"Peleo’s Hug: Surviving, containing and convincing in severe pathologies analytical experience".
Stefano Bolognini:
I’ll refer to some theoretical-clinical evaluations, based on my experience as a psychoanalyst with severely disturbed patients and on my activity as a supervisor of working teams in public psychiatric centres for adults and neuropsychiatry of children and adolescents.
Specifically, my interest will be focused on what an analyst may observe and process in relation to some basic psychotic disorders, psychogenetically associated with early traumas in the area of the primary needs of human being.
These psychotic dysfunctions can be differentiated with regard to intensity and frequency in isolated cases or in specific occasions, however they represent a serious obstacle to the understanding between patients and therapists and most of the time are a source of unbelievable anxiety, deep concern and, finally of further psychopathology in every contact the individual establishes with the objects.
This psychopathology is indeed transmitted, as we already know, from person to person (interpersonally), from generation to generation in what Money-Kyrle simply and evocatively called ‘traditional trade of misery among people’ (1951).
R. Kaes (1993), R. Kaes, H. Fainberg, M. Enriquez, J. J. Baranes (1993), R. Losso (2000, 2003) described a kind of ‘trans-psychic’ transmission, where the mind, in lack of transitional space, cannot change or familiarize with what is received from the other.
At the trans-psychic transmission that takes place in a mainly narcissistic dimension, the inter-subjective space is fairly limited or absent, the recipients’ transformative mental apparatus isby passed and the contents are invading and often annoying (Bolognini, 2005).
This pathological level of relationship is certainly involved in the complex phenomenon that L. Grinberg (1967) described as ‘projective counter-identification’: the communication doesn’t take place between the subjects but ‘through’ and ‘beyond’ them (or great part of them), and the preconscious of the recipient is deactivated or flat.
In this contribution, I intend to shed light on two sides- , relatively underestimated - regarding the objects’ function of containment : firstly, the one associated with the ability of the object to survive, which is clearly stressed by Winnicott and implicitly repeated by Bion’s (1959) term ‘attacks on linking’, but in which, in my view, there hasn’t been given enough emphasis on the work carried out in the therapy of difficult patients; secondly, that subsequent of ‘internal space’ which was studied by Meltzer in his studies concerning autism (1974).
The last years the transformative function of analytical containment through reverie was deeply explored: the contribution of Bion has been wonderfully developed, in that sense, by writers like Ferro (1996, 2002), Ogden and Grotstein with highly specific papers.
My contribution aims at giving value to an earlier constitutional phase of the containing receptacle, which in a way is more primitive (although it doesn’t seem right to use terms of time regarding the complex functions associated with the establishment and development of the functions of the reverie).
I shall start with a presentation of a short session, part of psychiatric work, and later shall move on to observations on the psychoanalytic aspect of this work.
PSYCHIATRY: FROM THE TRANS-PSYCHIC TO THE INTER-PSYCHIC.
This clinical vignette took place in the environment of a Day-Hospital for young psychotic patients in Venice, where I had been working for many years (today, I still engage upon this field as a supervisor in the equivalent Day-Hospital of Bolognia) and it refers to the interaction between Alfredo, a 21-year-old severely disturbed psychotic patient and Ester, an experienced nurse, very mothering and capable of establishing good contact with the patients.
Alfredo cooperates with Ester in the kitchen for the preparation of lunch.
It is however evident that today he feels particularly bad: he is nervous, he has a dark and morose expression and he seems much more absorbed in fantasies that clearly preoccupy him, but he doesn’t verbalize them, and so we cannot make out whether they suffuse him in a persecutory manner.
Today, the doctor of the unit was absent due to family reasons.
We know that Alfredo’s father died when his son was 9 years old.
We also know that this father had already been a figure with minimum presence due to his profession: he was a seafarer and travelled a lot, he was rarely at home.
Today, Alfredo is particularly peevish with Ester, he barely talks to her and he is tensed. It seems that Ester’s usual positive and affectionate attitude gives rise to an opposite result, as Alfredo is much more enraged.
Furthermore, we know that Alfredo’s mother had been seductive, allowing him to sleep with her for a long time before and after her husband’s death.
She is an impulsive, irascible woman with intense expressions and communication, in every way, erotic as well as aggressive, that provoked incestuous anxieties and violent reactions of anger to her son.
The evident lack of containing experience on her part didn’t favour the creation of an internal space in her son who, in turn, tends to evacuate everything in an urgent and massive way.
Alfredo couldn’t take advantage of a para-excitatory protective barrier (a protective "shield" against over-stimulating inputs too intense for his mental apparatus) neither from his mother, given her temperament and her excessively stimulating, concrete and overwhelming way of expressing herself and communicating, nor from his father, due to his absence both in reality and in his mother mind.
His father (or however ‘a father’ living with Alfredo’s mother in his fantasy) had therefore not been able to operate the structural function of separation that is necessary for his personal development.
Alfredo has, at the time, been overwhelmed both by anxieties of incestuous guilt as well as by guilt for the possibly healthier internal separation drives, which are however experienced highly conflicting.
Alfredo, without any understandable cause, grabs a vegetable basket and throws it violently at Ester; and immediately, without giving her the time to recover from the surprise and terror, he starts screaming to her: ‘ALFREDO WHAT ARE YOU DOING?!? HAVE YOU GONE CRAZY?!?’
Ester, shocked and confused, goes away in horrified.
One hour later there is the regular meeting of the stuff.
Ester, more calm and relieved by the presence of her colleagues, gradually manages to recall.
She narrates the incident and focuses on the fact that what frightened and disorganized her the most was not so much that he threw the basket, but seeing and feeling the ‘crazy’ patient telling the words that she would have been to say, and having the same expression that she would have had if she would have been telling these words.
"He had become me, and made me feel as if I was him: it seemed that I was going crazy".
Trans-psychic by-passes individual minds, and it can result in the violent elimination of limits, of the normal functions of thought and of the internal setting.
While in the trans-psychic there is a basic level of normal symbiosis, economically valuable with areas of peaceful union, without the subject and object feeling overwhelmed or disowned or "replaced" by the other (Bolognini, 1997, 2003, 2004, Fonda, 2000), the inter-psychic ‘invades’ in the other through random paths, in a traumatizing and unprocessed manner, occupying it as a foreign body that can enter "the driver seat" of the guest and be experienced as parasite, replacing his Self and forcing him to repeat the traumatic experience (actively this time, on a new victim).
Repetition (Freud, 1914) at this point refers not only to what cannot become an object of thought but mainly to what cannot be mentalized and be metabolised.
The most primitive defensive mechanism is that of identification which transforms the passive to active, and evacuates in the other the parts of self that are experienced as intolerable.
Alfredo identified with the object, which in this case paradoxically and simultaneously has the characteristics of a symbiotic object, of an object of partial incestuous desire and of a judging superegoical object.
Alfredo is unable to fully let himself go to a reassuring, non conflicting symbiotic regression, as he is going through developmental impulses of separation (so he is guilty because he also desires to break violently the symbiosis).
He cannot face the oedipal anxieties if he doesn’t feel protected from effective limiting objects (the father/the absent doctor).
He cannot endure the guilt for his aggressiveness due to his fears a catastrophic retaliation, and so he ‘becomes the other’ with threatening and suppressing functions.
If we accept the game of a neologism to be real, then we could define this occasional transmission of passive to active as an "identification with the scolder’ (practically, with a type of aggressor)
Alfredo is not a pervert: he didn’t invest erotically, libidinally or in any other way in this projective handling, nor handles it with any talent, he doesn’t master it.
This massive evacuation is not one of his usual strategies, it is the result of an internal breaking and splitting, and of a tensional, expulsive spasm/contracture; his trans-personal act asks for being contained (Ferro, 2002) by a "concave" object capable of handling it without breaking, and able to process the trauma.
This object today will not be Ester, but the working team.
I don’t intend to examine thoroughly here neither the concept of the ‘overpersonal container’ ( public service, group, institution) nor the dialectic between "constriction" (pharmacological therapy, hospitalization)and "containment" which is so many times misinterpreted in Psychiatry for reasons that concern the ideology of its servants as well as the deep fear, on their part, of contacting the most regressive and in greater need parts of the severely disturbed patients.
I am more interested in examining the concepts of the "endogenous persecutory pressure" and of containment from an analytic view , and I will do this through a short digression about an ancient Greek myth.
FROM CLINICAL TO MYTH, AND BACK TO CLINICAL
The legend says that the hero Peleas, having fallen in love with Thetis, the daughter of the king of the seas Poseidon, as soon as he saw her covered with the foam of the waves, asked her to marriage. But being she a goddess, and being he but a mortal, Peleas had to face a very cruel test for earning the right to unite with her.
The goddess, initially unwilling to accept him and gifted with transformative abilities, challenged him to hug her and to hold her tight, while she would transform in various ways, during a long and silent battle.
In order to have her, he should not once let go of his hug.
According to the various versions of the myth, Thetis transformed, in his hug, first in fire, then to ice, later in tip of an arrow, in snakes and many other forms, last of which, oddly, that of a squid, (maybe because of its slippery and therefore shifty surface, I imagine).
But Peleas, who was certain of his own love, never let go of the prey, until the goddess – subdued, but, we could think, mainly "convinced" by/of the certainty of his will – surrendered happy in marriage into his arms.
It is truly hard for anyone to imagine a love story more romantic and intense than this, but what is amazing is the analogy that connects this story to the kind of relationship that is often developed between the analyst and the patient during the treatment of seriously disturbed patients.
An authentic passion is required for this work, in order to face difficulties and possible wounds, that almost definitely will be inflicted on even the therapist, on the road that leads towards an at least partial reestablishment of the abilities to experience, to tolerate the turbolences of the primary relation to the object, and finally – possibly- to love.
Persistence, patience, illusion and disillusion…, even a basic availability to "become related" (in the litteral sense to become – eventually and for a short time- at least for a bit internally and timely "relative", almost a member of the patient’s family, in a working area of the mind) are necessary elements so that an analyst can truly work, with a satisfactory continuity, at the treatment of the severely disturbed patients.
I will present here as follows some components that I personally consider basic for this cause, beginning with the term "internal space".
CREATING AN INTERNAL SPACE, IF THERE ISN’T ONE
Creating an internal space, if there isn’t one, is a need that can not be disregarded in all those cases where the internal persecutory pressure (which could be occasional or reactive) or even worse a basic narcissistic, evacuative, structural and characterological internal organisation obstruct any introjection: that means, in all these situations in which the patient cannot simply take inside of him (introject) anything of what comes from the analyst or from the therapeutic environment.
A special attention payed by the analyst to such functional parameter (that corresponds in fact to a internal organization of the patient, temporary of chronic), produces a very special therapeutic result, which deep down is instinctively everybody knows in everyday life, but on which there are few pages in our psychoanalytic bibliography.
During a recent conference a colleague presented in a clinical group the transcript of a few sessions that were reported with precision and with a remarkable honesty.
A session, in particular, soon before a separation in analysis, presented an outline, in my opinion completely typical, which we could find again in many similar situations, a "schema" that I could reconstruct and present as follows :
- The patient attacks with vehemence the analyst and the analysis, that are subjectively experienced, at that moment, as negative, useless, or openly persecutory presences.
- The analyst attempts (usually with a sense of clarity and of contemporary, serious emotional difficulty) to connect the experience of the patient with the separation occurrencies, and with his corresponding experience from his childhood, in order to give a comprehensive meaning to the present intense emotional experience.
-The patient rejects the analyst’s words, and upsets her gradually with sarcastic criticisms and with a torturing feeling of deep mistrust to the process that is being carried out.
- The analyst, after few small unsuccessful exchanges, carrying the deep feeling of functional inadequacy and personal humiliation as mentioned above, at this point stops intervening actively, and lets the patient to go on with his breakout.
-Following twenty minutes of fierce slander, the patient showes a turn: he appears "empty" and at that point extremely depressive, or rather desperate.
- The analyst, perceivinging the internal void and the resulting decrease of internal tension that developed in the patient, feels that it’s the moment for telling him "something", and intervenes in a modulated way with a comment intentionally vague (general) (almost as if communicating: "I am still alive! And also our relationship is still alive!" but in an indirect and discrete way).
-The patient appears immediately relieved , but mainly signals, through the calmer and reassuring tone of his reaction, that he is now available to receive something from the analyst.
-The analyst suggests an essentially similar connection to the one she had formulated (without success) in the beginning.
-The free association flow of the patient restarts, accepting and producing important bonds with the presented clues.
We can estimate, according to me, the presence of a space dimension, in this analytic work, attached to the "placement", that is in saying / giving something to the patient, (in order to let him take it inside of him; to introject and be able to use it): one explores whether there is a space within which one can place something, if there is (etymologically) "some place".
In that way the "negative" in analysis, is not so much what someone denies, that cancels in the comprehensions and the representations; it is mainly, in another sense, the catabolic, toxic, destructive coordinate of the internal contents, of the relationship features and of the experience of Self and the world. Something that takes over the internal space, and that hinders the mental (psychic) food and the change.
The colleague, in her relationship with her patient who didn’t listen, who didn’t "take anything inside" him, gave space to the negative like a mother that understood how the child couldn’t take inside of him any food if the abdominal disturbances weren’t previously evacuated .
The analyst cannot and should not "deny the negative" , demanding to reinforce the positive (in the way of "putting" something in general, as well as in the way of suggesting vital and "positive" things, like interpretations, new representations, free associations etc) inside the mind of the patient, if there is no room in it.
To be more precise: I think we can talk about an "internal tension" of the negative (psychological equivalent of the body tendency to be freed from an annoying gastric content or an intolerable intestine faecal content) which should be recognized, and to which one should not resist: the acceptance of the "outer- pressure"" (= pressure from the inside, that is from the subject, towards the outside, that is towards the object: the equivalent of fire, ice, tips of arrows and snakes that were evacuated from Thetis in the container – Peleas) is a remarkable part of the therapeutic procedure, long before interpretation.
On the other hand Peleas, creating (with his own arms, in the beautiful image suggested by the myth) a space for holding Thetis’ primitive anxieties and turbolencies, also creates the conditions to establish in her a containing ability and in turn be able to be more accepted from her, in a consequent genital psychic and relational dimension that involves the ability of exchange and mute preoccupation.
It is clear that this mythical metaphor, apparently dedicated only to the relationship between an adult man and an adult woman, concerns on the contrary all the stages of the object relation, suggesting some themes: that of containment as a primary need to create the internal space; that of the power of the desire (in a wide meaning); and that of the holding/ perseverance capacity of the early maternal container, as well as the followings.
I wish to underline forcefully that the analytical space/laboratory, intra- and interpsychic, that is necessary for the representative process, for the instinctual exchange, in the inevitable and sometimes explanatory "enactment" and for the related interpretations that follow, is not a predetermined and guaranted component of the analytical field.
Often it is necessary, in our clinic, a long work for its construction, partially based on the shared experience, when this function has not been previously carried out in a satisfactory way by whoever raised and educated functionally the child.
Here, and not only on an interpreting level, the basic difference between a real therapist and any other person becomes evident: faced with evacuating emissions/ communications, any other person tends to be convex and not concave, i.e. starts immediately talking about the content without giving room to the evacuation needs (i.e. without listening but only for a short time), and tries on the contrary to immediately offer advice, or to explain to him the causes of his situation or to recount what happened to himself in his own past: tries, therefore, to make the other "accept" something at once.
Usually, this happens because any other person does not tolerate, after a while, to host inside him the stress, the tension or the doubt of the other.
But the patient, pressured by a persecutory inner tension, cannot receive: he can only evacuate, so that these can only be defined as "dialogues between deaf people".
We can dialogue and interchange, in fact, only when an internal space is – thanks to de-tension- created in both.
The analyst or a therapist who has been properly analyzed, no matter their own human difficulties, have due to experience and due to technique a specific internal space, and can allow the other to experience "visceral" acceptance, that in everyday reality is not completely obvious.
INTRUSIONS, TRANSMISSIONS OF CONFUSION, INDIFFERENT EMOTIONS.
Mario lived (and made me live) two sessions of hell, with tension, slander apparently with no cause, schizoid associative discontinuity, and mainly with a prolonged sense of nameless and meaningless malaise. It is a painfully recurring process for him, that is what happens in his life, with the people important to him, and this is the reason why he is alone.
Today, like many other times, he moves nervously on the couch, transmitting a sense of tension and of compressed and unexpressed suffering.
He reminds me of a person that has a kind of bothering intestine colic: that is to say, a tensional situation that is not possible to be solved through evacuation, due to an obstacle, due to a spasm that disrupts the normal flow of contents in a concave organ.
Only in this case the "concave organ" is the mind, and the disturbing feeling is that his mind cannot transmit anything else but these indifferent feelings of tense and indefinite bother, without a representative equivalent.
Knowing him for two years now, I’m aware his ability to use analysis is basically disturbed by a strong narcissistic resistance, anti-dependency, which prevents the perception of his emotions, of his needs and of his desires towards the object (i.e. in analysis towards me).
In the third session of the week, Mario succeeds in finally producing and mentioning a relatively simple intrusive fantasy: he fantasizes that he intrudes inside of me "from behind through the hole on the chair".
This fantasy, mentioned with an non innocent way, but with a certain aggression that can be easily perceived, could direct the therapist to read the situation in a way just as aggressive or perverted: the patient could in this way express his desire to control me, to concur me and literally – "to grab my bottom", which at a metaphorical and relational level means to fool me, to neutralize me as an analyst, to castrate me as a parental equivalent, to upset the setting, etc.
All these underlying aspects are of course true, but now I am in a position to think that things are not only this way.
I’m in condition to think, following these two years of work, that other basic needs are also involved at the moment:
the need to be contained
to be contained, indeed, but in a relatively unappearent way, in order to avoid the conscious and direct recognition of his dependence, and thus the intervention of his narcissistic Ideal Self that obstructs the relationship.
to transform the passive in active, in order to ease and control the experience of regression, about which he has an absolute need which however terrifies him.
The result of my internal achievements is that I am finally in a condition to not interpret (Bonaminio, 1993) reactively and prematurely.
I can give him probably the time and the way to stay in the relationship without making worse interpersonally his intra-pshychic conflicts (his Ego confused between the libidinal needs of him self and the narcissistic demands of his autonomistic Self Ideal); on the contrary, waiting for a possible internal solution, simply "assisted" by me.
Slowly the colic is surpassed, the internal spasm is decreased, free associations that refer to the external environment appear ("today there was a mad traffic jam in the peripheral road in order to come here; I thought that I wouldn’t make it here but then, thankfully, the traffic became better, and I managed to get here on time") that however describe a repetition of the internal "peristalsis".
The patient gradually is calmed down, and the moment of departure even says "thank you", in a rushed but sincere way.
It is clear that this situation has to be understood in a complex way: the need to be contained is only one of the factors of the game, and in this situation it came up to be the most important at that moment: the so called "urgent point".
The other components, the aggressive one and the partly perverted one, coexisted, but dynamically less important in that very serious moment (the difficult and painful case).
It is also clear that the analyst needs to have the ability to act accordingly to the situation. If he had a priori always only a containing attitude, without being able to change to other technical options, he would probably have to analyze one of his own masochistic characterological tendency, like a sort of St. Sebastian.
Basically the analyst should be coordinated with the patient through complex perceptual connection and attunement, such that enable him to perceive the various parts that are in conflict internally, and such that he doesn’t simplify his patient’s representation, in order not to end up on "empathism".
CONCLUSIONS
Among the various characters of the ancient Greek mythology, Peleas is strangely one of the most controversial.
Recalling his adventures, we could say that he truly combined in himself the precarious characteristics of a mortal: he was persecuted in different places where he had created troubles and disasters, and where he found himself in difficult situations [in Aigina, because he had killed a stepbrother with his brother Telamona; in Thessalia, because he had killed involuntarily his father in law Euruthiona while they were hunting together; in Iolko, where he was defeated in battle; in Atalandi, where he was wrongly accused for assault (swearing, damage) from Astidameia, the wife of the king Akastos, who fell in love with him and was rejected by him].
In general, nothing was working out for him and every time – following the customs of the time – he had to "purify" in a different place.
He was finally salvaged, earning his maturity and the respect of humans and gods, precisely by winning goddess Thetis.
Reading the various versions of this win, I was impressed by the presence, in the background, of a meaningful character: Cheiron, the wisest and the most known among all centaurs, so experienced in the arts of medicine, music, gymnastics, and in the prophecy, that even the gods (i.e. Asklipios himself, the god of medicine) would run to him for advice.
He had saved Pelea from the other centaurs that were ready to kill him, and in the episode of his Thetis’ conquest he supported Peleas with determination during the test (Pindaros, Nemea, 4.60).
In order to contain someone, one must have or have been contained, seems that the myth says.
One must have lived through this experience, or at least one must have gone through it during the clinical work.
How could we not recognize, in this great allegory of the past, an early equivalent of the intergenerational chain that transmits the ability to raise the immature human being, and also the relationship, until the goal of individuation and separation?
How could we not see this, again, in the everyday practice – i.e., during the analytical supervision or during the working team meeting in psychiatry - when one gives room to the colleague who is reporting his own experience?
And ( "ascertaning the tare" on the idealizing exaggerations that could be involved in this image) how could one not identify on Cheiron the analyst himself, when he supports the patient in his vital task of learning to contain the bad weather of his Self and of his object, towards the coveteded goal of the ability to create an intimate and generative connection with the other?
Stefano Bolognini
Via dell’Abbadia 6
40122 Bologna (Italia)