From Soma to Symbol: Psychosomatic Conditions and Transformative Experience

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This book traces the theoretical history of psychosomatics in psychoanalysis, and with it the ways that psychoanalytically-trained clinicians have tried to understand and treat patients with complex psychosomatic symptoms. It offers a rethinking of the mind-body relationship in psychoanalysis, eschewing past dichotomies between the psychological and the corporeal, and today's either-or distinctions between symbolizing and non-symbolizing patients. Theoretical and clinical issues are considered from a broad and integrative perspective. Psychosomatic patients' best interests are served neither by an indiscriminate embrace of dazzling new findings, nor by discarding established ways of understanding them. This volume exemplifies an approach that takes advantage of the rich history of the past as well as exciting new work in the neurosciences. The opening historical chapter delineates the evolution of the field of psychoanalytic psychosomatics. Out of the reductionism and divisiveness of the past, through a growing rapprochement between the American and French psychosomatic traditions, to the thoughtful integration of the work of allied disciplines, an emerging international perspective has emerged that has re-energized interest in psychoanalytic psychosomatics and holds much promise for our patients. This is also a clinician's book, however, aimed at helping psychoanalytic and psychodynamically-oriented clinicians to work more comfortably and productively with psychosomatic patients. The case histories are full of useful ideas about how to engage and maintain these challenging and vulnerable people in treatment. Clinicians will find many imaginative approaches to helping a patient know her own mind (often for the first time), and become capable of genuine aliveness, relatedness, and mutuality. There are also hints for dealing with the intense countertransference almost universal with these patients, which may be the analyst's chief source of understanding when words fail or are absent altogether. In addition, richly detailed discussions suggest how the new theoretical and clinical integration may apply to other patients with impaired symbolizing capacities, greatly extending the book's clinical usefulness.

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Chapter One - A Tale of Two Theories

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Phyllis L. Sloate

The field of analytic psychosomatics arose out of the dualistic Cartesian preoccupations of the late nineteenth century, but its development after that was shaped less by philosophy than by the cultural and interpersonal styles of its founders. The history of the mind–body question in psychoanalysis is a complicated and often tumultuous journey through psychoanalysis itself.

It begins with Sigmund Freud's and Pierre Janet's seminal investigations into the perplexing bodily expressions of hysteria. At first, Freud and Janet were not too far apart in their theories, but their thinking and methods of inquiry diverged, and with them their relationship. The legacy of their estrangement was an enduring bitterness and mutual disrespect that sadly retarded the theoretical and clinical development of psychosomatic studies. It has taken many years for their theoretical heirs—Freud's in America, Janet's in France—to begin to bridge the divide and reclaim a complicated but very rich double inheritance.

 

Chapter Two - Non-Mentalizing and Non-Symbolizing Psychic Functions and Central Sensitization in Psychosomatic Disorders

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W. Scott Griffies

Introduction

Psychosomatic disorders are disorders with physiologic, somatic changes that are thought to originate at least in part from emotional factors. Although historically psychoanalysts have attempted to treat these disorders, a significant number are very resistant to psychotherapeutic interventions. Writers have stated that many of these disorders might be untreatable by psychotherapy (Karasu, 1979; Sifneos, 1972). Psychosomatic patients can be viewed along a spectrum, from those that have a major somatic component and minimal psychological contribution (e.g., ulcerative colitis and hypertension) to those with little or no somatic involvement and major emotional input (e.g., conversion paralysis or pseudoseizures) (Speigel & Speigel, 2004, p. 336). Those that are more psychological have more capacity for symbolic functions and therefore express their conflict-ridden feelings through symbolic body language. Others, however, have significant deficits in fundamental stress and pain processing neurological hardware that leads to psych-neuro-endocrine-immunologic dysregulation and physical disease (Crofford et al., 1994; Heim et al., 2000).

 

Chapter Three - Just do it! Surgery as Psychosomatic Action

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M. Ann Simmons

Introduction

The current trend of body tattooing and cosmetic surgery shows itself, literally, more and more frequently in our consulting room. Indeed, the therapist herself might sport tattoos or piercings. Other individuals may openly discuss their desire for more radical change, such as breast augmentation surgery, “nose jobs,” or other body surgeries; in fact, some have decided on such action, or have had such operations, before beginning treatment.

Yet, it remains perplexing that some people want to transform or supplement their body in an attempt to destroy, deny, or heal internal wounds. The philosopher Susan Bordo (1997) describes the pressure of contemporary culture as a “pedagogy of defect,” one that encourages women to modify their bodies according ever-sophisticated technology (p. 36) and she argues that such a demand normalizes our desire to transform an internal sense of deficiency and damage into action (pp. 36–37). “Just Do It!”, Nike's message for our age, places physical action squarely at the center of our locus of self-control. Cultural proscriptions for physical beauty and women's objectified status, along with any particular woman's intrapsychic dynamics, may coalesce around, and become projected into, specific body parts. We are all incorporated in our bodies—we are our bodies—and yet some of us are more aware of our bodies, feeling its appearance and sensations as an intrusion into our minds, or experiencing it as damaged, defective, and a source of shame. Our self-image can become so identified with a particular aspect of our body, for example, that our body itself, or its parts, can become the site of obsession. To the extent that any one of us is driven to change our own body, we might hope to enhance our beauty and self-regard, as well as quell our painful internal torment. Indeed, we may do so.

 

Chapter Four - Psychosomatic Events: Self-Care as Technology of the Self

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Isaac Tylim

Psychoanalysts are familiar with the way the soma can suddenly intrude into an analytic process. This intrusion can affect both analyst and analysand, either at the same moment or at a different juncture of the analytic hour. A need to urinate, to take a sip of water from the ubiquitous plastic bottle, or have a bite from a granola bar hidden in a pocket are a few examples of the various ways the body calls attention to its existence. A headache declared in mid-session, a gradual falling asleep on the couch, and the appearance of a skin rush are other psychosomatic events that highlight the intrinsic connection of soma and psyche. Analysts are prone to react to their analysand's demands with strong wishes to leave the room, cover their ears, and, in extreme cases, to measure their blood pressure.

In the course of a psychoanalytic treatment, psychosomatic events tend to present themselves regularly. They appear in vivid and tangible form, and are hard to ignore by both analyst and analysand.

 

Chapter Five - When Words are Unspeakable: A Bridge beyond the Silence

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Randi E. Wirth

Psychoanalysts and other clinicians have defined psychosomatic symptoms in many ways over the past century and a half, often very contentiously. Recently, there has been a growing consensus that there are in fact many ways that the psyche can make itself felt in the body, and many reasons why it does. There is growing interest in the anatomical, neurological, physiological, and psychodynamic factors that can shunt emotional experience out of the symbolic sphere and into the physical one, and in the way these factors can interact. The results may be physical symptoms of the kind that have classically been associated with “psychosomatic” processes. But at other times, as in the following case, the shunting may not present as an “illness” at all, or even as a so-called symptom. Nevertheless, it is there, and clearly psychosomatic in nature.

Irrespective of the reasons for a diminished capacity to mentalize experience (Fonagy & Target, 2007), and the specifics of the results, patients who have been subject to this shunting have a very hard time verbalizing what they feel. These patients have trouble making sense of bodily sensations and are unable to express affective experiences with words. Fonagy and others elaborate on this, asserting that in order to achieve a sense of control over intense affects, such patients must be able to represent the idea of an affect (Allen et al., 2008; Fonagy & Target, 2007; Fonagy et al., 2004). This ability is absent in patients who have deficits in mentalization.

 

Chapter Six - Psychosomatic Illness in a Claustro-Agoraphobic Patient

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Susan N. Finkelstein

“Take a man who is released and suddenly compelled to…look up toward the light; and who, moreover, in doing all this is in pain, and because he is dazzled, is unable to make out those things whose shadows he saw before. What do you suppose he'd say if someone were to tell him that before he saw silly nothings, while now, because he is somewhat nearer to what is and more turned toward beings, he sees more correctly?…Don't you suppose he'd be at a loss and believe that what was seen before is truer than what is now shown?”

(Bloom, 1991, p. 194, stanza 515d)

In one of the most powerful images of Western literature, Plato describes a group of people who have spent their lives imprisoned in a cave, chained so that they face the back wall. All they can see are shadows cast on the wall by a fire behind them. These shadows are the only reality these people know; they have come to understand them as the only reality there is. Plato then imagines what would happen if a prisoner should escape from the cave and so become witness to another reality previously unknown to, and unimagined by, him. The Parable of the Cave vividly depicts the anxiety of living with uncertainty—uncertainty about safety and danger, about knowledge and ignorance, about where we stop and the rest of the world begins.

 

Chapter Seven - Plight of the Imposter: The Embodied Transference and Countertransference in the Analysis of a Woman with a Congenital Deformity

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Marilyn Rifkin

In his paper “Some character types met with in psychoanalytic work,” Freud (1916d) depicted “exceptional” characters (pp. 311–315): people who had suffered horribly in the past and, as a result, struggled with significant narcissistic defensive structures. Freud's main illustration was an applied analysis of Shakespeare's Richard III, an ugly hunchback who is “rudely stamp'd”, “deformed, unfinish'd”, and cannot “strut before a wanton ambling nymph.” Richard responds to the agony of his condition with this declaration: “I am determined to prove a villain / And hate the idle pleasures of these days” (Shakespeare, 1994, p. 98). For Freud, Richard's physical deformity was a metaphor for his deformed character. As Harold Blum notes, the psychological ramifications of such a character

extend far beyond the immediate consequences of the physical deformity or disability. There may be compensatory fantasies of grandiosity and uniqueness alongside exceptional narcissistic vulnerability, distortions of body image and disturbances of body reality extended to external reality. (Blum, 2001, p. 124)

 

Chapter Eight - The Realization of Meaning: Superego Analysis and Psychosomatic Symptoms

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Phyllis L. Sloate

Physical symptoms, like all other human experiences, are potentially meaningful, and analytic work is an effort to facilitate that potential. But this is complicated work, and requires of the analyst more than the usual tolerance for ambiguity and uncertainty. A symptom may indicate the presence of as-yet-undiscovered repressed conflict. But it might also be a manifestation of accumulated tensions, bodily or affective, that have never been thought about enough to be repressed. It may pre-exist treatment or be a creation of it—the result of unverbalized affect unleashed by structural change—and so may its meaning. It might mean one thing (or nothing) at one moment, and something altogether else at another. In short, symptoms express not only our emotional vulnerabilities, but also our corporeal interactions with them and a vast spectrum of other predisposing immunological, neurophysiological, genetic, and environmental factors. Despite advances in our understanding of these interactions, we still have much to discover about exactly how our emotions and affects impact upon, and interweave with, the actual workings of our complicated bodies.

 

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