The Impossibility of Knowing

Dilemmas of a Psychotherapist

Jackie Gerrard

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781855758247
• eBook ISBN: 9780429921049
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This is a book that assembles and integrates the author's clinical work and thinking over the many years of her working life. Part 1 focuses on patients with specific types of psychopathology and explores particular difficulties in technique and thinking. Part 2 addresses the issues of love, hate, and the erotic. In Part 3, specific challenges to the psychotherapeutic frame are demonstrated in chapters on enactments and on work with an absent patient. Richly illustrated throughout with clinical vignettes, above all, the author stresses the importance of the enquiring mind and the struggle not to "know" but to be ever ready to "not know" and to explore. The book should be of interest to qualified practitioners, to those who are training in psychodynamic or psychoanalytic work, and to anyone who has an interest in psychoanalysis and the "impossibility of knowing".

Part I
Specific Types of Psychopathology

Chapter One
On travelling hopefully: some aspects of the difficulties of working with patients with obsessional thought disorder

“To travel hopefully is a better thing than to arrive and the true success is to labour”

(Stevenson, 1878)

This chapter examines the difficulties for the analyst in working with patients who are heavily defended by obsessional thought patterns and, thus, do not have the psychic freedom desirable for analytical work. Their capacities for fantasy and symbolization are impaired, and they have not been able to approach their therapy as a space for “travelling hopefully”. Patients with obsessional thought disorder are generally recognized to be a particular challenge to the psychoanalyst.

The obsessional patient, because he seems to be powerfully defended against psychotic breakdown, finds it very difficult to play the “analytic game” according to our rule book. That is, he is normally censoring and controlling, in a way that does not allow space for fantasy, symbolization, and, of course, play.

This “space” I have called “travelling hopefully”, and why I have done so will become clearer from the two clinical vignettes below. If these patients cannot fulfil their part in the task of analysis, then, by continuing to try to do my part, am I at best working too hard and at worst reinforcing their passivity and masochism in their object relationships? Through a better understanding of the literature on early damage, particularly with regard to “autistic barriers”, I was helped to modify my technique and expectations.

George

George was twenty-eight years of age when he first consulted me, some years prior to the writing of this paper. He presented principally with what he called a travel phobia. He could not drive anywhere at all with a passenger in the car, and even driving himself short distances gave rise to a good deal of anxiety. His fears behind this “phobia” related directly to the accessibility of a toilet, and, in the event of one not being available, he was terrified that he would lose control, shit himself, and be seen by others as “weird”. He showed a marked lack of spontaneity with me, a strong tendency to be in control, and there was a lack of response to, or interest in, me as a person. I was “The Therapist” to whom he had been referred.

By the second session, it was clear that his thinking was concrete: all was in terms of the known and nothing unknown could be played with, imagined, or fantasized about. George was a man with typical anal characteristics, also confirmed when he brought me his first cheque—typed, handed over in advance of my giving him an account, precise and pedantic.

Early on in our relationship there were some changes; he lost some of his dread of going out and met and stayed with his first serious girlfriend (and, indeed, his first sexual partner). The driving problems somewhat abated in that he began to drive and travel with his girlfriend. However, he was still presenting me with two areas where he felt totally stuck. The first was his job, in which he felt denigrated (as he did by his father), unfulfilled, and unrecognized. The second was his total inability to leave his parental home and consider moving in with his girlfriend. Any efforts on my part to get him to fantasize and play with ideas about moving met with a sheer block. He could not imagine. When he actually travelled he would not set out to an unknown destination without a map, so all would be precisely known in advance. In therapy, there was no travelling hopefully with new thoughts or ideas and, because there was no map available, there could not be a journey.

Thoughts from theory

Fenichel (1945) wrote of the shift of emphasis from acting to thinking: “Thinking is preparation for action. Persons who are afraid of actions increase the preparation… they also prepare constantly for the future and never experience the present” (p. 298).

This patient would seem to have replaced his primary love object (mother) with his house, and is now so fixated on this house as the means to his security and his identity that leaving it brings terror on all fronts. With me, the “labour” that cannot be undertaken is the journey through the labyrinths of his mind, where fantasies with regard to changing jobs and leaving home reside but may not be tampered with. They are all classified as “unknown” and, therefore, untouchable.

In addition to his obsessional personality traits, George suffered from the type of psychosomatic character disorder McDougall refers to in her paper of 1974, “The psychosoma and the psychoanalytic process”.

The ego, instead of detaching itself from external reality, may create another sort of splitting, in which the instinctual body is not hallucinated but denied existence through psychic impoverishment.… The result then may be a super adaptation to external reality, a robot-like adjustment to inner and outer pressure which short-circuits the world of the imaginary. This “pseudo normality” is a widespread character trait. [p. 443]

I was also helped by Miller (1983), and her descriptions of what it is that happens to the infant that leads to the creation of the false self personality:

In obsessional neurosis… the mother’s (or father’s) scornful reactions have been introjected. The mother often reacted with surprise and horror, aversion and disgust, shock and indignation or with fear and panic to the child’s most natural impulses. [p. 109]

This is also discussed by Bacal (1987) in his paper, “Object relations theorists and self-psychology”. He examines the work of some of the British object relations theorists and describes Guntrip’s Central Ego, “which tries to conform to the requirements of the outer world, sacrificing spontaneity and creativity to achieve security” (ibid., p. 89). Bacal, quoting Winnicott, says that the false self… “is completely at a loss when not in a role and when not being appreciated or applauded” (Winnicott, 1960a, p. 150). “Winnicott regards the applause as the acknowledgement of the person’s existence, which the false self cannot otherwise feel” (Bacal, 1987, pp. 92–93).

George frequently felt annihilated by non-recognition, reportedly at work, and, more significantly, within our sessions. Bacal writes of the “highly organised reaction within the self to the failure of self objects” (p. 95).

McDougall (1974) lists several factors observed in seriously ill psychosomatic patients, some of which George displayed: unusual object relationships notably lacking in libidinal affect, an impoverished use of language called “operational thinking”; a damaged capacity for creating fantasy to deal with infantile and present-day anxieties (p. 444). She writes of mothers who allow too much or too little psychic space. George suffered from a mother who failed by being too emotionally distant and, as a consequence, he became over-autoerotic. In other words, he could not depend on her for gratification, but only on himself.

As well as the part played by mothers (McDougall), Freud, in Notes Upon a Case of Obsessional Neurosis (1909d), writes of the father complex as playing a significant part in the founding of an obsessional personality, and, in particular, the fear of castration by the father. George came to me already, to some extent, aware of his fear and hostility towards his father; once in therapy, this became much clearer for him. He had many violent dreams where his father, or father-type figure, was the victim. He also brought a childhood memory of lying in bed trying to hold his tongue down in his mouth, in case his father should come in during the night and lop it off!

Freud (1909d) stresses the domination of compulsion and doubt in obsessionals. George, however, defended against areas of doubt (travelling hopefully) by constantly refusing to enter, either physically or psychologically, the spaces where doubt may occur. His internal situation was so full of doubt that he experienced the wish on my part to get him to fantasize as a threat and an aggressive intrusion into his mind, adding to the doubt with which he already felt burdened.

In Freud’s words, “an obsessive or compulsive thought is one whose function is to represent an act regressively” (ibid., p. 245). For George, thoughts replace action; actions and new thoughts imply doubts (about love and hate, security, identity) and, therefore, cannot be contemplated, and his thoughts need to blot out my thoughts. Continuing analysis of this state of affairs for George only brought about his agreement and helplessness that it is so. To quote from Fenichel, “The fear of any change from the known present condition to a possibly dangerous new state makes patients cling even to their symptoms” (1945, p. 298).

George’s fears grew in leaps and bounds when he thought his girlfriend might accidentally have become pregnant, and we understood that his rage with his parents increased markedly at the time his mother was pregnant with, and subsequently gave birth to, his sister when he was four. There are to be no more babies—a deadening, murderous attitude both to real babies and also to my creative thoughts (see also Britton, 1989).

I also used theories of symbolization and autism to try to understand this patient. Plaut (1966), in his paper, “Reflections on not being able to imagine”, poses the hypothesis that the capacity to form images and use them constructively is dependent on the individual’s ability to trust. Failure in this, which reflects a failure in ego development, “impoverishes life and requires careful transference analysis in order to further the ego’s function to trust, both in relationship and in one’s imagination” (p. 147)

Klein, in her paper, “On symbol formation” (1930), concluded that if symbolization does not occur, the whole development of the ego is arrested. I feel that perhaps it is the other way round, as Plaut suggests, that is, first the ego has to develop to a point where symbolization can occur. Segal differentiates between early symbols (which she calls symbolic equations) and later symbols, with their characteristics of imagination and representation. An example of a symbolic equation is when Klein’s little patient, Dick, sees pencil shavings on the floor and says, “Poor Mrs Klein” (p. 33): to him, the pencil shavings were his therapist. It is the later symbols, those that enable imagining and representation, that are missing in this patient. Segal (1957) connects the “capacity to experience loss” with the ability to make use of symbols freely. “The symbol is used not to deny, but to overcome loss” (p. 395). In the depressive position, if all goes well, the capacity to symbolize is used in order to deal with the earlier unresolved conflicts by symbolizing them. If this does not happen, the conflicts and anxieties of earlier times remain and prevent healthy growth.

Klein’s patient, Dick, is interested in trains, stations, door handles, and the opening and shutting of doors, and Klein felt these “autistic objects” and this autistic behaviour was about the “penetration of his penis into mother” (1930, p. 29). Dick was unable to bring into his fantasy life his sadistic relation to his mother’s body. Here is a recent dream from George’s material that illustrates this.

My house was on fire, but didn’t seem to be too dangerous—nothing was really getting burnt. I went into my parents’ room—they were doing morning-type things (Dad was shaving or reading the paper). The fire was burning above them but not in their room. They knew they would have to leave the house but there was no urgency. Then the scene changed to me and Mum in the breakfast room. I was getting some explosives ready and Mum was encouraging me. I fired them into a broom cupboard. Then I went out of the house with Mum and Dad to get the car out of the garage. However, I remembered I’d left some evidence of the explosives, which the Fire Brigade might find, and so I went back in to get rid of the evidence. They were shaped like Italian bread sticks and called broden.

The fire the patient produced seemed to separate Daddy from Mummy, and then he could show Mummy that he, too, had explosives to fire. If he can fill her tummy with his faeces/penis then she will not have any babies from Daddy, only from him (and he will not have to face his exclusion and separation). Perhaps I am the Fire Brigade, who may find the evidence if he is not careful. George accepted my thoughts about the dream, but offered very little himself in the way of association, though he did confirm that the “broom cupboard” was very much seen as Mummy’s cupboard.

I read with interest Tustin’s book, Autistic Barriers in Neurotic Patients (1986), which started to make some sense for me of aspects of my patients. The fears Tustin describes have been referred to by George at various times in his therapy. These are: falling, being out of control, falling apart, spilling away, losing the thread of continuity which guarantees existence, threat of total annihilation, a state of being “gripped silly” and forgetting (ibid., p. 192)

He struggled against all these fears to keep on going, to maintain an appearance of normality, and to develop perfectionist expectations for himself. The “insufferable catastrophe” in these autistic patients that Tustin describes, and in the autistic part of neurotic patients, is the experience of bodily separateness from mother (ibid., p. 43) The result of this is that patients in encapsulated autistic states lack a sense of self and of individual identity. The primary psychic mishap leads to an obsessional need to feel in control of what happens and may also lead to phobic reactions (ibid., p. 26). This is an accurate description of George.

Tustin finds that autism has been a protection against panic, which seems to increase as the autism diminishes. Tustin also makes a point about safety, which she calls the “rhythm of safety”. This is a derivative creation of the baby’s rhythms and the mother’s rhythms while the child is at the breast.

The hope is for this rhythm of safety to be found in the therapy situation, arising out of a deep, reciprocal relationship. The autistic child’s lack of a sense of safety is due to his feeling that he is not in absolute control of mother’s body (as part of his own). Over and above his lack of control of her body, even less can he control her emotions. Autism is a technique to avoid becoming conscious of the “black hole” of separation, of partings, of endings, and, ultimately, of death.

Peter

Peter was an immature twenty-six-year-old when he consulted me for difficulties in sexual relationships. He described what I felt to be a very ambivalent, dependent relationship with his parents. He was effeminate, though heterosexually inclined, and was terrified yet desirous of an intimate relationship with a girl. He saw himself as undesirable and like a small child. He was highly obsessional, had bedtime rituals (which later abated somewhat), and set his thoughts, as they occurred to him, down on paper (to empty his mind). He would read a book, see a friend, view a programme on television, because his thoughts told him (compulsively) that this should be done. The task could then be ticked off his list. There was no conscious wish or ability to engage in pastimes and enjoy them for themselves. Initially, he used his sessions with me in the same way, for spilling out material that had to be got through. Having “vomited”, he then felt temporary relief. (He used to vomit frequently as a child, running around the room, spilling it out everywhere.)

His mother suffered from a disabling disease and had been confined to a wheelchair since Peter was young. He was the only child. Both parents were overprotective to the point of being stifling. Using McDougall’s model, while George’s mother was too absent and so he became over-autoerotic, Peter’s mother was too present, and so a healthy degree of autoerotism was not allowed to develop (i.e., he did not learn to depend on himself at all but always felt the need of an external object). The consequence of this is that Peter was now over-dependent on others for his sense of self, his security, and, as it felt to him, for his existence itself (see also Chapter Two, “Spaces in between”).

His fears were death, space, and becoming an adult (as well as falling apart, being out of control, forgetting, breakdown, and spilling away). His defences were, outside the sessions, phobic anxiety and compulsions, and within the sessions, exercising control over me and using obsessional thought patterns. Again, the theme arose of not feeling free to “travel” or to contemplate a state of being where “the true success is to labour”. Peter was hell-bent on “getting through” whatever he was engaged in. This might be the material he was bringing to the session, it might be a terrifying journey away from home, or it might just be a day at work. For him, too, there was no sense of enjoyment, no savouring of a chance to wander about, to imagine, or to play with ideas. He tried to control what I did, what I said, and what could be put into him. He censored and heard and felt what he chose to.

In Notes Upon a Case of Obsessional Neurosis, Freud tells us of his patient’s obsession for understanding.

He forced himself to understand the precise meaning of every syllable that was addressed to him, as though he might otherwise be missing some priceless treasure. Accordingly he kept asking: “What was it you said just then?” And after it had been repeated to him, he could not help thinking it had sounded different the first time, so he remained dissatisfied. [1909d, p. 189]

Peter demonstrated the same trait in our sessions. He went over and over what I said until he managed to make it all rubbish and senseless (i.e., destroyed it). However, we also got to the fact that he relentlessly persisted with unde...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• CONTENTS
• ACKNOWLEDGEMENTS AND PERMISSIONS
• ABOUT THE AUTHOR
• INTRODUCTION
• PART I: SPECIFIC TYPES OF PSYCHOPATHOLOGY
• PART II: LOVE, HATE, AND THE EROTIC
• PART III: CHALLENGES TO THE PSYCHOTHERAPEUTIC FRAME
• REFERENCES
• INDEX