Resonance and Reciprocity

Selected Papers by Dennis Brown

Jason Maratos, Jason Maratos

• Verlag: Routledge
• Jahr: 2013
• ISBN:
  9781134703852
• Auflage: 1
• Thema: Psicología
• Thema: Psicoanálisis

This collection of papers, published between 1976 and 2003, traces the innovative connections which the eminent group analyst Dennis Brown made between medicine and psychoanalysis. They reveal his important insights into how the principles of group analysis can improve our understanding of philosophy and ethics, and trace the development of trans-cultural dimensions of group analysis.

Beginning with Dennis' early work in dermatology, the first section of Resonance and Reciprocity provides a fascinating overview of the insights gained into psychosomatic conditions through the application of psychoanalysis and group analysis. The second section builds on the tenet of group analysis that therapy should change the therapist as well as the client, addressing the changes that can take place in the therapeutic milieu, both in client and provider. The chapter on drowsiness, a modern classic, provides a significant contribution to our understanding of the emotional and physical changes that the therapist experiences during analysis, and its wider implications for our appreciation of how changes in mental and physical states are affected by a person's emotional world. The final section reveals how Dennis Brown extended his interest and his activities beyond the individual, the small and the large group, and studied groups within and across cultures.

This book provides not only a solid understanding of complex analytical notions but also opens the road for future development. It will appeal to students and professionals in psychoanalysis, psychotherapy and group psychotherapy.

Part 1

PSYCHOSOMATICS

Introductory comments

1

LISTENING TO ECZEMA

Deductions and predictions

Introduction

Eczema, like any illness, occurs in people who are in a state of dynamic adaptation to their environment. This environment is really a complex interaction between objective and subjective worlds, outer and inner, present and past. One may argue that we are all in such a state of constant adaptation. Recently we have had hard evidence that illnesses are more likely to develop in times of change, when challenges to the adaptational resources of the individual are increased (Holmes and Rahe 1967; Rahe 1968; Brown 1972). This is true whether the illnesses are psychiatric, physical, or those so-called psychosomatic disorders in which psychological factors are widely held to play a prominent part in the onset and course, such as hypertension, ulcerative colitis, asthma and eczema. Understanding the illness and its role in the adaptational struggles of the patient necessitates an awareness of the patient in these interacting environments, and of why the illness is thus in a sense appropriate, if not ‘ideal’.

The new environment provided by the doctor and his treatment can then be seen as intervening in a way that colludes with the adaptation that incorporates the illness, or – if a psychotherapeutic approach in its broadest sense is intended – strives to modify it (Balint 1957; Balint and Balint 1961). If psychotherapeutic endeavour is to succeed, it is necessary to discern what troubles the patients are attempting to cope with. It requires us to listen to what they are telling us. They might do this directly in words, or else indirectly through mood, posture and gesture, or even merely through the physical disorder itself. Important clues might come from the way we feel in their presence, or after they have gone.

Eczema and its causes

Eczema is a specific inflammatory reaction of the skin, which can be acute, subacute or chronic. It is the commonest such reaction and accounts for over 50 per cent of dermatological practice (Pillsbury et al. 1956). It is probably responsible for the greatest number of rashes presented in general practice, which still account for one in six, or thereabouts, of attendances in such practice, despite the introduction in recent years of powerful steroid ointments and creams (Fry 1972). It is likely that very many cases occur in the general population which are either self-treated or clear spontaneously. In seeking to explain why some cases become chronic or seek the help of general practitioners, and why some are then referred on to dermatologists in a hospital, we need to take into account the various aetiological factors, prominent amongst which are psychological factors.

Eczema is readily recognised by the itching it causes, and by its fairly constant sequence of erythema, vesiculation, weeping and/or scaling; when chronic, lichenification often occurs. Histologically it is characterised by epidermal vesiculation and spongiosis. Clinically, however, it takes many forms, has many causes, and classifications have been based on a mixture of morphology and aetiology. Generally recognised types are: contact dermatitis, atopic eczema (disseminated neurodermatitis, the only form with an important hereditary factor, with coexisting predisposition to asthma, hay fever, and vasomotor rhinitis), seborrhoeic eczema, nummular eczema, lichen simplex (circumscribed neuro-dermatitis), infantile eczema, stasic dermatitis (secondary to peripheral venous disease), and chronic eczematous dermatitis (in which the original cause and pattern have been lost sight of, and various secondary factors play a predominant role). Among the causative factors which have been incriminated in eczema are:

1 External irritants, allergies, trauma, infection and gravitation stasis (as described in all dermatological texts).

2 Constitution – heredity, type of skin, neurophysiological constitution (e.g. Brocq and Jacquet 1891; Becker 1931; Ingram 1933; Schwartz et al. 1947).

3 Childhood experiences – especially in the mother-child relationship in infantile eczema (e.g. Spitz 1951; Williams 1951; Rosenthal 1953; Woodhead 1955; Selesnick and Sperber 1965).

4 Personality vulnerability (e.g. Vidal 1886; Walsh and Kierland 1947; Wittkower and MacKenna 1947; Allerhand et al. 1950; Kepecs and Robin 1950; Wittkower and Edgell 1951; Obermayer et al. 1952; Seitz et al. 1953; Fiske and Obermayer 1954; Cleveland and Fisher 1956; Sainsbury 1960; Brown and Young 1965a, 1965b).

5 Stress in the current life situation (e.g. Klauder 1925; O'Donovan 1927; Blaisdell 1932; Stokes 1932; Brunstig 1936; Finesinger and Greenhill 1942; Lynch et al. 1945; Robertson 1947; Brown 1959a, 1972).

6 Psychiatric illness (e.g. Wilson 1842; Lovett Doust 1952; Fonseca 1963; Herron 1965).

Obviously one or more causes may coexist. As in any problem in medicine, we are dealing with multiple causes, and while it is unlikely that psychological factors can be viewed as sufficient or even necessary for the development of eczema in many cases, it is proposed here that their recognition is of practical as well as of theoretical importance. Psychologically eczema presents a far from uniform picture, though in my experience emotional factors are almost invariably operative in all forms.

Clinical presentation

Eczema patients vary greatly in the overtness of the affective disturbance of which the rash is usually a part or a sole presenting feature. Some are so obviously distressed or disturbed that they are instantly recognisable by the family doctor or dermatologist to whom they are referred. Such cases are often treated by these physicians with tranquillisers or antidepressants, and if they fail to respond are often referred to a psychiatrist. In a previous study (Brown 1967) of 82 cases of eczema referred to the skin department of a London teaching hospital, the author interviewed 73 patients aged 18 to 65 who had had their rash for between six weeks and three years. Particular inquiries were made regarding the presence of new psychological symptoms; i.e. symptoms which were emerging for the first time along with the eczema or during a period preceding it. This was to distinguish between patients with ‘lifelong’ tendencies to experience psychological or psychophysiological symptoms, usually in response to minor stresses, and those with more definite episodes of emotional disturbance; and in order to distinguish between neurotic personality disorders and psychiatric illnesses or relatively clear-cut stress reactions. To do this, criteria were laid down to avoid the risk of wrongly interpreting such symptoms as evidence of an emotional disturbance that was significantly linked with the onset of eczema, rather than a ‘coincidental’ chronic emotional instability. Symptoms were to be counted as signifying neurotic personalities unless they appeared clearly worse from the history, plus either (a) they were complained of spontaneously, or (b) there was definite evidence of affective disturbance at interview. That is, a clear history of emotional disturbance had to be confirmed by the patient's spontaneous behaviour at interview, whether verbal or non-verbal. In distinguishing between psychological and psychophysiological symptoms, irritability and insomnia were counted as psychological unless plausibly attributable to the rash, fatigue was counted as physical. Clearly this was somewhat arbitrary, but seemed to accord with the view of the patients and the popular interpretation of the symptoms. On this basis two-thirds admitted to new psychological symptoms as shown in Table 1.1.

Those complaining spontaneously or admitting to new psychological symptoms on direct inquiry scored significantly high on the Neuroticism scale of the Eysenck Personality Inventory (Eysenck and Eysenck 1964), and were termed Unstable. In contrast the third who denied such symptoms scored significantly low, and were termed Superstable. They preferentially reported psychophysiological symptoms. Table 1.2 shows that, in both groups, psychological or psychophysiological symptoms preceded the onset of eczema in the vast majority. This, and the fact that the mean duration of the eczema in the Unstable and Superstable groups was identical, 11 months, points to the emotional disturbance as a cause or concomitant of the rash, not a result of it as some suggest (including some proponents of psychosomatic ideas, e.g. Leigh 1968).

Table 1.1 Incidence of new psychological symptoms in 73 cases of eczema

Percentage
Complained of spontaneously	37		67
Admitted on direct enquiry only	30
Denied, with signs of emotional disturbance	10		33
Denied, no signs of emotional disturbance	15
Denied, no signs, but had them earlier in course of eczema	8

Table 1.2 Time relation of new psychological/psychophysiological symptoms to onset of eczema

Percentage
Symptoms preceded eczema by one year or more	36		61^*
Symptoms preceded eczema by up to one year	25
Simultaneous	1		39
Eczema first	16
Not clear	18
Not applicable (no new symptoms)	4

^* 76% of those with new psychological symptoms.
25% of those with new psychophysiological symptoms.

The commonest symptoms were a mixture of anxiety and depression, and precipitating stresses tended to activate conflicts about aggression and dependence (Brown 1972). Further experience has confirmed this.

Description of a case

Mrs A, aged 40, falls into category 2. She presented herself as physically ill when seen at the outpatient department. She had had a rash on her hands and forearms for four months, spreading in the last month on to her face and neck. She had been subject to abdominal pain for four years, to migraine from her school days, and for six years in her twenties she had asthma. She gave a zero score on Sections M-R of the Cornell Medical Index dealing with psychological symptoms (Brodman et al. 1949) but scored 12 on a health questionnaire devised to detect the physical concomitants of emotional disturbance (Brown 1970).

Mrs A was a strikingly handsome and intelligent woman, self-driving and given to good works. After talking readily about her physical complaints, direct inquiry led to admission that she was having difficulty falling asleep because of worrying, that she had been more irritable over the last two years, had found it difficult to relax for about a year, and in recent months had felt suddenly tired in the evenings. Finally she admitted to worrying about her health since her mother-in-law developed abdominal cancer and died four years ago, after which her husband developed epilepsy. She realised how important it was for her to remain well, but worried, when her abdominal pains started, lest she had cancer too. This abated after a ‘talking-to’ by the family doctor, but was replaced by a fear of something happening to her husband. When asked how her spirits were she denied depression, insisting how much she enjoyed her many activities. However, if she sees her husband overworking she gets tense and ‘sort of angry with him for not being more cautious’. But at times her husband had commented on her appearance and said ‘What's the matter?’ She would reply ‘Oh, nothing!’ She thus showed a good deal of suppression, repression and denial of anxiety, anger and guilt.

Knowledge of her background throws a lot of light on her anxieties and defences. She did not remember herself as a nervous child, but at three and a half years of age she was in hospital for three weeks for a broken arm, and parental discord marred her early years, culminating in a divorce when she was 13. An older brother was awarded to mother, whilst she and a younger brother went with father, but were passed on to be cared for by different aunts. Mrs A seems to have felt particularly responsible for her parents’ discord, and still plays the role of pacifier between them. Apart from migraine, a tendency to worry, and a special sensitivity to disappointments, she had been fairly well adjusted, but from the age of 21, for six years, she had a possibly asthmatic condition following the loss of her younger brother on a wartime flying mission (the brother would have been about 18 months old at the time when she was away with a broken arm). She did very well at school and work, and reports herself as having been very happily married for 20 years. However, their one child was conceived after ten years of trying, and a Caesarean delivery was necessary, which was followed by a puerperal depressive illness.

Listening in more detail to her account of the last four years we find that she developed abdominal pain about a month before her mother-in-law died of cancer. Mrs A, who had looked after her for a while, feared she had cancer too. The pain has continued on and off since. X-ray showed no organic lesion. After her mother-in-law's death Mrs A became depressed and weepy, in contrast to her husband, who she said ‘took it inwardly’. Four months later he developed epilepsy. Naturally Mrs A was extremely worried about him, and this increased her depression. She felt increasingly unable to cope, and went to see her doctor. Finally, in an attempt to help her, he told her ‘rather severely’ as she says, to pull herself together. With an effort she was able to do this for the sake of her husband and daughter, but continued to be apprehensive about her husband's potential fits. Her abdominal pain and dyspepsia continued intermittently. Mr A's epilepsy led to a rearrangement of their lives. He continued with his professional work, travelling into London from the Home Counties by train, but Mrs A, who had formerly regarded him as a ‘tower of strength’, took on more responsibility and became, among other things, the family chauffeur. Mr A stopped having sexual relations, ostensibly because of the danger of conception, and this caused Mrs A a good deal of sexual frustration at first.

After we had been talking for about half an hour, she suddenly remembered, with a cry of surprise, that something had happened a week or so before the rash had started on her hands and arms four months before. One evening she had not collected her husband as usual from the railway station. He finally arrived several hours late, with broken teeth and a cut head. He had fallen off the bus (not in an epileptic fit as it turned out) and had been taken to the local hospital. It was as though her negligence had realised her greatest fear. Mrs A was diagnosed as having a neurotic personality of anxious obsessional type – sensitive, prone to anxiety and depression, selfdriving with mild obsessional traits of perfectionism and checking. It seemed likely that the origin of these traits lay in her early separation and consequent insecurity, and the fear of her own aggressive impulses, and perhaps death wishes towards, for example, her younger brother. It also seems likely that unconscious hostility towards her husband played a big part in the current emotional disturbance.

Dermatological diagnosis was contact dermatitis due to primula plants which she had kept in the house for the last several months. However, she had previously handled these with impu...