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Laura Arens Fuerstein
Printed
with permission from Jason Aronson Inc. Publishers. Originally appeared
as Chapter Eight in "Mind-Body Problems," by Janet Schumacher
Finell, editor. Jason Aronson Inc., N.J., 1997. Jason Aronson can
be reached at www.aronson.com. In recent years, the literature has increasingly addressed the issue of the mind–body connection. Areas of focus related to the psychosomatic patient that apply to Beryl include a deadening of feeling with poorly defined affect (alexithymia); an inability to experience pleasure (anhedonia); and a deficit in early object relations, which leads to short-circuiting of feeling paths to consciousness and a resultant substitution of emotion with somatization (disorder of regulation). While this chapter discusses how these elements are reflected in the case of Beryl, the primary focus is on the interpretive process and how it is infused with the intersubjective experience. Through this means, an attempt is made to break through the patient’s outer wall of deadness to reach the affect within her psychosomatic armor. The creation of the interpretation in the vignette to follow is delineated in two major phases: the approach stage is defined through capturing the heightened transference moment; proceeding from this, the wording of the interpretation stage is viewed as a two-part process, that is, the therapist’s internal and external communication experience. This involves first internally "reading" the patient’s nonverbal language, and ultimately transforming it into externalized words to be shared with the patient. The heightened transference moment delineated within the approach to interpretation reveals Beryl’s core issue: the use of the psychosomatic symptom to prevent damage to the fragile maternal object. I attempt to demonstrate how Beryl’s lifelong struggle to preserve the wholeness of a mother perceived as teetering on the edge of fragmentation from the time of her daughter’s infancy is a fundamental cause of her psychosomatization. Within the second phase of interpretation, that is, the therapist’s formulation of words, the powerful use of my own body’s responsiveness to Beryl’s somatic cues is pictorialized; the visceral reverberation and heightened visual sensitization triggered in me by her physical communications are transformed into a verbal language, which in turn melds with her own metaphorical expression to form the affect-evoking interpretation. The aforementioned basic elements of interpretation are depicted in this chapter as they appeared in the intimate analytic space of one woman’s treatment; however, an underscored thesis is that they might be applied in a more universal way to psychosomatic patients in psychotherapy. It should be noted that the interpretive process described is not meant to be taken as a schematized entity. In practice, there are obvious overlaps of and interactions between the phases described. This interpretive approach is offered as a uniquely personal (for both patient and therapist) piece of the intersubjective experience, which always involves creation; in this case, the therapist’s "listening" to the patient’s nonverbally defined affect through the language of the body leads to some transformation of both participants in the therapeutic space. Illuminating this idea, Ogden (1994) writes:"The analyst must be prepared to destroy and be destroyed by the otherness of the subjectivity of the analysand and to listen for a sound emerging from that collision of subjectivities that is familiar, but different from anything that he has previously heard" (p. 3). This chapter represents an effort to make this "collision’’ come alive.
My first impression was of a lovely young woman whose large, sad, blue eyes took up much of her face; the glimmer of light in them was obscured by heavy dark-framedglasses and short, blonde, curly hair. Through my connection with her gaze I could sense a deep well of mourning and pain but she seemed to carry it alone, in some remote place. Upon entering the room, she immediately conveyed the outer layer of herself, the false self which, as Winnicott (1956) states, conceals and shelters the authentic one. The latter is denied a rich emotional life experience because the false self"develops a fixed maternal attitude towards the true self, and is permanently in a state of holding the true self as a mother holds a baby" (p. 456). Beryl’s false self, made known to me from the start, was one of utmost self-sufficiency: she would be the one to hold me up, her eyes told me at first glance. I instinctively felt that she had learned well, through some as yet unknown contradiction of nature in her developmental process, how to achieve this goal of supporting me, the would-be caregiver. As her ego structure was gradually developed, and layers of defense were peeled away after several years of treatment, her inner fragility came to light; there was a helpless, neglected little girl hidden beneath the facade of independence and strength. Her self-reliance was buoyed by a hyperactive way of life; frequent, purposeful activity without much attached pleasure during the day and sleeplessness at night kept Beryl from staying with herself long enough to feel the inner hurt of emptiness or defectiveness. Her words, although often used to describe seemingly painful events, would lie flat in the treatment room; they seemed weighed down, powerless as evocative tools, with little capacity to pictorialize the feelings they were meant to express; moreover, they were useless as creators of transitional space between us for play, in Winnicott’s sense. Her free association was not free–it was brittle, and would seem to break off whenever she would get close to expressing a need or an angry feeling. Further, it appeared that the link between Beryl’s two worlds of fantasy and reality had been severed at some very early developmental point. In Loewald’s (1975) terms, in the healthy adult the play arena and the rational realm coexist and often mingle, as they do for the 2-year-old, and in the analytic setting this collaboration reaches an apex through the intensification of the transference. It was evident to me from the start that for Beryl this melding of the abstract and the concrete was not permitted, and that, paradoxically, in order for her tenuous sense of self to remain in some whole form, these two worlds had to be kept divided at all costs. As I came to know her better, a point was being driven home: from very early on in life, Beryl had learned that playfulness was dangerous; it would mean diversion from the serious mission placed in her hands from infancy onward–that is, to ward off her mother’s fragmentation. Beryl is the older of two children (a brother is 18 months younger). Her mother told her with pride that she was given the bottle propped up in an infant seat from the age of 3 months (and seemed to "like it better that way") and was toilet trained ("with no problems") by 15 months. In her mother’s words, she showed an "inborn self-reliance." For the first few years of treatment, Beryl conveyed a sense of very little available memory and affect in relating her history. Her past was often described as if she were giving a narrative of someone else’s life; the connection to feelings seemed tenuous. She did have a vivid memory of her mother lying in bed in a half-stupor in the early evening, often while having Beryl serve dinner to the rest of the family. Next to the bed would be a glass of water and a bottle of tranquilizers. Another clear memory appeared of herself at age 10, being asked by her mother to take over the housekeeping and mothering tasks related to her father and brother. Around puberty, Beryl heard her mother say to a neighbor that she was "going to fall apart," and did not know if she could go on. Soon after, her mother suffered hemorrhaging from fibroid uterine tumors; her memory vividly depicted the "bloody sheets carried to the laundry room by my aunt." Beryl’s reaction to these circumstances was ascertained only after years of attempts at reconstructions; her image of her mother was a body literally falling to pieces, but the striking aspect of this scenario was Beryl’s feeling totally removed emotionally, andfascinated, as an outside observer would be, by the blood on the sheets. The dissociation, which would be applied so effectively in the future through psychosomatization, had worked for the moment to block out the fear. When she began menstruating soon after, she feared that fragments of her body would fall into the toilet with the blood. Beryl’s father was an archetypal macho man, with a chest that she described as "pumped up fireplace bellows." She felt her husky voice resembled his, and that had always made her feel that inside she was really more boy than girl. She was conscious of both her attraction to and fear of him, and her wish to identify with him as the more vigorous parent. He was the one who would not "fall apart"; she saw his aggression in the context of strength and vitality, in contrast with her victim-mother who seemed sick and emotionally dead throughout most of Beryl’s developmental years. At the same time, she was terrified of his sudden physical attacks, alternating with sexual seductions that conveyed a message that she was the oedipal winner. The onset of Beryl’s symptoms occurred when she went to sleep-away camp for the first time, during puberty. One night, she had been petting with a boy she had had a crush on, and could not fall asleep later as "it felt like a large thing was jabbing away at my heart, and my chest blew up." The phallic connotations are most obvious. In
describing this event, she stated, "I think Mother gave me
a message that if I was free, she’d be threatened. Maybe I
thought she would literally break apart or go crazy if I left her.
It’s as if I had to abuse my own body in order to be loved
by her, and not be abandoned by her. My heart becomes like an enemy,
beating me up, when it gets like that, and I get afraid that I will
ruin it; it too, will go to pieces, like Mother, and"I’ll
have a heart attack and die. But somehow we’re still together
— even in death."
By the third year of treatment, when the transference had intensified (she could now at times express a feeling of seeing me as a nurturing figure, whom she would miss during weekends or vacations), the symptoms increased in frequency and quality, but they were not yet made visible in sessions. As she began to get more in touch with the emptiness and sadness beneath her outer layer of self-reliance, her dependency wishes in the transference began to emerge, as did her relational need for me as a real object. One day she described a dream she had had the night before: "I’m undressing my baby niece, and there’s a gaping wound on her chest, with all the cartilage and muscle showing." She went on, "That must be me. It feels like if I take away these symptoms, like the battering of my heart and the pressure pushing my chest outward, that something will just pop out of me; there won’t be anything left inside me. It’s funny, too, I had that dream after a day in which I had tried on a nightgown, and had admired my breasts– thought they were full and sexually exciting to Ray [her boyfriend]. The dream must be some punishment for thinking of myself as a sexual woman who can have more pleasure than Mother." We were then able to look more carefully ather fear that I, as the bad mother, would desert her for her sexual expression. It should be noted that for the first two years of treatment, Beryl had been unable to directly express any anger at me. The only available conduit for it was through indirectcues, saying that she was being made to suffer through the rigors of the treatment. For example, right before sessions were over, she would "shut down," saying, "Why should I allow myself to be vulnerable at the end of a session, when I know you will break off the connection?" At a later point in the treatment, she was able to metaphorically describe her experience, which triggered her closed-off behavior at the ends of sessions (particularly those marked by a gradual increase in her capacity to link words with emotion):"It’s as if I have been a tightly wrapped mummy throughout the session–my fear is that one of the bandages will come undone at the last moment, something will start to leak out of me, and I won’t be able to put it back." We were able to define her fantasy that anger toward me for leaving her after she had begun to open up would spill out of her uncontollably, as it would have after each of her mother’s abandonments of her–if she had not kept it "under wraps" inside her psychosomatization. There were reflections of her identity with her martyred mother, such as slightly pained facial expressions upon entering the office. At these moments I could so clearly see in her the long-suffering woman on the bed; moreover, I became aware of a countertransference reaction of responsibility for her pain–I experienced what I thought she must have felt as the little girl whose mission is to take away the mother’s suffering, particularly because she has caused it. It
should be noted that there was always a certain hidden grandiosity
in Beryl’s sense of victimization–that going through this
purgatory (which included her experiencing somatic symptoms) ennobled
her, made her superior to me and to others. But the grandiosity
was deeply buried and could only be confronted at a much later date.
The martyr self-image was ego-syntonic and essential, tobuttress
her defense of the self-sufficient child image. To identify the
secret wish for exaltation would highlight the idea that she had
a need of any kind–and at this stage in the treatment, this
would have been intolerable.
Second, the father is too seductive and abusive to function as a healthy source of rescue from the bad maternal object, but his vitality, in contrast with the mother’s deadness, makes him the more desirable source of identification (it should be noted there is some healthy ego reflected in this choice). Third, Beryl uses powerful defenses to isolate affects from words, and conveys these painful emotions through her bodily symptom. Fourth, Beryl evinces a marked inability to play and have a humorous side, both in the treatment room and the outside world. Fifth, a harsh, archaic superego leads both to pervasive projection of the superego onto me (the preoedipal object), and a need for utmost control over impulses, which leads to great restriction in expressing dependency needs and hostile wishes in particular. To sum up Beryl’s plight, one might say that, in order for her to preserve the mother, she cannot move too far from her side, feel too much, play, or be creative; moreover, the effect of her merger with the bad maternal object is that she maintains the reflected self-image as the sick, defective female. In other words, the great paradox of her life, is that she must remain dead like the mother in order to feel she has the right to live. Further, to be like the father is to be alive and vital, but also destructive and frightening, and in some ways to lose herself as a female. The following vignette reflects many of the aforementioned dynamics and reveals aspects of my processing of Beryl’s body language. It provides a description of my experience in capturing the transference dynamic–that is, the moment of linking the symptoms expressed in session with the specific object relations pattern being played out with me. The vignette also helps to pictorialize the internal and external aspects of an intervention. Following this vignette from the treatment setting, I shall present a conceptualization of what occurred. It should be noted that I have homed in on a single vignette, purposefully, to provide an intimate view of the intersubjective process. There were, however, other transference-countertransference enactments at other moments in Beryl’s treatment, and in that of other psychosomatic patients of mine, that resembled the one described in the vignette. It must also be pointed out that Beryl’s symptoms are not reflective of a disease; hence, an approach to her treatment may or may not parallel one applied to patients whose psychosomatization is interwoven with an organic illness. With these ideas in mind, the following therapeutic process is discussed with the hope that it might stimulate further exploration and clinical validation for a wider application.
When we explored what had set off these symptoms, Beryl could begin to recognize that her fear of some unknown devastation was reminiscent of an amorphous terror during her teen years, when her mother would seem to pounce on her for a pleasurable growth experience, statement of her own opinion, or sexual enactment. She remembered a day when her mother became silent, and went to "the bed and the pills" after seeing Beryl on the front lawn laughing with and hugging a boy she had developed a crush on. My countertransference reaction to her body language and symptomwas to want to reach her and comfort her in some way, and yet I felt a distance, as if her putting a wall between us would protect her from some unknown harm. I also felt some vague sense of responsibility for causing her pain. I asked myself, What unconscious message might I have passed on to Beryl to contribute to this set of circumstances? Was I the one who had created the space between us? I realized, through internal processing that a projective identification process had occurred. She had had to project onto me her identity as the toxic one, the child with the capacity to hurt that defective, fragile mother through growth or separation. In this way, she could be rid of the painful sense of herself as the destructive one, the one to cause fragmentation of the maternal object. In turn, I had taken on the persona of the destroyer. Through this empathic connection, I could further understand why her body had become such a useful sidetrack for impulses that she experienced as aggressive missiles of maternal destruction. For a short time in the intersubjective experience of the treatment room, I was Beryl as a small child, and she was her mother, suffering, and letting me know it in a big way through her body language. I felt my own visceral response–a tightness in my chest and a constriction of my musculature. In a fleeting moment, I saw the lifeless woman on the bed who could break into pieces at any time; I saw the frightened little girl who might save her mother from disintegration if she could just take enough of the pain into her own body. It struck me that my image of the child and mother was very detailed and specific: they each respectively reflected the physical qualities of one of my childhood friends and her mother. When I looked further at this vivid picture, I remembered that this friend had always exuded some quality of sadness. She had acted as acaregiver of her five younger siblings, as her mother had been chronically ill and her father was an alcoholic. I realized that my visceral and visual senses had been heightened in my effort to reach an empathic level with Beryl, and that perhaps her psychosomatization had triggered this reactive sensory response in me.
I find it useful to broaden the negative transference concept by translating it into object relations theory. In considering the dynamics of the vignette, I believe it is particularly effective to focus on the specific moment when Beryl’s terror of destroying me, the maternal object, through separation or growth is evident through her body’s response, as revealed in the session. This brings out what I view as her core issue, embodied in her role as the parentified child. A
Core Issue: The Breakable Maternal Object One tragic repercussion of this situation is that this child develops "the art of not experiencing feelings, for a child can only experience his feelings when there is somebody there who accepts him fully, understands and supports him. If that is missing . . . then he cannot experience these feelings secretly ‘just for himself’ [and] fails to experience them at all. But nevertheless . . . something remains" (Miller 1981, p. 10). The "something" that remains is often the psychosomatic symptom. It is a corollary that this same child would never feel free to move far enough from the concrete mother to explore the realm of fantasy, transitional objects, play, symbolization and humor. This impediment is accentuated, as in Beryl’s case, when the father cannot function as a true rescuer from the maternal engulfment. These issues are well reflected in Beryl’s statement regarding the sense of herself as a "mummy on the couch" or similar statements: "If only I could fly and soar high and away." "If only I could break out of this wall around me, then my life would be so free." "Sometimes it feels like my body is a barrier, not attached to my feelings, and not letting them out." A related concept is found in McDougall’s (1985) case of the "chasmic mother and the cork child." In this situation, the child is given the unconscious message that the only way for the mother to survive is through her daughter or son’s acting as a plug to fill up the infinite void within her. In applying these formulations to Beryl, I began to think of her as a "glue-child" –that is, a child who not only is called upon to fill the infinite maternal cavity, but also acts as the mortar that holds together the shards of the shattered maternal object. When Beryl would describe a wall around her that she could not go beyond we began to see it as representing the entry to the outside world, the world that would take heraway from the "Humpty Dumpty" 1mother the one who sat on the wall and would certainly fall into little bits as soon as her "glue-child" would part from their merged realm of defectiveness. The maternal object in this case is kept whole by her child’s providing a webbing for her tenuously attached fragments. The meaning of the expression "coming unglued" was driven home to me! 1. I must share a moment of astonishment with the reader. Several months after I had completed this chapter, and without hearing it from me at any time in the treatment, Beryl used the Humptv Dumpty metaphor to describe her symptoms as they appeared in session! While experiencing the sense of her chest inflating. she stated that she felt like Humpty Dumpty, who had a thin outer shell. Further, she said with a sad tone, "It’s as if this fragile layer is lifted up, creating a space between my real, feeling self down below and this external shield, presented to the world. I have to constantly work at keeping it up, because if I let up for a moment the whole thing will crash
It is interesting to note that Edmund has consumption. In real life, O’Neill was often ill; he smoked and drank excessively, and toward the end of his life suffered from an untreatable hand tremor and displayed subtly suicidal behavior, mostly through self-neglect and the resultant physical deterioration. His last wife said of him, "When he was hurt, he never said a word. He just sat there and died" (GeIb and GeIb 1962, p. 896). There are clear parallels between Beryl’s mother’s and Ella’s relatedness to their offspring, and equally visible similarities in their children’s lifelong efforts to rescue their mothers from destruction through turning against their own bodies. The above discussion underscores the concept that in many psychosomatic patients such as Beryl , preoccupation with down, and my free self will be let loose. I guess that thought still frightens me." While I had used Humpty Dumpty in writing to evoke the image of the breakable maternal object, Beryl had, in free association, applied it to her false self–the scaffolding used to prevent the mother’s fragmentation. Our separate use of this term as closely wedded entities might be viewed as a graphic example of Beryl’s symbiotic fusion . Moreover, in recognizing this evidence of the meeting of our unconscious minds, I experienced a sense of the uncanny: while our bodies had resonated in the intersubjective experience of the treatment room, our words, in parallel fashion, now reflected the congruity of our psyches, and depicted in microcosm the metaphorical leap from the somatic to the verbal realm the survival of the maternal object is the primary focus from infancy. The self-abuse directed at the body is viewed, paradoxically, as a necessary lifesaving act, since it begins before self-object differentiation occurs. This self-attack serves several functions: first, it is a biochemical track for discharging unacceptable feelings, ultimately leading to "disregulation of affect" (Taylor 1992); second, on a preoedipal level it rescues the mother from possible destruction by taking back into itself the primitive aggressive impulses initially aimed at the depriving or attacking object; third, it provides superego punishment for any guilt connected with separation, which can take form in hurting the mother through feeling too much (perhaps feeling too alive), experiencing one’s sexuality in a free-flowing way, or just differentiating (becoming too different from the mother); fourth, it provides a momentary sense of aliveness– since symptoms provide evidence of bodily sensations, the fear of falling into the mother’s state of deadness or fragmentation is diminished.
To summarize, how do we apply these ideas to the therapist’s response, in connection with the vignette presented? The first element in the approach to interpretation of the patient’s somatic shorthand is found in exquisite attunement to the heightened transference expression. I believe that the most palpable fearfor Beryl, expressed through the transference by way of somatization, is of harm to the mother caused by her growth (described as her core issue). Specifically in the vignette, separation, evoked by a pleasurable feeling of professional achievement, is equated with destruction of the mother. It should be noted that other events with a common thread of individuation occurred throughout treatment that seemed to set off the somatic response in the session following the particular experience felt as growth: anight of heightened sexual pleasure along with greater orgasmic intensity; a relaxing weekend in which Beryl was engaged almost solely in pleasure-seeking activity; a newly experienced sense of excitement felt during a surprise party arranged by a friend. Theoretically speaking, Beryl experienced herself as saving me, the maternal object, from destruction triggered by signs of separation, by hurting her own body. Interpretation Internal and External Phases The next stage in the interpretative creation is defined by a two-part process, similar in form to one that might be used with a more verbal patient. Poland (1986) delineates this experience by identifying an intrapsychic and a dyadic phase. The therapist must move from a level of self-analytic work in which speech (within himself) is silent to one of verbal sharing of parts of himself to the patient. In the case of the psychosomatic patient, we are one more step removed, since we must create words that will signify the meaning of someone else’s language without access to his or her own verbalization. We lack the key to more precise meanings that might otherwise be supplied by the patient with spoken associations to the unconscious. Poland writes that, as it is, verbal derivatives "even at their most free, are already translations. Interpretations thus, are translations of translations, having passed through the filter of the analyst" (p. 257). Recognizing this added obstacle can facilitate the interpretive process with the psychosomatic patient. Hogan (1995) reports that these patients can be reached through intensive treatment, contrary to a popular belief that the content of the fantasy life has been too deeply buried to be analyzed. He finds that, as opposed to their sole use of immovable repression, a good deal of suppression of content and denial of feeling is employed by these patients (both defenses can be affected by analysis and, at times, in-depth therapy). While I might take issue with this view when applied to some of the more disturbed, severely ill patients with ingrained disease, I find it useful when related to Beryl and other patients with like dynamics, manifesting fleeting clusters of physical symptoms. In applying this finding to the intrapsychic part of the interpretive process, it is a corollary that the therapist will be required to augment his listening skills and attunement to transfer from a process of deriving meaning from the patient’s words to one of decoding the message buried within the patient’s body language. Interpretation
Internal Process: What elements enhance the therapist’s inner process of creating the words to describe the meanings of the cryptic psychosomatic code? One is the concept of integration of cognition and creativity–science and art are joined in formulating any interpretation. There are many suggested facets of this melding process for example, Greenson’s "working model" for developing empathy and Tansey and Burke’s "internal processing." What I would like to focus on here, however, is the use of the therapist’s senses, particularly the visceral and visual ones, in internally translating the patient’s physical symptom that substitutes for a verbal expression. Fuerstein (1984, 1992), Jacobs (1973), and McDougall (1989) address how well suited the therapist’s body response is in achieving an empathic connection with the verbally blocked patient, because it so powerfully evokes the preverbal primary experience with the mother. In discussing this element, Jacobs considers that the treatment setting might be particularly adapted to the use of "body empathy," when partial regressions are experienced by the analysand (the psychotherapy patient can go through some regressions, albeit fewer and less intense). The author writes, "This temporary reinvestment of the body, which revives the latent sensitivity to kinesic cues that played so large a role in infancy and early childhood, then allows the analyst to react with bodily responses that reverberate with the unconscious communication of the patient" (p. 87). In the vignette, my own use of body empathy is demonstrated in interpreting my somatic responses to Beryl’s physical stirrings in the session; not only did I have a sympathetic visceral response to her symptoms, but I felt the countertransference and relational-based desire to reach her. When I examined this feeling, it involved wanting to move beyond the emotional touching to hugging and providing physical comfort. Moreover, in applying this concept in a broader sense of treatment of the psychosomatic patient, it may act as a particularly effective transition vehicle from observing the symptoms to translating the patient’s code. As one body reaction "speaks" to the other, it creates a common language ground from which a verbal communication can evolve. The use of the therapist’s visceral response, felt while the patient is describing the physical symptom as it occurs, is part of the intersubjective experience; the speaking and listening that normally take place in the therapy setting through a verbal process is substituted with a language of the body. Further enhancement of this communication, however, might be found through the visual sense of the therapist. It is theorized here that if the therapist can heighten her seeing response to the somatic expression of the patient, a picture will be available as a springboard to the hidden meaning(s) beneath the symptom. Freud’s (1900) theory of dreams is most explicit in providing a description of the regressive process involved in pictorializing thoughts. He states that the visual sense leads to a regressive experience in which ideas are transmuted into images. However,he emphasizes that the key thoughts that go through this conversion are those that are closely tied to suppressed or unconscious memories. Hence, the therapist’s need to experience partial regressions in order to empathize with the more verbal patient is intensified in responding to somatic symptoms."A picture is worth a thousand words" underscores the effectiveness of the therapist’s returning to a preverbal era of her own, when sense images such as vision defined her experience of the outside world, when words were not available as signifiers of affect. Interpretation – External Process: Use of Metaphor in Communication with the Patient The final phase of interpretation of the psychosomatic symptom begins with the therapist’s awakening of the patient’s slumbering affect buried within the body’s symptom. Once it is brought out into the light, it can be moved toward a reconnection with the primary intolerable fantasies into which it was once melded. To achieve this end, the therapist must take the product of her internal work, that is, understanding the meaning of the transference expression of the somatic symptom and the magnified use of her kinesic and visual senses, which interweave with other aspects of theory and technique applied to forming an interpretation, such as her associations, awareness of the patient’s ego strength, deficit versus conflict elements, transference– countertransference, and relational issues. The literature addresses the concept of the metaphor as the most basic form of language, powerfully evocative of the preverbal period of life. Sharpe (1940) writes that metaphor, as the earliest form of figurative speech is developed intandem with the period of learned control of the bowel and bladder; hence, the feelings that were connected with the related body functions find substitute paths during verbal development through metaphors. Searles (1962) presents the notion that perhaps the metaphor’s power to evoke strong emotion is due to its capacity to rekindle a preoedipal memory "when we lost the outer world–when we first realized that the outer world is outside, and we are unbridgeably apart from it, and alone" (p.58). He views this part of speech as both a sign and facilitator of transition from concrete to symbolic thinking. Arlow (1979) highlights the idea that metaphor evolves at that developmental period when the complexity of thought cannot be expressed by the limited number of words available to the child. In relating this to the treatment process, he states that the analyst’s use of metaphor in interpretation at a moment of heightened anxiety is particularly effective, because, due to its cryptic quality, it provides the patient with a reasonably safe space from content that might prove too anxiety-producing if more direct language were used. Hammer
(1993) underscores the potential role of the metaphor to evoke emotion
in the clinical setting. He describes it as enhancing a participatory,
shared experience of therapist and patient ¾ a sense of "trying
on the image." The patient can "think-feel" the interpretation;
a metaphor, as a word-picture, gives the patient the power to reach
into unconscious, preverbal experience.
One imagined, all-encompassing response from her might be, "My battered heart makes me feel alive, likemy father, and unlike my deadened mother–and touched, in contrast with me as a child, in the void of mother’s neglect. At the same time, it beats and abuses me, as both my mother and father did, to punish me for separation and sexual wishes, or for being a woman. My blown-up chest gives me the sense of power of Father’s phallus, with its combined penetrating and distancing capacity. There is also a sense of a fusion of abuse and stimulation, just as in Father’s way of relating to my body when I was a child." Hence, there are preoedipal and oedipal meanings, elements of the drives, object relations, and gender identity issues reflected in her symptoms. The task at hand, in leading to the ultimate communication to the patient, is, as with any interpretation, to select the words that will have the greatest degree of resonance, based on what is relationally sensitive, closest to consciousness, and respectful of defenses, and based on the intensity of the transference, object relations, and ego strength. In returning to the vignette and the approaches to interpretation previously discussed, the most pressing transference issue is viewed as fear of destruction of the mother, due to an individuation experience (in this case, professional growth). This leads me to think in terms of object relations issues of separation – particularly during the rapprochement, when the child might look back at the mother while stepping out into the world. The mother’s accepting glance, energetic body language, or tone of approval through words are seen as crucial reinforcers of growth at this stage. The related element of frightening aggression aimed at the maternal object is woven into the concept of Beryl’s career advancement. Oedipal guilt over beating out the pitiable mother also colors the picture. The internal work in forming the interpretation involves selecting the issues that can best be taken in by the patient, to lead to insight based on the patient’s relational needs and transference state. For Beryl, one issue is the surfacing of her preoedipal fear of losing me through separation; in contrast, her anger seems too amorphous and defended against at this point in the treatment, and her oedipal fear of competitiveness with me too threatening to be usable; further, gender issues are certainly not yet definable. Hence, I believethat the fear of loss of the object is closest to consciousness. Tone, manner, and timing are important in presenting the interpretation. As Greenson (1976) notes, it is these nonverbal nuances conveyed in the therapist’s speech to the patient that evokethe earliest object relations experiences, which become a heightened issue with a psychosomatic patient such as Beryl. More specifically, in this case the importance of a warm, nonconfrontational tone is stressed, because the fear of causing
The final phase of the interpretive process then evolves, using a melding of the above thoughts with a metaphor that incorporates the patient’s own metaphorical description (e.g.. a punching heart) of her symptoms. An example of this unifying verbal process is found in my words to Beryl: "Maybe you’re afraid that I would be angry and hurt if you grew, so you put your heart and chest in the boxing ring instead of me ¾ that way, I won’t leave you–I’m still here." Her immediate reaction to this was silence, then shared thoughtfulness. Over time, a shift in the treatment evolved, which will be described.
All in all, however, there was a gradual expansion (with many difficult setbacks) of Beryl’s capacity to positively internalize my maternal function, which allowed her to make more connections between feelings and thoughts; this, in turn, led to a dramatic lessening of the psychosomatization, to a point at which it no longer interfered with her outside functioning. It should be noted that during the middle phase of treatment, along with this internalization of the good maternal object who would not break as a response to affect-laden words, came an increase in Beryl’s presentation of her symptoms in session. I vividly recall the beginning of the period when I recognized a shift; it was several sessions after the one involving the vignette. Beryl described her sense of utter desolation when she had left my office on a gloomy, windy winter afternoon. A description of the deep void within her was articulated for the first time, as she linked the experience of leaving the office with a feeling of being forsaken by her mother. Further, I remember that this was the first time I was moved by her words and felt the poignancy of her deep sadness. It also was the first time she allowed tears to flow, as if the "mummy" could allow some of the bandages to fall off without danger of complete leakage of her inner self. During this phase I also sensed for the first time Beryl’s incipient capacity to empathize with the neglected little girl within. She saw a child at the park who clutched onto her babysitter and could not mix well with the other children, and was reminded of herself as a 3-year-old, needing to cling to her aunt’s leg when she attended her cousin’s birthday party. In relating this event, she remarked with some awe in her tone, "I can’t believe I always thought of myself as so self-sufficient before this, but when I saw that little girl at the park I saw me, needy and scared at that age." Other shifts that occurred over time involved Beryl’s increased capacity to express anger directly, at me and others in the outside world. Her ability to relax, be playful, and find more humor in things was enhanced, but there remained a difficulty with free association and spontaneity. The self-ennoblement through silent suffering lingered, too, although in some milder form. Her sex life became freer; on a preoedipal level, she could move from the mother to the father, because her separation was no longer felt as quite the threat it had been to the maternal objects survival; concomitantly, she seemed less constricted by superego guilt. This chapter has depicted the use of the therapist’s interweaving of relational and interpretive communication to facilitate the psychosomatic patient’s linking of affect with thought. Further, it shows how this process in turn leads to an enhancement of verbalization, and a lessening of somatization for the patient. Sugarman’s (1995) ideas about the need for integration of the relational and structural models are illuminating, particularly when considering the need to form an affect-evoking interpretation for a patient like Beryl, whose emotions are strangulated and buried in psychosomatic symptoms.He writes that the relational model highlights deficit and the real interchange between therapist and patient; the structural model, in contrast, underscores transference interpretation of conflict leading to insight. It is felt that the interpretive process presented incorporates some synthesis of the two models at work. These ideas are considered within the context of current theory. As Ogden (l994) states, "acting in" (such as that expressed through Beryl’s physical symptom in session) is defined by the author as a "communication-in-action," which might not be seen as growth-producing simply because it is immediately substituted with words; rather, if first given its own place in the treatment sphere, it might then be viewed as a significant element of the intersubjective experience, which interpretation can subsequently bring into bold relief. Ogden emphasizes that with less reachable patients this process is made more effective when the interpretation is a melding of words and responsiveness, synonomous with the holding environment. Related to this idea is McDougall’s (1985) description of the therapist’s translating function for the psychosomatic patient. She writes that bodily representations become feelings that can be "named, symbolized, verbalized, and elaborated" (p. 196). Through this process, the therapist provides a validation of the true self; as real feelings are freely named, they no longer need to be disguised behind physical symptoms. Another way to view this evolution is to link it with Shengold’s (1989) concept of soul murder. He applies this term to the deadened psyches of abused children, who have been repeatedly given the message that their authentic feelings are in question, or worse yet, obliterated. The author writes,
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