Psychosomatics Today

A Psychoanalytic Perspective

Marilia Aisenstein, Elsa Rappoport De Aisemberg, Marilia Aisenstein, Elsa Rappoport De Aisemberg

• Verlag: Routledge
• Jahr: 2022
• ISBN:
  9781000591989
• Auflage: 2
• Thema: Psychology
• Thema: Psychoanalysis

This revised edition of Psychosomatics Today presents a thorough introduction to the different international schools of psychosomatics, written by leading professionals, and includes three new chapters on current practice.

As well as exploring key psychosomatic topics, focusing primarily on the Paris School, the Latin American School, theAmerican school of psychosomatic medicine, and the Kleinian approach to the soma, this revised edition adds a chapter about the German School of Psychosomatics, expands upon allergic object relations, and tackles the contemporary topic of overflow in theory and clinical practice. Spanning a variety of theoretical approaches, the book is illustrated by many clinical case studies which provide an engaging, holistic picture of the field, including adolescent and child therapies.

Psychosomatics Today will be of great interest to psychoanalysts and psychoanalytic psychotherapists in practice and in training, students of psychiatry and psychology, and paediatricians and medical practitioners seeking a fuller understanding of psychosomatics.

1 Overflows in theory and clinical practice¹

Elsa Rappoport de Aisemberg

DOI: 10.4324/9781003216445-2

Introduction

I would like to put forward my ideas about such an interesting and up-to-date subject as that of the overflows in theory and clinical practice.

It is probable that these overflows have always existed; only nowadays, they become an object of our attention by virtue of not only the sociocultural changes that have altered the kinds of the patients’ demand but also the broadening of our understanding to include further regions of the unconscious, which in a recent paper I have termed “The Unconscious today” (Aisemberg, 2015).

In the first place, what does the term overflow mean to us?

All that is not contained within the psychic apparatus, all that lacks representation in the psyche, that is, the pre-psychic quantity. According to Green (2003), what overflows the psyche comes from the id or else from a highly traumatic reality.

The drive

In order to clarify this subject, I will start with the concept of drive, as it was described by Freud in 1915: the drive formed by the representation plus the affect corresponds to the erotic drive and/or the union of both drives (Freud, 1920) that has become sadomasochism. In contrast, there is another description of the drive, also from 1915, which describes it as follows: “lying on the frontier between the mental and the physical” and originating in the inner somatic excitation, which in turn is a product of the internal and external perceptions with the object, excitation that will be translated into the psychic representative of the drive (Freud, 1923), which gives place to the psychoneurotic functioning.

On the other hand, when the quantity of inner somatic excitation between the soma and the psyche fails to achieve mental transformation, it could explain, in my opinion, actual neuroses, such as Freud described in the beginning of his work. We could nowadays consider actual neurosis in the light of Laplanche and Pontalis’s ideas (1968) as the suppression of aggression and the basis for somatic phenomena. In the same vein, Green (1998) suggests that somatizations are the result of the suppression of aggression and constitute, at the same time, an equivalent to foreclosure.

Eros and Thanatos

It seems to me that the unbound, unrepresented quantity is closer to the notion of death drive, which in turn has led me to consider that the essence of Eros is different from that of Thanatos; while Eros is an organized drive, with representation in the psyche, Thanatos is a pre-psychic, disorganized quantity, verging on the limit between the soma and the psyche. The former is connected to the vicissitudes of the psychoneurotic functioning, and the Oedipal field, whereas the latter predominates in non-neurotic functioning and in the field of early traumas and the experience of pain.

At the IPA Congress of 2005, in Rio de Janeiro, I considered, on making reference to the concept of trauma, that the quantity that overwhelms the psychic apparatus, which cannot be bound and disorganizes and disobjectalizes the psyche, constitutes the essence of Thanatos or the destruction drive. And that trauma helps us reflect upon this drive in its masochistic as well as sadistic dimensions; the destruction drive directed both towards the interior and the exterior.

On the other hand, at the IPA Congress of 2007, in Berlin, I added that in my view, the unrepresented, disobjectalized quantity was nearer the death drive, which, blended somehow, would then charge the pre-psychic traces, which would, in turn, cause the demonic repetition (Bolognini, 2006).

Indeed, in Berlin, this notion was well-received, in particular by Cesar Botella (2007), a much-valued colleague. Lately, in addition, I had to comment on a text by José Luis Valls (2014), who, incidentally, is a profound reader of Freud and who expressed similar views when he defined Thanatos as an unrepresented quantity.

Overflows

It is precisely this unbound quantity that overwhelms the psyche and, because of its lack of inscription within, can result in three different outcomes: somatosis, [passage to] the act, or else hallucinations in a non-psychotic person.

These alternatives are similar to the concepts put forward by André Green in his last “will”, the book Key Ideas for Contemporary Psychoanalysis (2003), where he described the mechanisms of psychic short-circuiting: somatizations, acting out, and hallucinatory activity – the latter appearing to be the most directly related with a form of psychic organization (p. 154).

Traumatic traces

My own hypothesis is that this unbound quantity charges the painful, perceptive, traumatic traces, which, as I have pointed out elsewhere (Aisemberg, 2005, 2007, 2008, 2010, 2012, 2015), have not been afforded psychic translation into mnemonic traces and, therefore, cannot give rise to thing-representation.

As I have described in previous papers, these traces constitute the inscription of the experience of pain, which, following Freud’s ideas in the Project (1895), are useless to create psychic tissue because they are the object of splitting and/or discharge processes. Nor is this experience of pain cathected by the “guardian of life masochism”, a concept developed by Benno Rosemberg (1991), which, despite everything, helps with psychic survival.

The site of the traces: the unconscious proper

These traces of early traumas, of lost traumas, to put it in Roussillon’s words (1991), which belong to the non-neurotic field, linger in the unconscious proper, which, as Freud described in Moses and Monotheism (1939), is the unconscious that was never conscious, in contrast to the repressed unconscious that characterizes the psychoneurotic functioning.

My idea of two different unconscious systems is based upon certain Freudian statements from 1933 to 1939. This original unconscious might characterize the id with its roots in the soma, as Freud sketched in Lecture 31, from 1933, where he said this:

It is certainly hard to say to-day how far the drawing is correct. In one respect it is undoubtedly not. The space occupied by the unconscious id ought to have been incomparably greater than that of the ego or the preconscious. I must ask you to correct it in your thoughts.

(p. 78 S.E.)

Later on, in Moses and Monotheism, he claimed this:

The repressed material must be regarded as belonging to the Id and obeys its mechanisms; it differs from it only in respect of its genesis. This differentiation takes place during the early period, while the Ego is developing out of the Id. Then the Ego takes possession of part of the Id and raises it on to the preconscious level; other parts are thus not affected and remain in the Id as the “unconscious” proper.

(p. 155 S.E.)

In this text, he also pointed this out:

The impressions of the early trauma, from which we started, are either not translated into the preconscious or they are soon re-directed into the Id through repression. Their memory- residues are then unconscious and operate from the Id.

(p. 156 S.E.)

The mise en scène

The current triggering event of the previously described process can be a trauma or grief, which results in the mechanisms of psychic short-circuiting mentioned earlier: somatizations, [passage to] the act, or hallucinatory activity.

Interestingly, not only current traumas give rise to quantity “in excess”, to the always difficult-to-process somatic excitation, because these are painful experiences most likely to be split off or evacuated; but also recent mourning, which may be mentally elaborated, at least in part, inevitably has a somatic dimension, as I put forward in my presentation in Prague (Aisemberg, 2013), where I underlined that there is a somatic dimension to the processes of significant object-loss.

Not surprisingly, in the life history of these kinds of patients, we usually find both early and recent traumas, as well as unmourned losses.

I will now attempt to illustrate these ideas with two clinical cases. They are about two middle-aged women, of about fifty, who had consulted with an analyst following their respective doctors’ advice, after having undergone breast cancer surgery, as well as complementary chemotherapy and radiotherapy treatment. The medical circumstances of both women were similar, although naturally, it was their singularity that predominated.

Emma

Emma, a recent patient, was married and had three children: a son, who was schizophrenic, and two girls. Although she had a career, she was devoted to yoga and mystical activities. Intelligent though she was, she also manifested elements of profound distrust and paranoid traits. I found it hard to establish a transference relationship with her, although gradually, I managed to do so. Emma distrusted medical treatments and chemotherapy. Every time she attended the Oncologic Clinic where she was being treated, she made a scene, and her family and friends had to calm her down to convince her to receive treatment.

Her husband used to travel for business twice a week. It should be noted that with his work, he generously supported the whole family, but she used to torture him, creating a scene every time he left and also when he came back. Therefore, I had had to arrange some interviews with her and her husband, as well as others with the whole family, in order to help limit the extent of her overflow. In addition, I had suggested that she take medication, which she, always distrustful, had flatly refused.

We had been working on a three-times-a-week basis, face to face. The predominant feeling in her was that of hatred for having cancer as well as hatred and envy towards her hus...