The body one has and the body one is: Understanding the transsexual’s need to be seen

The transsexual individual confronts the analyst with a disturbing otherness. How this otherness is understood, that is, how the analyst ‘looks’ at the patient through her distinctive theoretical lens impacts, in turn, on the patient’s experience and what transpires between them. In this paper the author outlines a developmental model rooted in attachment and object relations theory to provide one alternative way of ‘looking’ at some of these patients’ experiences in the clinical setting. It is suggested that in some cases of transsexuality the primary object(s) did not mirror and contain an early experience of incongruity between the given body and the subjective experience of gender: it remains unmentalized and disrupts self‐coherence leading to the pursuit of surgery that is anticipated to ‘guarantee’ relief from the incongruity. Through an account of work with a male to female (MtF) transsexual who underwent surgery during her five years of psychotherapy, the author explores how a focus on the transsexual’s experience of ‘being seen’, that is, of being taken in (or not) visually and mentally by the object in their state of incongruity, affords another window through which to approach the transsexual’s experience in the transference–countertransference dynamics.     

DISTINGUISHING THE DRAMA FROM THE HISTRIONICS IN A CASE OF HYSTERIA WITH MULTIPLE TICS

The author describes a clinical experience with a hysterical patient with multiple tics, an upper-middle class, married woman, who when she started analysis at the age of 30 was in a state of profound tension and anxiety. The first eight years of this analysis are presented in order to describe how the analyst came to identify the dynamics of unconscious phantasies in a situation where analyst and patient found themselves involved in several roles of a drama dominated by theatrics. The insights and therapeutic benefits suggested that this patient unconsciously experienced her oral needs as intensely destructive and cruel, an experience she felt to have been exacerbated by her mother's lack of response to her emotional needs. This primitive cruel orality was accompanied by a split-off experience of a secret, mystical union with the primitive idealised mother. The author considers that this split experience of cruel and idealised orality suffused the patient's genital sexuality, hindering the evolution and realisation of her adult sexuality, giving her a distorted view of the primal scene as an impenetrable fused amalgam acting as an omnipotent, self-sufficient, excluding phallus. Gradually analysis enabled the patient to transform her bodily theatrics into thoughts and to broach the difficult task of relating to others instead of being either fused with them or totally excluded by them.     

Don’t tell me I’m normal: inpatient psychotherapy of a severely abused patient at the Cassel Hospital

This paper is a case study of a patient with severe personality disorder undergoing treatment at the Cassel Hospital. It looks at a phase of her individual psychoanalytic psychotherapy and how that sits within an institutional model of treatment that can be understood as applied psychoanalysis, in which Tom Main’s concept of a ‘culture of enquiry’ aims to observe and bring together splitting and projective processes operating at all levels of the organisation. The patient, who had been sexually abused and then suffered a prolonged suicidal breakdown, exerted intense pressure on the institution through her experience of herself as both a victim of abuse and a participant in it. A working through is described, in which different parts of the patient that had been projected into different parts of the institution are brought together, and her primitive demand for a two-person world gives way to an acceptance of triangulation. Themes from her individual sessions are enacted in the milieu-based treatment, and conversely struggles in the patient community appear in her sessions. It is from drawing these parts of the patient together as a whole institution that the treatment derives its power and effectiveness.     

Psychotherapy of an adolescent presenting a mystical delusion: an illustration of splitting processes and their consequences

The paper discusses the psychotherapy of an adolescent who, during a psychotic breakdown, developed a mystical delusion on a religious theme. Splitting processes and the narcissistic defences that accompany them are illustrated. After showing how the patient had recourse to splitting and how the split-off parts of the ego took refuge inside an internal object, the ego's efforts to make contact once more with these split-off aspects and to reintegrate them are highlighted. With the help of certain concepts developed by, for example, Rosenfeld and Meltzer - specifically those relating to the organization of internal groupings or 'gangs' and their destructiveness and the compartmentalization of internal objects - the author shows how certain particularities of the patient's internal world can be understood in terms of these splitting processes. In addition the clinical material presented raises several technical questions, in particular those relating to dissociative processes and delusion or delusional theories as they become manifest in the treatment.     

Addressing parts of the self

In this paper the author addresses the problem of framing an interpretation that properly takes account of the degree of splitting and projection the analyst encounters in a patient at a particular time. If the patient has needed to split off and project unacceptable parts of the self, the analyst has to consider how useful it is to describe this situation to the patient, who may no longer be in contact with the disavowed parts. The disadvantage of this situation is that an interpretation that refers to different parts of the personality may make sense intellectually, but may in fact reinforce the patient's defensive structure. The author describes one case in which such a situation prevailed, and contrasts this with a second case in which a greater degree of integration had developed, with accompanying internal conflict and pain. In this latter case it seems paradoxically more appropriate for the analyst to include, in his interpretations, references to the struggle between different parts of the personality.     

A NEW READING OF THE ORIGINS OF OBJECT-RELATIONS THEORY

The author presents a reading of Freud's 'Mourning and melancholia' in which he examines not only the ideas Freud was introducing, but, as important, the way he was thinking/writing in this watershed paper. The author demonstrates how Freud made use of his exploration of the unconscious work of mourning and of melancholia to propose and explore some of the major tenets of a revised model of the mind (which later would be termed 'object-relations theory'). The principal tenets of the revised model presented in this 1917 paper include: (1) the idea that the unconscious is organised to a significant degree around stable internal object relations between paired split-off parts of the ego; (2) the notion that psychic pain may be defended against by means of the replacement of an external object relationship by an unconscious, fantasied internal object relationship; (3) the idea that pathological bonds of love mixed with hate are among the strongest ties that bind internal objects to one another in a state of mutual captivity; (4) the notion that the psychopathology of internal object relations often involves the use of omnipotent thinking to a degree that cuts off the dialogue between the unconscious internal object world and the world of actual experience with real external objects; and (5) the idea that ambivalence in relations between unconscious internal objects involves not only the conflict of love and hate, but also the conflict between the wish to continue to be alive in one's object relationships and the wish to be at one with one's dead internal objects.     

Memoirs of a drug-abusing prostitute: Dynamics and treatment considerations in a case of intergenerational child abuse

This paper examines the dynamics of a 26-year-old prostitute who entered psychotherapy with a number of symptoms. The patient had undergone a series of traumas in her life and was reenacting them in her present behavior. Repetition compulsion, as described by Freud, was a primary form of resistance manifested by this patient. The repetition of the sexual trauma reenacted itself in her choice of profession; namely, prostitution. Additionally, this woman had lived her early years falsely believing that her parents were caring for her, when in fact, they were her grandparents. This early family secret led to the development of a false self within the patient, as well as a strong sense of entitlement, greed, and need for revenge.     

The termination phase of psychoanalysis as seen through the lens of the dream

The decision about when to terminate analysis has long been underpinned by a theory-driven criterion model, which may steer the analytic dialogue away from its customary activities of free association, empathic listening, and interpretation. As a remedy to this situation, the author proposes that by paying careful attention to less consciously crafted patient communications such as dreams, the analytic dyad can consider readiness to set a termination date from a perspective that is context-sensitive and less encumbered by preordained criteria. Tracing the dreams of one analysand from the vantage point of contemporary dream theory, the author demonstrates how careful attention to the dream elucidated the patient's readiness to terminate and her complex feelings about the termination process. Finally, the author challenges the notion that the termination phase is of greater evaluative than therapeutic importance, and provides clinical material as evidence that this is not the case.     

A case history: from traumatic repetition towards psychic representability

This paper is devoted principally to a case history concerning an analytic process extending over a period of almost ten years. The patient is B, who consulted the author after a traumatic episode. Although that was her reason for commencing treatment, a history of previous traumatogenic situations, including a rape during her adolescence, subsequently came to light. The author describes three stages of the treatment, reflected in three different settings in accordance with the work done by both patient and analyst in enabling B to own and work through her infantile and adult traumatic experiences. The process of transformation of traumatic traces lacking psychic representation, which was undertaken by both members of the analytic couple from the beginning of the treatment, was eventually approached in a particular way on the basis of their respective creative capacities, which facilitated the patient's psychic progress towards representability and the possibility of working through the experiences of the past. Much of the challenge of this case involved the analyst's capacity to maintain and at the same time consolidate her analytic posture within her internal setting, while doing her best to overcome any possible misfit (Balint, 1968) between her own technique and the specific complexities of the individual patient. The account illustrates the alternation of phases, at the beginning of the analysis, of remembering and interpretation on the one hand and of the representational void and construction on the other. In the case history proper and in her detailed summing up, the author refers to the place of the analyst during the analytic process, the involvement of her psychic functioning, and the importance of her capacity to work on and make use of her countertransference and self-analytic introspection, with a view to neutralizing any influence that aspects of her 'real person' might have had on the analytic field and on the complex processes taking place within it.     

Mental models and language registers in the psychoanalysis of psychosis: An overview of a thirteen‐year analysis2

The author suggests that the use of mental models and language registers may help an analysis to proceed, especially in psychosis, when the patient has not yet developed a mental space that will allow him/her the functions of knowledge and containment of emotions. Models, according to Bion, are a primitive approach to abstraction and a manifestation of the analyst's reverie that enables him/her to transform sense data into alpha‐elements. Ferrari, in a further development of Bion's theories, hypothesises a relationship between the transference and the internal level of body‐mind communication, and proposes the use of language registers to sustain the psychoanalytic process. The author presents several clinical examples from a thirteen‐year, four‐session‐a‐week analysis of a psychotic analysand who was initially confused, paranoid and altogether unable to bring self‐reflective thought to bear on her overwhelming emotions and had, by the end of the analysis, completely recovered from her psychotic symptoms. The clinical material shows how the technical tools of mental models and language registers helped in the construction of a mental space and spatio‐temporal parameters, permitting the patient to tolerate overwhelming concrete emotions and finally to recognise and work through the emotions of an intense transference.     

The seventh penis: towards effective psychoanalytic work with pre‐surgical transsexuals

The author reflects on his contrasting analytic work with two transsexual patients. He uses three previous psychoanalytic studies (Stoller, Morel and Lemma) to explore whether effective analytic work with the issues driving a person's determined wish for sex reassignment surgery (SRS) is possible. Particular consideration is given to how such work might navigate a path between traumatizing and pathologizing the patient on the one hand and avoiding important analytic material out of fear of so doing on the other. The author proceeds to ask whether it is possible to tell in advance, with any degree of reliability, who is and who is not likely to benefit from surgery. He considers certain diagnostic issues in relation to these questions. Illustrations are given of how, in practice, countertransference anxieties about psychopathologizing transsexual patients can contribute to significant difficulties in working clinically with them. It is argued that the understanding and containment of such anxieties could eventually lead to more effective analytic work, and that such work might be further facilitated by considering the contribution of mind‐body dissociation to transsexualism.     

Response to “Poison Cookies” Discussions

This is a response to the discussions of the case presented by this author. Responding to the discussions has allowed the author to pull together her own ideas about the case as well as about the work we do. The author sees Sheldon (Shelly) Bach's view of sadomasochism as a particular type of object relationship as informing her own point of view. Next comes a discussion centering on Steven (Steve) H. Knoblauch's emphasizing the importance of the internal symbolic world of the patient. The author makes the point that understanding the level of differentiation of the internal objects in the patient's representational world is important in thinking about the types and timing of interventions the analyst makes; for example, those which Mary-Joan Gerson describes in her comments. Finally, the author addresses Sue Grand's response, especially her emphasis on the importance of siblings in our patients’ histories and the resulting sibling transferences to the analyst.     

The role of the patient's remembered history and unconscious past in the evolution of Betty Joseph's 'Here and now' clinical technique (1959-1989)

The author historicizes one aspect of Betty Joseph's ongoing technical contributions in terms of its originating London kleinian context. Early on she drew upon both the patient's remembered history and unconscious past, linking these experiences in past-to-present transference interpretations in order to effect psychic change. In evolving the technique of 'here and now' analysis, Joseph came to emphasize a communicative definition of projective and introjective identification as well as the significance of enactments while marginalizing the use of part-object anatomical interpretative language. She gradually set aside directly linking the patient's past with the present, compelled now by making direct contact with her patients. She now tracked how difficult patients acted in and responded to interpretations from moment to moment. The author maintains that the explicit and implicit conceptual work of Wilfred Bion as well as Joseph's continuous group workshop for analysts led to an increased understanding of the patient's projective impact on the analyst's countertransference responses, and thereby increased the analyst's capacity with 'difficult to treat' narcissistic spectrum patients described by her colleague, Herbert Rosenfeld. In recent work, while Joseph continues to elucidate what patients recall about their early past, she formats her understanding in terms of a direct analysis of the structure of the patient's projected internal object relations in the transference. The analyst works with the patient's communications and enactments, with a greater emphasis on a more 'inside-to-outside' understanding of transference in contrast to the earlier 'past-to-present' work associated with both Freud and Klein. This investigation concludes with one example of Betty Joseph's significant impact on contemporary kleinian technique by taking up some of Michael Feldman's work. Now the analyst listens to the 'past presented,' the patient's projected internal world, as well as tracks how the patient hears and subtly mishears interpretations for defensive, equilibrium-maintaining purposes, as the analyst attempts to effect psychic change by widening the ego's perceiving functions.     

The Experience of Abandonment and Adoption,as a Child and as a Parent,in a Psychological Motivational Perspective

Abstract

The publication of the relationship between Sabina Spielrein and Carl Jung in 1980 gave rise to a veritable cottage industry of mythomania at the expense of historical truth. The fictions grafted upon the historical facts have conjured up a sensational aura of scandal and gossip about the protagonists. The arch fiction is that Spielrein and Jung had a sexual relationship during her analysis by Jung. At the very least, based on documents published by the author, this opinion can no longer be maintained beyond reasonable doubt. After 1905, Spielrein was no longer Jung's patient but continued as Jung's medical student, whereupon Jung sought her out as friend. In addition, it was Spielrein herself who fell passionately in love with Jung, and analysed this relationship as a case of mutual oedipal dynamics. The author further pursues the oedipal analysis of and links it to (1) love as reality and transference, (2) the reality of Jewish and Gentile relationships in Europe, and (3) mutual ethnic transferences between Spielrein and Jung. Jung, who was also passionately drawn to Spielrein, displaced his marital problems owing to a “Don Juan complex” to concocted problems in treatment, deceiving both himself and Freud out of the dread of social consequences.     

The reality of the other: Dreaming of the analyst1

The author discusses the obstacles to symbolization encountered when the analyst appears in the first dream of an analysis: the reality of the other is represented through the seeming recognition of the person of the analyst, who is portrayed in undisguised form. The interpretation of this first dream gives rise to reflections on the meaning of the other’s reality in analysis: precisely this realistic representation indicates that the function of the other in the construction of the psychic world has been abolished. An analogous phenomenon is observed in the countertransference, as the analyst’s mental processes are occluded by an exclusively self‐generated interpretation of the patient’s psychic world. For the analyst too, the reality of the other proves not to play a significant part in the construction of her interpretation. A ‘turning‐point’ dream after five years bears witness to the power of the transforming function performed by the other throughout the analysis, by way of the representation of characters who stand for the necessary presence of a third party in the construction of a personal psychic reality. The author examines the mutual denial of the other’s otherness, as expressed by the vicissitudes of the transference and countertransference between analyst and patient, otherness being experienced as a disturbance of self‐sufficient narcissistic functioning. The paper ends with an analysis of the transformations that took place in the analytic relationship.     

Exceptional musical performance in early childhood catatonia

Many years ago the author, jointly with a psychologist, described a patient who, in spite of her alleged idiocy, showed an exceptional musical capacity. However, in the meantime the author has recognized and described early childhood catatonics and, as a consequence of this new knowledge, he has to admit an error. Even according to our then findings it would have been identifiable that, as has been confirmed now by follow-up, the patient is suffering from catatonia, starting in infancy. The high musical performance, then arousing our greatest astonishment, is now explicable, for childhood schizophrenics do not develop general mental deficiency but only specific circumscribed deficits.     

Vanda Shrenger Weiss – the Croatian pioneer between two worlds: Her role in the birth of the Italian Psychoanalytic Society (SPI)

In this paper the author sheds light on Vanda Shrenger Weiss, a forgotten pioneer of the international psychoanalytic movement. Vanda Shrenger was born into a large Jewish family in Croatia (1892), and her life was thoroughly intertwined with the great tragedies of European history: the First World War, the anti‐Semitic persecution within Eastern Europe, which entailed the decimation of her extended family in Croatia. Finally, the introduction of fascist laws in Italy led to her and her husband – Edoardo Weiss, the founder of the Italian Psychoanalytic Society – seeking refuge in the United States of America. During her time spent in Italy (1919–39), Vanda Shrenger, doctor and paediatrician, dedicated herself to psychoanalysis. She played a crucial part in the reconstruction of the Italian Psychoanalytic Society (SPI), whilst also being a founding member of the Rivista Italiana di Psicoanalisi (Rome, 1932). Vanda was the first woman to be a member of the SPI as well as to present a paper for it. This insightful and extensive analysis relating to this pioneer of the psychoanalytic world, has been meticulously accomplished by use of a combination of original archival materials, along with access to previously unpublished documents and personal details, kindly made available to the author by Marianna, the daughter of Vanda and Edoardo Weiss, who still lives in the United States today.     

Nymphea: from psychic breakdown to the emergence of subjectivity

In the first part of the paper the author presents an account of the analysis of a woman who is psychically extremely disturbed. This clinical presentation focuses on the unfolding of the transference process, and on the countertransference difficulties encountered during the course of the treatment which lasted more than ten years. In the second part of the paper the author proposes a theoretical approach to the breakdown experienced by the patient, and puts forward the hypothesis that there was insufficient differentiation between her internal objects and the archetypes, and that this prevented the development of symbolization. The author proposes the idea of a collapse between internal and external objects, which destroys the space necessary for representation and symbolization that normally arise between the two poles of the object. The account of this transference process between the analyst and the patient is thus seen as the account of the (re)construction of true internal objects, and of the resumption of a symbolic process to make possible the development of subjectivity.     

Negative oedipal transference of a male patient to his female analyst during the termination phase

There has been some debate in the literature concerning the ability of the male patient to experience his paternal, and particularly negative oedipal, transference feelings directly toward his female analyst. In this context, the author describes paternal transference manifestations evident throughout her male patient's analysis, and presents detailed process material from the termination phase. At this time the patient's obsessional neurosis was revived in the context of setting a termination date, and transference to the negative oedipal father could be clearly demonstrated. The paper illustrates that even the negative oedipal component of the paternal transference can be experienced directly in the male patient/female analyst, dyad, and interpretation of this material can bring it into clearer focus. The author discusses some possible influences of her sex on the timing and intensity of the material.