Trauma and Primitive Mental States

An Object Relations Perspective

Judy K. Eekhoff

• Editorial: Routledge
• Año: 2019
• ISBN:
  9780429775871
• Edición: 1
• Categoría: Psychologie
• Categoría: Psychothérapie

Trauma and Primitive Mental States: An Object Relations Perspective offers a clinically based framework through which adult survivors of early childhood trauma can re-engage with painful past events to create meaningful futures for themselves.

The book highlights the use of the body and the mind in working with these early unmentalized and unrepresented states, illustrating the value of finding language that embodies emotions, and working in the here and now of transference and counter-transference. Including a range of examples of how early trauma can thus be re-presented and clinically understood, the book illustrates how patients can discover themselves and leave their repetitive patterns of suffering behind.

Written by a clinician with over 30 years' experience, this will be fascinating reading for psychoanalysts and psychotherapists as well as any mental health professional working with childhood trauma.

Chapter 1
Between body and mind

Transforming physical experience into psychic development in the clinical situation

The realm of the mind is a world of infinite possibilities of meaning from whose formlessness a coherent internal world must be constructed by thought operating on the perception of emotional experiences.

– Donald Meltzer

Bion says that truth is to the mind what food is to the body (Bion, 1965, p. 39). In that respect, it would seem that the work of analysis is to uncover truth and to the best of our ability speak what we uncover. What enables us to find and speak truth is our trust in our own internal worlds. If we can trust our internal worlds to guide us through the miasma of our ideas, our training, our clinical and personal experience, we can be with our patients wherever they might take us.

Sometimes we have patients who take us places we would rather not go. Those patients try us sorely because they do not fit our preconceptions about what it is we do. They seem to be unable to use analysis even though they want to be analyzed. Like Bion, I believe that our theories are sufficient to understand them and our models creative enough to use with them, but the “patient who is difficult to reach” (Joseph, 1975, pp. 75–86) forces us to modify our techniques (Ferenczi, 1928) and to pay closer attention to ourselves paying attention to them.

Using the theories of Freud, Ferenczi, and Klein and the background models of Bion and Meltzer, I want to describe what I believe is occurring with these patients and then discuss the analyst’s focus on the body of the patient as an aspect of the material used to find the patient’s truth in the moment of the session. In addition, the analyst pays attention to her own somatic responses whether or not she uses them for interpretation. I will briefly review the theory I am using in order to support my conclusions.

Theoretical background

In “On Narcissism”, Freud (1914) emphasized the importance of the body and the instincts in the development of the mind. His statement that “The ego is first and foremost a body ego” is often quoted. Later he writes, “The ego ultimately is derived from bodily sensations” (Freud, 1923, p. 26). Freud’s (1911) two principles – the reality principle and the pleasure principle – are firmly based on his beliefs about the body and its relation to the mind.

Klein (1933, 1946, 1952), believed that the play of children could be interpreted just as the free associations of adults were interpreted in adult analysis. She implicitly used the actions of her patients or their physical expressions as evidence of their unconscious worlds. She not only focused on the bodily expressions of her patients but also interpreted their unconscious phantasies about others’ bodies, most importantly their mother’s body, to them. Her interpretations to both children and adults frequently used body images to communicate the emotional experiences found in the immediacy of the transference.

Susan Isaacs, in her classic paper “The Nature and Function of Phantasy” (1948), describes unconscious phantasy as being on the cusp of the mind and the body, incorporating both. In a less well-known paper, “Criteria for Interpretation” of 1939, she says that included in the data for interpretation are:

The facts of the patient’s behaviour as he enters and leaves the room and while he is on the couch, including every detail of gesture and tone of voice, pace of speech and facial expression, any routine or any changes in behaviour and expression; every sign of affect, or change in affect, its particular nature and intensity, in its associative context.

(p. 148)

Focusing on the body and being aware of somatic defences offers an entrance to the psyche for analysts working deeply with severely withdrawn patients. In extreme instances, the analyst may find herself matching the patient, much as a nursing mother assumes the breathing rhythms of her infant.

Ester Bick (1968) and Didier Anzieu (1990a, 1990b) each dealt with the concept of a mental skin that allows boundary and space and facilitates emotional containment. The absence of a mental skin from fetal life through infancy can leave one stuck in a false self. Another way of saying this is that patients without a mental skin unconsciously mimic whomever they are with in order to feel that they exist. Without a mental skin, they find others and mimic them, thereby creating a second skin.

Joyce McDougall (1989) describes these patients as “‘anti-analysands’ in analysis because they seem to be in fierce opposition to analyzing anything that has to do with their inner psychic world, insisting on external reality as the only dimension of interest” (p. 93).

These patients, whom she calls “normopaths”, deny emotion. For them, according to her, since emotion is psychosomatic, their denied emotion can be projected into their bodies (p. 95). She believes that alexithymic and somatizing patients use their bodies to communicate because their emotions are not available to them and are absent in their verbal communication.

McDougall highlights that such patients use their illness in order to know they are alive. She feels they ultimately fear relationships because they believe that “Love leads to psychic death, that is to the loss not only of… mental barriers against implosion from others, but also of… body limits. Nothing short of total indifference… can assure… survival” (p. 39).

I believe this fear of relationship contributes to the difficulty analysts have in working with these patients. The transference is hidden, and emotional contact is scarce. Interaction is superficial.

Antonio Damasio (1994, 1999), the neuroscientist, believes that on the basis of his research all learning is initiated via the emotions. His research supports the psychoanalytic research of Wilfred Bion when Damasio (1999) states that “emotion is integral to the process of reasoning and decision making” (p. 41). Further, he sees all emotion as related not only to learning but also to relationship with objects. He writes that “The alleged vagueness, elusiveness, and intangibility of emotions and feelings are probably symptoms [of how we] sometimes… use our minds to hide a part of our beings from another part of our beings” (1999, pp. 28–29).

The theoretician that I am using most in this chapter is Wilfred Bion, who always emphasizes the importance of emotion and relationships with internal as well as external objects. Bion credits Freud’s (1911) exploration of the origin of thought and the mind’s attempts to deal with reality as having aided him in the development of his ideas. He also credits Melanie Klein (1946), particularly her understanding of the infant’s sadistic attacks on the breast and her discovery of the processes involved in primitive splitting and projection. These she named projective identification. This chapter comes out of Bion’s papers, and Bion’s papers come out of Freud and Klein.

Bion (1962a) writes:

The senses may be able in a state of fear or rage to contribute data concerning the heart-beat, and similar events peripheral, as we see it, to an emotional state. But there are no sense-data directly related to psychic quality, as there are sense-data directly related to concrete objects. Hypochondriacal symptoms may therefore be signs of an attempt to establish contact with psychic quality by substituting physical sensation for the missing sense data of psychical quality. It seems possible that it was in response to his awareness of this difficulty that Freud felt disposed to postulate consciousness as the sense-organ of psychic quality. I have no doubt whatever of the need for something in the personality to make contact with psychic quality.

(pp. 52–53)

In chapter nine of Elements of Psychoanalysis, Bion (1963) discusses speaking behaviour designed to develop thought as “doodling in sound” (p. 38) so what was inside could come out, be observed, and dealt with in order to discover their meaning. “Doodling in sound” is action, however, not communication. It is behaviour. Without explicitly saying so, Bion implies that he makes use of the psychotic patient’s behaviour, not only his words, when he gathers information in a session. Paul (1997) calls this “the imitation of human speech”.

Bion (1963) believes that meaning is made from thinking about body sensations or thinking about the perception of emotion as found in response to the environment. He called this meaning-making process alpha function. Alpha function uses emotion as a bridge between mind and body. He described the process of moving back and forth from the paranoid-schizoid position to the depressive position as the mechanism “as part of the development of a capacity for thought” (p. 42). He says that the beta elements, or affective somatic sensations, are “felt to contain a part of the personality in their composition” (p. 42).

I believe the healthy mind is continually attempting to hold the internal and external realities in balance, that is, to stay integrated, mind and body. In order to stay in contact with both realities, the mind seeks input from both places, inside and outside, physical and psychical. In health, then, the senses derived from the organs of perception are used to validate the emotional experience such data collecting engenders. The unity of mind and body provides a balance or equilibrium for optimal functioning. In early infancy, with good-enough mothering and without tormenting physical illness, the infant has the opportunity to explore this wholeness as well as this undifferentiation of mind and body. It is this primal experience that becomes the template upon which mature integration is formed.

Without good-enough containment, the infant may not have enough experience of wholeness, and may fragment. Containment comes both from within and without the primitive mind: from the mother and father, as well as from the physical sensations of the baby’s body. When the parent is depressed or ill or compromised characterologically, it is the parent who projects destructively into the baby instead of receiving and metabolizing the baby’s projections. With no one to project into, a baby may turn to things, or in extreme cases to his or her own body. It is at such moments that the body becomes the only means possible of communicating and receiving, for the mind of the mother is shut down and split off from her own self as well as from her baby. The relationship between the two is pathogenic.

I surmise in this situation that, in the baby’s mind, its body comes to equal the body of the mother, instead of representing the mother’s body. This symbolic equation (Segal, 1957) impedes symbolic processing and also interferes with the baby’s relationship to both internal and external reality. The development of thought is threatened. Emotional relationship to both self and others is shut down. Projection into the body instead of into the parent initiates a process that harms both the structure used for thinking and the thoughts that evolve. The developing child moves farther and farther away from a relationship with his own emotional truth as experienced internally and externally.

Technical applications

Technical applications of theory vary widely from professional to professional, even when there is consensus about technique. My understanding of Bion’s clinical papers from 1975 to 1978 (2014) has greatly influenced my work with passive, as-if patients. I am also grateful for his paper on differentiation of the psychotic from non-psychotic processes (1957). Although my intuition is informed by my theories and by my adapted techniques (Ferenczi, 1928), what I think I am doing is in fact always different from what I actually do. Attempting to describe what I am doing keeps me honest with myself.

With that caveat, I attempt as much as I am able to be present with my patient without “memory, desire, and understanding” (Bion, 1970, p. 46), although often I fail. This failure is often centred around my focusing on somatic memories, instead of staying in the moment with my patient. I attempt to understand the emotional connection, however hidden, between the patient and myself in the moment. Paying attention to the process, and to the form of a session more than to its content, keeps the immediacy foremost. My interpretations are often transference interpretations that shift between intrapsychic and transferential. Typically, but not always, I avoid making non-transferential interpretations. Also, with patients who are difficult to reach, I use description as a means of holding. This description may often be of my patient’s bodily expressions, when linked to an absence of expressed emotion.

Counter-transference responses

Since the groundbreaking work of Racker (1968) and Heimann (1950, 1956), using counter-transference has become an important aspect of any analysis. I use my counter-transference as information about my patient. Although I rarely disclose my experience, I use it to formulate my interpretations. Paying careful attention to my somatic responses to clinical material demonstrates the value of what my body tells me about me as well as about my patient. Sometimes it takes weeks or months to be able to perceive or to recognize a somatic response in me as communication from my patient, but the fact of it gives me hope that early unmentalized experiences can be communicated, brought into awareness, and eventually into language. Included in my somatic responses are images, tactile sensations, and olfactory memories, as well as daydreams. All these are information about both the patient and me and are part of the analytic field.

When I am ready to make an interpretation, I attempt to speak to the deepest anxiety, rather than to begin at the surface and move down towards it. In that way I have adopted a Kleinian perspective. Since the body is used as a background object in both health and pathology, the earliest anxiety is often about the body and about not existing or dying.

For this reason, the emotions triggered in me are often what I would call big emotions – that is, once I have begun to understand my patient, I feel quite horrified to be witness to the self-destruction continuing in spite of my best efforts. The utter disregard for anything I say and the inability of my patient to remember and make use of my interpretations makes the work slow and seemingly futile. Patients who have been traumatized as infants and young children, many of whom have been separated from parents at birth by medical problems, do not know how to use their objects and so not only must I bear these big emotions, I must bear not being used (Winnicott, 1969).

My emotional responses also include my own feelings of uselessness, inadequacy, confusion, and despair. Sometimes I have a feeling that I do not exist. What am I doing anyway? I believe these feelings are primitive affective communications from my patient that I must feel first in my body and then emotionally in order to find words that will always be inadequate. My belief in the analytic process and my compassion for the pain of integration sustain me.

The patient

I am trying to understand a certain aspect of the personality that exists to greater or lesser degree in all of us. I am trying to uncover the dead and dying aspects beneath the layers of false selves that we present to ourselves and to others, and that we discover in more malignant forms within our patients. For purposes of clarification, I will use clinical examples of patients where this deadness is more profound, although still hidden.

Repeatedly in my own analytic practice and in the practices of those I supervise are found patients about whom it is said, “I don’t know why she comes”, or “Nothing is happening”, or “I can’t tell if he is getting anything”. Sometimes, therapists say, “Somebody has to do something”. Others will say, “This patient is just not treatable”. These particular patients are seemingly not emotional and so they are not difficult. They may even tell interesting stories although often they do not appear to feel what they describe. It is as if they were talking about someone else or about someone they have heard of but do not know. It seems they are not talking about themselves.

Therapists may be interested in these patients but not moved by them. Some therapists may attempt to reach them by describing the feeling that “ought” to be under the story. Others may attempt to work with the patient’s body, following their breathing, or describing their postures and attributing meaning much as a mother might interpret a baby’s frown to mean the juice is sour or an arching away to mean “stop”. The attempt to translate body language into emotional communication and ultimately into meaningful words sometimes appears to help. This apparent effectiveness increases the therapist’s activity.

The therapist’s activity is an attempt to activate the patient’s passivity and to breathe life into dead bodies. These patients seem to eagerly adopt what they are told as their own. Yet the adoption is not about true learning or integration of their experience. Experience does not stimulate their learning, but provides material for mimi...