Minding the Body

The body in psychoanalysis and beyond

Alessandra Lemma

• Publisher: Routledge
• Year: 2014
• Print ISBN: 9780415718592
• eBook ISBN: 9781317637325
• Topic: Psychologie
• Subtopic: Santé mentale en psychologie

Minding the Body: The Body in Psychoanalysis and Beyond outlines the value of a psychoanalytic approach to understanding the body and its vicissitudes and for addressing these in the context of psychoanalytic psychotherapy and psychoanalysis. The chapters cover a broad but esoteric range of subjects that are not often discussed within psychoanalysis such as the function of breast augmentation surgery, the psychic origins of hair, the use made of the analyst's toilet, transsexuality and the connection between dermatological conditions and necrophilic fantasies. The book also reaches 'beyond the couch' to consider the nature of reality television makeover show.

The book is based on the Alessandra Lemma's extensive clinical experience as a psychoanalyst and psychologist working in a range of public and private health care settings with patients for whom the body is the primary presenting problem or who have made unconscious use of the body to communicate their psychic pain. Minding the Body draws on detailed clinical examples that vividly illustrate how the author approaches these clinical presentations in the consulting room and, as such, provides insights to the practicing clinician that will support their attempts at formulating patients' difficulties psychoanalytically and for how to helps such patients. It will be essential reading for psychoanalysts, psychologists, psychiatrists, mental health workers, academics and literary readers interested in the body, sexuality and gender.

1 Envy and the maternal body

The psychodynamics of cosmetic surgery

DOI: 10.4324/9781315758824-2

Across all ages and cultures we can find examples of body modification. The first recorded plastic surgery technique was performed as early as 1000 bc, in India, to replace noses that had been amputated as a form of punishment or had literally been bitten off adulterous Hindu wives by their enraged husbands (Favazza, 1996). The Italian surgeon Gaspare Tagliacozzi is often credited as the father of modern plastic surgery. During the sixteenth century, inspired by the need for plastic reconstructive surgery due to frequent duels and street brawls, Tagliacozzi pioneered the Italian method of nasal reconstruction (Gilman, 1999). The origins of cosmetic surgery are therefore to be found in the ‘covering up’ or repair of violent interactions – a dynamic that I will be suggesting is central for understanding some individuals who seek cosmetic surgery. I wish to emphasize ‘some’ because we must beware generalizations: there are no single psychodynamics that can account for the decision to pursue cosmetic surgery in all cases.

In this chapter I will firstly consider cosmetic surgery broadly, but I will focus the clinical example on a patient who sought breast augmentation specifically, because it is not only the most common surgery, but also because it illustrates very clearly some of the dynamics around envy and grievance that, I am suggesting, fuel the pursuit of surgery in some patients, especially those seeking breast augmentation.

My approach here is psychoanalytic and focuses on intrapsychic variables but, of course, the subjective experience of one’s body develops in a given family, in a given culture, and at a particular point in time, that is, the individual body is always also a social body and, importantly, it is a gendered body. The experience of being in a female body will differ from the experience of being in a male body, and this, in turn, will be coloured not only by internal world dynamics, but also by the prevailing cultural projections into the respective female or male body. This is a vitally important dimension of an individual’s experience of being-in-a-body, and one that has been eloquently articulated by many authors (see, for example, Cixous, 1976; Grosz, 1990; Frosh, 1994; Orbach, 2009). It is indeed impossible to think about the body outside of the cultural, social and political discourses that frame all of our lives, and that exert more or less pressure on us, in particular on our pursuit of a desirable appearance. But in this chapter I am primarily concerned with the internalized object relationships that drive the pursuit of cosmetic surgery in some patients and consequently I will not be addressing the contribution of sociocultural factors.¹

A cross-cultural overview makes it clear nevertheless that a variety of body modification practices have now entered the mainstream in both Western and non-Western cultures: not only cosmetic surgery and procedures, but also tattooing, piercing and scarification (Pitts-Taylor, 2003, 2007; Lemma, 2010). Their widespread use, at the very least, suggests a degree of caution in assuming pathology too readily in those individuals who avail themselves of such practices. After all, we all modify our bodies if only through clothes, make up, hair dye, orthodontics or contact lenses. Body modification per se is thus not the province of a group of people who are very different to the rest of ‘us’. But body modification can acquire a more compelling quality and its pursuit may then function as a way of holding the self together.

Cosmetic surgery today: some facts and research findings

As analysts we should be concerned by the staggering increase in people availing themselves of cosmetic procedures. All over the world (i.e. not just in Western cultures) cosmetic surgeons now yield their scalpels to reveal so-called ‘new’ bodies. The trend to relate to the body as a ‘project’ (Giddens, 1991) has fuelled the global beauty business that is growing rapidly and continues to thrive even in times of economic recession. In 2012 board certified doctors in the United States performed over ten million cosmetic surgical and nonsurgical procedures.² Such procedures increased more than 3 per cent in 2012. Surgery accounted for 17 per cent of all procedures performed, representing 61 per cent of total patient expenditures. In the UK a total of 43,172 surgical procedures were carried out in 2012 according to the British Association of Aesthetic Plastic Surgeons (BAAPS), an increase of 0.2 per cent on the previous year.³ In both countries the most frequently performed surgical procedure was breast augmentation, followed by liposuction, abdominoplasty, eyelid surgery and rhinoplasty. Recent market research suggests that the proportion of young people in particular who would consider having cosmetic surgery has risen sharply, reporting that young people are now less accepting of bodily ‘faults’ and that 35 per cent of young women would have breast implants if they could afford to do so (Mintel, 2010).

On the whole the research literature in this area is somewhat ambiguous. Most interview-based studies report evidence of psychopathology in patients undergoing cosmetic surgery, though this is not reliably the case when using standardized psychometric measures (Sarwer et al., 1998). Studies looking at the prevalence rate of mental health problems in those requesting surgery nevertheless suggest a higher percentage (19%) than that found in other surgery patients (4%) (Sarwer et al., 2004). The rate of patients with Body Dysmorphic Disorder (BDD), which one might expect to be high in this population, has been reported as varying between 9 and 53 per cent – this variability most likely resulting from the use of different measures (Ercolani et al., 1999; Phillips et al., 2000; Aouizerate et al., 2003). What is clear, however, is that there is a greater representation of patients with BDD amongst cosmetic surgery patients than in the general population, where the rate of BDD is 1–2 per cent. Requests for unusual facial cosmetic changes, for example, involving bone contouring, bone grafting or cheek and chin implants (when the face is felt to be too wide or too thin), are typically associated with a significant impairment in psychological functioning (Edgerton et al., 1990). Significantly, and in keeping with what we would predict psychoanalytically, relationship difficulties are associated with the contemplation of, and the decision to pursue, cosmetic surgery. Swami and Mammadova (2012) identified in their study that those women in more unhappy relationships were more likely to consider it.

The maternal landscape

Psychological research findings are relevant in so far as they confirm from a more systematic perspective based on large samples that the pursuit of cosmetic surgery cannot be reduced to a primarily sociocultural phenomenon but speaks instead of relational difficulties. As such it calls forth a fine-tuned understanding of internalized object relationships and how these impact on the individual’s capacity to relate to others. More specifically it requires an understanding of the baby’s relationship to the first body he interacts with – that of the mother.

Our sense of who we are is founded on the loss of the mother. A fundamental component of ‘who I am’ is inevitably ‘a person whose mother is gone’ since at birth the self is exposed to its first loss – the loss of residence inside the mother’s body. The fact of separateness, and loss, is an important dimension of subjectivity, and it is intimately linked to the experience of envy: when dependency and loss cannot be borne envy can dominate the psychic landscape. In some of the individuals who turn to the modification of the body for a solution to psychic pain, we can observe how this serves the function of bypassing the experience of being given to, of being dependent in any way on the other.

I have come to understand that the more compulsive and extreme forms of body modification reflect a difficulty in integrating this most basic fact of life: we cannot give birth to ourselves. This ‘truth’ is felt nowhere more acutely than in our bodies. The body is testament to our interrelatedness. The shared corporeality of the mother and baby, from which we all have to emerge, is the embodied version of psychic dependency. The emergence out of this shared physical space is never absolute, however, because the body is indelibly inscribed with the imprint of the (m)other. When the fact of our dependency on others cannot be integrated into our sense of who we are, the subjective experience of the body is compromised.

Both mother and baby have to manage their way through the anxieties generated by dependence and separation. This is difficult enough when all is progressing relatively smoothly in the mother–baby dyad, but when there are complications in this relationship, psychic processes may be perverted. Instead of an experience of dependent receptivity to the object, there may be envy of, and triumph over, the object.

Placing envy at the epicentre of our emotional life, Klein’s understanding of the baby’s early experience also placed the maternal body centre stage as the first site of the baby’s most intense psychical activity. Several of her papers underline the baby’s primordial relationship to the maternal body. The baby then appears to structure a world of meaning around it, especially through experiences of gratification and frustration, not only at the breast, but through the sensory exchanges that characterize the earliest exchanges. The experiences of the mother’s body and of the baby’s own body are, in Klein’s view, thus inextricably linked.

Klein proposed that the mother’s body houses her gratifying possessions, signified by the internal contents of faeces, babies and an incorporated penis. She suggested that the most primitive prototype of envy is envy of the physical possibilities of the other’s body felt to be denied to the self: envy of the breast’s ability to nourish is followed by envy of the maternal capacity to derive sexual pleasure from the father’s penis and the ability to procreate.

The baby’s relationship to the mother’s body could therefore be said to be acquisitive. This is intensified by the epistemophilic instinct – the baby’s urge to discover and conquer the internal territory of the mother’s body. The early Kleinian baby is thus presented as driven by its bodily needs and oral impulses to obtain from the mother the sustenance and prized goods that she, the mother, is seen to possess, quite concretely, in her body.

Although both boys and girls envy and covet the mother’s body, and its possessions, there is an experiential difference between the sexes: the girl can take comfort in her knowledge that, one day, she will attain the mother’s female attributes, but the boy has to accept that his wish to procreate like his mother is doomed to fail. The girl’s narcissistic mortification appears, at first glance, to be less harsh than the boy’s, and yet both boys and girls are faced with the physical impossibility of giving life. In this sense they both have to bear their relative impotence, and must share the realization that they cannot give birth to themselves. The body is ‘given’ to the child. We will return to this point shortly.

One way to manage the painful gap between self and other is through identification – a process that has been invariably disturbed in the patients I am describing. In his paper, On Narcissism, Freud (1914) reminded us that: ‘What man projects before him as his ideal is the substitute for the lost narcissism of his childhood’ (Freud, 1914: 94). The vicissitudes of identification are such that the fate of the idealized other can be uncertain depending on the self ’s capacity to grant the other its separateness and autonomy. A healthy identification is inspired, as it were, by the perceived ideal form of the other, but it is not equated with it. Rather it involves ‘forming an imaginary alignment’ (Silverman, 1996: 71) in our minds, acknowledging its source (the object of identification), and then making it our own. For example, a young woman with profound anxiety about her appearance came for her session with me one day dressed in exactly the same dress I had worn the previous week. Some years later, when the therapy ended and she had made considerable progress, she reflected on this phase of the therapy and observed: ‘Now I would never do that and yet I feel that I do dress a bit like you.’ It was her capacity to draw a clear distinction between ‘a bit like you’ and her early projection of herself into my body such that she had to ‘be me’, that evidenced the change that had taken place.

This brings us to the important question of identification – a process that has been invariably disturbed in the patients I am describing. The problem is well illustrated in the ever-popular TV ‘makeover’ shows. Here, we can observe how these shows support the aim to become the ideal, and not simply to strive to be like it, as we would expect if a more ordinary identificatory process were at work. The unconscious psychological mechanism deployed by this programme format is what Resnik (2005) refers to as ‘physical transvestism’: the self acquires another person’s bodily shape and character, dressing in someone else’s clothing, imitating their gestures and looks (as in the shows that invite participants to select their surgery according to the look of a particular ‘star’). Imitative identifications of this kind may conceal deep feelings of envy because they are an appropriation of the other through imitation. As Gaddini (1969) observed, imitation precedes identification and takes place primarily through vision. Such imitations are phantasies of being or becoming the object through modification of one’s own body. But there is an important difference between the object one would like to be and the object one would like to possess. The latter, according to Gaddini, bears the hallmark of envy.

Those who yearn to be the ideal apprehend the futility of their efforts through the dystopia of the fragmented body, not infrequent in the dreams of body dysmorphic patients, for example, attesting to their struggle to integrate the body into their image of themselves. Dream images of distorted, attacked, cut up bodies lay bare the envy that is felt towards those whose imagined bodily integrity and beauty is but a sore reminder of their felt insufficiency. Analysis reveals how these attacks are unconsciously aimed at a bountiful, but unyielding maternal body and what it stands for in the unconscious. For these patients the object is perceived to possess the wholeness or unity of which the self feels deprived. This has been a striking feature in my work with several women who underwent cosmetic surgery and who, through the surgery, appropriated something ‘better’ (e.g. the bigger breast...

Table of contents

• Cover Page
• Half-Title Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Foreword by Donald Campbell
• Acknowledgements
• Introduction: when the body speaks
• 1 Envy and the maternal body: the psychodynamics of cosmetic surgery
• 2 Whose skin is it anyway? Some reflections on the psychic function of necrophilic fantasies
• 3 An order of pure decision: growing up in a virtual world and the adolescent’s experience of being-in-a-body
• 4 Present without past: the disruption of temporal integration in a case of adolescent transsexuality
• 5 The body one has and the body one is: the transsexual’s need to be seen
• 6 Trauma and the body: a psychoanalytic reading of Almodovar’s The Skin I Live In
• 7 The body of the analyst and the analytic setting: reflections on the embodied setting and the symbiotic transference
• 8 Rapunzel revisited: untangling the unconscious meaning of hair
• 9 Off the couch, into the toilet: exploring the psychic uses of the analyst’s toilet
• 10 Entrepreneurs of the self: some psychoanalytic reflections on the psychic and social functions of reality TV makeover shows
• References
• Index