A Framework for the Imaginary

Clinical Explorations in Primitive States of Being

Judith L. Mitrani

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9780367106317
• eBook ISBN:
  9780429910302
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

An extraordinary depiction of one analyst's efforts to receive and respond to the vivid impressions of her patients raw and sometimes even unmentalized experiences as they are highlighted in the transference-countertransference connection. Mitrani attempts to feel, suffer, mentally transform, and, finally, verbally construct for and with the patient possible meanings for those immediate versions of lifes earliest experiences as they are re-enacted in the therapeutic relationship.She uses insights from this therapeutic work to contribute to the metapsychology of British and American object relations as well as to the psychoanalytic theory of technique. In these eleven essays, Dr Mitrani masterfully integrates the work of Klein, Winnicott, Bion and Tustin as she leads us on an expedition through primitive emotional territories. She clears the way toward detecting and understanding the survival function of certain pathological manoeuvres deployed by patients when confronted by unthinkable anxieties. In her vivid accounts of numerous clinical cases, she provides and demonstrates the tools needed to effect a transformation of unmentalized experiences within the context of the therapeutic relationship.

1

Unintegration, Adhesive Identification, and the Psychic Skin: Variations on Some Themes by Esther Bick^*

The failure of [the] containing function of the Skin Ego results in two forms of anxiety. An instinctual excitation that is diffuse, constant, scattered, non-localizable, non-identifiable, unquenchable, results when the psychical topography consists of a kernel without a shell in physical pain or psychical anxiety: he wraps himself in suffering. In the second case, the envelope exists, but its continuity is broken into by holes. This Skin Ego is a colander: thoughts and memories are only with difficulty retained; they leak away.

[Didier Anzieu, The Skin Ego]

Background

Born in Poland in 1901, Esther Bick earned her doctorate in child development in Vienna. Seeking refuge from Nazi persecution in World War II, she immigrated to London where she pursued her analytic training at the London Institute of Psychoanalysis of the British Psycho-Analytical Society. Along with John Bowlby, Bick established the training program at the Tavistock Clinic. She founded the technique of infant observation practiced there to this day (Bick 1964), the same technique that was later adopted as an integral part of the training at the Institute of Psycho-Analysis, London, of the British Psycho-Analytical Society, and one of the cornerstones of the training program at the Psychoanalytic Center of California.

It was Bick’s conviction that learning to become a good observer aids in learning to become a good psychoanalyst. She felt strongly that throughout the yearlong observation each candidate-observer comes to learn how a baby grows and becomes increasingly interested in the complexity of his development. She noted that this increasingly interested observer reinforces the mother’s own interest in her baby and encourages her to value her own capacity to understand him and to tend to his needs. Similarly, Bick also believed that the analyst, observing the patient, comes to learn how he has arrived at this point in his life. It seemed to her that the analyst who could sustain an appreciative interest in the complexity of that individual’s development reinforced in the analysand the healthier and more mature aspects of his personality and the inclination to value his own capacity to comprehend experience and to minister to his own needs.

Although Bick underwent her training analysis with Michael Balint, she was later analyzed by Melanie Klein and is remembered by many as a devout follower and a respected teacher of Kleinian theory and technique. Her own work, however, observing infants and treating and supervising the treatments of autistic children and severely disturbed adults, led to the development of some new models for understanding patients in analysis. These models of understanding form what can now be considered the basis for an essential extension of classical Kleinian thinking.

In her published work Bick (1964, 1968, 1986) delineated an extremely primitive type of “narcissistic identification” which developmentally precedes that which is implied in Klein’s theory of projective identification (M. Klein 1946). Bick’s notion of this very early form of identification subsequently provoked many workers to revise their psychoanalytic thinking by inspiring them to begin charting yet another dimension of object relations that had previously been little explored. This is a dimension in which the centrality of the process of “getting into” is subordinated to the primacy of “getting in contact with” the object: a very archaic process that always appears to be linked to an object of psychic reality equivalent to the skin (Etchegoyen 1991).

After a review of Bick’s work, I will touch upon the evolution and refinement of the concepts she introduced as they later appeared in the work of Donald Meltzer (1975) and his co-workers (Meltzer et al. 1975) and subsequently were extended by Frances Tustin (1972, 1980, 1981, 1983, 1984b, 1986, 1990) and others. As I trace these later efforts, I will also elaborate on the notion of adhesive pseudo-object relations (J. Mitrani 1994a), a term I have coined for the purpose of communicating about an archaic mode of object relations, more elemental than that which has been so well defined and documented by Melanie Klein and her exponents.

The Work of Esther Bick

In her 1968 paper Bick wrote about certain behaviors that caught her attention time and again in those infants she—as well as her colleagues and students—observed. Such observations led Bick to hypothesize that very young babies may initially experience the absence of boundaries sufficiently capable of holding together their mental and emotional contents, not yet distinguishable or differentiated from bodily contents. In her compact communication Bick proposed the notion of a “psychic skin” that ideally serves to passively bind together the experiences or parts of the nascent self on their way toward integration into a cohesive sense of self.

She described this psychic skin as a projection of or corresponding to the bodily skin, and she proposed that it is “dependent initially on the introjection of an external object, experienced as capable of fulfilling this function” (Bick 1968, p. 484).

The external object Bick refers to here is a complex, undifferentiated object composed of experiences of continuous interaction between a physically and emotionally “holding” and mentally “containing” mother, and the surface of the infant’s body as a sensory organ. This notion is one that Freud (1923) alluded to when he suggested that “the ego is first and foremost a bodily ego; it is not merely a surface entity, but is itself the projection of a surface” (p. 26).

Bick (1968) further hypothesized that “later, identification with this [psychic skin] function of the object supersedes the unintegrated state and gives rise to the [ph]antasy¹ of internal and external space” (p. 484). She forwarded the idea that this phantasy of space is the essential basis for the normal adaptive splitting and projection necessary to the processes of idealization and separation described by Klein. However, Bick warned that” ... until the containing function has been introjected, the concept of a space within the self cannot arise ... [and] construction of an [internal containing] object ... [will be] impaired” (p. 484).

Along with her description of the primary tendency to relate to objects in a two-dimensional way preceding the development of a sense of internal space, Bick made a crucial distinction between unintegration as a helpless, passive state of maximal dependency and the active defensive maneuvers of splitting and disintegration. She explicitly associated unintegration with the earliest catastrophic anxieties, while correlating disintegration with later persecutory and depressive anxieties. Along these lines, she stated that

the need for a containing object would seem in the infantile unintegrated state to produce a frantic search for an object—a light, a voice, a smell, or other sensual object—which can hold the attention and thereby be experienced, momentarily at least, as holding the parts of the personality together. [p. 484]

She continues to explain that

the optimal object is the nipple in the mouth, together with the holding and talking and familiar smelling mother ... experienced concretely as a skin. Disturbance in the primal skin function can lead to development of a “second skin” formation through which dependence on the object is replaced by a pseudo-independence. [p. 484]

In a further clarification of the subject, Bick (1986) additionally noted that these “secondary skin devices may arise in collaboration with peculiarities of the maternal care such as muscular or vocal methods” (p. 292). Stated another way, these psychic skin substitutes may be patterned after perceived sensual characteristics of the mother or other primary caretakers. Bick also suggested that such primeval defenses come under the heading of “second skin formations” and are originally “non-mental” phenomena constructed to protect the very young infant against what she described as

the catastrophic anxiety of falling-into-space, and the deadend [which] haunts every demand for change and which engenders a deep conservatism and a demand for sameness, stability and support from the outside world. [p. 299]

Although her published papers are brief and few in number, in them Bick provides us with many excellent clinical examples to illustrate her ideas. For example, she vividly describes one infant, Baby Alice, who was moved to develop a premature muscular type of second skin in compliance with the needs of an insecure mother who early on requires proof of her infant’s vitality and who later, out of the necessity of her situation, pushes her baby toward pseudo-independence. She also reports her treatment of Mary, a schizophrenic 3-year-old, who spoke of herself as a “sack of potatoes,” in constant peril of spilling out due to the holes that she picked in her sack. One adult patient was observed in oscillation between an experience of herself as a “sack of apples,” in which she felt easily bruised and threatened with catastrophe, and “the hippopotamus,” who was aggressive, tyrannical, and stubborn. And Jill, a 5-year-old child, conveyed the sense of how precariously she felt held together, insisting that her clothes be firmly fastened and her shoes tightly laced during the absence of her therapist. I will here add an example from my own practice.

Carla

When Carla was still a fairly young child, her mother died of respiratory failure in the child’s lap on the way to the emergency room. The mother’s death occurred only a short time after she, Carla, and four younger siblings had been abandoned by a philandering father. Carla presented herself in analysis, and to the world, as a hard, sassy, streetwise “chick,” whose toughness served as a second skin resembling the tight leather clothing she often wore. On the surface, the form of her defense might well have been traced to an idealized image of the father’s erect penis and the paternal function of protection. In the second year of her analysis, however, a fragile baby part of Carla began to emerge, crying out to be born and to be allowed contact with what she seemed at times to experience as the caring presence of a mother-analyst.

In one session Carla began to cry as we had not heard her cry before, a cry that penetrated me deeply. I felt that the depth of Carla’s cries corresponded to the strata from which they emanated, as if they came up from some very deeply buried experience in infancy. When I told her as much, she said, “I feel like something terrible wants out of me. I can’t let myself breathe. I don’t want it to come out. I’m afraid I’ll never stop crying.” She seemed to be communicating about that terrible feeling that she would spill out and be gone, unable to collect herself at the end of the hour as she experienced the loss of some very basic sense of security: a loss that would certainly have originated even earlier than the memorable events of either her father’s abandonment or her mother’s death.

Months later we were to come closer to understanding some of the most primitive origins of Carla’s fear of being spilled and gone, as well as the template for the development of her leathery protection against the threat of such dissipation. Both this anxiety and the defense against it appeared to be connected to a primary experience of the mother.

In the third year of her analysis, I noticed that almost invariably when Carla returned from the weekend breaks she would at first greet my arrival at the waiting room door with a warm and enthusiastic smile. She would then scan my face quite intensely before passing through the doorway on the way to my consulting room. It often occurred to me that she was perhaps looking for an expression on my face that might reflect her own, which nearly always ranged somewhere from mild pleasure to sheer joy at the sight of me.

By the time she reached the couch, however, this enthusiasm for her analysis and for me would dissolve into a tough, leathery air of indifference, if not downright disgust, at having to submit to my requirement that she return for yet another hour and another week. When I turned our attention to this transformation one day, suggesting that it might somehow be connected to feelings and fantasies provoked by what she seemed to see in my face when I came to the door, she said with despair, “You always look the same.”

Carla then went on to tell me that she had been happy that day when she arrived in plenty of time to use the restroom. However, when she found that it was “all locked up,” she was left feeling as if she might burst. Then, as if to deny the importance of her disappointment, she added resolutely that it was “really O.K.”

At that moment it seemed to me that the story of the locked restroom contained clues to the meaning of her radical transformation. She had indeed been filled to bursting with emotion, which she could barely hold inside when she arrived. But she was soon disappointed, feeling me to be emotionally shutting her out as she searched my face for signs of joy as evidence that I might be open to the overflow of her excitement and therefore able to provide her with some relief from these as well as other overwhelming feelings.

I told Carla that it seemed to me that she had been hoping that my face would reflect the enthusiasm with which she had come to see me that day, especially when she felt that it was not too late for her to get some relief, but that her hopes had somehow turned rapidly to disillusionment. She nodded in agreement and I continued, telling her that I thought she might be communicating to me about a little-she who was unable to bear that feeling of disillusionment, so that she had consequently resolved to toughen up for fear of bursting open.

Carla replied that she had only hoped I would be as happy to see her as she was to see me. I acknowledged this hope and added that she seemed to need to feel that the overflowing joyous baby-she could be seen and held in my facial expression so that she would not spill away and be lost again. I added that I also thought that today this need was so intense that, when it seemed to her that I could not reflect and reciprocate her joyous feeling for me, she transformed herself to match what must have felt to her like a locked-up, leathery, tough mommy-analyst, this in order to create a sense that she could catch herself by bringing us closer together with no gap in between.

Now crying, Carla told me that as I was speaking she had flashed back on the image of her mother’s face, looking just as it had when Carla, as a very little girl, would watch her mother admiringly at her dressing table. She then told me, for the first time, that her mother had been disfigured in a car accident as a child. As a result, her face had always looked strange, disgusted and remote, with a leathery skin full of scar tissue resulting in a frozen, unchanging expression. Carla admitted that she could never tell if her mother really loved her. It seemed to me that the baby-Carla may never have felt held safely and responsively in her mother’s gaze, as Mother’s unalterable expression would have hindered her ability to reflect her daughter’s joyous states of ecstasy and love.

Carla’s story is an example of a rigidified and therefore pathological second-skin formation. In contrast to this, I would like to give one example of the temporary loss of the psychic skin and the transient development of a second skin made up of muscular and visual sensations. This example is an excerpt taken from records of my own infant observation.

Matthew

During one observation hour, 6-week-old Matthew, upon being undressed for his bath, began to show signs of distress while his clothes were removed as he lay on the changing table, his mother’s attention diverted momentarily to the observer. His response to this gap in maternal attention—as well as the concomitant loss of the sensation of his mother’s close and affectionate handling and the clothing that contained his body, all perhaps felt as a part of his physical as well as psychic skin—was to rigidify his muscles by arching his spine, clen...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Foreword
• Acknowledgements
• Introduction
• Introduction to the Karnac Edition 2008
• 1 Unintegration, Adhesive Identification, and the Psychic Skin: Variations on Some Themes by Esther Bick
• 2 On the Survival Function of Autistic Maneuvers in Adult Patients
• 3 Notes on an Embryonic State of Minds
• 4 On the Survival Function of Pathological Organizations
• 5 To Err Is Human: One Patient’s Emergence from within a Pathological Organization
• 6 The Role of Unmentalized Experience in the Etiology and Treatment of Psychosomatic Asthma
• 7 Examining a Fragment of a Fragment: Freud’s “Dora” Case Revisited
• 8 On Adhesive Pseudo-Object Relations: A Theory
• 9 On Adhesive Pseudo-Object Relations: An Illustration
• 10 Toward an Understanding of Unmentalized Experience
• 11 Deficiency and Envy: Some Factors Impacting the Analytic Mind from Listening to Interpretation
• References
• Credits
• Author Index
• Subject Index