Julie's museum: The evolution of thinking, dreaming and historicization in the treatment of traumatized patients

The author contends that, following Freud, trauma may be viewed as a disruption of the ego's 'protective shield' and that a central factor of this shield is an internalized relationship to a thinking-containing mother. Severe trauma destroy this inner connection, resulting in the reversal of a-function and the establishment of a rigid traumatic organization (ß-screen) that brings coherence to the shattered psyche. However, this is an 'organized chaos' in which concrete forms of thinking predominate. The patient's ability to think, dream and imagine is signifi cantly curtailed and she is consequently locked in a traumatic world from which she is unable to evolve. He offers a detailed case history to illustrate these points and the vital role the analyst's imaginative capacities play in the analysis of such individuals. Finally, he addresses the development of the capacity to represent the trauma, starting with primitive, often somatically encoded experiences, and evolving toward the capacity for historicization.     

Forgiveness, acceptance and the matter of expectation

In this paper, the author argues for a dynamic conceptualization of forgiveness during psychoanalysis. The trauma of failed expectations in intimate relationships is narcissistically dislodging. When legitimate expectations in relationships are not met, forgiveness becomes a challenge for ego to restore the lost narcissistic balance through the resumption of a significant internal bond. The author argues that the ending of any successful analysis is marked by three possibilities regarding the patient's relationship to significant others and his traumas: in cases where the relationship was marked by minimal expectations, one simply learns to accept the wrongdoer without ever feeling the need for forgiveness; in cases where a relationship was marked by high expectations, the patient can learn to accept the trauma without the will or need to forgive its perpetrator. However, even with the painful frustration of high expectations in an intimate relationship, the patient can come to forgive his wrongdoer if there remains enough of a positive internal bond to be salvaged. The developmental roots of such forgiveness, as well as the addictive characteristics of 'nursing a grudge' and the conversion of the qualitative mode of seeking fulfillment into a quantitative one, are further investigated.     

Conflict theory/trauma theory

There has been a tendency in psychoanalysis to view the effects of trauma, and our ways of working with it, as something separate from our understanding and techniques of working with intrapsychic conflict. While appreciating certain differences, the author explores, primarily via clinical examples, how an integrated perspective may be most helpful to our patients, especially in the area of the patient's capacity to reclaim feelings.     

The patient's material as an aid to the disciplined working through of the countertransference and supervision

The author argues that the patient's largely unconscious observations of the analyst's functioning are, at times, communicated in the patient's material and that this can impart a sense of clinical relevance to the countertransference. The concept of 'understanding work' is used to provide a psychoanalytical model of this phenomenon. This is illustrated in a clinical case and it is argued that a selective consideration of the patient's material can provide a proper discipline which steers the analyst between the twin dangers of megalomania, on the one hand, and involvement in a symmetrical, self-disclosing relationship, on the other. The author then applies these ideas to supervision and uses them to distinguish psychoanalytic supervision from a practice that also derives from an intersubjective paradigm but which, to the author's mind, is not distinct enough from personal analysis.     

WORKING THROUGH ENVY: SOME TECHNICAL ISSUES

The author argues that envy appears in an analysis as a hostile, life-destroying force and is directed at the good qualities of the object, often manifesting in the patient's need to devalue analytic work that has been helpful. An intractable negative therapeutic reaction can thus become a persistent feature of an analysis. Sometimes powerful envy is silently operating beneath the surface, with the patient feeling continually wronged and mistreated by the object. The author argues that bringing the projected envy into the patient's personality structure is an important aspect of successful analysis, but that various technical problems have to be considered before painful insight can be achieved into the division in the patient's self. Presenting material from a relatively long analysis, she discusses some technical issues in dealing with these processes. Interpretation of envy can be a delicate matter, requiring consideration not only of how to interpret, but also of the nature of the countertransference and the form of the interpretation. A transference interpretation directed solely at the patient's self-destructive behaviour and destructiveness towards the object carries the risk of further stimulating the destructiveness, even if it is correct; it is also important to bring the patient's libidinal aspect into the interpretation.     

Der Stellvertreter

Based on the analytic work on colleagues the author investigates a writer’s block of German psychoanalysts when writing about their patients. In the process of their own therapeutic analysis, an inhibition of association in these psychoanalysts comes to the fore by them falling into the professional role and talking about their patients. The accounts of these colleagues on their own patients function as a doubled imago revealing the unconscious conflicts of the patients as well as acting as a proxy of the psychoanalysts’ impulses, affects and foreclosed memories in their own analysis. The inhibition of thinking, leading to a writer’s block, is the result of the correspondence of the trauma of the patient with the trauma of the analyst when the transference-countertransference relationship evokes annihilation anxieties in the psychoanalyst. Therefore the writer’s block of these psychoanalysts is rooted in their professional work and is the result of the internalization of precarious emotional contents of their patients. The author examines the role of institutionalized psychoanalysis in developing a professional writer’s block, and the results of the paper highlight the need of an emotionally supporting professional environment for the psychoanalyst during his training and his practice work.     

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.     

ACUTE ENACTMENT AS A 'RESOURCE' IN DISCLOSING A COLLUSION BETWEEN THE ANALYTICAL DYAD

The author discusses various aspects of the function of enactment in analytical practice, reviewing the concept, then describing a borderline patient with whom the analytic process seemed to be developing productively. Following a change in the setting, an intense, acute enactment took place. Understanding this led to observation of an unconscious collusion, in which a symbiotic relationship had been established between the patient, the analyst and his family, as a chronic enactment. This relationship had prevented the analyst from touching on highly destructive unconscious fantasies and archaic traumatic situations. Comprehension of the enactment enabled the collusion to be dissolved. The author suggests that, besides the resistance aspect, the collusion may have been useful in strengthening the patient's mental mechanisms and trust in the analytical work, which required some time. The acute enactment arose, unveiling the collusion, when the patient and the analyst felt able to face the terrible feelings related to the triangular situation. He speculates that both enactments may occur in the analysis of these kinds of patients, as part of the 'natural history' of the analytical process, and their function is to relive archaic experiences in the analysis, also with the aim of working them through. Finally, the author proposes a classification of enactments: normal, pathological, acute and chronic.     

The analyst's theory: A third source of countertransference

The author asserts that the analyst's theory, personal and/or academic, is an important source of countertransference which complicates our traditional understanding of the analyst's emotional responses as being constructed from a mix of his transferences and the patient's effects on him. From this perspective, theory - because it has no intrinsic relevance to the essential phenomena of individual analytic processes - may be a confounding, as well as a necessary, factor in clinical work. Although the analyst's theory might be conceptualized as a component of his personality that shapes his emotional reactions to a patient, the author believes that there is a valuable increment of conceptual clarity and additional clinical utility to thinking about a more direct role of theory in the process of countertransference formation. He uses aspects of the clinical analysis of narcissistic resistances to illustrate how some theories might predispose an analyst to confounding unconscious enactments by generating either positive or negative countertransferences which can be used defensively by the patient and/or analyst. He also illustrates how, in some contexts, an analyst's theory might attenuate potentially informative countertransference reactions and interfere in this way with the analyst's apprehension of the patient's psychic functioning. Finally the author addresses the importance of 'fit' between an analyst's working theory and a patient's psychopathology, and considers implications of his ideas for psychoanalytic training and practice.     

Facilitated and real trauma in the psychoanalysis of children of Holocaust survivors

The author investigates the effect of retraumatization on the children of Holocaust survivors who have appropriated their parents' trauma through unconscious identification. The author proposes that the working through of the real trauma results in a mitigation of the transmitted trauma in the psychic reality and mobilizes the work of mourning that facilitates the mastery of the real as well as the transmitted trauma. Two case examples are cited as illustration.     

Screen memory: its importance to object relations and transference

A screen memory of an obsessive and narcissistic man, reported early in psychoanalysis, both represented and disguised the patient's oedipal conflict, incestuous wishes, and sibling rivalry. It symbolized for him his relationship with his mother and was treated by him, in a repetitive and fetishistic manner throughout treatment, as the reason for his bitterness toward life, his sense of entitlement, his narcissism, and his distrust of women. In the transference, the memory-far from being inert- constantly played an active role in his wishes and disappointments regarding the analyst, and in his fantasied oedipal triumph over him. As the analysis progressed, and after years of treatment, the encapsulated nature of this memory began to give way to the patient's growing awareness of his oedipal wishes, the full range of his feelings toward his mother, and his sense of abandonment by her. The nature of screen memory is explored, including how it relates to a patient's personality and use of the past in general, how it may figure in the development of a person's object relations, and the decisive role it may play throughout a treatment.     

Who is who in dissociation?: A plea for psychodynamics in a time of trauma1

Contemporary theories of dissociation and trauma for the most part have evolved outside of psychoanalysis. Psychoanalytic writings have also been regarded as being in opposition to trauma‐based notions of human psychopathology. The specific psychoanalytic contribution—the emphasis on unconscious conflict and meaning—is for the most part excluded from the discourse on dissociation, often resulting in a mechanic conceptualisation of trauma. In this paper, based on clinical material, the author argues in favour of including conflict, unconscious intention and personal meaning in understanding the kind of dissociation we see in cases of multiple personality pathology. Textual analysis of letters written to the analyst illustrates how events of abuse are defensively elaborated. The author demonstrates that patterns of affect regulation and dominant object–relational strategies can be captured through analysis of the discourse structure. She focuses on how an organised character pattern, revealed mainly through narrative style and the analyst's countertransference, serves protective purposes as well as wishfulfillment. She argues that dissociation in the form of multiple personalities may imply an active, strategic agent.     

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.     

The body in the analytic session: focusing on the body-mind link

The author focuses on the importance of the body in the analysis of patients with a defect of thinking. In many cases this defect is not fully evident until concrete and bodily aspects begin to emerge in sessions. In the absence of awareness of the body, the patient's personality is deprived of the main source of emotional stimulus, and mental growth is consequently paralysed. Hence the body is considered the starting point of mental processes and a progressive source of experience requiring the exercise of responsibility and thought. To indicate the theoretical background to this essentially clinical paper, some hypotheses about the body-mind link are very briefly considered. Specific emphasis is given to the development of Freud-Klein-Bionian theories about this subject and to some of Ferrari 's recent proposals. The author discusses four clinical cases, emphasizing the encounter with the body in analysis and its integration in emotional and thinking processes. The analyst's function in such cases is conceived mainly as that of midwife for a dialogue between the analysand 's body and mind.     

The analysis of an adult with night terror.

The author discusses the analysis of a woman with night terror, a condition rarely seen in adults. The analysis revealed the pathogenicity of splitting mechanisms which had developed under the influence of an overstimulating environment and exposure to the primal scene, followed by the separation and divorce of the patient's parents.     

On boredom: A close encounter with encapsulated parts of the psyche

The psychoanalytical literature has numerous scattered references to the analyst's experience of boredom, especially amongst writers working with primitive mental states. In the present paper, the author tries to gather some of these references in an attempt to integrate the various facets of this widespread phenomenon, and reflect on some clinical issues and dilemmas it raises. It is suggested that the experience of boredom in analysis may be a reaction to an encounter with a hidden, encapsulated part of the psyche, a bidimensional area of experience in which mental activity has been suspended, and experience remains meaningless. This is a barren area of lack, an encounter with the autistic core of the psyche. However, boredom may also be an experiential expression of despair, a re-living of primitive object relations with an emotionally non-existent primary object. Through bringing the emptiness and desolation into analysis, the individual makes room for the empty, blunt, dead inner object which resides within him, and that needs to be integrated into the psyche. This inner object is a vital part of the patient's inner world, part of his history, and can neither be erased nor filled in order to eradicate the emptiness. This is illustrated by clinical material from patients along the spectrum of autism, autistic reaction following trauma and autistic barriers in neurotic patients.     

Why read Fairbairn?

The author offers a close reading of portions of Fairbairn's work in which he not only explicates and clarifies Fairbairn's thinking, but generates ideas of his own by developing concepts that he believes to be implicit in, or logical extensions of, Fairbairn's work. Among the unstated or underdeveloped aspects of Fairbairn's contribution that the author discusses are (1) the idea that the formation of the internal object world is always, in part, a response to trauma (actual failure on the part of the mother to convey to her infant a sense that she loves him and accepts his love); (2) the notion that the infant's unceasing efforts to transform the internalized relationship with the unloving mother into a loving relationship – thus reversing the effect on his mother of his (imagined) 'toxic love'– is the single most important motivation sustaining the structure of the internal object world; and (3) the idea that attacks on oneself for the way one loves, while self-destructive, contain a glimmer of insight into one's own self-hatred and shame regarding one's endless, futile attempts to change oneself (or the rejecting object) into a different person. The author, using his own clinical work, illustrates the way he makes use of his understanding of the 'emotional life' of internal objects to facilitate the patient's emotional growth.     

Screening for trauma histories,posttraumatic stress disorder (PTSD), and subthreshold PTSD in psychiatric outpatients

The ability of the Structured Clinical Interview for DSM-IV (SCID) posttraumatic stress disorder (PTSD) module's screening question to identify individuals with PTSD or subthreshold PTSD was examined. First, the screen's sensitivity for detecting a trauma history was determined. Second, the incremental validity of a more thorough trauma assessment was examined by determining how many individuals responded negatively to the screen but then were diagnosed with PTSD or subthreshold PTSD. Last, the optimal SCID termination point for assessing subthreshold PTSD was determined. Using a trauma list increased the number of participants reporting a trauma; however, the SCID screen captured almost all individuals who had PTSD or subthreshold PTSD. When one screens for subthreshold PTSD, the SCID can be terminated on failure to meet Criterion B.     

A loss function for alpha factor analysis

Most of the factor solutions can be got by minimizing a corresponding loss function. However, up to now, a loss function for the alpha factor analysis (AFA) has not been known. The present paper establishes such a loss function for the AFA. Some analogies to the maximum likelihood factor analysis are discussed.The author is greatly indebted to Prof. Henry F. Kaiser (University of California, Berkeley) for his kind encouragement. He is also indebted to an anonymous referee ofPsychometrika for having confronted him with the problem in 1977. Financial support by the Wiener Hochschuljubiläumsstiftung is gratefully acknowledged.     

Mixed Race and the Negotiation of Racialized Selves: Developing the Capacity for Internal Conflict

The author uses contemporary psychoanalytic theory in further understanding the negotiation of conflict and dissociation in biracial patients who are both African-American and White. Drawing on the work of contemporary theorists who have made efforts to navigate the relationship between inner and outer worlds in our understanding of race from a psychoanalytic perspective, the author examines the relationship between race, culture, and internalized self-other relations—how they interact with each other and impact splitting and dissociative processes among self-states. The author argues for a notion of the unconscious as one that contains historical trauma related to race relations that influences the developing capacity to sustain internal conflict between opposing self-states borne out of this trauma. The author shows how society works against the integration of racialized self-states and interferes with the capacity to contain conflict. Through an extended clinical vignette from an analysis of a mixed-race patient, the author looks at the interplay of self-states between a White analyst (author) and a mixed-race patient (African-American and White) as manifested through a series of enactments and the unconscious “mating” between dissociated self-states in both patient and analyst. The author argues that the analyst's engagement of his or her own dissociated self-states and containment of internal conflict is critical to aiding the patient in moving toward greater integration.