sensitive child could live a minute of separation from his family as if it were weeks or months, as Winnicott states (1971): The hate towards the skin doctor gets put together with the hate towards dad and mama, who you wished had taken better care of you. They left you on your own to look for and choose a skin doctor instead of accompanying you and taking care of you.

Only after this intervention of mine did the systematic delusion of wanting to kill the skin doctor stop being so rigid. I thought that with this intervention I was saying he was right about hating the dad and mama who didn’t accompany him in his medical care. The patient asked me, p:

You, doctor, do you let your son choose his doctor by himself?

Although I knew it wasn’t “politically” correct or psychoanalytically correct to make personal confessions, I answered: I would never send any of my children to daycare when they

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were still wearing nappies. I would keep them at home, in their familiar place, with their own rug, their own toys … with their grandmother or our maid. That’s what I did with my children. I wouldn’t let a child of mine go to the doctor alone; either I or my wife goes with them. I thought that I had committed a breech of the setting by telling him something personal, but the effect was that what I said managed to undo the intractable rigidity of his delusion of the scar, and the patient understood that he was quite right to feel so much hate because of not being better cared for. In sum, this idea of his hate was the line I went on interpreting: the hate due to not receiving more care and attention from his parents. The key was the hate for lack of attention and that was the scar on his soul. From then on, Philippe began to listen more and he paid more attention to me when I explained that his hate of the doctor had unleashed his hate at the lack of affective care from his parents. The scar condensed his hate towards those who had not taken good care of him. I put together the hate towards the skin doctor and the hate towards his mama and dad. This hate was condensed, mixed together and projected onto the doctor. Interpreting his threat of suicide, I again tried to make him understand the following: that it was a question of wanting to kill somebody the patient had inside his head (a mixture of the skin doctor and the parents). I repeated, t:

Philippe, it’s inside your mind, this is inside your inner world.

I reiterated that there are volcanoes that are silent for a hundred years until they start erupting, and this is what happened to him after many years. During the following month, hypochondria and the somatic delusion changed from his obsession about the scar on his face to talking about the meniscus bone in his left knee,

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on which he had already had surgery. Now the theme was the knee, which bothered him from playing soccer. Just as the constant and rigid theme had been the scar on his face, it was now the knee, the meniscus, and an injury to his ankle from playing rugby. That is, he kept on talking about hypochondria, but in another part of the body: this time he chose something more realistic and concentrated on the knee instead of his cheek. A short time ago his mother called me to say that they were going to take a vacation trip abroad. Both the psychiatrist, Dr V., who medicates him, and I were definitely against the patient travelling. We said that the treatment could not be interrupted, that only a few weeks earlier the patient had said that if the laser treatment hadn’t cured him by the end of the year he would commit suicide. His mother, astonished, said she didn’t know that. I answered that of course she didn’t, that these were things that he told his therapist, but that this was very serious and that he couldn’t break off the treatment.

Sex through the internet In these last few weeks, the constant theme of the delusion changed; he told me in detail about a channel that continually shows sexual relations. He went back to the theme of hypochondria and somatic delusion, saying that since he has a scar no girl was going to get close to him. t:

Do you think you’re the Phantom of the Opera, who covers his injured face? You’re not the Phantom of the Opera.

The use of the computer was not, now, just to see reports and injuries of the skin; he also used it to enter the sex site. He was also playing soccer and went to two parties with classmates of both sexes, where this time he was able to talk to them. At

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parties before this one, he would look at the floor and couldn’t look at his female classmates in the face. t:

You’ve started to be less afraid of women. You can start to look at their body, look at their face.

That week I asked him what would happen if the laser treatment of the skin didn’t work. This time his answer was diffuse, but as a therapist I was still worried and sometimes agonised day and night that there might be a psychotic explosion with suicidal fantasies again (Rosenfeld, D., 2011, 2013). It is a great countertransference and technical challenge to accept such seriously ill patients. I also thought so when I was seeing autistic children at the children’s hospital and some in my own office. In some moments of the treatment I thought of Philippe as a post-autism case as described by Maria Rhode (2004a) and Frances Tustin (1986). But with these patients we also discover new mental mechanisms that we did not know about before, and we need to create new hypotheses to understand these mental mechanisms. I was thinking about Freud, whom I quote: “But the chief consideration in this connection is that so many things that in the neuroses have to be laboriously fetched up from the depths are found in the psychosis on the surface, visible to every eye. For that reason the best subjects for the demonstration of many of the assertions of analysis are provided by the psychiatric clinic” (1925d). The mother returned from a vacation trip and, just as she told Dr V., who told me about the interview they had, she had no idea of the gravity of the clinical picture of her son, whom she wanted to take on a vacation abroad. Fortunately, he spent those ten days at his grandparents’ house, where he is dearly loved by his grandfather and adored by the grandmother who was in my office once. By being in this warm and quiet atmosphere with his grandparents, Philippe turned into a much calmer and more smiling person. They would take him

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to the university and be waiting for him there when he came out. They also brought him to his sessions, and the grandfather on the father’s side, a very affectionate person, wanted to greet me and to meet me personally to get to know the person that was taking care of his grandson. Philippe lived those days at his grandparents’ home, with his own perception of time. He led one to believe that he had spent several weeks there, but his parents’ trip really was only nine days. His Spanish grandparents transmitted the traditions and history of Spain, especially the grandmother, who is a history teacher and tells him the invasions Spain has suffered over the centuries: Visigoths, Vandals, Charlemagne, Hannibal, etc. Here we see how the notion of internal time depends on the patient and not the calendar. In the next session, I showed the patient again what I had told him in the days when I would talk to him and he would answer me mechanically. I reminded him that at that time, his only problem was the scar and the pimples on his face and that because of this he was thinking of committing suicide. Six months later, his mother came to another interview with me, after she had taken a short trip, and I was able to detect again and more clearly that the mama is also a stone wall that repels what we doctors say when we talk to her about the gravity of her son’s illness. I told Philippe again that now I realise that his mama is the same, that one talks to her about the gravity of his clinical picture and one is repelled and she does not listen to anything concerning the severity of his illness and his mental state. The patient was silent and seemed to feel the impact of what I told him. This was the beginning of another stage of the treatment in which the therapist was not treated as “stupid” or an “asshole” who always says the same thing, but appeared in transference as someone who helps him to think and perceive more clearly who he is and what kind of parents

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he lives with. Helping to perceive reality is also a role function of the analyst, as Herbert Rosenfeld taught me (Rosenfeld, H., 1980). For example, he talked about new professors at the university that helped him to understand the courses in economics better. He explained that they went to a bank and the Stock Exchange and then they played a game to see how to invest funds and that it was more fun to learn that way. t: I think you’re talking about me, that I’m different for you now, like the professor that plays. I asked the father to go out with his son more often, the two of them alone, to be able to speak as between men, and to also be able to speak about sex without being ashamed. The father was very affectionate and several times he went out with Philippe to their preferred hamburger restaurant.

The internet is now “Breaking Bad” In session, he asked about my personal life because he had gone on the internet and discovered my blog. He asked what Paris was like, why I had gone to study there, if I had been in London … I answered him as if this were a conversation with a mentally stable person. Then he asked me about the photos in my bookcase; he wanted to know who the man in one of the photos was, and I told him it was Jorge Luis Borges. During that hour, he did not talk about the scar or that he was going to kill the doctor or that he would commit suicide if his scar was not cured by the end of the year. Although the patient spoke a bit more formally and stably, I in countertransference thought about his psychotic, murderous, and suicidal aspects that didn’t appear. That was when I asked him what he thought about the scar, the skin doctor, and if he was still looking at medical reports on the internet. To my great surprise, Philippe told me that now he is dedicated to watching a TV series that has quite a hold on him, Breaking Bad. The series is about a

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university professor with cancer who starts to manufacture illegal drugs to pay for his treatment and ensure his family’s future. I asked the patient if he had anything in common with the protagonist, whether he felt he was an incurable patient. He said no. He ended the session by talking about what he had thought about when he left the previous session. He said that sometimes with so much medication he doesn’t remember his dreams or what he thought about in session. But he slowly remembered how he had felt anguished in the session when he told me that his mother scolds him at home, accusing him of answering her impolitely. The patient remembered what I told him another time, that his mother seems not to realise that Philippe was released only recently from a psychiatric hospitalisation, that he is taking medication that perturbs his character, that he suffers greatly and that, on top of everything, he is attending university for his studies. t: They shouldn’t scold you; they should hug you and congratulate you for the effort you’re making after having been hospitalised and with so much medication. The patient smiled silently, relieved.

Exams and nightmares Several weeks later In this session, the patient entered with a tense expression and seemed angry. He said, p: I couldn’t answer even half of the questions on the university exam. But then he leant close to say hello with the two kisses on the cheeks. He sat down and, shouting, repeated,

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I couldn’t answer half of the questions and on top of that, the psychiatrist told me I can’t go running alone because I take too much medication!

Even though he was shouting all this, I tried to tell him that Dr V. was right. But that he could play soccer because he did that with other childhood friends who knew he took medication and they could take care of him if he got dizzy. My words provoked a delusional explosion, with more shouts and anger (Rhode, 2004b). p:

That ignorant doctor destroyed my face, deformed it with scars! I’m going to go where she works and shout at everybody not to go into her office! I’m going to file criminal lawsuits with lawyers against her!

I tried to interpret the hate towards the doctor joined to the hate towards his dad and mama, but his shouts drowned out my voice. The patient went on with an unstoppable delusional psychotic crisis and would not let me talk, neither did he listen to me. In his violent delusion he went on shouting, p:

She destroyed my epidermis with acid!

I tried to tell him that it was retinoic acid, but he went on without listening to me and kept on shouting that he was also going to threaten the doctor by email. This shouting went on continually for the whole hour and kept me from speaking. Suddenly, I realised that the patient’s shouts sounded like those of a child that is on the verge of tears, and I wrote this down after the session. Conclusion: after this session, my countertransference was very intense; I was upset for hours thinking that if the delusion became chronic, I would have to hospitalise him again.

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I felt quite desperate in my function as a psychoanalyst. I was anguished and could hardly get to sleep.

He never woke up from his childhood nightmares But in the following session something quite special happened. Philippe came into my office with a big smile, came up to me to greet me and said, p:

Kisses like in France.

The patient did not remember the shouts and threats in the previous session. I asked him if he remembered that he had said he was going to put up posters accusing the doctor and that he was going to accuse her in a criminal court. The patient said he didn’t remember anything. He said he only remembered something about going to go and shout at the door of her office. The patient’s voice gradually became calmer. At that moment, my countertransference changed completely. I remembered that in the previous session he had shouted but sounded like a crying child. Then I discovered that Philippe was a child, between about four or five and seven, with the nightmares he had at that time, when he suffered from insomnia. Severe insomnia … and that he wanted to kill the monsters that were under his bed. Now I was more serene. I thought that children with nightmares at those ages cry out at night but the next day they don’t remember, exactly what happened to Philippe in the previous session. I discovered that he was not yet able to shake off his childhood nightmares and that he wanted to kill monsters that today are (or are called) the dermatologist. In the following sessions, I tried to follow this hypothesis and my new diagnosis. In my view, the patient never completely woke up from those childhood nightmares. He entered

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a kind of trance or terrifying daydream in which he wants to kill monsters that are hurting him. This is my current hypothesis about the patient’s mental functioning. He is a child between the ages of four and seven who had an episode of severe breakdown, a psychosis that nobody diagnosed. And I have been working with the patient on this line. Fortunately, after each session, I always write down my countertransference and, rereading the clinical material today, after so many months, I discover how many times I wrote, in the course of the treatment, that I was afraid the patient would attack and hit me. At this time in the final comment, my hypothesis is that I was, for long months, playing the role of a fearful four-yearold child, frightened that a six foot four “monster” might attack and hit me. That is, Philippe made me feel in my countertransference the fear of being attacked and hit. I played the role of a terrified four year old, and the patient projected his infantile part into me, the child terrified that monsters might attack and hit him.

And he played the monster that made me feel terror and fear In his undiagnosed childhood psychosis, he fell into a hole, like Alice in Wonderland, a world filled with ghosts and monsters. This happened to him between the ages of four and seven. Now, there are two little boys: one is four years old and the other is twenty. This patient reminds me of Freud’s paper about the Wolf Man and the nightmares he had in the same way as Philippe. I quote: “Thus he could recollect how he had suffered from a fear, which his sister exploited for the purpose of tormenting

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him. There was a particular picture-book, in which a wolf was represented, standing upright and striding along. Whenever he caught sight of his picture he began to scream like a lunatic that he was afraid of the wolf coming and eating him up” (Freud, 1925d; see also Ciccone, 2001). It would have been much easier to write a chapter summarising my countertransference. To say, for example, “For months, the patient shouted and I was afraid he would hit me.” But what I chose for this chapter is a detailed account of the sessions to show how a patient manages to inoculate fear in the therapist and I also chose to show a hypochondriac delusion (somatic delusion). My intention is to show what it means to work and think as a psychoanalyst about transference and the internal world of a psychotic patient, with all the difficulties involved in continuing to be a psychoanalyst even with such severely ill patients. To be a psychoanalyst is to think about transference, the patient’s internal world, and projective identifications onto the therapist and onto persons in the external world. And if we sometimes get an interpretation right and we understand the patient, so much the better. I thought in French: Ce n’est pas facile d’être psychanalyste [It’s not easy to be a psychoanalyst]. The patient, even in the middle of a psychotic crisis, came to the session helped by his mother and father. Inside the session is where he burst into psychotic lack of control, shouting, insulting, and threatening with violence. Inside the session is where the patient showed his emergence of psychotic mechanisms, his burst of psychotic violence. That is to say, the psychosis appeared to act within the analytic hour. The fact that the patient did not break the frame nor the treatment with the analyst is very valuable, as he continued coming to the session and the effort made by his parents to bring him is commendable.

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He cried for the first time and communicated moods, saying, “I’m sad” This was the first time. The patient came in with a smile that seemed rather forced. He sat down on the couch; actually, he flung himself onto the couch, and his weight made the metal parts of its feet groan. He got up to see whether some part of the couch had been broken. After a short silence, he looked at me and said, p: I’m sad, and not only sad, I cried just now in the car when I was coming here with my mom … I cried in front of her. t: Do you know why you cried? p: No. I don’t think it’s about the examination. It’s that I’m sad. Sad because of what’s happening to me. t: You’re referring to the scar. p: Yes, that makes me very sad; things that don’t get fixed up and won’t get fixed up. t: It’s the first time you’ve told me about a mood like sadness, and besides that, you were able to cry. I prefer for you to cry and not to want to commit suicide because of a pimple scar on your cheek. It’s not that I want you to cry all the time; I prefer for you to be able to tell your mom like you did just now when you cried in front of her, and to tell her why you’re sad instead of covering it up, feeling murderous hate or hiding it with the fantasy of killing the skin doctor and her son. Besides, you cried in front of somebody … in front of your mom; you were able to communicate with her by telling her how you feel inside, not only that, but accompanied by her and now accompanied by me. It was important that he could show his tears and sobbing and also sadness in front of me and in the session.

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Today he could cry in front of his mother because he found an affectionate and loving mother who was able to receive his sobs and sadness. He also rediscovered the wonderful effort his mother is making to take care of him: she brings him to the session, goes to work, drives him to university and picks him up. It is important that he recognises the mother’s effort, who is doing as best she can to help him and take care of him. t:

p: t:

p: t: p: t: p:

t: p: t:

I prefer this to you being hospitalised again in a psychiatric clinic for wanting to commit suicide. You can talk to me about your sadness; you don’t hide this inside (swallowing) everything inside you … without talking about it. (Deep in thought as I have seldom seen him.) As if a scar had changed your identity, as if you believed it changed your body and this changes your sexual identity and makes you a woman? (Silence.) What were you thinking about just now? About another dream I had. I dreamed that my cousin was dying or maybe was murdered. Which cousin? The cousin that lives in Ushuaia, down there in Patagonia, really far away. The last time I saw him was when he came to Buenos Aires to have an operation on his cruciate ligaments and meniscus disc in the knee about two years ago. He’s a little older than me. Why do you think he appears in the dream; why him in particular? It must be that two years ago I was happier. Listen, could it be that you believe that the happy Philippe that you were died, and that he died because of the pimple scar on the cheek, so that now you’re somebody else with a different identity, as if a scar had killed your identity, which is the happy Philippe? I think the dream may be this. What do you think?

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p: (Looking into space as if deep in thought.) The happy guy died, the one I was before the scar and that shitty ignorant doctor gave me acid when it’s prohibited to do that mixed with the salves they put on my face. t: So you dreamed about what you feel, that the happy Philippe died, that he died or maybe you dreamed that they killed him with a bad skin treatment; in the dream you’re the cousin, you’re the dream cousin; do you understand what I’m saying; I’m asking you … and besides, he’s the one that had the knee operation like you … and exactly two years ago. You dreamed that the happy guy you were two years ago died. But I remind you that you celebrated your birthday a few weeks ago. You were the cook at your barbecue, with over twenty friends who love you and went to celebrate your birthday, and in the afternoon all your family, your uncles and grandparents, with cakes … a lot of people that love you just the way you are. You’re not alone, dear Philippe. p: Yes, there were over twenty of my friends at my birthday party. t: It’s lovely that you keep up your friendships, friends since grade school, soccer friends, the three musketeers, your oldest, closest friends. Keeping friendships for such a long time gives a very good prognosis; you can keep them inside you too. Then, we talked about presents they gave him on his birthday, none from his friends, but from his grandmothers and uncles. A year ago I received an email and a New Year postcard from the patient, from Spain, where he had moved with all the family due to his father’s work. He told me he had finished a PhD thesis in economics at a very important Spanish university.

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Similarities between the patient Philippe and the Wolf Man in his treatment with Ruth Brunswick The Wolf Man had a fixed, unshakable hypochondriacal idea just as my patient Philippe did. Ruth Brunswick (1928) also describes that he was “the victim of damage to his nose caused by the physician’s bad treatment”. In the case of the Wolf Man, it was caused by the electrolysis they used, whereas the patient Philippe was the object of damage from “acid” on the skin of his cheek mixed with another product. Both the Wolf Man and Philippe complained about the scar left on their skin. There are also similarities in Ruth Brunswick’s description to the effect that “He had a great predisposition to undergo psychoanalytic treatment,” as also occurred with my patient, who agreed to come to my sessions and to accept medication. Both the Wolf Man and Philippe believed, in their hypochondriacal delusion, that “This cannot be cured and nothing can be done to cure the scar.” In both clinical cases, there was a suggestion, later expressed, that they felt unable to go on living, and Philippe said this more clearly when he talked about his suicidal fantasies. Both patients used similar words to explain that they feel mutilated or deformed and unloved. In Philippe’s case, there may have been an identification with the mother who, we recall, also had night terrors in which she looked for the orang-utan under her bed. I think that she must have been an anxious mother who was unable to contain the child Philippe with his insomnia and night terrors when Philippe wanted to kill the monsters under his bed. It may be that Philippe’s mother saw in Philippe her own childhood with night terrors projected into her son. There is a certain similarity with the Wolf Man’s mother in that the mother suffered from

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something similar to her son, which was that she had a black wart on her nose. Both the Wolf Man and Philippe were obsessed with gazing at themselves in mirrors in their home, in the gym, or in shops. The Wolf Man carried a mirror in his pocket so that he could look at his face constantly. In both cases, delusional hypochondria centres on gazing at themselves in mirrors. In the Wolf Man’s second treatment, now with Ruth B., the therapist said that when he arrived he was quite different from what he was during his treatment with Freud: he concealed his financial matters and now was working; he was no longer the wealthy personage with a great fortune. Another similarity is the sometimes compulsive masturbation: his aids were sexual type photos in the Wolf Man’s era, whereas in the twenty-first century, Philippe visited internet sites with videos of explicit sex. Ruth B. described in great detail how the Wolf Man began to have strange thoughts about his nose that gradually worsened, which is what also occurred in my patient Philippe, since his hypochondriacal delusion worsened progressively: for example, when he would say, “The pimple becomes a scar and I know that this is never going to be cured.” Both patients also consulted several physicians. When the session with me was about to begin, Philippe always went to the bathroom. Although he said that he was going to urinate, I suspect that he also went in order to look at himself in the mirror. In relation to women, the two patients were different: the Wolf Man looked for women on the street, whereas Philippe was afraid to approach his female classmates and friends. With respect to their relationships with their sisters, these were also quite different. The Wolf Man’s sister was hyperactive and seduced him, whereas Philippe may possibly be jealous of a sister who was a prize student.

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Both patients believed that they lose their identity or body image with a scar: the Wolf Man said that his nose is no longer the way it was before. Philippe felt that they had changed his face and that now nobody is going to love him because he is ugly. The Wolf Man submitted to a treatment with electrolysis and Philippe submitted to laser treatment for the scar on his cheek. Sometimes he left the doctor’s office where they treated him with the laser in a very violent mood, shouting epithets against this treatment, that it will certainly not cure anything he has, and besides that, the doctors damaged him. These are the same words spoken by the Wolf Man. Both patients believed that medical treatments made them worse and aggravated their skin problems. Even though the doctor told Philippe that he is better, he always repeated that “This will never disappear”—these are precisely the same words used by the Wolf Man. The Wolf Man’s hatred towards the doctor was intense, but was even more violent in Philippe, who talked about killing the doctor who burned his face with acid, and about filing a lawsuit against her. The latter words are the same as those of the Wolf Man: “to file a lawsuit”. There are some differences in setting: Ruth Brunswick did not charge him for the treatment, whereas Philippe paid me and always arrived punctually. However, in both cases there seemed to be a “concrete wall” as I interpreted it to Philippe. Ruth B. said much the same: “The patient entrenches himself in his impermeability.” Both patients brought their dreams: the Wolf Man told a different version in which the wolves are now grey, and Philippe brought in some dreams with his emotional states and violence. What was striking in both cases is that dreams and night terrors were triggered at the same age: they were both four years old.

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The Wolf Man saw the primal scene in the dream of the wolves, whereas Philippe in his night terrors had been looking, since he was four years old, with severe insomnia, for the monsters under his bed. This is a striking similarity, since the Wolf Man was also unable to sleep for fear of nightmares and night terrors. In Philippe, rivalry with his father did not appear in session or in dreams as it clearly did in the Wolf Man. It may be that hostility towards the father was projected onto the skin doctor who applied acid in Philippe’s case whereas in the Wolf Man, his hostility towards his father was perceived as the father’s vengeful persecution. The couch was used by Philippe a couple of times but he usually sat on it. In the Wolf Man this was not explained in the case history but it did appear in a dream in which there is a couch and he sees a star and a crescent moon on the ceiling. I interpreted to the patient Philippe that my words bounced as if off a concrete wall, and the Wolf Man dreamt of a wall and a closed door. In the case of the Wolf Man, if someone gazed at him, he felt it was unbearable; it seems that every gaze reminded him of the dream of the wolves and its nightmarish quality. Philippe for a very long time avoided exchanging gazes with the girls who were his classmates at school and then at the university. The Wolf Man had a dream in which he sees his therapist Ruth B. wearing pants, attributing her a phallus or penis. The first dream Philippe brought in is of a long hot dog. When hypochondria becomes psychotic delusion, Ruth B. attributed this to the field of psychosis, whereas I define it as a “somatic delusion” when it perturbs social relationships or provokes avoidance of people, as occurs in the chapter in which I described my patient Pablo.

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Ruth Brunswick described quite well how the Wolf Man, after four years of treatment with Freud, came to her twelve years later, with remaining residues of transference. She said, “It is one thing for the psychoanalyst to consider terminating the treatment, but what the patient decides is another.”

Countertransference Final comments From the scientific and methodological perspective, the concept of countertransference is a definition open to theorising, once the analyst has become aware of certain affects and certain feelings, which, even when nebulous, may disturb his emotional life. At times, countertransference can become a perturbing element. This refers, of course, to those moments when the countertransference is not detected as such but is experienced as a feeling, a sensation that cannot be decoded. From another point of view, we can detect countertransference as a useful signal, enriching our perception of the analytic field. At that other dialectic instant, it serves as an indicator for our work, our thinking, and our interpretation (Searles, 1979). I specially want to stress this fundamental aspect. Countertransference is not an element that should be hastily projected. On the contrary—the analyst should use it as an indicator for his work. This series of diffuse affects and often confused sensations that constitute the countertransferential aspect of psychoanalysis must be meticulously and precisely elucidated. Only then can countertransference become a useful element for our reflection, since it enlarges and enriches our perception of the analytic field. In my opinion, an accurate perception of countertransference is mostly the result of a good psychoanalytic treatment of the

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therapist himself, associated with a responsible supervision of his work. One can only write. It must be decoded and then used technically. We use it in the sense of certain feelings, certain affects the therapist experiences when confronting facts that are specific to the transference field and to his emotional relationship with the patient. It is therefore a signal—just a signal—that needs to be decoded, reflected upon, and finally evaluated by the therapist to be better understood, and not projected. The therapist must try to translate into words the feelings evoked in him by the patient through his preverbal language, or through the phonology or music of his voice. Above all, he must differentiate these feelings from his personal neurotic problems. Countertransference is a phenomenon that can shed light on certain elements of clinical psychoanalysis, if it is kept in mind during all investigations. In my opinion, it is an indispensable tool, especially for very disturbed or psychotic patients. If we take black-and-white photographs, we will end up with black-and-white pictures, and we might say that colour does not exist; but, of course, colour pictures also exist. The same happens with the greater richness provided by the proper use of countertransference. Therefore, assigning a countertransferential nature to a given material is up to a certain point, a hypothesis. There is what we might term the “pertinence” of a feeling. Each time we suggest one hypothesis, certain variables are ruled out, others are maintained.

CHAPTER FOUR

Katherine: body image transformations

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received a female patient, age thirty, tall, thin, with a sad facial expression. She told me that she had had a car accident months ago when she was on a business trip. She was not the driver; it was a company employee. The accident was the fault of a truck that crossed in front of them. The collision was terrible, on a lonely road in the north of Argentina. Luckily a farmer appeared just when the accident occurred, and told her not to move, not to move her neck or back, that they would get her out on a stretcher. When the ambulance arrived, they rescued her and at the hospital diagnosed the fracture of cervical vertebrae, especially C1. It was only a few millimeters away from entering her brain, which would have provoked respiratory paralysis within the brain stem. The patient spoke of how lucky she had been to encounter the farmer who had treated her so well and had kept her from moving until the ambulance arrived. She said that she is recovering after long months of being in bed with apparatuses on her back. The patient has two elder sisters and a younger brother and comes from a very close-knit family. She recalled that her mother was cold and distant in her childhood. We will see later

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how this influenced her body image, since her mother did not appreciate the body of a girl and adolescent, giving her old or used clothing. Her father, an important person not only in his family but also in his profession, exerted enormous power over the family merely through the strength of his gaze and voice. He introduced powerful subliminal orders, especially related to prohibitions regarding the opposite sex and the obligation to be the best at everything. They insisted that she is forbidden to be with a boy in the car, to have sex, etc. Adopting a technique I use in cases of trauma, I stimulated the patient to talk about the accident. We spent long months of treatment talking over and over again about the moment the accident occurred and how she woke up later in the hospital. Also about the apparatuses that held her spine in place from her shoulders to her skull, an attempt to keep the spine immobile, metal pieces nailed in from the parietal bones down to the waist. What she felt about those apparatuses throughout ten months of immobility was expressed in many sessions with anxiety and terror. It was not until the eighth month of treatment that she had her first dream. She is on a very wide and famous avenue in the city of Buenos Aires lined with large gardens and parks, where there is a sculpture of a giant flower twenty metres wide and fifteen metres tall. The sculpture is called Floralis Generica. The patient, passing by this place, stops to observe the sculpture, mesmerised, almost hypnotised, and has a dream which is the one she tells me: that she is there and doesn’t know whether it was her body or the sculpture, who was who.

I helped her to think about what she had experienced for so many months, so full of metallic apparatuses that when she was there looking at the sculpture, she saw her own body

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image projected onto that metal structure: that sculpture was her own body, her projected body image.

Evolution of the dreams The patient had several subsequent dreams, which I summarise below and show their evolution. She dreams that her hair is made of wire, as well as her eyelashes and even (she is ashamed to tell me) her pubic hair. For many weeks we work on these dreams, and the patient collaborates generously with associations. t:

It’s going to take you some time to recover a notion of the body and body image of an adolescent with a body that is sexed and is adequate for your age.

Many months later, these dreams stop repeating themselves, and the next dream is not that she has a metallic body but that she is at a wedding and is one of the bridesmaids, wearing a bluish dress. Gradually, the transformations of her mind begin to show, through the transformation of these dreams related to her body scheme. A year after the last dream she has a dream in which she has a baby of her own. He is in a crib, a kind of round baby basket, so he cannot rest his head properly. Then, the patient has to go to the movies and leave the baby. She herself shouts out in the dream: how can you leave a baby on its own just to go to the movies? This dream continues with another scene: her older sister who is married arrives to take care of the baby. The sister picks up her baby, makes it comfortable, caresses it, and affectionately puts it back into the crib. In this dream I showed her that now she could imagine herself having sex, getting pregnant, and having a baby. And

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that her sister is probably an adult part of herself, a part of her own self that can take care of her baby, which is her infantile part that is afraid to rest her head with cervical fractures. She goes on by telling the rest of the dream, describing how she sees a little boy who is with her; she appears to fetch the baby accompanied by this little boy. I interpret this boy who accompanies her as an infantile part of her that does not know whether she is a boy or a girl because her mamma forbade her to be a flirtatious, sexy adolescent. I told her, you probably dream about what happened when you were small, when you didn’t know whether you were a boy or a girl. Your adult part is going to take care of the baby, which is also you. A year later, the patient told me she is going to notify the company that she will leave her job, because it is hard to work there through the stress that some people in the company generate in her. She even had stomach aches, stomach cramps, and headaches. These pains coincided with the places where the nails that held the metallic apparatus she used were in place. Aside from feeling tense at work, she reacted with physical symptoms and emotional anxiety. She said that she can’t stand the shouting and pressure. I told her that she is very sensitive and cannot tolerate tense or rough relations, shouting or abuse. I pointed out that it reminds her of the constant shouting and tension between her dad and mamma. Following my interpretation, the patient told me in more detail about the tense relationship with constant shouting between her parents. The patient’s body image, a sexual, feminine adolescent, was never accepted by her mother. She never gave her new clothes, but instead gave her used or even ugly clothing. This was confirmed by a grandmother, a very simple farming woman, who once shouted at her mother in front of the patient, “Why do you dress her like a beggar in that ugly clothing?”

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Later on, she again brought in a dream of pregnancy and I interpreted that she did so in order to tell me that there is something in herself that is starting to be able to take care of her infantile and adolescent part, the part that they never allowed to have a sexuated body and an internal space to have a baby. What we discovered in this second year of treatment is how, with the family’s religious tradition, they taught her that having a baby means pain. She talked about the dream again and needed to repeat it again and again, saying that now she is again afraid of pregnancy and also something new to me: her fear of eating a whole plate of food. She repeated this in session, in transference. For example, to take some medicine, she asked me for a glass of water: she drank a bit of it and left the rest. What she was showing me was how she takes just a little and leaves the rest, how she repeats her relationship with her mother. At one point I was afraid she had anorexia, when she told me that she ate only a little bit from plates full of food and left the rest. She told me that she was like that, that everybody told her that she was so thin that she looked anorexic. She even fainted in a café because she had stopped eating for a day almost without realising it (Rosenfeld, D., 2006b). t:

When you faint in that café-restaurant and a young waiter picks you up and gives you mouth to mouth respiration to reanimate you, I believe you have fantasies that this might continue with that young man. It’s the fear of showing your sexual excitement that you have a hard time telling about here. You believe that dad forbids this, or that I will throw myself onto you; you believe I’ll get excited. What’s most important is dad’s prohibition that you carry around inside your mind. The dad that shouted at you in the garage of your home. What do you do, alone in the car with a man in a garage … for him to accuse you of being a

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fallen woman, a whore … and he was simply the driving instructor that was teaching you to drive so you could take your test to get a driver’s licence. When at work, in the elevator, your co-worker got too close to you and was about to kiss you and you got frightened and tried to push him away … You may dream or fancy that your body is made of metal like that flower sculpture, but this is your fantasy. What I see here is a young lady who is tall, thin, blonde, with blue eyes, who is very attractive to her co-workers. You’re telling me about your fears of getting close to a man and perhaps the fear of showing your sexual fantasies and that you masturbate, for fear that I might throw myself onto you if you believe you excite me sexually, if you tell about your sexual fantasies and dreams. In the following weeks, we started to talk about her serious difficulties with eating. Since she did not drink or eat everything she was served, everybody asks her the same: they go to a restaurant, she eats a little bit and leaves almost everything on her plate. t:

You repeat the relationship with your mamma: mamma is with you for half a minute and leaves you and goes off to take care of your siblings or abandons you. Your mamma was involved in something else and you do the same, you accept a little bit of the water I serve you and then you leave it and abandon me.

I asked her if the same thing happens with my words, my interpretations, if she absorbs a little bit and doesn’t listen to or vomits the rest. In the following months, she had another dream related to a delivery, but this time the delivery is without pain. But

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she said that she leaves the delivery room and gets lost, and nobody helps her find the room where the little newborn is. In the dream she gets very frightened and shouts out: “Who’s going to take care of the baby if I can’t find it.” t:

This is the first time you dream that you have a delivery; unlike the other time, it’s a normal delivery, without pain and you don’t have the fantasy you had before that your belly might explode because of the pregnancy. It’s also the first time you dare to be a mamma, to look for your baby in the room, which means to take care of the little girl that you are. Your body image is three-dimensional; an inner space appears to receive the baby. This dream is what happens in the relation with me or what happened in your infantile stage: you go out and you can’t find the way to get back in, and you wonder who is going to take care of the little baby, the child. Because this dream is related to the summer vacations that start not long from now in Buenos Aires, and I take my vacation for a month in January. And you dream about who’s going to take care of the little abandoned baby that’s you. It’s because I, your psychoanalyst, am going away. What matters is that you can dream and tell me this, tell me that you’re looking for the little baby, wondering who will take care of the little baby in Rosenfeld’s place when he goes away on a trip.

The treatment continued for several months, and there were transformations in the recovery of her body image. She came to session in new clothes she had bought for herself, and instead of selling her apartment, she renovated it with her architect friend. She painted it in light colours, renewed the furniture, etc. I told her,

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Well, this is being happy with the body you have and the apartment you have. And you’re making it beautiful, just as you’re making your own body beautiful, enjoying what you have. Not only your body; you’re recovering a new mind, a new little head, remodelling what you have inside, thinking about yourself. And trying to be happy with what you have, and you doubtless also received something good from your family. Not everything was destruction and evil, like the accident. The dream that your body is made of metal hasn’t come up in the last few months. Besides that, you discover that your body functions well, because you’ve just come back from a stay at the farm of some friends and you were able to ride horseback, even galloping, without being afraid that you would fall apart or break your back.

I added that this also helps her to discover that if she has sexual relations and orgasms, her body will not fall apart either. Altogether, with what she told me, it seemed she was trying to be happy with what she had. Months later, I learned that years earlier she had taken a male friend home, and her father neither spoke to nor looked at him, on the same day her sister was introducing her fiancé to them. This young man turned out to be the patient’s first boyfriend, out of sight of her parents, with whom she had sexual relations for the first time. It is interesting to observe how long the treatment went on before the patient was able to talk about this subject. I asked her if after that separation she had had other relationships and she told me, only with one or two married men. She said that it must be because of what I told her about her fear of getting married coming from her parents’ shouting. I interpret,

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You thought that getting married meant always arguing, and you conceive not only of what a stable couple or a marriage is, but also sexual relations.

During a stay in the weekend house with her older sister they did some “brain-storming”, criticising their father as they had never dared to do before. This argument was very tense. But afterwards, their father came to them and told them that they were right and gave them a kiss. The patient, a year after having resigned her job to finish her university degree, was offered a valuable position in her line of expertise. She answered them that she was interested, but that first she wanted to finish her degree or work only part-time so that her job would not interfere with her studies. She started to invite friends to her house and learned to cook some dishes for them. Her mother had never taught her to cook. She was able to reconnect with some friends who had never gone to her house because she was exaggeratedly tied down by her job. That is, she recovered many friendships and the satisfaction of being able to finish a university degree that she was unable to finish before. However, before each examination or presentation, she felt pressured by the father she carried inside her mind that demanded that she be the best. She continued to buy herself pretty clothes. She told me that family gatherings on Sunday are calmer, more serene, and pleasant.

A new dream In a dream, it was the house where they used to live, which was across from the Botanical Gardens. That house crumbled down and she fell into the void. I told her that this dream is similar to another dream she had had before. In this new dream: she is going up stairs, going up to get to the top, and somebody pulls on her clothing from behind.

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And the stairs start to turn around backwards as if they were going to fall, but she does not fall into the void as she did in the dream in the house across from the Botanical Gardens. It was not like falling down into the void. This is fear of falling but is not actually falling. t: When you dream that the building falls down and you fall into the void, this is your fear that I may not be able to hold onto you tight enough. But if I’m strong and I’m not frightened by a frightened girl, I’m very different from your mamma that used to get frightened when she saw you crying. I told her that going up is all the effort she is making to come here, trying to listen to me and tolerate me, the effort to go up stairs, to get well from the accident, from the rupture, the spinal fracture, months with the metal, of believing that her body was made of metal, her eyebrows, her steel eyelashes, that she was made of metal like the Floralis Flower. The effort of going up stairs is the effort to get well and reach a goal; also of not running away from any date when her friends invite her for a drink. She doesn’t fall because there is someone that holds onto her, that helps her, and that can be me. She insisted that the stairs fall, but it wasn’t the crumbling down of the house across from the Botanical Gardens. I told her I value the effort she makes to go up stairs, the day-to-day effort, with all that metal apparatus they put on her, holding her skull. k: Not only the apparatus but I wore a Philadelphia neck brace for months so my spine wouldn’t move in any direction. t: All the effort you made to be able to dress like a happy adolescent. Mamma gave you used clothing, even though they had plenty of money. She made you grow up with a deformed body image. It isn’t only because of the accident

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and the fracture, it comes from that. And the effort to go up the stairs and buy yourself clothes like those you’re wearing, which are very pretty, starting to cook when you were afraid to cook. The terror; if mamma doesn’t teach you, how is a girl going to learn? Mamma ran away from cooking, so you did too. A few weeks ago she invited some friends over for the first time, which is when the mozzarellas she had bought fell on the floor and she got terribly upset. And her friends laughed and picked them up from the floor and started to eat. Her papa was so strict that she thought she had behaved badly. She added something, speaking of cooking, that I gave her—an Armenian spice. I had told her to add some spices to her food and in her life, and she said she didn’t know what to put in, that she only adds salt. k: It isn’t just that mamma didn’t cook and didn’t teach me. Every time she had to make lunch, she cooked in terror, for fear that papa would shout at her. He was very authoritarian. t: Then that was not cooking, that was telling her little girl to be afraid of papa. And that’s how you end up being afraid of papa and all men. So afraid that the day you were learning to drive and papa saw you with the instructor entering the garage, he shouted at you, saying what were you doing alone with a man in the car, when you were twentyfour years old. Remember that cooking is playing and you never played.

Love letters The patient told me that she happened to be alone in her parents’ enormous house, and she did something that she had liked to do when she was little: rummage through her parents’ closets and drawers. I interpreted,

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Something like getting into their intimacy.

In a drawer, hidden, she found a package tied up with a coloured ribbon. They were the letters they wrote to each other when they were engaged. The patient said: “’What a surprise,’ I said to myself! I read them all. They were love letters. Mamma lived in a town near Buenos Aires and dad, according to the letters, answered her from the United States where he was studying.” I interpreted, after she told me about each letter in detail, t:

You discovered love scenes that existed between them. They weren’t just a couple always arguing. There was love, and fiancés in love, scenes of sex with love, and that must be the way they conceived you.

I also reminded her that her mother stayed at her side, day and night, to take care of her while she was in bed for long months with the apparatus that held her head in place, down to her waist. I interpreted, t: You discovered that there is also another mother who had very good things and did what she could to have a family … she did what she could … you can value what you did receive. Do you remember Ingmar Bergman’s film The Best Intentions? (1992) k: Yes. A long silence followed my interpretation.

Final comments She recovered memories from before she was three years old, when her mother had a postpartum depression. She remembered how she was coddled by her older sister and grandmother. She also thought that perhaps she had nice clothes.

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In connection with this awakening of a healthy part of her mind, she remembered good sexual relations and orgasms with a French boyfriend, Luc, and that she had had more affairs with married men than she had remembered before. Her sexual relations were half-forgotten, in a nebulous state. It was as if another part of her mind were opening, that had been in a nebulous state and asleep. She had never communicated these things before; she said she had forgotten it. t:

Why do you think it was asleep? Was it because of your father, who erases by being so repressive?

Her father was so powerful in her mind that she could not even hold these memories inside her mind. The patient recovered the loving relationship there had been between her father and mother in the past, including the recovery of feminine identifications with the mother of her infancy. This appeared in a non-verbal manner through her hairstyle, way of dressing, and sex appeal. Now, her classmates at university expressed their interest in her. Aside from the work of analysis in which I interpreted the father she had in her internal world, something unexpected happened on his part when her father told the patient, “I wonder when you’ll be bringing a fiancé home, have a sex life, get married …” In the area of her work, she was very happy because some former workmates, who valued her highly as a professional, had offered her a job as the creative director of a new company where she would have no need to deal with bosses or managers, and this transformed her. I can conclude this chapter by saying that the patient at this time was happy and content.

CHAPTER FIVE

The boy who said that bats were flying out of his cheeks

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interviewed patients at the Milwaukee, Wisconsin Children’s Hospital. One of these cases was a young man about twenty years old who hallucinated that bats flew out of his cheeks. His lower limbs were also paralysed and he said he had cancer. In the interview I was accompanied by neurosurgery and psychopathology teams. When I asked the patient about his family, he said he has a little daughter of one year old. He also told me that when he was small, a year after his birth, his mother died. When I asked him why he is in the hospital, he answered that it must be because of the bats that fly out of his cheeks and the cancer that paralyses his feet. Later, I asked him what his mother died of, and he answered that she died of lupus. I asked him if he knows what this illness is like and what it causes on the face and cheeks of people who have it. He said he does, that it causes marks on the face, and on the body, lesions. A colleague asked him how he was able to get through his mother’s absence, and he answered that he is very religious. They asked him if he knew where his dead mother might be, and he answered that she is in Heaven. 59

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I again asked him if he knows what the marks caused by lupus look like, since this is an illness that produces very special blotches, and nearly in unison we both said: blotches in the shape of bats. I told him, t: Could it be that now that your little girl is one year old— just the age you were when your mamma died—you’re recovering your mother by imagining that you have bats in your cheek that go up to Heaven? I believe that you turned into your mamma; it’s your way to recover her. You imagine that the bats, or rather your mamma’s cheek in contact with the skin of a baby, meaning you, a little baby, are going to Heaven. This is what you try to recover of the relationship with you mamma. You have them in your mind and your mamma had them on her skin, on her cheek … In your skin to skin contact, cheek to cheek with you, she flies out and goes to Heaven. Because you said that dead people go to Heaven. The bats that fly out of your cheek are the mamma that you’re losing, that flies out of your cheek and goes to Heaven. I repeated that it is the mamma that he is losing that flies out of his cheeks up to Heaven. This is his way to mourn, to grieve for the loss of his mommy. But he does it through a delusion, through the mark produced by the lupus on her face, which looks like a bat. I reiterate, t: A baby’s cheek in contact with a mother’s skin is the most primitive type of skin to skin contact, and this is why you try to recover that contact between you as a baby and your mamma. At the same time, this is your way to mourn her loss through the bats that go up to Heaven.

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The lower limb paralysis, instead of a delusion, became a psychosomatic clinical picture of paralysis and anaesthesia of the lower limbs. The opinion I gave the medical team was that they should change the focus of the treatment and that it was necessary to work on how the patient had become his mamma. He became his mother. This was my recommendation. Months later, I was told that the patient had been able to disidentify and to stop believing that he had become his mother with lupus and neurological lesions and paralysis, which demonstrated that he did not have cancer.

CHAPTER SIX

Inés: bleeding lips and tongue when separation occurs

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his patient’s psychosomatic clinical picture exemplifies Winnicott’s hypothesis of undifferentiation or total nonseparation between the baby’s lips and the breast, in the sense that each separation or withdrawal of the mother, in this case the therapist who is going away on vacation, causes her to react with her body as if when the breast goes away, it would tear off part of her lips and tongue. This is body language, without words, in which bleeding wounds are produced in her lips, tongue, and the mucous membrane of the palate. The baby’s sensitivity to separations is described in this way by Winnicott (1971). This was also elaborated by F. Tustin in her works with autistic children and the way they experience separations (1986). To understand better the great sensibility of this patient Inés each time she lost contact with her analyst, we can look to Winnicott to express better what happens to the infantile part of the patient. Winnicott (1971) described the child’s possible responses to his mother’s absence while she is away, suggesting that for the child or the baby the mother is dead. From the point of view of the child, this is what dead means. It is a matter of days or hours or minutes. Before the limit is reached the mother is still alive; after this limit is overstepped she is dead. 63

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In between is a precious moment of anger but this is quickly lost or perhaps never experienced, always potential and carrying fear of violence. Inés is a patient in whose functioning the primitive psychotic body image prevails, a fact that is expressed through body language in a psychosomatic illness. This case was supervised by me for many years; the analyst is a woman. The patient, a twenty-six-year-old woman, said that she became aware of her illness after she and her boyfriend had broken up. She wanted to be treated because “I am depressed, I want to die.” The patient said that her illness consisted in necrosed sores. Some of these physicians had suggested a diagnosis on the basis of biopsy tests. As a matter of fact, she was considered a hopeless case in view of the severity of her illness: when there was an anxiety or an emotional crisis, the mouth, the larynx, and the lips was indeed severe. On one of these occasions, she was unable to speak for six months, and, as she could not eat either, she had to be fed intravenously. One acute crisis resulted in a coma that lasted three days. The patient added that “There is no longer a prognosis for my illness.” I would like to sum up a few basic ideas. The possibility of detecting in the transference relationship what Inés feels every time she is abandoned was essential for understanding that bleeding amounted to becoming empty and/or losing an object relationship. That emotional wound seemed to turn onto a definitive injury; that is, her body’s boundaries, at the level of the psychotic body image, where only a weak arterial wall that surrounds and contains blood. The boundaries of her body encompass not the skin, the muscles, the skeleton, etc., but only arterial walls which play the role of the external skin and which become empty of blood that oozes out and is lost in the outside world. A better understanding of the nature of the patient’s transference made it possible to study more thoroughly, almost microscopically, the origin of her bleeding, sores, and necrosis,

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which were correlated with specific stages in the analytic transference. Only then Inés might say that she feels “something before” the appearance of her sores. This was the first step—a small one, indeed. She began to perceive affects instead of expressing them concretely through her body. That same year she had to undergo plastic surgery in order to reshape her mouth and lips, distorted by severe mucosal necrosis. Here we can study in greater detail material associated with the relationship between the nipple and the mouth, that is, her transference relationship. Due to the lack of boundaries between her body and the breast, every separation or loss seemed to imply that the nipple takes or tears away fragments of her skin. The nipple skins her, deprives her of her body’s outer boundaries. There is a murderous attack on the object that abandons her. The lost object takes away with it pieces of the membrane, and she bleeds through perforated pores (the skin of her legs, face, etc.). The confusion of subject-object-lips-nipple leads to the attack on the object in a space within her non-differentiated body; therefore, to attack the nipple implies an attack against her own lips. The lack of boundaries (fusion) (Mahler, 1968; Searles, 1979) is the reason why, by attacking the object that abandons her, she becomes identified with parts of her own body’s surface. In this case, the arterial and venous walls take over the function that should be fulfilled by the normal skin. Before the holidays there was a new intensification of the feeling of becoming empty of blood, manifested mainly in bodily terms—sores and necrosis—during the therapist’s absence. I would like to stress that in this chapter I deal with the psychological experience of the notion of a protective skin that covers and protects the body. The same applies to the psychological notion that her body is a kind of large artery or vein about to be perforated, but in no way do I refer to the organic concrete body, or to its anatomy, such as can be studied in anatomy or history.

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In my opinion, the type of hypochondria centred on and expressed as a fantasy through the psychotic body image—in the case of this patient, a fantasy that she had leukaemia—is different from all others, not only because it concerns the blood or the psychotic body image, but also because in my experience it implies the danger of accidents or suicidal attempts. Everything concerning the psychotic body image corresponds to a more primitive psychotic level. Here, as in the case of other patients, the fantasy of suffering from leukaemia is an example of a hypochondriac disturbance centred on the psychotic body image. It may indicate anything from becoming empty of blood to a severe persecutory delusion in connecting with monsters or organisms that eat away the blood, or an attempt at achieving hypochondriac control. These delusions sometimes bring about suicidal attempts. Transient hypochondriac fantasies concerning blood may emerge in every neurotic personality. I will illustrate this point by presenting dream material from Inés. It should be noticed that in the case of severely disturbed patients dreams may appear only after a long period of treatment. The first dream, five years after the beginning of treatment, concerned some chewing gum the patient has and keeps in her mouth. This was the first time there was a representation of something she keeps. Besides, it was semi-solid—different from the fluid that oozes out through all her pores—and, also, it was centred on a circumscribed erogenous zone: the mouth. Later, there was a period during which she could symbolise her fantasies through her dreams, while the disturbances of the body image were expressed on a linguistic level in a very peculiar way; for instance, the orifices did not appear in her skin but in her speech, that is, “the social skin”, which began to lose the normal linguistic structure. At a linguistic level, speech disorganisation may express destructuration of the body image. During this period the patient dreamt of the body as “a little woollen dress, knitted with holes and given as a present to a little girl”: fragments of skin-dress that cover

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her. The dream represents the dress/new skin—the protective envelope she had received from the therapist after so many years of treatment. The fact that the dream material shows that the loss or emptiness is not related to liquid or blood and that more solid materials, which are easier to retain—for instance, the solid faeces—begin to appear, was a very important clue that marked the beginning—though only the beginning—of her functioning on the basis of the neurotic body image and showed that the psychotic body image is not so dominant. In this dream the body was also emptied of its contents, but this time they were not only liquids or blood, but also faeces, which are hard and seen as a penis. Besides being more solid, they are introduced inside an orifice in her own body (vagina), which contains it. In connection with the psychotic body image, this was expressed at a different developmental level. The patient said in the course of a session: “… oh! I remembered the dream … I was in the waitingroom, laughing to myself, when I remembered. Is the session over? [she laughs] I took out a … I don’t know what to call it … puf … ouch … oof … [she makes noises].”

The therapist pointed out that he is not alarmed—like the patient is—and that he is not afraid. Then the patient seemed to believe in the therapist’s contention and went on: “Well, shit [faeces] came out, a very long one … My god! It wasn’t sticky, it was not disintegrated … to put it into my vagina … what a masturbation fantasy!” In this chapter I would like to stress particularly the importance of modifications in the conception of the body scheme as something liquid that becomes semi-solid and then solid, as the patient improves; for instance, when Inés stopped losing blood through the skin and started feeling something solid inside her like in the above-mentioned dream about a hard stool, which, besides, came out through a circumscribed erogenous

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zone. In turn, these transformations and improvements concerning the body scheme are experienced as internal modifications that generate new and different hypochondriac defences. Later the patient brought to therapy a dream including material related to the loss of blood associated with menstruation, in which she showed that the towel was not stained with menstrual blood. But menstruation was not expressed as before—that is, when she believed that it implied bleeding through all the pores. The important thing now was that she could dream of this and symbolised it. Previously, she had expressed through the psychotic body image her feeling of being emptied through her skin injuries. When an inner space may be created (Bick, 1968) and also a mental space between the patient and the therapist (Anzieu, 1974; Houzel, 1987; Winnicott, 1971, 1992) another stage will have begun. In a patient with such a severe illness as Inés, this stage brings with it the hope that the struggle will cease to be expressed through the body and will reach mental transference levels. We hope, as Shakespeare wrote, that: If god doth give successful end to this debate that bleedeth at our doors, we will our youth lead on to higher fields … (Henry IV, Part 2, Act IV, Scene 4)

CHAPTER SEVEN

Somatic delusion: Hugo and Pablo

Somatic delusion mechanisms 1. The process begins with what we could call classic hypochondria, the patient expelling part of his ties with his internal world onto an external object. 2. There is a second reprojection with a special ego destructuring quality. Now the somatic delusion develops as an effort to endow the self with meaning and organisation. 3. There may be a second reintrojection: the delusion is reintrojected, and there is a marked increase of paranoia. 4. The patient may also try to project his delusion onto the analyst and thus establish a delusional or psychotic transference (Rosenfeld, D., 1992).

Part 1: Hugo and the white skin Carlos Trosman and David Rosenfeld Early in 2013, Carlos Trosman received Hugo, a patient who later continued in psychoanalytic treatment with him. This young man of twenty-four told him about his anxiety crises. For fear of being rejected by people because of white blotches

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on his skin, diagnosed as vitiligo, he isolated himself, was ashamed, put on a hat and dark glasses when he went out, applied creams to his face and hands to hide the blotches, and abandoned his university studies. He isolated himself because he was afraid that everyone would reject him because of his blotches. He applied more and more creams to his face and hands to hide the blotches. He also transferred to a different university to be with different classmates, thinking that he would be able to adapt better. During our supervisions, Dr Trosman and I tried to understand the triggering factors of his anxiety crises. We observed features similar to those found in our experience both by Dr Trosman and Dr Rosenfeld in other vitiligo patients. For example, one young patient who had a kidney removed, then suddenly developed vitiligo, said that it was “a hole in the body and in the soul”. He suffered the disappearance of pigmentation under the epidermis. In another vitiligo case, it appeared in a child after the sudden loss of his father and brother in an automobile accident. Dr Trosman and I dedicated ourselves to listening and searching through the material for “the hole in the soul” of this patient, that is to say, the traumatic events and situations of massive stress we found in this case which could be the origins of the illness. The first important traumatic event in Hugo’s life was the death of his grandfather, the only person with whom he could converse and feel loved. The only memories he had of his parents were shouts and violent insults. He defined his mother as tyrannical and cruel; she used to keep him from visiting his friends and even threw them out of the house if his friends came to visit him. The death of his grandfather when he was thirteen years old was a mental catastrophe that now seemed to be represented through the vitiligo. Then, a second trauma occurred: his parents’ divorce and the psychotic clinical pictures of his two sisters following the

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divorce, with attempts to commit suicide by one of his sisters and his mother. Dr Trosman and I thought that the blotches represented that hole in the soul, his pain from having lived in a family with so much violence and madness. He possibly wanted to hide so much violence and suicide in his family from his internal world, and therefore he projected it into the vitiligo on his skin. Hiding the vitiligo meant wanting to hide and cover up his internal world, considering all the madness and violence in his family. The family’s psychosis, madness, and violence was what he was trying to hide from his own perception; this, projected onto the outside, was what Hugo called “shame for them to see my white blotches”. It is important to clarify that all types of verbal language or dreams are excluded (split off), but explode and reappear as a psychosomatic clinical picture, excluded from verbal expression. In transference, we saw the fear of being driven crazy by the analyst, just as he was on that battle field between mother and father. Six months later, he narrated the first dream. The patient said he goes into a shop in whose window a black cat is trapped and cannot get out. This dream is repeated in an abandoned house, instead of happening in a shop. A shark, bugs or insects, or a snake always appear to pursue him. The patient cooperated by making associations, until the bugs and insects could be connected with the mother that attacked him; that is, she was the mother in his mind. The black cat is the way he was treated throughout his childhood by a violent couple that left him trapped in a glass jail (the shop window) from which he could not escape. That was his internal world. As is habitual and typical in psychosomatic patients, he did not use words or emotions to express the impact and loneliness caused by the death of his grandfather, who was the only

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affectionate person in his life. He said in session that he never cried. Dr Trosman interpreted that he didn’t cry but that sobbing was the hole in his skin, the vitiligo. He also reminded the patient that the vitiligo appeared two years previously, when his parents divorced and his mother and psychotic sister attempted suicide. The latter event triggered the emergence, through a psychosomatic clinical picture, of affects, pains, and grief paralysed in his internal world. Only then did he start to say goodbye and grieve for his dear grandfather. The fact of not being able to go out for fear of being seen by people who knew him provoked the isolation in which he hid parts of his body, and for that reason we include him in the clinical picture that we call “somatic delusion”.

Part 2: Pablo and somatic delusion Pablo suffered severe identification disturbances. Pablo had escaped from Germany with his mother when the Nazi persecution started. When he began treatment with me, his desperate effort to work through his losses and mourning over his mother led him to try to preserve his earliest identifications, achieved through highly regressive and primitive mechanisms characterised by confusion with his mother’s female body. He thus tried to recover his lost identifications and bonds (Eickhoff, 1986). Among Pablo’s most vivid memories was the persecution and the punishment his mother and brother suffered at the hands of the Nazis. Another concerned an episode that includes a very special pattern of object relationship: white biscuits, which were lost in the snow while he was running away and which, because they were white, could not be seen and found again. This shows how difficult it was for Pablo to preserve anything and also how he lost the things he managed to take. This is a pattern of bonds and identifications that are lost.

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It is my belief that massive, total, pervasive persecution makes it very difficult to preserve identifications: identifications formed under the power of terror are hard to preserve. In the course of a session he spoke about a dream in which he saw a fellow called Davis, who “was nothing special, not too good and not in the least intelligent, whom I met in the Army”. Pablo, his children, and Davis, who was the driver, were in a lorry that caught fire and fell into a ravine. This dream was dealt with in several sessions within the transference, by linking it to what we had seen at the beginning of his treatment: his fear of surrendering to somebody who cannot “drive” him well and may destroy and set fire to his male and female infantile parts (symbolised by his son and his daughter in the dream). The dream obviously revealed that he distrusted my ability to drive the analysis-lorry and also associated Davis with David, my name. At the time, he saw the therapist as a father who could abandon him or as a mad man who might lead him away from safety. In later sessions we understood that the dream also represented his infantile history and his fear or a sign of an impending breakdown. The patient developed a somatic delusion and was convinced that people thought he had female lips and cheeks. Hiding his face behind a beard and hair, he used to run along the streets to my consulting room. The patient, Pablo, whose somatic delusion became manifest in the course of his treatment, sought help in order to be cured and helped to recover his lost inner objects; he also expressed his concern over his body, which, nevertheless, did not prevent him from doing well in his work. As the treatment developed, transference became more and more regressive, thus showing the patient’s relationship with aspects of the mother and the father in connection with parts of his body (lips, cheeks, penis). Pablo started speaking about his preoccupation with his ideas of his own face. He was thirty-nine years old and when he was eight, his father, who was then forty-three, had died. The

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mother died when she was fifty-three and Pablo eighteen. There was a brother, five years older than Pablo. The patient married when he was twenty-nine; a year later he became the father of a girl and, five years afterwards, of a boy they named Pablo. When the boy was two years old, Pablo and his wife decided to divorce. The patient pointed out that when his daughter was born, he felt left out of his wife’s life. When evoking his youth, he remarked that for a time he lived alone with his brother, but when he was eighteen he was absolutely alone; he added that, after living with an uncle for six months, he had decided to enter university and work in the summer to pay for his studies. He said he had difficulties with his girlfriend and that he ran away from people because he thought he was homosexual, and that is why he decided to grow a beard. After some time he stopped having sexual relations with his wife. In turn, his wife became reluctant to leave the house after the little girl was born. The same happened when the second baby was born, but to a lesser degree. Pablo then said that, while at a party, he felt terribly jealous because his wife was flirting with other men; he felt hurt and “slighted” by his wife and, because of his behaviour, weak in the eyes of the other men. The second baby was born severely ill. Pablo thought that his painful situation would solve his marital conflicts. His wife thought that an injection was the cause of the infection from which the boy suffered. In the course of a trip, Pablo caught gonorrhoea from a prostitute and told his wife about this affair, in a show of childish rebelliousness against her. He felt that in connection with their marriage the choice was between a kind of filial submission and divorce. They decided on divorce and the children remained with their mother. Pablo remarked that his relationship with his wife was cold, that there was no emotional surrender on her part, and that he had felt free when they divorced (Freud, 1917; Klein, 1945). In the course of his analysis it became more and more obvious that the patient imagined things that happened in other

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people’s faces and minds—for instance, when he imagined that others stared at him. At a microscopic level there were subtler signs. For instance, in one of the sessions he said: “You must be worried because I’m crying.” He thus projected onto me his own sorrow and worry over his crying, and he saw his own worry in me. Sometimes I had the countertransference feeling that Pablo’s material was something between unreal and dreamlike, for instance when he spoke about the party in which his wife tried to seduce all the men there. The events narrated might have been constructed as an episode of hysterical provocation on the part of his wife; instead, he conveyed with much more realism and conviction his feeling of weakness as a man, which he sometimes expressed as “muscle weakness”. In another session during the first month of treatment he told me of a dream: “I hadn´t remembered a dream for more than twenty years.” After the dream he said he liked reading and added that when he was a child he studied Hebrew in the afternoon; he added that he would like to be with his children for the following holidays (Passover). In another session Pablo talked about his father, whom he stopped seeing when he was four, although he met him once four years afterwards, not long before his father’s death. He and his mother were separated from the father because of the war and the Nazi persecution in Europe. He added that when he was a child, he went to a synagogue near Buenos Aires with a cousin of his; and he thought of his mother, whom he described as a wonderful woman, full of affection, a hard-working, tenacious person, who seemed to be weak but who was really hard and tender at the same time. The mother went through periods of severe depression after her husband’s death and was hospitalised once. Several years later she started a relationship with a man. The patient felt very guilty about this: “Guilty, I felt very guilty, because we put that man out of the house; that guilt is always persecuting me.” Spontaneously he went back to the time when he and his mother fled from Europe in the

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middle of the war. “I remember that one night many planes came. They said they were English. We hid in a basement for twenty-four hours. I wanted to draw a curtain and I felt a slap on my face because they could see the light.” (Here the cheek already appears as an important locus for representations.) I asked him a question, and he added that he remembered that “They took my brother out of my bed, we slept in the shelter and he kept jumping up and down.” He remembered something about that period: “Mother asked me to buy some cakes, and I lost them because they were white, and when they fell on the snow everything was white and I could never find them, and Mother couldn’t either.” He also remembered his nursery school: the teacher complained to his mother that he was rebellious, and he felt very ashamed on account of that. While he was alone with his father, he was an enfant terrible, he added. I interpreted that perhaps he now recalled his own infantile parts he thought he had lost in the dream, the two small children, and the patient answered in a sadder tone: “I remember that the young Nazis hit my mother and my brother for being Jewish.” He then remembered how his father managed to run away only a couple of years after they had. I went on with the interpretation and pointed out that the lorry on fire seemed to represent Pablo with all his infantile world, which he now remembered in the session and he feared had been lost and destroyed. He also feared that I, the driver, would not be there to save him from falling down the ravine, from a mental breakdown (Haesler, 1992). Later on we saw that the truck that catches fire and falls down the ravine already heralded his ego breakdown and the emergence of the somatic delusion. In his recollection of the “cakes that cannot be found” we discover the model of his internal relationship with objects—as difficult to retain: when he took something he lost it. I thought he had learned to retain things, but then they slipped through his fingers. After this dream it became obvious that his hypochondriac area, the lips

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and cheeks, began to invade the rest of the face. (His cheeks are also loci for the primitive skin-to-skin relationship of the baby who rests his skin on his mother’s breast. The baby looks first at the breast-nipple and introjects it through his eyes—in this case, via his contact lenses.) He let his beard grow longer and longer as his delusion invaded his eyebrows, his forehead and then his whole head and face: he feared people in the street might think he had the face of a woman or of a homosexual. When in the midst of his delusion he showed his lips, he said they are a woman’s lips, then the cheeks, and the same with the rest of his face. It seemed to be a desperate case of searching for and missing mother, his own sexual identity, localised in a bodily area—that is, his own face. On another occasion he touched his penis and said: “My circumcised penis is the same as my father’s,” as if establishing an equation: my penis is like my father’s, and I am like Father. At that moment his speech seemed to become more coherent. In that period of full-fledged delusion, as he walked to my office, he would sometimes hallucinate that people were telling him that he had a woman’s face, that he was a homosexual, and then he would start running towards my office. In another session he dealt with a different aspect of his hypochondria, in this case connected to his eyes. He spoke insistently about his eyes, about how they ached, and added that his contact lenses made them sore. He said: “My eyes ache so much I want to tear them out.” The interpretation centred upon his wish to tear out the perceptual apparatus in order not to see reality (closing his eyes, closing the windows to a dangerous and painful reality). But in later sessions there reappeared the fantasy of tearing off part of his body: his insistence upon having a woman’s lips and the way people looked at him in the street because they noticed led him to consider “tearing off my lips or having them removed”. There were also fantasies about people who persecuted him. I thought he seemed to want to tear off his ties with his mother as a means of recovering his

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infantile ties, but at the expense of mistaking his body for that of his mother/woman/female/homosexual. There were also melancholy aspects with their sequel of pathological mourning and persecution by the parents, reintrojected and experienced in bodily areas. At the time my interpretations were rejected when transference was very regressive (delusional or psychotic transference levels) since I turned into somebody who wanted to drive him mad; I became those who persecuted him in the street. It was a way of enacting in transference and projecting onto me his homosexual fears and the madness that was beginning to invade him. During that period he sat on the couch and had to control me by looking at me. On other occasions he clung to me as if looking for a father who might save him from “the bombardment of crazy ideas”. The protection was sometimes idealised. Ideas hinted at in the first interview began to reappear: the outside world persecuted him, hurt him: “It is society that makes me a homosexual”; “The man thought I was a homosexual.” The material became organised with paranoid structures. Even the story about “people in the street” near my office who told him he was a homosexual made us think that that, in fact, also happened in my office during the session, when after saying that he remained silent.

CHAPTER EIGHT

Luis: half of his body and brain are missing—in collaboration with Teresita Milán

T

he patient is a drug addict with pathological mourning in which fantasies that half of his body and brain disappear.

Interview by David Rosenfeld I interviewed a patient twenty-four years old that I had supervised for several years. His family asked for an interview with me while I was in a medical congress. The first comment from the patient’s mother was that her son, Luis, had been consuming cocaine for the last four years. When Luis came in, I observed that he looks blankly into space. He looked at some pictures in my colleague Lila Gòmez’s office in Mendoza. I called out to him, asking if he would like to chat with me or with the psychotherapist who was seeing him before. I said to him that maybe there are things he can tell me or her that he wouldn’t dare tell his mamma. While I was talking to him, he continued to have a blank expression, looking out of the window. At one point, he interrupted me and, pointing with his finger, asked me where the Aconcagua is. Afterwards, he said that he got disoriented.

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It seems that you didn’t listen to what I said to you before. If you don’t listen to me, your mind stays empty, you don’t absorb, you don’t get enriched, and you’re left with a feeling of loneliness. Words are food for your mind.

Luis continued to have a blank look and when I asked whether he is listening, he answered, stuttering: I’m very poor, I don’t absorb food, words. t:

If you don’t feed yourself with words, afterwards you feel empty or hollow. And sometimes, because you feel empty, you look for stimulation in drugs.

As the interview went on, I observed that his voice and mouth are pasty, and then I thought he was hallucinating as he looked out of the window into empty space. I asked him if he is dreaming and he said no. So when do you take cocaine? I take three grams a day. That would kill you. People that take three grams a day have heart failure. l: Yes, they die, but I’m not interested in living a long life, getting to be very old. I’m not interested in getting grey hair. He still had a pasty voice, saying something incoherent and went on: My sister was born when I was a year and a half old. t: l: t:

I talked to him but he was still lost, looking at the leaves of a plant. l:

I don’t like marijuana, it makes me introverted.

He answers my questions incoherently. For example, he says: homo sapiens, rational animal, etc. I ask again what happens if he takes cocaine.

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l: I don’t think 100%. To get money I sell the appliances in my house and the horses there are. t: What about your father? l: He died when I was fifteen. He died from an atomic bomb, contaminated the whole family. (He squints and goes on) He died in a car accident. I had an exposed fracture of the left hand. And all the left side of my body no longer existed, my head doesn’t function any more. I was left without a father structure. My left part of the brain and body are dead: they don’t exist. Only with cocaine my brain could be alive again. Here, in this part of the clinical material, it is very clear that his left part of the body and the left part of the brain had disappeared. Although I tried to ask more about his father and about the fact that the patient stayed by his father’s side in the car, he continued to answer incoherently. t:

You’re inside the car with your dad on your left side; you never got out of there.

He replied that he was taking drugs all night. Then he talked about the psychiatric medication he takes and asked whether I know what the Gioconda smile means; from Da Vinci’s painting. He got up to look more closely at one of the pictures in the office and straightened them so that they hang symmetrically. At this moment I thought that the patient is worried about his own body which is organised symmetrically: the left part is dead. t:

What do you think about what I told you about still being inside the car with your dead dad?

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He answered something that stunned me. l: t:

I left with my mind and came back with the coffin. You go through life mixed up with the dead man at your left side; that’s why you sometimes feel that the left part of your brain and body are dead. It seems that with the cocaine you believe you come back to life. Or maybe you take a lot of cocaine so you can die of a heart attack and be with dad in the cemetery.

Here we can read very clearly that his left part of body and brain are dead.

Luis and his family history by Teresita Milán Teresita Milán treated this patient in the city of Mar del Plata, in the south of Argentina, where Luis was living and studying. Doctor Milán was his psychoanalyst during more than four years and she supervised this patient with Doctor Rosenfeld. We followed during the supervision two theories about child evolution based on Thomas Ogden (2005) and his hypothesis on autistic-contiguous mode, and for countertransference we followed Bryce Boyer’s theories (1993). As an adolescent, Luis used to take a long time to comb his hair or to take a bath. He admired his own beauty, stimulated and encouraged by his mother who told him he was the most beautiful baby in the world. A dermatologist applied Botox and silicone to erase the wrinkles on his forehead. His mother told him, “You have a worried face, and your wrinkled forehead shows that you’re worried or sad.” In the supervision we worked with this hypothesis: that the patient imagines that by getting rid of the wrinkles on his forehead, wrinkled because of his grief, he could cancel the sadness-grief for his dad’s death in the car accident.

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We recalled that in the car accident, the father died on the patient’s left side. It is as if someone wanted to have an operation to remove both tear ducts to keep from weeping any more. Genevieve Haag, a French psychoanalyst, studied the peculiarities of the constitution of the body image of autistic children. She considers that integration of the body image takes place following the unification of the bipartition of the sagittal or vertical axis. The union of the two halves of the body occurs between the third and sixth month of life and is a symbol of the union of the tightly joined mother–infant relation. Any splitting provoked leads to a major lack of knowledge of the body image that can be identified and observed during psychoanalytic treatment (Haag, 1997, cited in Ferrari, 2013). In this patient, Luis, it is important to understand the left part and the right part of his body image. Henri Wallon (Wallon & Lurçat, 1962), on the other hand, created the theory of the mirror—a concept original to him. In it, he theorises on the origin of identity and the creation of the body image. He underlines the importance of bodily inner perception. These concepts are similar to those of Frances Tustin (1986) on the search for sensory stimulus. Moreover, these ideas on the concept of self, of “oneself” and identity, were later developed in detail by Winnicott (1971).

REFERENCES

Anzieu, D. (1974). Skin ego. In: S. Lebovici & D. Widlocher (Eds.), Psychoanalysis in France (pp. 17–32). New York: International Universities Press. Avenburg, R. (1998). Psicoanálisis: perspectivas teóricas y clínicas (pp. 34–37). Buenos Aires, Argentina: Editorial Publikar. Bergman, I. (1992). The Best Intentions. Film. Script by Ingmar Bergman, directed by Bille August. Bick, E. (1968). The experience of the skin in early object relations. International Journal of Psychoanalysis, 49: 484–486. Borges, J. L. (2005). El Alpeh. Obras completas de Jorge Luis Borges. Buenos Aires, Argentina: Emecé Editores. Boyer, B. (1993). Countertransference: Brief history and clinical issues with regressed patients. In: Master Clinicians on Treating the Regressed Patient. Northvale, NJ: Jason Aronson. Brunswick, R. (1928). A supplement to Freud’s history of an infantile neurosis. International Journal of Psychoanalysis, 9: 439–476. Ciccone, A. (2001). Naissance a la vie psychique. Paris: Dunod. Eickhoff, F. W. (1986). Identification and its vicissitudes in the context of the Nazi phenomenon. International Journal of Psychoanalysis, 67: 33–34. Ferrari, P. (2013). L’obsessionnalisation de l’appareil a penser dans psychanalyse et cognition dans le processus développemental.

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INDEX

Pablo 72–78 Philippe 9–41 Pierre 5–7 change of medication 21–22 childhood 22 childhood nightmares 32 chronic delusion 22 Ciccone, A. 34 countertransference 42–43 technical use of 19–21 with Luis 82 with Pablo 75 with Philippe 11, 19, 23, 27, 29, 31–34

Anzieu, D. 68 Avenburg, R. 13 Bergman, I. 56 Bick, E. 13, 68 body image concept of 2 definition 2–3 psychotic 1 Borges, J. L. 19, 29 Boyer, B. 82 Breaking Bad 29–30 Brunswick, R. 38, 40, 42 Buenos Aires 20, 36, 46, 51, 56, 75

dizziness 21 dreams 16–18 evolution of 47–53 love letter 55–56 new 53–55

case studies boy with bats flying out of his cheeks 59–61 Hugo 69–72 Inés 63–68 Katherine 45–57 Luis 79–83

Eickhoff, F. W. 72 exams and nightmares 30–31

89

90

INDEX

Ferrari, P. 83 Freud, S. 6, 11, 16, 21, 27, 33–34, 39, 42, 74 Haag, G. 83 Haesler, L. 76 the hole in the soul 70–71 hospitalisation 12 Philippe’s treatment 13 Houzel, D. 68 hypochondria 9, 11 Klein, M. 9, 74 Klimovsky, G. 2 Lurçat, L. 13, 83 Mahler, M. 65 medication 16 monsters 66 and Philippe 14, 17, 20, 23, 32–33, 38, 41 Ogden, T. 82 Philippe after hospitalization 12–16 and Breaking Bad 29–30 and sex through the internet 26–29 and sexual relations 17 and technical use of countertransference 19–21 as a monster 33–35 change of medication 21–22 childhood history 22–23 childhood nightmares 32–33 crying 35–37

dreams 16–18 exams and nightmares 30–32 first interview 10–12 laser treatment 18–19 scar condensing hate 23–26 similarities with the Wolf Man 38–42 psychoanalytic technique 22 psychosomatic diseases 9 psychotic body image 1–2, 5–6, 64, 66–68 psychotic crisis 10, 31, 34 Rhode, M. xi, 27, 31 Rosenfeld, D. xi–xii, 2, 7, 9–12, 14, 17, 21, 27, 29, 49, 51, 69–72, 79–83 Ruth, B. 39 Scott, C. 11 Searles, H. F. 42, 65 skin botox and silicone 82 laser treatments 18–19 somatic delusion 11, 41, 72 mechanism 69 Pablo and 72–78 Stock Exchange 29 terror and fear 33–34 Trosman, Carlos 69–72 Tustin, F. xii, 27, 63, 83 Wallon, H. 13, 83 Winnicott, D. W. 24, 63, 68, 83 Winnicott’s hypothesis of undifferentiation 63 Wisconsin Children’s Hospital 59