The Soul, the Mind, and the Psychoanalyst

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This book is based on various cases whose common factor is how the psychoanalytic setting is created: the internalization and realization inside the patient`s mind: with the feeling of fixed hours and the transferential relation with the psychoanalyst. Referring to the great masters of psychoanalysis, Rosenfeld guides us step by step through the mysterious terrain of the mind, especially in its most regressive, primitive and psychotic aspects. Thomas Ogden, commenting on the papers collected here, wrote that 'they represent two of the most important contributions of the past decade to the understanding of the psychoanalytic treatment of psychotic patients'. This book is intended to be felt and thought about. The reader is asked to read between the lines, to imagine and feel beyond the words on the page. It will appeal to psychoanalysts, psychotherapists and students.

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CHAPTER ONE: September 11th: military dictatorship and psychotic episode-year 1973

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Even in a state so far removed from reality as hallucinatory confusion … that at one time in some corner of their mind there was a normal person hidden.

Freud, 1940a

In this clinical history I describe the story of a young patient who could be considered a paradigmatic case illustrating the effects produced by military dictatorships that were similar in several South American countries.

In the methodological perspective, the therapist is faced with the not always easy task of continuing to think as a psychoanalyst in spite of the real traumatic events suffered by the patient, in terms of the patient’s unconscious dynamics in the transference, while also considering his infantile world—and, especially, to be able to bring to a verbal level the terrible traumatic experience of a child under 2 years of age, who was handed over to a neighbour while his parents were being kidnapped by military personnel and then taken to secret centres of detention and torture.

The traumatic stress for a child, unprepared to anticipate danger, faced with the terrible, abrupt disappearance of his mother’s and father’s familiar voices and faces, is very difficult to work through. This traumatic stress remains forever engraved on the child’s receptive mind, which is prone to great sensitivity and suffering in relation to separations and abandonment. For this reason I tried to pay special attention to our leave-taking at the end of each session (see the session in which the patient turns into a butterfly).

 

CHAPTER TWO: Eating disorders: psychoanalytic technique

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Who wanteth food, and will not say he wants it,
Or can conceal his hunger till he famish?
Our tongues and sorrows do sound deep
Our woes into the air; our eyes do weep
Till tongues fetch breath that may proclaim them
Louder.

Shakespeare, Pericles (Act II, Scene 4)

In this presentation, I describe the psychopathology of a female adolescent with eating disorders oscillating between bulimia and anorexia. I emphasize and highlight particularly the technical handling, based especially on transference interpretations.

I discuss the importance for her of having been abruptly separated from her mother, who was critically ill. The material of a dream shows how she now experiences and how she experienced this separation as a baby: the patient narrates a dream in which she says, “my mother dies and then I die too”. In this way, she expresses, symbolically and absolutely clearly, how she experiences having been abruptly abandoned.

This traumatic model, which is reactivated with each separation or loss of an object relation, shows that she is a young woman with the kind of hypersensitivity we find in autistics, for whom the rupture of a relationship is experienced as “annihilation” and loss of parts of the body (Tustin, 1990b). This is why I considered it especially important to pay particular attention to ends of sessions and missed sessions.

 

CHAPTER THREE: Drug abuse, regression, and primitive object relations

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And here we are mingled to each other, She is half alive, and I am half dead.

Victor Hugo, Booz Endormi

In this chapter I develop a conceptualization of the dynamics and psychopathology of the structures of drug addicts. I propose a theoretical classification and present a detailed history, complete with clinical material and dreams. I also introduce concepts related to the technical use of countertransference.

My objective here is to underline my view that many drug-addicted patients have different underlying psychopathological structures, and that we must therefore approach them through a different implementation of psychoanalytical technique, depending on their specific dynamics. Because of my clinical experience with such patients, I can conceptualize these ideas and classify different types of patients according to a series of models.

This proposed classification should be considered a research model. When a model is invented, it acquires strength from the explanatory perspective. This does not mean that the model represents the ultimate truth, but, rather, that it is useful for a specific stage of the research. The model is not an entity that can be observed at the concrete level. For example, nuclear physicists see the effects of atoms, but they do not see the atoms themselves. In the case of psychoanalysis, we can observe the clinical effects, the manifestations of the model, in various types of patients. Science is the ability to discover the facts behind the observations. The power of science rests precisely on the theoretical models of what lies behind observation, and on the possibility of then observing those models on the empirical plane.

 

CHAPTER FOUR: Psychotic addiction to video games

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The term “addiction”, from the Latin addictus, means “slave of his debts”. We speak metaphorically of addictive behaviour when referring to a strong dependence on something—for example, a drug. Sometimes substance addiction is substituted by addiction to an activity. In this chapter, which illustrates the case of Lorenzo, who is addicted to video games and computers, I shall present theoretical hypotheses concerning these types of addiction and their treatment.

“Lorenzo” First contact

Lorenzo’s mother’s first contact with me was over the phone: we arranged a meeting, and when I asked her whether her son would attend, she explained that Lorenzo, 17, had been hospitalized in a psychiatric clinic following an episode of violence. “They have diagnosed schizophrenia”, she specified. She wanted to know whether the father should also come; I said yes and added that I would prefer to see Lorenzo, too. At the first interview I met them in my office. They sat facing me: the boy to my left, the father further back, a little distant, to my right, and the mother between them. She began to tell me Lorenzo’s history: he had a lot of problems in his relations with people: behavioural problems, he was very violent, and, she added, “We took him out of the hospital a month ago, because we wanted to change the treatment and the doctor.”

 

CHAPTER FIVE: Listening to and interpreting a psychotic patient

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Ihope to demonstrate, through a detailed clinical description, the usefulness of psychoanalytic technique for the treatment of psychotic or severely regressed patients, and also to communicate my own experience in detecting subtle transference clues.

I discuss only a very limited period in the treatment of a patient: the first interviews and the first months of treatment. I describe moments of psychotic transference and then the psychoanalytic work during the psychotic episode. Thus I hope to stimulate theoretical discussion on the basis of clinical data and in this way suggest a number of themes to be discussed, in particular the relationship between models or theories and their influence on the interpretative technique.

I would first like to enlarge on the concept of psychosis and the psychotic part of the personality. Freud’s (1940e) description of the splitting of the ego in the psychoses into a normal part and another that detaches the ego from reality is of fundamental importance for the understanding of the psychoses.

 

CHAPTER SIX: Autistic encapsulation

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The theories of autistic encapsulation in one part of the mind, which also “preserves” parts of the infantile world and the individual’s identity and relationships, as we shall see in the clinical material, were proposed by me at the Hamburg Congress in 1985.

The hypothesis differs from Frances Tustin’s. My proposal is that these mechanisms, used as defences in autistic children, can be used again in parts of the mind by adult patients. Unlike Tustin, I show that they are useful for “preserving”. In this chapter, I also discuss the importance of autistic mechanisms or defences in patients who are drug addicts.

Another part of this chapter shows the importance of autistic mechanisms or defences in patients who receive organ transplants. These patients provoke sensory stimuli in the body—”bodily sensations”—as defensive ways of filling the emptiness that they feel in a part of their body whose original organ has been extracted.

Additionally, I would like to present to the reader a new problem: We are currently receiving cases in psychoanalytic practice of people who have undergone vital organ transplants and who have consequently developed a hypochondria—and, at times, a psychosis and psychosomatic illnesses—based on a specific psychodynamic mechanism. These patients with psychosomatic disturbances generally present with autistic mechanisms. Like autistic children, they are enveloped in a world of bodily and tactile sensations. Their psychosomatic symptoms give this type of patient a “sense of being” that is similar to the bodily sensations autistic children attempt to achieve by pressing a part of their body against a “hard” object. This use of bodily sensations—the disappearance or annihilation of a primitive identity—makes these patients difficult to cure. Even in patients who seem to make use of more “healthy” or neurotic mechanisms, it can be very useful to look for autistic pockets. It is also interesting to observe how these very primitive autistic pockets are hidden by apparently sexual or neurotic behaviour (Tustin, 1986, 1990b).

 

CHAPTER SEVEN: Psychotic body image

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Learn this, Thomas,
And thou shalt prove a shelter to thy friends, A hoop of gold to bind thy brothers in That the united vessel of their blood… .

Shakespeare, King Henry IV, Part II (Act IV, Scene 4)

This chapter is a theoretical conceptualization of the body image, based on psychoanalytic psychotherapy with psychotic patients going through acute crises as well as some psychosomatic disturbances. I will try to define and describe, from a clinical point of view, a new concept of psychotic body image and neurotic body image.

When Freud (1914c) speaks of the body, he refers to the projection of the ego onto the body’s surface and describes the organization of the libido in the body. He also deals with the development of the erogenous zones, the way in which they are represented, and their importance in the formation of the body ego. The development of sexual libido takes place in major concentration zones that are in contact with the external world—hence the paramount importance attached to orifices and their relationship with the external world; the relationship of each of them with the outer world prevails in the different developmental stages.

 

CHAPTER EIGHT: Dialogue with Shakespeare and Jean-Paul Sartre about psychoanalysis and scientific methodology

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All the world’s a stage,
And all the men and women merely players: They have their exits and their entrances; And one man in his time plays many parts… .

Shakespeare, As You Like It (Act II, Scene 7)

David Rosenfeld [DR]: Let us begin this seminar by trying to express the questions we have about “Analysis Terminable and Interminable” (Freud, 1937a).

Gerardo: What was the personal and social background of Freud’s treatment of this subject?

Elsa: Freud put it that the main purpose was to think again about what psychoanalysis achieved with patients.

Goyo: It is a taking stock of his life in 1937. With the Nazis already in Germany, perhaps he was thinking that he, as a scientist, was powerless to cure the diseases of cancer, Nazism, and war. So he returned to the destructive instinct, the death drive, and to the possibility of an equilibrium between Eros and Thanatos.

Arturo: Freud tried to deal with the question in the field of research with which he was familiar—that of psychoanalysis. He was particularly concerned with situations where a complete cure was not achieved. He examined clinical cases familiar to him.

 

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