Confer talk Maggie Turp

Part 1

I’m very pleased to have been asked to open this series of events on working with psychosomatic symptoms. I imagine that the audience is made up of practitioners from a variety of therapeutic orientations and for me this is an altogether positive thing. If counselling and psychotherapy are to survive and thrive as professions in the 21st century, we need these opportunities to share and exchange ideas and to build an atmosphere of mutual respect. So I would like to thank Confer for creating this opportunity for dialogue.

I am going to speak fairly briefly about some of the philosophical themes that inform our perspectives on health, illness and psychosomatic phenomena. I will then pause for questions and comments. After that, I am going to present a case study from my own practice, illustrating a contemporary object relations approach to working with psychosomatic symptoms. This will be followed by another opportunity for questions and comments. If there is time, I will go on to say something about Winnicott’s work on ‘the indwelling of the psyche in the soma’ and psychosomatic health. In case there is not time, bearing in mind that I want to allow you plenty of opportunity to speak as well, I have listed the Winnicott references in the bibliography. My book, which is on sale at the back of the hall, offers an overview of Winnicott’s work and links it to infant observation and case study material.

I am working on the assumption that most of us here tonight share a broadly holistic perspective. By this I mean that we see ourselves as creatures of thought, feeling, imagination and active behaviour and that we see all of these as expressions of something unitary, of an underlying and ongoing state of embodied being. To the extent that this assumption is correct, we are a part of a contemporary phenomenon wherein holistic perspectives have gained ground and continue to gain ground. I should perhaps speak of ‘regaining ground’, given that some of the ancient Greek and Hebrew philosophers believed that states of mind were fundamentally entangled with physical health. That same point of view has prevailed in many Eastern philosophies and practices associated with them.

In the Western world, an important shift away from holism occurred in the seventeenth century when Rene Descartes set out his ‘dualistic’ vision of the human subject. Descartes, an eminent philosopher, pronounced that mind and body were separate entities, composed of different substances and subject to different laws. He advocated different research methods for the two phenomena he had distinguished. The body, being a material object, could be explored via scientific investigation but the mind was of a 'higher' order and could only be investigated via introspection.

I find it interesting to speculate on why these particular ideas might have come to prominence at this particular time. Descartes was a devout Christian, whose idea came to him in that least rational of forms, the dream. Perhaps his dream owed something to an unconscious desire to see humans as God’s creatures, singled out from other animal species. According to Descartes’ philosophy, all creatures have a body but only human beings have a ‘mind’. And so dualism shored up the authority of the Christian church. If human beings were entirely different from animals – were ‘God’s special creatures’ - then the Church could claim a legitimate role in ministering to human souls.

Descartes’ work also encompassed many of the features that are characteristic of the scientific method, including a belief in the possibility of absolute objectivity, an emphasis on linear cause and effect relationships and reductionism. For example, Descartes expresses his ‘reductionist’ inclinations in a passage where he writes of his intention:

… to divide each difficulty I should examine into as many parts as possible, and as would be required the better to solve it (1654).

In what I have described elsewhere ( 2000) as one of history’s ‘long, slow, own goals’, Descartes’ work came to have the opposite effect to that which he intended. In the end, it made a major contribution to the decline of the church as a power and to the establishment of science as the new god of truth and knowledge.

In the longer term, we were left with a philosophical legacy of a mind and body split apart and this, not surprisingly, created certain complications. The thought, belonging to the mind, that ‘I would like to drink my coffee’ is undeniably linked to the action, belonging to the body, of moving my arm and picking up my cup. Philosophers in the dualistic tradition have made many attempts to formulate a satisfactory model of the interconnectedness between ‘mind’ and ‘body’ but none of them have been entirely convincing.

The biomedical model of Western medicine bears all the hallmarks of dualism. It is characterised by the view that thoughts, feelings and imaginings belong to the mind and are not capable of affecting the body. There is a belief that the physical aspects of the person can be understood without reference to person as a whole. The reductionism of the scientific method has found expression in a tendency to focus on smaller and smaller sub-categories of disease.

In 1949, Franz Alexander described the situation in the following way:

The fundamental philosophical postulate of modern medicine is that the body and its functions can be understood in terms of physical chemistry, that living organisms are physicochemical machines and that the ideal of the physician is to become an engineer of the body (Alexander 1949: p.18).

It is when there is a need to consider the whole person that Western medicine reveals its most serious limitations. Where the context of an injury or illness is important, where the whole person and his or her situation needs to be considered, then the biomedical model can part company with human compassion and ordinary common sense. This is a true story about a relative of mine.

A man in his 80s, was diagnosed as having cancer of the jaw, which was not causing him pain or disability. He was strongly advised to undergo major surgery, which would have removed about half of the lower part of his face and have left him unable to speak. With support from his family, he plucked up the courage to say that he wanted radiotherapy treatment alone, without the surgery. The hospital consultant told him sternly that he could not possibly sanction this course of action because it would reduce the chance of full recovery from 75% to 25%.

Eventually, this man succeeded in getting himself referred to a different medical establishment where, following much discussion, his wish to opt for less invasive treatment was respected. Without his family’s support, there is little doubt that he would have capitulated and agreed to the radical surgery suggested.

There have always been tensions between the medical model and a psychoanalytic perspective. Psychoanalysis has, I think, a commendable record of resistance to the medical model. The whole idea of ‘the talking cure’, as put forward by Freud, was anathema to medical practitioners of his time. It continues to be attacked and scorned by many contemporary physicians but has remained true to its principles. Franz Alexander wrote scathingly about the ‘laboratory period of medicine’ and called for change. Winnicott criticised the dualism of the medical model and spoke out openly, and to some good effect, against certain medical practices such as lobotomy. Michael and Enid Balint ran groups for general practitioners here in this building for many years, developing ideas on holding and on working with the emotion behind the illness and helping doctors to introduce this perspective into their medical practice. Sotiris Zalidis, a member of the Balint group, has just published an excellent book, which I can highly recommend to those of you who are interested in these developments.

As you will be aware, there have been important changes, although, unfortunately, few of them have filtered through into NHS practice. The postmodern critique of modernism and science has played its part, as has widespread public interest in holistic Eastern philosophies and associated practices. Science itself has changed and at the cutting edge there has been major rethinking of fundamental tenets. It has been acknowledged, at least by some scientists, that cause-effect models have very limited explanatory power. Field theories, chaos theories and other complex ways of understanding events now have an important place in science and these new models make much more modest claims about the possibility of predictability and control. Marshall and Dohar give a good account of these developments for the lay reader in their book ‘Who’s afraid of Schoedinger’s cat’ (1997).

The cherished idea of scientific objectivity has been severely dented. It has been conclusively shown that an observer has an effect on the person or phenomenon observed. Postmodern writing has drawn attention to the many subjective elements in play in the choosing and framing of research questions, in the allocation of research funding and so on. It has also become clear that some research results are disseminated while others are buried and that any single set of results lends itself to a plethora of different interpretations. As the limitations, and in some cases false claims of science have been revealed, the general public has also become more sceptical of scientific claims and more open to holistic perspectives.

I want to move on now to the term ‘psychosomatic’ itself, as it seems important to try to be clear about the way in which it is being used. These are the two definitions of ‘psychosomatic’ offered in The Concise Oxford English Dictionary (1995 edition):

(of an illness etc.) caused or aggravated by mental conflict, stress, etc.

of the mind and body together.

What is perhaps useful in this first definition is the inclusion of the phrase ‘aggravated by’, which opens the way to the recognition of psychosomatic elements in all illnesses. There has been a tendency to try to ring-fence psychosomatic illnesses and place them in a separate category. I myself am sceptical of the idea that this is possible. There is overwhelming evidence, for example, of the involvement of psychological factors in physical conditions such as heart disease. And we have an intuitive understanding that all illness is ‘aggravated by mental conflict and stress’. It is this understanding that underlies our concern that an ill person should have peace and quiet and a temporary release from the worries of everyday living.

This first definition is problematic in two ways, in its dualistic reference to separate physical and mental entities and to the idea of a cause-and-effect relationship between them. Linear cause-and-effect explanations are becoming more and more outmoded as we move further into the era of feedback loops, field theories and chaos theories. These newer models of causation suggest that events are multiply determined and that causative factors interact in a complex and unpredictable way. In this sense, they are much closer to psychotherapy understandings of human experience and behaviour and I know this is something that Roz Carroll will talk about on February 6th.

With regard to causation, I rather like Wilfred Bion’s reference to a ‘cloud of unknowing’. Some symptoms are not associated with a particular disease, while there are some diseases that have no particular symptoms. Sometimes it is only when we find out more that we become aware of having been in ignorance. For example, the illness porphyria was long thought of as a mental illness, because its symptoms mimicked those of psychosis. It was eventually discovered that the illness was caused by a genetic disorder involving the abnormal metabolism of porphyrin pigments. The excretion of these pigments into the urine gave it a purple colour. A dramatised version of this illness was shown in the film ‘The Madness of George III’, which some of you perhaps remember.

The second definition of psychosomatic – ‘of mind and body together’ is also dualistic in its use of the words ‘mind’ and ‘body’ and in the implication that these are in principle separate but might on certain occasions come together. If we replace the phrase ‘mind and body’ with something more holistic such as ‘mental and physical aspects of functioning’, then we arrive at a definition that refers to ‘the involvement of mental and physical aspects of functioning’. I can think of no illness that falls outside this definition and this is, perhaps, as it should be.

I want to mention one more issue. We have probably all come into contact with something that is part of the Zeitgeist, the idea that it is possible to be in full control of our circumstances and their effects upon us. To have succumbed to ‘mental conflict’ or ‘stress’, therefore, and to have allowed it to make us ill is experienced by some of us as morally reprehensible. The sense of shame that some individuals feel if their illness is described as ‘psychosomatic’ can become a major psychological problem in itself. In some cases, it leads to a desperate quest for a physical explanation for symptoms, taking the form of a never-ending succession of expensive and unpleasant medical investigations. Both Broom (1997) and Zalidis (2001) give examples of this phenomenon from their work as general practitioners.

So I will pause there on a question. - What exactly do we mean by the term psychosomatic?

Part 2 – The case study

Much has been made in some quarters of the distinction between therapeutic approaches that work with the body and those that, allegedly, do not. My own view is that it is impossible not to work with the body. We are all embodied – practitioners and clients alike. We meet body to body in a consulting room and are physically affected by each other’s presence, words and actions. Our concern, whatever our therapeutic approach, is with emotions and emotional conflicts and, as bodywork practitioner Stanley Keleman wrote in 1985 ‘the body is the somatic architecture of feelings’. This statement as relevant to the ‘talking cure’ psychotherapies as to those where the body is directly moved or touched.

Speech, of course, is a physical as well as a mental phenomenon. My book begins with this passage.

In the beginning, the word is just one aspect of bodily experience. To the new-born infant, it is all cadence, rhythm, volume and tone. Words soothe, tease, excite or shock; sustain or cut across the infant’s own sense of its being. At this stage, the meaning of words resides in their physical impact alone. Later, words are understood to have a representational value also. If I say to a friend, ‘Look! The cat has come in’ the words themselves have a meaning. But the physicality of the words remains crucial to a more complete understanding. It is the manner of my delivery, and that alone, which will reveal whether the cat is an accursed nuisance or a loved and welcomed family member (Turp 2001: 3).

As the verbal is also physical, so is the physical essentially communicative and replete with memory and meaning. Our fingers remember the number of the bicycle padlock. Our bodies remember how to ride the bicycle, even after ten years, twenty years, out of the saddle. Once we set aside the idea of separate ‘body’ and ‘mind’ categories, it becomes easier to see how different therapeutic approaches can be effective in working with psychosomatic symptoms. Inherent in the idea of bodymind unity is the idea that an experience that is primarily physical, such as massage, can have a profound psychological effect. Similarly, an experience that is primarily psychological, such as a conversation between two people, can have a profound physical effect. Effectively, any aspect of a person’s functioning can be reached through any channel.

A therapeutic encounter is a physical experience and the therapist’s use of his or her body as a sensing device and a barometer of change has probably always been a part of psychotherapeutic practice. I say this because I believe it to be impossible to avoid being physically affected by the close presence of another human being for fifty minutes at a time, week upon week. Since it is part of our work to reflect on what goes on in the consulting room, it is also impossible to imagine that we would not reflect on the physical aspects of our experience. What has happened recently is that somatic aspects of countertransference experience have been identified as a specific aspect of psychotherapeutic work and have been highlighted. I first came across the idea of somatic countertransference in Nathan Field’s paper ‘Listening with the body’, published in 1989. As I read it, I recognised a great deal that I had experienced and reflected upon over the years, without ever thinking to give it a special name.

This case study is an abridged version of one that will appear in my second book, Making Sense of Self-Harm (Turp 2002 forthcoming). Among other things, this particular narrative raises the question of whether or not physical injury or illness that arises from conscious behaviour, such as self-harm, should or should not be included under the psychosomatic umbrella and I will be interested to hear your thoughts.

The client, whom I will call ‘Tracey’ finds my name in the British Association for Counselling Directory. We arrange an introductory session, at which she decides that she would like to see me regularly. This wish is expressed in a way that is an airy and contemptuous manner that leaves me feeling dismissed. It is simply that ‘I need to do something and I suppose you’re as good as anybody’. Tracey tells me she feels stuck in a relationship that is going nowhere and that the same is true of her job. She also thinks it is may be time she moved out of her family home, as she is now 25. At this point, Tracey does not mention self-harming behaviour. I suggest that it might be helpful to meet more than once a week, at least at the beginning of the therapy, but Tracey says she cannot afford more than the a weekly session.

My initial impression is of a slim young woman with short blond hair and a working class accent, wearing a smart sweater and jeans. Tracey looks quite athletic (I later learn that she plays hockey for a team). I am struck by the fact that she is wearing a lot of make-up, including bright red lipstick, perhaps because this is somewhat at odds with the rest of her image. Tracey speaks in blunt way, swearing a lot, and that there is a grating coarseness about many of her communications.

At her next session, Tracey tells me that the man with whom she is having a sexual relationship is married and living with his family. According to Tracey, all of her problems stem from ‘.. the rotten bloody cards I’ve been dealt’. A picture builds of seething fury, reluctantly held in check for fear of its potential consequences. Tracey speaks in an angry and resentful tone of voice and soon she lets me know more directly about her anger by disclosing incidents of self-harm. She arrives with bandages on one hand and holds her hand up to show me. She tells me that she has been punching the wall of her room and looks at me in a challenging way, as if to say ‘Well, what are you going to do about it then?’.

From early on, Tracey recounts a litany of woes all of which refer in one way or another to what she sees as the essential unfairness of life. She feels she should be married and settled but is ‘caught up’ in relationship with a married man. She feels that she is intelligent and should not be in the secretarial position that she occupies but should have gone to university. Tracey experiences herself as the victim both of external events and of her own internal states. Arriving for a session three months into the work, she sits down and holds up her fist, apparently for me to see the new bandages on her hand. I feel rather threatened and notice that her posture is indeed threatening, as if she might punch me.

T: Look at this! I’ve been punching the bloody wall again, haven’t I? There’s a big dent in it where I punched it.

M: Can you tell me more about what you did and why?

T: Well, I don’t fucking well know, do I?

Sadness is also an event that Tracey experiences as coming in from the external world.

T: I’ve had three attacks of sobbing this week.

M: The way you put it, it’s as if a black cloud comes over and tears fall out of it, as if, in a way, it’s nothing to do with you personally ...

Tracey sits in a resentful silence.

M: Can you say anything about how you felt when you began to sob?

T: I suppose I must have felt miserable, otherwise I wouldn’t bloody well do it, would I?

Tracey describes difficulties in driving her car which seem to epitomise her refusal to own her part in her problems and sufferings. She has bought a car but cannot bring herself to drive it, because she feels afraid that she will panic. We talk about this at some length, trying to understand the nature of the difficulty. What emerges is that Tracey is paranoid about the thoughts and supposed judgements of other drivers. For example, she is convinced that the driver behind her will be watching her and waiting for her to stall the engine or crunch a gear or put on the wrong indicator. Her frustration about this is sometimes vented on the car itself.

T: That damned car just stands there and soon it’s going to need its MOT.

M: You’re still not driving it?

T: I get in it every night and start the engine but I don’t go anywhere. A few days ago the bloody thing needed petrol and I had to get my brother to drive it to the garage and fill it up. (Pause). Then last night I gave it a good whack. I was half-hoping it would break, but as you see I haven’t got any cuts, just bruises.

M: What were you hoping to break?

T: The car window. I punched the car window (This is said with grim satisfaction).

Another symptom to come to light involves what Tracey describes as ‘the shakes’. She cannot have a drink – alcoholic or otherwise – in a social situation because her hand shakes so violently that the drink spills. I learn more about this two months into our work together. Tracey describes a weekend spent with male work colleagues, playing army games involving shooting and ‘killing’ with paint pellets. She complains, not for the first time, that all her work colleagues are married.

T: I would try and find an unmarried bloke, maybe, if it weren’t for the shakes.

M: The shakes?

T: Yes, I can’t go to the pub and have a drink because I’m afraid I’ll start shaking and I’ll spill it everywhere. So you see, I can’t go and find myself another man..

Tracey goes on to fantasise about finding another relationship. I discover that under such circumstances she would plan to continue her sexual relationship with Pete. I express surprise and Tracey becomes angry with me, telling me that I can’t expect her to give him up. - She will have to hang on to him as an ‘insurance policy’. I suggest to her that her idea of a relationship includes no notion of love or loyalty from her side. Men are discussed as if they were inanimate objects, impervious sources of sexual gratification. Tracey sulks and I realise with regret that my intervention was prompted by feelings of sympathy for the man involved and not by concern for my client. No doubt her own lack of concern, echoed in mine, reflects a particular form of psychosomatic splitting. For Tracey, the physical sensation of sexual intercourse is entirely split off from her sense of herself as a person who might have an emotional effect on others.

I must say that I find being with Tracey an enormous strain. At a conscious level, I catch my thoughts drifting off towards what to eat for dinner or the clients I am scheduled to see later in the day. Physically, I notice that I feel strangely empty and low in energy at the end of each session. I suffer various kinds of physical malaise that thankfully disappear within an hour or so of Tracey’s departure. These include vicious headaches and, strangely, attacks of ‘pins and needles’ in my arms and legs. My understanding of these physical states is that they are probably connected to how Tracey has herself felt in the past. I find it therapeutically significant therefore (as well as a personal relief) when my symptoms began to abate during the second year of our meetings. What changes is that Tracey now seems to recognise me as a second person in the room, somebody who might possibly have something useful to say. My survival of her psychological attacks has perhaps mitigated the violent and primitive quality of her internal world and made a difference to the projections I am receiving.

During our more difficult sessions, I experience myself as wanting to make contact with Tracey but being kept at bay and as weak and useless. Ogden (1997) describes how the apparently random images that come to mind during sessions can be surprisingly illuminating. During one session, I recall a very old TV advert for Michelin tyres, something that I have not thought about for years, that featured a ‘steel man’ in the shape of a tyre flexing his ‘bands of steel’. This is a telling image in relation to my feelings when I am with Tracey, speaking of a sense of physical toughness and muscularity that holds her together and keeps me out. I see myself moving towards her and bouncing off again. These images and responses in turn call to mind the work of Bick (1968) on the development of a ‘toughened second skin’, a defensive psychic structure that succeeds in holding the individual together but reduces permeability and capacity for relationship.

I think you will all by now have recognised the enormous amount of anger being expressed by Tracey and the extent to which it is split off and denied. From a psychoanalytic point of view, it would seem that this disowned anger is being projected onto the external world, which is then experienced as vindictive and unfair. Tracey experiences herself not as angry but as a victim. Accordingly, she does not have to think about her vengeful feelings but she has to deal with them nonetheless. They return in the form of paranoid fantasies and physical symptoms such as self-hitting, physical shaking and driving-related panic attacks.

In order to work with this material, I endeavour to remain alert for occasions when Tracey’s destructive feelings are directed towards me and can be spoken about in the context of our relationship. These are not too difficult to identify. I frequently feel threatened, usually verbally but sometimes physically as well. This is one of my attempts to make a direct reference to this state of affairs:

T: I’m not blooming well getting anywhere here. How long is this going to take?

M: You’re not satisfied with the therapy and you sound really angry with me.

T: Angry? No, I’m not angry. I’m more, well, upset, that things go so badly for me. I had three attacks of sobbing this week.

On this occasion, my intervention is brushed off by Tracey, suggesting that it was either inaccurate or premature. Shortly before Christmas, Tracey complains again that all her colleagues at work are married and that she ‘never meets anyone’. Gradually, her mood becomes more vindictive.

T: It’s all right for that lot, isn’t it, looking forward to Christmas. They’ve all got wives and husbands and children and everything. (A long pause). Sometimes I wish something would happen to them – one of the wives would die or something.

M: I think you’re saying not just that ‘it’s all right for that lot’ but that ‘it’s all right for you, Maggie’...

T: Yes, well, OK. I suppose I do feel a bit like that. You’re not on your own like me, are you?. (Pause) I could go out and get myself a husband as well, you know, but I can’t drag myself away from Pete and he’s blooming-well married.

M: You feel very short-changed, very hard done by. Everybody seems to be luckier than you.

T: Well, it’s not fair, is it? They’ve all met somebody but the person I’ve met is already married.

M: It’s as if you’re stuck in the middle of a desert and glued to a tap that drips very, very slowly. You’re not satisfied with what you get but you can’t bear to take the risk of moving away to look for something better.

On this occasion, I sense some sadness behind Tracey’s anger and feel unusually compassionate towards her. This seems to be unconsciously communicated. Tracey begins to cry and some of the usual hostility and exasperation in the consulting room dissolves away. As happens from time to time, I feel that good work has been done and that Tracey has taken something useful in. However, as is so often to prove to be the case, envious attacks on the work follow, countering the progress that has been made.

Tracey attends all her sessions and pays a full fee, a commitment that suggests she is at some level be aware of the part she plays in her difficulties. She also shows a certain degree of ego strength. Her external life is not chaotic, insofar as she holds down a job and manages to more or less function in the outside world. I say ‘more or less’ because Tracey’s activities are curtailed, for example by not being able to drive, by not being able to drink in the company of others for fear of ‘the shakes’ and by her attachment to Pete. In my own supervision, I reflect regularly on Tracey’s unconscious positioning of me in the relationship between us. With the passing of time, it becomes ever clearer that I am the one now being blamed for her difficulties.

Before going on with the material, I feel it is appropriate to say a little more about projective identification and containment, even though I know that many of you are already familiar with these concepts. In an adult-to-adult context, the term projective identification (Klein 1946) refers to the process whereby feelings experienced in the past by the client, are stirred up in the present within the practitioner. Attending to the particular qualities of such ‘stirring up’ can help us to think about what is happening at an unconscious level and what it might mean. Containment (Bion 1962) referred originally to the process described in Chapter 2, whereby a mother receives her infant’s projective identifications, digests them by thinking about them and putting words to them and then returns them to the infant in a detoxified form. In an adult context, just as the mother models thoughtfulness and an ability not to be overwhelmed by strong feelings for her infant, the practitioner models thoughtfulness for the client in the face of experiences that are disconcerting, difficult or puzzling. The hope is that, through repeatedly witnessing and identifying with the practitioner’s capacity for containment, the client will eventually become more thoughtful and less reactive. This change, when it happens, is almost always accompanied by an amelioration or cessation of symptoms.

Projective identification is a marked feature of Tracey’s communications to me. She finds various ways to unconsciously attack me and our work together. In response, I find myself frequently feeling hopeless, useless and utterly stumped. Having no conscious knowledge of these matters, Tracey does not refer to them in a direct way. They are really body-to-body matters, finding expression in sequences of harsh words followed by silences, in action and gesture and in my feelings of foreboding, exhaustion and physical tension.

Sometimes, Tracey’s hostile stance sets up a situation where it is difficult for me to venture forth an interpretation. When little else seems possible, I endeavour to think about what is happening and to sustain and communicate the idea that thinking is possible, even in the most difficult of situations. Nevertheless, many of the sessions are dominated by raw and primitive emotions communicated primarily through non-verbal channels.

(Tracey comes in and sits down. She looks down at her hands for a minute then looks up and over towards me, her face absolutely furious).

T: I've been coming here for over a year, and I'm still no better. I’ve stopped doing the punching, but I still haven't got a proper relationship. I'm still stuck in the same dead-end job! What good is this doing me? Why should I bother to come?

This attack on my competence is very effective. I feel myself slump. I am inadequate, worthless, a complete fraud. After a while, I remind myself that Tracey's assessment is not entirely accurate and that there have in fact been changes. For example, she has started to study for a degree and has bought a flat of her own. These changes have been recognised by both of us, in happier moments, as significant achievements. I decide to speak directly about the projective identification in play.

M: I think you want me to know how it feels when all your efforts are for nothing, when no matter how hard you try, it simply makes no difference. You are just seen as a worthless drain on others.

At this, Tracey starts to weep. I notice that my own feelings change. My anxiety dissipates and I begin to feel warm and sympathetic. The rest of the session has a quiet and thoughtful feel, reflecting the connection that has been established between us.

Psychoanalytic practitioners place much importance, some might say too much importance, on the past and particularly on infant and childhood experiences. Tracey is reluctant to talk about her childhood, responding to my enquiries by saying that she doesn’t know what I want her to say and that it was ‘nothing special’. I ask some specific questions, listening for references to any particular events or circumstances that might account for her enraged state and her pervasive sense of having been cheated. Some people think that self-harm is always associated with sexual abuse but there is no indication here of either sexual or physical abuse. Tracey’s is clearly very fond of her father, who helps her a lot in practical ways. However, she is disappointed in and resentful of her mother.

T: If I had a child, I would take her to Kew and tell her the names of the trees. My Mum doesn’t even know the names of trees. If I want to know them, I have to look them up in a book.

M: You feel you’ve had to do everything for yourself?

T: Absolutely. Now if there’s a form to fill in. I’m the one that has to do it. And my Dad bought a camera but I was the only one who could understand the instructions. My Dad’s not stupid though. No, not at all.

My supervisor and I remark on the poignancy of these words, especially those relating to Kew and the names of the trees, which are spoken in an unusually dreamy and nostalgic tone.

On many occasions, Tracey refers to a strong attachment to her father and a difficult relationship with her mother. She talks about her mother in a very disparaging way. For example, she tells me on one occasion, ‘My mother nags and nags my Dad. – She’ll be the death of him’. In response to my enquiry as to the state of ‘Dad’s’ health, Tracey tells me he had a heart attack during the previous year.

T: If he had died... well that cow... Honestly, Maggie, I don’t know what I’d have done.

Although the words themselves are angry, I see that her eyes are full of tears. When I say that the thought of losing her father makes her feel very sad, Tracey gives me an angry look but continues to cry quietly.

Such material strongly suggests the operation of unresolved Oedipal issues. Tracey makes it clear in many ways that she wants to have her father to herself. She resents her mother coming between them. Her lover, a married man called ‘Pete’, is another version of her father. Tracey tells me about this via her frequent comments on Pete’s striking physical similarity to her father. Pete’s wife is another woman who comes between Tracey and her desires by being too demanding and ‘wanting Pete to be around all the time’. Eventually it emerges that I am also perceived as wanting to come between Tracey and her sexual gratification. In the following passage, Tracey is again talking about her colleagues at work:

T: Why do they get all the good cards and I get this rubbish hand? I mean, all right, I know you think I at least have a choice about carrying on with Pete. But Maggie, have you ever been without sex for a long time? I don’t think I could stand it. I need my nookie! (Tracey looks at me accusingly, as if this is something I might be trying to take away from her).

While Freud originally wrote about Oedipal issues with reference to the third and fourth years of life, Klein dates the onset of the Oedipal period to the first year of life. Thus, for Klein, Oedipal issues and questions of envy and gratitude are tied up together. The infant’s envy of the mother can spoil the mother’s love and obstruct the establishment of a good internal object (1957) and this makes it difficult to negotiate the feelings of rivalry associated with the Oedipal period. While Klein expressed the view that envy was primarily constitutional – that some infants are simply more envious than others – Winnicott took up a more ‘environmental’ position, arguing that the degree of infantile envy was related to the level of frustration experienced.

In infancy, thoughts and fantasies are, of course, felt to have real power. The line that divides internal and external worlds is blurred and it is not unusual for thoughts and fantasies to be equated in the child’s mind with externally directed actions. Tracey’s rage, distress and feeling of persecution arise, at least in part, from the power of her early (and quite normal) incestuous desires and the associated unconscious murderous intent towards her mother, whom, at an unconscious level, she would like to get rid of altogether. The resolution of Oedipal conflict entails identification, in one way or another, with the same-sex parent. Tracey has clearly resisted identifying with her mother and we may surmise that she was not helped with Oedipal issues. Instead, her anger, envy and desire have continued unabated, leaving her in the grip of fantasies of forbidden action and adult retaliation.

Tracey’s physical self-presentation and speech has a stereotypically ‘masculine’ quality, as do many of her leisure activities. The heavily applied red lipstick that creates such a jarring seems to be added as an afterthought, a disconnected gesture paying ‘lip service’ to her female gender. As a woman with feminist sympathies, who loves the outdoor life, who is happiest in T-shirts and jeans and who shuns make-up, I am well aware of the dangers of ‘masculine’ and ‘feminine’ stereotyping! But I believe that the case material undeniably points to confusion and difficulty in this area of experience.

Later on in the second year of the work, Tracey become more willing and able to respond to my efforts to understand her childhood experiences:

M: You know, although you’ve mentioned your mother in passing and I have gathered that you have very little time for her, I have no real idea of what it’s like to be with her – of what it was like for you as a child.

T: (thinks for a while). I don’t really know, Maggie. I suppose, - it was as if I wasn’t really there.

M: As if you were invisible?

T: Something like that. You know, she never came to a parents’ evening. And I was really good at the piano but she never said anything. I might as well not have bothered, for all she cared.

M: Are you saying she didn’t really care for you – not in a way you recognised as caring?

T: I felt, what’s the word, wiped out by her. She carried on in her own sweet way. Dad and me, I’d say that neither of us made the slightest difference.

From my point of view, this is an illuminating exchange, for the feeling of being ‘wiped out’ and of not making the slightest difference strikes an immediate chord. I have often felt myself that nothing I say or do in any way changes Tracey’s feeling towards me. Tracey’s comments confirm the operation of projective identification, with Tracey communicating to me the way she had herself felt as a child, through unconsciously stirring up similar feelings within me. In connection with this material, I reflect on Winnicott’s question:

What does the infant see when it looks into the mother’s eyes? ...

and his answer:

I am suggesting that, ordinarily, what the baby sees is himself or herself. In other words the mother is looking at the baby and what she looks like is related to what she sees there. (1971:112-113).”

In the place of this maternal seeing, identified by Winnicott as a kind of mirroring, it seems that Tracey saw a mother who was self-absorbed, who could not or did not wish to see her. Her symptoms have succeeded in making her more visible and this may be one reason for their persistence. I feel at this point that I finally have a strong grasp of the meaning of Tracey’s self-hitting. She feels both enraged and shamed by the narcissistic wound inflicted upon her by her mother’s self-absorption, by her mother’s failure to see and respond to her as a unique human being. As a child, she would have needed to repress such feelings in order not to alienate her mother further. She would have needed desperately to hold on to such attention as her mother did direct towards her. Repressed feelings are now emerging in the form of self-hitting and perhaps also in the shaking, which may represent a fear of the violence Tracey experiences as locked up inside her.

I try in a number of different ways to make sure that Tracey knows that I see her and acknowledge her, that it is her as a whole person who interests me. She does not need to have symptoms in order to hold my gaze and my attention. She seems surprised to find that this is the case, particularly when I remember and bring into the session something that she has told me at a previous meeting. We make progress in the work and this is marked by an incident when, for the first time ever, we are able to laugh together.

T: I bought a washing machine and I was going to pay to have it plumbed in, but Dad said ‘Oh, never mind that. I can do that for you’. He’s always round at my flat you know. (Smiles at me shyly). I told him, ‘It’s all right, you don’t have to’ but he said ‘Don’t you worry, I can do that for my best girl!’

I laugh. Tracey looks down, a little embarrassed, then looks up at me and laughs as well.

T: I’m afraid Pete does the same kinds of things from me. He’s coming over at the weekend to have a look at my central heating.

The last six months of therapy bring changes that suggest Tracey is beginning to be more in touch with her internal world. For the first time, she begins to remember her dreams and to describe them to me in the sessions. There is a marked change of atmosphere. Where the sessions were previously dominated by accounts of concrete events, accompanied by much complaining, we are now able to work with symbolic material. The dreams described seem to allude to some of the issues discussed above, the Oedipal wishes, the destructive feelings towards the wounding mother, the envious attacks on the parental couple and their relationship and the attendant paranoia. They testify to a bleak and devastated internal world and, not surprisingly, Tracey finds them very disturbing.

T: I had such a weird dream, Maggie. I was in a graveyard. It was misty, then I saw loads of headstones and I could hear this noise – like the wind howling. Then this kind of ghoul appeared in a black cloak. I could only see it from behind at first.

(Tracey stops and gulps). The worst thing was, she turned around and her face was just a skull, with empty sockets where her eyes should be.

M: You seem to know it was a ‘she’?

T: Yes, it was me, wasn’t it? It was me. (Now, Tracey is staring fixedly at me and her face has gone very pale).

On another occasion, Tracey describes a dream of being in hospital and finding she is a ‘vegetable’ kept alive on a life support system, fully aware but unable to act. A few weeks after this, she comes with a dream which we jointly identify as a horror film version of her ‘paint pellet war’ weekends. In the dream, the battlefield is a real one, strewn with real corpses. She cautiously approaches a body in a khaki uniform and it leaps up and pursues her. Running in terror, not looking back, Tracey hears a bayonet blade swishing past her ears. She wakes up screaming. She is not sure whether the figure pursuing her is a man or a woman.

Soon afterwards, Tracey she tells me she has dreamt of being in a small room. The walls are covered in blood. She is in there on her own and has a small rag and bucket. Her job is to clear up the mess.

M: This is quite a small room, isn’t it?

T: It could have been this room. It was just about this size.

M: A lot has happened here. You are worried about how much mess is left to clear up. In the dream you are doing all this on your own. – Do you still feel that you can’t rely on me?

At this point, I recommend to Tracey - not for the first time - that she come to see me more often, at least twice a week, even if she can only manage this for a limited period. Initially, Tracey seems open to this suggestion although she is concerned about her finances, having recently taken on a mortgage. I offer her a reduced fee for a limited period of three months and say again that this is an important time and that I do feel concerned for her. She says she will think about it.

The following week, Tracey comes along and tells me she will have to stop her sessions as she has lost her job. She announces this in a very matter-of-fact way and does not seem upset. My concern and my attempts to persuade her not to precipitate such a sudden and abrupt ending are in vain. Tracey just keeps telling me that she can no longer afford to come. Eventually, she agrees to come for one final session. At this session, she remains distant and pragmatic. We summarise the gains she has made during our time of working together and we discuss the possibility of my referring to our work together in a future publication. Tracey readily agrees to this and brushes aside my suggestion that she should think about it and let me know. She says in a dismissive tone more reminiscent of much earlier sessions, ‘You can say what you like. It doesn’t bother me really’.

Interpretations of such an ending suffer from the fact that they cannot be explored with the client. At the point when she left, Tracey perhaps felt the practical gains she had made were under threat and decided to call a halt to the proceedings. Her loss of her job played into this, of course, but I am convinced that it was not the only reason for her departure. Practical gains had indeed been made. A year into the work, Tracey enrolled for a part-time degree course (in philosophy). She began to drive her car to college. She bought her own flat and moved out of the family home. She stopped harming herself and was able to drink tea with her fellow students. These changes become possible as Tracey developed her capacity to recognise and think about difficult and contradictory feelings, feelings that were not previously experienced as feelings but translated instead into apparently incomprehensible symptoms.

At the same time, Tracey continued to find life enormously difficult. At college, she studied but did not socialise. She found seminar presentations a particular torture, repeatedly imagining that the other students were waiting for her to make mistakes. (This was such an insuperable problem that Tracey eventually changed her course to one where she did not have to give verbal presentations). She found herself unable to finish her relationship with Pete.

The content of Tracey’s dreams suggests that the gradual softening of her defences in therapy led to her being overwhelmed by unmanageable amounts of primitive material. Some of this material had previously been absorbed and expressed in her psychosomatic symptoms and in a sense she was the victim of her own success. – Her symptoms were no longer available to her. Looking back, I am left to wonder whether I interpreted too little, leaving Tracey feeling that she had to bear her intense feelings of hostility and resentment on her own, or whether I interpreted too much, moving at a pace that Tracey was unable to match. In a sense, by ending therapy in the way she did, Tracey had her final triumph over me as the quasi-maternal figure, leaving me feeling bemused and insecure.

Tracey’s self-harming behaviour, disclosed four weeks into the work, was the main reason for my choosing to include an account of this particular piece of work. You may well have gained the impression that very little time in the sessions was devoted to the discussion of self-harm and this is a true reflection of the work, which is not to say that the subject of self-harm was avoided. Because self-harm stirs up difficult and often intense feelings, it is possible to express a felt sense of urgency by focussing upon it heavily, perhaps believing that the main aim of the therapy is to eliminate the self-harming behaviour. In my view, this approach is counter-productive. It is more important by far to recognise that self-harm is meaningful, that it is there for a purpose, that it is fulfilling a need. An intense focus on the self-harming behaviour is unlikely to prove helpful, since self-harm is a symptom of something else and it is that ‘something else’ that needs to be given the space to emerge.

There always exists, of course, a temptation to abandon a psychoanalytic stance and engage instead in an educational endeavour or some other plan of action. To the extent that we do so, we unwittingly collude with the client's re-staging of his or her early experience of a poor containment, with potentially catastrophic consequences. We need above all to hold on to our own raison d’etre, which resides above all in our capacity for reflection, containment and continuing thoughtfulness.

I will stop again here for questions and comments.

Part 3

Psychoanalysis has been involved with psychosomatic symptoms, in the broad sense, from the very beginning. Freud developed and made famous the ‘talking cure’ to help patients with a variety of physical symptoms which had not responded to conventional medical treatments. The array of symptoms in question was extraordinary – nervous tics, paralysed limbs, an inability to drink water, sexual dysfunction, outbursts of speaking in a foreign language accompanied by an inability to speak in one’s native language. The term ‘hysterical’ has been largely replaced by the term ‘psychosomatic’, which has continued to be used in relation to situations involving pathology. Thus, we are accustomed to seeing the phrases ‘psychosomatic illness’, ‘psychosomatic symptom’ and ‘psychosomatic disorder’ but not the phrase ‘psychosomatic health’.

My own inclination is to begin with health and this is what I shall do now. Psychosomatic health finds expression in a harmony of verbal and physical self-expression. The body takes up its rightful place in the expression and management of feelings, which is complementary to the role of thinking and speaking. The body and the word act in concert. All aspects of our self-expression convey the same message and the same feeling and our subjective experience is one of ‘firing on all cylinders’. In the film of Jane Austen’s ‘Sense and Sensibility’, Colonel Brandon pleads with Elinor, sister of his beloved Marianne, who seems to be at death’s door:

Give me a task, or I shall run wild!

He is duly despatched on an errand and rides off on his horse. I am sure we can all think of other film or book scenes where the protagonist, having faced some major frustration or disappointment, sets off into the forest at a great rate, or sweats his way through a fiercely competitive game of squash. We do not see anything disturbed in this. It is simply a matter of physical activity playing its part alongside verbal self-expression.

I want to present a short clinical example to highlight the difference between psychosomatic health on the one hand and happiness and well-being on the other. It is the harmony between different aspects of functioning that is important.

Susan, who has decided to leave London to take up a very good job offer, comes to a therapy session and begins by telling me that a buyer has been found for her flat and that she is ‘really pleased’. The note of cheerfulness in her voice is strained and her shoulders have a definite slump to them. I feel a kind of tightening in my chest. I relate this to the tension emanating from the conspicuous contrast between what is being said and what is being communicated in a bodily way. I say ‘You’re happy that your plans to leave are moving forward?’ I allow my voice to express my reluctance to accept the statement at face value. We sit and think for a while.

After a few minutes, Susan begins to cry. She tells me she is afraid of leaving London, where she grew up and where she feels at home. She tells me how much she will miss me and the particular kind of space in her life that our sessions together have provided. I have a sense of a weight lifting as her words as her body language move in accord.

Although Susan is more overtly unhappy at the end of the session than when she entered the room, her psychosomatic health - or what Winnicott would call her quality of psychosomatic indwelling - has improved. Susan is more in touch with her visceral self. She is functioning as a whole. Like Winnicott, I believe that a good quality of indwelling is a necessary condition for the full recovery of health in its wider sense. Before we can find our way forward, we must have a proper sense of where we are and how we are in the here and now.

Charles Rycroft wrote that:

Psychoanalysis began as a branch of medicine and its raw material still derives from people who are in trouble and seeking help; it has therefore more to say about illness than about health, and a tendency to describe human nature in a terminology derived from pathology (1991 p.17).

Winnicott was a welcome exception to this main trend. He devoted a large part of his work to the consideration of play in childhood and the role of art and culture in adult life. Winnicott also wrote explicitly about health, which he characterised at one point as ‘much more difficult to understand than disease’. The following passage is taken from ‘Human Nature’ published in 1988.

We are not just simply concerned with illness or with psychiatric disturbances; we are concerned with the richness of the personality and strength of character and with the capacity for happiness, as well as the capacity for revolution and revolt (Winnicott 1988).

Those of you who are familiar with his work will recognise something of the same spirit in the writing of Christopher Bollas. A concern with health has also become an important aspect of contemporary post-Kleinian thinking, something that is not always recognised. We are currently in the UK home of post-Kleinian thought and I can say from personal experience that the MA in psychoanalytic studies here includes modules on ‘applications’ of psychoanalytic thinking to drama, film, art, our relationship to the outdoor world, sport, music and much more besides. It also includes, as do almost all the courses here at the Tavistock, a two-year period of psychoanalytic infant observation, where ‘normal’ infant development is studied through participant observation in an ordinary family.

We could talk about health and what we mean by health all evening, perhaps through the whole of the ten events, so I will narrow down my focus at this point and address myself directly to the phenomenon described by Winnicott as ‘the indwelling of the psyche in the soma’. In Winnicott’s view, a mark of health in the individual is what he refers to as the ‘unity psyche-soma’ and here I will quote Winnicott’s own words:

(I refer to) ... the inherited tendency of each individual to achieve a unity of psyche and soma, and experiential identity of the spirit or psyche and the totality of physical functioning (Winnicott 1966:112).

Winnicott began to explicitly explore the subject of bodymind unity more than fifty years ago. He developed his ideas during the period referred to by Franz Alexander as ‘the laboratory period of medicine’, when the medical model with its dualistic perspective on the human subject ruled supreme and this, I think, was an astonishing achievement.

Winnicott conceptualised the psyche-soma as a unity. In his work, ‘mind’ or mental functioning is described as no more than a ‘special case of the functioning of the psyche-soma’ (Winnicott 1949). Several writers have noted his distinctive emphasis on the physicality of the self: This quote is from Susie Orbach, who will be presenting the last in this series of events on March 27th:

In post World War Two developments, psychoanalysis has become primarily a theory of mind and mental contents. Winnicott’s work stands out from this tendency in the deeply physical sense that he conveys to us about his work and his understanding of mental processes (Orbach 1995: 3).

In recent years, a fruitful dialogue has developed between the Kleinian and the British Independent strands within psychoanalysis. In the sphere of psychoanalytic infant observation, for example, Winnicott’s understandings are thoughtfully integrated with post-Kleinian thinking. There are also links between the work of Jung and that of Winnicott. Both argue that the specialised mental function of thinking remains, in health, continuous with physical self-awareness, with the latter serving as a source of natural wisdom, spontaneity and energy. Disturbance of this continuity is linked in both accounts to experiences of dissociation and depersonalisation.

Winnicott also believed that the integrity of the psyche-soma was fragile. When there is damage, difficulties emerge that are ‘psychosomatic’, in the sense of involving a split between psychological and physical aspects of functioning. One the one hand, a person may experience the body as numbed and dissociated and have a feeling of 'living inside the head'. On the other hand, the whole burden of self-expression may fall on the body and somatic symptoms are likely to develop. When psychological functioning is restored through emotions being identified and words being found, the symptoms begin to abate.

Psychoanalysis has always been concerned with subjective experience as well as with behaviour as perceived from the outside. In the area of physicality, our subjective sense of ourselves as embodied emerges from many interrelated experiences. Winnicott refers a process whereby:

The infant becomes a person, an individual in his own right. Associated with this attainment is the infant’s psychosomatic existence, which begins to take on a personal pattern; I have referred to this as the psyche indwelling in the soma (Winnicott 1960ii: 45).

The first stage in this process belongs to the mother, as she joins up of physical and psychological aspects of her baby’s experience. In ordinary – to use Winnicott’s phrase ‘good enough’ - circumstances, this process begins before the baby is born, when the mother shifts from seeing herself as simply ‘pregnant’ to feeling herself to be in relationship to an unborn child, with personal characteristics of his or her own. Stroking the infant in the womb through the skin of the abdomen, attributing intentions to unborn the infant (‘I see you’re in no mood to let me have a sleep!’) and asking questions (‘How are you doing in there? Is it getting a bit squashed, eh?’) are some of the external markers of this shift. This maternal behaviour isn’t limited to mothers. I know one father in the room tonight, a musician, who played music to his unborn baby in the womb.

After the birth, this ability to ‘join up’ is communicated to the infant through maternal care which involves a seamless experience of being held in mind and physically handled. Winnicott suggests that maternal handling meets with and supports an inborn tendency within the infant towards integration and a proper sense of embodiment. As Adam Phillips puts it:

This natural ‘tendency to integrate’ is made possible by the mother’s care in which the infant is ‘kept warm, handled and bathed and rocked and named’ (1988, p.78).

Winnicott repeatedly returns to the physical dimension of living, which for him is absolutely entangled with mental and spiritual aspects of experience. The idea of ‘the psyche indwelling in the soma’ is explored in its own right in several of Winnicott’s key papers. In addition, it is woven through other, better known, aspects of his writing, for example his work on ‘holding’ and ‘handling’ in infancy and his exploration of the value of play. It is central to his concept of ‘true self’, described by Winnicott himself as:

... little more that the summation of sensory-motor aliveness (1960).

From this simple sense of aliveness emanates the spontaneous gesture of the new-born infant. It may be something as simple as a certain way of kicking or of beginning a feed. If the gesture is received and responded to, then the foundation is laid for the development of what Bollas (1993) calls the individual’s ‘personal idiom’. Over time, the idea takes shape in Winnicott’s work that a sense of self centred in the body is an essential precondition for healthy and enjoyable living. As psychotherapists, we may see in psychosomatic symptoms an unconscious request for help with difficulties in this area of experience, for is it not the case that such symptoms speak silently of a disjunction between physical and other aspects of experience?

In health, then, the psyche-soma is a unity. The appearance of a ‘duality psyche-soma’ is a consequence of defensive splitting in the face traumatic experiences. In the subjective sense, we are talking of experiences where the individual in effect says ‘I am not really here’ or ‘This is not really happening to me’ or ‘I am watching this happen but the person to whom it is happening is not really me’. Once enacted, psychosomatic splitting paves the way for those ‘mysterious leaps’ from mind to body, which some psychosomatic specialists take as their starting point.

In Winnicott’s model, psychosomatic symptoms oppose as well as express the underlying splitting and dissociation and in this sense they are health-seeking:

Psycho-somatic illness implies a split in the individual's personality, with a weakness of linkage between psyche and soma, or a split organised in the mind in defence against generalised persecution from the repudiated world. There remains in the individual ill person, however, a tendency not altogether to lose the psychosomatic linkage.

Here then is the positive value of somatic involvement (Winnicott 1966 :113).

To summarise, an individual is moved to make explicit the fact that his or her psychosomatic integrity has been damaged so that the damage can be addressed. The damage becomes visible in the form of psychosomatic symptoms. The symptoms oblige the sufferer to attend to bodily matters and to seek help from the outside world. In this way, physical aspects of self force themselves back into the picture. In a sense, the body refuses to be forgotten.

Whether he is considering the question of play, of mothering or of personal authenticity, Winnicott’s writing returns to a discussion of the internal and external factors which support or obstruct an individual’s capacity for relationship. He sees a feeling of being connected to, grounded in, one’s own physicality as crucially important. It is synonymous with access to the ‘true self’ elements which enable an individual to feel uniquely like himself or herself. It is the basis for a ‘gut feeling’, without which the individual has no internally experienced basis for his or her actions or plans. The term ‘indwelling’ refers to this feeling of ‘at-oneness’ with one’s own physicality. For Winnicott health involves these two inseparable aspects of being – a potential for authentic relationships with others and a firm grounding within one’s own physicality.

Last Updated April 5, 2005