Traumatic effects of political repression in Chile: A clinical experience1

The author examines psychic trauma resulting from human rights violations in Chile. Starting from trauma theories developed by authors such as Ferenczi, Winnicott and Stolorow, she posits the relevance of the subject's emotionally signifi cant environment in the production of the traumatic experience. She describes the characteristics of the therapeutic process on the basis of a clinical case. She emphasizes the need to recognize the damage that may be produced within the reliable link between patient and analyst, pointing out the risk of retraumatization if analysts distance themselves and apply ‘technique’ rigorously, leaving out their own subjective assessments. Therapists must maintain their focus on the conjunction of the patient's intersubjective context and inner psychic world both when exploring the origin of the trauma and when insight is produced. The author posits repetition in the transference as an attempt at reparation, at fi nding the expected response from the analyst that will help patients assemble the fragments of their history and achieve, as Winnicott would put it, a feeling of continuity in the experience of being.     

In-Between: Shapes of Subjectivities in the Analytic Situation

Starting from concepts that Winnicott developed and that are unexpectedly near to postmodern concepts, I attempt to map some features of the complex territory that lies between analyst and patient from the viewpoint of the relationship that exists between subjectivity and objectivity. In the first section, I give a personal reading of Winnicottian model, emphasizing the idea that the subject’s unconscious acts upon and transforms the object’s (thereby putting in motion further unconscious processes within the object). Then I highlight the presence, in the transference, of various levels of communication and of a paradoxical multidimensionality that upsets the traditional space-time categories and also upsets the analyst’s mental stance. In the third section, I present a new form of countertransference (pervasive), through which the patient’s unconscious creates a sensory environment of proto-emotions and atmospheres, of states and rhythms, that have permeated it and that, due to their intensity and nature, arrived there without symbolization. Finally, I attempt to demonstrate how the patient can undergo psychic change only if the analyst has, himself, inhabited an analogous process of transformation in response to the disturbances arising within the analytical relationship. The clinical-theoretical stance emerging from these reflections sees the relation to the other, to oneself, and to the world as made possible by subjective creation always taking place in the unconscious.     

Mutual Vulnerability: Intimacy,Psychic Collisions,and the Shards of Trauma

In this paper, I explore the profound potential, and the challenges, of mutual vulnerability in psychoanalysis. I describe ways in which analysts are penetrated by shards of our patients’ trauma, and how this interpenetrates with our own vulnerabilities and ungrieved losses (Harris, 2009; Levine, 2016). In my patient Lisa’s fierce determination to come into being, and in our mutual efforts to survive each other’s ruthlessness (Winnicott, 1969) we each struggle to recognize and own malignant “not-me” versions of ourselves (Bromberg, 1998), as we reach toward reparation, mutual recognition, and healing.     

The Anxious Amalgam of the Wish for “Recognition/Revenge/Reparation”: Discussion of Rina Lazar’s “What Are We Doing There? A Therapeutic Tale”

In this discussion, the clinical utility of Winnicott’s notion of “object usage” is described and applied to Rina Lazar’s clinical material. In the light of this concept, our understanding of trauma and the role of the other in both constituting and ameliorating the effects of trauma are considered. A related area of inquiry is how the realm of intergenerational transmission of trauma might be traced out by the particular conjunction of the object’s availability for use in the face of the subject’s trauma. In weaving together the ideas of “use of the object” and trauma, the question of regression and its manifestations and meanings in clinical work are illuminated.     

Silence as the Voice of Trauma

Silence is a key to the unspoken world of the patient. Rather than interpreting silence as a defensive maneuver, the analyst may understand this disruption as a royal road to the patient’s traumatic experiences. The author proposes to recognize traumatic silences in the analytic process and the transference as a re-experiencing of past, unpredictable traumatic affective states and memories. Silences in this context are both a repeat of a disconnecting experience as well as a manifestation of a silencing identification with the original silencer. The clinical material illustrates effects of a German mother’s World War II (WWII) personal traumata and collective shame-based silence on her daughter’s self and good object development. In the daughter’s analysis, the patient and the analyst, who herself experienced similar WWII traumata, face the pain of trauma recovery and un-silencing. The author suggests that the deadening effect of past traumata may be reversed by an analytic process of re-membering and re-speaking for both the patient and analyst. This allows for a more transparent, subjective experience in the transference and a verbal integration of ego functions.     

Surviving Deadness in the Analytic Experience

The transference/countertransference (third space) analysis is considered to be central in the therapeutic effectiveness of the analytic process. Less emphasis has been placed on the actual experiences of analyst and analysand in the conflictual reenactment of third space experience and its resolution. This paper recounts the shared experience of a patient who was silent throughout most of the analysis, and my reaction, in fantasy and enactment, to this disturbing experience—both for him and for myself. I argue that it is the affective re-experiencing of past repressed trauma in the analytic space that has a therapeutic impact, leading to growth in the patient and also the therapist. I contrast Freud’s emphasis on insight, making the unconscious conscious, with Ferenczi’s suggestion that the therapeutic impact lies in the repetition of past traumatic experience in the analysis but with the possibility of a different outcome with a more benign object, leading to symbolic representation of repressed trauma. Re-experiencing and symbolization, in the third space, of past traumatic experience can be an exit point from the endless repetition of trauma in internal and external object relations, leading to a new beginning in the patient’s life. Immersed in the experience of deadness in the analysis, which had become a dead womb, the struggle to remain alive and thinking led to a rupture out of the dead womb, like the Caesura of birth, into aliveness and the ability to mentalize what had previously remained unmentalized.     

The paternal function in Winnicott: The psychoanalytical frame

My first aim has been to identify the implicit assumptions underlying Winnicott's detailed notes on a fragment of an analysis dating from 1955 and published after his death. The importance given by Winnicott to the father figure as early as 1955 is one of my discoveries; another is the deep Freudian roots of his thinking. In this essay I propose a new way of linking together the concepts of ‘paternal function’ and the ‘psychoanalytical frame’. Developing my hypothesis, I compare my reading of Winnicott and my way of reading José Bleger's study on the frame. Like Winnicott, I explore in detail a process of discovery, focusing on what the analyst and the patient are nor fully aware of …'as yet'. I am not proposing to unify Winnicott's and Bleger's thinking. My aim is to avoid the pitfall of eclecticism and, in so doing, to recognize both the related depths they sound in their thinking and their otherness. I want to share with the readers their ‘meeting’ in my mind.     

On presence in the psychoanalytic relation

This paper discusses presence in the psychoanalytic relation, the analysand’s and the analyst’s. Clinical situations with different qualities of presence will be considered focusing on what kind of interplay between analysand and analyst they may lead to. As examples, I have chosen three different clinical situations: In the first there is an interplay between the analysand’s free associations and the analyst’s ‘evenly suspended attention’. In connection with this I will discuss Bion’s concepts of ‘reverie’ and of ‘O’. In the second there is where the interaction is characterised by what Meltzer calls ‘geographical confusion’. In the third there is a ‘transference delusion’ in the psychoanalysis of breakdown as Winnicott describes it.     

The Things We Carry: Finding/Creating the Object and the Analyst’s Self-Reflective Participation

I reflect on the interaction between the analyst’s dedicated attention to the patient’s internal object relations and the analyst’s self-reflective participation. Our stops and starts of attention to the patient’s internal objects and our own is in some sense one of the most important elements of our personal participation. I suggest that the patient’s and analyst’s needs for privacy and the illusion of privacy in the presence of the other, undertheorized within relational theory, is not at odds with an emphasis on valuing the patient’s capacity for a “read” on the analyst. Needs for privacy and the illusion of privacy held by patient and analyst need to be integrated into any psychoanalytic theory and form part of the basis of intimate regulatory systems between two people.     

Commentary on ‘The arms of the chimeras’ by Béatrice Ithier

In this Commentary I will first of all summarise my understanding of the proposal set out by Béatrice Ithier concerning her concept of the ‘chimera’. The main part of my essay will focus on Ithier's claim that her concept of the chimera could be described as a ‘mental squiggle’ because it corresponds to Winnicott's work illustrated in his book ‘Therapeutic Consultations’ (1971). At the core of Ithier's chimera is the notion of a traumatic link between analyst and patient, which is the reason she enlists the work of Winnicott. I will argue, however, that Ithier's claim is based on a misperception of the theory that underpins Winnicott's therapeutic consultations because, different from Ithier's clinical examples of work with traumatised patients, Winnicott is careful to select cases who are from an ‘average expectable environment’ i.e. a good enough family. Moreover, Winnicott does not refer to any traumatic affinity with his patients, or to experiencing a quasi‐hallucinatory state of mind during the course of the consultations. These aspects are not incorporated into his theory. In contrast (to the concept Ithier attempts to advance), Winnicott's squiggle game constitutes an application of psychoanalysis intended as a diagnostic consultation. In that sense Winnicott's therapeutic consultations are comparable with the ordinary everyday work between analyst and analysand in a psychoanalytic treatment. My Commentary concludes with a question concerning the distinction between the ordinary countertransference in working with patients who are thinking symbolically in contrast to an extraordinary countertransference that I suggest is more likely to arise with patients who are traumatised and thus functioning at a borderline or psychotic level.     

The Analyst as Catalyst: Cultivating Mind in the Shadow of Neglect

I describe an effort to cultivate mind and deepen relatedness in patients who exhibit rudimentary thought and constricted forms of object contact, due to the effects of certain neglect or serious disturbance. Some of these patients require the analyst to serve as a catalyst, who takes proactive steps to summon a psychic realm to the patient’s experience and to forge components of the dyadic bonds that promote such function. The insights of the object relations tradition into foreclosed development are noted. I argue that such insights can be optimally applied with the benefit of the relational school’s emphasis on forms of dyadic engagement and use of the analyst’s subjectivity. In some cases of neglect, and others in which serious developmental challenge is the result of disturbance, priority is placed on the patient’s growth. Similarly, in my case illustration, my goal in using my subjectivity, as a catalyst, is for my patient to take his own emerging mind and psychic self with interest.     

The Entropic Body: Primitive Anxieties and Secondary Skin Formation in Anorexia Nervosa

This paper develops a metapsychological view of anorexia nervosa, including not only its symptomatic presentation but also its etiology and characteristic psychic and relational styles. Because patients with anorexia are understood as not having internalized maternal comforting functions in the period of separation-individuation, they are unable to digest trauma experiences of infancy. I argue that the anorexic patient’s disturbed relationship with food reflects distortions in transitional object usage. Lacking the ability to contain intense anxieties about disintegration and falling apart, patients with anorexia must find other ways to hold themselves together. The fear of getting fat expressed by these patients is one way that this fear of disintegration is expressed. Furthermore, the almost addictive experience of emaciation holds the personality together. Elaborating this idea, I develop the notion of the entropic body, a particular version of the false body (Goldberg, 2004) employed by patients with anorexia nervosa in an attempt to compensate for absent maternal comforting functions. This body-state (Petrucelli, 2014), which develops against a background of profound early trauma, eschews hunger and dependence in favor of omnipotently controlled protection.     

Seeing,mirroring, desiring: The impact of the analyst’s pregnant body on the patient’s body image

The paper explores the impact of the analyst’s pregnant body on the course of two analyses, a young man, and a young woman, specifically focusing on how each patient’s visual perception and affective experience of being with the analyst’s pregnant body affected their own body image and subjective experience of their body. The pre‐verbal or ‘subsymbolic’ material evoked in the analyses contributed to a greater understanding of the patients’ developmental experiences in infancy and adolescence, which had resulted in both carrying a profoundly distorted body image into adulthood. The analyst’s pregnancy offered a therapeutic window in which a shift in the patient’s body image could be initiated. Clinical material is presented in detail with reference to the psychoanalytic literature on the pregnant analyst, and that of the development of the body image, particularly focusing on the role of visual communication and the face. The author proposes a theory of psychic change, drawing on Bucci’s multiple code theory, in which the patients’ unconscious or ‘subsymbolic’ awareness of her pregnancy, which were manifest in their bodily responses, feeling states and dreams, as well as in the analyst s countertransference, could gradually be verbalized and understood within the transference. Thus visual perception, or ‘external seeing’, could gradually become ‘internal seeing’, or insight into unconscious phantasies, leading to a shift in the patients internal object world towards a less persecutory state and more realistic appraisal of their body image.     

Treating Patients with Symptoms—and Symptoms with Patience: Reflections on Shame,Dissociation, and Eating Disorders

I offer the view that the symptom picture found in most patients with eating disorders, as well as in the symptomatology of many other so-called difficult patients, is the end result of prolonged necessity in infancy to control traumatic dysregulation of affect. I propose that the central issue for an eating-disordered patient is that she is at the mercy of her own physiologic and affective states because she lacks an experience of human relatedness and its potential for reparation that mediates self-regulation. She is enslaved by her felt inability to contain desire as a regulatable affect and is thus unable to hold desire long enough to make choices without the loss of the thing not chosen leading to a dread of self-annihilation. Trauma compromises trust in the reparability of relationship, and for symptoms to be surrendered, trust in reparability must be simultaneously restored. Because felt desire is the mortal enemy of an eating-disordered patient, this fact becomes a central dynamic in the analytic field, leading analyst and patient into a struggle over who shall hold the desire and whether the issue of control over food is allowed to become a subject for negotiation. I discuss the inevitability of the analyst's own dissociative reactions in response to the patient's internal war over desire and control, and the different types of interpersonal enactments into which an analyst is drawn. In this tension, as illustrated through clinical vignettes, analyst and patient slip in and out of a constantly shifting array of self-states and thereby have an opportunity to coconstruct a transitional reality within which the patient's impaired faith in the reliability of human relatedness can be restored, and eating can become linked to appetite rather than to self-protection.     

Did You Say He Has a Hitler Mustache?: Analytic Vulnerability and Destabilization in the Face of Trauma

This paper looks at analytic vulnerability and destabilization through a detailed clinical example. There are different ways in which we may be vulnerable with our patients. In this paper I describe the raw and sudden vulnerability of allowing ourselves to be in a place of not knowing when both patient and analyst are unable “to see.” I describe an experience in which I lose my ability “to see,” both literally and metaphorically, while in session with a patient who is unable “to see” because she has dissociated her experience of loss and her experience of a sense of danger when in the presence of her stepfather. I link this clinical experience to the patient’s dissociated feelings and to my history of intergenerational trauma as well to current cultural violence and hate.     

Performative and enactive features of psychoanalytic witnessing: The transference as the scene of address

This paper will attempt to broaden the conception of witnessing in analytic work with traumatized patients by extending the idea to incorporate the patient’s developing and varied capacity for witnessing, as well as a witnessing that occurs within the analytic relationship itself. Actions occuring as part of traumatic repetition are understood to represent memory phenomena and are distinguised from dissociated self‐state experience. These experiences are not therapeutically intended to be symbolized, but rather lived‐through with the analyst, thus transforming the patient’s own relation to the experience. I suggest that the scene in which this living‐through takes place is the transference–countertransference matrix, and that it is the analytic encounter that allows traumatic repetition to take on the quality of a communication, an address to another, rather than remain meaningless reproduction. A clinical vignette illustrates the turning of trauma’s imperative for witnessing into an address in the analytic encounter.     

Befores and Afters of the Womb: Reply to Commentaries by Jeanne Wolff Bernstein and Dodi Goldman

This reply engages with Wolff Bernstein's and Goldman's rich discussions of Farhi's work. Wolff Bernstein's exploration of the relationship between Winnicott and Susan as a perversion of the phylogenetic shield operative in primal repression furthers our understanding of Milner's treatment of her patient. Following Wolff Bernstein's thoughts of the problems caused by Winnicott's mishandlings of Susan, I suggest that we might consider the referral process itself as an analogue to pre-natal life, the conscious and unconscious significations of which can have an important impact on the qualities of relational bonds to be built with the treating analyst.

Goldman's commentary deepens our insight into Milner as a person and as an analyst. At the same time, it also raises an important question about how early in biological life it is logical to assume the possibility of psychic material's registration, which Goldman sees as equivalent to considerations of psychic organization. Seeing the two as temporally distinct, I draw from critical analyses of Laplanche's theory to discuss how experience can be registered as yet-misaligned bits that await a later developmental time before it can become invested with meaning and become psychically organized.     

Cutting the silence: initial,impulsive self-cutting in adolescence

The paper explores initial, impulsive self-cutting in adolescence and conceives of early cutting as having the most potential for a communicative function, as the adolescents themselves and those around them may be most shocked at their self-harm. The author also conceives of the symptom of early, initial cutting as an effort to ‘cut through’ an emotional and familial circumstance that has been silent, suggesting that cutting generally implies a failure in containment and symbolisation. Using Green’s (1975) discussion of the original word symbol as ‘an object cut in two, constituting a sign of recognition when those who carry it can assemble the two pieces’ (Dictionnaires Le Robert), the author demonstrates that cutting has the potential to elicit intense feelings in the analyst who can have (in Green’s terms) a homologous experience to that of the patient. This elaboration within the analyst’s feelings returns a part to the patient. The meeting of the two communications (the patient’s cutting and the elaboration in the analyst’s mind) can create a potential space between them. The paper uses clinical vignettes and extended clinical material from a 16-year-old girl to elucidate the relationship between cutting – an emotionally inarticulate state – and the development of communication, containment and symbolisation through homologous experiences in the analyst.     

It is All Personal: Further Thoughts on Therapeutic Action: Commentary on Paper by Noelle Burton

This paper evolved from an earlier panel presentation on conceptual tributaries to relational thinking at the 2015 International Association for Relational Psychoanalysis and Psychotherapy Conference in Toronto. Representing the place of Object Relations theory in the DNA from which Relational Psychoanalysis emerged, I emphasized—and provide here an abbreviated review of—the contributions of Fairbairn, Klein, and Winnicott. Then, as now, believing in the communicative power of clinical examples, I offer an extended clinical narrative in which the medium is the message and clinical phenomena such as multiple self-states, enactments, negotiation, play, and the residue of internal object relations (in both patient and analyst) are brought to life. Also, as the Toronto Plenary overview paper by Jody Davies has developed into its current substantial elaboration of distinctly relational issues (multiple self-states, co-creation, and the interplay of process and insight) and serves as the capstone paper for this published version of our panel, I respond to Jody’s conceptual contributions and her perspective on Relational thinking.