Challenges in treating patients with psychosomatic disorders: some patterns of resistance

The treatment of people suffering from psychosomatic disorders poses important clinical challenges to psychoanalytic practice, including early abandonment, difficulties in engagement and superficial involvement in the treatment. The lack of systematic research on the subject suggests that a better understanding of the resistances and dynamics involved in such episodes is needed. Using supervision group to study treatments and inspired by action-research paradigm, this paper presents the results of an 18-month mixed-method qualitative clinical research on treating 22 cases. Thematic analysis revealed a frequent pattern of resistance to experience emotions that presented in two states: failure of repression (thin-skin) and massive repression (thick-skin). Narcissistic dynamics in the therapeutic relationship taking the form of ‘resistance to transference’ and a tendency to action were evident in both presentations. Symmetric and complementary counter-transference reactions, which compromised treatment, were also identified. Some technical implications are highlighted, such as the need to focus in the recovery of the patient's actual emotional experience and to understand such experience in the context of the ‘here and now’ of the therapeutic encounter. These findings suggest the need for a flexible approach to therapeutic work that moves between an ‘intrapsychic’ and a ‘relational’ focus.     

Relational treatment of a borderline analysand

Abstract

This paper, in case material, examines the role of the analyst is co-creating the sado-masochistic enactments so common in the transference/countertransference with borderline analysands. Emphasis is placed on how to resolve the enactments so that a new paradigm is created based on trust and cooperation.     

Where we live: some dilemmas and technical issues for the child psychotherapist in interpretative work with looked-after and adopted children

This paper addresses, from a Kleinian perspective, some of the dilemmas and technical issues faced by the child psychotherapist in work with looked-after and adopted children. A selective review of psychoanalytic literature focusing on the use of transference and countertransference is given. Clinical material provides some examples of different kinds of interpretation, and of the importance of timing and emotional resonance in the interpretations.     

The unconscious

A discussion of the unconscious leads naturally to Freud and to a theory on subjectivity we may designate as de-centred. The unconscious reminds us that not only do we not know ourselves. In the core of our subjectivity, we have to acknowledge the notion of otherness. Re-reading Freud's text, The Unconscious, from 1915, the current author emphasises the character and function of the unconscious as radically different from what we know about conscious processes. This allows for the concept of the preconscious, which the author links to Winnicott's intermediary area and Green's tertiary processes. Taking as point of departure Freud's differentiation of word presentation and thing presentation, the author points to Freud's introduction of the term thing-cathexies of the object as designating the primal psychic representation. The Freudian perspective is broadened, encompassing the notion of otherness as discussed by Laplanche and Aulagnier. Concluding the paper, the author draws some implications for psychoanalytic technique, focusing especially on transference.     

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.     

The making of a tragedy: perversion in the perception of truth

A type of wilful blindness can pervert an individual's perception of truth or reality, not because that reality is too much to hold, but because it is distasteful. Undesired. The case of Adam will be used to explore perversion as it twists an analytic process, affecting the transference and countertransference in ways that are difficult to see. Theorists of Freudian, Kleinian, Lacanian, and Jungian traditions are drawn from to explore potential roots to this perverted turn, and the way it can rigidify an individuation process. The anxiety that haunts this case echoes Jung's anxiety as he wondered if the stone saw him or he saw the stone. Object and observer blend when both analyst and patient hide from themselves and one another, knowing the truth of what is being discussed but blind to it.     

MOURNING,DREAMING, AND THE DISCOVERY OF THE OEDIPUS COMPLEX

The author argues that the structure of mourning and the structure of the Oedipus complex are triadic, the latter being obvious and easy to conceptualize, while the former is quite subtle. When it is the father who is mourned, the son must repeatedly invoke the dead object so that libidinal cathexis can be reinvested in living objects. Such was the situation in which Freud found himself in 1896 when his father died—the triadic nature of the Oedipus complex ironically not yet discovered by him. In the author's belief, Freud's mourning and his attendant rich dream life occurring between 1896 and 1897 gave him access to the unconscious raw material that would eventually help him conceptualize the triadic structure at the instinctual core of the Oedipus complex.     

Transference symptom

Transference symptom is a hazy notion in Freud's writings. The notion is presented here as a particular moment in the crystallization of the transference neurosis. It results from a double cathexis of the analytic frame and the analyst resulting in a symbolic distortion that is represented plastically within the session, as occurs in dreams. The transference symptom proceeds from two different preconscious cathexes, one attached to the reality of the frame, the other to the drive linked to the analyst. A psychic space is thereby opened up for interpreting both the resistance and the unconscious derivatives of infantile conflict. The transference symptom is a compromise formation that includes the analyst and questions the countertransference stance. Three different analytic situations give rise to transference symptoms according to the relative balance between frame and process in the analytic encounter. The concept is compared with enactment.