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

Alsenstein-Averoff

-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

anxiety

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

derailed

erotic - her sons - molested

her husband she actively abused

had no sexual desire for her husband

autoerotic desires

authorities

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

confrontation

if the object relation is loaded

Subject relationship

Links

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

Aisenstein-Averoff

-difficulty with the patient with this explosive affect

• it’s not a neurotic transference
• it’s total madness
• much more difficult to handle

Aloupis

• 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

analyst 

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 

exasperation

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 stomach....now 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

Symbolism

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

Haunted

Anxiety

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

guilt

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

psychic 

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.