Trauma and primitive mental states : an object relations perspective 9781138364363, 1138364363, 9781138364387, 113836438X

Table of contents :
Cover
Half Title
Title
Copyright
Dedication
Contents
Foreword
Introduction
Acknowledgements
1 Between body and mind: transforming physical experience into psychic development in the clinical situation
2 Affective bridges between body and mind
3 The silent transference: clinical reflections on Ferenczi, Klein, and Bion
4 Somatic counter-transference
5 Finding a center of gravity via proximity to the analyst
6 Infantile trauma, therapeutic impasse, and recovery
7 Finding the impulse: healing from infantile trauma
8 The body as a mode of representation
Bibliography
Index

Citation preview

“Vindicating Ferenczi’s contributions on the importance of early trauma, or what I have referred as ‘pre-conceptual trauma’, Dr Eekhoff has produced an insightful book much needed for the psychoanalytical understanding of psychopathology. This generous and well documented contribution, also proves using clinical material, how pre-conceptual traumas could induce with time, alexithymic reactions as well as somatic pathology, as if the body attempts to dream a repetitious undreamed dream. I highly recommend this book to all professionals in the field of mental health who are interested in the comprehension of psychic trauma.” Rafael E. López-Corvo, MD, Training and supervising psychoanalyst of the IPA, Venezuelan (ASOVEP), Canadian (CPS) and American (APsA) Psychoanalytical Associations. “Dr Eekhoff presents us with her view that mental representations are not a given. The outcome relies – she argues – on the meeting of the baby’s innate dispositions and the parental function. Through the chapters of this valuable book we are invited to follow her study of a variety of clinical experiences and pathologies, from autism to trauma, where the function of representation went awry or was arrested and how she treated them. The reader will be met with a talented writer and psychoanalyst, which Eekhoff certainly is.” Dr Robert Oelsner, Training and Supervising Analyst, Northwestern Psychoanalytic Society & Institute and the Psychoanalytic Training Institute of Northern California, Author & Editor, Transference and Countertransference Today. “This book is a jewel that should be studied in all psychoanalytic seminars. It is a wonderful description of clinical experience with detailed theoretical explanations. Dr Eekhoff describes severe pathologies from the moment of birth to adulthood. Her book provides clinical examples of object relations analytic work with patients whose representations of experience have been inadequate for emotional meaning making. Throughout the book, the excellent examples of countertransference and its use in the here and now are instructive. The patient obliges the psychoanalyst to feel, without words, what happened in the first months of life. Dr Eekhoff has the courage to write that we all have somatic reactions, but that anything is possible to be analyzed and put into words. She is courageous when dealing with what is called non-analyzables when she says ‘this is not impossible to treat’.” Dr David Rosenfeld, Ex-vice-president, International Psychoanalytic Association, London; Consultant Professor of Psychiatry, Buenos Aires University; Training Analyst, Buenos Aires Psychoanalytic Society.

Trauma and Primitive Mental States

Trauma and Primitive Mental States: An Object Relations Perspective offers a clinically based framework through which adult survivors of early childhood trauma can re-engage with painful past events to create meaningful futures for themselves. The book highlights the use of the body and the mind in working with these early unmentalized and unrepresented states, illustrating the value of finding language that embodies emotions, and working in the here and now of transference and counter-transference. Including a range of examples of how early trauma can thus be re-presented and clinically understood, the book illustrates how patients can discover themselves and leave their repetitive patterns of suffering behind. Written by a clinician with over 30 years’ experience, this will be fascinating reading for psychoanalysts and psychotherapists as well as any mental health professional working with childhood trauma. Judy K. Eekhoff, PhD, FIPA is an IPA certified training and supervising psychoanalyst and a licensed child psychologist. Eekhoff is a full member and past president of the Northwestern Psychoanalytic Society & Institute and a full faculty member of the Seattle Psychoanalytic Society & Institute in Seattle, WA, USA. She has a private practice in Seattle, Washington, USA.

Trauma and Primitive Mental States

An Object Relations Perspective

Judy K. Eekhoff

First published 2019 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 52 Vanderbilt Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2019 Judy K. Eekhoff The right of Judy K. Eekhoff to be identified as the author has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice : Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Names: Eekhoff, Judy K., author. Title: Trauma and primitive mental states / Judy K. Eekhoff. Description: Milton Park, Abingdon, Oxon ; New York, NY : Routledge, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2018048259 (print) | LCCN 2018049534 (ebook) | ISBN 9780429431401 (Master eBook) | ISBN 9781138364363 (hardback) | ISBN 9781138364387 (pbk.) | ISBN 9780429431401 (ebk) Subjects: LCSH: Psychic trauma. | Psychic trauma—Treatment. | Mind and body therapies. Classification: LCC RC552.T7 (ebook) | LCC RC552.T7 E35 2019 (print) | DDC 616.85/21—dc23 LC record available at https://lccn.loc.gov/2018048259 ISBN: 978-1-138-36436-3 (hbk) ISBN: 978-1-138-36438-7 (pbk) ISBN : 978-0-429-43140-1 (ebk) Typeset in Times New Roman by Apex CoVantage, LLC

For Bruce

Contents

Foreword

x

H O WA R D B . L E V I N E , M D

Introduction Acknowledgements

xv xx

1

Between body and mind: transforming physical experience into psychic development in the clinical situation

2

Affective bridges between body and mind

15

3

The silent transference: clinical reflections on Ferenczi, Klein, and Bion

29

4

Somatic counter-transference

42

5

Finding a center of gravity via proximity to the analyst

50

6

Infantile trauma, therapeutic impasse, and recovery

63

7

Finding the impulse: healing from infantile trauma

78

8

The body as a mode of representation

94

Bibliography Index

1

112 120

Foreword Howard B. Levine, MD

Trauma and Primitive Mental States: towards a metapsychology of process Contemporary psychoanalysis has responded to the challenge of how to extend its reach to patients and mind states whose problems defy the classical formulations of neurosis by shifting its attention from a predominant focus upon the repressed (hidden or split-off) content of thoughts to “the origin of thoughts and the way these thoughts enable the individual to become a thinker” (Bion, 1965, 1970) (chapter 8, this volume). As it has done so, we have increasingly faced the impossibility of being able to fully describe the processes that transform enigmatic raw, unrepresented existential experience into represented, potentially verbalizable, ideational psychic elements (Levine, Reed, & Scarfone, 2013). As Bion (1970) has pointed out, the realm of psychic reality and the unconscious is ever expanding, infinite, and ultimately ineffable. Attempts to find words to fully describe this realm and encompass its movements are epistemologically impossible. And yet we must find words with which to communicate and to convey some aspects of our ineffable experience – with our patients, with each other, and with our own thoughts – as we struggle to try to understand and think about these matters. In the epigraph that begins this book, Donald Meltzer offers a succinct intimation of the problems that we face when he says: “The realm of the mind is a world of infinite possibilities of meaning from whose formlessness a coherent world must be constructed by thought operating on the perception of emotional experiences” (Meltzer, 1998, p. 92). He describes “a formless realm of infinite possibilities” filled with “perception of emotional experiences” – and, I would add, potentials for action and somatic sensations – out of which coherence of meaning and consistence of being (identity) must be wrought! How to accomplish this enormous task is the challenge confronting analysts and patients, especially when faced with the residues of preverbal trauma and primitive mental states. These are severely withdrawn or “undrawn” (Alvarez, 2010) patients, who may use their physical and emotional distress to reassure themselves that they are alive. True emotion is

Foreword

xi

often unavailable to them and emotional contact with objects is weak or nonexistent. Their interactions in analysis and with the people in their lives are often superficial, and their transferences – more perfunctory, instrumental, and adhesive than truly relational – may remain hidden (see chapter 3, this volume). This is the provenance of operational thinking and mechanical living (Marty, 1976), of somatization, hypochondria, omnipotence of thought, disobjectalization (Green, 2005), profound passivity, and “a deeply hidden nearly invisible structure of mimicry that hides a more serious psychopathology.” (see chapter 1, this volume). The discourse of these patients is often emptied of emotional content, relational connection, and lexical meaning. “The capacity to check inside [oneself] with the internal objects that commune there and speak from a whole self about personal thoughts, feeling, and desires is lacking” (chapter 1, this volume). And the very category of desire, true desire originating from a true self, as opposed to what might be called a tropism, a reflexive movement to escape from painful feelings or to adhesively imitate the speech, attitudes, or actions of the analyst in a vain attempt to create a simulacrum of existence, may be beyond their ken. Their speech is often an imitation of human speech (Paul, 1997) that may be soothing or discordant, numbing or enlivening, but . . . [ does] not communicate emotional meaning from the patient to the analyst. It is the analyst who attributes meaning. In doing so, the analyst gives the patient something to imitate, as light gives a plant a direction to turn. (chapter 1) This creates an important dilemma for the analyst around the problems of suggestion, compliance, and the roles of interpretation and construction: Will the explanations and attributions, the directional “turn”, that the analyst’s activity and presence offer help the patient to establish and/or discover a true self, or will the self that emerges be just another adhesive, imitative prosthesis that does not really offer the patient the foundation for an identity and a solidity of being? For the analyst, counter-transference and counter-responsiveness must serve as guides to the level of deadness or aliveness in the patient’s presentation. If all goes well, they will furnish the leading edge of the analyst’s intuition, creative construction, and transformational action and activity that are required to help co-create the necessary representations, symbolizations, narrative bits, and associational linkage in the patient’s psyche and inner world. This level of analytic work may imply – and be – a kind of activity that is a far cry from the abstinence and neutrality usually associated with the treatment of the classical neurotic. There, the watchword for technique is often to help a patient to begin to free associate and then get out of their way (Elvin Semrad, personal communication, 1974)! Here, instead, the analyst is faced with the conundrum that while action risks impingement or flooding, and may invite new layers of

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Foreword

compliance and adhesive identification, the failure to act may leave the patient devitalized, abandoned, and emotionally dead. Recall Green’s (2005) observation that: Sometimes, paradoxically, it will be less damaging to the process to allow a lively countertransference reaction to be expressed, even if negative, in order to gain access to the internal movements animating the analyst. These are all evidence of [. . .] spontaneity [. . .] having more value for the patient than a conventional pseudo-tolerant discourse which will be experienced by the patient as artificial and governed by technical manuals. (p. 35) Hope for therapeutic efficacy at these levels of analytic work lies in the availability of the analyst as an object capable of lending his or her transformational capacities to the patient’s interrupted project of building a competent self with the emotional capacity for autonomous psychic regulation and processing. Bion (1962b) referred to this capacity as alpha function; the psychosomaticians of the Paris school speak of having a well-functioning preconscious (Aisenstein, 2010). DeMasi (2009) has described this regulatory capacity as an attribute of the “emotional unconscious”. What Eekhoff emphasizes is that prior to achieving psychic representation, the domain of the unrepresented, the pre-psychic or proto-psychic, the potentially emergent but not yet formed, is in and of the body. It consists of or is related to affect, action, and somatic sensation. These make up the raw material of what can become psychic if adequately transformed. It is “the body’s response to experience . . . [that] is transformable via relationship and the development of an apparatus for thinking that builds representational systems, strengthening psychic structure”. Once it becomes possible, “Unconscious phantasy transforms and facilitates internal and external relationship” (chapter 2, this volume). This work of transformation often begins with the analyst’s recognition of the silent, secret infantile transference and the understanding that it “reveals stuck places where the inborn affects have not been mediated by relationship or experienced and contextualized via dream thoughts” (chapter 2, this volume). Here, “dream thoughts” is used in Bion’s (1962b) sense of waking dream thoughts. Eekhoff’s formulation offers analysts a guide to how this transference might be handled and previously disrupted development resumed. Infantile experience is not remembered in the mind via narratives . . . [It] is remembered in the body via memories in the sensorium and memories in feeling. Infantile experience is remembered in action in the repeated structure of relationships, and is discovered when the analyst becomes a participant and can observe herself and the patient in relationship with each other. (chapter 3, this volume)

Foreword

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What may then come into focus is this infantile, silent transference that “is not strictly speaking a state of fight or flight; rather it is a state of frozenness or blankness” (chapter 3, this volume). The latter is not the result of forbidden wishes that cause anxiety and so must be banished at the behest of the superego, but rather is related to trauma, failed development, psychic voids, and disruptions in psychic capacities. Such emptiness is not found to be part of a hidden and imagined phantasy story, “but has nothing under it, is puzzling and confusing. It may be tempting for the analyst to fill in the gaps, as such a state is extremely difficult to tolerate” (chapter 3). But as Laplanche (1992) has taught us, there is great value in not rushing in to fill the “hollow of the transference”. Left unfilled, the gravitational pull of the hollow, the demand it makes upon the mind for work, produces a gradient of tension that can lead the patient to elaborate or discover his or her own spontaneous interpretive and constructive conclusions. Repression, which is characteristic of neurosis and the presence of psychic organization and structure, requires awareness of experience. Here, instead of being repressed, that which is missing was never mentally processed enough to be banned. The analyst is left with ‘nothing’ to name. There appears to be blankness where an infantile traumatic experience might be. [. . .] Unformed, unmentalized experience remains unremembered and unexpressible, except in the body. (chapter 3) That this level of experience and the empty pseudo-discourse that it produces go on embedded in and along with the more classical presentations of other, later, or non-traumatic experiences only adds to the complexity of the situation and to the analyst’s potential confusion. Ferenczi (1949c) spoke to this when he said: It is unjustifiable to demand in analysis that something should be recollected consciously which has never been conscious. Only repetition is possible with subsequent objectivation for the first time in the analysis. Repetition of the trauma and interpretation (understanding) [. . .] are therefore the double task of analysis. (p. 261; italics in original) Ultimately, what is at stake in the cure of these patients is their capacity or incapacity to experience and to learn from that experience. What appears absent in the patient is a subjective sense of self that includes a center that would hold emotional experience and make meaning of it. The missing center, in phantasy, has been projected out into the universe in search of a container and has found none. Space is infinite for them, without the capacity of being closed. [. . .] There is no center of gravity. (chapter 5, this volume)

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Foreword

It is the analyst, the analytic setting and the analytic relationship that must become the center of gravity for the patient and the foundation upon which a structure of meaningful experience can develop (chapter 5). This situation produces tremendous pressure on the analyst’s capacities for trial identification, regredience (C. Botella, 2014), and self-analysis. As Eekhoff writes, Focusing on the body [including one’s own bodily feelings, states, and reactions] and being aware of somatic defences offers an entrance to the psyche for analysts working deeply with severely withdrawn patients. In extreme instances, the analyst may find herself matching the patient, much as a nursing mother assumes the breathing rhythms of her infant. (chapter 1, this volume) At times, this matching may require us to face and experience our own agony and threats of annihilation and disintegration, as we find ourselves thrust into contact with the deepest and darkest layers of our own souls and personal histories. Eekhoff’s work is a courageous and instructive guide to the dangers that must be contended with and overcome when addressing these vital issues and to the opportunities offered by encountering our patients and ourselves at these primal levels of the psyche. Howard B. Levine, a former member of the Board of Directors of the International Psychoanalytical Association, is on the faculty of the Psychoanalytic Institute of New England, the editorial boards of the International Journal of Psychoanalysis, and Psychoanalytic Inquiry. He is in private practice in Brookline, Massachusetts.

Introduction

Much of the current interest in non-represented states is based upon a foundational belief in primary narcissism and a primary void (Green, 1999; Levine, Reed, & Scarfone, 2013). Such a void leaves the infant adrift in a sea of affective and perceptual chaos. The infant’s capacity for representation and relationship, if one believes in primary narcissism, develops out of the mother’s ability to mediate this innate affective and perceptual chaos. Kleinians and Bionians have an alternative view, as do I. They believe the infant is born object related; that is, with a very primitive capacity to differentiate self from other and to make use of the parent’s mediating functions. By implication, the infant is born with a primitive capacity for representation. The mother still plays an important role in mediating affective and perceptual chaos, but the infant communicates. Furthermore, the object-related infant is born with an expectation of being met (Anderson, 2017). Bion called this a preconception waiting for a realization. Such differing theoretical beliefs impact clinical work with patients who are difficult to reach and treat. For Object Relations analysts, a void exists not as a primary condition but as a result of interactive failure between infant and parents. It can come from the combination of what the infant brings and what the infant finds. Maternal unavailability or indifference and misattunement impacts the mediation of what is brought. Infantile receptivity also impacts what the mother provides. Narcissism is secondary to a traumatic early experience. Both beliefs are valuable to the clinician who works with difficult-to-reach patients. The technical innovations found in both bodies of clinical research are helpful to clinicians working with patients locked in perpetual pain and who seem unable to learn from their experiences. These patients bring us non-represented or weakly, poorly represented states and these states arise as challenges to development and often impede analytic progress, resulting in impasses and therapeutic failures. Both analysts and patients despair of finding means to reduce the pain and suffering and to reclaim the lives impaired by such profound difficulties. This collection of essays, following after Ferenczi, Klein, and Bion, represents my professional passion and growth over a number of years. They exemplify my interest in reaching patients who previously might have been thought

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of as unanalyzable. These are the patients who have turned away from life and retreated deeply into themselves, leaving others out of their worlds. Even though many of them have been successful in their professions, few have considered themselves successful in personal relationship without analytic treatment. All of them suffer intense and unrelenting mental pain. This poses a special problem for analysts working with them. Although often consciously highly motivated for treatment due to their intense suffering, their unconscious processes keep them out of relationship via a denial of the object and out of touch with themselves via a denial of their own subjective existence. Without a subjective sense of self, they lack emotional agency and do not appear to need others. Relationship is not consciously a source of satisfaction or pleasure for these patients. Rather relationship represents unconscious pain, suffering, and disappointment. Vulnerability and dependency are enemies as they are evidence of existence. Awareness of others is also unbearable since relationship brings with it dependency and vulnerability. Awareness of others poses a threat to the defences and brings panic and physical symptoms that once again interfere with relationship. In the process the patients have attempted to wipe themselves out as active participants of love, laughter, and living. Since relationship is the foundation of psychoanalytic work via our use of the here and now transference and counter-transference, working with such patients is extremely challenging. If they cannot find themselves they are, in turn, difficult to be found. One such patient told me, “I am not a human being. I am a human doing.” She was right. At the time she told me this, I was too young in my profession to help her. She left after a year of therapy, only more ensconced in her encapsulated action. I felt confused as she expressed gratitude to me without having changed. This book provides clinical examples of Object Relations analytic work with patients whose representations of experience have been inadequate for emotional meaning-making. As a result, they have been patients who were difficult to reach and difficult but not impossible to treat. These patients are loners who suffer continually. Although I do not typically use diagnosis as a part of my practice, these patients would most likely be labelled as suffering from chronic post-traumatic stress, schizoid, or borderline personality disorders and even psychotic depressive disorders. Poorly formed representations doom them to repeating their pasts, rather than learning from their experience and envisioning and having a different future. These patients have a weakened capacity for representation and poor apparatuses for processing their experience. I believe that the only treatment that can impact these resistant-to-change states of mind is psychoanalysis. The psychoanalytic treatment will not be brief, but long and complex. This means the analyst and the patient must both be committed to the work of discovery. For the analyst, the transference of being a no-object must be endured before it can be interpreted. The analyst must be patient and use interpretation to mark, name, and describe processes that are visible in the moment of the here and now of the session. The patients in this book are experts in being in the moment. Their difficulty is in

Introduction

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being unable to bring those experiences into a context that includes a past and a future. The analyst must become the memory for the patient and recognize that interpreting the transference takes time. We risk interpreting at a higher level than appropriate. When we do that we provide material for mimicry but do not aid in the development of structure that makes learning from experience possible and accumulative. For experience to accumulate there needs to be an experience of a space that can be closed. These patients seem to have difficulty apprehending an enclosed internal space. This also explains why they experience time only as a repetition. *** Here are an outline of the chapters and brief summaries of their contents: In chapter 1, “Between Body and Mind”, I am exploring the role of the body in relationship to the development and health of the mind and I present a method of using bodily awareness to deepen psychoanalytic treatment. Currently, psychoanalytic therapists and analysts are treating patients who come to therapy complaining of being “dead” or “shut down”. These patients are very different from Freud’s hysteric. As such, they present new challenges to our understanding and our techniques. Clinicians who recognize the body as a processor of emotional experience are able to work with seriously disturbed or regressed patients who use language as “action” and behaviour as communication. For these patients, the Talking Cure does not cure so much as it continues the defence against experiencing the early traumatized infantile part of themselves. In the absence of emotional awareness, bodily sensation and action fill the gap. If the clinician can remember the function of the body as both an aid in understanding reality as well as a defensive blocking agent, these patients become more accessible to treatment. In chapter 2, “Affective Bridges Between Body and Mind”, I lay the intellectual foundation for the book in an integration of Freudian and Kleinian drive and Object Relations theory. The chapter uses examples to highlight the importance of the clinical use of transference and counter-transference. It integrates instinctual drive theory with affective emotional representations of experience. Neurobiological and neuro-psychoanalytical research is used to support the descriptions of clinical experience. Chapter 3, “The Silent Transference”, contains my current understanding of the silent transference in light of my clinical experience and my psychoanalytic heritage of Ferenczi, Klein, and Bion. By silent transference, I mean a transference that seems not present in the therapy hour. I use clinical examples from patients who were traumatized at birth by the dual challenges of being born medically compromised and separated immediately from their mothers. They faced death as they were born. The twofold trauma impacted their internal object relations as well as their external relationships, including their relationship with me and mine with them. It also affected their ability to represent their experiences.

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Introduction

Chapter 4, “Somatic Counter-transference”, discusses the use of somatic countertransference as a means of learning about the patient, about projective and adhesive identification, and about the object-relating nature of a traumatized and withdrawn part of the personality. It uses clinical material to illustrate the hypothesis that the analyst’s somatic counter-transference is an indicator of a very elemental communication occurring from an aspect of the patient’s psyche that is united in a body/ mind or mind/body. The chapter assumes that this body/mind state was object seeking at birth and perhaps before. In chapter 5, “Finding a Center of Gravity via Proximity to the Other”, I describe how emerging from autistic encapsulation is a painful and terrifying experience. Primitive anxieties that are simultaneously defences against reality have previously functioned to protect the person from unbearable states of mind that are at the center of their origination. With increased capacities for bearing pain, these defences are minimized. Although these primitive anxieties are always available for all of us, they are increasingly less necessary protections against the reality of separation as projective and introjective identifications develop. Bearing the pain of separateness enables the previously inhibited capacities for learning from experience to develop, and with this development the frozen self and unformed self emerge. The emerging self suffers the primitive anxieties that were previously not experienced – and suffering them then emerges. Emergence cannot be done in isolation but requires a relationship with an alive and unfrozen other. Chapter 6, “Infantile Trauma, Therapeutic Impasse, and Recovery”, describes how the psychic struggle to exist or not is held in the body. When emotions bypass the symbolization process and reside as bodily processes, they cannot be thought or remembered consciously, yet are primitively represented. This chapter, using Ferenczi and Bion as theoretical background, explores the clinical development of impasse in the treatment of hard to reach patients. These patients are problematic for analysis because they are not self-reflective, although they can be addicted to “processing” in lieu of emotional connection. Impasse occurs when the analyst does not detect the mimicry involved in the processing. The chapter offers the idea of recovery, rather than repair, in that such patients have “gone missing” in infancy. Recovery of lost potential can be found in relationship with the analyst and with significant others. In chapter 7, “Finding the Impulse: Healing from Infantile Trauma”, I describe how patients who have been traumatized as infants present in the consulting room as difficult to reach. Depending upon the stage of their recovery, they appear passive, overly compliant, and eager to please. They seem to find their initiative in others, taking their cues from the environment and not feeling their own healthy impulses. Both the desire to connect with others and the ability to connect with themselves seem to be stunted. As they heal in their therapy, impulses return and they must learn, much as young children do, to manage the turmoil these impulses stimulate. These are the moments in the treatment during which impasses occur, for coming alive is terrifying and enraging. Coming alive is overwhelming and traumatizes the patient again.

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This chapter uses a clinical example to demonstrate the process of recovering lost impulses from infancy and dealing with the overwhelming affect that is evoked in psychoanalytic treatment. In chapter 8, “The Body as a Mode of Representation”, I am revising my previous use of the word “unrepresented” and suggesting, along with Oliner (2013), that representation occurs along a continuum. The elements that I previously grouped in the unrepresented category covered too wide a range. Primitive body memories – not just memories in feelings, but memories held in the body as traces or impressions – are modes of representation. There are primitive representations in sensations, sounds, smells, and images. Clinical evidence indicates that more than one mode of representation exists. The Botellass’ (C. Botella & S. Botella, 2005) exploration of figurability also emphasizes the role of the body in early primordial symbolization. This chapter provides clinical examples of a patient’s experience of innate primary affects and their communication to the analyst via the body and visual images. The analyst’s role is to receive that communication first in her body and then in her mind and to aid the patient in developing a capacity for increased symbolization and representation via language. *** This book describes states of mind that occur before the paranoid-schizoid and depressive positions. Thus, interpretations of envy or aggression, or negative therapeutic response, miss the patient with post-autistic or post-psychotic states. We are not looking at aggression but at a structural component that is prior to splitting and projection. It is as if the fusion that one would trust as necessary for development is unreliable. This means that the patient is oriented towards an object in a tropic manner. The analyst provides a direction for his or her attention. There is no defence against experience or even a feeling of conflict. There is a deficit in the ability to introject and contain. Before one can split one has to be whole. These patients become unintegrated or fall apart, but strictly speaking they may not have ever been integrated enough in order to split well. My hope is that this book will aid others in working with these patients who suffer ongoing and relentless pain. I believe their pain is analyzable.

Acknowledgements

I am grateful to the following sources for allowing me to reprint, with minor changes: The Canadian Journal of Psychoanalysis for material in chapter 3 that originally appeared as “The silent transference: Clinical reflections on Ferenczi, Klein, and Bion”, in 2015 in volume 23(1), pages 57–73. The American Journal of Psychoanalysis: for material in chapter 4 that originally appeared as “Somatic countertransference as evidence of adhesive identification in a severely traumatized woman”, in 2018 in vol. 78(1), pages 63–73; and for material in chapter 6 that originally appeared as “Infantile trauma, therapeutic impasse, and recovery”, in 2013 in vol. 73, pages 353–369. The Taylor & Francis group for permission to reprint in chapter 5 material that originally appeared as “Finding a center of gravity via proximity with the analyst”, in H. Levine & D. Powers (Eds.), Engaging Primitive Anxieties of the Emerging Self: The Legacy of Francis Tustin, pages 1–19. London: Karnac, 2017. I am grateful to my patients who have had the courage and commitment to work deeply in search of their own personal truth. They have taught me much, pushing me to the limits of my ability so I could understand and be with them in their suffering. I also want to acknowledge my analyst, Austin Case, who did not shy away from going deeply into places I might have preferred not to go. He helped me face myself in preparation for what I now face daily. I am grateful to the analytic societies and institutes that have nurtured and stimulated me: the Northwestern Psychoanalytic Society and Institute, the Western Canadian Psychoanalytic Society and Institute, and the Seattle Psychoanalytic Society and Institute. They have given me stimulating discussion, conscientious feedback, constructive criticism, and ongoing support and the opportunity to teach.

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Finally I want to thank my colleagues who have read and critiqued my papers, argued ideas passionately, and inspired me with their own work and passion: Elie Debanne, in Vancouver, BC, Canada, deserves special mention as a careful reader and responder to my very first analytic papers, as do Robert Oelsner, Mirta Berman Oelsner, and Bruce Pollock. I thank Endre Koritar who always encourages me to publish. Especially, I thank Sigrid Asmus, a careful editor and psychoanalytically informed reader, who helped me bring my vision to completion. At Routledge, I want to thank Russell George and Elliot Morsia, who supported me through the transition of Karnac to Routledge, picking up my project midstream and with their excellent staff making it happen. Finally, I would like to thank my friend Judy Lightfoot.

Chapter 1

Between body and mind Transforming physical experience into psychic development in the clinical situation

The realm of the mind is a world of infinite possibilities of meaning from whose formlessness a coherent internal world must be constructed by thought operating on the perception of emotional experiences. – Donald Meltzer

Bion says that truth is to the mind what food is to the body (Bion, 1965, p. 39). In that respect, it would seem that the work of analysis is to uncover truth and to the best of our ability speak what we uncover. What enables us to find and speak truth is our trust in our own internal worlds. If we can trust our internal worlds to guide us through the miasma of our ideas, our training, our clinical and personal experience, we can be with our patients wherever they might take us. Sometimes we have patients who take us places we would rather not go. Those patients try us sorely because they do not fit our preconceptions about what it is we do. They seem to be unable to use analysis even though they want to be analyzed. Like Bion, I believe that our theories are sufficient to understand them and our models creative enough to use with them, but the “patient who is difficult to reach” (Joseph, 1975, pp. 75–86) forces us to modify our techniques (Ferenczi, 1928) and to pay closer attention to ourselves paying attention to them. Using the theories of Freud, Ferenczi, and Klein and the background models of Bion and Meltzer, I want to describe what I believe is occurring with these patients and then discuss the analyst’s focus on the body of the patient as an aspect of the material used to find the patient’s truth in the moment of the session. In addition, the analyst pays attention to her own somatic responses whether or not she uses them for interpretation. I will briefly review the theory I am using in order to support my conclusions.

Theoretical background In “On Narcissism”, Freud (1914) emphasized the importance of the body and the instincts in the development of the mind. His statement that “The ego is first and foremost a body ego” is often quoted. Later he writes, “The ego ultimately

2

Between body and mind

is derived from bodily sensations” (Freud, 1923, p. 26). Freud’s (1911) two principles – the reality principle and the pleasure principle – are firmly based on his beliefs about the body and its relation to the mind. Klein (1933, 1946, 1952), believed that the play of children could be interpreted just as the free associations of adults were interpreted in adult analysis. She implicitly used the actions of her patients or their physical expressions as evidence of their unconscious worlds. She not only focused on the bodily expressions of her patients but also interpreted their unconscious phantasies about others’ bodies, most importantly their mother’s body, to them. Her interpretations to both children and adults frequently used body images to communicate the emotional experiences found in the immediacy of the transference. Susan Isaacs, in her classic paper “The Nature and Function of Phantasy” (1948), describes unconscious phantasy as being on the cusp of the mind and the body, incorporating both. In a less well-known paper, “Criteria for Interpretation” of 1939, she says that included in the data for interpretation are: The facts of the patient’s behaviour as he enters and leaves the room and while he is on the couch, including every detail of gesture and tone of voice, pace of speech and facial expression, any routine or any changes in behaviour and expression; every sign of affect, or change in affect, its particular nature and intensity, in its associative context. (p. 148) Focusing on the body and being aware of somatic defences offers an entrance to the psyche for analysts working deeply with severely withdrawn patients. In extreme instances, the analyst may find herself matching the patient, much as a nursing mother assumes the breathing rhythms of her infant. Ester Bick (1968) and Didier Anzieu (1990a, 1990b) each dealt with the concept of a mental skin that allows boundary and space and facilitates emotional containment. The absence of a mental skin from fetal life through infancy can leave one stuck in a false self. Another way of saying this is that patients without a mental skin unconsciously mimic whomever they are with in order to feel that they exist. Without a mental skin, they find others and mimic them, thereby creating a second skin. Joyce McDougall (1989) describes these patients as “‘anti-analysands’ in analysis because they seem to be in fierce opposition to analyzing anything that has to do with their inner psychic world, insisting on external reality as the only dimension of interest” (p. 93). These patients, whom she calls “normopaths”, deny emotion. For them, according to her, since emotion is psychosomatic, their denied emotion can be projected into their bodies (p. 95). She believes that alexithymic and somatizing patients use their bodies to communicate because their emotions are not available to them and are absent in their verbal communication. McDougall highlights that such patients use their illness in order to know they are alive. She feels they ultimately fear relationships because they believe that

Between body and mind 3

“Love leads to psychic death, that is to the loss not only of . . . mental barriers against implosion from others, but also of . . . body limits. Nothing short of total indifference . . . can assure . . . survival” (p. 39). I believe this fear of relationship contributes to the difficulty analysts have in working with these patients. The transference is hidden, and emotional contact is scarce. Interaction is superficial. Antonio Damasio (1994, 1999), the neuroscientist, believes that on the basis of his research all learning is initiated via the emotions. His research supports the psychoanalytic research of Wilfred Bion when Damasio (1999) states that “emotion is integral to the process of reasoning and decision making” (p. 41). Further, he sees all emotion as related not only to learning but also to relationship with objects. He writes that “The alleged vagueness, elusiveness, and intangibility of emotions and feelings are probably symptoms [of how we] sometimes . . . use our minds to hide a part of our beings from another part of our beings” (1999, pp. 28–29). The theoretician that I am using most in this chapter is Wilfred Bion, who always emphasizes the importance of emotion and relationships with internal as well as external objects. Bion credits Freud’s (1911) exploration of the origin of thought and the mind’s attempts to deal with reality as having aided him in the development of his ideas. He also credits Melanie Klein (1946), particularly her understanding of the infant’s sadistic attacks on the breast and her discovery of the processes involved in primitive splitting and projection. These she named projective identification. This chapter comes out of Bion’s papers, and Bion’s papers come out of Freud and Klein. Bion (1962a) writes: The senses may be able in a state of fear or rage to contribute data concerning the heart-beat, and similar events peripheral, as we see it, to an emotional state. But there are no sense-data directly related to psychic quality, as there are sense-data directly related to concrete objects. Hypochondriacal symptoms may therefore be signs of an attempt to establish contact with psychic quality by substituting physical sensation for the missing sense data of psychical quality. It seems possible that it was in response to his awareness of this difficulty that Freud felt disposed to postulate consciousness as the senseorgan of psychic quality. I have no doubt whatever of the need for something in the personality to make contact with psychic quality. (pp. 52–53) In chapter nine of Elements of Psychoanalysis, Bion (1963) discusses speaking behaviour designed to develop thought as “doodling in sound” (p. 38) so what was inside could come out, be observed, and dealt with in order to discover their meaning. “Doodling in sound” is action, however, not communication. It is behaviour. Without explicitly saying so, Bion implies that he makes use of the psychotic patient’s behaviour, not only his words, when he gathers information in a session. Paul (1997) calls this “the imitation of human speech”.

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Bion (1963) believes that meaning is made from thinking about body sensations or thinking about the perception of emotion as found in response to the environment. He called this meaning-making process alpha function. Alpha function uses emotion as a bridge between mind and body. He described the process of moving back and forth from the paranoid-schizoid position to the depressive position as the mechanism “as part of the development of a capacity for thought” (p. 42). He says that the beta elements, or affective somatic sensations, are “felt to contain a part of the personality in their composition” (p. 42). I believe the healthy mind is continually attempting to hold the internal and external realities in balance, that is, to stay integrated, mind and body. In order to stay in contact with both realities, the mind seeks input from both places, inside and outside, physical and psychical. In health, then, the senses derived from the organs of perception are used to validate the emotional experience such data collecting engenders. The unity of mind and body provides a balance or equilibrium for optimal functioning. In early infancy, with good-enough mothering and without tormenting physical illness, the infant has the opportunity to explore this wholeness as well as this undifferentiation of mind and body. It is this primal experience that becomes the template upon which mature integration is formed. Without good-enough containment, the infant may not have enough experience of wholeness, and may fragment. Containment comes both from within and without the primitive mind: from the mother and father, as well as from the physical sensations of the baby’s body. When the parent is depressed or ill or compromised characterologically, it is the parent who projects destructively into the baby instead of receiving and metabolizing the baby’s projections. With no one to project into, a baby may turn to things, or in extreme cases to his or her own body. It is at such moments that the body becomes the only means possible of communicating and receiving, for the mind of the mother is shut down and split off from her own self as well as from her baby. The relationship between the two is pathogenic. I surmise in this situation that, in the baby’s mind, its body comes to equal the body of the mother, instead of representing the mother’s body. This symbolic equation (Segal, 1957) impedes symbolic processing and also interferes with the baby’s relationship to both internal and external reality. The development of thought is threatened. Emotional relationship to both self and others is shut down. Projection into the body instead of into the parent initiates a process that harms both the structure used for thinking and the thoughts that evolve. The developing child moves farther and farther away from a relationship with his own emotional truth as experienced internally and externally.

Technical applications Technical applications of theory vary widely from professional to professional, even when there is consensus about technique. My understanding of Bion’s clinical papers from 1975 to 1978 (2014) has greatly influenced my work with passive,

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as-if patients. I am also grateful for his paper on differentiation of the psychotic from non-psychotic processes (1957). Although my intuition is informed by my theories and by my adapted techniques (Ferenczi, 1928), what I think I am doing is in fact always different from what I actually do. Attempting to describe what I am doing keeps me honest with myself. With that caveat, I attempt as much as I am able to be present with my patient without “memory, desire, and understanding” (Bion, 1970, p. 46), although often I fail. This failure is often centred around my focusing on somatic memories, instead of staying in the moment with my patient. I attempt to understand the emotional connection, however hidden, between the patient and myself in the moment. Paying attention to the process, and to the form of a session more than to its content, keeps the immediacy foremost. My interpretations are often transference interpretations that shift between intrapsychic and transferential. Typically, but not always, I avoid making non-transferential interpretations. Also, with patients who are difficult to reach, I use description as a means of holding. This description may often be of my patient’s bodily expressions, when linked to an absence of expressed emotion. Counter-transference responses Since the groundbreaking work of Racker (1968) and Heimann (1950, 1956), using counter-transference has become an important aspect of any analysis. I use my counter-transference as information about my patient. Although I rarely disclose my experience, I use it to formulate my interpretations. Paying careful attention to my somatic responses to clinical material demonstrates the value of what my body tells me about me as well as about my patient. Sometimes it takes weeks or months to be able to perceive or to recognize a somatic response in me as communication from my patient, but the fact of it gives me hope that early unmentalized experiences can be communicated, brought into awareness, and eventually into language. Included in my somatic responses are images, tactile sensations, and olfactory memories, as well as daydreams. All these are information about both the patient and me and are part of the analytic field. When I am ready to make an interpretation, I attempt to speak to the deepest anxiety, rather than to begin at the surface and move down towards it. In that way I have adopted a Kleinian perspective. Since the body is used as a background object in both health and pathology, the earliest anxiety is often about the body and about not existing or dying. For this reason, the emotions triggered in me are often what I would call big emotions – that is, once I have begun to understand my patient, I feel quite horrified to be witness to the self-destruction continuing in spite of my best efforts. The utter disregard for anything I say and the inability of my patient to remember and make use of my interpretations makes the work slow and seemingly futile. Patients who have been traumatized as infants and young children, many of whom have been separated from parents at birth by medical problems, do not know how

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to use their objects and so not only must I bear these big emotions, I must bear not being used (Winnicott, 1969). My emotional responses also include my own feelings of uselessness, inadequacy, confusion, and despair. Sometimes I have a feeling that I do not exist. What am I doing anyway? I believe these feelings are primitive affective communications from my patient that I must feel first in my body and then emotionally in order to find words that will always be inadequate. My belief in the analytic process and my compassion for the pain of integration sustain me. The patient I am trying to understand a certain aspect of the personality that exists to greater or lesser degree in all of us. I am trying to uncover the dead and dying aspects beneath the layers of false selves that we present to ourselves and to others, and that we discover in more malignant forms within our patients. For purposes of clarification, I will use clinical examples of patients where this deadness is more profound, although still hidden. Repeatedly in my own analytic practice and in the practices of those I supervise are found patients about whom it is said, “I don’t know why she comes”, or “Nothing is happening”, or “I can’t tell if he is getting anything”. Sometimes, therapists say, “Somebody has to do something”. Others will say, “This patient is just not treatable”. These particular patients are seemingly not emotional and so they are not difficult. They may even tell interesting stories although often they do not appear to feel what they describe. It is as if they were talking about someone else or about someone they have heard of but do not know. It seems they are not talking about themselves. Therapists may be interested in these patients but not moved by them. Some therapists may attempt to reach them by describing the feeling that “ought” to be under the story. Others may attempt to work with the patient’s body, following their breathing, or describing their postures and attributing meaning much as a mother might interpret a baby’s frown to mean the juice is sour or an arching away to mean “stop”. The attempt to translate body language into emotional communication and ultimately into meaningful words sometimes appears to help. This apparent effectiveness increases the therapist’s activity. The therapist’s activity is an attempt to activate the patient’s passivity and to breathe life into dead bodies. These patients seem to eagerly adopt what they are told as their own. Yet the adoption is not about true learning or integration of their experience. Experience does not stimulate their learning, but provides material for mimicry. Their language can be vague and non-specific; their complaints are often quite abstract. Betty Joseph (1975) writes about these passive patients as a subcategory of patients who are difficult to reach. Patients who come for analysis after such treatments frequently will appear to understand themselves. They will have words for things. They will have stories about themselves. Initially, they may even appear to gain much from their

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analysis. Unfortunately, upon reflection, I have discovered these thoughts and behaviours to be mostly remnants of their previous therapists, combined with habits gleaned from self-help books, TV talk shows, or movie characters they like. At best they have words for words; at worst they have a deeply hidden nearly invisible structure of mimicry that hides a more serious psychopathology. Often they have many physical conditions that send them frequently to doctors and may even require surgeries. After a time, they begin to describe physical sensations that trouble them. They can go on and on about one sensation after another. All of these frighten them, and they are sure the sensations are precursors of death. Why do we see such patients? Perhaps we see them because we are fooled by their presentation or we have faith in psychoanalysis or excessive faith in our own abilities. Or perhaps we do not recognize them. If we did, we too might ask, “Why do they come?” They come because they have a vague sense that something is wrong. They often have long histories of seeking help, not only from doctors and social workers, counsellors, and ministers, but from anyone who will see them. In their search they are not passive. They will say things like, “There’s something missing”, or “I think there is something really wrong with me”, or “I don’t know what’s real”. They come because they are persistent in their search for truth. Like Betty Joseph, I believe this condition comes in a variety of diagnoses. No matter what diagnosis might be given to these patients, this hidden psychic structure underlies the superficial external persona. Words that seem to have meaning are in fact merely words about other words that are put together to seem like communication. They are not even words about feelings. The words are what Michael Paul (1997) calls “the imitation of human speech”. They are sounds. They are rhythms. They may be soothing or discordant, numbing or enlivening, but they do not communicate emotional meaning from the patient to the analyst. It is the analyst who attributes meaning. In doing so, the analyst gives the patient something to imitate, as light gives a plant a direction to turn. In spite of a seeming lack of connection, I believe there is always an emotional connection hidden in the session. It may be difficult to find in the content of the spoken words or in the images of a dream. Instead, the invisible emotional connection may be communicated in the body of the patient and conveyed to the body of the analyst. It is frequently outside of mind and found in action and behaviour. Passive patients who need the analyst to do everything for them are like infants barely able to feed. They do not assert their needs because they do not feel them. What they express depends upon what the analyst gives. It is mimicry, but rarely immediate mimicry. If it were immediate it would be easier to detect. By that I mean that what appears to be an emotional response is unconscious pretence drawn from introjected bits and pieces of earlier experiences. These non-integrated introjected pieces are then drawn upon when responding to external stimuli. The capacity to check inside with the internal objects that commune there and speak from a whole self about personal thoughts, feelings, and desires is lacking. Awareness of personal feelings and desires is severely

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limited. The capacity to put these bits together with other internal objects and create something new is damaged. Often, there is no awareness of being a person with a body. As a result, the thoughts these patients report are filled with “shoulds” and lacking in emotional depth. The internal defensive structures so necessary for sorting through experience, for prioritizing, and for reflecting are mostly absent. Interpreting what appear to be defences therefore only provides the patient with more material out of which to construct a fabricated self. What masquerades as insight is mimicry that cannot be internalized. Rather than an integration and accumulation of experience, there is an agglomerated mass of seemingly unrelated bits. When such patients speak, it is either with a pre-planned agenda, as in the beginning of the hour, or by deciding on what response the analyst is seeking. Often, there is no impulse to speak, either from a desire to say something to the analyst or out of a desire to be understood. Desire for anything is not felt, unless pleasing the analyst could be a desire. However, even what looks like an attempt to please the analyst is more about becoming the analyst for the moment. The impulse to speak may come from a thought that says, “Analysands speak; analysts listen”. Even the impulse to be silent may come from a thought that says, “The analyst expects me to be silent now”. Even silence can be the analyst’s silence reflected back to her. On the manifest level, it appears that an analysis is going on. However, over time nothing changes. What the analyst initially thought was evidence of therapeutic action in fact is mimicry. Because this mimicry is so subtle and so hidden, it is difficult to understand what is truly happening in the session. Bion says that what is of interest to the psychoanalyst is that which is not known. This is good guidance, as in a session with such a patient hardly anything known is trustworthy. Behind the mimicry is a two-dimensional, depleted, passive aspect of the self. The mimicry is a secondary characteristic of a deeply pathological substructure, autistic in nature. As this passive patient is talking, and there may even be a great deal of drama in the story, the only clue that true communication is not occurring is found in the analyst’s counter-transference. Often the analyst’s first clue is a physical sensation. The transference itself is extremely difficult to discover – not that it is not present, but that it is covered by whatever role the patient is playing that day or that moment. The shifting states of mind we analysts are accustomed to interpreting occur rapidly. The speed of the splitting makes them difficult to catch. In fact, since these patients frequently leave us feeling unmoved, their projections are feeble and what Tustin (1986) and Meltzer (1974) would call adhesive in nature. Rather than projecting them into us, these split-off aspects of the patient are projected into their bodies – their senses, their perceptions, and into their delusional structures. Noticing this is difficult and naming these shifts feels futile. Here concepts that have been put together do not really relate to one another, so ideas do not accumulate into meaningful dialogue. The analyst speaks and the patient mimics. Bizarre internal objects, the origins of which are difficult to discern, dominate. Representations that may once have had meaning are done

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via alpha function in reverse. Hallucinated physical symptoms take precedence (Bion, 1957, 1965, 1970).

Clinical examples I will describe several patients who exemplify these phenomena. The first patient has a psychotic substructure within a primarily neurotic character. The second has a neurotic substructure within a psychotic character. Sometimes after long work, patients are able to state something of their experience that rings true. They know something without knowing they know it. To give an example: A woman who was severely anorexic in her adolescence enters, smiles with her head cocked slightly to the right. She glances at me before lying down and says, “How are you?” She giggles, ducks her head, and lies down. She lies still, and after a minute says in a cheerful proud voice that she had a fight with her husband. She is silent for several minutes. I feel a mild pressure as I know she rarely fights with anyone. Although I have interpreted her upset with me, she denies it. She has never told me she was upset with me. I can think of nothing to say, but do not mind it. I wait, also without moving. She thanks me for the insight gained from the Monday and Tuesday sessions. I feel those sessions were good sessions, but now I have the slightest feeling of doubt. I notice a fatigue that surprises me as it is 8 a.m. and only my second session of the day. Then she says proudly. “And I had a dream”. There is quite a long pause: I come into the office of a scientist in a white coat and he has a yellow file on his desk. He tells me that I have checked out and closes the file on me and puts it in a tall file cabinet. I feel relieved. She uses her hands while telling me the dream, demonstrating how the file is put away with a flicking of her wrists. Her associations to the dream are of a special she watched on TV about polio. The researchers experimented on developmentally delayed institutionalized kids. Some of them died when the researchers made a mistake and gave the children live virus. She then went back to the fight she had with her husband. They never fight, but she got mad when he didn’t help her finish the pots and pans after he had cooked dinner. I find myself thinking that she was unreasonable – if her husband cooked dinner, she should wash the pots. I notice my judgement and wonder about it. I pull myself back and believe my judgemental thought is a defensive reaction. She may be talking about me and her wish that we could close “the file on her”. I remember that while she was an adolescent a doctor wrote a paper about her anorexia and published nude pictures of her. She reported he diagnosed her but

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didn’t help her. She felt used and abandoned by her parents and her doctor. I also think I could write about her, as clearly, I am now. She is speaking quite animatedly and with a lot of drama. I am left feeling very little, although I am thinking a lot. I notice I am having difficulty believing her emotional display. She is twisted sideways and using her hands as if pushing something away. I also think I am the researcher who gives her live virus that she is afraid will kill her. I am beginning to wonder about my earlier doubt. I do not say any of this, and listen, feeling no pressure from her to reply. After a long silence, during which she lies unmoving on the couch, she says: I was a screen, an absolute blank screen. He could hurl his insults and I did not correct him in any form. Like mom and dad hitting me. They leave and I don’t want it to happen again. He builds up an image of me that’s not me, but they think it is. It doesn’t look like me or walk like me or talk like me. Eventually I blow. “That’s not me”. He is talking to the sculpture [of] me he created. At first I am confused. Then I realize she is speaking of her second husband, not her current one. She is also speaking of her parents and mixing up her pronouns. Time seems to be confused. I remember that when she first came to see me, now more than five years ago, she told me she had gone to her closet and picked out a designer dress and shoes, thinking, “This is me today”. She is talking animatedly while these thoughts run rapidly through my mind. My memories and thoughts are my own attempt to cover my confusion and minimize hers. I change the history – right there on the spot. Instead of admitting that I see him as a slacker, I deny. I didn’t say that. I would not have owned I thought he was a slacker. Then people get mad, because they know what they heard, so now the anger is because not only have I deflected them, I am dissolving. When she said she changed the history, she ostensibly began talking about her second husband, not the third with whom she reportedly fought. Again, I notice that this well-educated woman is mixing up her pronouns. I feel confused again. The last sentence is about all of us. I remind myself to notice the process, not the content. She continues: First version – I’m a hard shell. Second version – I am dissolving, losing myself, gone. I can fight for a revised version. Third version – I’ll feel shame, I’m a bad person and a liar, caught between a rock and a hard place. I am having trouble following her. She has shifted from talking about her third husband and their fight to talking about her second. Then she speaks of her

Between body and mind 11

parents, and then she goes back again to speaking of her current husband. She is talking about herself. I am trying to follow her and can see she is agitated by her hand gestures, which play out her words. Her voice is soft now and no longer dramatic, but almost a monotone. Still, there is a pattern in the whole piece that could easily be interpreted in the transference. On this occasion, I choose not to do so because I can see how much distress she is in, despite her proud and upbeat demeanour. I also think that interpreting the transference would be interpreting at a higher level than the one in which she is functioning. It might add to her confusion of time and space, of who is who when. I feel awful when the whole thing’s over. I take these experiences and use them as bricks to build a fortress around myself and they are numbered as if I can remember. But can I? I’m so split-off, constantly revising.

I get it that people know when I am split off. My ex would get upset. “You’re not here – so passive”. He’s right. I am not.

In this brief vignette, my patient is telling me what she does, not only with two of her husbands, interchanging them and conflating the time and person, but also with me. She shifts rapidly back and forth between then and now and at times seems to have a good understanding of her process. I especially like the three versions she has of herself, all of which seem accurate to me. However, I truly do not know if her three versions are my words or hers. It is conceivable that they are remnants of my earlier interpretations that she has put together in a comprehensible way. It may be that I am agreeing with myself here. It may also be that she “knows” these things about herself without knowing what she knows. She can speak the words and not feel them. She uses her body to display who she is today but she is not in her bodily experiences. I myself find it difficult to stay in my body, using my mind in a frantic attempt to deal with my confusion, as Lombardi (2008) has described. The next day she came in and told me how she had felt the day before, in the third session of the week: I had a feeling I was going through the floor yesterday. This time, I knew it was not vitamin D deficiency. I could tolerate it, and try to think about it. I thought I saw myself as a blob on the floor, with no arms or legs and I had a thought, “I am a baby”. But I couldn’t hold it. It was pretty scary, different than a panic attack. I have had it before and I always thought I was going crazy.

I felt like I was turning to liquid, pouring through the floorboards.

Although she reported that she felt this outside of our session, I am not sure. I felt confused. I had no clue of it during the session, but it may have occurred then. Time warps with her; she may have felt it and hid it from me. She may have felt it after leaving at the end of a session. Although she is always friendly and cheerful, I know the sessions are very difficult for her. She doesn’t know why, though,

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and often experiences the absence from me as a relief. She doubts she has ever loved anyone or that anyone has ever loved her. Another patient whom I have found to be very difficult due to her compliance and mimicry exemplifies my searching for the truth of her by observing her body. I write about her in more detail in chapter 5. She came to me after two of her three children attempted suicide within three months of each other. Her doctor told her to come and so she did. She was a very compliant person so when told that she must be feeling something about her daughters, she trusted her doctor and did as she was told. She told me she did not know if she had ever felt an emotion, but merely acted as if she did. She did not believe she was capable of love, even for her children and grandchildren. Although she is much more ill than the first woman I am describing here, she did grow. I believe her growth is in a large part due to my searching for her amidst the bits and pieces of me that come back to me in her copycat behaviour. My awkward and unskilful attempts to stay alive in the midst of her deadness centred around my intuitive searching for her aliveness and naming what I find, even when the only aliveness I notice is her physical, barely breathing body on the couch. Even when I was wrong and she agreed with me, or right and she agreed with me, I had little to go on but my intuition. Agreement doesn’t make it so, just as disagreement doesn’t make it wrong. I could not trust her when she disagreed with me because she felt I wanted her to “be able to disagree” and so she disagreed. She truly did not know what felt right to her. Her random agreeing or disagreeing highlighted for me her inadequate splitting processes. Although she seemed to make judgements about what was right or wrong or good or bad, her classification and categorizations were faulty. I discovered that, at times, my intuition was informed by my own physical sensations, not so much my emotions. At first I disregarded these as being only about me. Then, I became curious about my lack of emotional response to her, even when her stories were dramatic. I knew that had I been watching a movie or listening to a radio drama of her stories, they would surely have elicited emotional responses from me. My body was receiving messages before my mind could notice them. I noticed my mind was quite stimulated and active. I had many thoughts while sitting with her. Intellectual explanations for her experience came to me with increasing regularity. After a while, I recognized them as theories about her. I had little awareness of my own thoughts about the process. Sometimes I found myself in a dialogue with her, about her, almost as if we were two analysts analyzing a patient together. Only, the patient was missing. With her stories, I felt nothing, except a mild curiosity. I did have more than intuition. I had my training and my studying Freud, Ferenczi, Klein, and Bion as well as a host of other psychoanalytic thinkers, and I had my faith in my internal world. In spite of all I had, at times that part of me that was trained to understand and to think was also a hindrance in my relationship

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to my patient. I fell back on the descriptions of theory in an attempt to know something. Her mimicry of certain but not all aspects of me was a distortion of me and added to my confusion. It was as if I were contagious and she caught moods and behaviours from me. I could sense that what she was saying had some distorted truth in it. It was especially difficult when I did not recognize the “me” coming back. Bion would call this a bizarre object as it was the part of her she projected out, mixed with the part of me she took in, and ejected again. At times, I lost my faith in the psychoanalytic process when confronted with her barrenness. I could not tell whether she was the plant reaching for me, the light, or I was the plant reaching for her who was the light. Her fear of not knowing what was real became mine. The two of us were one in that fear.

Conclusion A psychoanalysis, like any analysis, is a process of observing and thinking about a reality. It is about a psychic reality that can only be experienced in the moment and then transformed into a thought that is then verbalized in a dialectical conversation that moves back and forth between the analyst and the analysand. The fluidity of that exchange is then analyzed. When the exchange is twisted and includes mimicry as its foundation, it is very difficult to discover what is real, or, as in Bion’s model, what is the emotional truth. The session becomes filled with “should” and “as if” behaviour. What masquerades as insight is mimicry that cannot be internalized. The deep structure of the patient and the transference and counter-transference may be difficult to find (Ogden, 1984). To quote Bion (1965) again: In practice the problem arises with schizoid personalities in whom the superego appears to be developmentally prior to the ego and to deny development and existence itself to the ego. The usurpation by the super-ego of the position that should be occupied by the ego involves imperfect development of the reality principle, exaltation of a “moral” outlook and lack of respect for the truth. The result is starvation of the psyche and stunted growth. (p. 38) Discovering the truth inside of ourselves and speaking it as only our opinion is an important aspect of psychoanalysis. Patients who have suffered early trauma from parents who cannot hold and contain their projections develop not only defensively but without an internal compass. The course of their development is skewed because both the information from reality and the information gathered from their internal worlds is processed via damaged internal structures. Using the experience of truth for psychic nourishment is compromised. With patients who have no awareness of their own sense of agency, the analyst is thrown back upon her own physiological and emotional experience as the only compass for finding

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the truth in the moment. Imaginative conjecture arises in relationship to the patient before relationship with the patient can be discovered. Psychic overwhelm arises not only as a result of environmental deficit. Traumatic overwhelm can also arise from the quality of the fit between mother and infant. Good-enough development is dependent upon both what the infant brings and on whom the infant meets. The same is true in the analytic consulting room. An effective analysis depends upon the fit between the patient and the analyst. Much of what makes for a good fit is concerned with the analyst’s ability to meet the patient authentically and be in the moment with what is true, not with what is necessarily presented. This is only partially conscious. Much of the unconscious experience remains unspoken and unreflected upon, but is contained in the relationship between the two. This is the communication between body and mind and between subject and object.

Note The statement from Donald Meltzer in the epigraph is from page 92 of his book The Kleinian Development (London: Karnac, 1998, published for the Harris Meltzer Trust, reprinted London: Karnac, 2008).

Chapter 2

Affective bridges between body and mind

A fruitful obscurity is worth more than a premature clarification. – André Green

There has been a trend in psychoanalytic thinking away from Freud. In place of the structure he described, based in drives and instincts, has come an implicit belief that the infant is born a blank slate with innate potential. Whatever character the infant develops is then dependent upon its environment and parental interactions, not its biological inheritance. When the biological is acknowledged, somehow the affective component, which supports Freud’s ideas about instinctual drive, is minimized. British Object Relations theorists, including Klein, Bion, and Meltzer, believe both in the biological origin of drives, and in the impact of the environment on character. Neurobiological and neuro-psychoanalytical research supports our beliefs in Freud and Klein. Whenever two or more disciplines attempt to communicate, there is difficulty with language and definition of terms. Often the same term is used very differently by each separate discipline. In these cases, even when attempts are made to clarify and define the terms more precisely, the habitual use of the terms holds sway over the newly established definitions. Although I am attempting in this book, and in this chapter particularly, to discuss a point of view on affect and emotion that incorporates neurobiological and neuro-psychoanalytical research, I imagine I may commit the same error. For that reason, I wish to begin clarifying my use of two important words: affects and emotion. By affects, I am referring to the instinctual, biology-based nonpersonal feeling that moves one to action. I say nonpersonal because although the quality and quantity of these instincts may vary from person to person, their reality does not. In fact the noun “affect” is also usable as a verb meaning to move, impact, disturb, upset, or touch someone. The word “affect” implies a force with energy behind it. Whereas each infant is born with its own unique quality and quantity of affects, the affects themselves are the same as those of other mammals. Affects are forceful and intense. When experienced without mediation, they are violent. Panksepp (1998) has identified seven basic affects common to all mammals: seeking, rage,

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fear, panic, play, lust, and care. Solms (2015) links those affects to Freud’s ideas about drive. In doing so, he finds neurological research from other researchers, including Damasio (1999) as well as Panksepp (1998), which supports Freud’s ideas about drive. Being human includes more than just our instincts; it includes our unique process of managing them. By emotion, I mean that expression of affect that has been mediated by experience and by awareness. Emotion, like unconscious phantasy, links body and mind. It is both mental and physical. Emotion is the necessary mediator of our survival affects and our cognition. Damasio (1999) refers to “drives and motivations and pain and pleasure as triggers or constituents of emotions” (p. 341). Emotion, although founded in mammalian affects, is uniquely personal. It enables us to learn from our experience and make meaning from it. Emotion develops from affects and relationship. It expresses them. In doing so it enables the individual to link internal experience with external experience. Just as affect links mind and body so does emotion link subject and object. Each of us develops our emotional system out of who we are and the context within which we live. This personal emotional system enables us to love, to laugh, and to learn. This includes the capacity to represent our experience and make meaning of it. Representation and meaning-making are uniquely human capacities. Linking emotion with learning, as also supported by neuro-biological research (Damasio, 1999; Gallese, 2015; Panksepp, 1998, 2001; Schore, 1994; Solms, 2013), guides our clinical applications of theory. Linking emotion with learning also links learning to relationship. Relationship links emotion and learning to representation and to one of the tasks of analysis: finding language for that which has not been mentalized or previously represented lexically. Language manages emotion, limiting our experience by containing it. Language describes and finds meaning in the processes of the mind that have inhibited growth and development, including the destructiveness that can strip representations of their meaning. Bion (1962b, p. 25) calls this the reversal of alpha function. Green (1995) sees emotions as an expression of affects. I will quote him generously in order to place what I am saying within a psychoanalytic context. He delineates the expressions of affect, linking them always to the drives, in the following ways: The term affect is often used carelessly for various states of mind. I propose to reserve the term affect to describe the following categories of psychic phenomena: 1

Tonality: refers to the colouring of any manifestation of psychic life. We are frequently unaware of it because it accompanies psychic life, often unnoticed behind our thoughts and representations. From time to time it makes itself known as moods, or as a mild depression when the usual colouring of thoughts is lost. It can be perceived ordinarily through body dynamics or through the voice.

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2 3 4

Feelings: happen when in the stream of tonality experiences occur in which we are subjectively moved and involved. Emotions: arise when we have feelings over which we have little or no control. They are transitory and intense experiences, which shake us. Passions: are emotional states, which are about or directed towards an object. Passion invades the whole field of consciousness, overshadowing the usually important matters of life, and is long lasting. (p. 210)

Green’s categories of affect constitute what I am calling affective bridges between body and mind. These categories are the evidence of the affective foundation that underlies all human learning. In addition, learning itself comes from emotional relationship (Bion, 1962b, 1965; McGilchrist, 2009, p. 98). Bion (1970) draws our attention to primordial emotions that link us within ourselves and with each other: love, hate, and knowledge. Knowledge is sometimes labelled as curiosity and awe. We can see how Bion’s linking emotions relate to the seven basic affects. They are mental and physical without being directly related to perceptions, although perceptions may get linked to them. Primordial emotions exist within and between us. Love, hate, and knowledge are affective bridges between internal and external objects. Within an individual, these primordial emotions drive individuation and integration. Without a containing other, they may also overwhelm and cause severe emotional restriction. Other assumptions I am making also deserve to be mentioned here. I believe, with Klein and Bion, that the infant is born object related and with a very primitive capacity for representation. I believe with Green that the infant is born with a primitive capacity for binding affects. Binding holds the affective charges together, mediating their intensity (Freud, 1920). I also believe the infant is born with preconceptions and a capacity for unconscious phantasy. This suggests to me that the infant is born with an embryonic capacity for alpha function: for making meaning out of experience. This capacity enables the infant to make use of the mother and the mother’s reverie. In clinical application, alpha function enables the analysand to make use of the analyst. How the experience with the analyst is received is of utmost importance. As analysts, we recognize this reception in the transference. The internal bridges between affect and emotion, and between body and mind, uniquely influence the reception of each analysand. A bridge is not only a link, it is a narrowing channel that can inhibit, contain, and manage the energy flowing over it. These bridges allow the patient to make use of us only if their defensive cognitions do not interfere with their experience of their own psychic existence as well as ours. When an infant does not have help in mediating affects, defences against their intensity block the links, interfering with integration and the development of representations that can organize experience and strengthen the ego. Without a mediating other, not only are defences against affect formed, but also an internal structure that makes use of experience is not adequately formed. When this

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occurs in infancy, the ability to make use of their experiences becomes compromised. When they arrive as adults in our offices, making use of us is difficult. Learning from experience has been compromised. Instead of learning from experience, learning has occurred using observation and mimicry. Green (1995) asks the question whether the affects themselves are not a primitive form of representation. Ultimately he decides they are not. Rather, he sees them as two separate systems that inform each other. He says: Classically all representations are born from perceptions or derive from them. There is a dual system of opposition between representations and affects. They are connected with each other but relate differently to the mental organization of things or words. Unconscious representations are the products of transformations, passing from consciousness to unconsciousness without a major change in the complexion or texture of the representation. The case is quite different with affect. They do not go through a transformational system converting to a thing or a word representation. They can be inhibited or mastered, but do not change in their structure. Affects accompany, define, qualify and connote mental states, giving tone and colour to representations. (p. 211) This supports my assertion that affects are the base while emotions themselves are beginning representations. Affects are the bridge between the mind and the body, just as unconscious phantasy is. Unlike unconscious phantasy, affects do not transform but are corralled and harnessed, dammed, and channelled. They can be used for creative or destructive purposes. Emotions are transformable. The body’s response to experience also is transformable via relationship and the development of an apparatus for thinking that builds representational systems, strengthening psychic structure. Unconscious phantasy transforms and facilitates internal and external relationship. Unconscious phantasies are a primary link between affect and emotion and between body and mind. They can be transformed. I am using the Kleinian definition of unconscious phantasy, differentiating it from daydreaming and preconscious fantasy. Analysis recognizes that each patient brings to us the psychic structures they created from what they were born with and what they themselves uniquely and personally did with the experiences they met. This belief is the foundation of what makes it possible for change to happen via the analytic process. The analytic relationship enables previous representations to be transformed and the structure for making representations to be strengthened. Patients seeking relief from lifelong suffering (Green, 2007) often have tragic stories of trauma and neglect that they seem unable to integrate. Their capacity for making meaning out of their experiences and for transforming their emotional responses into representations that manage them has been overwhelmed and sometimes damaged. Scarfone (2015) describes these patients as being out of time, caught in the “unpast” and unable to move into the future. They appear to be

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in a forever present. They also seem to be in pain due to their continual ongoing and unmediated relationship with their primal affects. Often their pain is found only in their bodies and not in their minds due to what Lopez-Corvo (2006, 2014) calls the preconceptual nature of the trauma. I describe this a little differently in chapter 8, but we are each attempting to understand primitive experiences that are repeated without the mediation of language. Psychoanalysis is viable because it changes people’s relationship with themselves and with others. It is validating that, in a world of technological innovation, biological research supports our theoretical beliefs and our working models, which place affect and emotions at the centre of learning and development. Before I give a clinical example, I want to briefly name the technical assumptions of my work with patients whose primordial affects have been inadequately mediated by relationship.

Infantile transference Analysis is interested in the infantile transference. The infantile transference reveals stuck places where the inborn affects have not been mediated by relationship or experienced and contextualized via dream thoughts. Speaking to this primordial experience is not easy, especially with patients who cling to external experiences as a concrete way of holding themselves together. Interpretation to this deep primordial arena, where affects and emotions are mixed and behaviour is more predominant than thinking, can result in an increase of paranoia and rage. If the patient can tolerate this and the analyst can allow herself to become what is needed in the moment (a bad object), old stuck patterns can become unstuck. This response in turn makes it possible to channel the affective foundations for creative rather than destructive purposes. Speaking to the infantile transference also highlights a dependence that patients who have a weak subjective sense of self deny. Some patients cannot tolerate these interpretations. Analysts must then proceed cautiously and with care. In these instances, the setting and frame become the primary interpretative function. Relationship begins in the body’s response to sensory stimulation, which includes the physical proximity of the analyst (see chapter 5). The reality of the analyst as an other is denied. The analyst is a noobject for the patient.

Becoming the no-object Being a good object is always easier than being a bad object. However, worse still, as can happen when working with patients who have a weak subjective sense of self, there are times when – from the patient’s experience – the analyst is no object at all. Always we must try to understand the patient’s point of view. Does the patient have a sense of self or are there primitive autistic defences where reality has come in too soon (Tustin, 1986) and the patient has become non-existent?

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Has the work of the negative (Green, 1999) created a void so that the patient is unaware of his or her own existence? If so, the analyst may become too big, psychically becoming the only one in the room, with the patient being the one who psychically does not exist. Either way, the psychic phantasy is of an autistic object relation (Korbivcher, 2017). Such a relationship is two-dimensional. Two-dimensional relating involves a psychic experience of not having an inside. Without an inside, everything is a surface to be clung to, adhered to, or moulded by. The analyst then becomes, in the patient’s experience, a surface (Meltzer, 1974; Ogden, 1986; Tustin, 1986). This experience is a sensate one where the senses come to represent deceivers and need to be curtailed or eliminated. This adhesive experience is perceptual in nature and linked to the primitive affects, but does not provide a bridge to emotional relationship with either the self or the other. Instead, it interferes with bridging, as it denies any gap. In denying a gap, the representations of both self and other become distorted or do not form. When the patient develops a subjective sense of self, the analyst becomes an object. Three-dimensional relating is achieved. Both self and other are perceived as having interior spaces. With an object to project into, the patient can find relief from the excessive affective charge of a lifetime. This is necessary for change to happen. As an object, the analyst can become a container of all that cannot be managed. In doing so, the no-object analyst has been transformed into a badobject analyst. The bad-object analyst provides relief and psychic space so the patient’s subjective sense of self can develop. This occurs due to the link between perception and representation. Internal and external linking gradually build and strengthen an internal bridge between body and mind.

Differentiating innate affects from learned emotions Bridging is possible because of differentiation. The capacity to differentiate internally as well as between inside and outside enables relationship to mediate experience. Differentiation is a component of separateness but does not necessarily imply separateness or whole-object relating. Analysis of differentiation as well as analysis of innate and learned structure requires the analyst to pay attention to the process occurring both within the patient and within herself and between the patient and herself. Even attending to the affective and emotional experience without saying anything is powerful. Paying attention eventually enables emotion to be named, recognized, and remembered. Remembering involves the accumulation of experience. Learning from the experience then becomes possible.

Clinical example My patient Ada has courage and a commitment to growth and development that taught me much and affected me deeply. She despaired that our work was only

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bringing her further and further into her pain and rage. She and others like her challenge my own faith in the analytic process and in humanity. Each tests the limits of my patience and security (Bion, 1970), while demanding that I meet them where they are. When one of us faltered, the other persevered and together we reached what Winnicott called a “good-enough” outcome. In any analysis, perseverance and determination go a long way. Clearly, I am presenting a very condensed version of our work. Analysis, like a dream, cannot be described adequately. The transformation that occurs in the telling enables both analyst and analysand to tolerate unbearable affects and emotions generated in the analytic connection. My relationship with Ada spanned two decades during which she came and went from me. For the purposes of this chapter, I will use Panksepp’s seven affects to describe our analytic work. These will be contextualized using British Object Relations theory and technique. When first I met Ada, she appeared bright, successful, and entertaining. In spite of never marrying, she appeared to have many friends. This impression was far from the truth. Tormented by a hypersensitive disposition, she felt continually intruded upon and in danger. She had difficulty thinking and often felt confused. As a result, she covered her confusion with an obsessive eye for detail and a certainty in her speech, which interfered with her ability to communicate. Her sense of humour was sarcastic and biting. Barricaded inside her home on weekends, she did not answer the phone, preferring to space out on movies. In other words, she pretended to be normal and happy and extroverted, but in fact was quite the opposite. She was unhappy, suicidal, isolated, and paranoid. Although she was attractive, she had a tense and wary demeanour that hinted at an internal unattractiveness. She hated herself and others, envying her own and others’ goodness. She demonstrated all of this in the transference from our very first meeting. She hoped to keep me far enough away so as not to impinge on her delusional system of nonexistence. She also described a multiple-year eating disorder, in which she restricted her food intake severely and occasionally used diuretics or laxatives. She said she could not tell the difference between a physical sensation and an emotion and so did not know if she was hungry or sad. The two felt the same to her. She thought she binged when anxious. She thought she might have had a panic attack “once or twice”. Our years of analytic work evolved around the lack of psychic separateness and Ada’s immense terror of psychic space. Space, as initially represented by silence in the session, was experienced as “the gap”. There was also a terror of relatedness, which I have come to understand as a defence against awareness of her psychic existence. Instead of relating to me as a separate person, she denied any relationship with me. At the same time, she unconsciously psychically clung to me. All of this occurred within a context of unconsciously denying her existence. Her subjective sense of self was mostly determined by what she did and what she thought about her actions. Although I do not typically diagnose my patients, I believe she was on the autistic spectrum.

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Such a summary statement does not begin to convey the agony and pain both of us experienced in her tenacious holding on to me, while denying my importance. Her hope of healing from her constitutional and environmental deficiencies kept her with me. Nor does it speak of my struggle to meet and understand her and not give in to the tremendous pressure to enact and recreate the nonrelatedness that had become her life. Her metaphor, until recently, was that she was moving from one monkey bar to the next, never letting go until she had the next firmly in hand. Today she feels she is more able to swing, let go, and grasp the bars of the trapeze when it arrives. In that way, she can tolerate space and not be afraid of falling forever. She has faith in herself and in her relationships. She also can love and feel love. Using Panksepp’s categories of the seven affects, I will describe her affects and her emerging emotions and the transformations that occurred in our work. Initially she seemed to be unable to use her representational processes to harness them. Since she feared relationships, she also did not know how to use me to help her. The consequence was that she frequently wondered what was real and looked outside of her self to discover it. Her movement from having a very limited sense of self and other to being able to relate to and use her objects has been profoundly moving. With this newly gained capacity for personal relationship has come an increased capacity to communicate. Seeking Ada told me there was something missing in her. She could not love. In order to tolerate frustration, she shut down her seeking impulses and withdrew. In spite of her wish to isolate herself and restrict her contact with others, she kept seeking. She joined a Buddhist group, meditated, chanted, and followed a leader to Japan. There she found some peace, not in meditating or in the group contact but in cleaning the toilets. She returned disillusioned and shortly thereafter came to me. In spite of two previously failed treatments, she attempted another with me and ultimately agreed to psychoanalysis. She rarely missed a session, was always on time, paid faithfully, and stayed engaged in our process. Her seeking drive aided her. Rage In spite of her seemingly agreeable nature, Ada was always in a rage. These rages would spill out onto innocent strangers, on co-workers and friends. When someone did not match her expectation, the rage was immediate. The rage showed itself in her first session when she was resentful with me because she needed me. Often the rage was turned against her self and expressed by a Bionian early superego that broke up her thinking and fed her suicidality, her anorexia, and her self-hate. She suffered with intense guilt at her inability to be normal.

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Further she had no insight into these rages and no means to think about them. She did not seem to notice the irritability that went with them nor the frustration beneath the surface of her actions, and so felt there were no warnings. She described her rageful emotion as “coming from nowhere” and as often accompanied by violent imagery. Attempting to corral the rage by depriving herself of stimulation that might evoke these states was only partially successful. She restricted food, drink, and social interaction. She was in her late twenties before becoming sexual. Often, instead of feeling sexual desire for an attractive man, she felt unexplainable rage towards him. Fear Fear accompanied the rage. She was hypervigilant. She noticed every detail of her environment. When she walked down the street, she looked everyone in the eye, checking to see if they were aggressive. She imagined men carrying knives or lurking behind doors. Sometimes, in meetings, she feared and envisioned a man’s penis, thinking he could rape her. Fellow co-workers, she was sure, were talking about her behind her back or looking in the windows of her office to know what she was doing. She felt everyone expected something from her, but she did not know what it was. Personal decisions were difficult. Buying clothes, choosing paint colours for her house, deciding what to eat caused consternation and concern over doing the right thing. Her fear was also of her own bodily responses; she did not want to be touched, felt no sexual desire, did not experience hunger or feel an impulse to socialize in spite of having a social circle. Change was very hard, as were transitions from workweek to weekend, summer to fall, vacation to business life. Panic In spite of her avoidance of relationships, Ada was adhesively attached, via mimicry and sensory vigilance, to whomever she was with. Perhaps this is why she avoided intimacy, in that to be intimate was to lose her self in the other. She was not sure she existed except as a reflection of those around her. Losing proximate contact resulted in unexplainable panic attacks, and a paradoxical further reduction of food intake, sensory stimulation, and social interaction. Since she denied needing anyone, her unconscious fusion with others left her in a two-dimensional world. Contact with others challenged her psychic reality, causing rages and panic. She felt she could not trust her own perceptions of reality. Loss of the analytic object was difficult to interpret since she denied needing me, too, and had elaborate delusional and somatic explanations of the causes of her panic attacks. I was initially a no-object to her. As analysis progressed, she became aware of feeling she was lost in space, untethered, and falling forever. She panicked with people and without them.

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She described feeling hopeless and powerless and not being able to breathe. She felt sure she was dying. The more alive she became through her analysis, the more panic arose. Her panic seemed related to the gap: the distance between her immense unconscious need and her object. Play Initially, Ada seemed not to play. She could not relax. She needed to be constantly doing things, even though what she did do did not bring satisfaction. Even her gardening was a task she had to do so as to appear good to her neighbours. Pulling weeds satisfied her obsessional, concrete need for action to release her pent-up affective energy. She would go through the motions of going out to dinner, or to a movie or concert, but claimed not to enjoy them. She enjoyed being at home, alone, working on mundane tasks in the garden, repairing broken mechanical items, or spacing out in front of “mindless TV shows”. Even going to bed was no pleasure for her. She described rubbing her stocking feet together and rocking in order to go to sleep. She was troubled by her dreams. She also could not play in her mind. Her ability to imagine was severely restricted. Her capacity for daydream and using illusion, each so necessary for ordinary pleasure and security, had not developed. For example, it is an illusion we all share that we know what will happen next. We feel secure in that illusion. It creates an illusion of safety. Ada could not imagine or envision anything in the future. Therefore, she could not imagine a future security. She was concretely caught in a forever present that consisted of concrete perceptual experience. After her second analysis with me, she had more internal psychic time and space. She could imagine a future. She found herself enjoying “just walking down the street”. She found beauty in her environment, pleasure in joking with her neighbours, and she desired making love with her husband and playing games with her daughter. She felt pleasure at being with her family, her neighbours, and her friends. She loved to laugh and see others laughing with her. She could imagine a future. Lust Initially, Ada did not feel her own desire. Desire implies a relationship with another as well as a relationship with the self. Ada’s severe restriction of her emotional life interfered with her awareness of her own impulses. In spite of images of penises and constant thoughts about sex, she preferred not to be touched, much less being sexual. She did not feel a need for either masturbation or sexual intercourse. When she gave in to her husband, she was highly orgasmic and enjoyed the feeling. Shortly afterwards, she would feel extreme disgust at the thought of what she had done. When her daughter was born, she felt repulsed by her infant’s searching for her breast or “clawing at her” when she nursed. She held her baby stiffly and avoided

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touching her. Later she could grieve this and tell me it just felt too sexy for her. She felt everything her baby did was filled with lust, joking that maybe Freud was on to something. She discovered with a shock that her racism, her fear of living in a racially diverse area of Seattle and of being raped by her African American neighbours, was based on her own projections. She herself is lustful. Her neighbours are alive, as she wanted to be. As analysis progressed, she began to engage, first in the transference in a juicy and alive way. She became eager for her sessions and felt guilty for giving me what she did not give her husband and her daughter. She said she just couldn’t handle more than one person at a time. Nor could she want something from anyone, as she was so sure of losing it. She felt betrayed by her own hope. Today she feels her desire and initiates lovemaking. She hugs and touches her daughter and welcomes embraces from her. She feels so sad about her earlier responses to her. Care To nurture and be nurtured seemed a foreign concept to Ada. She saw it demonstrated in movies, but did not remember experiencing it in her self or in her own home. Once she told me she had never seen her parents be affectionate with one another. She could not imagine them sleeping together or touching each other. They also did not touch her or her brothers. As a child, she remembers holding on to her mother’s skirt, bringing her mother flowers she found in fields, making gifts for her. She does not remember being received or recognized for her efforts. She described her father as being silent and withdrawn unless overwhelmed, when he exploded, like she did. She described her mother as indifferent. She doubted she had ever experienced loving or being loved. She did not know what affection felt like, only what the behaviour looked like, and so she could imitate affection. Imitating love was harder for her and she felt little empathy or compassion for herself or for others. She was aloof and unreachable without noticing it. Her husband did notice this and told her, which brought Ada back to me for a second analysis.

The analytic experience Patients like Ada suffer tremendously. It seems that insight only makes them suffer more. They can see how others are, as if through a glass bubble, and their affective desires for companionship, play, and care leak through their stimulus barriers, driving them to seek help. Simultaneously, their affective fears, panics, and rages impede their own ability to be in relationship and to learn from experience. Their internal capacity for linking has been compromised (Bion, 1959). Often, they have learned to mimic social interaction. True intimacy is threatening. The usual protections against unmediated affect are weak and at times just not present. As a result, these overstimulated and overwhelmed patients use shutting down, withdrawing from contact with others, and

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limiting sensory input as mechanical attempts to control what is overwhelming unmediated affect. They also use their good minds in an attempt to control themselves and others. The usual defences of repression, splitting, and projection, and the relief they bring, are not reliably available. A more primitive defence still, an autistic defence, is the defence of suspension (Eekhoff, 2017; Meltzer, 1975b). Suspension stops time and fills the gap, eliminating psychic space. Suspension is the use of somatic experience to blot out awareness of excessive affect and emotion. Suspension isolates the senses from each other, attacking relationship at a primary level. Without suspension, the psychic floor collapses; as a consequence these patients experience panic attacks and sensations of falling, spilling, and dissolving until they no longer have a subjective sense of self. Our biological affects provide a floor for experience (Ogden, 1991; Eaton, 2015), a floor that grounds us if we are able to experience our senses in relation to each other and our bodies in relation to others. Our affects further activate us to reach for what we need. They alert us to dangers so we can defend ourselves when we feel threatened. Our biological affects fuel our curiosity and enable us to move creatively and productively in the world. In order to make use of them as bridges to our minds, we need an other: first as a proximate presence (Eekhoff, 2017), then as a witness and a recognizer who can name and make meaning out of our experience. Bion calls this the container and contained relationship. Personal meaning is found in emotional relationship. Unconscious phantasy links affect and emotion. Emotion, not the affective drives, represents creative relationship internally and externally. This enables finding meaning in our own experience and communication in our bodily affects, our emotional responses, and the images evoked in our minds. Emotion has an object while the affects do not. When the use of early defences of suspension has been predominant, the ability to recognize and use an other becomes impaired. Perceptual identity itself becomes separated from thought identity. Emotional signification of experience, which enables integration and learning from experience, is compromised. In such circumstances, as with Ada, analytic contact can become overly intellectual, further bypassing ongoing emotional representation. Habitual behaviour and mimicry will continue to substitute for integration and connection. The analysis will flounder. Affective bridging is hard to do if proximity poses a threat. Containment of the most primitive sort requires much patience and security (Bion, 1970), because without adequate containment accumulation is difficult. In such circumstances, emotional meaning cannot be held over time and accumulate. In working with patients such as Ada, accumulation of experience and the memory of emotional meaning occur first in the analyst. This creates a technical difficulty. Intellectual attribution of meaning coming from the analyst bypasses meaningmaking from the patient. Ada needed to use me, not mimic me. I needed to let her use me in her own time and her own way so that she would not be swamped by her panic, her terror, and her rage. Meaning is determined by the reality of difference. The process of registering an experience and then finding meaning is

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extremely important, as the signification comes out of patterns and structures that were created in infancy. However, no two events are ever the same, and therein lies the threat of differences. These patients work hard to keep everything the same, creating a myth that they are in control. Analysis is not just about naming this process, but also about discovering gaps where meaning can only mean threat. Gaps disturb the continuity of the surface, the delusion of oneness, and bring the reality of separateness too near. Once a patient is emotionally understood by the analyst, containment can occur, enabling accumulation and learning from experience. When accumulation does not occur, it is not just that there is no containment. It is also that representation is compromised. The process of meaning-making after the fact in analysis is one of re-signification – that is, attributing new meaning to present and past events. Without accumulation, future similar events cannot be given new and creative meaning. Neuropsychological research validates clinical experience and our theoretical models. It also helps us with our psychoanalytic technique. It reminds us that although psycho-educational responses may provide a temporary comfort to our patients, they ultimately do little to reduce their suffering or change their structure. Rather, psycho-education provides these patients with more material to mimic. Insight without emotional connection and understanding increases pain and suffering and can trigger negative therapeutic reactions. Emotion defies language, being difficult to articulate and impossible to describe, yet emotion is an intrapsychic and interpersonal bridge. When it seems the bridges within and between our patients and us are closed, broken, or have never been built, we sometimes find our methods ineffective (Bion, 1962b). These traumatized patients seem unable to make use of what we attempt to give them. They are preoccupied with their sense of danger and their need to survive at all costs. Focusing on survival puts them at odds with us, who are perceived as the enemy. If we are to reach them, we must delve deeply into ourselves and find the links there to our patients’ internal worlds. Internal affective and emotional links between body and mind within and between both analyst and patient provide opportunity for growth and development and for learning from the experience of relationship. The analyst must provide an experience in which two people are engaged. Deep understanding and active emotional engagement call for a willingness on the part of the analyst to be whatever the patient needs in order to change structurally. This includes being the no-object, as well as the present object, and being the bad object as well as the good. It is not only what happens to us that makes us who we are, it is also our unique combination of affects, in both quality and quantity. These determine in part how we receive and respond to life’s experiences (Ogden, 1984). Our innate affects influence how we are in relationship, which is a key to our ability to learn from experience. Psychoanalysis is an experiential treatment. The alive experience of the transference and counter-transference is an important element in any analysis Oelsner

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(2013). Analysis deals with the infantile transference as it presents itself in the moment, not with adult problems. It includes infantile sexuality. Psychoanalysis also includes the analyst’s experiences of unrepresented, poorly represented, and represented states that have been mutilated or destroyed. The capacity to represent enables one to tolerate frustration and to constrain premature action in favour of thought. Psychoanalysis includes the analyst’s experiences of her or his own and her or his patient’s capacity to facilitate representation. To do this, if we believe in biologically inherent affects, we must develop a theoretical application that guides us in understanding the interplay within each unique analysand. It is not as if the seven basic affects can be eliminated. They are part of our mammalian heritage. Our capacities to mediate our rage and our fear and to channel our seeking and play into creative vocations make us human. Using lust to channel our desires makes us creative participants in our own and society’s development. The mental movement from affect to emotion to thought recycles, enabling more and more learning. Such is the current work of analysis. Psychoanalysis is transformative. As my patient said, “All these years with you, I have fought your interpretations. I did not accept myself. I was angry with you because you did not make me into someone else. Now I realize what is just me, my biology, and what I can change and what I cannot”.

Notes An abridged version of this chapter was presented to the Eleventh International Evolving British Object Relations Conference in Seattle, Washington, October 28–30, 2016. The statement by André Green in the epigraph is from page 140 of his 1977 article, “Conceptions of Affect”, in the International Journal of Psycho-Analysis, 58:129–156.

Chapter 3

The silent transference Clinical reflections on Ferenczi, Klein, and Bion

Infants come into the world uniquely themselves. Our patients bring the uniqueness they were born with to us. It is what they brought to their parents. They also bring to us what they have become and what they have learned from experience, expecting us to behave in predictable ways. The only way we get to know them is by what they bring us. They bring us their earliest experiences without knowing it. Their responses to the internal and external traumas of their lived experience can then be discovered in the transference and in the counter-transference. Infantile experience is not remembered in the mind via narratives. Although patients’ stories may help us understand them, ultimately what we experience when we are with them tells us more. Infantile experience is remembered in the body via memories in the sensorium and memories in feelings. Infantile experience is remembered in action in the repeated structure of relationships, and is discovered when the analyst becomes a participant and can observe herself and the patient in their relationship with each other. Patients who have been traumatized as infants and toddlers and who have been separated from their mothers in earliest infancy bring us their pain. They do not expect us to receive it even though consciously that is why they come. They bring us their disappointment and they unconsciously expect to be disappointed again. Often they retreat from emotional contact with others to avoid their pain and disappointment, and so they retreat from us. For them, the primary objects of infancy, their mothers, were not present to receive their communications, or to make meaning of their experiences, take them in, and give them back in manageable ways. They keep searching for their lost mother of infancy and cannot find her. Thus these patients in pain do not expect anything else from us other than disappointment and absence. In fact, any options that differ from what they know may be difficult for them. If they experienced their mothers as not there, as noobjects, then they will experience us, their analysts, as a no-object as well. Being a no-object is difficult for any analyst. It may even feel unbelievable. We can imagine that an infant in the Neonatal Intensive Care Unit (NICU) might have felt like a no-object too, but there are no words to describe this and no way to identify a no-object without experiencing it ourselves. We may recognize that we are being left out of the experience in the consulting room and not be able to

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believe or tolerate it. The earliest experience of the infant in the NICU is found in us via the perceptual identification of the body and our experience of not existing for the patient. As I said earlier, analysis is an experiential treatment. If one or both of the participants appear to be left out, what kind of an experience is that? Of course, we know that something is always left out of any analysis and of any therapeutic session and, by extension, anything we might write. This chapter is about a kind of trauma that expresses itself as a silent, left-out transference and countertransference. Such an expression of trauma creates particular difficulties for the analyst, and speaking to the interactive process in the session is one aspect of the difficulty. Ferenczi understood the power of his own counter-transference to inform him, not only of himself, but also of his patients. He recognized that his own blocked places blocked his patients’ development and that they knew the flaws in him. Today, I doubt that anyone questions the reality that external trauma damages and interferes with the development of the self and interacts with internal psychic structure to create more trauma. No matter what psychoanalytic language we use, we agree that a traumatized internal world interferes with our external relationships to love, to work, and to pleasure. Disagreement amongst us more often occurs around the techniques we use to treat trauma survivors and the language we use to describe the traumatic effects within the patient and within and without the transference. This chapter represents my current understanding of the silent transference in light of my clinical experience and my psychoanalytic heritage. By silent transference, I mean a transference that is seemingly not present in the therapy hour. I am using clinical examples from patients who were traumatized at birth by the dual challenges of being born medically compromised and also by being separated immediately from their mothers. They faced death as they were born. The twofold trauma impacted their internal object relations as well as their external relationships, including their relationship with me and mine with them. These adult patients seem more dead than alive. They seem unable to feel love, although they do behave as if they love. Often they are bright and more or less successful professionally, although they are passive in relationship. In treatment, these patients appear to have an unformed or non-existent relationship to the analyst, making transference interpretations difficult. I acknowledge that some patients without obvious medical traumas at birth also share aspects of this clinical picture. Not all patients who present as passive and difficult to reach share these histories, although many do. Patients who have suffered physical trauma at birth develop internal object relations that reflect that trauma. By internal object relations, I am referring to the earliest corporeal memory of relational experience, the relational experience that has been internalized and held within the psyche-soma before language (Winnicott, 1974). I personally believe these memories and resultant patterns of relationship begin in utero. These internal objects are not verbal representations.

The silent transference 31

They are representational only in the most primordial ways, memorable as physical sensations or memories in feelings. They are felt. They are also repeated. Ferenczi (1920–1932) intimated this impact when he wrote, “In the moment of trauma the world of objects disappears partially or completely: everything becomes objectless sensation” (p. 261). The objectless sensation is held in the body/mind of the infant as a memory of a no-thing or no one. It is experienced by our adult patients as a sense of something missing. Sometimes they tell us they are unable to love. They can also be unable to receive love. They experience us as a no-object. These patients have also suffered the secondary trauma of having mothers who have been traumatized by the near death of their infants. When the infant was returned to the mother, two hesitant and traumatized people attempted to engage and/or resist one another. The early opportunities for repair that occurred when the two were reunited seem to have been missed because neither’s experience was adequate to address the extreme difficulty. The trauma of the infant thus expanded upon reunion with the mother. Memories of these early traumas are carried in their bodies and in their emotional responses or lack of them to internal and external experience. The cycle continues on into adulthood with continual disappointment and disruption of relationship. Thus Ferenczi’s (1913) magic signals and gestural communication within the therapy become the communication idiom of the silent transference. Ferenczi, Klein, and Bion, building on Freud, believed that an excessive amount of anxiety interferes with development of relationships. I am looking at how patients who appear to have no relationship to us, who do not respond to transference interpretations, nonetheless have a relationship. It is evidenced by the silence and the apparent calm. This calm is deceiving for it originates not in integration but in extreme fragmentation and dispersal of anxiety. The patient does not appear anxious nor project anxiety. There appears to be little projection and little expectation of a projection-receiving other. The transference relationship mirrors these patients’ relationships to themselves. Their internal unconscious process of non-relationship is extremely demanding and draining. With minimal projection, they appear passive and indifferent to us. Since they may appear to lack agency, we may overlook that they are also out of contact with and not engaging with themselves. Their very existence is hidden from both themselves and from us. The infant’s will to survive can be thwarted by a trauma that separates infant from mother and leaves the emerging self on its own, with only the damaged body as recipient of projective and identification processes. The body becomes the container (Anzieu, 1990a, 1990b; Bick, 1968, 1986), and in a symbolic equation (Segal, 1957) is equated with the mother. The mother is then perceived as damaged as well as absent. The infant in the adult resorts to a psychic omnipotent survival without needs. Without needs, there is no necessity to act. It is as if the intrauterine experience of being continually fed and held is omnipotently maintained psychically.

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The struggle to live without evidence of the mother’s care and concern leaves the infant passively accepting of whatever happens. The only action possible within the neonatal hospital environment is mental, and the only consistent interaction with an alive other is with the damaged alive body of the self. The physical trauma of a damaged and malfunctioning body is amplified by the trauma of the loss of the mother’s body and mind. Further, when the two are reunited, there is an inevitable mismatch of needs. Passivity and lack of agency result, leaving the infant passive and ultimately resigned to turning away from human contact in favour of contact with the concrete things of the world and with his own mind. These inanimate objects (incubator, needles, feeding tubes) provide the infant with sensations that inform. Due to their unchanging, static nature, these inanimate objects cannot be identified as life-giving, although they are. The “dead” object cannot be given meaning by the immature infantile mind. What is left for the infant in the absence of the containing and loving mother is a confusional mental state that is averse to any stimulus. The aversion can compensate for the confusional mental state and take the place of the mother–infant relationship. The infant cannot then make the primitive discernments between pleasure and lack of it. Splitting processes that may possibly develop in utero are nevertheless inadequate to cope with the trauma not only of life-threatening circumstances, but also of the loss of the mother and her functional care. Without the mother’s mind to contain what has been split off and projected, normal communicative projection becomes compromised. Autistic defences that interfere with relationship predominate (Alvarez, 2006, 2012; T. Mitrani & J.L. Mitrani, 1997; Meltzer, 1975a; Tustin, 1986, 1990). Ferenczi and Bion link agency and meaning. Passivity within these patients exists as evidence of the depressed and dying baby within the adult patient. However, they counter their passivity by action and often use manic attempts to reach an imagined perfection. Meaning is found in meeting the external ideal. Going through the motions and doing what is expected is satisfying and is held to be meaningful. Impulses thus originate outside of the self and in the mind, appearing as ideas about how one should behave. What gives life meaning? First, there must be a link between two things: between nipple and mouth, penis and vagina, mother and baby, between mind and body, between self and other. There must be an emotional engagement with life. Without emotional engagement in the form of attention and interest, no meaning can be found. In Transformations, Bion (1965) says: “The patient’s relationship with himself is prejudiced if he cannot advance to recognition of a new experience and so falls back on existing meaning, or does progress and has to face frustration he cannot tolerate” (p. 54; italics in original). Adults who have been traumatized as children suffer from both difficulties. During analysis, the historical meanings attributed in the past and used in the present are called into question, creating a degree of frustration that is intolerable. Recognition of a new experience, such as the experience with the analyst, would interfere with the patient’s relationship with him or her self. As a result,

The silent transference 33

in order to remain the person such patients believe themselves to be, they must deny any relationship with the analyst. New experiences and new ideas are catastrophic and linked to death instead of to life. The patient retreats within a pathological organization (Meltzer, 1975b; Steiner, 1993; Tustin, 1986) and becomes seemingly unreachable. Bion (1965) articulates the dual dilemma found when the internalizing process is disrupted and then disrupts the development of an apparatus for learning. Further, he highlights how a disrupted emotional relationship to self interferes with the capacity for accrual of meaning: Meaning is a function of self-love, self-hate or self-knowledge. It is not logically, but psycho-logically necessary. The constant conjunction, once named, must then be found, as a matter of psychic necessity, to have a meaning. Once psychologically necessary meaning has been achieved reason, as the slave of the passions, transforms psycho-logically necessary meaning into logically necessary meaning. (p. 73) Bion might say that these patients do not have an apparatus for experiencing themselves experiencing and for learning from that experience. They have difficulty thinking about their sensory experience (Bion, 1962a). Instead of loving and receiving love, they behave “as if” they love. They go through the motions. Going through the motions reinforces their isolation and builds their protective shells, removing them even further from reality and from relationships. When others do not notice their imitation, they feel powerful in their isolation. Their omnipotence is reinforced and they become even more difficult to reach. The aversion they originally experienced becomes hate and judgement. Others seem to them to be more damaged than they are and so are incapable of understanding them. Ferenczi (1913) recognized infantile omnipotence as contributing to this disturbance of reality with the phantasy or “The feeling one has all that one wants, and that one has nothing left to wish for” (p. 219). This infantile omnipotent feeling is found in the silent transference in the form of an unconscious belief that such a stance is necessary. The patient perceives the analyst as a no-object – as an absent breast and not there (Bion, 1965, pp. 53–55). If the analyst is not there, there is nothing to be gotten. Only the patient is there and the patient is also insufficient, missing something. The only resort is to the delusion of omnipotence. What appears to us to be missing is an apparatus for being aware of self and other and for receiving and giving love. Both the perceptual and the thought identifications are damaged as a result. These patients are exquisitely sensitive to every change and appear hypervigilant. They are constantly at risk for overstimulation. Although they may compensate for this sensitivity behaviourally and even precociously develop cognitively, their relationships with themselves and with others often suffer. Ferenczi (1912) observed this in his traumatized patients: “after a shock the emotions become severed from representations and thought processes and hidden away deep in the

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unconscious, indeed in the corporeal unconscious, . . . while the intelligence goes through [a] progressive flight” (p. 203). This premature aging bypasses emotional development. These patients flee their fear via frozen emotional development. Their infantile trauma continues to exist as a pre-repressed, poorly represented state within their corporeal psyches that cannot be processed emotionally. Their emotional representations are held in their “corporeal unconscious”. Former representations, via alpha function in reverse (Bion, 1962b) are undone, distorted, or destroyed. Since this destruction interferes with meaning-making and relationship with an other, the patient remains locked in the omnipotent phantasy of having no needs. Sensory experience, including the awareness of self, is not used for accumulation and elaboration of meaning. The traumas are not thought or named, but repeated and re-experienced in relationship. This repetition involves identifying life as the aggressor. Death and dying are the mother. It is no wonder these patients’ relationships suffer. They are based on proximity and physical sensation. They are also overly cognitive and mechanical, as if to duplicate the reliability of the life they knew in utero and in the incubator. Their capacity for emotion is dulled. Receiving love is difficult if not impossible. They can talk about love, but they find it difficult to participate in the mutual activity of love. Love is a two-person experience. These patients live in solitary confinement emotionally. Recognition of outside input as nourishing is lacking. Instead, such contact feels intrusive and dangerous – as a risk for loss of self. To freeze is the only option. Basic trust in self or other, if present, is fleeting. Impulses to connect with another person seem to be dampened or hidden. Rather than fighting in rage or fleeing in terror, they appear frozen. When they begin to thaw, the pain is unbearable. Their relational agency appears to originate outside of them instead of inside. This means that, within the analytic session, no matter what the analyst does or does not do, that action becomes the source of agency and meaning for the patient. In tropic fashion, like a plant turning towards light, the patient attends to whatever the analyst indicates. The response following such attention is mimetic. Yet the mimicry of their responses to this experience with the analyst does not lead to an accumulation of learning. Experiences within the session, as in life, seem to not be internalized as representations to be used for learning. Instead these experiences repeat and reinforce the existing structure. The infant’s relationship to his own somatic expression and experience forms the basis of the relationship between the infant and the mother as well as the infant and her own mind. The mother’s responses to the infant call forth the potential and facilitate the development of the capacity for relationship. Without the mother’s body, her breasts and her nipples, her skin and her smell, her eyes and her voice to call the infant forth, the infant survives as a body. The infant’s body is not only damaged but has been abruptly separated from an emotional connection with a loving mother who would discover him and call forth his potential. Somatic experience within the incubator or intensive care unit begins to take the place of the mother, creating a psychic barrier to relationship. Within the

The silent transference 35

somatic experience, neither self nor other exists – not the mother and not the infant. Instead it is a universe of objectless sensation, lacking meaning. Based upon my work with adults who have survived these traumas, there also appears to be a state of mind where the person cannot experience herself existing. I speculate that this state of mind exists on the cusp of sentience where neither self nor other exists. Whereas infants who are not separated from their mothers may experience such a state for moments, hospitalized infants experience this for days. Often, these patients come to treatment because they have been sent by their partners or their children and told that “something is missing in you”. Some will come on their own, describing previous therapies where “something was missing”. This something-missing experience in the consulting room, if recognized, understood, and spoken to, can reach patients in their most withdrawn infantile states. The irony is that patients who have been traumatized as infants present both as passive – as lacking agency – and as omnipotent, needing nothing. The needing nothing applies because the unconscious phantasy is that “this is all there is”. Again Bion (1965) helps us understand this: Inadequacy of hallucinatory gratification to promote mental growth impels activity designed to provide “true” meaning: it is felt that the meaning attributed to the constant conjunction must have a counterpart in the realization of the conjunction. Therefore the activity of the reason as the slave of the passions is inadequate. (p. 73) Infants born with medical conditions that necessitate immediate separation from their mothers have difficulty hallucinating the breast and the nipple. For hallucinatory wish-fulfilment to be effective in the experience of the infant, some previous satisfaction or realization of a breast must have occurred. The internal objects that compose the mother and the mother’s integrating love are stunted in their development. In the transference, it appears as an absence that is baffling in its subtlety. The reasonableness of the patient’s stories also leaves the analyst wondering what is missing in herself. Although the analyst may be missing an ability to recognize these states inside and outside of her, what is missing in the patient are the internal and external links that connect emotion to reason and reason to meaning. Person-to-person linkage is damaged as a result. The infantile omnipotence, which Ferenczi and Bion trace from prenatal life, is often not interpreted because it is difficult to detect and denied when named. The oscillating idealization and denigration of the analyst is seemingly missing. The aggression as well as the love towards the analyst and the analysis is passive and silent. In fact, all emotion appears blunted or absent. More primary than the relationship to the analyst is the instinctual aggression against the self in the form of being in limbo, frozen outside of relationship, where fighting or fleeing is irrelevant. The unmentalized and unformulated traumatic experiences of earliest infancy are revisited in moments of relational stimulation.

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The silent transference

Primitive defences of intense primary affects are body-based, and these respond to the deprivation of instinctual need for the mother by a psychic holding of the breath. The mental process of splitting of both the ego and the other and their resultant internal objects damages the self in an oscillating idealization and denigration of self. Since this splitting is itself a higher-order mental defence, it is inadequate to deal with a felt sense of not existing, or with the blankness of an unformed and uncomprehended dual trauma of deformity and abandonment. Splitting as a mental process covers over the blankness and in doing so hides the lower-order bodily based replacement of one affect by another. Splitting destroys not only the linkage of infant to mother, but of mind to body, of the self to self. Perceptions become blunted and distorted and meaning is lost in the process of becoming. Higher-order defences that come later in experience, such as superiority and self-sufficiency, may be cloaked in compliance and in mimicry of a therapeutic relationship. As Ferenczi (1949a) describes this sensitivity, “the patients have an exceedingly refined sensitivity for the wishes, tendencies, whims, sympathies and antipathies of their analyst, even if the analyst is completely unaware of this sensitivity” (p. 226). Even apparent disruptions or negative therapeutic reactions may be stimulated by the patient’s awareness that this is what the analyst expects. The analyst must recognize the mimicry and seek to find any flicker of authenticity within the frozen landscape. Patients are on the road to recovery when they can feel their own spontaneous gestures (Winnicott, 1949) or impulses. Often these must first be discovered by the analyst’s imaginative conjecture (Bion, 1965) and reflected back to the patient – hence the terrible therapeutic dilemma. Since most of these gestures or impulses begin as mimicry, much as a day-old baby will stick out her tongue in response to her mother’s sticking out her tongue, the analyst must be both tentative and present. The patient experiences desire as something observed in others and repeated mimetically, so the desire is perceived to belong to the analyst. Desire as an impulse or a wish is rarely recognized by the patient as coming from inside or experienced as motivation for relationship. For this reason, analysts must be empathic towards the missing piece. The missing piece is not found in the content of the speech, but in its sound and rhythm. That which is missing is also found in the patient’s body and expressed there. A patient taught me this and helped me help him. His earliest trauma occurred in utero when his mother responded to her unwanted pregnancy by reportedly attempting to abort him with a hanger. When that failed, she attempted to use her pregnancy to get her husband back. When he was born with a malformed forearm and missing hand, she gave her damaged baby up for adoption. After hospitalization and numerous foster placements, he was adopted. He never loved his adopted parents and blamed them for his deformity. His whole life he suffered from a hidden psychotic depression that went unrecognized and untreated. The result was failed marriages and mediocre work performance in spite of being bright, well

The silent transference 37

educated, creative, and seemingly longing for relationship. He lived psychically alone and angry even though physically he was always married or living with someone. As he explained this to me, “You see, I think I am totally lost when I am not connected. I can say it . . . and still not be connected. Then I say it again and I am connected and then I feel like I got there by myself”. When I reflected back that he felt I was not helping him, he said he always felt he did it on his own, but that it helped him to just be in the room with me – to see and hear and smell me. It did not matter to him so much what I said but that I continued to see him and to talk. He needed the sound of my voice in order to know that I was there and, more importantly, that he was. He was hearing me. His connections to me were either mental – the idea of me – or physical. In that way, they were adhesive (Meltzer, 1974; Tustin, 1986) in nature. He required concrete perceptual evidence of his existence and of mine. He did not experience emotion so much as he talked about emotion, whether mine or his. His writhing on the couch was unbearable for me to watch. It took many months for me to find meaning in his movements. He seemed to be trying to get away from something. I didn’t know what. I felt he was trying to get away from the hanger-me who threatened his existence, yet that seemed too pat. It also seemed he was getting away from his pain, but what pain was that? It was as if he could not stand being inside of his own skin. I needed to endure not knowing, not naming whatever it was. I also needed to endure being a no-object for him. As this gradually began to change, he became suicidal. One day as he left, he said: “I can’t get away from this thing that is me. I can’t get away from you either. I want to blame you for hurting me by not being my mother, for not letting me grow inside of you. I also blame you because you won’t just let me die”. Another patient who had several surgeries during his first two weeks of life, being born with congenital breathing problems, said: “It’s like there is a vacuum around me that I want to have filled that was never touched by my parents – a vacuum around me that leads to a desire to have people define me. Then I am angry when they do. I am always losing myself”. This patient too felt desperately needy and confused. He could not imagine why his marriages failed or what he did to be so alone. His marriages failed because of his silent rage. Since he did not feel rage and he never fought with his wives, he did not understand. Just when he began to connect with me, he precipitously stopped his therapy. A general description of how the silent transference reveals itself in session may be helpful. Once recognized and experienced by the analyst, the relational gap can be interpreted. This is a slow process of naming what is on the cusp of the developing mind and experienced in the body. I want to reiterate that I am speaking of a very primitive, unformed phantasy state that foregrounds in relationship. It is not strictly speaking a state of fight or flight; rather it is a state of frozenness or blankness. This phantasy state is indicated in sessions in a variety of ways: agreement with everything the analyst says, ignoring what the analyst says, agreeing while

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qualifying with “Yes, but . . . ”, repetition of words and sentences, word-for-word recall of previous sessions. Life stories become so familiar to the analyst that they can almost be repeated by either member of the analytic dyad. Cryptic and vague speech maintains the wall of the pathological organization and the impasse in the treatment. Speaking in a monotone that is almost hypnotic, dulling the senses of both analyst and patient, is common. One patient who talked incessantly called it his “wall of sound”. Blankness, which may seem dissociative but has nothing under it, is puzzling and confusing. It may be tempting for the analyst to fill in the gaps, as such a state is extremely difficult to tolerate. These patients demonstrate a lack of selfreflection. There is little self-awareness. Speaking theoretically, awareness or sentience has several components, all of which use the perceptions and sensations of the body as indicators of existence of self and other and of relationship between them. Eventually these experiences of awareness are categorized and ordered within the mind and form gestalts with meaning. When the gestalt is loosened and the psychic structure released, an undifferentiated state of possibility arises. The undifferentiated, unintegrated state of the infant or of the creative adult differs significantly from disintegration or fragmentation. Disintegration and fragmentation occur via splitting and regression of experiences that have been represented in the mind. Unintegration is an experience that has not been ordered via memory and representation. It is more sensory and emotional than mental. Winnicott saw it as the potential state of the infant, out of which emerges the self. Vestiges of these unintegrated states remain as “magic signals” (Ferenczi, 1913, p. 224), left for the analyst to decode. These magic signals are before language and have never been thought. They are found not as words or images but as sensations. They are presymbolic and preverbal, what Klein called memories in feelings, or what I have called memories in sensorium. The representations are primitive and perceptual. The memories are implicit, not explicit. All of us know these states although perhaps only the artists within us value them as transformative creative sources. Others do not notice them, while still others experience them as terrifying and as evidence of nonexistence. Patients who were traumatized as children have walled off their emotional capacity to engage, making it difficult to meaningfully connect with them. Their attachments, inside and outside of the session, are superficial and “as if”. The brighter these patients are, the better they are at mimicking relationship. Yet within the transference something is missing. When they speak, we analysts find ourselves interested but not emotionally affected. When we venture a conjecture in the form of an interpretation, these patients have no means of determining our accuracy. One patient helped me learn this when she said to me: “You may be right. I really have no way of knowing. Because I am sure that you know more about me than I do, I will take your word for it. There really is nothing else I can do. I don’t have enough of a sense of myself to know”.

The silent transference 39

The responsibility of the analyst is huge in such instances. The power is too much. No wonder these patients seem unreachable to us. Their pre- and post-natal experiences have interfered with their abilities to repress. What is present is raw and unprocessed experience, closer to primary process than to secondary process. Repression requires awareness of experience. Here, instead of being repressed, that which is missing was never mentally processed enough to be banned. The analyst is left with “nothing” to name. There appears to be blankness where an infantile traumatic experience might be. It is not that these patients do not repress other, later, or non-traumatic experiences that can be found within the infantile transference. Instead, unformed, unmentalized experience remains unremembered and unexpressible, except in the body (Levine, Reed, & Scarfone, 2013). In these primitive places, projection and projective identification are minimal, hence the analyst experiences minimal emotional responses to material and may find nothing to interpret in the transference. Introjective identification is compromised by an unconscious no-place or a blank space, making learning from experience difficult. It is difficult to find a place within to hold that which might be internalized (Bick, 1968, 1986). The capacity to project and introject as found in a healthy interactive process is compromised. Metaphorically speaking, it is as if the infant never took that first breath of air. Therapeutic progress occurs when these body memories and magic signals can be acted out so as to be decoded, understood, and translated within the hour by the analyst. The action, in the cases like these, is inaction. The communication is silence. Mimicry may appear as action but is meaningless. The analyst must use her intuition and sensitivity and communicate her receptivity to the faintest of clues. The analyst’s inference may be right or wrong, but the attempt creates the possibility of a link. The failure to understand is a part of every therapeutic action. As these two-person exchanges occur, the patient’s innate ability to project and introject, to trust in a receiving other, can be activated again when the object is found. Sometimes, at first, projective identification begins to occur indirectly, through a relay or intermediary (D. Rosenfeld, 2006, p. 154). The intermediary may be the physical space of the analyst’s office – the feel of the couch, the smell of the air, the colour of the walls, or the entry code at the door. The relay may be the patient’s wife or child or the previous patient who is seen leaving or imagined. The analyst may notice these and be patient. If the analyst can be patient and perceptive, with faith in the analytic process, the infant in the adult will begin to breathe, to nurse, and to grow. Studying infants in infant observation and noticing certain commonalities between patients who suffered pre- and post-natal trauma have given me a beginning understanding of the earliest vestiges of infantile trauma found in the adult and reenacted in the silent transference. I have used examples from my most difficult to reach patients who faced death even as they were born. Traumatized by medical problems at birth, they were in fact doubly traumatized, for their medical

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The silent transference

problems immediately took them away from their mothers. Hence they find in me an absent mother analyst who isn’t there and who always fails no matter how hard she tries. Rediscovering the lost good mother from infancy within the transference is difficult because these patients appear to not have a receptor for receiving love. Losing the mother so early results in a loss of self that later is often blamed on the mother. Ferenczi (1949a) speaks to this process when he says, It is unjustifiable to demand in analysis that something should be recollected consciously which has never been conscious. Only repetition is possible with subsequent objectivation for the first time in the analysis. Repetition of the trauma and interpretation (understanding) – in contrast to the purely subjective “repression” – are therefore the double task of analysis. The hysterical attack can be only a partial repetition, analytical attack must bring it to a complete development. (p. 261, italics in original) Today we use a different language, and no longer call these responses hysterical. We acknowledge that access is found in the re-enactment within the therapeutic relationship. Once accessed, acknowledged, and experienced, repair is possible. Discovery of the lost potential for loving and being loved in the session re-enacts the pain of the infantile trauma. However, the pain of the loss is so severe that it takes many moments of rediscovery to make a structural impact. Many patients choose to leave rather than experience love.

Conclusion As analysts who love our patients we must stay true to the invisible within them. The theories we have evolved serve us well for treating neuroses and psychosis. They also serve us in understanding conditions that originate before these defences form. With elasticity of technique and creative intuition and imagination, we are better able to reach the invisible missing pieces in our patients. Before we can reach them, however, we ourselves must feel them and respond to them. This is painful for it activates our own early defences. Our frozen places, like those of our patients, hurt when thawing. Our blank places are invisible to us, except as our patients discover them. Ferenczi recognized this truth: that our patients feel our dead spots before we do. In order to help them, we must identify our own frozen states of mind. In order to help them we must suffer the absence of the patient, and accept the truth of this state of mind that is seemingly unreachable. We must bear the narcissistic wounding that their mothers bore: the reality of an infant that might die, and that cannot be held or touched or nursed. This is the realty of an infant in the NICU. There is nothing we analysts can do but watch through the windows of their defences and be there to notice when they look at us, through slitted lids and

The silent transference 41

out of the corners of their eyes. When we do, new possibilities for relationship and integration occur, within these patients and within us. Because of the extreme nature of their early traumas, these patients teach us about the infinite possibilities available to us throughout life, some chosen and some evoked. Some have gone missing never to be found again. Some are found after years of painful and tedious therapy. A patient who was on the road to finding and knowing herself after years of living in limbo said to me: I like how you point out that I am ignoring you . . . because I am not aware of it. With my eyes and ears and senses, I have known you, but I do not realize how I don’t include you. I don’t think I have ever included anyone. I thought showing up was physical. I know how to do that. I don’t think I ever show up emotionally. Thank you. My hope for these patients comes from the clinical experience of accessing the deeply held prenatal experience. They are reachable. These infants were held and contained in utero and remember that containment in their bodies and in their unconscious phantasies. It is for this reason they can come to us saying, “There is something missing”. Missing the lost good object of infancy – the mother who carried them and birthed them and then was withheld from them, and whom they can never have again in quite the way they would have had – is the hope they have for grieving what was lost, raging at what was unjust, and recovering what can be. Although many of these patients have repaired that early trauma as best they could, the trauma of a repeatedly abandoning other is too often repeated in their lives. This repetition marks a loss of self that has not been mourned. Analysis can help these patients relate deeply to themselves and to others: with love and with hate, with life and not death as the measure.

Chapter 4

Somatic counter-transference

This chapter discusses the use of somatic counter-transference as a means of learning about the patient, about projective and adhesive identification, and about the object-relating nature of the most traumatized and withdrawn part of the personality. It assumes an elemental knowledge of British Object Relations and uses clinical material to illustrate the hypothesis that somatic counter-transference is an indicator of a very elemental communication originating from the aspect of the psyche that is united in a body/mind or mind/body. I assume that this body/mind was object seeking at birth and perhaps before. Because these early aspects of the personality are nonverbal and non-conceptual (Lopez-Corvo, 2014), the analyst must rely not only on the verbal material in a session but on the emotional and sensual experiences within the transference and the counter-transference. Such reliance requires a faith in one’s own intuition without a certainty that one is “right”. Because speaking of such early experience is difficult, writers and analysts often appear to be more certain than they are. That is a hazard of this type of analytic work. All of what I am writing about is conjecture or imagination or dream. It is only that I am suggesting that such dream-work is a valuable tool for analysis of patients who were traumatized in infancy or early childhood. One of the ways we analysts notice this is by our own somatic responses to the patient. Another is by our recognition and reception of our patients’ adhesive identifications. Adhesive identification, according to Tustin (1986, 1990) is a defensive state of mind that occurs before projective identification and serves as a defence against disintegration. I believe that pathological states of mimicry are expressed via adhesive identification. In adhesive identification, the experience of space between two individuals is denied and replaced with a delusion of oneness. Bick (1968, 1986) linked this with a failure in the development of the psychic skin. When I was first introduced to the idea of adhesive identification, I felt confused and immediately disagreed with the concept. It seemed contradictory to use the word identification when referring to adhesion. I asked myself, “Are not the two in opposition, with adhesion being to surfaces and identification implying interiority?” Tustin (1986, 1990) too seems to have had difficulty in using the term adhesive identification and preferred the term adhesive equation. It seems

Somatic counter-transference 43

there are two distinct states of mind, with adhesive equation being the more primitive. Then clinical experience began to accumulate in me that supported both these concepts. I found myself returning again and again to articles that described my clinical experience and began to appreciate the usefulness of these imaginary concepts. Further, I have come to appreciate and surmise that this very primitive form of identification is somatic in nature. I believe this experience as I myself have felt it is what Bick (1986), Meltzer (1974, 1975a), Tustin (1986, 1990), and others have called the reception of adhesive identification. In addition, I believe that I can become aware of this defensive state of mind by paying attention to my own somatic counter-transferential response and by recognizing its corollary in me. In this way my counter-transference of adhesive identification aids me in understanding the process in my patient. Adhesive identification then is the unconscious sensory use of hearing, seeing, smelling, and touching to take in and fuse with the other. In this way, perhaps Albert Mason (personal communication, 1999) is correct when he states that all identificatory states involve projection, even this most elemental and primitive one that appears to be about surfaces instead of about interior spaces. The projection involved in adhesive identification would then not be in the form of mentation but in the form of sensation (Eekhoff, 2016b), and it would originate in the most primitive body/mind or mind/body of the patient. Such projection makes the connection with the other seamless and hidden in the treatment, so much so that there may seem to be no relationship at all. For me, some of the ongoing work of the hour has become that of differentiating what my personal bodily experience is from what I have received as a somatic projection, just as I must differentiate what is my personal emotional experience from what is a projected emotional experience. The differentiation of somatic projections is more difficult because I have come to associate certain bodily sensations with my own emotional experience. The temptation then is to superimpose my emotional experience onto an interpretation about the patient. But this bypasses the primitive nature of the communication and sends both analyst and analysand down a false trail. Further, it seems to be a defence about such a primitive use of me. It is important for the analyst to remember at such times that somatic communication is sensation, and the primitive mentation present may not yet be nameable or experienced by the patient as a differentiated emotion. Rather, if present, it is most likely experienced as undifferentiated affect that is related to instinctual needs. Moreover, no somatic or emotional experience is consciously available to the patient. Everything is going on outside the patient, and in the analyst – and, in these particular instances, in the body of the analyst. Unless the analyst is willing to allow her body as well as her mind to be used, these communications may go unrecognized and be untranslatable. Adhesive identification involves the denial of self and the entrance into and the becoming of another. Yet there appears to be little or no interior experienced

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– because the interior is, in phantasy, denied and projected via the senses. Bion (1958) describes this reversal of sensate perception in his paper “On Hallucination”. Patients who use this defensive process seem to have a fascination with the sensual, which I speculate is a defence against existence. The identification is with the surface of things. The subsequent use of sensorial experience seems to blot out the awareness of the other, as the result of blotting out awareness of the self. In addition, the senses are not linked in the usual way but are often separated one from the other. I have come to notice in my attempts to understand a somatic and sensate experience in the hour that there is information about my patient within my own somatic counter-transference. In tracking somatic responses in my counter-transference, I believe that I have learned what Ferenczi (1912), Freud (1926), Klein (1946), Isaacs (1948), Winnicott (1949), Bion (1962b), and Ogden (1984) told us about the deep unconscious – that it is somatic. By paying attention to the appearance and changing expression of my own somatizations within the hour, I have discovered my own understanding of the concept while simultaneously increasing my capacity to bear primitive states of mind and body in both my patient and myself.

Clinical vignette I think of one particular patient who has taught me this, although I could tell you of others. I will call her Sara. I met Sara many years ago, during my analytic training. Her initial presenting problem was her desire to have “help with my children”, as she was planning to leave her husband of twelve years without having him know she was leaving. Sara explained to me she was preparing to leave him because, in spite of being a professional, he was an addict. She had denied her knowledge of this until she discovered his plans to leave the country, assume a false identity, and take their children with him. Therefore the violent leaving she was planning was necessary “for the sake of the children”, who at that time were four and six. She feared that if he discovered her plans, he would take the children and they were “too young to defend themselves”. In our first session, I saw a well-dressed woman who told an unbelievable story. In spite of the story’s unbelievable nature, I found myself believing her. Sara required no help from me in telling it. Her masklike face, her matter-of-fact story, and her hysterical and theatrical movements, which contrasted with her demeanour, impressed me. By that I mean that she smiled at places in her story where smiles “should” be, and showed a kind of anxiety where anxiety should be. There were no tears. Eye contact was steady and appropriate. I felt shocked by her inaccessibility and her determination to act for the sake of her children. She was the most artificial woman I had ever met. She was ostensibly coming to therapy not for herself but for her children. Sara did not seem to have needs of her own. I imagined she would not stay nor do deep work as I could not imagine developing a relationship with her nor her with me. Yet even after the first session I wanted her to return. I did not know why as I had not felt her presence and my responses seemed to be clearly my own.

Somatic counter-transference 45

But she did stay, perhaps because she connected to me immediately and adhesively with words. She would come session after session and talk nonstop with little room for me to say anything. I believe now that that early attachment of this kind is adhesive in nature: sound, smell, and sight being of primary importance. Content was nearly irrelevant, although I valiantly attempted to make meaning where there was little, to listen to what I thought was behind the words and seek any genuine feeling, and to notice any spontaneous gesture. These were few. She even agreed to come twice a week and then three and even four times a week to “dump”, as she called it. Again looking back, I realize now that she did whatever I suggested. After the first few months of once-a-week therapy, Sara would only have left had I told her to leave. She was adhesively connected to me and neither of us knew it. At that time, I was counter-transferentially pretty blank, though curious. I was also well intentioned. Perhaps my most noticeable countertransference response was my wish to work with her. The first several years, I mostly listened and looked for any sign of genuine affect. I found little. Instead I encountered acting, as-if behaviour, or what Winnicott called a “false self”, although of course my patient did not know this. In myself, I found mild curiosity and little else, which I recognized as unusual for me. I also did not experience any somatic responses to her, or at least none that I noticed. Initially, I too found that unusual. Also, any attempt I made to interpret the transference seemed useless. Sara was always polite and seemingly interested, but reported no awareness of having any feeling at all for me. She would say, “I don’t feel that, maybe it is there”. She brought me no dreams, no childhood memories, only detailed descriptions of her everyday life outside the consulting room. She seemed enmeshed in concrete reality with little emotional or imaginative life. Nor could I bring her into the room with here-and-now references. After a while, I stopped trying. Sometimes I wondered if she experienced herself as shallow or empty, but she didn’t seem to experience anything like that, nor did I when I was with her. I might have used this wondering to interpret her emptiness, but she never told me she was empty. She seemed to never have had an experience of her own interior world. To be empty and experience emptiness, one has to know there is an inside. I believed, in my naiveté back then, that my task was to stay with what was verbally presented. I did that, but it locked me into a false analysis, into an as-if analysis. What was also lacking initially was any boredom on my part. I would have expected to be bored, but the original fantastic story about her husband seemed to imply something more was coming. Yet since I too was “adhered to the content”, I did not notice the deadening in the hour. After her divorce was over, which included a difficult child-custody battle, I suggested she join a mixed group a colleague and I were leading. This is not something I would do now. At the time I genuinely thought it would be good for her. I see now that this was an acting out on my part, my attempt to make something happen. I had no idea how ill she was, attributing most of what I had seen in her to a difficult marriage and divorce problems. In the group she did not speak for one year, although she came faithfully. This not-speaking behaviour brought

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our analytic work closer to “in the moment” work. I was able to recommend she leave the group and focus on her analysis It also marked a change in my counter-transference responses. In the beginning I did not recognize that she was beginning to project more. I became more active, which may have marked the first hint of projection. I began trying to reach her, to get a word in, as I could not bring together the silent terrified woman in the group with the talking one in sessions. I began to speak more and more to the moment and to experience a kind of urgency to get through to her. Again I attributed the change to my learning more, to my wanting to “go in and get her”. Now, looking back, I recognize that pressure to speak as evidence of a sadomasochistic enactment. Our roles had not changed, they had merely switched. There were also moments when I felt sleepy, so I too was switching! I was oscillating between a manic attempt to penetrate and get inside of her and a drowsy, deadened analyst with no words at all, an analyst who was merely trying to get through the hour, while seeming to be interested in her endless and meaningless stories. At this time, I began to notice that she would rub her skin on her left hand with her right thumb and fingers and, at times, it seemed she was even pinching herself. Sara told me she did it in order to stay in the room. At the same time, there came occasional bits and pieces of history. She told me her parents had never been happily married and that her alcoholic father was psychotic when he died from cancer. She described their violent verbal and physical fights and her attempt to protect her younger sister from them, and from her father’s drunken rages. I tried to interpret that she attempted to protect me from her own angry parts as well. She told me she never felt like that with me. Now I can understand the truth in her response, in that we were together re-enacting the childhood so as not to feel it nor speak about it. After four years, she mentioned that her mother, whom she also worked for in a masochistic re-enactment of her childhood, was bipolar. Later, she stated that her father was “a raging alcoholic”. As her story of a horrendous childhood unfeelingly unfolded, I felt increased awe that this woman was managing to function at all: to work, to mother, to marry again as she did several years ago. Sara seemed to function very well both socially and professionally. A major change came, looking back on it now, when I became able to speak to a somatic hallucination I was having in a session. Again I do not know if the change was in her or in my own ability to be present and separate enough from her to receive a powerful somatic projection. Perhaps it was both. She was talking in a rather familiar way about her job, how she was underpaid and underacknowledged, and about how her mother was planning to bring in a partner and leave her out of the business. This also occurred as she was falling in love. While she spoke, I became extremely ill. I felt hit with a wave of nausea that persisted in its strength and force for more than fifteen minutes. At first, I thought I was going to vomit. I imagined I had eaten something bad for lunch and had food poisoning. I thought about how to say, “I have to get out of here”. And even fantasized that I could use the wastebasket if I had to but feared that would

Somatic counter-transference 47

be devastating for the patient, who frequently expressed concerns over my wellbeing after listening to her. I saw an image of myself bolting from the room and seeing a shocked look on my patient’s face as she sat up. Along with the nausea came a blinding headache and an inability to breathe. “I am really sick!” I told myself. Then I realized that this horrific feeling was coming from my patient. I cannot explain how I knew it. It was something about the way she was lying on the couch with her hands crossed over her stomach. She looked calm and relaxed, but dead and unmoving, like a woman lying in a coffin. The moment I thought, “This is not about me being ill”, my nausea passed, my headache was gone, and I could breathe. I was also able to think. I wondered what it meant and chose at that moment to say nothing about my assumption that something foul was poisoning her, deadening her, and making it impossible for me to reach her with my transference interpretations. I only knew how violently I had been given a message. I truly did not know what it meant. I imagined that her need “to get out of here” was being projected into me and felt relief at an understanding, whether it was correct or not, that held me in the next few sessions. I felt, with my headache, that the “top was coming off”. I also surmised that something was “threatening to come up”. At the end of the session, I attempted to say something like that to her. It was awkward and not very articulate, but well intentioned. She responded with a vague, “Oh, you think so?” Even then, I recognized that my attempts at interpretation were trite, off-the-shelf interpretations designed to get me out of there.

Somatic counter-transference Now, instead of exploring the evolution of this case, I want to look again at my responses to this dramatic counter-transferential somatic experience. After the initial shock and urge to leave the room, I told myself “This is not me”. Perhaps in that was a response that said, “I am not the crazy one”. In thinking that, I felt relief. I maintained my relief via my thoughts of theory. By calling on all the trite and clichéd Kleinian interpretations I could find, I created a delusion that this experience was only about my patient and had nothing at all to do with me. Notice that I did not ask myself, “How is it you can be so moved?” Except for the last statement in the hour I describe, I did not say aloud any of these “interpretative” thoughts I had. It was sufficient for me to place them all in my patient, to project them into her, as if giving her a dose of what she had given me. As I write this, I recognize that saying or not saying my thoughts in those moments was not the issue. My patient felt what was being communicated. In fact it was after this session that she began talking about how terrified of being crazy she was. I think now, even though I knew that she was afraid of being crazy like her parents, it was also her way of communicating to me how terrified she was of my craziness. Yet in this example, one of many with her over the years, I was crazy enough to be with her in this terrifying experience. I think I needed to be. Over

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time, I have learned to speak out of such mutual or fused experiences in such a way that hopefully what I say does not push them back into her. Instead I am able to place the experiences between us and use them to find meaning. After that session many years ago, I noticed my own somatic delusions in nearly every session with her. None were as dramatic as the one I have described. Perhaps in paying more attention to these somatizations there was less of a backlog in communication. Also, I learned and am continuing to learn to use this countertransferential information to inform my interpretations. The work did become more immediate, and more in the transference, although not without times of grave enactments that we needed to recover from and then to discover what they meant. I credit the change to my ongoing supervision and training, to my own analysis, and to the learning from experience that Bion tells us about. My patient was a forgiving and tolerant teacher, healing me so I could help her to heal. Sometimes she would comment on our process by saying things like, “You know I don’t know what I am saying”. Once she said, “Speaking to what is memory is like commenting on the air”. Whereas, when I met her, Sara had no childhood memories, only memories from earliest infancy, eventually she began to have memories, such as remembering, from her earliest recollection through leaving home at eighteen, how much she hated being touched by her mother. Her mother’s touch and smell repulsed her. Over time she came to believe that as an infant she could sense her mother’s mood changes by her smell and identify danger from the odour that emanated from her cycling mother. Sara came to identify herself with the smells in my office and to notice changes in my well-being by the smells she told me she noticed coming from me. Although I would have difficulty telling you how I knew this, it seemed to me that she became me, by identifying with these smells. But in becoming me she lost herself – there was then no self, but only the selves originating from sensate fusion with me and with the other important people in her life. At the same time, it was only after years that she could occasionally acknowledge our separateness, and therefore both my presence and her need for me. Sara frequently said things to me like “I’m wired differently” or “It’s been hard-wired in”. Or “Judy, I have no words for this, the closest thing I can say is that it is cellular”. The “that” or “it” she was referring to was a way of relating that wiped out her existence and awareness of her self. These were the times, when she was struggling to understand herself, that she would pinch herself, “to stay here”. I want to clarify that this was not the drama and imitation of hysterical mimicry, nor the high-order defence of dissociation, although these are also present in her psychological makeup. Rather it seems to have been an adaptive and an early form of pathological splitting of a somatic nature that involved separating her senses one from the other and projecting them outward. The evidence I had for this appeared in my own body first as sensation, as counter-transferential hallucination.

Somatic counter-transference 49

Conclusion Learning to speak to the unspoken and the unspeakable makes it possible to work with patients who have been traumatized not only by the families into which they were born, but also by their own bodies’ exquisite sensitivity to somatic stimulation. The interaction between the two, or what Ferenczi (1920–1932), Freud (1940), Klein (1946), and Isaacs (1948) might have called their instinctual lives, is reactivated in the transference and counter-transference so that the physical and emotional presence of the analyst is experienced by both analyst and patient as unbearable at times. The mutual experience can reach awareness first in the body of the analyst and must be experienced, held, and endured before it can be identified (Borgogno, 2014). Once identified, it can be thought about and used by the analyst for the development of an interpretation. This careful and primarily unconscious communicative interactive process between analyst and patient makes it possible for the containment of very primitive and often disruptive communications to come into the counter-transference and be thought about, understood, and worked through in the transference. The first experience of relationship to other and to self occurs in utero and is experienced as a physical holding of the skin within the watery depths of the womb. Within the womb, the infant adds the aural sense of sound. Then, the sensorial realm of sight is added. For this reason, the skin becomes an important metaphor as the container, not only of the body and the senses, but also of the psyche. When this sensorial experience of the skin is eventually united with the other senses, a web of holding for the self is formed. In this way, the body becomes a psychic container that represents mother. And, as such, I believe that bodily sensations – even when experienced as overwhelming – carry with them an association of relationship. This association may then be used, when felt in the counter-transference, to name a transference relationship that has previously been hidden and is seemingly not present. In this way, concrete and seemingly non-relational patients can be treated within an analytic frame.

Chapter 5

Finding a center of gravity via proximity to the analyst

I have created a shell out of assessment and the stories I make from it. It is what holds me, what gives me a center of gravity. When you expose me, I feel flayed open and back to a place where no one exists, not me, not you . . . nothing. You cannot possibly know what that feels like – when reality comes in and nothing is there. – An analytic patient

Center of gravity Psychoanalytic technique has changed. Some of this change involves learning to work increasingly with more and more difficult-to-reach patients (Joseph, 1975). British Object Relations clinicians working with autistic and post-autistic states such as those described by Tustin (1986), Meltzer (1974, 1975a), Bion (1967, 1979), Mitrani (1992, 1998, 2001, 2011), T. Mitrani & J.L. Mitrani (1997), and Alvarez (1981, 2006, 2010, 2012) have, following Freud and Klein, greatly influenced this change. They, along with others, shifted psychoanalytic technique away from a one-person exploration of repressed states towards a two-person exploration of evolving internal and external relationships. The analytic task is no longer limited to being an observer who interprets. Instead, the analyst has become a participant-observer who engages. Transference and counter-transference have taken on new meanings as a result and are used differently than once was the case. When working with autistic or post-autistic states, this change is particularly relevant. The analyst’s counter-transference becomes a guide. Primordial states of suspension require different responses from the analyst than other more developed states of mind. A patient in suspension is difficult to engage. In order for there to be any kind of engagement, the analyst may allow herself to become an extension of the patient. More accurately, she becomes aware of how she is being used in this primordial sense. Just as an autistic child borrows the body of the analyst, using her hand to pick up a toy, so do emerging adult patients borrow aspects of the analyst, via mimicry, in order to have an experience of existence. In this way they exist outside of themselves, in the space and substance of others, finding their centers of gravity in whomever they

Finding a center of gravity via the analyst 51

are with. If the analyst does not notice this, the work will come to an impasse, as even their speech reflects the way in which they use borrowed symbols to communicate. In working with neurotic patients who have autistic barriers, it is easy to focus on their neurosis and not the autistic mechanisms that underlie them. Without an analyst or another person to recognize the somatic and concrete nature of these barriers, these patients will be caught in a cycle of mimicry, imitation, obsession, and somatization that seems unchangeable. They will be stuck to their bright minds and adhered to obsessive attempts at perfection. Their autistic barriers foreclose recognition of the other, so they cling to the analyst sensually while being relatively unaware of their own or their analyst’s psychic existence. In clinging sensually, they are lost to the emotional connection that makes learning from experience possible. Boundary confusions enable these patients to identify with and become whomever they are with at the cost of their own capacity for identification. They adhere to objects around them, rather than project into them (Bick, 1968, 1986; Meltzer, 1974). Tustin (1972, 1980, 1986) calls this process of fusing with whomever they are with entanglement. Gaddini (1969) explores the imitation through which they create themselves. Eekhoff (2012) examines the value these mimicries serve upon emergence. By emergence, I mean moving out of the state of suspension and mimicry. Living in a forever now, without a sense of life and a future, these psychically dead patients are protected from the awareness of their own mortality. Time and space are not relevant. When the patient begins to use the analyst as something other than an extension of herself, time begins, space opens up, and death becomes inevitable. One must be alive in order to die. Emergence from fusion with everything and everyone makes these patients painfully aware of having been lost in space and suspended in time. This suspension makes all experience of equal weight, with no gravity that would enable foregrounding and backgrounding different aspects of experience. Such equalizing of experiences renders decision-making difficult if not impossible. All details are equally important, so how can one choose? Emergence involves the classification and ordering of information, so as to create differing values or weights for each experience. Emergence, at the point where awareness is heightened, is terrifying, disorganizing, and shame-provoking. It may include severe psychosomatic or life-threatening illness or psychotic states. Emergent states, when emotion is unleashed and separateness is encountered, are states of terror, horror, and rage, which the analyst will feel first. Emergent states feel intolerable. The proximity of the analyst does not initially help mediate these states. That proximity, of which the patient has been unaware, places the analyst in a helpless and vulnerable position of being witness to the ongoing psychic annihilation without being able to have any impact on it. Being witness is not exactly what happens either, for the analyst is personally impacted by her experience of observing the patient. Instead of projecting into the analyst, the patient, via massive projection outside of the analyst, spills, falls, dissolves, or floats into

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infinite psychic space. The patient disperses. Nothing seems to hold the patient together. The analyst can only observe, without being able to reach or gather, hold or contain the patient. This helpless vulnerability and willingness to be personally impacted begins to affect the patient. The patient’s own observer notices the existence and proximity of another. To see and observe is to be alive. Being proximate to someone who has suspended growth and development via the extreme methods used in dismantling sensory perceptions, so as to interfere not only with symbolic processing but with emotional relationship, is also narcissistically wounding. Initially, the experience for the analyst is one of disbelief and then one of horror. The analyst must persevere and survive not being used or related to (Winnicott, 1969) in order to get to know the unique and individual essence of the patient. In getting to know the patient, the analyst will learn things about herself she would rather not know. Surviving as a person and as an analyst is particularly difficult when working with such primordial states in our patients. To analyze a patient who does not seem to be psychically present seems impossible. To be treated as if one does not exist is deeply troubling. Equally troubling is to experience the absent patient. What appears absent in the patient is a subjective sense of self that includes a center that would hold emotional experience and make meaning of it. The missing center, in phantasy, has been projected out into the universe in search of a container and has found none. Space is infinite for them, without a capacity for being closed (Meltzer, 1974). Without the sense of a containing space as found in the other, there can be no introjection of an internal containing function. There is no center of gravity. Without internal containment, these patients have phantasies of falling, spilling, dissolving, or evaporating. These states of flowing-over at-one-ness (Tustin, 1972, 1981, 1986) – where the patient projects everything that might have been inside out into infinite space – resemble but are not the same as what Freud describes as primary narcissism. Patients often speak of themselves as being a sieve, or of having an empty core. The empty hole is contained within a shell created from concrete sensory experiences that have been dismantled (Meltzer, 1975b) and reconfigured as something else. The analyst’s proximity enables her to gather these dispersed bits. Meltzer (1967) has called this “gathering the transference”. Patients who are difficult to reach struggle with overwhelming sensate experience that interferes with their introjective processes. Equivalency replaces identification as a primitive method of relationship (Tustin, 1986, p. 127). Equivalency clouds the mind, much as fog surrounds and blurs objects, wiping out differentiations that mark opportunities for identification. Equivalency distorts the senses, turning the perceptual body into an obstacle that distorts and interferes with development. Equivalency places the center of gravity outside the body instead of inside. An internal center of gravity anchors the subjective perceptual experience in a reality that informs, teaches, and facilitates identifications, which accumulate and form a sense of identity. Bion (1962a, p. 8) calls this process alpha function.

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Although focused on sensate experiences, these patients demonstrate very little awareness of being in their bodies. Without being in their bodies, they have no ongoing sense of being (Winnicott, 1960) or existing as a solid person. Without this sense of solidity, they have no center to hold them to the ground so as to have a “floor for experience” (Eaton, 2015; Ogden, 1991). They psychically exist in space or in the bodies of those around them, without recognizing the other as being important or even present. In an analysis, they exist in the analyst, or perhaps more accurately on the analyst or as the analyst, even while they appear to not be in relationship or to benefit from transference interpretations. Existence as the analyst occurs through a primordial sensory experience of adhesive equivalency. What appears to be emotional awareness of another person is a visual acuity about appearances, an auditory sensitivity that recognizes every tone, timbre, and rhythm of the analyst’s voice, and a tactile awareness that distracts from an accumulated storehouse of experience. Since these patients are often bright, they are able to use their observations for a parody of relationship. When these observations are put together into stories, it may appear that the patient is attuned and in relationship with others. This is a mirage. These emergent sensory states are an elaboration of the tactile world of autistic states (Meltzer, 1975a; Tustin, 1986). They are not yet connected to the imaginary world of symbol formation, of individuation, and of separateness from their internal and external objects. They are not relational except in the most primordial sense. Bion gives us a way to think about these sensory states of emergence when he writes about beta elements. As he says: If there are only beta-elements, which cannot be made unconscious, there can be no repression, suppression, or learning. This creates the impression that the patient is incapable of discrimination. He cannot be unaware of any single sensory stimulus: yet such hypersensitivity is not contact with reality. (1962b, p. 8) The evacuation of beta elements can only happen with projection, something these patients are not able to do well initially. As they emerge from the suspension, they begin to be able to split and project and identify. These capacities make it possible to make better use of their analysts. Evacuation of beta elements occurs with emergence. In a pure autistic state, the sensory can be pleasurable and self-protective (Meltzer, 1975a). As projection of the sensory begins, the internal and external objects become confused. The analyst’s reverie and alpha function are used to bring reality to the relationship and the accompanying turbulence is extreme. Many, but not all, of the patients I have seen clinically who suffer from what appear to be post-autistic states have suffered a premature separation from their mothers at birth, either through medical necessity or through their mother’s suffering of severe postpartum depression or psychosis. They may also have had a genetic vulnerability, but I am unable to know this. These patients have recovered

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from what seems to have been their infantile psychogenic autism and are able to lead productive professional lives. However, they continue to suffer from postautistic states that severely inhibit their relational abilities. I believe that a therapeutic alliance begins with proximity that invokes somatic and sensory associations within the analyst. The analyst must notice and identify with these sensory experiences so as to find the patient. Once found, these identifications evoke or call forth the patient (Alvarez, 2012). These identifications are vitalizing. Initially it may appear that the analyst is identifying something foreign to the patient and using identification to fantasize or dream into being a person who is not there. It may also appear that in introjectively identifying with the patient, I am no longer following Bion’s admonition to use no memory, no desire, and no understanding (1970, pp. 41–54), which, according to Elizabeth de Bianchedi (1991), would also imply no identification. On the contrary, I believe that such identification comes from an evolution in the analyst of the non-represented experience of the hour and enables me as an analyst to deepen my reverie and my receptivity and make a connection with my difficult-to-reach patient. In deepening my receptivity, I am left in the world of my imagination and illusions of connection since these patients are underdeveloped relationally. This identification reflects the degree to which I as the analyst am dependent upon my patient. It is related to Bion’s (1970, p. 28) idea of at-onement and its evolution. The psychic proximity of the analyst, which is manifested physically and emotionally, consciously and unconsciously, enables her to communicate via her body and her emotions, first with herself, then with her patient. Her eyes, voice, and facial expressions demonstrate the impact of the patient upon her. In this way, the analyst’s introjective identification communicates openness and receptivity as well as a presence that calls forth the lost soul (Alvarez, 2012; Scarfone, 2015). Calling forth or going in and getting the patient eventually includes putting into language the experience of introjective identification (Ferenczi, 1909). Introjective identification is the vehicle that enables the analyst to become at one with the patient. At first it is the analyst who becomes a center of gravity for the patient, thus enabling the patient to gain one. Having a center of gravity is a necessary component of becoming integrated (Ferenczi, 1932c). Since without substance there is no reliable shape, no inside or outside, there is also no phantasy of the inside of an object or of a space that can be closed (Meltzer, 1974). Attachment to the surface of the other is evidence for existence while interest in mental processes is minimal. It then becomes necessary for the analyst to find within herself identifications that link with the patient. It requires a simultaneous experience of self and other such as is found in integration of the paranoid-schizoid and depressive positions. In this sense, the analyst becomes the center of gravity for the patient, enabling a floor for experience to develop. Emerging patients have their center of gravity in the space outside themselves and in the analyst. It is as if the experience of their skin (Bick, 1968, 1986) or their skin ego (Anzieu, 1985) cannot hold them

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together. These patients experience themselves as non-solid and so cannot count on themselves to “be there”. Even when they have a sense of themselves, they seemingly have no means of gathering themselves together or experiencing how these aspects of themselves relate to each other. It is as if their very molecules lack cohesion and disperse. All aspects of themselves have equal weight, making decision-making difficult. Their center of gravity is found in infinite space, not in substance. Until they become more solid in phantasy, they cannot have an internal psychic center of gravity to stabilize them and to allow them to have a foreground and a background of experience. Equilibrium is not possible without a sense of solidity. Being embodied with an internal center of gravity makes having a floor for experience possible. A floor for experience helps build a subjective sense of self and other. I want to introduce a patient who taught me this. Since working with her, I have been able to recognize these somatic defences in other patients and to understand that their seeming lack of anxiety, affective expression, and valued relationships are side effects of the deeper process of suspended existence that must be understood if a therapeutic alliance is to be formed. Let me tell you about Kay and, more specifically, since I have written about her before (Eekhoff, 2012), of her emergence.

Kay I worked with Kay for many years, first as a once-a-week therapy patient, later increasing to four times a week analysis. Initially she came to see me because she said something was missing in her. As she reported, she carefully thought about and planned everything she did. As a result, she was a successful professional with a graduate degree, intelligent and competent. Her husband was successful and good. She was “politically correct”, with two children and a beautifully decorated home and garden. She was a soft-spoken, gentle, well-groomed woman who read all the best books. She had a large social network, entertained regularly, had hobbies, and no one knew “she preferred to be alone”. She had the life she had because she wanted to appear normal. She reported feeling nothing for her husband or her children. When she went to the movies, she saw a lot of people loving and having all kinds of emotions. She reportedly did not have those. She came to me because she believed she did not know how to love. Kay was initially a good storyteller, describing her observations in such a way as to amuse and entertain me. Her vocabulary was extensive and contained many words about emotion. I was not moved by them, in spite of their difficult content. Her stories seemed flat to me. Soon I realized that her words were borrowed, not embodied. Her stories were meaningless and interpreting them as if they were symbolic was an error. The same was true about her dreams, which were plentiful. At times, I doubted that she knew the difference between storytelling, dreaming, and hallucinating. Nothing seemed to have meaning except as it enhanced her image.

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I alone was dissatisfied with the therapy. She felt she was a good patient and I was a good therapist. She told me she got a lot out of her work with me. She had an amazing tolerance for silence, speaking only if she thought I was uncomfortable. When she began using the couch, she could be silent for whole sessions, unable to read my posture and facial expressions, and did not mind. Later, she described that time as “agreeable, with me floating a foot above your couch”. I remember it as her lying there, as if in a coffin, unmoving, hands crossed upon her chest, seemingly not even breathing. She was extremely compliant, precise about details, observant about every change in what I wore, how I looked, the content of my office. These changes did not bother her; they were just noticed. In fact, looking back, nothing seemed to bother her. She was primarily indifferent to most things, which made her appear calm and unruffled, in spite of her obsessive preoccupation with appearances. I came to understand that this indifference represented the way in which all experience was of equal weight to her and did not last beyond the moment. She cared a lot about appearing normal and so her cooking, her decorating, her dress and makeup were perfect. Details were all equally important to her. She reported that when she went to restaurants, she never knew what to order and so always ordered what someone else did. I believe this was because the perceived equivalency of her choices made decision-making impossible. She received accolades for her work, but felt she was fooling others by “copying the good workers and stealing everybody else’s ideas”. When I was with her, I did not recognize myself. That is, I could not feel any emotions, other than a very mild curiosity. I found this disturbing. I was often overly busy in my mind and came to recognize this cognitive busyness as a defence against something I had not begun to know. I felt no projective identification and initially could find little with which to connect with her. I really could not imagine why she kept coming or what I gave her. We were the same age, yet she seemed ageless. Through the years, I aged but she did not. She maintained her youthful body, her clear expressionless eyes, her smooth and unlined face, and her unruffled mien no matter what happened to her. Until her emergence from her sensate cocoon, she was unruffled by any life event or by anything I said or did. I simply could not reach her. No one did. Transference interpretations were met with some variation of, “If you say so”. I first recognized her as emerging when I began to recognize bits and pieces of myself in her – gestures, phrases, and tones of speech. As she emerged somewhat more, she became quite dramatic, but again she was not in her drama. She was merely being a better actress than when I met her. I had given her more sophisticated material for mimicry. During this stage, I began to find myself more and more in her. This was extremely disturbing. I felt crazy and disoriented. When I attempted to interpret, she would agree and change, once again becoming whom she perceived I wanted. Today I might think of this as my introjective identification with her very weak projective identifications.

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In spite of this, she was a wonderful teacher for me. Once she learned that I was not interested in her stories about others, she began to describe herself. Her observational capacities meant that she could describe states with a detail I had not heard before. Although she did not seem to embody what she told me about herself, I learned that her descriptions were accurate. She did not have much of a contact barrier between inside and outside. Primary process material was presented as reality. Once named, it was gone forever unless I remembered and brought it back. The Freudian concept of repression did not seem to apply to her mental process of forgetting. She could not repress that which had never been thought. I had difficulty believing she could say something without thinking it. After the fact, I came to think of these lost experiences as sensory rather than mental and so impossible to be remembered. They were unrepresented in spite of having been spoken. Perhaps these descriptions were of events that Scarfone (2015) would call re-presentations. They taught me much about her. I learned of her states of dissolving, falling forever, of floating in space, and of indifference to her experience or the experiences of others. She simply did not get upset about anything. In retrospect, this may also have been due to the fact that time was an immediate experience for her. Once past, the event was no more. As her descriptions evolved, I became increasingly more and more disturbed. I had never imagined such a barren internal world or such an artificial, superficial, and unconnected life. It was not that she had an empty mind. Her mind was full to the brim, spilling with the details of her life, her observations, what she saw and read. She was extremely sensitive. She reported to me that the hardest thing about therapy, and then analysis, was that she had to speak first. She was usually silent and comfortable in the company of others, including her family. She spoke after figuring out what others thought and fed back to them some version of themselves. As she emerged, I experienced immense rage, cruelty, and horror. I feared I could not help her. I feared I was making a terrible mistake and driving her crazy. I was flooded with corrosive doubt. Eventually I felt a terror I had never known before, a terror that she would kill me, her children, and herself. I had been fooled by her stories in spite of not believing them or seemingly being moved by them. I had been perplexed by her dreaming as I did not think she symbolized, but borrowed symbols. Could she be having borrowed dreams? None of her thoughts seemed to begin inside of her. Instead, everything she presented to me – from her movements, gestures, clothes, makeup, and jewellery, to her stories, thoughts, and behaviour – was evoked by outside stimuli that she claimed as her own, just like she claimed and became me. Whereas initially she created a perfect match with me, as she emerged she demanded that I match her perfectly. Since this was impossible for me to do, I failed her again and again. She began to harshly judge me for my failures. At times, I sat still, barely breathing out of my attempt to reach her. Much as a mother often matches the breathing of her nursing infant, I found myself breathing with

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her. My failures were very frustrating for her, as they meant I was not perfect. They also meant that we were not equivalent. We were not identical, or even the same. As she emerged, many illnesses occurred. I feared her health would deteriorate so seriously that she would die. A lung collapsed and required two surgeries. I wondered about the breathing in the office. Her back “went out”; her skin broke out into rashes, hives, and pimples. There were days when she could not get out of bed except to come to my office. Other days she sat in her rocking chair, rocking, and wondered how the days could pass so fast. Still she never missed a session. I felt that what I interpreted did no good at all. Again I wondered why she kept coming, perhaps unconsciously hoping she would stop. Just as she was going to many expert doctors for help with her ailments, I began to find consultants to help me find her. I felt comforted by whatever they said about her. It was also about this time that her posture on the couch began to change. Rather than lying like a corpse in a coffin, hands crossed upon her chest, she began to move her hands. I soon learned to interpret these hand movements. For example, while telling me a dream, she would gesture, then stop, leaving her hand suspended in the air. The story of her dream would continue, but I came to recognize these suspensions as post-autistic states of sensory dismantling (Meltzer, 1975b, pp. 11–12). They were aspects of an obsessional attention that pushed all awareness of me away. At the time, I thought she was dissociating while still talking. Today I would not call those states dissociation, although she was separating or disassociating her mind and her sensations. I would call them suspensions. She would also put her hands together and move them apart in idiosyncratic gestures of union and separation. She would latch on to the thumb of her right hand and pull on it with her left, sometimes causing me to cringe in sympathy with the pain it might cause. She did not seem to feel pain. At other times, she would pinch her left hand with her right, telling me it made her feel present with me. Again, I would cringe, although one day when she pinched herself, I had an image of a nursing baby pinching her mother’s breast. In the hour, I would interpret the moments when I felt I was not there in her experience. I marked, just by naming, the moments when I sensed she psychically disappeared and was gone. These were two distinct states that felt very different. It seemed there was room in the session for only one of us at a time. We seemed to take turns. I described this to her. At first, she did not know what I was talking about. This experience was horrific to me. As I watched her “disappear” herself or me, I despaired of reaching her. I felt helpless and guilty for not helping. When I could no longer explain or describe, I used what Alvarez (2012, p. 12) has since called a vitalizing level of interpretation where I created the meaning. I feared that I was again making it up, giving her more material to mimic. Yet I intuited I had to try to go in and get her (Eekhoff, 2015). When I failed to be one with her and she could not find a perfect fit on me, she began to disintegrate. The first time I noticed this came after I had moved my office space. Afterwards I realized that she had attached sensually – not to me but

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to my previous office. The move deeply affected her. As a result, she could not use her senses to attach to me. This was very different from the earlier suspensions. She was not angry with me but began to hallucinate. First she entered my consulting room convinced that we had just met in the street. She wondered why I did not say hello, and how I got back so quickly since I was walking in the opposite direction. Another time she thought I was attempting to strangle her. She leapt from the couch screaming “Don’t kill me”, putting her hands to her neck to remove what she perceived to be my hands strangling her. Later, she thought someone else was in the room threatening me. When she sat up, she said, “It must be me”. This began, slowly over months, a presentation in the transference of her anger and disappointment in me. She was projecting. I celebrated this change silently. I felt she was beginning to experience herself and me as having an inside. The analysis began to feel like the analysis of a borderline woman who alternated between clinging and claustrophobic fear of me. It was a very tumultuous time, with doorslamming, forgetting sessions, coming late, and veiled threats about killing me or herself. Once, she turned at the door of my consulting room and said, “If I ever come here when it is not my time, please do not let me in”. Still these states would alternate with the previous states of entanglement and fusion. When I spoke, she would cringe. When I was silent, she would weep silently. If I moved too fast, she would dissociate. These dissociations were experienced differently than the previous states of suspension. I was able to again mark these and later interpret them. Differentiating post-autistic states from borderline states was not easy. I had to observe and feel her carefully. I had to listen to her replies to my interpretations and determine if she were mimicking or taking me in whole, identifying or copying, integrating or incorporating. It was slow, painstaking work. I continually felt inadequate and despairing. Worse still, as her psychic deadness changed and she came alive, so did the suffering I had previously felt was experienced in both of us. She was suffering too. I could barely tolerate her suffering. I felt so cruel, so sadistic. I doubted psychoanalysis and myself. I wondered if she weren’t better off psychically dead and whether I shouldn’t have encouraged her to end our work. She began to physically age and arrived at one session with her hair dyed a bright red. I was horrified. I began to want to get rid of her. Her concrete focusing on every minute element in life decreased, but there were no illusions to soften the edges of her experience. These counter-transference feelings were difficult, but also useful. I was able to use them for what felt more and more like analytic interpretations. The work progressed. The transitional space between us opened so that there was more ambivalence and less black-and-white thinking. Her world began to take on colour. Her sadness and grief were profound. Three times she set an end date and, each time, would cycle through all the previous levels of our work together; yet she was not grieving. I attempted to stay open to her leaving without completing the analysis. The grief for me was great. I did not feel she was finished. Some of this was my own feeling, for I had come to value her and her persistence in being what she called “a real woman”. In spite of trying to work without memory and desire, I felt

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hope for her. Faith in the process returned to me. The faith and hope were also hers. There was separation between us at times. There were two people in the room. Two people in the room meant two centers of gravity. This meant that the center of gravity in the session could be the unknown, not the concrete details of her life. I was no longer afraid she would kill herself or me. We had more ability to collaborate and not just take turns. She now had a center of gravity within her that made it possible to have a floor for her experience. Her experience with me was accumulating. She had attached to me, not as equivalent to her but as a separate person. She felt dependent upon me, and this was interpretable just as her indifference to me had been. As the indifference lessened, she began to be able to give different experiences differing values. She could make decisions. Her lack of grief could also be interpreted, and so as each date of proposed termination approached, it was changed. Changing a termination date is not something I typically do, and yet letting her go and letting her stay seemed extremely important. We circled around each other, orbiting, with a gravitational pull that kept us separate and attached, separate and connected, not lost in space. Eventually she began to feel and express gratitude. With that gratitude came grief over the way she had treated me. She was appalled at how indifferent she had been to me, then superior to me, then dismissing of me – and so on through murderous rage, unspeakable terror of me, and finally horror as she stepped aside to observe herself behaving as she did. She was sorry for her threats and intimidations as well as for her clinging refusal to leave and let others have what she had. She set a fourth date for termination. This time as the months passed and the date approached, she grieved. She remembered the good times with me and reclaimed good times from her childhood. She grieved the premature loss of her innocence and reindexed her life experiences in ways that gave them meaning. For example, whereas when she came to therapy she believed she had been terribly abused as a child and unable to remember it, she now came to believe those fantasies were part of her resentment for not being believed about hallucinations she had had as a child. She had now emerged from the suspended and psychotic states in her childhood. She recalled her meanness and cruelty to her mother and to children at school with sadness and shame. At the same time, she developed compassion for herself, and humility. When finally she left me, both of us acknowledged that neither of us was perfect. There would always be more work to do. We could have done it better and faster and with more grace. However, our work together had been good enough. She was able to laugh and make fun of herself and me. She was able to miss me and still leave. She knew how to love.

Conclusion Psychoanalytic proximity includes but is not limited to the physical and emotional presence of the analyst in relation to the patient. Psychoanalytic proximity

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includes an analytic capacity to experience and name primordial states of being in such a way as to resonate with an unrepresented, yet present, emotional and sensate state of the patient. Such proximity involves the courage to speak the unspeakable and faith in the animate enlivening capacity of human relationship. And while it includes being with the patient without memory or desire, I believe it simultaneously involves a state of reverie that includes an understanding of knowing when to be absolutely still and open, and when to “go in and get” the emerging patient. This reverie includes the analyst’s introjective identification of the patient’s unformed and unrepresented potential for existing as an alive and relational human being. Emerging from autistic encapsulation is a painful and terrifying experience. Primitive anxieties such as mimicry, psychic equivalency, suspension, and dismantling, which are simultaneously defences against the reality of separateness, have previously functioned to protect the person from unbearable states of mind. These anxieties are at the same time not defences, but normal aspects of all development. With increased capacities for bearing pain, defences against an awareness of existence are minimized. Tustin reminds us that treating these difficult-to-reach patients will take us places where no normal person would wish to go. Although these primitive anxieties are always available for all of us, they are increasingly less necessary protections against the reality of separation as projective and introjective identifications develop. Accompanying and analyzing these emerging patients begins with patient and analyst in proximity. Proximity is a spatial and temporal condition that challenges the delusions of flowing-over at-one-ness. Subjectively, proximity is a perceptual sensate experience, not an emotional or cognitive experience. It is not a traditional transference relationship, but is relational. Psychoanalytic proximity is more emotional and empathic than sensate, yet the sensate is informative. Awareness of a live other’s physical proximity is seemingly absent in autistic children. My experience with patients like Kay is that emotional awareness of the other comes and goes, depending upon the stressors in life and in the moment of the analytic encounter. To be aware of proximity is to be aware of separateness. Such awareness is also at times lacking in neurotic patients who have an empty core and are difficult to reach. Some neurotic patients experience states of mind where they do not exist. Without a sense of existing there can be no awareness of the proximity of the analyst. For the analyst, being in the now without memory or desire is particularly difficult when the now of the patient is a delusional state of nonexistence of both self and other. The analyst may therefore confuse clinging and adhesive secondskin phenomena for connection. The patient’s flowing-over at-one-ness as a defence against the awareness of separateness creates a force field that evokes these primordial symbiotic processes in the analyst. This twinning experience enables the analyst to introjectively identify with the patient and to be emotionally proximate with her. Twinning experiences, although often nearly unbearable for the analyst, are more tolerable for the patient.

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Proximity enables the analyst to introjectively identify with the patient. This introjection creates a space between the unmentalized aspects of the patient and the analyst, facilitating space for identification that enables mentalization, as well as the emergence of the other as an object, available for internalization by the patient. About such a state of being, Green (1973) writes: “All that can be said of this metaphorical moment which suspends the inquiring function is that it can only be expressed in terms of being. Yet no knowledge arises from it, because it is itself the point at which knowledge can start” (p. 116). Facilitating emergence means that the analyst becomes a center of gravity, which then provides a gathering point for the condensation and distillation of the patient’s lost self. To do this, the analyst must allow herself to become an extension of the patient and to speak as if they were one. The patient’s attachment becomes very concrete – a matter of proximity and of physical contact, not emotional intimacy. Proximity assures a sensate experience of surface-to-surface oneness, almost as if the two were one, but not quite. Meanwhile, the analyst is in multiple states at once, lending herself, and suspending her own ego functions while using her reverie to invoke projections from the patient, with which she can introjectively identify. Once this happens, she has available within her the data with which to formulate a thought and to speak. I believe this is what Alvarez means by vitalizing interpretations. In working deeply in a long-term analysis or with patients suffering on the autistic continuum, the analyst must become the unformed “I” of the patient in order for the patient to find his or her own subjective experience. This is not a cognitive task. We are back to the very essence of existence or being, and are engaged in a process of becoming. The analyst and the patient fuse so closely as to lose the self experience. This is new territory within psychoanalysis that Freud did not explore, but that Bion, Meltzer, Mitrani, Tustin, Alvarez, and their followers have. Emergence is difficult for both the patient and the analyst. The intensity of primitive states of horror, terror, and rage, along with the psychotic and autistic defences against them, create corrosive doubts about the value of our work. Patients suffer tremendously as they emerge. Analysts do too. I will end with a quote from the patient I quoted at the beginning of this chapter. She said, “Before feeling gravity, you have to have a sense of existing. There is no gravity without existence. There is no sharing without having”.

Chapter 6

Infantile trauma, therapeutic impasse, and recovery

Ferenczi valued what his patients taught him. He wished to help the most difficult to reach patients, many of whom had been traumatized. I return to studying Ferenczi again and again because of his explorations of preverbal and bodily communication, his unique ideas about introjection where the patient takes in and becomes everyone encountered, and his ideas regarding mimicry and imitation. I have come to understand that mimicry and imitation are possible via the psychic phantasies of adhesive and projective identification. Ferenczi explored the selfannihilation that trauma initiates. I value his self-searching and his willingness to be moved by his patients and to attempt to reach them by challenging not only theory and technique, but his own beliefs about himself. I return to Bion for the same reasons. This chapter addresses the progress patients traumatized in infancy make in analysis, moving in fits and starts, forward and backward between multiple and simultaneous states of mind. I will follow my own clinical experience in light of Ferenczi’s belief in the existence of infantile trauma in both the analyst and the patient. The combination of external, reality-based traumatic events and the internal repercussions of psychic overwhelm, along with separation from the mother, is difficult to treat. These patients are difficult to reach because the trauma occurred before the infant’s mind was developed sufficiently to cope with the overwhelm. The infant in the adult remains silent, the infantile transference appears absent, and the analysis stagnates almost before it begins. Trauma destroys the infant’s capacity to split, leaving the infant, and the adult when regressed, in a confusional state, unable to remember herself. This confusional state is not, strictly speaking, pre-splitting, rather it is a retreat from splitting. It occurs via the psychic defence of alpha function in reverse (Bion, 1965). Defences against the confusional state include precocious maturity, precocious mental development, obsessionality, passivity, and a focus on the sensual aspects of life. Ferenczi also notes that adults traumatized as infants are more anal (Ferenczi, 1932a, pp. 123–124). Anality includes a hanging-on to sensuous experience – that which is seen, touched, or felt – and a rigid adherence to routine. The patient may appear to have certitude. Certitude can seem to be splitting, but clinically it differs significantly. Typically the patient can name these states

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without experiencing them. These patients present special difficulty for analysis because they are not self-reflective, although they can be addicted to responses I call processing in lieu of emotional connection. Impasse occurs when the analyst does not detect the mimicry involved in processing. The infantile trauma affects the analyst’s responses and the analyst’s responses affect the patient. Only together can the infantile experience be uncovered. Yet to work with such patients requires a great deal of the analyst because, as I have said previously, the dead place in the patient is mirrored and discovered first in the analyst. In the case of medical trauma at birth, it is discovered first in the body and emotions of the analyst before finding expression in the mind of either. I will follow Ferenczi’s lead in understanding deadness and lack of object libido as they express themselves in impasses, confusional mental states, and premature terminations of the treatment. Like Ferenczi and Klein, I advocate an active and lively interaction with the patient as a method of making contact. Patients born with medical difficulties that require immediate removal from their mothers, urgent and invasive medical procedures, or ongoing hospitalization present special challenges to psychoanalysis. They are limited in their capacities to feel themselves or others. Lifelong residues of their infantile trauma interfere with relationships and creativity. Although there may be higher-order disruptions to their functioning in life, work, and in play, lower-level disruptions centre around their capacity to experience themselves loving and being loved. Early infantile trauma brings special difficulties for the analyst. Since the trauma occurred before the infant was able to process and remember via language, it is held in the body, not the mind (Ferenczi, 1931, 1949c). The memory of the trauma is not in feelings and not in thoughts, but in perceptual sensations. The experience has not been mentalized (Mitrani, 1995). There is an absence where emotion and thought would be. The loss occurred before its existence could be realized. Without emotion or thinking about the trauma, there can be no resolution (Borgogno, 2007, 2014; Ferenczi, 1926, 1931). Yet the trauma, the loss of self, is relived again and again and disrupts the patient’s relationships. There are also thoughts and feelings that have developed in response to these later reenactments. These interfere with patients’ relationships as well as with progress in their analysis. The preverbal and pre-mental nature of the trauma leaves the patient alone with a disaster that cannot be communicated except unknowingly via the medium of the body (Bion, 1970, pp. 106–124). In spite of the external realities of that disaster, the trauma is intensely personal and unique to the infant. Whatever the cause, the infant was alone with unbearable and overwhelming sensory experience that could not be mediated by mind or by mother. What enables these infants to survive psychically is the intelligent adaptation they make to adverse circumstances. Primitive psychic defences guard them against continual retraumatization at the infantile level of defencelessness. What is sacrificed is personal agency and relationship. A psychic experience of one’s own existence is a necessary prerequisite for agency. Not being able to feel one’s life force as winning out over the death force

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cancels out existence and agency. Yet agency is not manic override. A patient articulates an example of manic override this way: “I would wake up in the morning and not remember who I was. I would have to ask myself questions and then, after a moment, I would remember myself”. What is also sacrificed is an ability to think symbolically, specifically around the area of relationship. Underlying these defences is generalized existential anxiety. Above that anxiety are the more familiar anxieties about survival and the defences of fight or flight. Existence anxieties often express themselves in somatic symptoms, mimicry, and emotional flatness. As Ferenczi taught us, they are also expressed by over-intellectualization, where mind becomes everything. The psychic struggle to exist or not is held in the body and in the mind object. As one patient described this struggle: “When my despair and terror destroy my conscious will, my body goes on. I feel at those times that my body betrays me. It just keeps going on”. Her conscious will was her mind object, the internalization of her intellect as an object to contain her. When intellectualization is used to deny instinctual affects instead of mediating them, a massive split between mind and body occurs. Instinctual affects bypass the symbolization process and instead reside as bodily processes, unable to be thought or remembered. Massive adhesive and projective identifications deplete these patients, leaving them with phantasies of not existing. Analysts experience nothing when hearing these patients’ stories and sometimes wonder if they project at all. They are unable to internalize, due to their unconscious belief that they do not exist; instead they mimic. Relationally, the traumatized infant in the adult patient behaves as if she or he has never been born. Living inside the object allows these patients to behave as if they need no one. Claustrophobia and fusion exist simultaneously. There is little difference at this most primitive level between inside and outside, between self and other, or between conscious and unconscious. Thus, instead of appearing fused they appear to be fiercely independent and averse to intimacy. Simultaneous clinging and averting responses are present in the relationship with the analyst. What appears to be no relationship is as much a lack of relationship to self as to other. Therefore, strictly speaking, nothing is transferred onto the analyst and classical transference interpretations are not possible at this level of functioning. At best, the transfer is of nothingness. One patient described herself as being a soulless shell when I went on vacation because she lived only inside of me. Behaviours in the hour are chiefly mimicry of what therapy might be. Initially, nonverbal clues and bodily postures and processes are more accurate conveyors of the trauma and its repercussions in the relationship than the stories these patients tell us. Again, Ferenczi’s pioneering work on the nonverbal is helpful. Yet the transference relationship powerfully exists, no matter how absent it seems. The relationship exists as a fusional mental state that is enacted. The fusion is with the analyst as the embodiment of the whole universe, not as a person. I believe with Ferenczi and Bion that recovery can only happen when the traumatized person experiences the reception of their nonverbal communication in

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the here and now of analytic relationship. Experiencing involves having an emotional response while being accompanied. The experience transforms both patient and analyst, taking each to their earliest sentient experiences.

Therapeutic impasse Therapeutic impasses with patients who suffered from preverbal trauma both include and are different from other therapeutic impasses. They are not the same as those discussed by André Green (1999) or Herbert Rosenfeld (1987) as being related to destructive narcissism and the death instinct. That is not to say that some patients who have been traumatized do not exhibit symptoms related to the death instinct. These particular impasses occur when the fear and pain become too much for one or both members of the analytic couple. Impasses between infantile trauma survivors and analysts arise when progress cannot be tolerated. Progress cannot be tolerated because it is catastrophic, destroying the fabricated world built over the traumatized infantile self. Terror arises as contact is made with the nothingness state that enabled them to survive their individual traumas. The infantile delusion of not existing is challenged. Terror and horror arise when patients emerge from the trauma of the enactments within the hour. Repetition of the trauma within the hour is particularly difficult for the analyst to detect because patients who were traumatized in infancy use a defence outside of language and often display minimal emotion. They communicate via passivity hidden in mimicry. Mimicry is often used when the patient cannot access agency. In Ferenczi’s Clinical Diary (Dupont, 1985), his May 29, 1932, entry intimates as much when he writes, “Repression of the self, annihilation of the self, is the precondition for objective perception” (p. 111). The objective perception of the other is expressed via pathological mimicry. The patient becomes the analyst in an attempt at fusion. Fusion with the analyst is in fact an accomplishment, as often the infant in the adult patient has been unable to bring together or fuse the primitive affects. Pathological mimicry, although necessary for survival, is a parasitic relationship that makes learning from experience impossible. It is an autistic defence that protects a person from unbearable delusional states of nonexistence. It relieves the pressure of constant puzzlement in regard to both time and space. The emotional realization of space between mother and infant or between self and other in adults is frightening because such a realization is equivalent to the recognition of separateness. With separateness comes vulnerability and potential annihilation. Spatial puzzlement enables patients with autistic defences to mimic and be as-if they were the other, leaving them with difficulty in being themselves (Eekhoff, 2012). When the patient becomes the analyst, the analyst can also become lost and confused, unable to find the patient. The analyst finds herself involved in analyzing herself as reflected back to her by the patient. Discovering this is horrific, as the analyst is watching herself being used for the annihilation of the patient.

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Unless the analyst recognizes and understands this process, it can only be enacted and repeated, not empathically received, named, analyzed, and transformed. The person of the patient cannot be found. The analyst is reflected back to herself in an infinite hall of mirrors found in the patient’s behaviours. Ferenczi (1949a, p. 227) intuited this defence when he described the trauma victim as identifying with the aggressor. Mimicry involves taking in the other and becoming “other”. The infant becomes colonized by aliens taken in as a defence. In infancy, extreme dependency, physical vulnerability, and an inability to communicate verbally mean that during difficulties everyone else is the aggressor. This is reenacted in the transference of infantile trauma victims. When an analyst does not realize identification with the aggressor is present in the therapeutic relationship, an impasse occurs. The silent collusion creates an as-if analysis that leaves the patient lost behind a wall, frozen and suspended in time, mimicking an aggressor. When the analyst interprets the aggression, the patient experiences herself as invisible and unseen. Frozenness is covered by an intellectual brilliance that unites the mimicries of their lifetimes, so that it is not only the analyst who is being mimicked, but those in every significant relationship to date who are also brought to the session. Mimicries are not of an internalized other, but of an introjected and unincorporated other. The analyst cannot know who she is in the transference. The patient shifts continually, and since these are mimicries, the shifts are meaningless. Since these patients are often successful professionally and academically, the mimicry may be difficult to detect. Mimicry is not, strictly speaking, what is meant by transference. Since it takes patience, empathy, and intuition to reach beneath the mimicry and intellectualization, the beginning work is physical. Setting the frame is extremely important and includes, for the patient, the sensate experience of being in the setting as well as in the presence of the analyst. The analyst’s appearance, smell, sounds, rhythms, and tones of speech, as well as demeanour, are part of the frame. For the analyst, following and becoming the patient is more important initially than understanding, which requires differentiation and separateness. Carefully following the patient makes meaning-making possible later. Analytic work with such patients is slow and often seems overly cerebral. The patient appears to enjoy processing every historical trauma over and over again without apparent change. Attachment disorder researchers link this excessive processing to the anxiety of insecure attachment, often associated with early infantile trauma (Cassidy, 1995). Although the analyst cannot force a therapeutic relationship, I agree with Ferenczi (1931, p. 140) that it is also important to not reinforce intellectual processing about the patient. This can sometimes mean paying attention to process as well as to the somatic counter-transference in the moment. Listening to the stories remains important as an action. The content of the stories, while occasionally informative, is less important than the sound of the voice and the rhythm of the speech, or what Meltzer called the musicality of the speech. Intellectualization and storytelling can also indicate an impasse.

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Infants who are born with medical difficulties are often ambivalently related to by their parents. Doctors may even say to parents, “Go home. The baby will die anyway”. Ferenczi notes that infants who are not wanted respond from the beginning of life by becoming psychically dead. They need to be called into the world. This is a mutual process with mother calling baby and baby calling mother. This process is traumatically destroyed when infants are separated at birth for medical procedures. Ferenczi (1929) writes: The child has to be induced, by means of an immense expenditure of love, tenderness and care, to forgive his parents for having brought him into the world without any intention on his part; otherwise the destructive instincts begin to stir immediately. And this is not really surprising, since the infant is still much closer to individual non-being, and not divided from it by so much bitter experience as the adult. Slipping back into this non-being might therefore come much more easily to children. (p. 128) Patients separated from their mothers at birth, placed in incubators or suffering surgeries, do not experience their mother’s love, tenderness, and care calling them into existence. Their fragile state of expecting mother’s care is challenged. Their preferred state becomes one of nonbeing. There are no expectations in a state of nonbeing. When finally they are returned to their traumatized parents, the parents too may not have the reserve necessary to call the child into being. Later, in our offices, these unclaimed states must be experienced in all of their primitive agonies so that unlived life can be lived (Ogden, 2014, 2016; Winnicott, 1974). The unexperienced terror of infancy lives on as fear of breakdown and unlived primitive agonies that our patients describe as something missing in them.

Clinical example A highly anxious patient returned to see me ten years after she completed an eight-year analysis. Her infancy was especially troubled due to her mother’s postpartum depression and her own failure to thrive. Reportedly, she was the result of an unwanted pregnancy, and her birth was induced two weeks early. She was the middle of three children born less than three years apart. Her mother, who was an orphan at age three, told her that she had never wanted children. The patient’s analysis had been difficult, beginning with her resentment that she needed it. Before her analysis, she had been in psychotherapy with three therapists for ten years. She was simultaneously passive and reactive. She was hypersensitive to light, noise, touch, and personal intrusion. I have also written about her in chapter 2. Her courage taught me much. Ten years into her reportedly satisfying marriage, she was having trouble. She told me she needed help so as not to leave her marriage as she had earlier left me. Her husband had confronted her: “Do you really want to be with me?” She was

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shocked to realize she did not know. It wasn’t that she wanted to leave; it was that she could not feel her desire to either stay or go. This made no sense to her. She recognized that her husband had seen a truth about her: she was always pretending, even to herself. She never knew what she wanted. In admitting to him that there was a wall between them, she acknowledged to herself a withholding from everyone. She promised to “take down the wall brick by brick” with his help and with mine. She recognized that pulling away from her husband, recoiling at his touch, and being angry with him for loving her resembled the way she felt when she left her analysis. It also reminded her of how she had felt when her longed-for baby was born. She cringed from her infant’s touch, recoiling when she felt her newborn’s fingers on her back in the night. It was she who was withholding behind a wall. Sometimes she described the wall as Plexiglas. She could see what was happening outside of it. At other times, it was solid and she was alone in the dark. She had earlier left me, thinking I had withheld from her. She left because she had gone as far as she could without acknowledging her own withdrawn state behind the wall. When she returned, she was angry with me for letting her go; she realized that she was not finished with her analysis. She said she had to leave me because I had become “a part of her wall”. She felt she should leave her husband and child as she despaired of ever being truly alive and in love with them, fearing they too were part of her wall. I believe her. Her analysis had been very hard for me. She was very difficult to reach (Joseph, 1975). Sometimes she appeared frozen. Other times she reminded me that she simply did not exist. I struggled to contact her and suffered both when I did and when I failed. In the first instance, she would passively agree with everything I said. She took in my words and used them. When she repeated them back to me, I erroneously believed she understood. Instead, she was stripping them of meaning and parroting them back to me. It took me awhile to identify this process, for I was only too happy to believe I was helping her. During this time, I did wonder about her lack of dreams and imagery. In the second instance, everything I said was wrong. Within minutes she was reactive, emotionally volatile and angry. If I said yes, she said no; if I agreed with her, she disagreed with me and told me she hadn’t meant what she said. She mocked me for being fooled. Since she wasn’t helping me help her, but expected me, like the mother of a day-old baby to know what she needed, she was right to be frustrated. I was not meeting her expectations. She turned her head away from me because I had nothing to offer her if I could not be her and know her experience exactly. Even if I used her exact words, she became furious. She told me I was wrong. I had not listened closely enough. She had not said that. Later as she became less dissociative and remembered more, she acknowledged she had used those words, but by the time I said them back to her, they were no longer her experience. I should know that, in her view. Why had I not realized that that was then; this was now? Now she had moved on from what she had said a minute ago. Often she

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would say, “That is about you”. Or “I know that”. It seemed there was nothing I could do to reach her, and in attempting to do so I became weak and colluded with her, becoming her. I have come to realize that my becoming her or her becoming me in a fusion that annihilated both of us was part of the therapeutic action of the analysis. In this case the pathological mimicry alternated between her mimicking me and my mimicking her. When I unconsciously did so, attempting to match and mirror her, she calmed. For a while I thought that my techniques were working to help her integrate and feel less anxiety. In reality, my attempts were building her wall higher and stronger. This violent battle between us and within her was also found in me. I battled with myself, doubting my attribution to her of destructive narcissism. I criticized myself for not aggressively interpreting her envy and her death instinct. Yet instinctively I felt that interpreting at that level would only wound her further without aiding. I could not think or feel my way out of the double bind. For a while, I was frozen with her. After a time of tolerating this experience, I began to be able to think about her and the process that was causing the treatment to stall. As angry as she was, she had left her analysis telling me she was grateful for our work. She said that without analysis she would not have been able to meet a man, become engaged, and plan a wedding. But now, looking back more than ten years later, she said she left because she felt she had damaged me. She did not want to kill me off completely, but it felt to her that it was her or me. Both of us could not survive the analysis. The question remains as to whether leaving analysis was a self-destructive act of choosing me over her. It does seem to me that she left as she was coming out of her autistic encapsulation and more relationally entering the fighting and fleeing of the paranoid-schizoid position and then retreating psychically (Steiner, 1993). In retrospect, I saw there was another reason why she left. Emergence from nonbeing meant that she had to feel her own presence inside of herself. What I had interpreted as her fear of me, her claustrophobic fear of entrapment by me, literally in phantasy inside of my body, was also her claustrophobic fear of being inside of herself, embodied psychically. Her first awareness of what she termed “the presence” she attributed to having me inside of her. It made her uncomfortable even though she thought it meant she was gaining object constancy. Only later did we both come to realize the presence that made her feel claustrophobic was her experience of her own self inside of her. As an adult, the patient was emerging from her preferred state of nonbeing. She felt she could not have a relationship with both her husband and me. To be in relation to both of us at once evoked her early oedipal anxieties and threatened her wall of mimicry. Having a child also threatened these primitive imitative defences. She struggled, unable to stay present to two people at once. She wondered whether she had ever been able to stay present even to herself. In not staying present to herself, she experienced not existing. After years of analysis she articulated her dilemma:

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I am this circle within a circle within a circle. Maybe hundreds of circles and they create a vortex and pull me inside until I am gone – away from you and from me. At the same time, I am gone outside myself into the TV show, becoming all the characters of Mad Men. I use all kinds of ways to block myself from myself and from you. My anger holds me together somehow but it also becomes one of the veils or lines of the circles. I am not saying this very well. When you see that I am gone and name it, you pull me out. I feel present now. I need you to do that for me. [crying]. Patients like this one were psychically traumatized by premature emotional separation from their mothers while in a state of physical sensorial overwhelm. Left alone to deal with these bodily sensations, they were unable to make meaning of them. In the face of such overwhelm, they became isolated from their own emotional experiences as well as from a mothering other. They became caught in a process of undoing. The fusion of mother and infant during pleasant and unpleasant moments did not occur often enough for these patients to develop a sense of themselves from the inside and the outside. The trauma of being born with life-threatening problems to mothers who did not want them, or to mothers who were depressed or ill physically or emotionally, and unable to care for them, overwhelmed their infantile bodies and minds and required defences too soon (Tustin, 1986). These infants turn prematurely to their own minds to help them. They become masterful intellectually and seem to rely as little as possible on others. Instead of relying on others, they become them via mimicry. Appearances to the contrary, these patients are highly dependent. They become whoever they are with, psychically taking on their shape and form. Because they have to follow and become whomever they are with, they have difficulty relating to more than one person at a time. To follow and become someone else is difficult in a threesome or large group. In groups, these patients are often silent, appearing wise, when in reality they are frozen. They typically do not experience loneliness, although those who love them often report feeling lonely, like my patient’s husband. In following and becoming others, they lose themselves and are not present. When my patient returned to me, she was able to recognize herself doing this. She could ask the questions “Who am I? Do I exist at all?” Her husband’s awareness that his wife was detached from him and his pressing her brought her up against her vacancy. She could ask me, “Who decided to marry him? He did. He saw himself in me and I became him”. This realization was at first horrific to her, as if she were watching herself from a distance. She was still not participating in her life, but was at least able to observe it. The observer was coming out of hiding. She also became able to dream and to see herself in images. Recently she told me: I see a dark room with hardly any light, lots of shadow. I am in the crib, tiny, holding my breath, pretending to be asleep. I am looking out of the slits of

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my eyelids. I am swaddled, wrapped head to toe in something white, so I cannot move. You are standing in the shadow of the corner. You see me. You know. But you are withholding, doing nothing, just watching. It is why I left analysis. It is awful to me to feel you withholding, sitting there behind me just being there. After a few weeks she told me: Over the weekend the image changed. I am in the crib still, but there is light coming through the window, even sun, I think. It is spring and the tulips are blooming. I am still a baby but I am not swaddled. My arms and my legs are free and moving. Babies need to attract their mothers, don’t they? I am smiling and gurgling. I don’t know where you are though, but I feel you are there. Still later she reported that the infant in the crib had rolled over and was lifting her head and looking around the room. My patient was beginning to be present to herself and to feel my presence. Even the first image shows progress in that she is inside her swaddled body and looking out from slitted eyelids. She also recognized that she needed to present herself in order to be known. Presentation is necessary before representation and symbolization can occur. Presence and being aware of it is related to the earliest sentience of the infant. An analyst’s capacity to tolerate and accept shape-changing and psychic fusion enables a traumatized infant in the adult to exist. Presence signifies existence and embodiment. Both are issues for adult patients who have been traumatized in infancy. For these reasons treatment ultimately consists not of repair, although repair of later difficulties is essential, but of recovery. Recovery requires the analyst to fuse with and become the patient so as to be able to understand and name previously unexperienced potentials such as longing and desire or as unlived psychic breakdown. The recovery is of lost potentials that could not be realized. Recovery is what Ogden (2016) has called reclaiming unlived life, emotionally living infantile experiences that overwhelmed the fragile isolated infant and resulted in a breakdown which, rather than being experienced, was projected out into a universe to be experienced at a later time (Winnicott, 1974). The impasse occurs when I as the analyst become locked behind my own wall of thinking I understand or know something that in fact is not knowable. I might misinterpret my patient as having feelings that I would have in similar circumstances. These feelings are not my patient’s experience. Impasse occurs because my patient is incapable in that moment of correcting me. Rather, she becomes me, even to the extent of mimicking my emotions. To correct me would open up the wall. She would exist. In existing, the frozenness would thaw and pent-up emotion would explode. The explosion would re-enact the infantile loss of her “self”. Rather than experience the pain of thawing, the patient unconsciously considers herself “finished

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with her analysis” just before she re-experiences her early infantile anxiety and breakdown. Since such experience overwhelmed her then, she unconsciously fears a repetition with the analyst that will not be bearable for either one of them, as it apparently was unbearable for her mother and her infant self. She fears having the breakdown she has already had in infancy (Winnicott, 1974). Leaving her analysis prevents the emergence of confusional mental states, which impede healthy splitting. Leaving also prevents the implosion and explosion of pent-up rage and terror that are experienced in the body. This explosion, if allowed within the analysis, is both cathartic and retraumatizing as it too is a defence, not a response that can be contained and understood by the patient or the analyst in that moment. The explosion is helpful because it breaks the patient out of the passivity and frozenness, bringing her into her psychotic terrors and infantile annihilation anxieties. Naturally this is not pleasant and feels destructive. The patient fears that if such an explosion is survivable, one or both persons will die or go crazy. Often, the analyst too is terrified and attempts to stop the progression, mislabelling the aggression as regression. Accompanying the explosion can also be somatic symptoms that are alarming and even life threatening. The defences of confusional mental states as well as those of implosion or explosion keep the trauma at a body level where somatic illness can kill and perceptual distortions interfere with relationship to the self. Impasse occurs when the analyst cannot understand the communication in these somatic defences or when the mimicry embedded within them goes unanalyzed. Interpretation at a higher level, a symbolic level, when the patient is relationally functioning at a pre- or proto-mental level that has never been thought or formulated verbally, creates increased anxiety and supports the intellectualizing defence. Thoughts proliferate to fill the empty space. Such interpretation also gives the patient something to mimic. Mimicry hides the physical anxiety of being separate from the other, which is evidence of the trauma. The trauma itself cannot be remembered, repressed, or dissociated as it has not reached the level of imagery. It has reached a level of mimicry, which is a sensory level, however, and therein lies the hope. In taking the shape of the analyst via mimicry, the patient avoids total annihilation. Even though the defence of mimicry is a psychic death wherein the patient becomes whatever and whomever they are with, it supports the physical reality of existence. The psychotic fear of annihilation is that this psychic death will become concretized in reality. The struggle of differentiation between two people cannot be experienced, as the mimicry and moulding create a delusion of oneness. If the patient is not born but remains psychically inside the analyst, it seems that death cannot happen to either one. The analyst too must be overwhelmed and recover in order to help the patient integrate via emotional experience and symbolic language. In being overwhelmed with the patient, there is psychic fusion. The analyst’s recovery from deadness and overwhelm gives the patient an experience that differs from the first experiences with their absent mother. These experiences can then be felt and named.

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Impasse blocks emotion from surfacing from behind the wall of mimicry. However, the emotions of rage and terror are ultimately also “just more bricks in the wall”. These bricks block the patient from feeling dependency and vulnerability as they did as infants. So catharsis and narcissistic rage become contributors to the impasse. Beneath these are confusional mental states where self and other are conflated and interchangeable. The patient and the analyst are neither fused as one, nor are they two people. Impasse highlights both the passivity of patients who mimic, and their rage. Impasse highlights the impotency of the analyst and the omnipotent phantasies of the patient. In becoming whoever and whatever they are with, the states resemble Freud’s descriptions of primary narcissism. However, as I have said earlier, I believe these states of undifferentiation are defensive states of dissolving, evaporating, and becoming atomized as a result of infantile trauma (Ferenczi, 1933; Klein, 1946). Impasse covers over the confusion and what lies beneath. The confusional mental states go beyond secondary process and thought identity as found in language. Confusion occurs at the perceptual level and the senses themselves are not trustworthy. It occurs between the fusion of the at-one-ness with the universe and the two-ness of self and other. It is a breakdown of splitting and projecting as well as a breakdown of fusion (H. Rosenfeld, 1987). In normal development the infant progresses psychologically by oscillation between fusion – being one with the mother – and relating with the mother as a separate person. Splitting and projecting, introjection and identification promote integration. Becoming a whole person involves movement between differentiation and non-differentiation and alternates with fusion or healthy symbiosis. Unfortunately, patients who have suffered infantile traumas are retraumatized in every relationship where the mimicry and lack of emotional connection between the participants goes unnoticed. Breaking the internal retraumatization cycle can only be done in external relationship. Yet these patients identify with others as aggressors and so hide from them by becoming them. Instead of two people in the relationship, psychically there is only one. This is also true in the analysis, which makes interpreting the transference difficult, if not impossible. When this begins to change, there is confusion between self and other and a breakdown of healthy splitting processes. Relationships that are tumultuous are also retraumatizing. Over and over again, the patient asserts her existence with opposition. To be with someone who is loving and easy-going is to disappear into them. As the patient moves out of the fusion and passivity, rage and anger support her beginning sense of herself, even as her interpersonal relationships suffer. Such patients need someone to survive their rage and to value their unique individuality. These patients cannot tolerate goodness out of fear of psychic annihilation. The nicer we are to them, the more unseen they seem to feel. Perhaps they are drawn to fusion, as if to re-enter the womb, and know this means psychic death. Yet if we are superior and distant, they also do not feel seen. In both instances, the analyst is unable to make contact and the patient is left abandoned behind the wall the trauma evoked. Therapy retraumatizes by abandonment, introjectively taking

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away the struggle to emerge from behind the frozen wall. It retraumatizes no matter how well-meaning and well-informed the therapist is. It retraumatizes when the patient mimics the analyst, as it duplicates the earliest infantile experience of colonization by the aggressor. The analyst then must tolerate being the abuser, the aggressor, and the living enemy.

Recovery A successful therapy with adults traumatized by physical and emotional overwhelm as infants moves by fits and starts and often includes numerous endings and beginnings. I believe it also involves many empathic failures and misunderstandings on the part of the analyst. Confusional states reside both in the patient and the analyst and cause many mistakes. The analyst must be able to learn from these mistakes in order to reach these patients, to think about them, and to find words to represent them (H. Rosenfeld, 1987). The analyst also must have been well analyzed in order to differentiate herself from her patient. The secondary trauma is the trauma of interest for the psychoanalyst. It is not the historical event that is of primary importance to the analyst, even when that event is particularly horrendous to us. When such events occur in infancy, they are not able to be integrated emotionally. The traumatic events resulted in unintegrated states that nevertheless never go away. The trauma continues to exist as something missing. Rather than the trauma being of primary importance, it is the patient’s response to what has gone missing that is important. The missing is always repeated in the relationship with the analyst. The analyst responds both to being witness to the event as well as a participant in it as the trauma is enacted in the hour. What the patient does in response to trauma accumulates within her. It reverberates in hundreds of patterns of perceiving and organizing data, creating ongoing retraumatizations that are enacted within the therapeutic relationship, outside the consciousness of both participants. Such trauma also shapes identity. Without the infantile trauma, our patients would not be who they are when they come to us. Bion (1970) alludes to this when he says that the deeper we go in analysis the more both patient and analyst come to think about who the patient is. Ultimately a point is reached where analyst and patient accept that this is the patient. Infantile trauma has particularly difficult ramifications in that the patient often develops normally around the encapsulated trauma. Such patients can succeed brilliantly academically, professionally, and even economically. They are less likely to succeed in their relationships and often seek treatment because someone who loves them demands that they do so. They may also feel that something is missing in them, although initially it is usually that those around them who are more bothered by this absence than they are. Ferenczi (1909) hints at the way in which these patients adapt to their environment by becoming it when he writes, “The psychoneurotic suffers from a widening, the paranoiac from a shrinking of his ego” (p. 48). This widening means my patient becomes everything. When she becomes everything, she in effect is nothing. She does not exist. She is unable then to take in or internalize because

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she already is what she experiences. Again, when Ferenczi speaks of the importance of introjection, he acknowledges that trauma interferes with introjection. Continuing, he says, “The first ‘object-love’ and the first ‘object-hate’ are, so to speak, the primordial transferences, the roots of every future introjection” (p. 49, quotes in the original). Without differentiation, there can be no object, hence no object hate or object love. Internalization cannot happen because the infantile internal space collapsed with the explosion. Cognitive development occurred around the collapse. When infantile trauma overwhelms the infant, or the infant in the adult, object love and object hate are not possible because in the moment of overwhelm there is no subject. There can be no internalization when the subject is not present. Relationships are forever compromised by an unmentalized aspect of the personality that has been encapsulated or walled off by numerous layers of defences that are barriers to psychic existence or subjectivity. Within those unmentalized aspects are innumerable unrealized potentials that have gone missing. As each layer is breached by the therapeutic relationship, the patient panics and is retraumatized. Words are grossly inadequate in those moments. Presence, patience, and faith in the psychoanalytic process hold the analyst through these very difficult experiences, enabling the patient to courageously continue, because in reality two people are present. Impasses can occur at each layer of the process. If an impasse does not occur, the analyst risks moving too fast for the patient, provoking a possible premature termination of the analysis. When the phantasied defences of omniscience and omnipotence, as well as the infantile defence of omnipresence, are recognized as such by the patient, grief and depression are overwhelming. The newly discovered state of need contributes to preverbal infantile memories of unmet need and total helplessness. If the patient and the analyst are courageous enough to continue, the despair that is accessed is intense and seemingly intractable. In these moments, our patients say they need us twenty-four/seven. At these moments, we ourselves may lose faith and fear our patients will kill themselves or us, or alternatively become permanently psychotic. After the freezing, after the fleeing, after the rage that goes with fighting, there is depression and despair. The depression and despair come as the projections are returned and integrated. This experience is intensely unpleasant both physically and psychically. Somatic illness seems to be necessary as part of the grief of coming back into the body. Once embodied the patient can truly grieve. Only then is acceptance of self as well as other experienced. Only then are subjective experiences free of pathological mimicry, and relationships with internal and external objects freed of distortions. Only then is the self embodied so experience can be registered subjectively. Grief and mourning again occur, grief over all the lost potentials. Once grieved, there is recovery into selfhood that frees the patient and the analyst to use what skills and talents they possess to be creative and productive and connected to the world with love. The analyst must go into her own depths in order to accompany

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the patient into hers. Both must face their limitations. To do this, both must be both subject and object for themselves, embodied and relational so they can reach each other and be changed.

Conclusion Following Freud, while differentiating from him, Ferenczi began a lifelong attempt to help those whom others considered unanalyzable. Those who followed him have held this wish, even as the branches of thought have differed theoretically and technically from one another. Ferenczi first named and studied the primitive defence mechanisms of splitting, projection, and introjection. He valued the infant’s experience with her mother and the ongoing role of the body in mental health, and recognized that unthinkable, unspeakable infantile states existed in our traumatized patients and could be accessed via the analytic relationship. Ferenczi believed we all hold within us every psychic defence, the psychotic and the neurotic. Today we would add the autistic defences as available to us when we need them. I believe Ferenczi also understood those defences although he used different language to describe them. He spoke of fragmentation that occurred so often as to become atomization (Ferenczi, 1928, 1933). Atomization was later described as evaporation by Tustin and Meltzer when referring to the defences of autistic children. Ferenczi, Klein, Bion, as well as H. Rosenfeld attempted to treat and heal patients who suffered from early childhood traumas and who were in various stages of recovery from them. All came to believe that if the patient is to heal the analyst must be willing to go to the depths of her own infantile trauma and face the terror and the rage of being a helpless and vulnerable infant, as well as the horror of splitting into an “other” who was an observer of that trauma. Ultimately, that vulnerable other is the subjective experience of watching one’s infantile self suffer to the point of breakdown. To recover from infantile trauma, the self must reunite and bring observer and observed together into being and participation in life. The observer, when called upon by the analyst, can help the patient reach the walled-off parts of the self. Patients who have been traumatized as infants retreat into the psychic womb of whomever they are with by becoming them via mimicry. As they emerge, they are confronted with the multitude of losses possible in life, including their own deaths. To not be born is never to die. To not be born is never to suffer. To die never having been born is to miss suffering. Unfortunately, it is also to miss life and love.

Note Ferenczi’s statement in the epigraph is found in the entry for June 18, 1932, at page 130 in Th.e Clinical Diary of Sándor Ferenczi, edited by Judith Dupont (Cambridge, MA: Harvard University Press, 1988).

Chapter 7

Finding the impulse Healing from infantile trauma

The thinker must be a man of action.

– W. R. Bion

Patients who have been traumatized as infants present in the consulting room as difficult to reach. Depending upon the stage of their recovery, they appear passive, overly compliant, and eager to please. They seem to find their initiative in others, taking their cues from the environment and not feeling their own healthy impulses. The desire to connect with others as well as the ability to connect with themselves seem to be stunted. As they heal in their therapy, impulses return and they must learn, much as young children do, to manage the turmoil these impulses stimulate. These are the moments in the treatment during which impasses occur, for coming alive is terrifying and enraging. Coming alive is overwhelming and traumatizes the patient again. This chapter uses a clinical example to demonstrate the process of recovering lost impulses from infancy and dealing with the overwhelming affect that is evoked in psychoanalytic treatment.

Mothers and infants Mothers of newborns typically pay attention to their infant’s every gesture. They notice contact. They interpret lip movements, head turns, breaths, and sounds. They know there is meaning in their newborn’s impulses, and they look for that meaning. When they cannot find it, they seek it, touching a cheek with a nipple, caressing a head with a hand, looking into baby’s eyes and cooing. They call a baby forth, saying, “Come out, Baby”. When an infant cries, a mother quickly learns what each cry means, and attends. And when an infant cries, he is calling forth his mother saying, as only an infant can, “Are you my mother?” “Come, Mommy, come”. Adults who were separated at birth from their mothers have within their internal worlds an infant that was not called forth or met, an absent or indifferent mother, and a raging inferno of unmediated and undifferentiated affect. Most of

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them do not know this, but their partners, if they have partnered, do. If they come to therapy, they may say, “something is missing”. Although they may be bright and engaging in a superficial sense, they may complain of not reaching their potential or of being passive in their endeavours. Analysts who attempt to reach these patients do so by working in the moment, in relationship to the coming and going contact as well as the transference and counter-transference between them. Analysts who work with the infant in these adults must answer the infantile call for a lost mother and become the mother who calls them forth from the silent depths of themselves. To become the lost mother of infancy, the analyst must use her intuition and her imagination, which is informed by contact with the patient and by the counter-transference. According to Bion (1962b), the boundary between self and other, between self and self, between conscious and unconscious is maintained by the contact barrier. The contact barrier is itself formed from making meaning of sensate experience, a process that Bion calls alpha working on beta. The contact barrier is permeable and fluid. It is constantly shifting just as our states of mind and our vertices are constantly changing. Our contact barrier protects us from a sensory world fraught with danger where we are constantly being impinged upon by internal and external physical and psychic reality. The combination of somatic and mental experience without an adequate contact barrier overstimulates and overwhelms us. Our alpha functioning develops in relationship with an external other, beginning in the first moments of sentience within the mother’s body. At birth, our alpha function continues to develop with contact or in relationship to the perceptions or awareness of our senses, as well as through the engagement of our parents, most specifically our mothers. When alpha function is sufficient to continually maintain a good enough contact barrier, containment makes learning possible. Bion developed his model of container and contained using the mother’s containing function of the infant’s sensory experience as a representation of the process. Learning to dream or to play with our sensory world in relationship develops our alpha function. Alpha function, which enables us to play with language and use our imaginations, is what makes us uniquely human. Alpha function is much more than thinking. It is reverie that informs thinking. It is much more than dreaming, although dreaming is a factor. When our alpha functioning becomes compromised, we are confused. We defend against the confusion by retreating to the world of the senses where we are aware of everything without finding meaning in it. This awareness is not the same as consciousness, for awareness can threaten us with losing our relationship with ourselves as well as with others. Consciousness is about having a relationship with ourselves as well as with others. Unmediated awareness of our perceptions overwhelms our minds and forces us to defend via concrete thinking, where our world becomes rigid and tight, limited by what we cannot tolerate. Patients who have been prematurely separated from their mothers at birth and left too long alone with their somatic experience become attached via hypervigilance to the sights, sounds, and sensations around them. Their awareness impedes

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their development of consciousness. They also may become attached to their own thoughts in what Ester Bick (1968) called the second-skin phenomenon. As I have said in chapter 2: I believe, with Klein and Bion, that the infant is born object related and with a very primitive capacity for representation. I believe with Green that the infant is born with a primitive capacity for binding affects. Binding holds the affective charges together, mediating their intensity (Freud, 1920). This suggests to me that the infant is born with an embryonic capacity for alpha function: for making meaning out of experience. This capacity enables the infant to make use of the mother and the mother’s reverie. When a life-threatening medical condition removes infants or young children from their mothers, a multitude of circumstances impact the development of the contact barrier, and create in the adult patient areas of the psyche that are difficult to reach. Then adult traumas, most especially those found in everyday relationships, and certainly in the analytic relationship, provoke a return to infantile states of mind where, in extreme cases, the adult cannot be reached because he does not experience himself or the other. His contact barrier has been replaced by a wall of somatic perceptions, what Bion called a beta screen (Bion, 1962b). The patient with a seemingly impenetrable beta screen loses his subjective sense of self. Instead there is a mental void (Lutenberg, 2007) or a black hole (Grotstein, 1990; Tustin, 1986). In those instances, the analyst must call forth the infant and receive the call to come forth herself. This is true because the patient has retreated to a fused place of projecting out into the universe. This “place”, which Teising (2005) calls the monadic, and Ogden (1989a, 1989b) calls the autistic-contiguous position, interferes with the patient’s own subjectivity. Without a relationship to self, the patient loses contact with his or her own impulses and desires. Instead of love or hate, as found in the Kleinian paranoid-schizoid position, there is indifference. Indifference is difficult for any analyst. Indifference occurs when experience is flattened, so that everything carries the same weight and is of equal importance – that is, unimportance. The resulting passivity makes relationship one-sided. It then appears that the only one in the relationship is the analyst and whatever is dealt with comes from her. The extreme passivity creates impasse (Joseph, 1971, 1975). In some instances, the impasse comes with the first contact, whether by phone or in the office.

Clinical vignette To give an example of the previously described process I will describe my work with a long-term patient I will call Josh, with whom I worked first in psychotherapy and then in analysis for many years. He is a patient who taught me much and who had amazing courage in facing the truths about himself. He also eventually became able to face truths about me. He taught me about myself as well, setting

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me up against my own horrors, terrors, and retreats, up against my own limitations as well as my misunderstandings of theory. Josh’s trauma was twofold. Reportedly, after three days of labour, the doctor came to his father and told him “You have a monster baby. You will have to choose: Should I save the baby or the mother?” As the family myth goes, his father could not choose and eventually the baby was born via caesarian. The mother and baby remained in hospital, separated from each other for several weeks. Both nearly died. Hence, I say two traumas, one involving life and death issues physically and the other involving life and death issues psychically. My work with him also nearly died. Often, I felt we were getting nowhere. Just when something began to happen, he would interrupt his treatment. Even when he was present physically, I couldn’t find him emotionally. Often I experienced myself as being “gone” to him, no matter that I was listening, responding, and speaking. He seemed unaware that I was there. If I tried to speak to this, he retreated and was “gone” from me. I was left with myself and my observations and thinking. Since there were external changes in his life, I felt something important happened. We made contact with each other after he was able to connect with himself. That period of time was chaotic and painful for both of us. When his indifference began to break up, his idealization of me and denigration of himself made our work nearly impossible. When his idealization of me broke up, and we began to be able to analyze his own grandiosity and infantile omnipotence, his alternate raging and suffering was awful for both of us. His grief seemed to go on and on. Still, during the last years of our work, he married, and he gained professional success and recognition, which gave him financial stability. Better still, he left, grieving but happy, saying to me that he had “found himself”. He called me his Beatrice. I felt both of us had been through nine circles of hell and survived. Tracing the differing kinds of silences in the years we worked together demonstrates both a technique and a counter-transference process of making contact with him in the hour and in the moment. Counter-transference enables us to find our difficult-to-reach patients and to find ourselves. Some of this takes place in noticing ourselves noticing them and noticing them noticing us. Noticing is important because in order to mimic, noticing (Eekhoff, 2013) must take place. Noticing is not blankness. It is an impulse to connect. These patients get rid of that impulse too. One patient, who was integrating, and therefore able to speak about it, called it “Getting rid of the ridder”. Josh often “got rid of the ridder”. In doing so, he appeared to be in limbo, and in fact it was his self-perception of this that ostensibly brought him to me. Before focusing on silences, let me provide context. In the first session, Josh told me he was desperate for a “good therapy”, but that he had no money, earning only a subsistence living doing the odd consulting job. In what was then an uncharacteristic stance, I told him I was sorry he had no money but I could not treat him for free or even for a reduced fee. He would have to find a way, and I would be happy to work with him. He said, “OK, I will come once a month”.

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Again, I said, “No. I would only be taking your money and not helping you”. He left, calling me several months later and asking to come in, telling me he had found a job to pay for his therapy. I agreed to see him. Initially he presented as a charming, handsome, intelligent man who was underachieving. At fifty, he had never been married, never held a job longer than a year in spite of a graduate degree. He told me he had a good year if he made $25,000. In spite of this, he moved in circles with the rich and famous and artistic. In our once-a-week session, which he paid for at the time and with cash, he told me story after story about his life. Whereas I found the stories interesting and somewhat engaging, I was not moved by them, even as I had not been moved by his request for a low fee or a once-a-month treatment. I wondered about this, but in my inexperience felt it was something only about me. I did not then understand that his stories were walls of sound that kept us from making contact with each other. Rarely was there silence between us. Neither of us could tolerate it. His eye contact was good. His manner was polite and somewhat distant. His stories were articulate and at times amusing. His vocabulary was impressive. Still, I did not feel charmed or entertained. In truth, I did not feel much at all, something unusual for me. I carefully paid attention to my seeming indifference, analyzing myself to try to understand what was happening to me with my patient. From the beginning, I could not find the meaning in his stories. Whenever I made an interpretation, he would listen politely, nod, agree, and move on. I was left feeling how intelligent he was and how ignorant and uneducated I was. When the story returned again later, as it always did, it was obviously the same story I had heard before. Nothing had changed. He once said, “You must be getting tired of hearing the same thing over and over”. The truth was that I was not, as I was so struck by his ability to tell the same story with the same words and inflections over and over again. Again, my feeling was that there must be some way he felt I did not hear him or did not understand. Perhaps my indifference to his stories bothered him. Yet my attempts to explore this were stopped, usually by being ignored. The exploration between us failed. However, I continued to explore inside myself, looking for the sources of my indifference. Also missing in these first months of our work together, as I said earlier, were silences. I began to look for the slightest of changes in him or in me. When or if I noticed them I would say something about the change. Doing this had a surprising effect on him. He began to try to please me, elaborating his story, watching my face and proceeding or not depending upon what he imagined he saw there. He seemed to be trying to find me now, as if I were not there. I began to feel useless and under scrutiny, but I had no sense that he felt anything. What I was feeling was about me, not yet about my patient, or so I thought. He did not complain about me. No matter how I interpreted the transference, he would politely deny any such thing. There were occasional silences. These had a quality I did not understand at the time. I thought he was using them to think. He was not. I thought he was waiting for me to say something else. Nor was he doing that. The silences appeared

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empty, which I had difficulty comprehending. The silences were dead. Later he said it was as if his mind stopped and was in suspension. I came to realize, after more than a year of working with Josh, that I really did not exist as a person for him. When I told him this, he was surprised. He said, “I thought you knew that. Of course you are not here”. I wondered aloud, as I had numerous times wondered silently, “You still keep coming for some unexplainable reason”. He was silent. I too was silent. It seemed he was waiting for me to show up. He was looking at me looking at him looking at me, looking at . . . well, you get the picture. There really wasn’t anything to say to that. Both of us seemed suspended in a hall of mirrors. We were two-dimensional reflections of each other, getting smaller and smaller into infinity. The unconscious phantasies of both analyst and patient create an environment that may or may not result in both learning from experience (Bion, 1962b, 1970). My horror at noticing myself as absent to him soon became awareness that my patient also was gone. Both of us were suspended in limbo, awaiting a spontaneous gesture (Winnicott, 1971). In the waiting, I began to focus on my own or his impulse to speak. I noticed that the impulse to speak seemed to originate in the mind of one or both of us, not in any affective wish to communicate. In waiting, there were also many possible kinds of silence. The silences between us, when we could tolerate them, were sometimes hostile, some comfortable, some oppositional, some mixed, along with another, more difficult silence. The difficult silence was blank and empty. The blank silence seemed to have no impulses or thoughts in it. Since I believed this to be impossible, the blank silence horrified and terrified me. How could there be so little projection occurring in either direction? Since working with Josh, I have found this blank silence with other severely regressed patients and with schizoid patients. It occurs with psychotic or autistic patients. I since have found it exists with patients who might be called as-if personalities (Deutsch, 1964). My patient did not appear to be any of these. He seemed to be primarily neurotic. Yet there was a mental void inside of him, a place where nothing seemed to be. No wonder my patient Josh and I both avoided silence. I now believe it was because of the horror we each experienced at recognizing the empty silence, of having no one and no thing present. Each of us had disappeared into infinity. The limbo was a frozen state where nothing could be learned and no one could be found. Instead of two people sitting across from each other, I became aware of sensations: sounds, images, smells, and the minutest physical sensation. Initially, these somatic awarenesses seemed without meaning, merely defensive. It was as if I were quick-frozen and suspended in time. The action in the moment and in the session was of freezing of sensate experience. Freezing meant that I became my environment. I became the background and blended with my patient. When I noticed this, it was possible to find words to describe something that was also true of my patient. When I spoke and became the foreground for my patient, I discovered ways in which he became like me, adopting my posture, my gestures, even my tone of voice, if not my words. I noticed subtle mimicking. In accessing

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this awareness, I was able to think about it. There was an important relationship between us that I had previously been unable to detect. The relationship was not about fight or flight, which involves an awareness of danger. It was not about survival. This relationship represented the infantile experience of relationship to the concrete sensations of the machines that kept him alive in the absence of his mother, before he had an awareness of danger. He related to me as an ever-present machine, or as a placenta, or as an absent mother. I believe such suspended limbo states occur naturally for all babies in utero and even periodically for babies in the first three months of life. Infants separated at birth from their mothers have a frozen place that cannot be thought about or mediated where they are in limbo, waiting to be called into existence. When accessed in adulthood, this limbo state is the ultimate preverbal defence. It is an area of unsymbolized and unrepresented somatic experience.

Mimicry Development continues when an infant’s life is saved. Moms and babies reunite and babies develop physically and mentally. During an analytic process in search of the infantile transference, cognition continues. Emotion superficially develops. Yet in the absence of drive and deep emotion there is no impulse to act or to think. The psychic retreat that an analytic process uncovers is a time of clichéd speech or mimicry where emotional contact between two people is impossible. It is a time of stories, repeated word for word with the same inflection. These stories are hypnotic. This frozen in limbo state is more complicated than either imitation (Gaddini, 1969) or going through the motions, because there is no awareness of it. Imitation comes later in development, because in imitation there is a self who imitates and an “other” who is being imitated. In mimicry, it is as if the pause button has been pushed; yet in becoming the other, there is acknowledgement the other exists (see chapters 3 and 5 of this book). Adult patients who have been separated from their mothers as infants seem to develop around a blank place where they do not psychically exist. In the silence of the couch, they at times do not find themselves. Without themselves, they experience the analyst as “not there”. They feel nothing, so have no impulse to speak, no desire to do anything. These blank moments are extremely difficult for an analyst because it is tempting to attribute meaning to them that is not there – as for example resistance or aggression. Interpreting at the aggressive or resistant level will only feed into the patient’s deep sense of shame for being somehow inadequate, without knowing why. The shame itself is diffuse, and cannot easily be attributed to either the patient or the therapist. Attributing meaning that is not there reinforces the defences that have grown around the unthought, but known, empty core. The blank place is not depression or resistance or even passivity, although it can look like all three. Nor is the blank place shameful. Shame is a later development. Analyzing the shame, while important, is a distraction from the blankness, the no-place, and the no-person of the patient in the silence. Shame

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also may at least in part be the analyst’s own narcissistic shame at not understanding or being confused. I believe that this blank place interferes with many analyses, because it is so pervasive. The blank place contributes to a feeling of having no floor for experience. If I do not realize that one or both of us has disappeared quietly from the room and into a black hole, I analyze what is developmentally at a higher level than the infantile transference of blankness. The analysis may become interesting and engaging, but it ultimately misses the underlying dynamic. Once this blank place has been accessed, the patient and the analyst must experience the horror of witnessing it, then the terror of embodying it, and finally the rage over the loss. Only then can it be grieved. In grieving, symbolization can begin. All of this can only be accomplished in relationship. Because horror and terror and rage are unpleasant, one or both members of the treatment can flee. Sometimes it is obviously the patient who interrupts his treatment. In the hour, it is as often the analyst who cannot tolerate the intensity of nothingness and the horror and terror it evokes in her.

Continuation of clinical case Back to Josh. Following his surprise that I had not known that I did not exist for him, I suggested working twice a week. He readily agreed. He was still sitting up. I began to look forward to seeing him and decided this was evidence he was beginning to project, and to project positive feelings. When I interpreted this, he denied it, apologetically. He told me it must be hard for me to work with him since he felt absolutely nothing for me. He found our sessions mildly interesting, he said, but they really did not change anything important about his character. His core was the same. He said he was the monster, unfeeling, uninterested, and too much for this world. I became the one to care for him while he denied any feelings – either good or bad – about me. I was suffering and in labour. He was unable to be born. At the time, I did not know that. I only felt that I was failing. I believe now that he was correct in that not much was changing at his core. Something was changing in the relationship, however. He had been seducing me and I was succumbing. Here was another impasse. I had become the needy baby and he the unavailable and unapproachable mother, who had everything. Of course, he matter-of-factly denied anything I said about him. He was mildly interested in knowing what I was experiencing. And in a way, he seemed to be trying to take care of me. Silences were present as something almost titillating and mildly exciting, but mostly the silences yielded no insights and few interpretations. The transference had become perverse, because the adult was hiding the baby who desperately needed a mommy analyst and was terrified. In the silences, I began to pay attention to his body and to mine, noticing and remarking on his breathing or his movement, attempting to mark and find meaning in his nonverbal presence. About this time he began to talk about the women he was dating. Coincidentally I learned that he had had many therapies. Although he did not talk about his

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previous therapies, he did talk about what he called “my other women”. There were always at least two, besides me. I learned about his history with women, of having sex with a fellow patient in a therapy group he was in, in spite of the rules of the group. They would have sex in the parking lot before and after therapy. He told me he did not initiate contact with women. They initiated contact with him and set the frame for the relationship. Sex was at their request. Since he was indifferent, not caring one way or another, he would have sex with them. He did not deceive them by making promises or even by hiding his indifference or his other relationships. There was a feeling of perversion, of voyeurism I could not escape. What I might have called promiscuity was, to him, merely giving women what they wanted. The promiscuity in the hour was found in his inability to attach to any thought or idea or emotion. One was as good as the next or the last. The silences implied that only my words were valuable. He was waiting for contact from me. He was indifferent to our attempts at understanding, but he seemed to cling to the sound of my voice and the rhythm of my speech. The perverse sexual excitement in the room was daunting. The silences became loaded with it. Yet it was difficult to speak to and get a response. I gradually sensed that I was in the room but he was not. I was an innocent watching a perverse pornographic film, where the sadist and the masochist changed roles continually. Again, I was horrified. After some time, I came to realize that this was not an erotic transference in the classical sense. Instead, this was a transference of infantile polymorphous sexuality. Every interaction was exciting. It frightened me, as I felt there was no escape from being myself in the room with him. He felt my interpretations as seductions. He felt my very presence as seduction, much as a plant is seduced by the light. My dread deepened. I could not find a way to speak to his infantile need that he could hear. The next change in my counter-transference happened so subtly that I still cannot say what or when it was. I only know that I began to dread seeing him. This was not just dread in the sessions, but dread of seeing him at all. For weeks, I would feel tense and withdrawn before our sessions. There was no longer any talk of other women, only talk now about his mother and how seductive she had been and how clinging and weak and demanding. He said his father was pretty much out of it, leaving him to care for her. I interpreted his feeling about my being seductive. “Who wouldn’t like attention from a beautiful and wise woman?” was his reply. When I interpreted the infantile transference in the here-and-now of the session, he would pause, cock his head, and say, “Maybe”. Usually he would say, “I do not have needs”. Certainly, he did not seem to have needs. He reportedly lived in a small, barely furnished apartment. His needs seemed to be books and art. He was indifferent to or passive about most things. The passivity I am talking about is one of having no desire at all. He seemingly felt no impulses of his own to do anything. Passivity without desire or impulse is also not about resistance or opposition. Resistance is something we analysts understand. This matter of having

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no impulse is more difficult to grasp. My experience of dread seemed to mark a break in his passivity. When I interpreted the dread he might feel about coming to see me, he would say, “It is so useless”. My dread, I have since come to realize, covered over an intense horror. I was witnessing something I could barely hold in my mind, something so horrific as to be unbelievable. He was violently erasing himself over and over again, and somehow I was responsible because I allowed it, or didn’t get it, or was indifferent to the violence he did to himself. It was not me who was absent in the room all these months, but he. Now that I knew it, I remained a helpless witness, almost as if he were a monk, burning himself alive in the midst of a crowd of “mes” who were helpless to stop him. Saying it aloud seemed to fan the flames. When I suggested he come three or four times a week and use the couch, he said “No”. As much as I believed he needed analysis, I was pleased with his clear “No”. Maybe I was also relieved. I told him he had to find a way to find himself by opposing me. He told me he could not oppose someone who did not exist for him, who was a nothing inside of him. He thought I still did not get how unrelated he was to me or to anyone. I told him that I thought it was he who did not exist except as a mirror for me. He denied this also, but soon confirmed this by telling me I did not get how he annihilated himself over and over so that no experience could accumulate within him. He brought me a Winnicott article about this process the day that he told me he had accepted a job four hours away and would have to stop his therapy. I protested, and told him we were just starting. He shrugged, and said I was the one who told him to get a job, referring back to our very first session. I saw him two more times to say goodbye, and he was gone. A year later, he telephoned and asked to come in. When I saw him he said nothing had changed although he was making good money. He wondered if I would be willing to work with him again, after his precipitous leaving. He said he knew I had been right, that he shouldn’t have left, and wondered aloud, “Don’t analysts have ways of stopping people like me who do self-destructive things?” I interpreted his disappointment in our work and his anger at me for not being good enough for him. He said, “You still do not get that this has nothing to do with you. I am the monster”. For more than a year he commuted four hours twice a week to see me. His stories were more and more about his present life and relationships or about what he was reading. He frequently quoted Shakespeare or talked about Dante’s Inferno, quoting sections of it. He acknowledged his anger more often, although he blamed himself for it. The silences were more frequent and we were able to speak about them, noticing their variety and differing meanings. One day after being pleasant and chatty, he sat silent for several minutes. I too was silent. I was mostly waiting for him, looking out the window at the budding green trees, feeling relaxed and patient, occasionally looking at him. He too was mostly not looking at me, but seemed to be somewhere internal. Suddenly, I felt a very sharp pain in my chest. I very nearly gasped aloud with the pain. I couldn’t breathe it was so intense. I looked at him, fearing he had noticed. But he was

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looking out of the window, a serious expression on his face. The pain went away when I looked at him. After a moment, he turned to me and told me he didn’t know what his thoughts had to do with me or with our work together. He was silent again. Then he said he was remembering a National Geographic article about an Eskimo woman who had gone fishing with her infant and her two-year-old. The ice upon which she was standing broke off and floated away from the mainland before she noticed. The three had lived for a while on raw fish and snow. No one found them. Slowly it occurred to her that they were going to die. Still she tried to live and keep her babies alive. She nursed her infant and her toddler, knowing she no longer had milk. She taught her toddler to chew leather. Then one day her baby bit her nipple. My patient’s version said the baby bit the nipple off, something that hardly seems possible. Certainly in his phantasy it was true. In my reception of his unbearable phantasy, I felt the tearing of my own flesh, along with both horror and then fear. His story continued. The mother then strangled her baby and her toddler, throwing them into the sea. Her rescue from a patrolling Coast Guard boat came later, apparently on the same day. My patient was silent, soundlessly weeping for the first time in our work together. I too was silent and wordless. No words came to me, only an unbearable physical pain in my body and then an overwhelming mix of indescribable emotions. Later, outside of the session, I felt fear and incredible grief. I sobbed after he left. This event became the material for an exploration of our transference/countertransference relationship that moved between intellectual analysis of the backand-forth of our process to emotional interactions with tears, anger, and pounding the couch he was sitting upon. He said he was afraid he was killing me. Then he feared that I would kill him. There simply could not be two of us alive at the same time. Often we would be silent for minutes at a time. I would attempt to process these silences, since no two of them felt the same. During one such silence, he told me he had been mostly blank but then an image of a chicken had popped into his mind. He said it was as if he were a chicken and I had a cleaver that I used to split apart his breast bone and rip out his heart. He tried again to leave his analysis, this time less successfully, as he left for only a month, using business travel as an excuse. When he returned, he was angry with me that I had not suggested that we talk on the phone while he was out of town. Several months afterwards, he began to use the couch. Using the couch made a huge difference in our work together. Silence became a regular feature. I no longer felt so scrutinized or pinned down by his manner. I rarely felt the dread that had been pervasive for so long. Although he still maintained I was not there for him, he began to spontaneously free associate, something that had never happened before. He began to remember his dreams. Just as I was feeling our work was going well, in spite of my frequent confusion and doubt, he once again prepared to leave. This time he was thankful and grateful for our work but said he thought it could go on forever. Some days as he prepared to leave he would tell me how disappointed he was in himself and in me that we could not go further.

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He said he knew it was not just his limitations but also mine. Still he was quite generous, saying he never thought we would get this far. He was no longer afraid of killing me, but he hoped not to take care of me in my old age as he had his mother. Now we had reached both our limitations. Again, after the session, I realized that we had reached the trauma of his birth and that he could not be born. One or both of us would die. He needed me to birth him and he was angry with me for failing. Somewhere in this leaving came a remarkable session. In the session before the remarkable one, he told me that I was just like his mother, weak and unable to take his intense emotion. He complained that if he did not have to take care of me, he would be able to get at his rage and murderous feelings. So, what good was it to stay with me anyway? I couldn’t take it. I didn’t know what to do, and he was just tormenting and punishing me session after session. He also accused me of clinging to him and making him feel guilty for wanting to leave. I remember attempting to interpret his fear that I would have to choose and if it would it be him, the monster, or me, the mother, who would die. When I said this, he was silent, seemed to be crying, and reached back with his hand to me. I momentarily took it. In the session I am recalling, he came in and lay on the couch. He wiggled about a bit, shifting from side to side and then settled in, lying stiffly, as if in a coffin, on his back, arms crossed on his chest, legs stiff and straight. Then he did not move for forty-five minutes. I watched him, silently. He did not speak. During this session, I felt every imaginable emotion. In spite of feeling unbelievingly cruel, I did not speak. I watched him, noticing the tension in his body, noticing how little his chest moved when he breathed. I felt that if I spoke, as my impulses told me to, I would be asking him to meet me, to take care of me, to follow my agenda. I do not know why he did not speak, but he did not. At the end of the hour when I told him, “It is time”, he rose, nodded without speaking, and left. He cancelled the next week’s sessions. When he returned, he was furious with me. However, his anger and attack did not last long before he began to sob. He cried for a very long time, wordlessly, but this time with sounds. I nearly cried with him, so moved was I by his grief. Again, our silent session became the source of weeks of processing, of rages and recriminations, of tears and silences. I continued to interpret his need of me and his need of four-times-a-week analysis. He admitted it was true but could not imagine how it could happen. I asserted he needed to see me more often, not leave as he had been threatening for months. He said he knew that was true, it just seemed physically impossible. Perhaps he could call me. I agreed, so our compromise was that he would continue to come twice a week and on two other days call me. The phone sessions were revelatory for me. The sensory deprivation, except for sound, enabled him to feel himself, much as a fetus in utero must be able to hear his mother’s voice. He became able to express his disappointment in our work and in himself. Several times he was able to tell me he felt angry with me when we were not together. Finally it seemed that both Josh and I were present on the phone at the same time. It was harder to be in the room together at the

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same time. It seemed our physical presences were too much for him. The phone sessions appeared to enable a shift so that both of us could tolerate the reality of the emotional and alive other. Still, more often than not, one or both of us would disappear. Of course, on some level, the patient is always there and wants to be. He may work hard on these other levels, trying to reach something that has gone missing in him. When Josh told me I was not there, he was already changing. He could perceive something missing. Perhaps that something was the lost mother of infancy when hospitalization took the infant away from his mother. Perhaps, too, I had surrendered to his internal phantasy world and become the lost mother of his infancy. I believe that whatever it was that changed in him was related to allowing myself to feel so lost and horrified by what I saw in that House of Mirrors. My recognition of my own overwhelming awareness and nonexistence enabled him to recognize his own absence. Later he would say to me, “There is no there, there” – referring to himself. There were other comings and goings during the rest of his analysis. The ending phase was quite tumultuous. We revisited all of what I have described to you. When he left for good, both of us were sad and happy. In the years since, he has periodically contacted me, calling or sending a note to thank me and to tell me he is doing well. I am always glad to know.

Conclusion Most of us have learned to continue to exist via the coming and going of our mother’s bodies and minds. Freud’s (1920) imaginative understanding of his grandson’s play, both with a spool and its thread and also playing peek-a-boo with himself in the mirror, gives us insight into the responses of certain patients who, like Freud’s grandson, are able to “disappear themselves”. However, some are not able to reappear themselves, and so for much of their lives remain hidden behind a sensory wall of experience that enables them to function via mimicry and to suffer minimally the slings and arrows of outrageous fortune. By focusing on concrete sensory bodily experiences instead of emotional relationship with others, these patients have been absorbed by their own concrete sensations, their physical selves. They have also become absorbed by the workings of their own minds, having much intellectual understanding without finding emotional meaning. Lost inside their own mental activities, they do not experience themselves experiencing. They have lost an ability to see the emotional impact they have on themselves and others. In spite of this, they are able to describe and tell us about states they themselves do not understand. It is our task to remember them and make meaning of them. Patients who are hard to reach owing to early infantile or even conceivably prenatal trauma present some specific problems for therapists. Pathological mimicry (see chapter 2, and Eekhoff, 2016b), the imitation of human speech (Paul, 1997), and passivity (Joseph, 1971) that alternates with reactivity are some of the silent manifestations of the difficulty. Reactivity can be particularly difficult because it

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is often silent and unspoken, especially in the initial stages of treatment, and often results in the patient leaving the analyst prematurely. These patients may be very concrete, while brilliant in specialized areas. Patients who are difficult to reach (Joseph, 1975) require a firm frame and clear expectations, as without them they become almost unbearably anxious and reactive. Their reactivity also changes the frame subtly, which frightens them even more. In spite of needing the firm frame, I find myself bending it sometimes, as I did when I agreed to phone sessions, or by holding my patient’s hand (Ferenczi, 1928). The challenge for me is to hold the frame while keeping the patient. Because these patients have difficulty with representation, they also have difficulty differentiating conscious processes from unconscious processing. They rarely report dreams, as their ability to make images and use them is inaccessible. After some years of analysis, they become aware of dreams that are sensory in nature. This is the beginning of an increased capacity for symbol formation. In their depths, and even in what seems like their everyday functioning, they are adept at being in the moment, without a past or future. Without a sense of time or space, it is difficult for them to connect with their own desires, their own impulses, and hence they seem passive by nature. Impulse comes from desire. Early trauma, which separates the infant from the mother at birth or within the first year or two of life, interferes with the meeting of impulse, desire, and satisfaction. Without a containing mother to help the infant identify herself, the subjective sense of self is frozen in time. The self becomes suspended (Eekhoff, 2017). Impulses and desires are lost and the infant in the adult becomes passive and overly compliant, overly accepting, mimicking relationships instead of having them. Mimicry is physical and somatic and provides the infant, and the infant in the adult, proof of existence. This beginning of life makes analytic work with patients suffering from infantile trauma treatable. Sometimes, mimicry is the most authentic response to others that they master, in spite of the fact that it can contain mockery, hostility, contempt, rivalry, and envy. Mimicry is also evidence of an inanimate mechanical defence. Since no two people are the same, the attempt at sameness evokes a mechanical, non-human matching. It is this that produces the feeling of horror in the analyst who experiences being mimicked. The horror lies in being forced to witness and be used as an instrument of the patient’s self-annihilation. Mimicry can also contain admiration, curiosity, desire, and agency. It is evidence of the earliest relationship and prenatal containment. When mimicry is observed and valued, and interpreted with patience, small incremental changes in the patient’s relationship to self and then to the therapist as other can occur. Mimicry is never perfect and it is in the imperfections that the existence of the patient is discovered. The treatment becomes alive when the patient can tolerate more somatic experience and be found by the analyst. This adaptation includes identification with and becoming whoever one is with – whether or not the other person is aggressive. Perhaps identification with an aggressor (Ferenczi, 1933) includes identification with an absent mother, where absence was experienced as aggression.

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The process of identification is extremely important here. It is not only that the absent mother is an aggressor; it is that the instinctual aggression in the infant is not held or contained by the absent mother. In the subsequent shattering, unconscious phantasies are projected out into infinity and are only partially contained by the environment. This projection is different from projective identification. It is not meant for communication, nor is it a by-product of splitting. To the analyst, it may appear that there is little or no projection or identification. The projection is so complete at this primitive level of the mind that there is only blankness and nothingness. The identification is with every living thing. The opposite is also true. The identification is with nothing living. When projections go out into the world and the universe, instead of into a containing mother/analyst, the patient becomes lost in space, projected into infinity. The patient becomes whomever she or he is with and whomever the other requires. The simultaneous existence of multiple states of mind and being in both infant and mother can have a severe impact on the infant in the absence of the mother. The absence then impacts the infant by breaking experience down not just into related bits and pieces, but into fractals that seem unrelated. Life becomes a perpetually moving kaleidoscope with the patient becoming shards of reflected light. Making deep emotional contact with such a patient is difficult. What is lost is innocence as well as potential. Innocence allows for the spontaneous gesture of being. It is not only that reality comes in too soon. It is also that defences come in too soon, interfering with and inhibiting the impulses to learn, grow, and develop. The self liquefies, evaporates without a container. Freezing appears as a defence against liquefying or evaporating. Freezing is a destruction of fluidity and a fear of the loss of cohesion. Tonic immobility is experienced as psychic immobility. Discrete particles exist outside of relationships. A person or object is experienced from moment to moment as a totally different one. It is not as if difference is erased, but that difference is so great as to make one instance unrelated to the next. Subject and object are continually lost, not to be found or recognized again. Space and time collapse, and what remains is blankness or absence or nothing. Tustin (1986) writes about this in her book about autistic defences in neurotic patients. The primary impulse that remains is the impulse to observe and mimic. Being a participant observer is lost to them, yet all is not lost – for every infant was once contained, and when the infant and mother reconnect after hospitalization, every infant experiences some maternal containment that makes alpha function take place again. The mother too experiences the infant calling her motherliness forth. It is this experience, as well as the inborn life instinct, that makes these patients treatable. My patient struggled to comprehend this experience. He told me he was never the same person from day to day or moment to moment. Nor was I to him. He could trust no one, including himself. He feared that I would choose to believe only one part of him and never see the whole of him. He brought me out, engaged with me, entertained and provoked me. He forced me to keep looking for him and

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to remember what I found and bring it back to him. When I despaired, he came out and got me. Together we found his lost infant and lost mother of infancy. Our relationship changed both of us.

Note The statement by Bion in the epigraph is from an undated 1960 note, “The painful component”, in his Cogitations, Francesca Bion (Ed.), p. 169. London: Karnac, 1992, as well as the new extended 1994 edition.

Chapter 8

The body as a mode of representation

Thinking has to be called into existence to cope with thoughts.

– W. R. Bion

Most of what we experience is not knowable. To become knowable – that is, for our emotional experience to have a form that allows us to become conscious of it – emotional experience must link the senses with the mind via representations that take shape both in our bodies and minds. Although psychoanalysis has been called “the Talking Cure”, such talking relies heavily on the senses that underlie the lexical representations of language (Bion, 1970; Lakoff & Johnson, 1980). The senses then represent that which is knowable yet not necessarily named. Consciousness, according to Freud (1900, 1925), is the sixth sense, used to perceive psychical qualities. Psychoanalysis today works with more than the lexical mode of representation, using modes of representation found in unconscious phantasy, somatic manifestations, repetitive movement, and dreams and counter-dreaming, among other paraverbal and nonverbal modes. Psychoanalysis is increasingly focusing on multiple dynamic unconscious processes and using them to understand and make meaning out of the experiences of the transference and counter-transference in the hour. Whereas in Freud’s time psychoanalysis was primarily concerned with making the unconscious conscious and using lexical representations, today psychoanalysis has placed its attention upon the origin of thoughts and the ways these thoughts enable the individual to become a thinker (Bion, 1965, 1970). These thoughts begin in the body. Origination of an apparatus for thinking thoughts also begins in the body. Bodily expressions of drives and bodily responses to internal and external stimuli are communications in search of a receiving object. The origination of an apparatus for awareness of sensorium is essential for the subjective development of a self. This apparatus also serves as a foundation for ongoing creative living in relationship. Such an apparatus also prevents perceptual disorders that interfere with a person’s capacity to trust what they know.

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These shifts in psychoanalysis have changed our focus from the past to the present and the future. Creativity and fulfilment of potential are aspects of expected analytic outcome. The future involves the analytic couple in the ongoing growth and development of the self. New analytic experiences add new connections, and work with innate genetic potentials to heal intrapsychic divisions and fixations, thereby enabling more and more realizations of the self. Connecting on the edge of growth of both analyst and patient enables new vitality, increased originality, and recognition of previously unrealized potentials for both analysand and analyst. Our understanding of the function of relationship, internally and externally, continues to expand. Relationship and association function on all levels. They are the basis of representation and symbolization. Relationship is a taken-for-granted essential of integration, and forms elements of the psychic floor for experience. Our subjective relationships with our own minds and bodies and the minds and bodies of our patients inform us and contribute to the ongoing development of a future self. I name these as relationships in spite of believing in their unity. The mind and the body are one. Separating them, for the purpose of discussion, is a convenience that sometimes forgets the reality of mind and body unity. Such forgetting might also be defensive in that most of the infinite possibilities of human experience are unknowable. Separating the mind and the body unconsciously, as happens in borderline, psychotic, and autistic processing, for the purpose of attempting to control overwhelming perceptions and chaotic unmediated affects, is also defensive. Such defensive separation involves the mind turning the body into an object that can be used to project into, thereby also splitting mind from body. Such defensive and delusional separation enables one to survive in the absence of the object or in the presence of an indifferent and abusive object. In the absence of another person who is a projective identification-welcoming object (Eaton, 2005) able to receive and make meaning of projections, the body becomes objectified and the person loses embodiment. Embodiment is essentially the unification of infantile sexuality and a driver of integration. Without embodiment, perceptual identification cannot proceed to thought identification. Representation is threatened. When this occurs, the person loses capacities to symbolize and make meaning from new experience. Identification becomes rigidly attached to past experience. Facts are used to support certitude. Concrete thinking may result in symbolic equations instead of symbolic reasoning. Lexical representations, in that they are distanced from sensory and emotional facts, become untrustworthy. The apparatuses for thinking and for perceiving become impaired. The person is less able to use thoughts or representations that exist as memories in sensorium for meaningmaking. The result is a certainty that defies exploration. The certainty is a clinging to representation that is at risk of being destroyed. Bion (1962b, 1970) called this “the reversal of alpha function” (1962b, p. 25, 1970); Meltzer (1978, 1986) elaborates on this process of alpha function in reverse.

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In this chapter, I am revising my previous use of the word unrepresented and am suggesting, along with Oliner (2013), that representation occurs along a continuum. That which I previously grouped in the unrepresented category was too broad. There are aspects of experience that continue to be unrepresented. However, between unrepresented and lexical representation lies a wide spectrum of weakly represented and partially represented experience that is held in the body (Levine, 2010, 2012; Levine & Powers, 2017). There is also representation that has been undone via alpha function in reverse. I now believe that primitive body memories, not just memories in feelings, but memories held in the body as traces or impressions, are modes of representation. Some of these are unconscious phantasies (Isaacs, 1948; Klein, 1946). Others may be preconceptions (Bion, 1962b, 1970). I wonder too whether some of these might be representations that have been undone. I believe there are primitive representations in sensations, sounds, smells, and images. They are representations because they not only mark experience via implicit memory, but are subject to change and transform over time, thereby altering perceptions and thoughts about reality. These changes occur in every successful analysis. Larry Brown (2017, personal communication) asserts that Bion’s transformations are representations. Such transformations begin in the body as perceptual events we sometimes call hallucinations or in the mind refer to as delusions. This term, hallucination, is misleading – because, as with representations, hallucinations too are on a continuum, from being grounded in the body to not being grounded in the body but found only in the mind as aspects of the delusional system. The language of the body used by the early Kleinians in making interpretations of primitive unconscious phantasy demonstrates their awareness that phantasies held in the body are primitive modes of representation. In this chapter, I am attempting to briefly present my reasons for believing this. Representations are important because they are the building blocks of symbols and of thinking. They allow “the mind to present to itself the image of something not actually present” (Rycroft, 1968, p. 137). Representations are also an attempt to control reality. They limit infinite emotional experience. Representations signify. Significations of relationship are meaningful. They serve an integrating and organizing function (Bion, 1962b, 1970). Representational organization distances us from “the thing in itself”, making the emotional experience of “the thing in itself” notable and bearable. Emotional relationship as a mode of representation is at the core of Bion’s model of the mind. Affective bridges of L (love), H (hate), and K (knowledge) provide internal and external links making the thinking body and mind grow to be able to comprehend more of the infinities of experience. Symbol formation is a two-person process and deeply unconscious. For example, without an external relationship children cannot learn language. Symbol formation and the capacity to represent experience are essential to meaning-making. Symbol formation, which is included in Bion’s alpha function, requires a container and contained relationship. It links together two absent things, such as two ideas or two images.

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Symbol formation occurs in the absence of an affective ability to manage internal conflict. It occurs in the absence of the ability to manage any conflict, internal or external. This is particularly important in working analytically with traumatized patients. Symbol formation is not only an unconscious cognitive process, but also an affective one (Damasio, 1999). Affects, with us before birth (Panksepp, 1998, 2001; Solms, 2013), are body-based and intimately related to our drives. Emotion, which links affect with the mental awareness of experience (see chapter 2), might be thought of as precursor to a symbol or as an indicator, such as a sign or signal pointing towards the meaning. As such, emotion itself is a representation of experience. Symbols are evidence of mind/body and body/mind unity. Symbol formation requires two people. Hanna Segal (1957) defines symbol formation as “a relation between the ego, the object, and the symbol”. She goes on to say: Symbol formation is an activity of the ego attempting to deal with the anxieties stirred by its relation to the object. That is primarily the fear of bad objects and the fear of the loss or inaccessibility of good objects. Disturbances in the ego’s relation to objects are reflected in disturbances of symbol formation. In particular, disturbances in differentiation between ego and object lead to disturbances in differentiation between the symbol and the object symbolized and therefore to concrete thinking characteristic of psychoses. (p. 392) Symbol formation starts very early, probably as early as object relations, but changes its character and functions with the changes in the character of the ego and object relations. Not only the actual content of the symbol, but the very way in which symbols are formed and used seem to me to reflect very precisely the ego’s state of development and its way of dealing with its objects. If symbolism is seen as a three-term relation, problems of symbol formation must always be examined in the context of the ego’s relation with its objects (Segal, 1957, pp. 392–393). André Green’s definition is slightly different in that he focuses on the process without referring to the subject or the object: “The creation of a symbol demands that two separate elements be united to form a third element, which borrows its characteristics from the other two but which will nevertheless be different from the sum of those two” (Green, 2004, pp. 106–107). Relationship always includes the mobilization of primitive, bodily generated affects that become, via the mind, emotions. Emotion is key in symbol formation. Affect, the bodily precursor of emotion, is no longer viewed as an impediment in treatment or as the driver of repression, as in early Freud, but as a link between mind and body and an essential element of representation and symbol formation. Affect that evolves into emotion is recognized as intrapsychic communication, much as dreams are. Freud himself began to explore this link when he differentiated signal anxiety from traumatic anxiety. Ferenczi (1933) also explored it in his work with Elizabeth Severn and his own self-analysis. Affect and its mentalized

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counterpart, emotion, link subject and object. Affect then links intra- and intersubjective experience so as to make it memorable and symbolic. It is the body and its affect that mark, recognize, and recall. Repetition in action marks representation and enables increased representation. Increased representation includes psychic elaboration and the ability to think before acting. Increased representation is a characteristic of the language of achievement (Bion, 1970) and uses language as a prelude to action. Moreover, the process of using affect to bridge or link internal experiences gives us a way of describing a procedure where perceptions are ordered, stored, and made usable as conceptions (Bion, 1962b). This process, which Bion named alpha function, includes but is not limited to the process of symbol formation. It is intimately linked to the process of embodiment, of becoming a subject, and then a person with agency, desire, and relationships. Embodiment cannot occur in isolation. To become a person, one needs a (M)other who desires to know her infant and who finds and recognizes her infant. Such a person exists as a reality in a real world of others. To be recognized and desired enables the development of an embodied self within a physical and a psychic world. The embodied self is a sexual self with relations to others (objects) that are driven by desire, not only thwarted by fear. The embodied self is able to use consciousness as a sense organ for noting and paying attention to internal processes (Freud, 1900, 1911). Emotional links between mind and body play an essential role in the integration of experience. Paying attention to primitive modes of representation that present in undifferentiated affective corporeal states enables the analyst to understand the primitive communication of all of her patients and to take in developing representations in their primordial forms. This enables the analyst to experience in increasing depth the complexity of the patient’s inner world as it is lived in the analytic hour with the analyst. Why is representation important? Representation enables embodiment just as embodiment enables representation. This ongoing interactive process is at the core of making meaning from experience, enabling a person to have an integrated subjective sense of self and an ongoing relationship with his or her objects. Such a sense of self has a past, a present, and a future. The foundation of representational development is the body and its affects as they are discovered in unconscious phantasy and in relationship to persons, places, and things, thereby providing a sense of time and space. What are the implications of my belief in the body as not only a mode of representation but the ongoing foundation of representation and its elaboration? The body becomes a background object for the ongoing subjective realization of self. Such a belief opens up analysis to a broader approach for working with nonneurotic patients (Levine, 2012; Levine, Reed, & Scarfone, 2013). It involves the work of the analyst as a participant, body and mind. César and Sára Botella, in their book The Work of Psychic Figurability (2005), name this working as a double in the process of figurability. Working as a double is not a rational logical process. It requires disciplined and trained intuition. Bion calls this at-one-ment. Such work is a two-person work; both patient and analyst are required.

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The analytic work involved is one of facilitating the growth and development of the patient’s capacity to make meaning out of complexity. Meaning-making involves an emotional ordering of experience that contains and orders inchoate perceptual and conceptual experience. Meaning-making is a two-person process that utilizes both body and mind: affect, emotion, intuition, and cognition. Intuiting and understanding such a complex process further enables the analyst via the relationship of the transference and counter-transference to notice places in the processes that have been sidetracked, aborted, reversed, or were never formed. All of our patients no matter how ill already have an apparatus for representational thinking. Recognition of unrepresented or partially represented processes enables the analytic dyad to create order out of chaotic perceptual and emotional facts via categorization, classification, and subordination of experience by representing it in the body and mind. Once represented in the body, the experience is able to be presented, re-presented, and represented. Interpretations and reflections are then possible that focus not on that which has been thought and repressed, but on what has been experienced but cannot be fully symbolized. Another way of saying this is that the intersubjective process of analysis involves the coming together of two minds and two bodies so a relationship can be formed that facilitates the growth and development of an apparatus for thinking and an apparatus for processing sensorium. This is a representational body/mind. It is also an embodied mind/body. I am interested in how and what the analyst infers from the patient’s behaviour as well as in the analyst’s ability to receive adhesive and projective identifications. Inferences of the patient’s unconscious and evolving subjectivity and its alive presence in the analytic hour enable increased communication and emotional connection between the two. These inferences come not only from a phenomenological experience of the other. They are at least partially derived from a perceptual level that remains as memories in sensorium and can partially, but never fully, be accessed in hallucinatory and somatic experience in the presence of an other. While they may never be fully accessible, they can be partially discovered in intuitive conjectures by both analysand and analyst. They serve as the background objects of experience and of meaning-making. The body as a background object provides an ongoing holding via sensorium, some portions of which are never brought to consciousness, but nonetheless serve a sustaining function (Peter Goldberg, personal communication, January 2017). Speaking about the importance of internal and external relationship is reductionistic without briefly acknowledging the exponential impact relationships provide. To reduce the evolving complexity of relationships is to skim over the increasingly complicated patterns that develop and are configured in both integration, disintegration, and unintegration. Such patterns are kaleidoscopic and continually shifting, changing shape, and transforming again in both health and disease. The patterns of sensory expression, of somatic symptoms, of dream and daydream images and sensations, as well as more obvious behavioural habits and seemingly

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familiar repeated emotional responses, speak to the fluidity of possibilities that form one’s perceptual and thought identities.

Perceptual identity I am not aware of analytic authors other than Piera Aulagnier (2001), César and Sára Botella (2005), André Green (1999), and Marion Oliner (2013) who are speaking of the power of our perceptions and the ongoing role they play throughout our lifetimes in our evolving sense of our own identities. Their thorough descriptions of the role of perception in the origins of thought and in the process of figurability are the background to what I hope is an extension of their thinking, while I am incorporating Kleinian and Bionian understanding. I believe that projective identification contains both the perceptual identity and the thought identity of the projector. Adhesive identification is even more closely related to perceptual identity, while including thought identity. Both are intimately associated with infantile perceptual experiences and unconscious phantasy, and are employed in an attempt to satisfy needs and desires via delusion and hallucination. Both signal primal and primordial representations. They are also associated with a drive towards satisfaction and the reduction of dissatisfaction. These needs and mechanisms continue throughout the lifespan. Perceptual identity underlies everything and becomes, via actual bodily sensations, the background object we all rely upon. These terms, perceptual identity and thought identity, originated with Freud (1900) and have been elaborated by numerous psychoanalytic writers since. In Freud’s The Interpretation of Dreams (1900, as translated by Joyce Crick), he writes: The primary process aims to discharge excitation in order to set up a perceptual identity, using the amount of excitation accumulated in this way to do so; the secondary process has abandoned this intention and taken up another in its place – to set up thought-identity. (p. 397, italics in original) Freud seems to be saying that the goal of primary process is to form a perceptual identity while the goal of secondary process is to create a thought identity that harnesses the primary processes. Discharging excitation is necessary for maintaining psychic equilibrium, which includes the capacity to think (Bion, 1962a, 1970; Freud, 1911). Primary and secondary processes influence psychic determinism and function throughout our lifetimes. Trauma impacts the work of figurability, overwhelming the dream processes that make meaning out of experiences. Patients who have been traumatized in infancy and early childhood experience implicit memories in feelings and memories in sensorium that remain present and presented throughout their lifetimes. Analysts who work with these primitive unmentalized and unnamed bodily states

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face overwhelming affect and nameless dread. Meltzer (1986) believes that these states cannot be forgotten, and that these experiences may also not be open to new experiences. He revises that somewhat, adding that he has come to believe that in the reversal of alpha function the apparatus itself is not necessarily damaged. Such patients rely on their perceptual identities not as a means to find themselves in the outside other, but to reduce their overwhelming affect at all costs. The cost is often highest in relationships, thereby thwarting their possibility of receiving help. The methods used are complicated, one of which is adhesive identification (Meltzer, 1974). Working with traumatized patients at the level of perceptual identity requires a great deal of us, in what the Botellas term “working as an animistic double” (C. Botella & S. Botella, 2005, p. 83) and Bion calls at-one-ment. We analysts must be capable of regressing to infantile levels in order to understand and later describe our experiences in language. The theoretical link between affect and drive, between hallucination and wish fulfilment, carries over to Bion’s idea of thoughts without a thinker and of his ideas of at-one-ment. Such analytic regression, which I have described previously as being outside of time and space, is also related to Bion’s ideas about setting aside memory, desire, or understanding. Our own and our patients’ perceptual identity can be discovered only in the moment by focusing on the configuration of patterns, rather than their meaning, and on the affective drive for satisfaction of primal needs (see chapters 2, 3 and 5), which includes a search for the lost object of infancy. All of us know from experience the process wherein a song triggers a memory of childhood or a smell of lilacs evokes memories of springtime in Berlin. Recently a patient recalled the smell of rooibos tea as evoking memories of her Dutch grandfather. How are these conscious memories examples of psychic determinism? They illustrate mood changers: that is, a smell, a sound, an image or sensation evokes not only the dreamlike hallucinatory memory. These sensoria also evoke mood states. In much the same way, perceptual identity underlies all experience in the clinical hour for both analyst and analysand. Perceptual identity forms a foundation for the psychic determination of transference and counter-transference. Working with perceptual identity rather than only with thought identity allows for psychic elaboration and increasing capacity for representation. A clinical example, Jasmine, from the Botellas’s book, provides an illustration. For more detail, see their text (C. Botella & S. Botella, 2005, pp. 100–106). Jasmine was adopted from Viet Nam by a French couple. Before she was two, she had reportedly witnessed her parents’ death and the death of most others in her village in an enemy raid. She began treatment in latency when she presented with learning problems at school and difficulty in relationships. The Botellas describe her as “condemned to live in the immediate present” (p. 100) due to her inability to integrate her early traumas into her current life. For example, the discrepancy between her face in the mirror and the appearance of her French parents was disturbing to her, creating an experience of seeing a ghost. She felt estranged

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and disconnected from everyone in France. Initially her sessions with her analyst were mostly silent. Progress occurred when Jasmine was able to draw an image of her “natal village nestled in a mountainous landscape under the radiant sun” (p. 101). This image was in sharp contrast to her ability to relate to her parents, her peers, and her analyst. Her analyst, who recognized the communication in the drawing, was able to use these images over time to find language that enabled Jasmine to integrate her early perceptual and thought identities with her current experiences.

Multiple modes of representation Multiple and simultaneous modes of representation enable us to mark our experiences and give meaning to them. Representations themselves relate to earlier representations, and in multimodal fashion – much as senses relate to each other – enhance the emotional meaning of experiences via perspective. Patients who have been traumatized in infancy and early childhood present with difficulties in knowing what is real and what experiences signify. Their preverbal processes of representation have been disrupted and associations may develop idiosyncratically. Their internal relationship to each other may be compromised. Often they will say to us, “Maybe I made this up”, or “I am not sure about this”, or “I really don’t know if it happened or not”, or “I hope you believe me because I can’t believe myself”. Following an interpretation they may say, “I really do not know if what you say is true. I have to trust you, because I simply do not know myself”. They doubt not only their thoughts but their perceptions. They mistrust their dreams as being too real to bear. Knowing what is real and what is imaginary is an ongoing goal. To a very real extent, this is true for all of us. Reality is unknowable. What we perceive with our senses and describe with our words is not the actual object we observe. Yet we are continually behaving as if our perceptions were true. We do not suffer from crippling doubt. Patients who have been traumatized rely heavily on their senses to concretely tell them what is real, denying much that is not sense-able as not existing. The Botellas describe this pull towards the concrete sensual in the following manner: however ‘unknowable’ reality is for man, it nonetheless brings him a certain type of knowledge from which he can no longer free himself. It could be said, just as the falcon lured by the bait returns to the hand, the psyche is trained by the lure of the sense organs. (C. Botella & S. Botella, 2005, p. 155) The lure of the sense organs creates protection from the spaciousness of the abstract and metaphorical world. Their power to fill in the spaces between associations serves to protect as well as inform. This protection can lead to misconceptions (Meltzer, 1983; Money-Kyrle, 1968) that are extremely difficult to

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dislodge owing to their defensive function. Our patients who employ their senses in this manner often have a feeling they are misleading themselves in spite of how certain they may appear. One patient described psychic determinism this way: It is like there are two worlds and the world outside this looks normal and joyful and positive, because others can’t see this . . . this thing. I think it is that way. But this thing is like a lens over my life that alters the perspective and makes me doubt everything I experience. This informs real life instead of real life impacting that. Real life – that is, the world of the senses – is not the arbitrator of reality. Perceptual identity is. Another more dramatic use of the senses for defence occurs with patients who employ focusing on one sense at a time, disconnecting their multiple sensual relationships from one another. Rather than using the senses together for information, they dismantle them. Meltzer (1975b) calls this defensive use of disconnection of the senses dismantling. In this defence they use their senses, via suspension, to blot out reality by paying attention to only one sense at a time. Even though the senses inform, they can become a difficulty. They can interfere with the mind even though they are vital for the development of embodiment and thinking (Bion, 1970; Money-Kyrle, 1968). The body has its own methods of marking, remembering, and moving through experience. The body even elaborates experience. Memory, not in language or feeling that can be recalled but implicit memory in the sensorium, can recognize and identify early signifiers and their significance. Awareness of body sensations captures the attention, enables the suspension of overwhelming affects, and, via proximity and adhesive identification with an object (see chapter 5 and also Eekhoff, 2017), provides an organizational structure for experience. When early childhood trauma disrupts the organizing function of perceptual identity, hallucinatory wish fulfilment is damaged. Healthy illusions are disturbed. Both kinds of disruptions impede the healthy development of internal and external relationships. Such thoughts are disturbing. We want to believe what we see and taste and hear and touch are real. Yet psychologists who study perception tell us we perceive what we expect to find (C. Botella & S. Botella, 2005, p. 171). This supports what analysts know: internal psychic reality is more powerful than external reality, even in regard to the senses. The senses find in the external something recognizable, something identifiable, and attribute meaning to the external in an attempt to organize and comprehend that which has been experienced but not mentalized. As César and Sára Botella write, “infantile trauma, non-representation with its negativity and its hallucinatory tendency, converge with the primal trace and its relations” (p. 171). I am adding the idea that what is present is a representation: a primitive form of representation in sensorium that is tenacious in its presentation. As a representation it is open to transformation, an assertion that makes working with patients who have been traumatized in infancy and early childhood possible.

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An example: My patient, whom I will call Ada, looks up as I enter the waiting room, cocks her head, and smiles. She follows me into my consulting room, sits, and does it again. I think she looks so young and so eager to see me, which surprises me on this our last session before a two-week break. I say, “You look like a third grader who is just seeing a teacher she loves”. She laughs and says, “You plucked that right out of me. My favorite teacher of all time was my third-grade teacher. She really got me”. My first intuitive statement revealed my introjective identification with her demeanour, which served to illuminate something other than the fear and despair she thought she was coming in with. Our exploration became one of presence and the loss it brings with it. I believe it also exemplifies an intuitive use of perceptual identification – in this instance mine with my patient. Again, quoting the Botellas: If we are seeking intelligibility with regard to the functioning of two psyches in a retrogressive state due to the analytic situation and if we adopt a standpoint comprising the primordial, hallucinatory, perceptual, and representational processes as a whole, at this level, meaning is engendered in simultaneity, in the non-separability between movement, form, and content of the processes. (C. Botella & S. Botella, 2005, p. 179) Accessing these primal states, which I believe are always present, is easier for our traumatized patients than for us in that their protective systems have not fully developed. They have less of a barrier between their perceptual identities and their thought identities. Using Bion’s (1970) suggestion of attempting to function without memory, desire, or understanding enables us to meet them where they are.

Dreaming, illusion, and hallucinatory wish fulfilment In non-traumatized patients, the body informs and contains. It is a background object, a facilitating environmental mother that surrounds, contains, and makes meaning out of perceptual experience. The body seeks the lost mother object in the world and is able to discriminate safe from unsafe, inside from outside, satisfaction from dissatisfaction, pleasure from unpleasure, and reality from unreality. Eros and Thanatos mediate each other. Perceptual identity, the search for finding the self in the other in the world, unconsciously underlies all creative efforts. It is the source of Bion’s intuition and of “O”. It is the Real that cannot ever be fully known. Perceptual identification brings two objects together, creating an illusion of oneness. Undisturbed by too much trauma, perceptual identity-seeking becomes

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a source of inspiration and creativity. It is life-giving and life-serving. It is an unconscious background of sensory experience that includes prenatal and early postnatal states of satisfaction and oneness with the mother. In traumatized patients, the body is not so likely to be a facilitating background object. Rather it becomes linked to the overwhelming affective charges associated with danger. Often radical and violent cutting off of the body and its informative perceptions becomes a necessary means of psychic survival. As later cited in C. Botella & S. Botella (2005), Freud (1920) wrote that A general overvaluation has thus come about of all mental processes [. . .] Things become less important than ideas about things; [. . .] the reflection of the internal world is bound to blot out the other picture of the world – the one which we seem to perceive. (p. 88) The mind then becomes a less than accurate background object, creating distortions in the perceptual field. The distortions occur to compensate for the inadequate protections of the repression and contact barriers. These distortions differ from the ordinary hallucinatory wish-fulfilment that Freud describes. They also differ from the illusory world of symbol formation and the transformative generative process of dreaming. The mind as a background object uses words to speak of other words, thereby stripping meaning from them. Post-autistic and post-psychotic states in adults who suffered infantile and childhood trauma are particularly difficult for analysts to recognize and treat. This is so because these patients have access to primal states of mind that most people have repressed, contained behind a contact barrier, and modified with dreaming, illusion, and hallucination. Without these protections, such patients are terrorized by suffering (Ferenczi, 1933) and tormented by pain (Eekhoff, 2018). Without the recognition of the primitive defensive states that often present as mimicry, somatic symptoms, obsessions, concrete thinking, and repetitive movements – and without a recognition and understanding of the reason for those defences, which are used to combat the states of terror, persecution, and dread – analysts find themselves caught in impasses that are difficult to resolve. Impasses occur in part because some of what is interpreted as defensive is idiosyncratic psychic structure that was formed prior to later defensive processes. Even the terror, persecution, and dread can be mental representations of instinctive affects and cover over an area that is as yet unformed, unmentalized, and not named. When analysts do not comprehend this difference, patients despair of ever being understood and of ever being able to live without extreme suffering. Freud understood this when he wrote “Analysis Terminable and Interminable” in 1937. Such patients suffer unbearable psychic pain. They suffer from traumas that occurred before they could speak. When they come to us, they have no words for their suffering. Whether their trauma occurred at birth and included separation from their mothers, or somewhat later and included a mismatch between their

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needs and the mother’s ability to understand them, their apparatus for perceptual identity becomes compromised. Their ability to use their perceptions to find satisfaction in the world via identifications is damaged. Often, they also have a very weak sense of self. They seem unable to find themselves in the world, whether in the gaze of the mother or lover, in the curve of a blossoming cherry tree, in the aria of an opera, or the fugues of a Bach concerto. In our perceptual discoveries of ourselves outside in the external world, we elaborate and develop our depth and our unique identities that began the moment we were conceived. These traumatized patients have lost their abilities to search for their perceptual identities in the world via illusion and hallucination. Their dreaming terrifies them rather than informs and guides them, hence they may report few dreams. The importance of dreaming, illusion, and hallucination in healthy relating to the world is lost if an analysis becomes an intellectual search for motivation and historical origins of suffering. Dreaming, illusion, and hallucinatory wish-fulfilment are the ways in which we continually invent ourselves. They also return us to pleasure and to satisfactions first experienced in infancy at our mother’s breast or in our father’s arms. Although we can never again recover these idealized states, we do continue to search for them. The illusion of finding them, even momentarily, occurs when we fall in love, find a new friend, and discover great works of music and art. Again I turn to the Botellas to help me describe this process: “Dreaming is an immediate and momentary means of escaping the original trace owing to the hallucinatory re-cathexis of the object from which the dreams proceed” (C. Botella & S. Botella, 2005, p. 172). Origination of the self involves the perception of new experience as it relates to the old – that is, using one’s senses to perceive and pay attention to that which one recognizes and identifies in the emotional experience. Both must be experienced long enough to enable the differentiation of the old from the new. The new is always a threat, just as otherness is a threat. If the threat is too much and overwhelms the subjective experiencer then the learning process is disrupted and the mechanism or apparatus of figurability becomes faulty or damaged. Excessive damage interferes with the patient’s capacity for satisfaction, pleasure, and relationship. Analysis provides an opportunity for the patient to discover themselves via their perceptual identity of the analyst in the transference.

Clinical example Ada (see chapters 2 and 6) has been in a long and painful treatment. When I met her she was suicidal. She was also angry with me for needing treatment, as if my very existence were a threat. She had been referred by her former therapist after ten years of treatment. Her fear was that she would spend another ten years and still be the same. She reported no dreams, only physical symptoms that included an eating disorder, difficulty sleeping, rocking herself to sleep, rubbing her feet together, and chest and stomach pain. She was hypersensitive to sounds, to bright

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light, and to being observed. She frequently went to the doctor, fearing that one symptom or another was cancer and that she was dying. She believed something terrible had happened to her when she was a child but had no recollection of any kind of sexual or physical abuse. Over time, she gathered stories from her family of crying continually in her crib in her first year of life. Her parents left her to “cry it out” and her brother who was one year older would come to her and put his hands inside the crib and touch her, attempting to calm her. Her mother reported handing her to a stranger in a hurricane shelter when she was two and then losing track of her overnight. Her brother also told her that she had been forgotten at a rest stop when she was three. When the family returned, she reportedly was sitting on a picnic table, staring at the trees. These stories suggest an infantile trauma of accumulated parental indifference. Clearly I cannot summarize years of treatment in a few paragraphs. She began by sitting up, because she needed to see me. Only after five years did she begin to use the couch. By then she was no longer suicidal and no longer had an eating disorder. However, Ada would still begin to do mathematical equations whenever she felt anxious in our sessions. She would also trace the geometric pattern in the carpet hanging beside the couch with her eyes and sometimes her fingers, even though she feared I would be upset when she touched it. She reported physical symptoms, which I treated not as conversion symptoms, because they were not that, nor as psychosomatic states because mostly they were not that either. Her physical symptoms appeared to be expressions of a search for something in her own body, even as they served to keep her at a distance from me. These symptoms drew her attention away from the external world to auditory sounds such as stomach or intestinal gurgles and heartbeat; tactile sensations such as itching, hot or cold sensations, pressure and constrictions, and to visual patterns such as the patterns on the carpet, the lines in her skin, the shape of her fingers, arms, and body as she lay on the couch. It took both of us a long time to notice these as she did not think to report them and she was able to talk while attending to them. In fact her talk itself, as interesting as it was to me, was also a sensory experience of her mouth, tongue, and lips, and an auditory engagement with her own voice. Understanding this caused me enormous pain. I struggled to comprehend her experience and to cope with my own failure to reach her. I simply did not exist for her except as a function she herself did not notice. While holding tight to the analytic frame, I changed what I was paying attention to. The nature of my interpretations changed too. I spoke about her breathing and holding her breath. I spoke about sounds and sensations, and I myself made many more “Hmms” and “Ahs”. I also spoke about her psychic presence and absence, concretely in a here-and-now way. Doing this began to open her up to speaking about these physical experiences that she described as “helping me do my job”. Eventually I could describe my own experience of not being there and wonder about whether she felt she had left me or I had left her. Importantly, through it all, I suffered with the realizations of

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her unfelt suffering. I was horrified at how she obliterated herself and me, thereby eliminating any hope for help. In spite of my awareness, she seemed indifferent. Rarely did she feel I had left her. I was not that important. She simply did not notice me. She was self-sufficient, feeding herself with her own sensorium. After some time, there was another change in what she told me. She still only rarely reported a dream, but after a few years began to report what she called images that popped up as we were talking. The nature of our transference and counter-transference changed. Although she still did not miss me, she could talk about somehow needing to be with “someone who listens”. She began to intellectually engage in analyzing herself. At first, I was so relieved by this. Her insights were impressive. However, her pain was no less. Her critical superego was vicious. Only gradually did I come to realize that her self-analysis was leaving me out while covering over something terrifying. When I interpreted this, she stopped, once again becoming compliant to what she perceived to be my wishes. The sensations and images that began to come were hardly informative, as disturbing and violent as they were. Yet the images changed with my attention to them. For weeks, she described pain in her whole body. Doctor after doctor could find nothing wrong with her. Then the overall pain shifted to pain in her throat. A constriction in her throat and chest whenever she swallowed interfered with her eating and her speaking. Often in sessions, she would attempt to clear her throat and describe a sensation of being choked. She felt she was dying of throat or esophageal cancer. She said she knew I thought it was psychological and expected me to make an interpretation that minimized her physical and psychological anguish. She said now that she wanted to live, it made sense she would die. Again, in spite of numerous invasive tests, her doctors found no physical cause. Her physical sensations shifted when she suddenly had an image of me holding her by the neck over a pit. She said I was trying to help her stay “in it”. Her words were: “You have me by the neck and are holding me over the pit of infinity”. In spite of our exploration of this image, nothing seemed to emerge. In retrospect, what seems more significant is that she had an image with two of us in it. I existed. The image also changed over a number of weeks. At first she described the image as just being there, mechanical and not human, without feeling or meaning. I was functioning as a piece of equipment and so was she. Both of us were our current ages. Later she reported: It is interesting how the vision has changed. You had me over the pool and were shaking me by the shoulders. Now I am much younger, an infant and you have me by the neck and there is no movement. I am not moving, your arm is not either. There is no movement. My earlier counter-transferential feeling of being unable to reach her had somehow in fact reached her. Her image had changed. Then it changed again, mostly

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via the silent work of at-one-ment, of being a double. My words were not as important as my presence and my intuitive introjective identification with her experience. These are her words: “Something just happened . . . within the last minute . . . this image changed . . . it felt more dangerous, but I moved closer to you, maybe not for good purposes”. A: P:

A: P:

You had a feeling I was here and that was not good. I don’t know, I can’t feel this about with this vision . . . like how can what I am talking about make it different. I feel safe telling you all this, not that you will retaliate or take it personally so I must feel your support. For me to say, “I feel like you are strangling me” is pretty harsh, but the truth is that is just how it feels. Yeah, the vision is not so clear, more gnarled up . . . if it wasn’t so gnarly I would be embraced . . . like I am being eaten by the tree and taken in and you are taking all my energy and life force . . . I will be poof and gone or a knot on the tree as evidence . . . that is where that creature used to be . . . otherwise you would look at the tree and think, “old tree, old scary tree”. So something moves when the images change. Yes, there is movement from one image and then it moves to the next, not like my hand-over-hand thing. [This is a reference to her previous description of using her mind concretely, hanging on to facts or counting.] Now the image is an old wise tree and I am not being strangled anymore. Oh, [sitting up] I just had the thought, my mom will cut the tree down. It is too bad that I experience my growing up the way I do. It wasn’t personal . . . and she feels bad, that she was a bad mom. Now she is trying. We both are trying. For the most part, it is working . . . you know?

The image of herself as a knot on a tree being chopped down by her mother was startling. Again, I felt impotent, helpless to impact such a solid non-human image. I also was having vivid images of her descriptions, almost as if I were watching a movie. Feeling despair once again, I waited, silently. I too was trying, but I was not at all sure it was working. I could recognize transference in her comments about her mother, but felt it was important to not speak at the transference level. This may have been an error, given what happened later. Several weeks later, she reported she had hired a woman to chop down an old pear tree in her back garden, because of the mess of falling pears. Her husband had agreed to it in spite of feeling it was a beautiful old tree. Her mother, who was visiting, had convinced her to leave one branch and a limb as a kind of sculpture in her back yard. Afterwards my patient had been distraught, feeling she had acted without understanding why she needed to chop down the old tree for its mess. She said, “I feel bad about my tree. It seems really harsh”. In my countertransference, I was shocked and saddened by her actions, which seemed to match the images she had had of herself and her mother-me only a few weeks before. I imagined and envisioned the tree and believed it could survive. My body felt tired

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and drained. I was emotionally devastated and grieving. Only later did I remember her being found at the rest stop staring at the trees. Somehow her movement from sensation to somatic symptoms to images that transformed ended in the action of cutting down the pear tree. Over the following weeks, we were able to find words to describe these experiences of being a block of wood to a person overwhelmed to the point of action. The representations in her body were able to be used for transformation into words that lead to meaning making.

Conclusion This chapter has explored a clinically derived idea of multiple modes of representation that is different from the ideas presented by French and American authors on the nature of representation. For example, the Botellas (C. Botella & S. Botella, 2005) state, “no representations are possible, or repressible, as long as the thing-presentations have not been linked up with word-presentations” (p. 106). I am only in partial agreement with their statement. I agree that the process of being unable to recall a traumatic infantile experience is not repressed or repressible. I do not agree that representation is not possible without having been linked with word-presentations. Instead, I believe that memories are held in the body in the form of unconscious phantasy. These unconscious phantasies are partially body-based and are linked via implicit memory and perceptual identity to a primitive mode of representation that is perceptual in nature. This experience is recognizable without being nameable. The recognition is found in the bodily representation as memories in sensorium. Such memories are presented again and again in search of a receiving and accepting other. It is the dynamic nature of the unconscious that such unconscious phantasies can be impacted and changed. Unconscious phantasies are not static. They are dynamic and impacted by relationship. They emerge into the preconscious as images that can be used by the analytic couple for meaning-making. Kleinian and Bionian analysts have recognized this in their technique of recognizing the body systems as representations of unconscious phantasy (Isaacs, 1948). They have used the metaphor of the digestive system as a basis for many interpretations. Unconscious phantasy changes over time and with relationship. Also unconscious phantasy is powerfully impacted by external experience. Patients with a history of infantile trauma, namely trauma that occurred before they were proficiently verbal, retain in their bodies representations of the trauma that require an other for transformation. This process of transformation is similar to the process of dreaming. The body is a dream space where the evolution and transformation of representations takes place. I believe this to be the most primitive form of thinking and the area where psychoanalysis moves from being an analysis of history to being an analysis of present process. When trauma impacts the apparatus for making meaning out of experience, the internal use of subject and object for transformation

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or representation-making itself becomes compromised. As analysts, we are not interested in the content, but in the process of meaning-making. Bion suggests, as does Ferenczi, that such meaning-making requires a relationship with another actual person. In addition, I have emphasized that analysis is not only interested in the past. It is also interested in the future. The meaning of transference and countertransference and their manifestation in the therapeutic interaction has deepened and become “the total situation” (Heimann, 1956; Joseph, 1975; Klein, 1952, 1955). Included in this total situation is the idea of Freud, Klein, Bion, Meltzer, and Joseph, as articulated by Grotstein, that it “should be analytically treated as an ongoing dream. Consequently, every object in the session (dream) refers exclusively to either the analysand or to the analyst” (Grotstein, 2009, pp. 28–29). The function of the object is inherent in the development of the subject. Whereas analytic work with patients who have been traumatized in infancy and early childhood requires a great deal from the analyst, I hope I have made clear that such work takes two people working together. Both patient and analyst are necessary. Deep counter-transferential work on the part of the analyst requires something equally deep on the part of the patient (Robert Oelsner, personal communication, 2016). It takes two. Finally, much of our experience is unknowable. If one only knew what exists, psychoanalysis and life itself would not be such a mystery. The terms we work with: conscious, unconscious; representation, non-representation; perception, identification, and hallucination, as well as many others, are constructions we use in order to describe our clinical experiences to each other. Sometimes we forget that the realities of our experiences in our consulting rooms are unknowable and that these words we use to describe them are constructions. We only use these terms to mark something that we may then be able to think about together. Our ability to think about these experiences grows with our ability to tolerate the unknown and unknowable, the chaos that is forever within us. Perhaps what Bion (1967) at least partially was referring to when he wrote “Thinking has to be called into existence to cope with thoughts” (p. 111) were the primal representations present within us from birth.

Note The Bion statement in the epigraph is from “A Theory of Thinking”, in chapter 9 of Second Thoughts (London: Heinemann, 1967) [Reprinted London: Karnac, 1984 (p. 111), following earlier publication in the International Journal of Psycho-Analysis, Vol. 43, parts 4–5, 1962.]

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Index

adhesive identification see identification affective bridges 17, 96 agency xiv, 13, 32, 34–35, 64–65, 68, 98, 111 Aisenstein, M. x alpha: alpha function x, 4, 9, 16–17, 34, 52–53, 63, 79, 80, 92, 95–96, 98; alpha function in reverse 9, 34, 63, 95, 96; alpha working on beta 79; reversal of alpha function 16, 95, 101, 117 Anderson, M. 13 Anzieu, D. 22, 51, 74 atomization 77 at-one-ment 54, 98, 101, 109 Aulagnier, P. 100 autistic defenses 19, 32, 62, 66, 77, 92 autistic encapsulation xvi, 61, 70 background object 104 beta: beta elements 4, 53; beta screen 80 Bick, E. 2, 31, 39, 42–43, 51, 54, 80 Bion, W.R.: absent breast 33; alpha function x 4, 52–53; alpha function (reversal of or in reverse) 16, 34; alpha working on beta 79; at-one-ment 54, 98, 101, 109; beta elements 4, 53; beta screen 80; bizarre objects 13; constant conjunction 35; contact barrier 79; container and contained 26; containment 26; “doodling in sound” 3; dream thoughts x; emotional truth 13; language of achievement 98; no memory or desire or understanding 5, 54, 101, 104; patience and security 26; preconception xiii, 95–96; representation 95–96; senses 3, 44, 103; sensory experience 33, 103; thoughts without a thinker viii, 101; truth 1

bizarre objects 13 black hole 80, 85 blank moments 84 blank screen 80 Borgogno, F. 64, 113 Botella, C. xii Cassidy, J. 67 center of gravity xi, xiv, 50, 52, 54–55, 60 communication: elemental communication xvi, 42; primitive affective communication 61; somatic communication 43 confusion xi, 6, 11, 13, 21, 57, 74, 79, 88 confusional mental states 32, 63–64, 73–75, 79, 88 contact barrier 57, 79, 80, 105, 118 container and contained 26, 79, 96 constant conjunction 33, 35 corporeal unconscious 34 Damasio, A.R. 3, 16, 97 delusion: of omnipotence 33; of oneness 27, 42, 73 DeMasi, F. x denigration 35–36, 81 differentiation 5, 20, 43, 52, 67, 73–74, 76, 97, 106 difficult to reach 1, 5–6, 30, 33, 39, 50, 52, 54, 61, 63, 69, 80–81, 90 dimensionality: three-dimensional 20; two-dimensional 8, 20, 23, 83 Eaton, J. 26, 53, 96 Eekhoff, J.K 26, 43, 51, 55–56, 68, 81, 90, 91, 103, 105 embodiment 41, 72, 85, 95, 98, 103 emergence 51, 53, 62, 73

Index emotional truth 13 empty silence 103 entanglement 28, 51, 59 equation: adhesive equation 42–43; symbolic equation 4, 31, 95 equilibrium 55, 100 equivalency 52–53, 56, 61 evaporation 63 Ferenczi, S. 36, 40, 49, 63–65, 67, 74–75, 91, 97, 111; atomization 77; gestural communication 31; identification with the aggressor 67, 91; infantile omnipotence 33, 35; introjection 63, 76–77; introjective identification 54; magic signals 31, 35; objectless sensation 31; terrorized by suffering 105 figurability x, 98, 100, 126 floor for experience 26, 53, 55, 105, 115 Freud, S. 1–3, 17, 52, 74, 86, 90, 94, 97–98, 100, 105, 111 Frozen xi, xvi, 34–37, 40, 67, 69–71, 75, 83–84, 91 Gaddini, E. 51, 84 Gallese, V. 16 Green, A. ix, xiii, 15, 18, 20, 28, 62, 66, 80, 87, 97, 100 Grotstein, J. 80, 111 Heimann, P. 5, 111 hypervigilance 79 idealization 35–36, 81 identification 54, 95; adhesive identification 42–43, 100–101, 103; introjective identification 39, 54, 56, 63, 65, 92, 95, 100; perceptual identification 30, 95, 104; projective identification 3, 39, 42, 56, 63, 65, 92, 95, 100 identity: perceptual 26, 100–101, 103–104, 106, 110; thought 26, 74, 100–101 imaginative conjecture 36 impasse 38, 51, 63–64, 66–67, 72–74, 76, 78, 100, 105 indifference 3, 13, 56–57, 60, 80–82, 86, 107 infantile omnipotence 35 infantile trauma xi, 34, 39–40, 63–64, 66–67, 74–78, 91, 103, 107, 110

121

internal object relations 30 introjection 52, 62–63, 74, 76–77 Isaacs, S. 2, 44, 49, 96, 110 Joseph, B. 1, 6–7, 50, 69, 80, 90, 91, 111 Klein, M. 1–3, 17–18, 38, 44, 64, 74, 96, 100, 110–111 Korbivcher, C. F. 20 Lakoff, G. and Johnson, M. 94 language of achievement 98 Laplanche, J. xi Levine, H. viii, xiii, xviii, 39, 96, 98 Lombardi, R. 11 Lopez-Corvo, R. 19, 42 Lutenberg, J. M. 80 Marty, P. ix McDougall, J. 2 McGilchrist, I. 17 Meltzer, D.: adhesion 37, 51; adhesive identification 43, 101; alpha function in reverse 95; autistic and post autistic states 50, 53; dismantling 52, 58, 103; evaporation 77; open or closed space 52, 54; rhythm and musicality of speech 67; suspension 28 memories in feelings xvii, 29, 31, 36, 96, 100 memories in sensorium 29, 38, 95, 99–100, 110 mentalized 16, 64, 97; unmentalized xi, 5, 35, 39, 62, 76, 97, 100, 105 mental void 80, 83 mimicry 6–8, 12–13, 18, 23, 26, 34, 36, 42–43, 48, 50–51, 56, 61, 63–67, 70–71, 73–74, 76–77, 84, 90–91, 105 missing piece 36, 40 Mitrani, J. 32, 50, 62, 64 Money-Kyrle, K. E. 102, 103 narcissism: primary narcissism 13, 52, 74 negative therapeutic reaction 27, 36 objectless sensation 31, 38 object relations: autistic object 20; bad object 19, 20, 27, 97; good object 19, 41, 97; inanimate objects 32, 35; no-object 19, 20, 23, 27, 29, 31, 33, 37, 76; whole object 26 Oelsner, R. 27, 111

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Index

Ogden, T.H. 13, 20, 26–27, 44, 53, 68, 72, 80 Oliner, M. 96, 100 Panksepp, J. 15–16, 21–22, 97 pathological organization 33 Paul, M. ix, 3, 7, 90 perceptual identity see identity position: autistic contiguous position 80; depressive position 4, 51; paranoidschizoid position 4, 70, 80 preconception xiii, 17, 95–96 preverbal trauma 66, 91, 103, 107, 110 projection into the body 4 proximity 19, 26, 34, 50–52, 54, 60–62 psychosomatic 2, 51, 107 Racker, H. 5 Rosenfeld, D. 39 Rosenfeld, H. 66, 74–75, 77 Rycroft, C. 96 Scarfone, D. viii, xiii, 18, 39, 54, 57, 98 Schore, A.N. 16 second skin 80 sensorium x, 29, 38, 94–95, 100, 103, 108, 110

silent transference xi, xv, 30–31, 37, 39, 41 Solms, M. 16, 97 somatic communication 43 somatic counter-transference 42, 44, 47, 67 somatic memories 5 somatic responses 2, 5, 42, 44–45 splitting xvii, 2, 8, 26, 32, 36, 38, 48, 63, 73–74, 77, 92, 95 Steiner, J. 33, 70 suspension 26, 50–51, 53, 58–59, 61, 83, 103 symbol formation 96, 98 Teising, M. 80 thought identity see identity transformations 96 tropic 34 Tustin, F. 8, 19–20, 32–33, 37, 42–43, 50–53, 61–62, 71, 77, 80, 92 unconscious phantasy 2, 16–17, 26, 35, 94, 96, 98, 100 undifferentiation 4, 75 unintegration 38, 99, 112 Winnicott, D.W. 6, 21, 30, 36, 44–45, 52–53, 68, 72–73, 83, 87