Saturday, December 1, 2012

Psychoanalysis and Somatic Patient, Athens Psychiatry Conference, 2012

Psychoanalysis and somatic patient
Chairs: P. Aloupis (France)
  1. Alsenstein-Averoff (Greece)
Dec. 1, 2012

This was the most uplifting presentation underscoring the almost miraculous or magical results that can be seen in psychoanalysis as actual physical bodies are healed alongside the healing of the psychic body.  I’ve just in note taking captured phrases here and there like strains of music. To anyone who has had exposure to the depth of the unconscious these phrases will serve as oasis along the journey that the analyst makes with the patient.  The presentations were read as is normal in these analytic presentations.  To be truly appreciated the full report would have to be seen. I guess I’ve taken this down to get the ‘flavour’ to hear the ‘music’ as it were in this great anthem of healing that is the analytic process.  Too often today there’s a slash and burn approach to the knots that Laing and others appreciated for their complexity and importance.  We are so at risk of losing our minds if only we treat the brain,  This presentation so re inforced the criticalness of the ‘research’ involved in each analytic case, a kind of n of 1, in the deep anthropological study of a single person in the world joined by a healer.  There was a gentleness too in this room and presentations that spoke to all the most intriguing and attractive aspects of the psychiatry that took me away from the simplicity and sensationalism  of surgery to the mystery and uncertainties of the human condition.  I was touched by the honesty and caring of the presenters.  Here was the wisdom of Athena in Athens of all places.   These briefs presentations are often about hundreds and thousands of hours of treatment over many months and years of work.  The vast spaces between are heard by all of us who have listened to our patients and walked with them on the marathon journeys. Today I regret at times what little resources we have and the hammering at the door as government and insurance demands we see more and do more with less and less.  Mostly analytic work despite it’s critical value to our profession as a whole has moved or been pushed away from the ‘administration’ model of psychiatry which sees each patient as a ‘unit’ in a factory where the word ‘euthanasia’ is cropping up more often as a natural end result of this kind of unanalyzed apparently 'economic' reasoning. 

  1. Aloupis opened the round table discussion with a clinical vignette
  • eg. Patient can not express his emotions
  • context of our session
  • summer
  • one month after father died
  • feels unwell, anxious, doesn’t know why
  • can’t imagine why his fathers death would influence how he feels
  • can’t understand how his office renovations would affect him
  • I said there is a psychic body and a physical body
  • says I can’t accept myself
  • says that he wasn’t close to his father as a child
  • I say because he wasn’t accepted he may not accept them
  • After that he disclosed much new information about his early life and feelings

-Freud psychic and somatic
-(missed the name of the latin analyst being spoken of ) psychosomatic leader in latin america - one of the founders of psysomatic analysis
-germain arguing physical treatment - interpret the exact
-evidence of somatic - trauma overload -subject finds other paths of psychic discharge
-chicago school highlight importance of emotions
-neurophysiological linkage to organs
-for Kleinian somatic is determined by the psychic from very beginning of life
  • psychoanalytic models of psychosomatic
  • unconscious meaning - radically changes meaning of the symptons

Three presentations
-model from Paris - somatic invasion
-model from Greece and Paris - transforming somatic symptons into psychic
-sharing work with 

  1. Baudin (France)
Voices of transference with somatic patients
  • love, abandonment, transference and countertransference
  • several style
  • somatic and psychosomatic - problem - we find ourself confronted by more primary
  • explore mechanisms 
  • difficulty obtaining mobilization
  • alot of primal
  • what is at work in our own mind - how do we listen to the psychic suffering
  • what kind of forces will we get in this work
  • what risks do we take on with these patients
  • 2 dimensions - importance of the actual
  • best if the patho experience belongs to the past so his ego can stand separate 
as opposed to acute crisis
-actual reality like headaches, or known physical illness, like cancer
-it reduces the distance between past and future
-patient is in constraint
-counter transference and transference
-one of the major difficulties of the psychic work, binding and rebinding
somatic pain contributes to not being involved
removes energy
actual complaints
during many years and some cures of somatic patients
understand the idealization 
psychic economy
therapist stimulates or reveals what is hidden
burden on patient to be psychically drained

eg 35 year old 
some years before 
important surgical tumor
threatened life
stopped analysis
felt unable to speak
came to me some years later
on advice of friend
uncontrollable headaches
difficulty to be with herself and with another
her body since her childhood - physical and psychic crisis
need to be glued 
the sheet of her parents bed
her father
her older sister’s breast
father , alcoholic
depressed mother with different lovers
divorce when patient 12
older brother severe personality disorder
picture of her family she’d started 6 years ago
erotic - her sons - molested
her husband she actively abused
had no sexual desire for her husband
autoerotic desires
her headaches were a sort of breast
headaches authoritized
family actions she had witnesed as child
engaged herself with me
repeated in session the violence
saw them as outsde and inside
listening to her - on the couch
I had the feeling she hardly heard when I shared
She had a specifically sad passion
Not only patient who presented like this

eg vaginal burning patient
we are called to bring closure and to see
as if they are seeing again and again 
the sins of childhood
asking me to see as she did
I was tired by the wearing repetition but she was not

I’ve met this affect in other patients
During this the body says something before subject says something

one was mute - i dared to remind her the ‘rule of talking’
is she asking if I’m here despite the violence
I get the impression she makes me wait
I was expecting something to happen
I try to be silent to this silence
many patients will use this to try and swap the role
With my patient though there was a different meaning
Muteness, anxiety with wrestling with the affect which is projected outside
Rather than put in service of the analytic recreation
Not even worked through
Demand for partial payment on doorstop
When she thinks she controls
Anxiety before the stranger
Ego from non ego
identity disorder
psychic space
somatic trauma

She projects on me in very concrete way
Psychic dimension
Pay attention to the movement of seduction
A witness
Agitation in the acting
Thread of association
To do violence
Role elaboration
naturally loaded by affect
burning hot and freezing
what is danger to tread on this difficult ground
Psychoanalyst knows he’s working with highly explosive forces
The analyst - the unconscious and repressed -treat the analyst as intruder
The analyst is the sitting guardian and isn’t the intruder
The abandonment is worked through
Question of status
Psychic functioning
if the object relation is loaded
Subject relationship
Illness brings overloading to the enigma
Real work of reparation
The analyst moves from not being seduced to not falling back to neglect and reject
No easy matter

-difficulty with the patient with this explosive affect
  • it’s not a neurotic transference
  • it’s total madness
  • much more difficult to handle

  • shows link between violence and passiveness
  • countertransference
  • when we asked participants the clinical cases were about violence and passiveness

response - she was acting and she was acting onto me

Aisenstein - Averoff
Asked about other practitioners outside the therapy
Response was the therapy was even more complicated by the patient self medicating but that while they got reports from medical nature but they did not report to anyone

  1. Dimopoulos
-the transition from somatic disorder to bodily pain

Analysis with other patients is different transference countertransference with psychosomatic
other techniques must be used beyond the classical
when the patient said that somebody was persecuting him
or recounting a dream didn’t feel anything
I said he would feel anxious
at another point I said he might have been feeling angry and couldn’t express it

I will focus on an aspect of a patient who had gastric bleeding
Gastric bleeding came suddenly
One doesn’t talk about a body because it is well
Or because it is ignored
Psychosomatic fail to acknowledge symptons
Denial - splitting between body and psych
i chose to see the patient 2x a week 
Rather than on the couch
Because he didn’t seem to be aware of his lack of reaction to his body

I did not propose classical analysis on the couch
The couch can be conducive for free association
But this is only for those with the basic capacity for this

He kept speaking about the bleeding as if it meant nothing to him
When he talked there were at times vagueness
When I asked him what he meant he was surprised
As if he believed I understood or should have understood
He became annoyed 
Typical of this kind of patient - a mirror - consider the other
Not so much as another but rather a narcissistic expression of themselves
They feel the other should have understood
Mirroring relationship
In classical analysis a technique i avoid in this situation helped to move forward
When he was nervous and asked what we were doing, but he kept coming and was exasperated.
I’d in fact grown tired of him - I believed the patient perceived my mood
He ‘d experienced it but could not work it through or express it, just experienced 
he became able to talk about therapy but not about his feelings about me
The transference was becoming -gaining the place of talking about our relationship
Connections being made
When he talked about choices he’d made and not made in his life he developped pain in his he’d not talk so much about his pain, not like he’d talked about his bleed - but he now talked about his description of his relationship in adolescence of his father and his relationship, this ambivalent relationship was reflected in the spasms of his stomach
The object is not internalized but we are moving
It is as if he swallowed the object rather than digested the object, the internalization, here in the digestive system things happen
Capacity for understanding and transmuting to affect
Somatic pain was expressed
His stomach was speaking
At the same time somatic pain may constitute old pain empathic
May be more than organic disease
If psychic pain is relationship to differentted object but somatic pain is narcissistic
relationship with an object.  It might lead to organic disease - the bleed in this situation.
The analyst undertakes to do the difficult work
In the neurotic patient they undertake to do the work.

Encounters with breast cancer patients
  1. Fafouti  (France)
Experience over 2 years as consultant to large breast cancer unit

Conscious and unconscious

Why me?
Internal world seems out of control
Breast cancer violently destroys outward control
Saddened realization of mortality
Everything is changed - with family, friends
All will play an important role in the revival that follows massive anxiety
In order to save themselves must abandon themselves
From independent to become dependent
Beginning of a long journey
Fantasies of mutilation and real mutilation
Psychological distress
Sex and sexuality

Wig, make up and prosthesis - every night I take them off - am I a real woman, 
Breast as sexualized
Effects on them and partner

Shame and embarrassment
Impossible to hide

Is a woman without breasts still a woman
Little girl confronted by her mother’s body
The loss

Gazing at oneself in material amputated flesh
Forever changed

Traumatic discontinuity
Scar reactivates trauma

Some women keep scar as war scar
As others regaining control will get another breast reconstruction even if this is not ideal or too soon

Loss of Love

Loss of hair
Loss of menstruation

Unhappy childhood, abandonment, fathers
All come forward

Cause of breast cancer not known

Clinical vignette
referred to me for anxiety after chemotherapy
often anxious and confrontation
after diagnosis - partial resectomy
attractive single woman in 40’s
malignant tumor found
she was angry that cancer she thought appeared before found
depression before this
she was wondering whether to have a baby
now it was certain motherhood not possible
went for days without sleep
never ending activity
no time to slow down and rest
no time to process emotions
anxiety and panic
father’s death and diagnosis of breast cancer
brought mother to live with her
mother illness
relationship full of personal attack
-she admitte d that the dx of cancer was only ‘permitted’ excuse to slow down and rest
had difficult childhood with 9 children
arranged marriage between her father, father educated,
father would at times became mad and destroyed everything
fear as a child
mother illiterate
during childhood considered her mother sacred who needed protection
From father who would become physically violent unable to tolerate mother’s stupidity and ineffectiveness
as child went to mother’s room to ensure she was alive, afraid she’d been murdered
early age helping her mother
age 4 - baby brother found dead
age 7 - baby sitting baby brother - died 2 months later
mother said - you see you didn’t want to look after him and now he’s dead
did everything in her power to help her mother
mother never missed opportunity to humiliate her
‘the girl with the long hair’
mother would in anger would grab me by hair and drag me
puberty - mother took me to hairdresser and cut my hair short
my father cried at my short boy like hair and trousers
tied bandages around breasts trying to make them disappear
dirt and germ phobias
washing rituals
Around menstrual blood
Became cruel to animals
OCD rituals = school became poorer
Built life of own few relations ambivalent
migration to new country
saw psychiatrist, treated with antidepressants which helped with depression but not obsessions
became more open 
became aware of her rage attacks on her body
saw image of her body not taught to be accepted of her body by her mother
took possession of her body
identity re emerged
came forward in therapy
for many women cancer is an enemy
therapy not to cure cancer but to address what the cancer becomes for women and how it can be put into words.

1 comment:

Anonymous said...

I must say and I'm sure other do not really understand what you are doing

Dispite all my education and experience

I am clueless on how to help the people you are dealing with

thank God that you have the grace to help these people