Applying Psychoanalysis in Medical Care

Harvey Schwartz

• Publisher: Routledge
• Year: 2021
• Print ISBN:
  9780367765934
• eBook ISBN:
  9781000520095
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

Applying Psychoanalysis in Medical Care describes the many ways that analysts interact with the medical world and make meaningful contributions to the care of a variety of patients.

Clinicians with a deep psychoanalytic understanding of our vulnerabilities, fears and hopes are well suited to participate in the care of our body. This book brings together contributions from caregivers who have dedicated themselves to deeply knowing their patients, from prenatal care, pediatrics, oncology, and palliative care. The chapters are rich with moving clinical vignettes that demonstrate both the power and gracefulness of dynamic listening and insight.

This book will be valuable reading for psychoanalysts as well as practitioners and students in medicine, psychology, and the social work disciplines.

Chapter 1

An incentive to use psychoanalytic psychosomatics in everyday medicine

Joachim Küchenhoff

DOI: 10.4324/9781003167679-2

Introduction

Ever so often, it has been heralded that by initiating biological therapies all psychological dimensions can be left out and forgotten. The detection of Helicobacter is a good example: as a consequence, virtually all clinical research on the psychodynamics of gastric ulcers which included methodologically impeccable empirical research (Weiner 1992) have been discarded. So searching the internet by the key words “gastric ulcer psychosomatics” will produce many results for ulcer, but in nearly all of them “psychosomatics” have been excluded. In line with that finding, an actual Wikipedia article on peptic ulcer states:

While chronic life stress was once believed to be the main cause of ulcers, this is no longer the case. It is, however, still occasionally believed to play a role. This may be due to the well-documented effects of stress on gastric physiology, increasing the risk in those with other causes, such as H. pylori or NSAID use.

(https://en.wikipedia.org/wiki/Peptic_ulcer_disease)

A more actual example would be gastric banding that indeed is effective in weight reduction but leaves the formerly adipose person alone with the effects of an extrinsically achieved change concerning the body image and the regulation of psychic homeostasis (Hsu et al. 1998).

In the domain of psychiatry, so called interventional methods are becoming predominant, like deep brain stimulation (Delaloye and Holtzheimer 2014) or ECT. They are applied as if they could supersede psychological approaches. It is quite normal for everyday psychopharmacology treatment not to monitor their subtler psychological implications below the threshold of established side-effects (e.g. the influence on concentration or on self-awareness and self-confidence).

What George Engel had in mind in the 1950s, to establish a psychosomatic-somatopsychic attitude in medicine, should not be forgotten but be re-introduced using modern psychoanalytic concepts:

Engel viewed the human organism as a psychobiological entity that is constantly open to influencing and being influenced by its environment and the people in it. He rejected the term ‘psychosomatic disease’ since it implies a special class of diseases of psychogenic aetiology, and asserted that the basic task of psychosomatic research is to identify psychosocial factors that alter individual susceptibility to any disease.

(Taylor 2002, p. 455; see also Engel 1967, 1974)

To consider individual susceptibility as an important factor entails to take into account the personality or the subjectivity of the patient. The German pioneer in psychosomatic medicine, Viktor von Weizsäcker, strongly advocated the “introduction of the subject” into medicine (cf. von Weizsäcker 1953, p. 50):

The true potential of psychosomatic medicine, Weizsäcker ventured, lay somewhere else entirely. The new medicine would have to stop considering organic disease/illness purely as an objective event – in the sense of an event that occurs in and as an object – and approach it instead in terms of questions that can only be asked of a subject, namely questions concerning motives, values and aims.

(Greco 2019, p. 111)

If we understand psychosomatic medicine as a medicine that in the sense of Engel or von Weizsäcker includes individual susceptibility or “the subject” in medical treatment, psychosomatic medicine no longer is a specialty that comes as the last resort after having tried everything else, but becomes an attitude within medicine anew.

The introduction of the subject into medicine does not exclude the body or the soma by any means. Soma and psyche cannot be isolated from each other, instead they are closely intertwined in any form of disease. Nevertheless, for heuristic purposes this psyche-soma interaction should be broken down into separable aspects:

First, the psycho-somatic effects: In psychoanalysis, psychic representations can often be traced back to interpersonal or intersubjective experiences; this holds true for many bodily expressions, as well. In clinical terms, the bodily symptom in many psychiatric disorders can often be interpreted and deciphered as a hidden form of addressing the significant other when the verbal interchange is blocked by various intrapsychic mechanisms. Psychoanalytic drive psychology, ego psychology, object relations theory and self psychology have contributed to an understanding of this infralinguistic “body talk”.

Second, the somato-psychic effects that have to be considered in clinical practice. Take the clinical symptom of euphoria so often seen in disseminative encephalomyelitis patients; it is not necessarily a sign of a biological brain alteration but may be attributable to a defense operation in response to the severe and threatening disability. Take the severely anorectic patient as another example; the somatic status eventually leads to a (reversible) brain atrophy and, as a corollary, to many psychological disturbances, like a miscalculation of the body image.

In the beginning, psychosomatic medicine emerged from psychoanalytic sources or situated itself within the scope of psychoanalytic theory and practice. This linkage is no longer obvious. But still, it is worthwhile to have in mind the various models or concepts that have been forged in the heydays of psychoanalytic psychosomatics. These concepts are models that are valid and helpful in clinical practice in medicine. The search for “the” psychosomatic phenomenon or “the” psychosomatic patient has long been abandoned. This does not mean that the psychoanalytic concepts presented throughout the last hundred and more years have to be discarded. On the contrary: they are most valuable as models for the therapist to try to understand his or her psychosomatic patients. They do not allow to explain certain diseases specifically, but they may be useful in the encounter with the suffering individual. I have coined the term “constellative psychosomatics” (Küchenhoff 1994) to account for this epistemological turn in psychosomatics. Psychoanalytic concepts in psychosomatic medicine can be used as tools for the health professionals in the everyday encounter with a given patient.

Psycho-somatic effects

Models of Psychogenic Effects on the Body

Elsewhere I have outlined the most important models still valid in psychoanalytic psychosomatics on the influence of the psyche on bodily disease by using semiotic concepts, (i.e. the science of signs and signification) to classify the “body language” (Küchenhoff 2019). The overview presented here summarizes the models.

Conversion

Conversion signifies the transformation of mental energy into somatic innervation on the basis of a psychic conflict and by incorporation of these neuronal processes in expressive behavior – in such a way that the symptom has expressive content and can be deciphered in terms of body language. In the classical model of conversion hysteria, the drive conflict is oedipal; displacement onto the bodily level follows the pathways of the voluntary motor function and those of the senses; the outcome can be deciphered as a compromise-based enactment of the defense against oedipal wishes.

Sigmund Freud presented the first clinical and scientific account of a psychosomatic correlation in the model of conversion, which was, as we know, very successful in elucidating the causation of hysterical or hysteriform disorders. After considerable reflection, Freud remained totally within the province of psychology. This self-imposed limitation had consequences: the particular significance of psychoanalytic psychosomatics was initially to insist on establishing distinctions between the mental mechanisms contributing to the understanding of the psychosomatic transition, and this remains true to this day.

Affect Equivalents

Not every symptom is formed by conversion. Freud himself does not that all psychogenic body pathology is attributable to symbolization. (Freud and Breuer 1895, p. 179). The symptom then is not a symbol of a conflict, it does not represent it, but is merely an indication of it, assuming an indexical rather than a symbolic function. The index (forefinger or index finger) points to the designated object as does a physical forefinger to a physical object; it is a sign in the sense of an indication, a pointer; but there is no connection of content between the sign and what it designates. Freud calls this “conversion through simultaneity” (ibid., p. 178).

The realization of the indexical function of bodily symptoms is implicit in some important concepts of psychosomatic theory. One of these is the model of affect equivalents or affect correlates attributable to the psychoanalytic pioneer Otto Fenichel, a model applicable principally to somatoform disorders. We normally feel our emotional reactions as an integrated whole; emotions are experienced close to the body – that is, they are associated with bodily states. Now according to the model of affect equivalents, in a somatoform disorder disturbing mental events do not elicit integrated affective reactions. The functional affective reaction is preserved, while the mental ideas are repressed (Fenichel 1945). The sufferer may notice that “something is wrong”; the bodily symptoms can be deciphered as an indication of a psychic disturbance, but not as the condensed representation of a psychic conflict.

Alexithymia

In the early days of psychoanalytic psychosomatics, the conversion model was uncritically expanded. The symbolic interpretation of bodily processes increased beyond all limits, thus for a long time impairing the credibility of psychoanalytic psychosomatics. Freud himself countered this risk by contrasting the model of the actual neurosis with that of conversion. The former is not a psychoneurosis – that is to say, the psychic conflict is not processed and elaborated on the mental level – but arises in the immediate and present situation of a damming up of drives that cannot be relieved by a “specific or adequate action” (Freud and Breuer 1895, p. 108), so that the energy finds “abnormal employment” (ibid.) – namely, for the production of bodily symptoms such as vertigo or meaningless anxieties. Hence the paradigm of actual neurosis is characterized by the short-circuiting of the level of psychic representation and processing and the direct transformation of the mental conflict into bodily symptoms. This model of a somatic reaction due to an incapacity for psychic representation of experiences subsequently led to the model of alexithymia. The manifest inability of psychosomatic patients to describe their images of self and others in the clinical situation with appropriate affects and in differentiated form, their “disaffectation” (McDougall 1978) and norm-oriented, de-individualized narratives, suggest a need to investigate structural pathologies and ego restrictions in these patients. Nemiah and Sifneos (1970a, 1970b) termed the poverty of expression of affects “alexithymia,” while Pierre Marty (1976) focused on exclusively technical and rational thinking (pensée opératoire), in which patients describe only external action situations, but not subjective attitudes and emotional impacts.

The alexithymia model suggests a deficit of representation in somatizing patients. The symptom assumes neither a symbolic nor an indexical function, but is meaningless and merely betokens a void in the context of the capacity for mental processing. However, the conclusion that a biological deficit underlies the alexithymic form of spoken communication is ultimately untenable. Alexithymic pathology can also be understood as a defensive process, albeit an archaic one. In this model the incapacity for representation is attributable to a destruction of representation, which is in turn always a psychic action and not a deficit.

The Body as a Locus for Enacting Relationships

Object-relations theory permits the investigation of unconscious ideas of the object; this is particularly fruitful where images of self and object are on the one hand modified and on the other transferred (e.g. projected). In severe personality disorders, such as those of the borderline type, ideas of self and object are split into dichotomized entities mostly in opposition to each other. In this way a threatening, confusing world of relationships is simplified and made readily comprehensible; polar black-and-white images replace complex differentiation of ideas of the self and graduated conceptions of other people. Since properties (e.g. good and bad ones) are thus no longer mixed together, good relationships that would otherwise be endangered by the dominance of destructive phantasies are preserved. The relevant point in psychosomatics is that the split-off images of self and others may be projected onto the body. A dialogue in the body then arises: a part of the body or the whole body is objectalized (treated as an object), and this part takes on properties of the object in the patient’s phantasy. This projection onto the body is particularly significant in the dynamics of two pathologies – namely, hypochondria and self-harm.

Bodily Symptoms and Cohesion of the Self

Both hypochondria and self-harming behavior can also be seen as examples of the importance of the approach of self psychology to the understanding of bodily symptoms. The heightened concentration of attention on the body or bodily symptoms serves to enhance the experience of the body, and with it that of the self or ego, which is after all initially a bodily experience. In this way a reinforced sense of self can arise via the detour of increased cathexis of the subject’s own body. This is relevant to all forms of psychopathology involving a threat to the sense of self. In patients suffering from diffusion of identity, as is typical of borderlines, the orientation (e.g. in hypochondria) to their body may constitute an attempt to regain cohesion of the self. The increased concentration of attention on the body intensifies the subject’s experience of himself. In patients whose identity is under threat, a process of self-healing can be discerned in, for example, the formation of hypochondriacal symptoms: the looming fragmentation of the subject’s self-image can be countered by hypercathexis of his body.

The Models’ Practical Usefulness

The models presented above might be interesting for the specialized psychoanalyst as a starting point in therapy and for the scholars eager to understand better the mind-body-connectivity. I am deeply convinced that they can be useful for any physician or medical practitioner (MP), like a GP or a specialist for internal medicine, as well.

Acknowledging Psychogenetic Pathogenesis

The MP normally has been educated to think in pathophysiological and biochemical rather than psychological terms. Therefore, he or she tends to regard those phenomena that cannot be explained by ...

Table of contents

• Cover
• Endorsements
• Half Title
• Series Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of contributors
• Series Foreword
• IPA in Health Committee
• Introduction
• 1. An incentive to use psychoanalytic psychosomatics in everyday medicine
• 2. At a Crossroads: The Psychoanalytic Model and the Medical Model
• 3. On Becoming a Parent: When the Psychoanalyst Meets the Front-Line Professionals Involved in the Perinatal Period
• 4. Cruel Fate
• 5. Day Hospital Intensive Care for Patients with Eating Disorders
• 6. Eating Disorders in Childhood and Adolescence: An Interdisciplinary Approach
• 7. Psychoanalysis and Psycho-oncology: How Each Specialty Enriches the Other
• 8. Psychodynamic Contributions to Palliative Care Patients and their Family Members
• 9. How a Lack of Human Connection May Lead to Dehumanization and Addiction
• 10. Psychoanalytic Approaches to the Skin Patient
• 11. The Balint Group: The Arc of the Enduring Bridge between Psychoanalysis and Medicine
• Index