ABSOLUTE TRUTH AND UNBEARABLE

PSYCHIC PAIN
CIPS Series on The Boundaries of Psychoanalysis
Series Editor: Fredric T. Perlman, PhD, FIPA

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also hosts the Direct Member Society for psychoanalysts belonging to other
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When Theories Touch: A Historical and Theoretical Integration

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A New Freudian Synthesis: Clinical Process in the Next Generation

edited by Andrew B. Druck, Carolyn Ellman, Norbert Freedman
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Another Kind of Evidence: Studies on Internalization, Annihilation Anxiety,

and Progressive Symbolization in the Psychoanalytic Process
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with Jesse D. Geller and Joan Hoffenberg

The Second Century of Psychoanalysis: Evolving Perspectives on Therapeutic

Action edited by Michael J. Diamond and Christopher Christian
 ABSOLUTE TRUTH
AND UNBEARABLE
PSYCHIC PAIN
Psychoanalytic Perspectives
on Concrete Experience

Edited by
Allan Frosch
First published in 2012 by
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Copyright © 2012 to Allan Frosch for the edited collection, and to the
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This book is dedicated to the memories of Norbert Freedman, Ph.D.,
and Laurence J. Gould, Ph.D.
CONTENTS

ACKNOWLEDGEMENTS ix

ABOUT THE EDITOR AND CONTRIBUTORS xi

SERIES EDITOR’S PREFACE xv

INTRODUCTION xix
Allan Frosch

CHAPTER ONE
Concretisation, reflective thought, and the emissary
function of the dream 1
Maxine Anderson

CHAPTER TWO
Content and process in the treatment of concrete patients 17
Alan Bass

vii
viii CONTENTS

CHAPTER THREE
Transitional organising experience in analytic process:
movements towards symbolising space via the dyad 35
Joseph A. Cancelmo

CHAPTER FOUR
Enactment: opportunity for symbolising trauma 57
Paula L. Ellman and Nancy R. Goodman

CHAPTER FIVE
The bureaucratisation of thought and language in groups
and organisations 73
Laurence J. Gould

CHAPTER SIX
Painting poppies: on the relationship between concrete
and metaphorical thinking 83
Caron E. Harrang

CHAPTER SEVEN
When words fail 101
Richard Lasky

CHAPTER EIGHT
Some observations about working with body
narcissism with concrete patients 119
Janice S. Lieberman

INDEX 135
ACKNOWLEDGEMENTS

Special thanks go to Norbert Freedman who first came up with the idea
of a CIPS book series and to Fredric (Rick) Perlman who, as president of
CIPS, brought it to the executive board. The board’s approval led to the
appointment of Meg Beaudoin as the series editor and the formation
of a committee to discuss the structure, theme, and possible publisher
for the series. I was delighted to be asked to work on this book, and I
am grateful for Meg’s calm oversight. The recent appointment of Rick
as series editor highlights the talent and dedication at CIPS that two
such accomplished people—Meg and Rick—would take on the job of
series editor. I especially want to thank all the contributors to this book.
Their talent, cooperation, and patience made my job as editor that much
easier.

ix
ABOUT THE EDITOR AND CONTRIBUTORS

Maxine Anderson, MD, FIPA, has been a psychoanalyst for over

thirty-five years, training in both North America (Seattle in the
Seventies) and London, England in the late Eighties. She is a train-
ing and supervising analyst in the Seattle Psychoanalytic Society and
Institute, the Western Branch of the Canadian Psychoanalytic Society
(Vancouver, BC), and a founding member and training analyst and
supervising analyst of the Northwestern Psychoanalytic Society
(Seattle), and a full member of the British Psychoanalytical Society.
Recent interests involve Wilfred Bion’s work, especially his notions
of learning from emotional experience and the forces for and against
knowing and growth. Most recently she has begun to integrate the evo-
lutionary perspective of primitive mental states into her psychoanalytic
understandings. Maxine lives and works in Seattle.
Alan Bass, PhD, FIPA is a training analyst and faculty member of IPTAR,
the New York Freudian Society, the National Psychological Association
for Psychoanalysis, and is on the graduate faculty of the New School
for Social Research. He is the author of Difference and Disavowal: The
Trauma of Eros and Interpretation and Difference: The Strangeness of Care
(both Stanford University Press) and many articles.

xi
xii A B O U T T H E E D I TO R A N D C O N T R I B U TO R S

Joseph A. Cancelmo, PsyD, FIPA, was president of IPTAR (2008–2010),

chair of the IPTAR board of directors, the IPTAR outside advisory
board, training and supervising analyst (fellow) and faculty member
of IPTAR. Previously, he served as coordinator of adult clinical serv-
ices and outreach coordinator at IPTAR’s Clinical Center (ICC). He is
a certified school and clinical psychologist, psychoanalyst, has writ-
ten articles on diagnosis and clinical technique (most recently, The Role
of the Transitional Realm as an Organizer of Analytic Process: Transitional
Organizing Experience), and co-authored books on parents’ relationships
with their child care providers (Child Care for Love or Money: A Guide
to Navigating the Parent-Caregiver Relationship) and an edited book on
the impact of 9–11 and worldwide trauma on the providers of clini-
cal care (Terrorism and the Psychoanalytic Space: International Perspec-
tives from Ground Zero). Dr Cancelmo is a graduate of IPTAR’s Adult
Psychoanalytic Training Program and a graduate of the IPTAR
Socio-Organizational Training Program in Organizational Consultation
and Executive Coaching.
Paula L. Ellman, PhD, ABPP, FIPA, is a training and supervising ana-
lyst in the New York Freudian Society (NYFS) and the IPA. She is direc-
tor of training of the New York Freudian Society and Washington DC
Psychoanalytic Institute and a member of their permanent faculty.
She is a board member of the Confederation of Independent Psycho-
analytic Societies (CIPS). She has written and presented in the areas of
female development, analytic listening, enactment, 9/11 terror, culture
and psychoanalysis, and sadomasochism. She is co-editor (with Harriet
Basseches and Nancy Goodman) of Battling the Life and Death Forces
of Sadomasochism: Theoretical and Clinical Perspectives (Karnac, 2012).
She has a private practice in psychotherapy and psychoanalysis in
North Bethesda, Maryland and Washington, DC.
Allan Frosch, PhD, FIPA, is a training analyst and supervisor at the
Institute for Psychoanalytic Research and Training (IPTAR) where he is
also on the faculty. He is the author of a number of psychoanalytic arti-
cles and is twice past president of IPTAR, former dean of training, and
former co-director of the IPTAR Clinical Center. Dr Frosch is also on
the faculty at the Institute for Psychoanalytic Education (NYU Medical
Center).
Nancy R. Goodman, PhD, FIPA, is a supervising and training analyst
with the New York Freudian Society and the IPA. She has written papers
 A B O U T T H E E D I TO R A N D C O N T R I B U TO R S xiii

and published in the areas of female development, analytic listening,

Holocaust trauma and witnessing, film and psychoanalysis, 9/11
terror, the study of enactments, and sadomasochism. She is co-editor
with Marilyn Meyers of a forthcoming volume: The Power of Witnessing:
Reflections, Reverberations, and Traces of the Holocaust (Routledge, 2012).
The book presents ideas about trauma and the way witnessing creates
a living surround where symbolising can take place. It contains contri-
butions by survivors, psychoanalysts, and scholars. Dr Goodman was
director of training at the Washington DC Training Institute of the NYFS
and is a member of the permanent faculty. She is chair of a teleconfer-
ence group on enactment for CIPS, and has a full time psychoanalytic
practice in Bethesda, MD.
Laurence J. Gould, PhD, FIPA, was a former director and professor of
psychology in the Clinical Psychology Doctoral Program at the City
University of New York. He was also a visiting professor and the found-
ing co-director of the Program in Organizational Development and
Consultation at Tel Aviv University, the founding editor of the journal
Organisational & Social Dynamics, the director of the Socio-Analytic
Training Program in Organizational Consultation and Executive
Coaching at the Institute for Psychoanalytic Training and Research
(IPTAR), and was the recipient of the American Psychological Associa-
tion’s Levinson Award for outstanding contributions to the theory and
practice of organisational consultation. Dr. Gould had a private practice
of psychoanalysis and organisational consultation in New York City.
Caron E. Harrang, LICSW, FIPA, is a clinical social worker and
psychoanalyst working with infants, adolescents, and adults in Seattle,
Washington. She teaches infant observation at the Northwestern
Psychoanalytic Society. Caron has written on parent-infant psychother-
apy, the relationship of aggression to original thought, and other topics
related to psychoanalytic process and technique.
Richard Lasky, PhD, ABPP, FIPA, is associate dean and fellow at the
Institute for Psychoanalytic Training and Research. He is clinical pro-
fessor, training and supervising analyst, New York University Postdoc-
toral Program in Psychoanalysis and Psychotherapy. He is clinical and
research associate and supervisor of psychotherapy, PhD Program in
Clinical Psychology, City University of New York, and supervisor of
psychotherapy, PsyD Program in Clinical and School Psychology, Pace
University, New York.
xiv A B O U T T H E E D I TO R A N D C O N T R I B U TO R S

Janice Lieberman, PhD, FIPA, is a psychoanalyst in private practice

in New York. She is a faculty member and training and supervis-
ing analyst at the Institute for Psychoanalytic Training and Research,
where she is the program chair and on the board of directors. She is
also a member of the Psychoanalytic Association of New York (PANY).
Dr Lieberman is the author of Body Talk: Looking and Being Looked at in
Psychotherapy (2000) and co-author of The Many Faces of Deceit: Omissions,
Lies and Disguise in Psychotherapy (1996), both published by Jason
Aronson, as well as numerous articles about deception, gender, and
contemporary art. She has been on the editorial boards of the Journal of
the American Psychoanalytic Association, The American Psychoanalyst, and
the PANY Bulletin. Currently she is North American chair of the IPA
Public Information Committee. She has been a lecturer at the Whitney
Museum of American Art for twenty years.
SERIES EDI TOR’S PREFACE

Fredric T. Perlman, PhD, FIPA

I am honoured and also moved to introduce Absolute Truth and

Unbearable Psychic Pain: Psychoanalytic Perspectives on Concrete Experience.
This volume, the fifth instalment of the CIPS Book Series on the
Boundaries of Psychoanalysis, offers a wealth of original contributions,
all promising steps towards a fuller understanding of the phenomenon
of “concreteness” and towards more effective approaches to the clinical
challenges concreteness poses.
The terms “concrete thinking” and “concreteness” have more than
one meaning in the professional literature, and are sometimes utilised
to describe the incapacity to form higher-order concepts, categories, and
abstractions from experience or, in some cases, the literal understand-
ing of abstractions or metaphors. The essays comprising this volume
address a different phenomenon, one that appears across a spectrum of
diagnostic and clinical contexts and often underlies diverse clinical man-
ifestations such as impulsivity, enactments, intractable transferences,
bodily preoccupations, and the general fixity of the patient’s represen-
tational world. Each of these clinical phenomena is discussed in one or
more of the papers herein. In each of these clinical situations (and oth-
ers like it), the patient unconsciously assigns a fixed meaning to persons
and events, including the analyst and the analytic relationship, which
xv
xvi S E R I E S E D I TO R ’ S P R E FAC E

is, for the patient, obvious and self-evident. These assigned meanings,
which are dynamically determined and serve compelling psychological
needs, nullify the possibility of any other meanings. The patient’s ideas
and feelings are thus experienced, not as products of complex mental
activity (which includes but is not limited to perception), but as facts of
life: inescapable, fundamental, and absolutely true.
In the grip of these convictions, the patient is trapped by his or her
own construals in a narrow universe that squashes the potential for
reflective deliberation and creative adaptation to life situations. At the
same time, the analyst is similarly trapped. Any effort to interpret
the patient’s reality as a construction, forged of fact and fantasy, and
shaped by forces beyond the patient’s immediate grasp are, naturally
enough, apt to appear to the patient as foolish or superfluous (at best)
and as hostile, destructive, or crazy (at worst). Persistent efforts at inter-
pretation are likely to eventuate in apparently unproductive conflicts
between patient and analyst about “reality”.
In some patients, concrete thought is restricted to certain sensitive
areas of psychological concern, allowing a more or less normal analysis
to proceed in other areas. But this is not always so. When such absolute
certainty is pervasive, it may be understood as a character defence, stra-
tegically deployed to maintain a fixed phenomenal world, and aimed
not at a particular set of contents, but rather at the core act of psychoa-
nalysis itself: the interpretation of latent meanings. It will be seen that
concreteness can pose a problem in any analysis, though the dimen-
sions and specific features of this challenge will differ from patient to
patient, as will the clinical approach that best promotes the psychologi-
cal distance or “space” the patient needs in order to reflect upon his or
her experience.
The papers that follow are all individual efforts but, as Thomas
Kuhns, Ludwik Fleck, and many others have observed, no scientist or
theoretician develops his or her ideas in isolation: every contributor is
part of a scientific or professional community, a “thought collective”,
to use Fleck’s evocative term. It will be evident that the authors of these
papers are steeped in different psychoanalytic traditions. It may not be
equally evident, however, that the authors of these papers are all part
of a single but theoretically diverse psychoanalytic community that has
been addressing selected clinical and theoretical issues, including the
issue of concreteness, for the last twenty years. I am referring here to
the CIPS community, a group of four psychoanalytic societies based
 S E R I E S E D I TO R ’ S P R E FA C E xvii

in New York, Los Angeles, and Seattle, with individual members in

New York, the District of Columbia, and elsewhere across the country.
Over its history, CIPS has celebrated its theoretical diversity while
simultaneously endeavouring to make that diversity productive
through clinical conferences, ongoing seminars, and more recently, by
establishing this book series. In recent years, CIPS has held two clinical
conferences, one on the topic of enactments and another on related top-
ics of concreteness. These events, and the two book projects which they
inspired (the current and upcoming volumes of the series), reflect the
vibrant intellectual culture of the CIPS community.
Many people have contributed to this culture and this book series.
Meg Beaudoin, the founding editor of the series, worked tirelessly to
forge the right relationship with the right publisher, to bring together a
team of editors, and to inspire our members to band together to develop
book projects that reflect the work of our community. Steven J. Ellman
has contributed enormously to our community dialogue by offering us
a comprehensive review and integrative analysis of contemporary psy-
choanalysis in his book, When Theories Touch, the introductory volume
in this series. The editors of each of the succeeding books in this series
(Chris Christian, Michael Diamond, Andrew Druck, Carolyn Ellman,
Norbert Freedman, Allan Frosch, Jesse Geller, Joan Hoffenberg, Marvin
Hurvich, Aaron Thaler, and Rhonda Ward) as well as all the authors who
have contributed so generously to these volumes have each advanced
our thinking, our culture, and our sense of collective purpose.
Love, grief, and realism all converge to bring Bert Freedman to mind
as I contemplate the growth and development of the CIPS community.
Norbert Freedman, who died on November 30, 2011, was a towering
figure in the IPTAR and CIPS communities, an analyst of rare erudi-
tion, creativity, and insightfulness whose contributions to psychoanaly-
sis and to the organisational life of both IPTAR and CIPS are beyond
calculation. My grief, and perhaps our collective grief, at his loss may
be soothed by the knowledge that this book series, now publishing its
fifth volume, is one of the many fruits whose seeds were first planted
by Bert. It was Bert who first proposed the creation of the CIPS book
series, predicting that a book series of our own would stimulate creativ-
ity, productivity, and new patterns of collegiality within our community.
Those who are familiar with Bert’s scholarly work will also be moved,
as I am, to observe that the papers in this book reflect and advance
Bert’s pioneering work on the subject of concreteness and its opposite,
xviii S E R I E S E D I TO R ’ S P R E FAC E

reflective thought, insight, and integration, all of which Bert referred

to as “symbolization”. Virtually every author represented herein was
influenced by Bert’s ideas, either directly or indirectly, as evidenced
by the frequent references to his work in these papers. Readers whose
interest in Bert’s work is piqued by this volume are referred to Volume
Three of this series, Another Kind of Evidence, inspired and animated by
Bert’s creative ideas and his devotion to research, to the works cited
in the bibliographies of these papers, and finally, to the exceptional
volume published in his honour ten years ago, edited by his close
colleague Richard Lasky, entitled Symbolization and De-symbolization
(Other Press, 2002).
In April 2012, the IPTAR Board of Directors voted to celebrate Bert’s
life and legacy by establishing the Norbert Freedman Center for Psy-
choanalytic Research to honour his name and continue his work.
INTRODUCTION 1

Allan Frosch

Abstract or conceptual thought is so much a part of our daily lives

that, more often than not, we become acutely aware of it in its absence.
Harold Searles (1962) brings this to our attention when he says to one
of his patients, “It’s just not in the cards for you, is it?” The patient
responds to the metaphor by saying “I’m not playing cards,” (p. 27).
The literalness of the response can take us aback. This breakdown in
metaphorical thinking is one form of what we call “concrete”.
Concreteness, or what many refer to as desymbolised thinking/
experience (Freedman, 1997, 1998; Freedman & Lavender, 2002; Searles,
1962) or thing-presentations (Freud, 1915), reduces complexity. Things
are what they are! There are no other possibilities. Concreteness takes
many forms, can be intermittent or persistent and, depending on our
theoretical orientation, has different aetiological contexts that predis-
pose analysts to take diverse technical positions in their clinical work.
The contributors to this volume come from a variety of theoretical/
clinical perspectives and their work highlights the protean nature of
our subject.
In this introduction I try to articulate what I think may be a com-
mon thread in the diverse approaches whereby we attempt to help
people transform the world of the concrete to the world of abstraction.
xix
xx INTRODUCTION

In my effort to do this, I will use different terms or theory-based

constructs to refer to the same thing. In using theoretically different
but functionally equivalent concepts, I am responding to the richness
of psychoanalytic pluralism that encourages us to look at things from
multiple perspectives.
In this paper the term “symbolisation” (or abstraction) refers to a
process whereby we can meaningfully understand that an event can
be looked at from a variety of perspectives. Symbolisation makes it
possible to look at things in an “as if” way rather than as “true” or
absolute. It is a process where we can view our thoughts as objects of
our thoughts (Flavell, 1963). We self-reflect. Furthermore, it is a term
that always includes its counterpart: desymbolisation (concreteness),
where things are what they appear to be (Frosch, 2006). In the lan-
guage of metapsychology, the abstract and concrete correspond to
“word-presentations” and “thing-presentations” (Freud, 1915). Thing-
presentations operate according to the laws of the primary proc-
ess. They are unconscious, absolute, driven, and have a “perceptual
identity” like the hallucination of the breast for a hungry baby. Word-
presentation, or thought identity, is a secondary process activity that
stands for/symbolises the unconscious thing-presentations. Here lan-
guage is seen as a necessary part of a process of transforming primary
process to secondary process organisation so that people can play
with ideas, i.e., follow different paths between ideas without being led
astray by the intensity of those ideas (Freud, 1900, p. 602; Laplanche &
Pontalis, 1973, pp. 305–306). With this transformation we are no longer
in the grip of compulsive adherence to the unconscious fantasies, i.e.,
thing-presentations. Words, however, while necessary, are not sufficient.
The words of the analyst must take place in a particular emotional
context.
I believe the analyst’s capacity to regress to more primary process
levels of organisation and then to re-establish his/her own level of
symbolisation or secondary process activity is the central organising
theme of our clinical work with all patients but, in particular, with those
patients whose worlds are split into discrete bits of “reality” defined
by the immediacy of experience. That is to say, those patients organ-
ised on a primary process “thing-presentation” or desymbolised level.
This movement between primary and secondary process, between the
concrete and the abstract, must take place in a libidinally charged emo-
tional atmosphere in order for thing-presentations to be connected to
 INTRODUCTION xxi

word-presentations in a meaningful way. The libidinal investment,

like the movement along the continuum of desymbolisation and
symbolisation must be bidirectional. Although I believe each member
of the analytic dyad helps the other in this fluidic process (Frosch, 2006),
it is the analyst who must take the lead in the initiation and mainte-
nance of this analytic milieu.

Psychoanalysis and concreteness

If the capacity for symbolisation is a basic requirement for social dis-
course (Searles, 1962) we can easily understand why the “concrete
patient” is often considered persona non grata as a candidate for psychoa-
nalysis. This exclusionary attitude is not limited to people who have dif-
ficulty with abstract (or conceptual) thinking and experience. It seems
to be a tradition in our profession—although one best honoured by its
breach—to exclude from analytic work people who make us uncom-
fortable. In this volume, however, we are focused on psychoanalytic
perspectives of concrete experience and, in my opinion, it was Harold
Searles as much, or more than anyone, who extricated the concrete
patient from exclusion from the human race and from analytic treatment.
He did this by making it crystal clear that the concrete thinking and
experience we encounter in psychoanalysis is part of a dynamic process
that he called “desymbolisation”. Desymbolisation refers to a process
where conceptual or abstract thought, secondary process thought,
is now very literal or concrete so that once-attained metaphorical mean-
ings have become “desymbolised” (Searles, 1962, p. 43). The impact of
Searles’s paper cannot be overestimated. He laid out the conceptual ter-
rain for future generations of analysts to explore (see Lasky, 2002).

Concreteness and complexity

Concreteness is a topic that has been denigrated because it is both
poorly understood and, most importantly, because it makes us as peo-
ple and analysts so uncomfortable. As Searles says, we tend to look at
the concrete person as alien, not part of the human race. The very title
of this volume, Absolute Truth and Unbearable Psychic Pain: Psychoanalytic
Perspectives on Concrete Experience, includes a variety of perspectives on
how we view desymbolisation as a way of coping with psychic pain;
but I think it is most likely the defensive function that we think about.
xxii INTRODUCTION

And this has been a major emphasis in the literature, but not an exclusive
one at all (see Frosch, 1998; Grand, 2002; Schimek, 2002).
My own approach to this subject is to view concrete or desymbolised
experience as a compromise formation driven by psychic pain. Like all
compromise formations it has a defensive function as well as express-
ing libidinal and aggressive wishes. As analysts we tend to highlight its
maladaptive aspect although a more even-handed approach that also
highlights certain adaptive aspects is necessary for a more complete
understanding of the concept. Consider the following vignette pre-
sented by Dr Stefano Bolognini (IPTAR, 16 January 2011):

In her first analytic session a woman in her mid-twenties presents a

dream rich in religious and sexual imagery. As she begins to associ-
ate to the dream, she stops and asks the analyst whether he would
prefer to be paid in cash or by cheque.

In the context of this volume, this is a very clear example of the

movement from the metaphorical to the concrete serving a defensive
function. The patient seems to move away from the passionate imagery
of the dream to the more prosaic topic of the business arrangements of
the relationship. As analysts we know, however, that money is rarely,
if ever, a passionless issue; and Dr Bolognini tells us that the issue of
money came to play a significant role in the transference. The patient
wanted to be the analyst’s special child and be treated free of charge.
So her movement from the abstract to the concrete also allows this
patient to express an inchoate transference wish; and it provides the
analyst with an opportunity to have some sense of the unconscious fan-
tasies as they present in early derivative form.
When we embrace the notion that the “the concrete” is another piece
of complex analytic material, we can bring our psychoanalytic explo-
ration of concrete experience into a more encompassing domain that
allows us to look at things from multiple perspectives; but not all the
time. When we are riddled with unpleasure (e.g., anxiety or some form
of depressive affect) we can all narrow things down to one point of
view. It is a point of view that reduces our emotional discomfort; and
it is a point of view that stands alone. That is to say, it is not part of a
world of ideas.
Searles (1962) puts it as follows: concrete thinking has a static, fatalis-
tic quality, associated with severe psychopathology that sets the person
“hopelessly apart from his fellow human beings” (p. 23). What Searles
 INTRODUCTION xxiii

is referring to here is the schizophrenic patient being stuck in a world

where things are what they seem—absolute truth. In the world of the
concrete, there is no differentiation between inside and outside, between
thought and actuality, between self and other. Thoughts and emotions
have a “thing” quality that is absolute. There is no other, no other per-
spective. “Rarely indeed, in these writings, is there any intimation
that the therapist can have the rewarding, and even exciting, experi-
ence of seeing a schizophrenic patient become free from the chains of
concrete—that is, undifferentiated—thinking, able now to converse
with his fellow human beings” (1962, p. 27). In this scenario, of course,
Searles brings in the clinician’s countertransference. In other words, the
therapist/analyst may also be stuck in a static, fatalistic world vis-a-vis
the patient: “I found him [the same patient as above] maddeningly and
discouragingly unable to deal with any comments which I couched in
figurative terms. When, for example, antagonised by his self-righteous
demandingness, I told him abruptly, you can’t have your cake and eat
it, too!, I felt completely helpless when he responded to this at a literal,
concrete level, by saying, I don’t want to eat any cake in this hospital!
You can eat cake here, if you want to; I don’t want to eat any cake here”
(1962, p. 26).
In this vignette Searles shows us how the analyst’s emotional
state (antagonised by his self-righteous demandingness … told him
abruptly) is a trigger to the patient’s “failure” to understand the meta-
phor. While this kind of concreteness is not typically seen in an outpa-
tient practice of most analysts, nor do most analysts treat schizophrenic
patients, Searles makes it clear “that there is an essential continuity in
all symbolic functions, the psychodynamics to be described here pos-
sess relevance to other kinds of symbolization than metaphorical think-
ing alone” (1962, p. 23). I would add to this that the ideas contained
in Searles’s paper need not be confined to the schizophrenic patient.
For example, a non-schizophrenic patient said to me: “My life has
always been this way and will always be this way; and there is noth-
ing you can tell me that I haven’t thought of already.” In other words,
“There is no inner world that I can understand so that my life can be
better; and there is no difference between us.” I think this example is
probably fairly common and easily identifiable by most analysts. What
is also identifiable, but not necessarily in the clinical moment, is the
analyst’s input into an enactment. Clearly, this is not peculiar to Searles
or to work with a particular kind of patient. My own experience (Frosch,
2002, esp. pp. 622–629) is that the analyst’s discomfort is an important
xxiv INTRODUCTION

catalyst for these enactments; and concrete patients often make us very
uncomfortable.
The pre-Oedipal world of concrete patients is a world of great inten-
sity. It is alive in a very particular way. It certainly may not be pleasur-
able in the ways that we ordinarily think of pleasure. But it is passionate
and action-oriented. More often than not the passion does not have a
libidinal quality but is more organised around aggression. This link to
the perversions (Bass, 1997) highlights a world of part objects, driven by
the immediacy of the moment. The consensual world of “reality” pales
in comparison to this fantasy world (see Steingart, 1983), driven by sen-
sation and infused with wishes that reign supreme. What we ordinarily
call “emotion” is qualitatively different in this anal/paranoid-schizoid
world. Emotions have a primary process “thing” quality, feel all power-
ful, and are inexorably linked to action (Frosch, 1995, p. 432).
The world that I am describing exists to a greater or lesser extent for
everyone. We can all think of myriad examples in our own lives—just
consider the battles and attendant feelings on an organisational level in
the world of psychoanalysis, or at your own institute. We can certainly
identify such feeling states in the patients we work with. For some, this
world is intermittent and represents a regressive alteration in ego func-
tioning; for others it has, as Searles put it, more of a static quality. And on
the world’s stage, assassinations are done by people who unequivocally
believe that only through a direct expression of aggression to another
can their own lives have any meaning. The “rightness” of their cause is
absolute. And when as analysts we feel that the rightness of our cause
(our interpretation) is clear and we are passionate in our conviction,
we might consider that we can be setting the stage for an enactment.
It is customary to say that certain kinds of patients “induce” us into
an enactment. Cause and effect become organised from our subjective
perspective, and we label as accurate and absolute what, in retrospect,
may be our countertransference. Arnold Rothstein talks about the ana-
lyst’s love for his patient as the analyst trying to work through his/her
countertransference (1999); and Hans Loewald (1960) talks about the
analyst’s resistance in a similar way.

Thing-presentations and word-presentations

In this section of the paper I will outline some of Loewald’s (1960,
1970, 1980) thinking that allowed him to bring the metapsychology of
 INTRODUCTION xxv

psychoanalysis—“the hypercathexis of word and thing presentations”

(Freud, 1915)—into the world of an emotionally charged relationship
between analyst and patient where each is affected by the other.
Loewald’s work addresses the question of how we understand the
transformation of a patient’s desymbolised or unsymbolised expe-
rience, i.e., experience/mentation that is regressed, or has never
attained secondary status. Loewald’s answer to this is the same as
Freud’s: there must be a “hypercathexis” of word and thing pres-
entation to “bring about a higher psychical organisation and make
it possible for the primary process to be succeeded by the second-
ary process” (Freud, 1915, p. 202). In his discussion Loewald moves
hypercathexis from a purely energic term to a transformational
concept that takes place in a libidinised reciprocal psychic field (1970,
pp. 64–65). Loewald is very much aware of the impact of his words:
“While this may sound unfamiliar and perhaps too fanciful, it is only
an elaboration, in nontechnical terms, of Freud’s deepest thoughts …”
(1970, p. 65).
For Loewald defence—and here he is talking about repression—is
“understood as an unlinking” (1980, p. 188) between thing and
word presentations. The link between symbol and that which is sym-
bolised (word and thing presentations) is repressed, i.e., severed or
loosened; and the act of hypercathexis re-establishes the link (1980,
pp. 183, 188). The analytic task involves (and here we can say this
in a number of ways), e.g., 1) making the unconscious conscious, 2)
transforming experience-bound and action-oriented unconscious
things to “mental representations that stand for the experience”
(Lasky, 1993, p. 260n.), or 3) bringing the primary process under the
domain of secondary process organisation. The language we use to
describe this process differs depending on our theoretical orienta-
tion. Whatever terminology we use, however, the process of trans-
forming things to words is life-altering. It is a new way of ordering
the world and allows the person to make inferences about an event
that go beyond the immediately observable experience (Bruner,
Goodnow & Austin, 1956). And the analyst does this through the use
of words, i.e., interpretation. Even if we leave aside what we mean
by “interpretation”, there are a number of points to be made about
this statement that bear directly on our understanding of the ana-
lytic process in general and, in particular, on how we understand the
notion of concreteness.
xxvi INTRODUCTION

Love and miracles

The interpretive work that links primary process things and secondary
process words represents a link between analyst and patient. And this
is Loewald’s “novel” (1970, p. 68) approach to the concept of hyper-
cathexis. “Hypercathexis, I believe, cannot be adequately understood if
we fail to take into account that it originates within a supraindividual
psychic field. Expressed in traditional psychoanalytic terms, the essen-
tial factor is that cathected objects are themselves cathecting agents.
The subject which cathects objects is at the same time being cathected
by those objects …” (1970, p. 63). The mother—infant/child relation-
ship and the analyst–analysand relationship:

Are relations between mutually cathecting agents, and the

cathecting of each partner is a function of the other’s cathecting …
The higher-order cathecting activity of his libidinal objects (par-
ents) constitutes, as it were, the first hypercathexis. In so far as
the objects’ cathecting operations are on secondary process levels
(although they are by no means exclusively so), they have the poten-
tial of hypercathexes in terms of the subject’s psychic processes.
(1970, p. 63)

In the therapeutic situation it is the analyst “[who] helps to bring this

about … the analyst, mediates this union … a new version of the way
in which transformation of primary into secondary processes opened
up in childhood, through mediation of higher organisation by way of
early object-relations (1960, p. 31).” And Loewald makes it clear that
in order to immerse himself in the patient’s world, the analyst “must
be able to regress within himself to the level of organization on which
the patient is stuck …” (1960, p. 26). The analyst, like the good-enough
parent, must also be able to return to a more secondary process mode
of functioning.
And all of this occurs in the context of love. For Loewald the analytic
relationship is based on love and respect for the patient and the patient’s
love for the analyst. Just as it is impossible to have an analysis without
loving the patient (1970, p. 65), it is impossible to have an analysis with-
out the patient’s love for the analyst. We can put all of this into the
language of libidinal investments or transference/countertransference.
 INTRODUCTION xxvii

In doing this we communicate to our colleagues and ourselves that the

love we are talking about falls within the “scientific”, the “analytic”,
domain. We do not want to be misunderstood, and Loewald is acutely
aware of the potential impact of his words: “In many quarters there still
seems to be a tendency to put up a ‘no admittance’ sign when metapsy-
chological considerations point to object relations as being not merely
regulative but essential constitutive factors in psychic structure formation”
(1970, p. 66, my emphasis). In the words of the poet, when we make
an emotional (i.e., libidinal) investment in another person, “that per-
son seems at once to belong to a different universe, is surrounded with
poetry, (and) makes of one’s life a sort of stirring arena …” (Proust,
1913, p. 334). It is in this stirring arena of the analytic situation that the
words of the analyst can take on a special meaning, a meaning that
leads to an internalisation of a differentiated relationship that increases
“the hypercathectic resources of the individual” (1970, p. 63).
It is this emotional atmosphere, this hypercathexis of self and other,
that Freud was talking about when he said that the words of the analyst
have the power to create “miraculous cures” (1905a, p. 289). It is easy
enough to write off Freud’s comments as hyperbole, as the overly opti-
mistic words of someone embarking on a path of great discovery. While
this may well be the case, consider for a moment the patient that Searles
discussed who was so concrete. This patient, Searles tells us, “after five
years of work … can communicate confidently, with rare exceptions, in
metaphorical as well as literal terms, seeing both levels of meanings in
his own comments and in mine” (1962, p. 30). This seems like quite a
miraculous accomplishment.

Passionate abstractions
Although Freud’s language in the 1905 paper is very far from the meta-
psychology of energy transformations, his ideas in this paper are con-
sistent with his own metapsychological abstractions in 1915 as well as
Loewald’s use of metapsychology. In the 1905 paper Freud presents,
in the concrete immediacy of experience, the underpinnings of his ener-
gic abstractions. When Freud talks about the rapport between analyst
and patient and likens it to the relationship between a mother and her
infant (1905a, p. 295), he begins to tell us about the bidirectional passion
and intensity of the analytic relationship.
xxviii INTRODUCTION

Freud says quite directly that the analyst helps to create an

expectation of faith and hope in his patient that lends a certain magic
to the analyst’s words (1905a, p. 291). And it is the analyst’s interest
that potentiates this “propitious state” of mind in the patient (p. 293).
And, I would add, it is not an interest that can be understood in purely
intellectual or cerebral terms. In English the word “interest” refers to
the relation of being objectively concerned in something. In the German
(Interesse), there is more of a sense of personal involvement. It is related
to a very common phrase (im stiche lassen), “to leave in the lurch”
(cf. Freud, 1910, p. 12); thus “one’s interest or personal involvement
with a patient allows us to enter most profoundly into the core of the
patient’s life—or soul” (Seele, 1905a, p. 283n.; 1905b, p. 254). Without
this interest/involvement we are left out in the lurch.
Freud’s language conveys a very personal connection and repulsion
that speaks directly to the passions of the analytic relationship. In the
complex and highly charged analytic situation the reciprocal relation-
ship between expectations based on hope and faith and the analyst’s
interest argues against linear statements of cause and effect, so that
interest and expectation are co-constructed or subject and object are
hypercathected. This kind of process has been described by Bach (2006)
who likens the analyst’s attention to his patient as a kind of secular
prayer with curative value in its own right.

Concluding comments
It is in this emotional context that we can best understand Loewald’s
thinking that the analyst’s interpretive activity gives rise to a new men-
tal representation: “an intrapsychic perception induced by the words of
the analyst that may be conscious but in all likelihood may occur outside
of consciousness” (1980, p. 183). I emphasise the latter part of Loewald’s
statement because it resonates so well with much of our current psy-
choanalytic outcome research that highlights the central importance
of the internalisation (largely unconscious—see Falkenstrom, Grant,
Broberg & Sandell, 2007, p. 666) of the differentiated relationship with
the analyst for long-term therapeutic gain (Frosch, 2011). I believe this
is what Loewald means when he talks about increasing the patient’s
resources for hypercathexis. I understand this as an increased capacity
to [re]-establish a link between the thing and the word so that the con-
crete can enter into the world of abstraction.
 INTRODUCTION xxix

But Loewald has more to say about interpretation and the trans-
formation of the concrete to the abstract. It is not simply establishing
or re-establishing a connection between the unconscious fantasy
(thing-presentation) and the consciously (Loewald refers to it as
preconscious) perceived object (word-presentation). There must be an
optimal linking. Mental functioning is seen as a compromise between
a too intimate and intense closeness to the unconscious (with its “crea-
tive and destructive aspects”, 1980, p. 189) and a less than adequate
libidinal link between word and thing so that language has a “hollow
quality … no longer vibrant and warmed by the ‘fire’ of the uncon-
scious” (p. 189). In the first instance the unconscious fantasy replaces
reality and we are in the world of things—the concrete. In the second
instance language is meaningless and the consensual world of reality
loses any significance. These are two aspects of the same multidimen-
sional continuum differentially emphasised by the authors in this vol-
ume depending on their theoretical orientation and clinical technique.
In the chapters that follow, the abstractions of thing presentations and
word presentations in a hypercathected psychic field are replaced with
the concrete immediacy of the relationship between analyst and patient
as they work to transform absolute beliefs into ideas that stand in rela-
tion to other ideas.

References
Bach, S. (2006). Getting from Here to There: Analytic Love, Analytic Process.
Hillsdale, NJ: The Analytic Press.
Bass, A. (1997). The problem of “concreteness”. Psychoanalytic Quarterly, 66:
642–682.
Bolognini, S. (2011). A session with Antonia. Presentation at IPTAR.
Bruner, J. S., Goodnow, J. L. & Austin, G. A. (1956). A Study of Thinking.
New York: Wiley.
Flavell, J. H. (1963). The Developmental Psychology of Jean Piaget. Princeton,
NJ: Van Nostrand.
Freedman, N. (1997). On receiving the patient’s transference: The symbol-
izing and desymbolizing countertransference. Journal of the American
Psychoanalytic Association, 45: 79–103.
Freedman, N. (1998). Psychoanalysis and symbolization: Legacy or heresy?
In: C. Ellman, S. Grand, M. Silvan & S. Ellman (Eds.), The Modern
Freudians: Contemporary Psychoanalytic Technique (pp. 79–97). Northvale,
NJ: Jason Aronson.
xxx INTRODUCTION

Freedman, N. & Lavender, J. (2002). On desymbolization: The concept and

observations on anorexia and bulimia. Psychoanalysis and Contemporary
Thought, 25: 165–199.
Freedman, N., Lasky, R. & Ward, R. (2009). The upward slope: A study of
psychoanalytic transformations. Psychoanalytic Quarterly, 78: 201–231.
Freud, S. (1900). The Interpretation of Dreams. S. E., 5. London: Hogarth.
Freud, S. (1905a). Psychical (or mental) treatment. S. E., 7. London:
Hogarth.
Freud, S. (1905b). Freud’s psycho-analytic procedure. S. E., 7. London:
Hogarth.
Freud, S. (1910). Five lectures on psycho-analysis. S. E., 11. London:
Hogarth.
Freud, S. (1915). The unconscious. S. E., 14. London: Hogarth.
Frosch, A. (1995). The preconceptual organization of emotion. Journal of the
American Psychoanalytic Association, 43: 423–447.
Frosch, A. (1998). Narcissistic injury and sadomasochistic compensation in
a latency-age boy. In: P. Beren (Ed.), Narcissistic Disorders in Children and
Adolescents: Diagnosis and Treatment (pp. 263–280). Northvale, NJ: Jason
Aronson.
Frosch, A. (2002). Transference: Psychic reality and material reality. Psycho-
analytic Psychology, 19: 603–633.
Frosch, A. (2006). Analyzability. Psychoanalytic Review, 93: 835–843.
Frosch, A. (2011). The effect of frequency and duration on psychoanalytic
outcome: A moment in time. Psychoanalytic Review, 98: 11–38.
Laplanche, J., Pontalis, J.-B. (1973). The Language of Psychoanalysis. New
York: W. W. Norton.
Lasky, R. (1993). Dynamics of Development and the Therapeutic Process. North-
vale, NJ: Jason Aronson.
Lasky, R. (Ed.) (2002). Symbolization and Desymbolization: Essays in Honor of
Norbert Freedman. New York: Other Press.
Loewald, H. W. (1960). On the therapeutic action of psycho-analysis. Inter-
national Journal of Psychoanalysis, 41: 16–33.
Loewald, H. W. (1970). Psychoanalytic theory and the psychoanalytic
process. Psychoanalytic Study of the Child, 25: 45–68.
Loewald, H. (1980). Primary process, secondary process, and language
(1978). In: Papers on Psychoanalysis (pp. 178–206). New Haven, CT: Yale
University Press.
Proust, M. (1913). In Search of Lost Time, Volume 1, Swann’s Way. New York:
The Modern Library, 2003.
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541–558.
 INTRODUCTION xxxi

Searles, H. F. (1962). The differentiation between concrete and metaphorical

thinking in the recovering schizophrenic patient. Journal of the American
Psychoanalytic Association, 10: 22–49.
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ties. Jamaica, NY: Spectrum.

Note
1. My thanks to Dr William Fried, Batya Monder, and Ruth Oscharoff for
their input during the preparation of this paper.
CHAPTER ONE

Concretisation, reflective thought, and

the emissary function of the dream
Maxine Anderson

Introduction
It seems that we live in at least two mental worlds: one defined by
intense sensory experience, and another more gently crafted by attune-
ment and thought. While we may wish to think of ourselves as residing
primarily and maturely amid thought and reflection, a clear-eyed view
will reveal that we spend much if not most of our time in the concrete,
sensory-dominated world of “how it is”. Indeed this sensory level of
experience shades and shapes much of the texture of our emotional
lives, but perhaps due to its bedrock nature and profound impact, it
may also exert a gravitational pull, easily dismantling the products of
thought and our capacities to think back into the basic sensory elements
from which they evolve. In this chapter I will attempt to explore some
aspects of this to and fro between these two realms of the psyche and
the de-animating power of the entropic pull. In addition I will illustrate
some countermeasures we may employ to restore and protect the realm
of thought. And I will also suggest that the well-attended dream has
a role to play both as guide to and emissary between these different
realms of the psyche.

1
2 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

One added introductory note: while heavily influenced by Bion, and

several of his students, whom I will note, I will try to remain descriptive
of clinical and personal experience in this discussion, hoping to invite
new ideas to emerge and to avoid the possible narrowing of thought
which heavy reliance upon theory can impose.

The concrete state of mind

Simply put, the concrete state of mind relates to reality in terms of
sensory perception and sensory experience, defining reality in terms
of what the peripheral senses convey. More specifically it is a state
of mind in which metaphor and symbolic thought are not available.
For instance, before the laws of gravity came into general awareness,
people explained apples dropping from a tree as “just falling down”.
Without access to symbolic thought or reasoning we rely on sensory
experience and sensory-based explanations of reality.
From this perspective there is no reference to interiority or to inner
space where one may feel held in mind or where thought might reside.
Years ago a five-year-old patient responded to my giving a thought-
ful context for his rampages with a startled statement of “Oh, at my
house we don’t do that … things just happen and then Mom yells at
me.” This young patient was expressing the experiential world of “how
it is” (“things just happen”), but once he felt held in mind by my efforts
to understand he could begin to contrast this with his experience of
his mother’s non-receiving (“yelling”) state of mind. At the time I was
impressed by this very young child’s observation, but also I could more
deeply appreciate how a child’s development including his capacities
for thought may be impacted by his parent’s (in)capacities to receive
and to really think about his experiences and expressions.

The development of the capacity for thought

My current notions about the development of the capacity for reflective
thought involve the notion of “reverie”, Bion’s notion of the quality
of the care-taking mind’s openness to respond to tension or distress,
and by way of thinking about that distress to transform it into mean-
ing (Bion, 1962). The distress-based self then gradually learns that a
mind “out there” is transforming his/her unthinkable experience into
meaningful communication. The growing self thus learns through the
 C O N C R E T I S AT I O N , R E F L E C T I V E T H O U G H T, D R E A M F U N C T I O N 3

process of being thought about how to think about itself and the world.
This capacity, born by feeling held in mind, offers a leap beyond the
two-dimensional, concrete “how it is” world. A three-dimensional
mind with space for thought and reflection comes into view via the
experience of having been thought about, and having felt known. And
it is this same function that serves our therapeutic efforts to nourish our
distressed patients, as well as our own distressed selves. Nevertheless,
when concretisation is predominant, we need to be aware that these
thinking and knowing capacities will often collapse back to the two-
dimensional (“how it is”) mental world defined by sensory experience,
often with such intensity as to be considered a so-called “truth”.

The tension between two mental realms

Such a collapse into the concrete may occur more often than we
might imagine, as evidenced by our powerful uncontained emo-
tions. For example, when we are encumbered by fear, anxiety, or rage
we feel pressured and defensive but also probably unable to concep-
tualise that we are being tormented by fear, pressured by anxiety, or
swept away by rage. Our clamorous emotions so easily overtaking the
quiet space of repose and thought reduce any sense of inner space to a
two-dimensional, reactive experience etched by that affect. And when
we cannot think about this process we are condemned to be defined
by that sensory experience, so that we are unable to think about being
tormented or pressured; instead, we feel concretely “trapped for-
ever” within that fear, rage, or anxiety. A similar state is characteristic
of our intensely held “certainties”: in the absence of thought we are
condemned to the pressured insistence of being either absolutely right,
or catastrophically wrong.
The similarity continues, when as the clinician I feel I have become
the target of an intense barrage, such as a penetrating accusation, or
overwhelming rage, I may feel my boundaries thinned or breached,
and feel myself inclined to slip into a concrete, reactive place as well.
The barrage may be something my patient cannot bear to feel, such
as a sense of futility, incompetence, or stupidity, which then is uncon-
sciously but violently projected my way. In my clinical openness I may
then feel that unbearable emotion, and because of the intensity of the
projection I feel overtaken or defined by its “truth”, and then in turn
“become” the hopeless, incompetent, or stupid one. Of course, when so
4 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

defined I do not have access to my thinking self, and am thus unable

to think about the situation as a matter of my receiving and not being
able to metabolise a mind-numbing projection. In order to reverse this
process of concretisation, that is to rescue my thinking capacity, I need
to be able to develop a sturdy boundary, in the moment, if possible, or
continuously, as I can, in order to protect my thought and my capac-
ity for awareness about the nature of this type of functioning. And,
as most of us know, acquiring this facility often takes years of clinical
experience.
Another circumstance related to my slipping into the concrete,
reactive mode is my own inner debilitation, be it from fatigue,
pre-occupation, chagrin, or any other of those elements that can trigger
doubt about my own capacities. My own doubt can penetrate and
wither my thinking capacities as thoroughly as can my patient’s accu-
sations, and can lead to my connection with my thinking self giving
way to a heavy, dull sense of “being incompetent or stupid or wrong”.
It is as if doubt mimics the erosive effects of concretisation, acting to
neutralise the products of thought, and altering meaning from an ani-
mate (thinkable) state toward a deanimated (drained of meaning or
unthinkable) one. It follows here that when I am without thought I am
condemned to concrete experience and reactivity.

Concretisation as the mechanism for the deanimation of thought

I would now like to turn to some of the mechanisms involved in this
concretising process. In a previous paper (Anderson, 1999) I include
a quote from P. C. Sandler (1997): “There appears to be a universal
tendency to replace psychic reality with material reality, which coexists
with and opposes the development of thinking … [that is] the exist-
ence of an active concretization … [which] ‘turns’ in phantasy, in the
mind of the person, either patient or analyst, what is animate (linked
with meaning) into what is inanimate (a more meaningless sensory
state)” (p. 47).
In his argument for the concept of a normative concretising function
which he terms “anti-alpha function”, Sandler further states:

The human mind has difficulty containing immaterial abstrac-

tions within psychic boundaries … The material products result-
ing from the action of anti-alpha function carry with them from the
 C O N C R E T I S AT I O N , R E F L E C T I V E T H O U G H T, D R E A M F U N C T I O N 5

beginning the marks of such defensive processes as denial, reaction

formation, displacement and condensation. The concretization
of psychic reality precludes the occurrence of free association …
[and fosters] acting out. When anti-alpha function is in operation,
one is bound to “transform”, as it were, energy into matter … it
seems that the mind promotes an active transformation of what is
alive into what is dead, and people deal with living creatures and
their productions … as if they were inanimate … the container or
receptacle is also regarded as an inanimate thing. (1997, pp. 47–49)

As part of his discussion, Sandler also reviews the way concretisation

fuels the virulence of some forms of projective identification:

Projective identification is the concretization of an emotion and of

feelings; through this very concretization one is enabled to build
up a phantasy of “projecting” something into someone else, for the
“something” projected is not a thing, it is not material, but the per-
son who projects deals with it sensuously, as if it were a concrete
thing amenable to be projected … (1997, p. 48).

Elsewhere in my paper I also mention Meltzer’s notion that the

vulnerable receiver of those projections also deals with them
sensuously. When we do not have access to our protected thinking
selves (our “good internal objects” to use Meltzer’s terms) we are sub-
ject to being overwhelmed by the bombardment of untransformable
sensory elements (withering projections or accusations) and thus to
being defined by them (“becoming dull and incompetent”) which—
again in Meltzer’s terms—is finding oneself encumbered by “dead
objects”. Meltzer holds that this is a universal human occurrence when
live-minded thought is not available. Concretisation, then, may usefully
be thought of as the mechanism active in the deanimation of thought
or as providing the gateway where dead objects may enter or prevail
(Anderson, 1999, p. 513).

The lack of inner agency and the pull to the familiar

The self in a sensory-dominated world, then, not in touch with the
interiority of mindfulness, has no notion of mental space or of inner
agency. Instead the self is experienced as a two-dimensional target or
6 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

surface for sensory impact, and can only relate reactively to agency
and responsibility as if to causes and powers residing outside the self
(“It’s all your fault” … “My boss is so mean and I am so small” or …
“There is no help available”). And in this state without the protection
of compassionate thought the cruel, self-battering so-called superego,
as the embodiment of psychic trauma, is experienced concretely as a
brutal, condemning “truth” about one’s inadequacy or badness.
One patient, Ms A, lost her mother when she was very small, and
due to an overwhelmed family atmosphere she seemed to have had lit-
tle or no experience in feeling held in mind or known about. While she
has attained moderate success professionally, she seems to have spent
much of her life feeling lost or “in hiding”, moderately and at times
seriously depressed, paralysed by passivity, and unable to feel much
sense of attachment or commitment to person or place. Loyalty to and
identification with her dead mother appears to underlie a “bleak for-
ever” state of mind, which early in our work seemed impervious to my
attempts to bring understanding. While more recently she has come
to feel more accompanied and understood—and thus more alive—this
reprieve is short-lived as she seems to gravitate back to the identifica-
tion with the inanimate bleakness as “who I am … what I have always
known”. It appears that loyalties to the familiar past, as deadened and
painful as they may be, can powerfully outweigh the as yet unknown
possibilities for new life and hope which my patient discovers when
she can internalise our work and begin to connect with live-minded
thought, attendant self-reflection, and budding self-respect.
Yet at times our patients do have rather clear insights into these
burdensome dilemmas that can so entrap them: Mr B, subject to vio-
lent outbursts but also capable at times of reflecting upon his own
concreteness, observed, I thought astutely, that his immaturities and
agitations seem to propel him back into the state where his familiar
violent primitive emotions take charge, convincing him that to invoke
restraint and concern is “too hard … not fair … too much of a burden”.
Mr B seemed to eloquently express how the violent protest from his
own concrete states could attack or expel potential thought and inner
agency. He further seemed to be describing an outrage that creates
a war zone, violently shredding his inner authority (“It’s not fair …
I shouldn’t have to”) such that at those times he feels caught in the
debris field of jagged self-loathing (“I’m so worthless … just a piece of
shit”). He continues to describe these attacks upon his own capacities
 C O N C R E T I S AT I O N , R E F L E C T I V E T H O U G H T, D R E A M F U N C T I O N 7

as preserving a “perverse bubble” (his words) as a residence for the

infantile, impulsive, impoverished self, which so hates (and so refuses)
to grow up. These reflections, he muses, are an elaborate description of
a complicated, self-perpetuating temper tantrum.
While Mr B cannot yet fully appreciate the development of his self-
observing capacities, I can appreciate them and can also witness their
continued growth even alongside the violent outbursts, which, while
diminishing, can still wreak internal havoc. Meanwhile, these states of
self-condemnation are heart-wrenching to witness because when the
patient is in their grip he is entirely out of touch with any sense of his-
tory, hope, or the possibility for growth.
We can see then that what we consider as emotional growth is a
complex business. The rather quiet forces for mental growth are coun-
tered by familiar and thus persuasive sensory intensities, which con-
cretely press towards the status quo as “the truth” or “what I have
always known”. These resistances to change, because of their power
and tenacity, seem to resemble a force of nature.

Working clinically with concrete mental states

I would now like to illustrate some aspects of the dilemma that emerges
at the interface between concreteness and reflective thought, by way of
a few clinical vignettes from my work with a patient I have seen for sev-
eral years, a woman, whom I will call Ms C. This woman, the youngest
of several children, felt exposed not only to the absence of an emotion-
ally available mother but also to the presence of paternal cruelty, as well
as to the consequence of family chaos, abuse, and neglect cascading
from preceding generations. Such trauma and the absence of protective
reverie have for much of her life left my patient feeling persecuted and
identified with the chaos, ready to defend it as “freedom” in the face of
any attempts to bring order or containment. Even so, she has struggled
ceaselessly to get the therapeutic help she so desperately needs in order
to grow. I think our mutual regard for the therapy and for each other
bring resilience on both our parts to this often tempestuous work.
Technically, I find my attempts to speak therapeutically to her require
ongoing care. For instance, when she is feeling tormented and chaotic
any comment of mine is felt to be an attempt to restrain her, to limit her
“freedom” and thus to force something upon her. I often have to speak
to that very issue to demarcate the way she experiences my attempts
8 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

to label and contain her chaos as “squelching her freedom”. Also, since
in this state of mind she perceives her literal experience to be the only
possible view, any difference on my part is felt as my being at best “not
understanding” but more likely as my causing her distress by my non-
alignment. Here then, “understanding” is equated with “agreement”
and any separate-mindedness is considered to be a cause for suspicion
and blame. I therefore have to remain aware of this tension regarding
non-alignment and at times speak to “how misunderstanding and per-
haps even how mean you feel me to be when I do not agree with your
point of view” or something similar.
In addition, as suggested, when Ms C is caught in a pit of hate and
despair she feels defined by that brutal chaos of her childhood, and
all my best efforts are likely to be seen through the lens of negativity.
Recently I realised several hours before an appointment with her that
I might be late in returning from an emergent appointment of my own
away from the office. I felt that she would likely become very agitated
if I was not there at the accustomed time, so I thought it wise for me to
call and leave word that I might be a few minutes late. The only oppor-
tunity I had to make this call, given the timing of the day, was just a
couple of minutes before another patient came. I did manage to reach
and inform Ms C, who seemed appreciative, but I then had to ring off
as my next scheduled patient was ringing in. At the time I felt relieved
to have reached her.
As it turned out I was not late, but when she came in several hours
later she was in a rage, saying “Never call me again, never … never ….”
It took her several minutes to calm down and I could see that the call
had deeply distressed her, which was at first puzzling to me. Over the
hour I could piece together that she felt my possibly being late meant
that I was preferring to be with someone other than her, and to make
matters worse that I had rung off abruptly, probably to see that some-
one else, an action which just rubbed her nose in the “fact” of my not
preferring her. Ms C’s outrage filled the room and nearly the whole
of my mind as well, and it was difficult for me to think or say any-
thing helpful; further, any potential understandings were only mocked
and belittled. Feeling quite attacked I had to fight to keep a clear head;
and any attempt to frame her rage in terms of her feeling so hurt was
met with such disdain that at the time I only felt small and helpless.
In addition I could feel myself nudging towards descent into a concrete
 C O N C R E T I S AT I O N , R E F L E C T I V E T H O U G H T, D R E A M F U N C T I O N 9

retaliatory rage, a wish to throw up my hands and more or less yell back
at her. But in my efforts to stay thoughtful about my patient, I recalled
a dream we had looked at together in the previous hour, a dream
whose clear understandings now seemed to offer something for me to
hold onto:

She and another woman are in the army and were about to go and
see an explosion. She is terrified about the explosion, as if it could
go off at any time. But the woman says she will go to a safe position
to view the explosion and she, the patient, says she will go too, even
though she feared that it might make her AWOL. She does go along
with the woman and yet she feels guilty. After the explosion, which
did not injure either of them, the patient thinks she may sneak back
to pretend she had been there, at the site of the explosion all the
time, so she won’t be reported as AWOL.

The dream had been understood as the two of us being capable of wit-
nessing her explosive rage safely, but that she also feels compelled by
old rigid and adherent aspects which demand that she remain strong
and loyal, that is not go AWOL, from that militant explosiveness.
She seemed relieved by this understanding.
I was able to remind my still angry patient of this dream and some
of our understandings, wondering aloud if they could help us sort out
some of her current intense feeling. She seemed able to calm down
and listen to me and to recall the dream and its potential meanings.
Shortly thereafter, perhaps reconnecting with thought, she was able to
admit that following the previous hour, perhaps because of the work
we had done with the dream, she had become obsessed with the wish
to possess me and all my capacities, and so that my needing to ring
off in my call to her had been felt as my defying her possessive aims.
In an instant she felt sure that I was wishing to get rid of her alto-
gether, a jarring perception felt as a “certainty”, which then triggered
the current explosive rage. Carefully we were able to sort out that
following the work on the explosion dream in the previous hour my
patient’s gratitude for the emerging understanding was overtaken by
her greed to possess the source of that understanding; that the obses-
sion to possess me was allowing the lust for power to overwhelm the
gratitude and respect which our work had engendered. My patient’s
10 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

experience of my phone call reflected her intensely felt fantasy of my

dispossessing her for her greed, preferring others, and rubbing salt
into an old wound.
As we carefully found our way out of this morass I was reminded of
how greed and envy can so degrade the realm of thought and gratitude
into the concrete states defined by possession, power, and revenge. But
I was also reminded how disturbing any change in the frame, such as
my phone call, can be. And indeed, in the absence of reflective thought
any alteration of the frame can only be viewed with suspicion if not the
conviction of negative intent.

The dream as guide through concrete experience

On several occasions while working with concreteness and concreti-
sation I have found the patient’s dreams to be quite helpful. I find it
my style to work actively with dreams and of course that encourages
the patient to bring more dreams. From this way of working, I have
found many instances in which the dreams seem to bypass the defen-
sive, entrapped, concrete state of mind of the patient, and as it were
to “speak” to the analyst as if pointing the way forward. For example,
Ms C had a dream in which:

She told a couple, who were asking for directions, how to reach
their destination, by going up a hill and then turning right at the
top of the hill. But after the couple left, she then turned around and
without watching, she allowed herself to slip into a pool of green
slime such that she nearly drowned.

She awoke in a panic, fearing that indeed she was about to drown in
that slime.
Following her reporting the dream she complained of feeling tired
and restless and did not want to think any more about it. After a bit
I offered that the dream might be suggesting that in it she could point
the way forward to the couple, our working dyad, indeed up a hill,
probably hard work, but something attainable. But then the dream may
also suggest that in the absence of the couple (that is, between our ses-
sions) she seems to turn back to being neglectful of herself, easily slip-
ping back into a drowning pool of self-neglect. Her dream, I continued,
may be more wide awake than she could be at times, showing the way
 C O N C R E T I S AT I O N , R E F L E C T I V E T H O U G H T, D R E A M F U N C T I O N 11

out of the mess she can so readily slip back into. This way of viewing
the dream was of interest to my patient and we were able to utilise this
message from the dream for some time.
An alternative view of the same dream, which came to light dur-
ing discussion of this clinical material with colleagues (Princeton, NJ,
March 19–21, 2010) was that between her therapy hours, when she
imagined that I would be with others perhaps in an excited way (a cou-
ple going up the hill), she could easily lose touch with the strenuous
work she and I have done, and collapse into self-neglect, slipping into
a drowning pool of envy (green slime). Both of these readings of the
dream pertain to the patient’s deep issues and perhaps these readings
of slightly varying relevance demonstrate the multi-faceted nature of
the dream.
And another dream from Ms C, which has been of interest:

She is on a fire escape and looking down to see her father and sib-
lings on a landing, seemingly stuck. She feels great pity for them,
and notices that, surprisingly, she can walk past them and continue
on down the fire escape to safety, feeling sadness for them, but
relief for herself.

As we initially tried to look at the dream she was again at first restless
and wishing to find distraction from the dream. Having her tendency
for self-neglect in mind, I then suggested she was having difficulty see-
ing clearly what the dream might be trying to show her in terms of
her being able to gain safety and freedom from the fiery experience of
her childhood family. While the path towards emergence was available,
there was still a part of her that was reluctant to move past the trauma-
tising family and to leave them on the fire escape.
Once my patient had a clear sense of this dream she was able to hold
it in mind for several weeks, and we were both able to think of her
reluctance to change which involved separating from her childhood
family; it seemed that my being able to link with the clarity of the dream
allowed her to do so as well. It is inviting to think that the dream itself
was a fire escape of a sort, showing the path down to safety and to clear-
eyed thought, which seemed to be the links needed to fully access that
way forward.
Again, in discussion with the same colleagues the possibility
that these dreams occurred sequentially was raised and we mused
12 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

that such a sequence could be viewed as a chronicle of her potential

development:

1. The explosion dream depicting her entrapment by or addiction to

the traumatising chaos and abuse, but also expressing the possi-
bility of gaining help in transforming this violence by way of our
mutual work.
2. The dream about the couple and the green slime, representing her
dependence upon the analyst and the work, while also subjecting it
and herself to the ravages of self-neglect and envy.
3. And the fire escape dream, depicting the possibility of separating
from the familiar chaos and abuse (leaving the family) while also
beginning a process of mourning (feeling sad for the family) which
such separation makes possible.

I offer these creative musings to illustrate both the kaleidoscopic nature

of the dream and the evolving meanings possible among collaborative
minds.
As I wrote these vignettes, while also appreciating the creative
elaborations just mentioned, I recalled with awe the complexity of
the dreaming process, its communicative potential, and the depth of
the wisdom of the dream. In addition I came upon the recently pub-
lished works of Jim Grotstein (2009) and Thomas Ogden (2009), both of
whom review Bion’s notions of dreaming and its profoundly important
impact on the organisation and growth of the mind. As a counterpoint
to Sandler’s comment on an intrinsic deanimating process, “Bion is pro-
posing that the human personality is constitutionally equipped with
mental operations that generate personal symbolic meaning, conscious-
ness, and the potential for unconscious psychological work with one’s
emotional problems” (Ogden, p. 103). Ogden further mentions that the
dreaming function for Bion is synonymous with unconscious thinking,
due in large part to its binocular capacity to view an emotional situation
from both conscious and unconscious perspectives. Via this binocularity
“dreaming is our profoundest form of thinking and constitutes the
principal medium through which we achieve human consciousness,
psychological growth, and the capacity to create personal, symbolic
meaning from our lived experience” (Ogden, p. 104). My attending
to my patient’s dreams may have served to help her connect with the
value of this binocularity, that is to gain access to the lessons from
 C O N C R E T I S AT I O N , R E F L E C T I V E T H O U G H T, D R E A M F U N C T I O N 13

these dreams—her loyalty to the militant explosiveness, her hesitation

to bypass her chaotic family on the landing—and to be able to think
about rather than be enmeshed by these ancient concrete states of mind.
My helping my patient to value the dream lessons may have aided her
developing symbolic capacity, helpful in counteracting the deanimat-
ing pull of the self-neglect, the loyalty to the explosiveness, and her
addiction to “chaos as freedom”.
Even with the help of the dream, however, the way forward is not
always this clear-cut: my patient is often caught in a place defined by
the past, bound by its intense concrete “certainties”. But she is also in
dread of anything new, for that would involve uncertainty, which trig-
gers dread of the unknown. While the dream might show a clear path
forward (fire escape), my patient often seems to get caught on the land-
ing with the old entangling internal family, unable and/or unwilling
to move away from that dreaded familiarity towards the perhaps even
more dreaded uncertain future. Such is the pull towards the ancient, the
familiar, the unchanging which lends conviction to the simultaneous
wish and dread that seem to shape “how it will always be”.

The struggles of the analyst to metabolise concrete experience

In such stuck times I try to take care to refrain from collapsing into
the impatient (“If I’ve told you once I’ve told you 1000 times …”)
state of mind, which occurs at moments when I am feeling weary and
thus susceptible to slipping towards the concrete reactivity myself.
The deanimating pull to the “unchangeable” presents itself in many
guises. For example, early in our work Ms C made frequent significant
steps forwards in terms of feeling understood and finding that I had
food for thought that could help her grow. But almost predictably these
“realisations” were followed by a sense of suspicion about our work,
a feeling that I was fraudulent, only out to rob her, only wanting her
money, that I wanted her to remain stuck so that I could bleed her dry
of funds. In these circumstances we have understood that her envious
wish to rob me of my resources is what triggers her conviction that I am
intent on being a thief of what is valuable to her.
But when I feel caught off-guard by these denigrating distortions,
my immediate experience can be a flash of defensive fury, such as
“Here after all our work, and your recent gain, you see me as this
money-grubbing figure … you are dragging down our good hard
14 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

work … and I won’t have it.” At these times I have had to do a bit
of intense inner work in order to gain the wider view that I am being
drawn into the concrete retaliatory place; this recognition—plus a few
deep breaths—generally help me to regain my analytic stance and to
recognise that I have just taken in but not yet metabolised a concrete
projection of fraud and greed, rather than being able to maintain my
separate-minded awareness of the hard work at hand, while also appre-
ciating the pull from that concrete aspect. As well, I want to remain
clear-eyed about what was going on if my patient is to gain any clar-
ity about and thus rescue from this situation. Sometimes it seems that
these denigrating encounters are hate- or envy-fuelled, but at other
times I have come to feel that the entropic forces towards meaningless-
ness are not so intentional, but just, as Sandler suggests, that they press
relentlessly and impersonally to prevail.
Occasionally I have considered whether my guilt over being away
and thus causing pain, perhaps even re-traumatising my patient,
might impede my ability to be the fully receiving, containing object
whom she needs. I think that the analyst at times can be so overwhelmed
by her own guilt in causing such a painful repetition of loss that only in
retrospect can she fully see how her guilt prolonged the concrete situa-
tion. On more than one occasion with Ms C, who approached my breaks
with great apprehension, I found it very difficult to be deeply empathic
with the pain my absence was about to bring. Instead I would shift
into a defensive position of slight irritation or impatience with Ms C’s
“over-reacting” to my upcoming absence, or at other times, I might
subtly nudge my patient to do something or be positive, or to find the
opportunity in the absence. These postures of mine would convey not a
guilt-free, patient mind for her pain but a guilt-tinged impatience, which
left her feeling bereft if she could not remain “happy” for the duration.
On these occasions, only when I returned from being away could I see
how abandoned my guilt had made her feel. And the repair at these
times involved my careful attention to how dismissed she felt deep
down when she experienced me to be urging her to be “happy” rather
than to accompany her in the upcoming pain of my absence. My finally
being able to offer a patient, receptive, undefensive mind, even after
the fact, went quite a ways in terms of providing a container for that
pain while also finally accompanying her in that effort. In addition my
patient felt affirmed in her experience that I had indeed missed her
pain, and I was reminded of how encumbering emotions such as guilt
can be to the analyst’s clarity and working capacities.
 C O N C R E T I S AT I O N , R E F L E C T I V E T H O U G H T, D R E A M F U N C T I O N 15

Concluding considerations
In review, concrete experience is intense and vivid; it often resides
indelibly in memory as well as in the body, and it carries a punch
that seems to declare its intense assertions as unassailable truths.
It returns to the fore via the process of concretisation whenever our
capacities for reflective thought are strained or depleted, whether from
internal or external sources. Indeed, our uncontained emotions, felt as
intense sensory onslaught, or clothed as withering doubt, seem able
to trigger this concretising function which appears to exert an entro-
pic, deanimating pull upon thought, easily dismantling its products
into their sensory elements and thus reconverting the “thinkable” into
the more ancient “unthinkable” sensory state. It may be that concrete
functioning and thought are two poles of an evolutionary spectrum,
with the more ancient and now hard-wired modality inevitably draw-
ing our valiant thinking efforts back to the sensory bedrock that is so
ingrained.
Reflective thought presents much more quietly. Within bounded
mental space, being open to various possibilities, we can feel tenta-
tive in our quest amid uncertainty. In this softer scape, derived from
and also giving rise to human reverie, the experience of being held in
mind and emotionally known provides potential transformation of the
“unthinkable”. Even so, the products of thought and reverie as part of
our everyday humanity cannot enduringly resist the relentless forces
of concretisation. It may be, however, that another possible source of
reverie that embraced by the well-attended dream, has the potential
to do so.
The remembered dream may be sturdy in appearance or only fleet-
ingly so, but to the interested mind the dream seems to be able to
express a deep wisdom. One important element here may be the quality
of the receiving mind, such as my providing a mind which could hold
on to and think about the dream which my patient would initially only
have dismissed. This attentiveness may provide a model of sturdiness
regarding value for the dream, that is, space to regard its messages,
such as a fire escape past the chaotic childhood family, or the loyalty
to the militant explosiveness. Thus the dream messages, received and
thought about, might lead to steps towards transcendence of the chaos
and “noise” of entrenchment and deanimation.
And yet the wisdom of the dream does not seem to reside in the
interplay between the receiving mind and the dream itself. Indeed,
16 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

it feels like the dream messages “come” from a place beyond what
the usual listening mind can provide. The wisdom of the dream may
derive from the binocular capacity of the dreaming process, that dis-
course between conscious and unconscious regions, from which mes-
sages may emerge relatively erosion-free to be further protected by the
receiving mind. My being able to hold onto the dreams for my patient
seemed to allow her then to think about the dreams’ messages, but the
wisdom of the messages—of loyalty to militant explosiveness, or the
fire escape possibilities—these messages, it is suggested, derived from
that internal binocular discourse.
The pairing of our attentive minds with the wisdom of the dream
may allow investigations beyond our current considerations. Just as
the animating capacities of human reverie give added dimension and
“knowability” to concrete experience, the animating capacities of bin-
ocular dream-reverie partnered with our attentiveness may foster a
“getting to know” into deeper regions of the psyche.
Are these contemplations a flight of fantasy? Perhaps, but with the
dream as a guide or perhaps as a co-pilot it is intriguing to ponder just
where our future psychoanalytic investigations might lead.

References
Anderson, M. (1999). The pressure toward enactment and the hatred of
reality. Journal of the American Psychoanalytic Association, 47: 503–517.
Bion, W. R. (1962). A theory of thinking. International Journal of Psychoanalysis,
43: 306–310.
Damasio, A. (2003). Looking for Spinoza, Joy, Sorrow and the Feeling Brain.
Orlando, FL: Harcourt.
Grotstein, J. (2009). Dreaming as a “curtain of illusion”: revisiting the “royal
road” with Bion as our guide. International Journal of Psychoanalysis, 90:
733–753.
Meltzer, D. (1968). Terror, persecution and dread: a dissection of paranoid
anxieties. International Journal of Psychoanalysis, 49: 396–400.
Ogden, T. (2009). Rediscovering Psychoanalysis, Thinking and Dreaming, Learn-
ing and Forgetting. London: Routledge.
Sandler, P. C. (1997). The apprehension of psychic reality: extensions of
Bion’s theory of alpha-function. International Journal of Psychoanalysis, 78:
43–52.
CHAPTER TWO

Content and process in the treatment

of concrete patients
Alan Bass

O
ne of the great difficulties of working with “concrete” patients is
having the flexibility to move back and forth between traditional
and novel forms of interpretation. To explain what I mean,
I have to give a summary of my basic ideas about concreteness.
We are all familiar with the problem: the patient who appears ana-
lysable, but resists any interpretation that presumes meaning and
symbolisation. Strangely, though, the patient stays in analysis. One
of the earliest examples in the literature is from 1919. Karl Abraham
writes about patients who can tolerate no interpretations, instead argu-
ing with the analyst about who is “right”, and yet showing a “never
wearying readiness to be analyzed” (p. 304). Abraham uses all the
theory at his disposition at the time to explain this “special form of
resistance”—defiance, anality, sadism, narcissism, auto-eroticism, envy.
But he cannot conceive of something about the interpretive process
itself that would provoke such intense resistance.
Integrating many sources, reflecting upon my own clinical work
and that of supervisees, I came to the conclusion that concreteness is
a compromise formation that defends against the possibility of mean-
ing and symbolisation (Bass, 2000). The possibility of meaning and
symbolisation is difference. The assumption that a symptom, a dream,
17
18 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

a behaviour, and, most important, the relation to the analyst can be

meaningful presumes that something is related, but not identical, to
something else; they are different. To interpret that “x” means “y” is a
differentiating process. Many analysts have emphasised that the con-
crete insistence that “x” can only mean “x” is due to separation anxiety.
This is half true, because difference implies separation. But difference
also implies connection: “x” is not “y” (they are separate), but “x” is
related to “y” (they are connected).
To cite two major influences on my thinking: Loewald (1960)
thought that every interpretation implies the differential between the
patient and the analyst and that the “therapeutic action of psychoa-
nalysis” is the internalisation of this differential; Winnicott (1951) said
that symbolisation depends upon paradoxical transitionality, simulta-
neous separation and connection (difference itself). However, neither
Loewald nor Winnicott thought about defences against difference and
transitionality. In scattered places, Freud offered some crucial, uninte-
grated insights on this question. In Group Psychology (1921c) he wrote
of a primordial, aggressive-defensive response to difference, and in
Beyond the Pleasure Principle (1920 g) he understood Eros, the simul-
taneously self preservative and libidinal life-drive, as a tension rais-
ing separating-integrating force of difference. True to his conviction
that the pleasure principle always aims at tension reduction, Freud
called Eros a tension raising “mischief maker” (1923b, p. 46). The death
drive, the counter-force of Eros, is then the tension reducing force of
dedifferentiation.
Some contemporary Kleinians have made important contributions
on this topic. Betty Joseph, in an early paper on the repetition compul-
sion and the death drive, wrote of patients who drain all interpreta-
tions of meaning in order to resist the analyst’s embodiment of Eros,
the life drive; these patients, she considers, suffer more from contact
than from loss (1959). In a related vein, John Steiner uses the concept of
psychic retreats to understand patients who avoid meaningful contact
with the analyst (1993). My view is that defences against differentiated
contact are an unconscious retreat from Eros’s tension raising, para-
doxical (transitional) aspects. Such defences against Eros interfere with
its function as libidinal self-preservation. This is why concrete patients
almost always manifest difficulties with both self care and connection to
themselves and others. To put it formulaically: Eros’s self-preservative
function is split from its libidinal function, enhancing the tendency
 C O N T E N T A N D P R O C E S S I N T H E T R E AT M E N T 19

towards tension reduction (the death drive). This is an affective and

cognitive process: the patient is warding off the tension of differentia-
tion, and so often cannot reflect upon anything the analyst says that
might be helpful. Hence, the patient defends against the process that
makes meaning possible, not against specific content.
Two major clinical problems emerge. How does one address defence
against the process that makes meaning possible? And when does one
use traditional forms of intervention which presume meaning? Concrete
patients sometimes speak in a way that allows the analyst to interpret
in a content oriented way. The analyst usually breathes a sigh of relief:
analytic work as he/she understands it can finally take place. But the
patient never stays in this position; typically the analyst then despairs
of the effectiveness of the treatment. And what about those moments
when a patient who usually responds to traditional forms of interpreta-
tion becomes surprisingly concrete? Are such moments swept under the
rug? The primordial defensive response to difference/Eros implies that
we are all internally divided between tension raising life and tension
reducing death, between differentiation and dedifferentiation. Anyone
can be concrete at times.
Because concreteness does interfere with cognition, it is often viewed
as a deficit. As a defensive response to the possibility of meaning, how-
ever, I view it as a compromise formation. As in any compromise forma-
tion, what is defended against is unconsciously “there”. If the patient is
defending against tension raising, paradoxical difference, this difference
must have been registered. How to understand this phenomenon? This
is where I draw upon Freud’s conception of disavowal (1927e). Disa-
vowal is a way of describing ego splitting: one simultaneously does and
does not know something. One oscillates between the knowing and the
not knowing. Freud describes this process as the registration and repu-
diation of reality, a process exemplified by fetishism. However, I believe
that Freud was inconsistent in his description of fetishism. He described
it as a disavowal of the “reality of castration”, a clear oxymoron. In my
view, fetishism is a disavowal of the reality of sexual difference, and is
more complex than Freud thought. As a defence against sexual differ-
ence, fetishism first registers this reality and then repudiates it, creating
a primary oscillation. The fetishistic compromise formation replaces
sexual difference with the fantasy that it equals phallic or castrated.
There is then a secondary oscillation between phallic and castrated,
as described by Freud (Bass, 2000).
20 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

Concrete compromise formations do the same thing. There is

a primary registration and repudiation of difference. The real differ-
ence repudiated is then replaced by two opposed fantasies conflated
with reality. This substitution produces a black or white, all or noth-
ing, objectively right or objectively wrong conception of reality, which
replaces those aspects of reality which cannot fit into these categories;
difference itself is a “both and” not an “either or” reality. But just as
the fetishist has to have been made anxious by registered sexual differ-
ence, so concrete defences indicate an anxious response to a registered
differentiating process, manifesting itself as resistance to interpretation
per se in treatment. Always keeping in mind that concreteness is also a
defence against tension raising, libidinal self-preservative Eros, one can
begin to understand why concrete patients are threatened by the pos-
sibility of interpretive help.
The anxieties aroused by differentiation are closer to the traumatic
end of the spectrum. When one repudiates the “reality of difference”
via a system of opposed fantasies, to re-experience what has been repu-
diated feels uncontrollably chaotic. The concrete patient talks to the
analyst, “free associates”, in order to prevent the re-emergence of such
intense anxiety. In other words, despite coming to treatment and appar-
ent compliance with the fundamental rule, the patient is speaking in
order to prevent an analytic process from taking place. The possibil-
ity of interpretation becomes the threat of loss of control over reality.
The analyst must intervene carefully in a defensive process which will
lead to re-experiencing near-traumatic levels of anxiety. The concrete
patient can be on the verge of panic if he or she actually experiences
interpretive help. It is counterintuitive, but necessary, to understand
that what the patient is paying us for is precisely what threatens him or
her the most.
To show how all this emerges clinically, I will give an example from
two sessions of a supervised case. Mr A, in his mid-thirties, is a pro-
fessional actor. An only child, Mr A’s “liberal” parents exposed him to
adult sexuality in early childhood. His father died during his adoles-
cence. He began treatment towards the end of his professional training.
He was near graduation from a fine conservatory, but was doing every-
thing he could to sabotage it. He did not hand in necessary forms, was
obstreperous with teachers and administrators, and lived in chaos. He
had difficulties following through on anything that involved self care.
For example, he had an opportunity to work abroad, but waited until
 C O N T E N T A N D P R O C E S S I N T H E T R E AT M E N T 21

the very last minute to try to find his passport. He could not find it, and
so had to forego the opportunity. He had great difficulties relating to
people, tending to spend a great deal of time sleeping, online, or com-
pulsively practising acting parts in a way that did nothing to improve
his skills. And he had a sexual fetish of which he was deeply ashamed:
his sexual interest in women was confined to their feet.
Dr B was midway in her training when Mr A was referred to her. She
had two very difficult problems to deal with from the start. As one might
expect, Mr A wanted a woman analyst precisely because he would be
aroused by her shoes and feet. And he was as obstreperous with Dr B
as he was with all authority figures, to the point of throwing pillows off
the couch when he was angry. One could reasonably wonder about a
borderline personality organisation, but the course of Mr A’s treatment
did not bear out this diagnosis. Eventually his obstreperous behaviour
faded away. He did not graduate from the conservatory, because he was
offered a job in a professional company, which he accepted. At the time
of the sessions to be reported, Mr A had lost and regained this job. He
was chronically plagued by insecurities about his masculinity because
of his foot fetishism, and was still prone to not taking care of the neces-
sities of everyday life.
Mr A was markedly concrete in treatment. He often responded to
interpretations by accusing Dr B of criticising him. In a way he was
right. Dr B had all the typical countertransference responses to a con-
crete patient: she often felt frustrated, overwhelmed, confused, unable
to think, and incredulous—“You can’t possibly be for real when you say
that.” But she persisted and Mr A persisted. There were often difficul-
ties about payment, but Mr A always eventually paid what he owed.
Over time Dr B was able to raise his fee. At the time of the sessions
Mr A had just ended a relationship, his first.
Mr A begins the session by talking about a hiking trip he had taken
with friends earlier in the day. He goes on to say: “I sort of feel like
I don’t know what to talk about right now. I am trying to remember
what we talked about at the end of the last session. Vaguely I remember
talking about the idea of my difficulty staying in reality, and how it was
connected to my fear of establishing relationships with people. I guess
I was making a point about that, but I don’t remember what it was that
led me to talk about that.” He yawns. “Excuse me.”
There is nothing unusual about a patient having difficulty remem-
bering something that had felt important in the previous session.
22 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

The analyst naturally thinks of the need to re-establish defences.

But note the topic: staying in reality, establishing relationships, i.e., con-
nectedness. From long experience, Dr B also knows that Mr A retreats
from these issues by sleeping, and he yawns here. I take the yawn to be
an expression of Mr A’s unconscious need to protect himself from the
tension of connecting to reality and other people, and also to himself,
to what he was saying in the previous session. Dr B and I have often
discussed this topic, and she intervenes along those lines here, saying
“So this is also about not being with yourself.” Her words are simple,
but they convey a complex thought: Mr B uses splitting and disavowal
not only in relation to reality and other people, but also in relation to his
own inner processes.
Dr B’s intervention here illustrates some important aspects of inter-
pretation of defence against differentiating process. She is addressing
Mr A’s affective-cognitive experience as he speaks, his state of “being”:
“This is also about not being with yourself.” She does not address spe-
cific content, nor does she say anything about why Mr A has difficulty
being with himself. This last point is critical. Our usual assumption
is that when we address meaning, we also address causality: you say
or do “x”, because it means “y”. But when we address defence against
the possibility of meaning, we have to free ourselves of any sugges-
tion of causality, which always implies the differential relation between
“x” and “y”.
Analysts are trained to think in terms of meaning and causality.
Hence, it is very difficult for us to refrain from making causal inter-
pretations. When patients resist interpretation itself we tend to revert
to some form of suggesting that we know what things mean and why
they happen. We think that we know all this because we are analysts.
However, clinical experience with concrete patients consistently shows
that the implication of meaning and causality leads to power struggles
over who is “right”. (This is what happened between Abraham and his
patient.) I have found this to be an almost generic countertransference
response to concrete patients, which often leads to concreteness in the
analyst. Dr B and I had spent a long time in supervision discussing
this issue. When the analyst feels devalued and frustrated because the
patient dismisses his or her knowledge, the analyst is tempted to depart
from neutrality. Because it is so difficult to sustain the attack on one’s
knowledge and competence, the analyst may either try to reassert some
kind of authority, or retreat into defensive silence. Unfortunately, the
 C O N T E N T A N D P R O C E S S I N T H E T R E AT M E N T 23

departure from neutrality plays right into the patient’s need to engage
in a defensive power struggle, in which there is always a winner and a
loser. That is why it is important that Dr B is effectively neutral in her
simple intervention about Mr A’s not wanting to be with himself. She
has not retreated, and is not speaking from the position of confusion,
despair, frustration, and the need to prove she is right.
Mr A says: “Yeah, those things are somewhat connected”—an unu-
sual response for him. He pauses, and goes on to speak about the woman
he has been involved with, Ms C. “I’m thinking about how difficult it
was for me to be with C … A lot of the difficulty had to do with us not
being compatible, but overall I didn’t know how to be with her. I was
always fighting to create space, instead of allowing myself to be with
her. The tension of being with her was too much for me to handle.”
Mr A had also spoken a great deal about wanting to fondle and lick
Ms C’s feet. He had been too ashamed to ask her. Much of his sexual
history did seem to explain why he was a foot fetishist. He vividly
remembered feelings of revulsion, stimulation, and inadequacy related
to seeing his mother’s naked body.
Mr A then says: “I think the reason I did that was because the tension
of being with her was too much for me to handle.” Here, I want to speak
of my own response as supervisor. Dr B and I had a long-standing, good
relationship. She was very eager to learn. At times, however, she coped
with the difficulties of treating Mr A by using what I said in a didactic
way, as if she could resolve his difficulties by teaching him what she was
learning from me. We also talked about this issue in the supervision.
When Mr A speaks of the tension of being with Ms C, I wonder if he is
parroting Dr B. I was concerned about compliance and intellectualisa-
tion, even parallel process: I was teaching Dr B and she was teaching
Mr A. I did not intervene, however, waiting to hear what happened next.
Referring to Mr A’s statement about a tension that was too much to han-
dle, Dr B asked: “What kind of tension did you experience?” Mr A said:
“I guess being with her represented a sense of being in reality. It was so
much and so difficult that I was trying to escape from it, but that way of
managing tension added another level of tension and anxiety, and I was
trying to fight against that too.” As I listen I am divided in my thoughts:
Mr A does sound possibly compliant and intellectualised, but he is
also possibly connecting to himself in a non-defensive way. And he is
describing the kind of galloping anxiety I expect to hear when concrete
patients begin to experience “differentiated connection”, whether in
24 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

analysis or in life. So I still wait. Dr B reports that Mr A paused and then

said: “I feel like I’m having trouble connecting with you today. I’m hav-
ing thoughts about my way of being with you. I can’t understand the
reason. I am feeling afraid.”
This is an even more unusual comment from Mr A. He reflects upon
his internal experience of Dr B, rather than concretely objecting to her
“criticism” of him, or parroting by rote what he has learned. My thought
at this point is that Dr B’s simple interventions, which have described
Mr A’s experiences without attributing meaning or causality to them,
have been effective. He is not intellectualised or compliant. But my
hypothesis is that entering into this analytic space will make Mr A even
more anxious, leading him to retreat to concreteness.
Dr B asks him what he is afraid of. He says: “I wonder if I’m afraid
of talking about the thoughts I have about my relationship to you.”
Dr B says “Uh-huh.” Mr A pauses and continues: “I think one of the
things that happens is—when I talk to you, I feel the need to go over
what I did during the day and think about whether or not I have been
good or bad. I didn’t really think about doing that today because
I went hiking, so that automatically meant I was doing good. So it
meant that I didn’t have to be concerned about doing good today. But
I’m wondering—feeling relaxed about that makes me feel like I am
doing something wrong. Every time I talk to you, I go through this
process. Talking to you feels like a confession to me … Is it a good thing
that I approach talking to you in this way? I’m wondering what you
think … I guess I was wondering what you think of me … One of the
things that happens is—when I talk to you, I am coming from the point
of view of being alone. I find it easier to talk to you if I approach you
from that place of being alone rather than speaking from a shared space
with you. I find it difficult to do that, so every time I talk to you, I am
fighting not to be in that shared space.”
These associations bear detailed commentary. As I listened, my
sense was that Mr A was approaching the anxiety about actually being
in an analytic process. When the patient internalises the transitional
space between himself and the analyst, so that there is also transitional
space within himself, opening the possibility of meaning and symboli-
sation, he panics. Mr A accurately describes how he generally copes
with the possibility of this kind of anxiety. He concretely and fetishisti-
cally divides his experiences into good and bad, and anticipates what
will happen if he tells the analyst about his good or bad experiences.
 C O N T E N T A N D P R O C E S S I N T H E T R E AT M E N T 25

While this sounds like typical superego projection, Mr A has concretely

insisted that this is really how Dr B listens to him. Because he went
hiking with friends—i.e., did not spend the day retreating into his fan-
tasy world—Mr A says he has done “good”. But what if his confidence
about having done “good” is false, what if he is “too relaxed”, is caught
off guard, and then is made to feel he has been “bad”? In other words,
he concretely experiences the analyst as a “superego fetish”. He girds
himself for his sessions by swinging back and forth between these two
fantasies conflated with reality. But then he explains that he does this
so that he can remain convinced that when he speaks to Dr B he is
not in a shared space, is not connected to her. Although he is literally
in the room with her, psychically he is alone, as he says. In fact, he
has to destroy shared psychic space, which he does via his concrete,
“superego fetish” fantasy construction. In terms of process, this is the
manifestation of tension raising, connecting-separating, differentiat-
ing life, versus tension reducing, dedifferentiating, destructive death.
These two forces are always intertwined in the concrete transference.
When Mr A registers the reality of differentiating space, he has to
repudiate it.
Dr B asks Mr A how he fights against being in a shared space with
her. He responds: “By wishing that the session is over, or by wonder-
ing about what you are thinking about me.” Mr A makes clear that he
wants to use wish fulfilment to get out of the shared time and space of
the session, and that he uses his image of Dr B as a “superego fetish” in
the same way. He then goes on to say: “Before I came here today I was
dozing off. I’m still feeling sleepy.” As in his yawning earlier in the
session, for Mr A sleep is the ultimate retreat from the tension raising,
time-space of analysis. But he continues to speak about it—progress
for him. He says: “I’m trying to tell you that it is not easy for me to
know how to really connect with you and stay connected with you …
I am pushing against that connection—I am trying to push it away from
me … My thought is that I have been good, so I don’t want or need to
talk to you. I want to come back and talk to you when I feel as though
I am not being good.” In other words, unless he is concretely “bad”, and
so deserving of criticism from Dr B, Mr A would rather not be there.
This raises another important point. While Mr A has complained about
Dr B’s “criticism” of him, we see here that the “criticism” is preferable
to sustaining an interpretive process. He needs to feel the protection of
his concrete good-bad fantasies.
26 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

Here Dr B says: “You wish to make me into a parental figure.” I am

uncomfortable with this intervention. Just as it is difficult for the con-
crete patient to stay with the anxiety about engagement in the analytic
process, so it is difficult for the analyst to stay there with the patient.
The analyst can relieve his or her own tension by returning to content
oriented, causal interpretations. Is Dr B doing that here? One does not
know for sure: her intervention can go either way. Dr B goes on to say:
“If you don’t turn me into a parental figure, you will be more frightened
about the kind of connection you have with me in a shared time and
space.” My internal reaction is like the one I mentioned above: I wonder
whether Dr B is using what we have discussed in supervision to make
sure she is doing the right thing. Is she being good for me?
Mr A responds: “That’s true—but I can’t pinpoint where the source
of that anxiety is.” Mr A is saying something that our theories of anxiety
do not usually tell us. We are accustomed to thinking about signal anxi-
ety, separation anxiety, traumatic anxiety, persecutory anxiety, depres-
sive anxiety (to use the major Freudian, ego psychological, and Kleinian
categories), but not the kind of all-pervasive anxiety Mr A speaks about.
One might think about “free floating anxiety”, neurotic anxiety with an
unknown source. However, Mr A is saying that he knows his anxiety
is about his connection to Dr B, but that he doesn’t know where it is
coming from. There is an apparently non-psychoanalytic way of think-
ing about this kind of anxiety. Heidegger (1996) conceives of existential
anxiety, Angst, as an all-pervasive, non-localisable feeling about what
we are, about our existence as creatures who are always in a world that
we are open to. This kind of openness is also for Heidegger the time
and space of interpretation. I find this a useful way to think about what
Mr A says here. As he stays connected to his fear of being in a shared
time and space with Dr B, a time and space in which he is open to the
process, he also experiences something enigmatic: he cannot “pinpoint”
where this anxiety comes from. Heidegger says that Angst comes from
everywhere and nowhere. For patients who defend against differentia-
tion, being in the open time and space of an interpretive process is too
strange, too overwhelming, too nearly traumatic.
After saying that he cannot pinpoint the source of his anxiety,
Mr A says: “If I am able to exist in the shared time and space and connect
with you, it will make me realise that escaping to fantasy is not adequate.
I push against that thought because I am afraid of realising that I need
other people. I am holding on to the fantasy that being alone is good,
 C O N T E N T A N D P R O C E S S I N T H E T R E AT M E N T 27

because being in reality is scary for me.” This is a cogent statement of

the concrete patient’s dilemma. To conflate one’s fantasies with reality
is in the everyday sense to be alone, and in the more technical sense
to exist in an auto-erotic, wish fulfilling world in which the need for
anything other than oneself is eliminated. To feel the need for others, to
be open to something other than oneself, to be in reality, is, again, to re-
experience an all-pervasive anxiety. Dr B asks, “What’s so scary about it
[i.e., needing other people, being in reality]?” Mr A answers, “Not being
able to be with people and people not being there for me. I’m afraid of
finding out that I’m not able to find anyone to be with.”
Here I think that Mr A is understandably getting away from the inten-
sity of his anxiety. My thought is that he is most afraid of finding that
someone is there for him, especially his analyst. My hope is that Dr B
will say something about this to Mr A, but that can also be concreteness
in the supervisor, not allowing for the supervisee’s different thoughts.
In fact, Dr B does say something unlike what I am thinking. She inter-
venes: “I wonder if what you are saying is that you are afraid that your
approach to yourself will not change, so that at the end of this long
process, you will not get what you deserve.” I am a bit jarred by this
interpretation, thinking that it is too far from what Mr A is saying. Mr A
responds: “I think you are saying something very different from what
I am saying.” In my opinion, Mr A is right; Dr B has made a leap here.
But in terms of clinical process, this is another unusual moment. Mr A is
able to think about Dr B’s intervention, able to consider that it is different
from what he has said without feeling criticised, without engaging in
a power struggle, without retreating into concreteness. Could it be that
enough work on defence against process, motivated by all-pervasive
anxiety, has been done to allow Mr A to tolerate the differentiating proc-
ess of interpretation for a while?
Dr B explains her last intervention: “What I am saying is—your way
of avoiding building a connection is a direct reflection of how you treat
yourself.” Mr A: “When I heard you say that I somehow started feel-
ing like I was undeserving of being in the world and being happy.”
It seems that Mr A is confirming Dr B’s interpretation about not getting
what he deserves. Here, then, I have to change gear. Perhaps Dr B’s ana-
lytic intuition was correct, and it was time to begin working on content.
Dr B continues in a content oriented vein: “What did you do that was
so bad that you do not deserve to be happy?” Mr A: “When you asked
me that, the feeling of guilt about living came up. It’s associated with
28 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

how I am living and my dad is dead. That speaks to my fear and all
the trouble I’ve had connecting with people. I didn’t feel sad when he
passed, so I felt I was not a good person. I felt like I was a psychopath,
a sociopath. Another thing that comes to mind is—I think, maybe, in
order to have a real connection with people I have to be able to look at
myself and feel okay about what I see in myself. I find it hard to look at
myself and think about my sexual desire, and at the same time, not to
feel ashamed of it.”
We are now on familiar analytic ground. Mr A had been conflicted
about his father’s long illness and deterioration during his adolescence,
and over-stimulated and intimidated by both parents’ “liberal” sexual
attitudes when he was young. His foot fetishism is a complex compro-
mise deriving from issues of sexuality, death, castration, anality, maso-
chism, and defence against sexual difference. It is the intersection of
content and process issues. Immediately after speaking about his shame,
Mr A says: “I don’t know. I am talking about my sexual desire, but I won-
der if this is a way of seeking to escape from you.” Again, he is unusually
self-reflective, and able to think about the transference. Dr B responds:
“It is almost as though you are saying that exploring what is going on
with you and connecting with me can’t happen simultaneously. These
two things are somehow contradictory to one another.” My sense is that
Mr A and Dr B are now working together productively. Mr A can see
how he might use content as a defence against process; Dr B addresses
his difficulty integrating content and process—which itself is a process
oriented intervention, without direct causal implication.
Mr A responds: “I think that’s true … Being with you forces me to
be with me, and I find that extremely uncomfortable … I do everything
I can to prevent myself from facing who I am … I am thinking that
I can’t be with other people unless I am being with myself. I notice
there is a sense of self-hatred or shame associated with that idea. I can’t
accept that I am unable to connect with people—I feel like I am always
running away from that awareness. I am afraid of putting myself in
reality and connecting with people. I guess I am talking about the ten-
sion of being with myself and applying that to being with people …
I wonder if there is something about this sense of who I am that makes
it harder for me to stay in reality, take care of myself, and really try con-
necting with people … I am wondering what you are thinking.” Dr B:
“I am thinking that all of these things you are telling me apply to the
work we doing together.” Mr A responds by describing the fetishistic
 C O N T E N T A N D P R O C E S S I N T H E T R E AT M E N T 29

compromise formation which registers and repudiates engagement in

the process: “My mind is going to this place where it is telling me things
are this way or that way. I am attempting to escape from this moment
by setting up a kind of dichotomy, two oppositional views.”
Dr B again intervenes very simply: “Does that mean you are feeling
uncomfortable right now?” Mr A assents, and Dr B asks him if he has
any idea why. He says: “Because I am feeling confused. It feels as though
things are undetermined right now.” In other words, Mr A knows at
this moment that he would prefer to escape by retreating to his fetish-
istic dichotomies which give him a feeling of control over reality, but
he stays in the moment. Doing so takes him to a place of confusion
and indetermination. His anxiety is escalating. He says: “Maybe I don’t
understand what you mean …” Mr A’s “maybe” indicates that he is
vacillating between understanding and not understanding, meaning
and non-meaning. He had understood Dr B a moment ago, but since
staying with understanding takes him to a place of confusion and inde-
termination; he wants to retreat. He starts to go back to his concrete
conviction that Dr B is criticising him: “Maybe you were pointing out
that I was not relating to you.” But then he comes back: “Maybe by say-
ing what I just said, when I am relating to you, I feel like I am conduct-
ing a form of retreat … I find it difficult to both look into myself and
understand how I am being with you … I don’t know how to do that
without feeling the need to escape from the moment when I am with
you.” Mr A’s direct statement of his conflict over exactly what analysis
is—looking into oneself and understanding how one is relating to the
analyst—helps him to emerge from the concrete conviction that Dr B
is criticising him: “Your comment did not mean to say that I was miss-
ing the point … .” But this emergence from concreteness again increases
his anxiety: “This entire conversation is making me feel really anxious.
It feels very undetermined. I feel like the anxiety I am experiencing is
not helpful. Maybe I have trouble experiencing that kind of anxiety—at
this point our conversation is making me feel like it is not healthy for
me to experience this much anxiety. I feel like there is no point in expe-
riencing anxiety in this way.” The session ends.
There is no way to know for sure at the end of the session whether
Mr A has been helped or not by experiencing this much anxiety.
He claims he has not been helped, but my sense is that he probably
has been. To shake his concrete certainties, to modify his defences
against engagement in the process, is to deal with his most important
30 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

transference-resistance. This is the crux of every analysis, and is

always difficult. It is particularly difficult for the concrete patient for
just the reason Mr A describes: it takes him to the paradoxical place
where effective interpretive help produces near-traumatic anxiety. One
hopes that even though Mr A ended the session by saying that there
was “no point” in sustaining such a difficult experience, he will uncon-
sciously put it to work. But there is always the risk that he will retreat
further into his self encapsulated auto-erotic world, as he has done so
many times in the past.
Generalised defence against analytic process is often directed against
all the factors that make interpretation possible, including the analytic
frame itself. We have seen Mr A’s reactions to sustaining shared space;
retrospectively it is possible to wonder whether his throwing of pillows
at the beginning of his treatment was a concrete expression of an imper-
ative need to attack that space. The analytic frame is also temporal, and
difference itself has a temporal aspect: as simultaneous separation and
connection it is not immediately present, but is an expression of what
is “not now”. Another aspect of concrete compromise formations, with
their urgent immediacy, is their insistence on the “now”. Difference is
a tension to be eliminated now. Things are what they are now. One has
to know who is right or wrong, in control or out of control now. Now
is the time of wish fulfilment. Dreams, Freud says, have only one tem-
poral mode—the present (1900a, p. 566). Lateness or non-attendance
become ways of controlling time. Mr A neither missed nor was late for
the next session, typical occurrences for him in the past. The simple fact
that Mr A arrives for the next session on time may indicate that he was
helped in the previous session.
I will not give as much detail about this session, but will emphasise
how the question of confining time to the now in order to control the
process eventually emerged. Mr A begins by recounting a long talk he
had the previous night with Ms C. He says that he really never cared
as much about her as she did about him, and that he doesn’t miss her
that much. But he wonders whether he is avoiding any feeling of loss.
He says: “I guess I sense there is a strong connection to her, and I want
to push that away—I want to get myself away from that … I pull myself
away from the emotional connection I have with her. I am hoping that
I will change my ways by talking to you … I want this to be over so
I can be all by myself again … I want to keep thinking I have the option
to escape. I don’t like that part of me because more and more I feel like
the act of escaping takes me to a dangerous place. But in the moment
 C O N T E N T A N D P R O C E S S I N T H E T R E AT M E N T 31

when I am seeking to escape, that is what I want to do and I expect

that doing so will make me feel better.” Mr A lucidly articulates his
dilemma: connection to anyone—Ms C, Dr B, and himself—is too much
for him. He wants to convince himself that escape is justifiable.
As the session proceeds, my sense is that Dr B herself is having trou-
ble with Mr A’s justifications for escape. She again becomes didactic,
telling Mr A that when he retreats he is in fantasy, asking him if he is
willing to spend the rest of his life in fantasy. He says that he is not
getting any benefit from talking to her. He also says that he doesn’t
take care of everyday issues, because doing so will make him feel
lonely. One can empathise with Dr B here: Mr A uses contradictory
arguments—he wants to be alone, he is afraid of being alone—to sup-
port his arguments for escape. My thought is that although Mr A’s on
time arrival at the session indicates an increased tolerance of his anxi-
ety about the analytic process, he is now using the session to avoid this
anxiety. And in fact he says: “I am afraid that therapy will make me
feel anxious—it will make me deal with anxiety that I am trying not to
experience in my whole life.”
We know how easy it is for the supervisor to assume a superior
position. The difficult balance is to be realistic that one should know
more than the supervisee, but that it is all too easy to know what to
do when one is not on the “firing line” of the session. My sense is that
Dr B should remain silent after Mr A’s last statement, to let his words
reverberate, and to see where he goes. But the pressure from Mr A was
apparently too much. Dr B explains to him that experiencing anxiety
and talking about it are helpful to him. I think that this is a non-neutral
intervention. Mr A was clear about his resistance to the analytic process,
a statement to be honoured. As Dr B tries to convince Mr A of the value
of the analysis, he becomes more focused on time. He says: “I would
like to know from you—how can I use therapy in a helpful way even
in the next ten minutes?” It is as if Mr A is saying to Dr B: since you
are telling me that the therapy is helpful, prove it, make it helpful now.
Make it helpful in the ten minutes I still have to endure. He is using
the actual clock time of the session to put Dr B in an even more impos-
sible position than when he said he both wanted to be alone and was
afraid of being alone. He is becoming concrete, but in part, I think, as a
response to Dr B’s non-neutral interventions, which abet his defences.
However, Mr A does not entirely lose his understanding of himself:
“I am feeling so anxious right now, and I don’t know what the source
of this anxiety is. Am I feeling anxious because I am recognising I am
32 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

wasting my time right now? … In a few minutes I will stop talking to

you, but I am wishing this moment to happen sooner, so I don’t have
to continue talking to you right now … I don’t know what I want from
therapy. I want it to be over so I don’t have to think about what we have
talked about.” Mr A is on the cusp of meaning and non-meaning, of
registering the analytic process and repudiating it.
Dr B says: “Well, ironically the point of therapy is for you to
continue thinking about what we talked about while we were
connecting with each other.” What is the status of this intervention?
Is Dr B still in the didactic, non-neutral place, or, by stating what is
apparently most self-evident about the analytic process, has she
addressed Mr A’s most important transference-resistance? He responds:
“That seems like a simple idea, but I have not done that for a long time.
But hearing you mention that is helpful. What I often do, instead, is to
push away what we talked about because the anxiety is so much …
I feel relieved that the session is over. I then feel like I could finally go on
the internet, or do something that would make the anxiety go away …
If I have to hold on to the anxiety I don’t know what I will do with
it. I look at the clock just now because my anxiety is so strong. I want to
go back into fantasy … I know I need to talk to you about my anxiety,
but I know that the time is almost over.” Dr B: “How do you feel about
the fact that we have to end the session at this moment?” Mr A: “I feel
fine about it.”
One sees in these two sessions an oscillation between toleration of
anxiety and retreat from it, between registration of the possibility of
an analytic process and repudiation of it, between sustaining the open
time-space of differentiating connection and retreat to the closed auto-
erotic now. This oscillation also characterises the overall arc of these
analyses; the analyst can never stop moving back and forth between
process and content interpretations. One cannot underestimate how
difficult this is for the analyst. Recently, after moving ahead profession-
ally, Mr A regressed to the kind of action he had demonstrated at the
beginning of his treatment: he kicked open a door to make a rehearsal
possible. However, he immediately understood what he had done, and
took steps to remedy the situation. In the next session, he paid Dr B
for two months of treatment, an internalisation of the frame. He said:
“When I pay you, I feel open to you. I want to avoid that.”
 C O N T E N T A N D P R O C E S S I N T H E T R E AT M E N T 33

I want to express my profound gratitude to Dr B for providing me

with this process material, and for her devotion to Mr A’s treatment.

References
Abraham, K. (1919). A special form of resistance to the psychoanalytic
method. In Selected Papers on Psychoanalysis. London: Maresfield Reprints,
1927.
Bass, A. (2000). Difference and Disavowal: The Trauma of Eros. Palo Alto, CA:
Stanford University Press.
Freud, S. (1900a). The Interpretation of Dreams. S. E., 4–5. London: Hogarth.
Freud, S. (1920g). Beyond the Pleasure Principle. S. E., 18. London: Hogarth.
Freud, S. (1921c). Group Psychology and the Analysis of the Ego. S. E., 18.
London: Hogarth.
Freud, S. (1923b). The Ego and the Id. S. E., 19. London: Hogarth.
Freud, S. (1927e). Fetishism. S. E., 21. London: Hogarth.
Heidegger, M. (1996). Being and Time. J. Stambaugh (Trans.). Albany, NY:
SUNY Press.
Joseph, B. (1959). An aspect of the repetition compulsion. In: Psychic
Equilibrium and Psychic Change. London: Routledge, 1989.
Loewald, H. (1960). The therapeutic action of psychoanalysis. In: Papers on
Psychoanalysis. New Haven, CT: Yale University Press, 1980.
Steiner, J. (1993). Psychic Retreats. London: Routledge.
Winnicott, D. W. (1951). Transitional objects and transitional phenomena.
In: From Pediatrics to Psychoanalysis. New York: Basic Books, 1975.
CHAPTER THREE

Transitional organising experience

in analytic process: movements
towards symbolising space via the dyad
Joseph A. Cancelmo

Introduction
Psychoanalytic process offers unparalleled opportunities among
therapeutic interventions for the transformation of states of concrete-
ness and compromised symbolic capacities that often arise as impasse
or stalemates as lived in the transference-countertransference. How
these states are conceptualised, and, in turn, navigated by the analytic
pair, is seen as central to and facilitative of such potential transforma-
tion towards the development of greater symbolic capacity. This chapter
attempts to address this potential from both structural and intersubjec-
tive perspectives, rather than simply one or the other.
Based on Winnicott’s (1951) construct of the transitional realm1 and
rooted in Freudian notions of structuralisation and internalisation
(1923b), the shorthand transitional organising experience has been sug-
gested to help describe such moments of potential transformation that
may arise in an analytic process (Cancelmo, 2009). These moments
are viewed as representing compromised internalisations or patho-
logical organisations, based on early empathic failures, impingements,
and traumatic experiences, in particular, as they may emerge via the
dyad in the analytic process with some of our more challenging patients.

35
36 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

It is the view offered here that such moments represent opportunities

for developmental movements of compromised structural and inter-
subjective capacities that are the hallmark of the transitional realm and
the emergence of symbolisation that it represents.
Both structural and intersubjective frameworks are enshrined in
Winnicott’s prescient construct of the transitional realm—i.e., the devel-
opmental progression from a nascent to a separate self, the organisation
of drive experience via the (m)other, and the sorting out of one’s own
mind in terms of subjectivity and objectivity. These are core products
and processes that are forged in early life. While they remain with us as
lifelong tensions (Kohut, 1971; Loewald, 1978), what Winnicott (1951)
called the “strain of relating inner (subjective) and outer (objective)
reality” (p. 240), they are also the basis for creative and authentic exist-
ence, a capacity for transitionality2 in human experience. Ellman (2010)
most recently notes that Winnicott likely implied in these words “a con-
tinuous dynamic relationship between subject and object (or subject
and subject) throughout life” (p. 370), and by extension, in the analytic
process.
In the view presented here, less than optimal or pathological devel-
opment in these core structural and intersubjective components of the
transitional realm inevitably will serve to organise the analytic process
and shape the transference-countertransference experience for some of
our more concrete patients. This is due, in general, to the illusory qual-
ity of analytic experience (Freud, 1914g; Sanville, 1991; Steingart, 1998),
and, more specifically, to the inherent ambiguity of the analytic proc-
ess in which self and object, active and passive, and past and present
are perpetually negotiated (Adler, 1989). “Pathological”, as used here,
refers to less than optimal outcomes during the transitional phase that
are manifest in compromised development in the internalisation of
holding-soothing functions, organisation of drive experience, and the
development of symbolic capacities, and managed via a range of substi-
tutive or prosthetic transitional phenomena (e.g., addictions, psychopa-
thy, perversions, and false-self/narcissistic organisations) as described
by Winnicott (1951) and extended by others (see Cancelmo, 2009).
Steiner (1993), and more recently Brandchaft (2007), have described
pathological organisations of internal object representations based in
early traumatic impingements; these internal structures are relatively
fixed patterns of reaction and defence that have an addictive, adhesive
quality (see also van der Kolk, 1989) and become activated in analytic
space as transitional areas. Bollas (1987) likewise described such early
 T R A N S I T I O N A L O R G A N I S I N G E X P E R I E N C E I N A N A LY T I C P R O C E S S 37

compromised experiences in “being and relating” (p. 3), rooted in

failures in the earliest caretaking environment, as a “process” experi-
ence that inevitably re-emerges via the transference. In the process of
analytic regression, the analyst comes to serve as a potentially (new)
“transformational object” (Bollas, 1979) providing the background for
authentic existence, however compromised, and in that sense, offering
potential for transformation via analytic process. Earlier, Bach (1984)
described the unfolding of such difficulties and potentialities in the clini-
cal setting as “problems in transitionality”, notable in patients’ struggles
around the boundaries of perception and conceptualisation, subjectiv-
ity and objectivity, and more concretely, negotiating transitional areas
and moments within the analytic space. From the perspective presented
here, the need for the analyst’s empathic attunement to the emergence
of such moments of potential transformation seems central to the task
of articulating the compromised internal structure as lived in the inter-
subjective space of the transference-countertransference.
Transitional organising experience is seen from this perspective as
both organising and also marking movements towards greater sym-
bolic capacities as lived between and within the dyad. In a sense the
shorthand transitional organising experience might be considered a heu-
ristic tool, a way of thinking about the repetition compulsion in the
clinical moment for these patients from both structural and intersubjec-
tive perspectives, as embodied by Winnicott’s prescient construct of the
transitional realm.
This chapter will focus on the ways in which the developmental pro-
gression towards greater symbolic capacity is embedded in Winnicott’s
theory, in conjunction with Contemporary Freudian notions of struc-
turalisation and internalisation, and as elaborated in various ways by
others. Particular attention will be paid to his conceptualisation of the
earliest experiences with the environment and object mother and the
gradual integration and internalisation of these maternal presences
as symbolised in transitional phenomena; these are viewed here as
core transference-countertransference configurations that may emerge
via the dyad as transitional organising experience (albeit as less than
optimal, or compromised attempts to fashion transitionality). Analytic
vignettes will serve to illustrate how transitional organising experience
may emerge over time: 1) as a repetition of early compromised internal
structure and related intersubjective experiences and fantasies rooted
in the faulty development of transitionality, 2) as an empathic function
of the analyst in the transference-countertransference, and 3) as an
38 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

articulation of these experiences in ways that foster shifts in symbolising

capacities via the dyad. Familiar dynamic constellations3 that emerge
in analytic process over time are also viewed from this perspective as
representing opportunities for a re-experiencing (as a two person psy-
chology) and a reorganising (as a one person psychology) towards
less “pathological” transitional modes of functioning, allowing for a
developmental resumption of transitional (symbolising) space. These
vignettes were described in a previous publication (Cancelmo, 2009)
and are presented here to describe such nascent shifts in and a resump-
tion of the development of symbolising space via the dyad.

The transitional realm and the development of symbolic capacity

For Winnicott, the transitional realm is a developmental achieve-
ment. It is rooted in the bedrock experience with and internalisation
of a “good-enough” mother (1960a) as represented in the emergence
of symbolic capacities via transitional phenomena. The emergence of
transitional phenomena4 in this sense may be seen as both product and
process, a way station in the development of symbolic capacities and
the structuralisation they represent.
Winnicott described the infant’s experience of mother as taking
two forms: 1) the environment mother of “quiet” states whose ego pro-
tects the infant from impingement and organises early experiences,
and 2) the object mother of “excited” states experienced as the object
of instinctual tensions (Winnicott, 1963a). It is the inevitable (and ide-
ally, optimally timed) misalignments that occur between mother and
infant around the provision of these developmental needs that serve
to articulate the separateness, and later the subjectivity, objectivity,
and interdependence of mother and infant in the intermediate area
(Ogden, 1990).
The transitional object represents a pivotal step towards the growing
experience of separate, objectively perceived external objects. At this
point, mother (as other) is also a subjectively perceived object, still con-
nected to an earlier phase when internal and external, self and other
are less differentiated. The paradox and power of the transitional
object (and related transitional phenomena) is the capacity to both rep-
resent mother and mother’s care and to hold as well as to concretely
embody mother. Here we have Winnicott’s description of the roots of
symbolisation (or the aspect of symbolisation that evolves within the
 T R A N S I T I O N A L O R G A N I S I N G E X P E R I E N C E I N A N A LY T I C P R O C E S S 39

object relational sphere). Something stands for something else, i.e., the
external object stands for the internal mother and her supplies.
Winnicott (1963b) noted that the needs met by the environment
mother and the instinctual wishes associated with the object mother
were most likely non-linear and concurrent developmental processes
whose coming together is noted in the transitional realm. Bollas (1993)
has described these two experiences of mother more broadly as varie-
ties of maternal presence, not so neatly dichotomous, that overlap and
inform each other. Abram (1997) underscored the sense of active inter-
nal struggling towards an integration of these two mothers in enact-
ments via the transitional object (p. 316) which include, according to
Winnicott (1954), “instinctual loving, and also hating, and, if it is a fea-
ture, pure aggression” (p. 233).
Winnicott also addressed the ways in which these normal (ideal)
developmental processes can go awry due to traumatic experiences
(impingements) in the early environment. He noted that resulting fail-
ures in the integration of bodily and mental/affective spheres (soma
and psyche) may lead to narcissistic pathology at best and self frag-
mentation as worst (Winnicott, 1949; 1960b). Due to a premature break-
down of the infant’s developmental need for the illusion that he/she
creates mother and mother’s environmental provisions, a dissociative
process sets in (i.e., something is concretely the thing itself, one thing
or the other). The hallmark of symbolic capacity, to represent one thing
by another, to consider another perspective, is compromised. This is a
familiar enough event in clinical practice, when the “as if” experience
of the transference breaks down, fails to develop, or is absent (i.e., only
external and concrete versus symbolic, and containing some internal
referent and meaning).
Winnicott (1963b) described a kind of compliant communication
typical of the “false self” as a central pathological split between the
subjective and objective object, noting that this communication is with
the object as external (i.e., concrete and devoid of internal representa-
tion). He saw this as a precocious (not a gradual) development that
should ideally emerge around good enough mothering and a solid
internalisation of related holding-soothing functions. Instead, due to
early impingements and environmental failures, a false-self develops.
In this pathologic adaptation, the false-self complies in order to manage
impingements from the external object, and to protect the core self, defen-
sively separated in a form of private communication. (This is not to be
40 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

confused with a healthy, private non-communicating core of the self that

is central to authentic existence.) This pathological core was conceptu-
alised as a more cordoned-off self, involved in what Winnicott called
“cul-de-sac” communication—a more defensive and private communi-
cation in the realm of the subjective self. Winnicott expanded and organ-
ised these ideas later in his paper Thinking and Symbol Formation (1968)
that described this precocious ego development and adaptation in ways
that echo current ideas about the development (or failed development) of
mentalisation (Fonagy & Target, 2007); Winnicott (1968) believed that due
to maternal failure, an “inadequacy in the mother’s attitude”, the infant’s
“need for thinking becomes stepped up … and strained as a function or
acquires a new function” (p. 213).
We could consider this type of derailed communication and false-
self development as representing a more schizoid mode, a self-object
fantasy of care, reflection, and responsiveness of the environment and/
or object mother who is available in ways that are (again) within one’s
omnipotent control (with the self precociously fabricating the maternal
portion of the early object subjectively perceived). In this framework,
the distinction between subjective and objective is potentially blurred
or compromised; the related capacity for a symbolising process (i.e., that
something might represent something else) is also poorly formed or
compromised by a kind of premature and inauthentic articulation of
the subjective self.
It is an essential feature of analytic process (however conceived) that
traumatic failures and adaptive (defensive) manoeuvres are re-created
via the transference as transitional space—from a Winnicottian perspec-
tive, a return to the situation of failure and hope for a new experience
(1954). Some patients as described here may continue to need either or
both the environment and object mothers as less than optimally inter-
nalised or integrated, and, in some cases, as profoundly split or dis-
sociated functions, concretely expressed in the transitional organising
experiences they bring to the analytic space. The gradual articulation
of these transitional organising experiences may vary depending on
the nature of the early disturbances and also particular environmental
endowments, but the pull for the expression of these earliest experi-
ences around these compromised core functions is similar: the oppor-
tunity for a resumption in the development of transitionality towards
the developmental “use” of the object (Winnicott, 1971b) as separate,
objectively perceived, and able to survive instinctual expressions of love
and hate in a new object relationship (Loewald, 1960). Via the analyst
 T R A N S I T I O N A L O R G A N I S I N G E X P E R I E N C E I N A N A LY T I C P R O C E S S 41

as a facilitating presence, the analytic process supports the regressive

experience needed for this new transitional experience.
There is a debate in recent analytic literature (Dunn, 1995;
Ellman & Moskowitz, 2009; Fossage, 2005) about the relative effec-
tiveness of verbal, interpretive interventions to reach early trauma
and false-self development (seen by some as rooted in non-symbolic
or pre-symbolic modes of experience), versus work focused on the
intersubjective modes of experience (the realm of “implicit relational
knowing” linked to early mutual dyadic regulation). It is also taken
for granted that a capacity to hear and make use of transference or
intrapsychic, conflict-focused interpretations (versus more concrete,
affirmative, containing interventions) implies symbolising capacity.
On the cusp of this capacity, however, described by Freedman and
Russell (2003) as points of “incremental symbolization”, there is a felt
tension between concrete experiences and a nascent capacity to both
feel and observe one’s reactions as internal and symbolised in the trans-
ference. As implied here, these are always less than perfectly formed
capacities; in that sense, like any early traumatic or conflictual configu-
ration, they are prone to be repeated as a fixity of contemporary exist-
ence and a press for expression in analytic process as an intermediate
(transitional) area.
Clinical experience suggests that the capacity to symbolise, whether
conceptualised as defensively absent due to conflict, not encoded due
to primitive anxieties (Bass, 2002; Freedman, 2002) or a function of defi-
cits based in traumatic experiences (Silverman, 2002), is never entirely
absent. It is useful to consider that Winnicott’s notion of the role of
the mother’s adaptive capacity to regress to her infant’s needs, also
included the mother’s higher ego functioning as mediating presence to
both protect from impingements and also to optimally fail her infant’s
illusion of perfect attunement with mother as part of the self.
Considering such moments of potential transformation in clinical
process from the perspective of Winnicott’s construct of the transitional
realm may help to capture both the intersubjective aspects of experi-
ence and the unique internal structures of patient and analyst. From
this vantage point, it is the analyst’s capacity for empathic attunement
(as a kind of adaptive, creative regression in the service of the ana-
lytic ego) as well as adaptive movements to and from higher levels of
internal structure (in sync with the patient’s varying levels of psychic
organisation) that mediates and bridges movements from non-symbolic,
concrete experience towards symbolisation of transference experience
42 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

(see Akhtar, 2002 and Kilingmo, 1989, for examples of an oscillating

analytic technique from this perspective). These notions were elaborated
by Loewald (1960) in his conceptualisation of the need for transference
experience via the analyst’s role as new object, in order to put words
(i.e., symbolic structure, meaning) to what had been unorganised and
compromised in early experience—in some sense related to what Bollas
has referred to as the unthought known (1987) and Fonagy and Target
(2007) describe as unmentalised experiences.
An emergent transitional organising experience may first be noted
as a shift in the clinical atmosphere, a more deeply felt affective pres-
ence, or tension around mutual engagement such as a willingness to
play or not (i.e., a more deadened or aggressively avoided, concrete
holding onto experience versus a consideration of symbolic connec-
tions in the transference). In the perspective presented here, such clini-
cal moments (in which the analyst’s adaptive capacity for attunement
to and articulation of his/her own as well as the patient’s concrete,
psychosomatic, and emergent unconscious fantasies) hold the potential
for transformation towards greater symbolisation of experience.
This way of thinking about clinical process is rooted both in Freud’s
(1914g) description of transference as playground, with the analytic
space as intermediate area “between illness and real life …” (p. 154),
and Winnicott’s crystallisation of Freud’s notion with his creation of
a construct, the transitional realm, to capture this as yet unarticulated
area of human experience, between internal and external, between
structured and intersubjective experience.
Aspects of the transitional realm have been utilised in a number
of convergent ways as a conceptual tool to describe the emergence
of such potential transformative shifts in the symbolisation of expe-
rience in analytic process. For example, Grunes (1984) referred to the
importance of the analyst’s adaptive capacity to enter states of “empathic
permeability” in which mutual interpenetration between patient and
analyst serves to capture emergent unconscious processes. In a simi-
lar way, Steingart (1998) noted that the analyst’s mental state should
ideally become emotionally arranged so as to foster the unfolding of
the patient’s repetition compulsion (p. 162) and to become receptive to
communications within and between the dyad. Bollas (2001) seems to
capture the interface around these positions in his reference to such
states of intersubjectivity as a unique style of relating of the “Freudian
pair”, situated between the patient’s free associations and the analyst’s
 T R A N S I T I O N A L O R G A N I S I N G E X P E R I E N C E I N A N A LY T I C P R O C E S S 43

free associations, that “transfers the patient’s unconscious contents to

the psychoanalyst’s unconscious organization” (p. 98).
Andre Green’s (1987, 1987) construct of the “analytic object” (affective
and bodily experiences situated between patient and analyst that
become the object of analytic awareness and understanding) furthers
the conceptualisation of the transitional realm as a joint or intersub-
jective creation of analyst and patient situated in intermediate space.
Ogden’s (1994) related construct of the “analytic third” is the experi-
ence of being simultaneously within and outside the intersubjectivity
of the analyst and analysands. His notion of “interpretive action” (more
palpable aspects of transference-interpretation that evolve from mutual
intersubjective experiences in the analytic third) are interventions that
serve as transitional phenomena and are facilitative of symbolisation.
Freedman (1985, 1994, 2003, 2009) has described such nodal moments
within the analytic process as shifts in transitional cycles of disruptive
enactment, incremental movement, and transformation along a contin-
uum of desymbolisation—symbolisation.
While virtually every psychoanalytic school now subscribes to some
form of mutual influence between patient and analyst, there remains a
range of acknowledgement and emphasis on the unique internal struc-
tures of patient and analyst and opinion on the degree to which these
subjectivities can be objectively observed, adaptively negotiated, or
even interpreted in the transference-countertransference (Dunn, 1995;
Fossage, 2005). The burgeoning literature on intersubjectivity in the
analytic process considers the analyst’s influence and contribution as
ranging from countertransference and enactments to “co-constructions”
of content and experiences with the patient, seen as both dominating
and moving the analytic process. Gentile (2007) offered an important
reminder, however, about the tendency of contemporary intersubjec-
tivity theorists to view the co-constructed aspects of analytic process
as central as opposed to on a continuum that takes both subjectivity
(psychic reality) and material reality into account (as described by Freud
and later by Winnicott and implied in the view presented here).

Movements from concreteness to symbolising space

via transitional organising experience
Compromised development of transitionality, viewed as based in early
trauma and developmental failure, may emerge in analytic process in
44 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

myriad ways. For some patients, more concrete objects, substances, the
analyst him or herself, or some feature of the analytic milieu may come to
serve this purpose; for others, some conscious or more unconscious self-
representations or self/object fantasies may be operative and suggest a
potential for shifts in symbolic capacity. These various shapes undoubt-
edly emerge in the dyad via the transference–countertransference. While
such clinical presentations suggest a clinging to phenomena within the
transitional realm to manage states of self-fragmentation and narcis-
sistic vulnerability related to early trauma and developmental failure,
analytic process in the neurotic-conflictual realm may also become
organised at phases around aspects of transitionality (e.g., at termina-
tion). The fact that the analyst is a real presence (even for more sym-
bolising patients) is confirmed by most patients’ environmental as well
as object needs, and ongoing use of transitional phenomena, however
subtle or undetected, and are therefore always in the transference mix.
It seems useful to recall Winnicott’s (1951) reminder that something as
subtle as a familiar sound or touch might be used in transitional fashion
and may go unnoticed by parents in the course of early development
(and perhaps analogously, by analysts in the regression of analytic proc-
ess). Freud (1912b) first noted that the transference also needs a point
of connection to some concrete piece of reality in the analyst in order
to articulate the “stereotype plate” already established in the mind
of the person (p. 100), perhaps an early acknowledgement of the way
in which material and psychic reality coexist in creative intermediate
space (Frosch, 2002).
The transference–countertransference might then be viewed within
this framework as representing two (often intermingled) poles—the
environment mother and the object mother, depending upon the degree
to which compromised and/or unintegrated structural and intersubjec-
tive aspects are emergent via the transitional organising experience in
the analytic process. It is the analyst’s observational capacity, as well as
attunement, empathic resonance, and intersubjective experiences, that
help elucidate and articulate these experiences in the move towards
symbolising space via the dyad.
In the following vignettes (Cancelmo, 2009, pp. 12–15), transitional
organising experience emerged from the perspective of the two poles
noted above. For Ms A, the analyst appeared to be used concretely,
more as environment mother, yet also elaborated in fantasy, as an ide-
alised but prosthetic (external) substitute for an early maternal failure.
For Mr B, the early maternal failure had likely been compensated for by
 T R A N S I T I O N A L O R G A N I S I N G E X P E R I E N C E I N A N A LY T I C P R O C E S S 45

a masochistic but secretly grandiose fantasy of a self-object relationship

of perfect “Christ-like” attunement to and with the object mother. Pre-
sented here5 are moments where such organising and potentially trans-
formative experiences emerged in the transference–countertransference
via emotional resonance and related intersubjective experiences, but
also as observed and articulated (and eventually interpreted) by the
analyst.

Vignette: shifts in the use of the analyst as transitional

organising experience
Ms A, an exquisitely controlled woman in her late forties, is moving
reluctantly towards the realisation that an authentic life can only be
lived without her constant pressured focus on gaining praise and adu-
lation from others. She has laboured since her earliest memory in this
way and feels “a high” (what she calls her “addiction”) whenever eval-
uated by others as the smartest, the most competent, the most generous.
She has become increasingly dissatisfied with this false-self life, devoid
of spontaneity; however, without it, she feels empty and panicked, and
drawn back to her compulsion to please. She says lately, “It’s an illusion
I delude myself with.”
After the August break, I had returned with a beard—something
contemplated for several years, but typically dismissed due to concerns
about how she might respond to the change. This particular year, none
of this material emerged beforehand for either Ms A or for me. While
I had thought about my patients’ reactions in general, she did not come
to my mind, specifically. August breaks usually brought her concerns
that she would forget our work, or that I would forget her, lose track of
her; in her mind, we both suffered from problems with constancy and
mentalisation.
Several days go by as we begin again. She makes no mention. I hear
nothing derivative. Then she comes in late and for the first time, she
does not apologise or agonise over her transgression. She tells me
“nothing” is in her head; “I’ve stopped dead in the middle of my anal-
ysis.” She feels empty—her worst fear realised, now that she is less
focused on pleasing others and basking in their praise (both real and
fantasised). She says, “Last night I had the thought—nothing is com-
ing out of me. He is going to have a hard job now. He’ll really hate me
now.” She admits to feeling stubborn, and I say to her: “So we’re stuck
here together.”
46 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

She agrees. She shifts her carefully composed posture on the couch
(a rare event). I am aware of feeling something deadened has come
alive. In my reverie, she feels to me suddenly womanly and vibrant.
Then an unusually long silence ensues. She says she has nothing in her
mind. I say maybe we might consider that her angry feelings had scared
her, and she pushed out any thought. She blurts out, uncharacteristi-
cally angry for her:
“I didn’t even recognise you when you came back—that beard—
you’re like a different person I all of a sudden never knew. Then, who
cares anyway, it’s your business, who cares about your vacation, your
wife, your children, your reasons for growing a beard. I know it’s crazy,
but it’s just how I feel! I expected I could leave here eventually, and then
if I came back everything would be the same, you would look exactly as
I remember” (p. 14).
She connected this change in my appearance to loss of her use of
me as someone who would cherish her perfection, and ultimately, to a
new memory of a mother preoccupied with her new baby brother who
was ill for many weeks after his birth. She notes that according to fam-
ily lore, she stayed with relatives nearby while mother tended to him.
When Ms A returned home, she was electively mute towards mother
for days.

Dynamic formulation
On one hand, this clinical sequence could be viewed simply as an angry
transference reaction, an instance of countertransference, or even an
enactment. While such familiar dynamic constellations were all likely
participants in this moment in the dyad, I believe that these terms,
used in isolation from Winnicott’s construct, can sometimes fail to cap-
ture the richness of the clinical process over time. I see these familiar
dynamic constellations more broadly here as articulating movement in
the transitional realm, a transitional organising experience, reflecting
shifts towards higher levels of symbolisation via the transference as
object relational experience.
Ms A, the child of a chronically unavailable mother and an intellectu-
ally demanding father, had created an idealised parental figure in her
ego ideal that she felt “addicted” to (her words) for regulation of good
feeling via a false-self. Ms A’s concrete use of me in this way came to
a crisis point in the transference–countertransference (as a transitional
 T R A N S I T I O N A L O R G A N I S I N G E X P E R I E N C E I N A N A LY T I C P R O C E S S 47

organising experience) due to this change in my real, actual, external

appearance (i.e., analogous to an alteration of the transitional object).
In this change I had, like mother, not thought of her but rather
thought of myself, my family. She had been reluctant to give me up as
an idealised source of narcissistic supplies but experienced me as fully
beyond her defensive omnipotent control.
My reference to a shared experience (via my countertransference
attunement), in retrospect, addressed her worst fear—that her aggres-
siveness could not be contained and would be felt by me and retaliated;
she was now able to risk expression of her anger in cutting me off, throw-
ing me away, and I was there to receive and survive her aggression.
She could have filled the hour in a way she felt might please me,
but gave this false-self mode of pathological transitional experience up.
It is interesting to note here the physicality, the shift in posture, and
the sense of embodiment felt in the countertransference, as a more
creative use of personal space on the couch; this could be viewed as a
move towards integration of psyche and soma that parallels her shift
towards authentic expression of feeling and a more symbolised trans-
ference experience.
It felt to her that I had disrupted her illusion of being fed by me
due to the change, the forgetting to consider her, yet she had not been
so fearful of our separation either. The new awareness of this change
in her was triggered by something outside (my appearance) but also
something increasingly inside (her internal sense that she no longer
wanted, needed constant praise and idealisation to feel full), and in the
dyad, my internal experience of her as able to give up something real
and addictive in the transference–countertransference (my not thinking
of her specifically). Again, while my stance could also be considered a
countertransference role responsiveness over time (Sandler, 1976), that
view alone fails to capture the empathic attunement (“timing and tact”)
to keep my personal needs and wishes out until a readiness was sensed
(an analytic co-construction outside conscious awareness) for an inter-
pretive shift due to structural changes.

Vignette: negotiating the subjective/objective paradox

as transitional organising experience
Mr B, described here in the middle phase of a four times per week
analysis, exemplifies a type of repetition of pathological adaptations
48 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

and resulting compromised transitionality as noted in his transference

experience. He had begun to articulate an unconscious fantasy of self
as the suffering Christ, as noted in descriptions of the pain, agony,
and ecstasy of his “masochristic” (his slip) enslavements to others, his
Christ-like but grandiose and omnipotent compensatory fantasy of
offering his life for the care of others in a state of perfect attunement.
Here he is in a typical repetitive mode, his private struggles to
see me as other than the archaic, pathological self-with-object (Stern,
1985), now aired via the transference as his capacity for perfect
attunement broke down. Talking to him about this helps elucidate, in
fits and starts, a core dilemma that likely interfered with basic aspects
of his early structuralisation, yet provides a “reliable” enslavement,
a pathological transitional organising experience he brings to the
analytic process. (“Pathological” in this context also refers to his
experience of the new object in the transference as meagre in com-
parison to the toxic, enduring and familiar, yet secure old object of
failure, who he tended to at his own expense and managed with a
compensatory grandiose fantasy.) The emergence and painstaking
working through of his conviction that his mind cannot be his out-
side enslaved connection to the other, can be seen in my view here as
a pathological transitional space that is paradoxically a painful island
of safety.

Mr B: I’m late today, so I’m feeling not here … like I spoiled it so what’s
the point? … I can feel myself on the surface of things, distant
but I’m tied into you at the same time … . It all feels disjointed …
the questions keep coming …why am I here? … who is this for?
I’m tied up with you and resisting at the same time. Had a simi-
lar feeling with Dee [his girlfriend] this morning … I got her
text message—she was on her blackberry, so I know she’s right
there, so it was nice and immediate, right there to me, but it feels
like a demand to respond to her … I can’t have my own good
feeling because hers takes over. She says she liked how I looked
while shaving this morning; she said she was looking forward
to the weekend. I feel I can’t be free in the midst of her need
for me … no way I can do my thing … have to respond to her
wish to be with me … . I feel enslaved by her wanting me even
though I want her … she has to take precedence. I can only
have this dialogue in my head not in reality with C … can’t risk
the exposure.
 T R A N S I T I O N A L O R G A N I S I N G E X P E R I E N C E I N A N A LY T I C P R O C E S S 49

I’m telling you all this right now … and it feels like you’re not
here … like I am talking to myself and hearing about myself …
presumably you are the audience, so you must be here but
you’re not here. I can talk but it seems unreal.
A: You have some sense I exist, as an audience, but you need to
leave me out of the equation, so maybe you don’t feel caught
up with a sense of pressure and demand you’ll feel nothing that
I am here listening even though you are late … maybe you fear
using me here because you will end up feeling used, and tend-
ing to me, so the price is feeling unreal.
Mr B: I can’t navigate this with you … with Dee … like in the triangle
with my mother and father. Can’t have one if I’m aligned with
the other … it’s the ‘Vulcan mind meld’6; if I’m close and con-
nected, I’m inside their thoughts and needs, they become mine,
but then where am I?
I feel like that right now … F—YOU!! [with anger]; … I don’t
want to have to be present … it’s painful to take the space for
myself and then in the same breath feel doomed to regret it …
I will end up having to lose something. [tearfully] … I had no
right to let that out … that anger and frustration. You only let
me hear back what I’ve been saying. I see that you are alive
here and I register for you, I have an impact on you here when
I’m not present. But you don’t seem to mind, to begrudge
me. I hear you but I see my mother’s angry face, the scowl
and then the dead absence, the silence in the house, the icy
removal. … It feels hopeless … I know I’m rejecting your help
right now when I say that … It always comes back to this …
has it changed? Do I want it to change? I remember your old
office … saying how hopeless I felt … this feels not so bottled
up, not so hopeless, but I can’t fully give that to you … I imag-
ine you could hold it against me and expect repayment for
helping get to a less hopeless place … a constant debt to repay
so I get caught up in my enslavement again … it is something
I know, it’s reliable.

Dynamic formulation
I feel a familiar struggle in the countertransference, a gut feeling, like a
rock lodged inside my chest, a concrete presence and sensation he has
described to me when feeling stuck with his attachment to mother as an
50 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

immovable presence, a dead weight he felt destined to move around in

order to keep her (and him) alive. Again he is here and not here, now
dead weight to me, as if collaborating but not, making me ineffectual,
turning me into a self like his, a concordant identification (Racker, 1953)
in which we both cannot feel autonomous and still connected. The
reconstruction via the transference–countertransference of this basic
bind around negotiating subjectivity and objectivity appears to move
via his aggression; I feel it, and then he becomes aware of feeling it, and
my presence in the face of it, as well as its impact on me and on him,
and some oscillation is felt between us that suggests a nascent transi-
tion towards a more objective stance—a moment of transitional organ-
ising experience in the dyad. It is the “holding onto” that perpetuates a
pathological transitional mode. His awareness of this via the exchange
in the transference helps mobilise the expression of aggression to self
and other (the analyst in the transference). This moment contains much
more than aggression-frustration and reflects a complex situation of
repetition and adhesive masochistic and sadistic attachment that is
noted via the dyadic experience, one unlike the psychic reality of his
earliest structuralisations in the transitional mode. It is symbolisation
in statu nascendi, a nascent capacity to observe and feel this experience
as (also) transference and not merely a painful repetition. It is uncanny
to note that the blackberry technology takes on both transitional and
persecutory qualities, and he becomes aware of the holding-soothing
aspects in a new way (“… I know she’s right there … it was nice and
immediate, right there to me, but it feels like a demand to respond
to her …”).

Summary
This chapter considers the organisational and transformational power
of Winnicott’s construct of the transitional realm to both elucidate and
facilitate movements towards greater symbolisation—referred to here
as transitional organising experience. This perspective on Winnicott’s
work suggests that the essential developmental tasks that are the hall-
mark of transitionality (a sorting-out of a separate yet interdependent
self with a mind of one’s own, negotiating the subtleties of subjectivity
and objectivity, the development of creative space for symbolic expe-
rience), less than optimally formed due to early impingements and
compromised internalisations, may come to organise analytic process
 T R A N S I T I O N A L O R G A N I S I N G E X P E R I E N C E I N A N A LY T I C P R O C E S S 51

for such patients. These less than optimal structuralisations and

compromised intersubjective capacities inevitably press for expres-
sion in the regressive experience of analysis as intermediate space
via the transference–countertransference. Such moments are often
felt clinically as impasse and stalemates, states of concreteness, and
compromised symbolic capacity. The particular manifestation of these
compromised structural and intersubjective capacities is, of course,
unique and varies for each patient according to particular emotional
endowment, early environmental experience, and the transference-
countertransference that inevitably develops. There may be, how-
ever, some common elements as implied in Winnicott’s construct
and suggested by the clinical vignettes presented here, for example:
a) a subjective-objective dilemma which may coalesce around a false-
self, b) a fantasy of self-care, either in regressive or defensive form
(as in a self-object dependency, or a pathological grandiose self), and
c) a tendency towards a fixity of experience, an attachment that encap-
sulates both a repetition of the trauma and a hope for a higher level of
structuralisation.
As conceptualised here, moments of transitional organising expe-
rience are, by their very nature, an admixture of concrete and sym-
bolic experiences. They present a potential for the transformation of
structural and intersubjective capacities, in particular, for some of
our more challenging patients with compromised internalisations
and pathological organisations based in early disturbances. Via the
analyst’s attunement to the possibility for a re-experiencing and
reorganising of pathological transitional modes and related compro-
mised symbolic capacities (versus a more unitary clinical focus on
such difficulty as merely structural “resistance”), a resumption of
development in symbolising space via the analytic process may be
possible.

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Notes
1. The term transitional realm is used to describe the wide applications
and extensions of Winnicott’s construct of the intermediate area of
experience (including transitional space and potential space) as well
as the various developmental markers that signify its development
(i.e., transitional phenomena and the transitional object). Brody (1980)
noted that this conceptual umbrella has been used in the literature
(e.g., Abram, 1997; Coppolillo, 1967) because of the inherent vagueness
(which some might call the paradoxical, illusory, and creative quality)
of Winnicott’s construct.
2. Transitionality refers here to an optimal capacity, crystallised in the
transitional phase, that allows for the full experience of the creative and
adaptive potentials that live between illusion and reality, an immersion
 T R A N S I T I O N A L O R G A N I S I N G E X P E R I E N C E I N A N A LY T I C P R O C E S S 55

in transitional space as interpsychic experience between self and other

(Bolognini, 2004), and intersubjective space where ownership of crea-
tivity is also co-constructed (Aron, 2006). In the view offered here,
these capacities rest on the secure developmental achievement of self
and other definition, separation, and internalisation (i.e., an intrapsy-
chic structure), towards which there is an inherent organising thrust
(Loewald, 1960).
3. I refer broadly here to fantasies, enactments, and adhesive attachments
to and transformations of self and object representations that may
emerge in the transference–countertransference and may come to serve
as transitional organising experiences.
4. Winnicott used the terms transitional phenomena and transitional
object both in distinct ways and synonymously between 1951 and 1971
(a) to imply a developmental sequence from early tactile and sensory
processes as transitional phenomena that proceed and blend into the
transitional object and its usage, (b) to denote phenomena subsequent
to the period of the transitional object, such as the older child’s use of a
tune or repertoire of songs, to developmental moves towards phenom-
ena in the area of cultural and religious experiences, and (c) to create a
conceptual umbrella, “transitional phenomena” as a designation of all
phenomena (including the transitional object) within the intermediate
area of experience.
5. Copyright © 2009 by the American Psychological Association. Adapted
with permission.
6. The “Vulcan Mind Meld” (http://www.memory-alpha.org) refers to
the TV series Star Trek and a lead character, Spock, who can take on the
mind of the other, a sharing of consciousness between two parties as a
function of extraordinary cognitive capacity. There is an inherent risk
of loss of one’s own identity in the procedure and its aftermath. Mr B’s
metaphor captures this aspect of his precocious capacity for attunement
to the other and the subjective-objective blurring that paradoxically
remains his dilemma.
CHAPTER FOUR

Enactment: opportunity for symbolising

trauma
Paula L. Ellman and Nancy R. Goodman

W
hile psychoanalysis, by tradition, has emphasised the medium
of thought and fantasy, the call to action likewise takes place
continuously in psychoanalytic treatment (Loewald, 1975),
sometimes in subtle tones and nuanced body movements or startling
unexpected interactions. Over the past twenty years, the term enact-
ment has been developing as a way to identify a stream of activity and
to acknowledge the richness of communication contained in the action
process. These evocative action sequences involve analysand and ana-
lyst, and are frequently motivated by the analysand’s traumatic history,
bypassing the symbolic verbal narrative, and making its way into the
nonverbal transference/countertransference arena. Within the analytic
dyad, the analysis of enactment leads to the symbolisation of trauma
and the multiple meanings it has in psychic life.
In psychoanalysis, analysts often find that there is a drama by
reflecting on the role they have been drawn into playing (Sandler, 1976).
In this way, therapeutic listening catches up with what has been taking
place and becomes recognised after the fact (Goodman et al., 1993). It is
through countertransference awareness (Ellman, P., 1998; Ellman, S. &
Moskowitz, 1998; Freedman, Barroso, Bucci & Grand, 1978; Jacobs, 1986;
Tyson & Renik, 1986) that the analyst comes to know the enactment and
57
58 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

finds the story of what has been repressed or never known. Jacobs first
introduced the concept of enactment in 1986 in a paper entitled, “Coun-
tertransference Enactments”. Attention to the idea of enactment has
led psychoanalysts to clarify the existence of a new road to the uncon-
scious augmenting Freud’s royal road of dream imagery. Chused (1991)
reported that psychoanalysts involved in a 1989 panel discussion on
enactment “… agreed that enactments in analysis are inevitable …” and
wondered, “… whether and how enactments could beneficially contrib-
ute to the analytic process …” (p. 615). In their edited book, Enactment:
Toward a New Approach in the Therapeutic Relationship, Ellman, S. and
Moskowitz (1998) brought together historic and contemporary articles
addressing the enactment process, breaking barriers by allowing for
the discussion of analytic interactions playing out unconscious matters.
At the same time, Katz (1998) offered a review of the “enacted dimen-
sion of the analytic process” where transference is not just represented
on a verbally symbolised level. Enactment is a bridge term “… sub-
suming both the overt patient-analyst interaction and the underlying
unconscious fantasies being actualised …” (p. 1153).
The enactments arising from traumas often bypass symbolic verbal
narrative and are communicated through action. The concept of “con-
creteness” (Bass, 1997) offers further definition of the nature of psychic
functioning in enactment. With regard to the place of trauma in the
mind, concreteness results from the overwhelming affects not available
to symbolisation. Stern (1983) developed the idea of “… unformulated
experience … the unformulated is a conglomeration not yet know-
able in the separate and definable of language” and “is composed of
vague tendencies … which can be shaped and articulated … . Meaning
becomes creation …” (p. 72). In his work with survivors of mass trauma
including Holocaust survivors, Laub (1992) identified “holes” in the
mind. Likewise, Kogan (2007), in her treatment of children of Holo-
caust survivors, noted that enactments were the first steps to coming
to know. Lear (2000) wrote of a lack of content accompanying “deepest
forms of human helplessness” that he described as “quantity without
quality” (p. 109). When the psyche is overwhelmed with affect, mean-
ing may not yet exist since language may not be available to symbolise
the trauma. The concreteness indicates an event existing where internal
fantasy and external reality are not distinguishable. Hanna Segal wrote
of the “symbol equation” (1957) “… where there is non-differentiation
between the thing symbolised and the symbol … this is part of a dis-
turbance in the relationship between the ego and the object …” (p. 393).
 E N A C T M E N T: O P P O R T U N I T Y F O R S Y M B O L I S I N G T R A U M A 59

Once a concrete enactment is identified within transference/counter-

transferance configurations, symbolisation begins. Naming the affects
in interaction brings clarity and further differentiation to traumatic
experience and to the associated unconscious fantasies. Central to the
transformation into symbolisation is the analytic dyad affording the
contextual meaning for the symbol. The enactment is the event where
unformulated experience is perched and ready for translation into a
language having symbolic meaning in the mutuality of the dyad.
The authors present two diverse analyses so as to further clarify how
analysing enactment provides for movement from concreteness to sym-
bolisation, thereby bringing about a more meaningful understanding of
the unfolding psychic reality. One case demonstrates how trauma can
come to be expressed and understood through an ongoing enactment
related to a pervasive character structure that Goodman (1998) referred
to as “character enactment”. In the course of the patient’s analysis,
language was used in a concrete way to disavow the communication
potential of words and analytic vitality. Speaking became a means of
controlling the analyst’s existence through the creation of a mood of
deadness. In the deadness of the enactment resided the patient’s uncon-
scious certainty that contact brings traumatic annihilation, recapitulat-
ing an early object relationship. The patient attempted to feel alive by
ridding himself of the terror that separateness brings and his sense of
deficiency over which he despaired. The second case involves a dramatic
interaction of a hug with the analyst, followed over the next four years
with reaching out many times to touch the analyst. The enactments were
representations of interactions holding overwhelming affects of terror
and helplessness belonging to traumatic situations that had never been
symbolised in the analysand’s mind. The event of the “hug” became
the centrepiece of analytic work leading to understanding of the impact
of traumatic events and their sequelae. Then, the analysis was able to
identify the network of fantasies about seduction, surrender, and death
that had become part of the patient’s psychic reality and now were part
of the psychic reality of the treatment. The two cases illustrate the rel-
evance of trauma active in both discrete enactment events and in ongo-
ing enactments related to character.

Case: Mr T
Mr T wanted an analysis because he was unassertive, was unable
“to feel”, and felt deficient. Early in the analysis, Mr T recounted
60 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

memories without any apparent meaningful connection to his current

state of mind or life. He found satisfaction in his claim that he was
doing his analysis correctly by “free associating” and not censoring.
He brought in dreams, not because he remembered them and was affec-
tively attached to them, but because he had written them down. He told
of events that he thought “should” stir him; he stated that he knew how
he “should feel” but did not feel.
Mr T wanted the analyst to be fully “attuned”, to feel what he feels
as he feels it. To feel for herself, as his analyst, was not sufficient. Mr T
associated his longing for attunement to his mother “raising me by the
book”, according to strict rules. He remembered minimal involvement
with an unempathic stern mother and remote ineffective father. Mr T
frequently returned to his memory of an event that he “supposed” to
be traumatic and formative: the “trip to the institution”. He had dis-
obeyed, mother threatened to leave him at the nearby institution, he
continued to disobey, and she drove him to the institution. The car ride
created sheer panic for Mr T, as he begged his mother to take him home,
believing in his impending abandonment. Upon arriving at the institu-
tion, she immediately returned home with him. The memory suggests
a traumatic history of relatedness and attachment, and provided a way
to understand the transference/countertransference of his using lan-
guage to deaden the analysis and prevent contact. He could disable the
analyst from driving the “analytic car” with its risks of destroying him
and keep himself from having awareness of his terror of aggression and
annihilation.
For the analyst, Mr T’s words lost their vitality and prevented contact.
The analyst felt she did not exist. At times, she felt a drugged sleepiness
come over her as she saw herself as a helpless ineffectual mother or an
inanimate object. An excerpt from an hour illustrates the patient’s lan-
guage and its power in evoking an ongoing enactment with the analyst.
The “dead” mood that Mr T created in the analytic hour is apparent.
The concept of “concreteness” brings further understanding to the
functioning of Mr T’s psyche in this ongoing enactment where language
coupled with the absence of affect became an action to prevent contact.
The action was the concrete expression of trauma, and as the traumatic
meaning was not yet symbolised, action made for a distorted function
of his language. In this session the patient’s wish for a tape recorder
serves as a condensation illustrating the patient’s mechanistic approach
to language that was used to create deadness with the analyst.
 E N A C T M E N T: O P P O R T U N I T Y F O R S Y M B O L I S I N G T R A U M A 61

A Friday:

Patient: I would like to tape record Wednesday and Friday hours.

I’d get back into where I left off, especially when the previous
time is not present in my mind, like right now. It would help
that sense that something is wrong with me; I’d retain a full
sense of the previous hour.
Analyst: [Annoyed at his efforts to control with the intrusion of a
machine, thereby feeling attacked in her analysing function.]
You’re feeling this is not satisfying and you’re finding some
way to overcome this feeling. [The analyst responds with just
one possibility of meaning, facilitating the concreteness of the
exchange. Another possible meaning not considered is that he
is afraid people do not exist when they are apart.]
Patient: I don’t seem to notice a strong feeling; I just thought taping
would be advantageous. When I talk, it seems unproductive.
It’s not a strong feeling. I thought taping is a way to be more
productive, not that I have unbearable, painful, or strong feel-
ings. I always look for an edge. [Silence, patient falls asleep
and snores. The patient here fends off the analyst and the
analysis, and at the same time is expressing his feeling that he
is falling off the abyss.]
Analyst: [Also feeling sleepy in response to the patient’s opposition to
the analyst’s clarification.] Having an edge might help stave
off the temptation to sleep. [Concrete.]
Patient: I think of sleeping as something else. It’s just due to being
tired on Fridays. The edge is to avoid hours when I think
nothing is going on here, when I didn’t see anything in a new
light. I want to jump over those times, and get on a roll. What
do you think?
Analyst: [Feeling helplessly ineffective, and believing that he truly does
not want to know what she thinks.] What do you think you
may be keeping out of analysis by recording it? [The analyst
is concrete in speaking to one possible meaning and only a
defensive one, thereby joining the patient in creating a dead-
ness and an enactment of concreteness.]
Patient: What I’d be keeping out is not such a big thing. Maybe
I don’t give full weight to noticing that I feel something else.
I would only use the recording to cut interference between
62 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

hours. [Could the “interference” be about his being left at the

institution; but the analyst did not see this meaning at this
moment.]
Analyst: [Feeling irrelevant to him and the analysis, like she does with
his writing notes after hours.] Like when you write down
what you remember after each hour.
Patient: But it’s better than writing it down. I don’t want any of it
to get lost. By taping, I’d not forget even a step, an insight.
[The patient is terrified of losing the analyst but the analyst
remains deaf to this communication.]
Analyst: [Thinking about transference in terms of the possible concerns
he has about separating from her.] Anything else you are wor-
ried about getting lost?
Patient: Not so much the insight, but how I came to the insight.
To capture the little steps leading up to its gradually unfolding.
I’d listen to the tape before the next hour.
Analyst: As if no time elapsed.
Patient: Exactly, no time would elapse. It would be like a continuous
two hours in a row.
Analyst: Like we would not be apart.
Patient: Of course that could be the meaning, but it doesn’t strike me
that way. I think of it like two separate tracks, like film spliced
together while what happens day to day wouldn’t throw the
film off track.
Analyst: [Move from concreteness to contact.] And you could direct the
film and not chance any frightening feeling.
Patient: Seems like I would want to continue a satisfying experience.
It would be disappointing to not be able to have it, I’d forget
it, and it is not alive anymore. [Here is the annihilation.] I am
reminded of the meetings I lead. I need to prepare enough to
get back the sense of excitement, aliveness.
Analyst: Is it hard to get that back, that aliveness?
Patient: Something is deficient in me; you imply that something is
really going on here? One has to think about deficiency if
one’s arm is cut off. This could fit with re-creating the moment.
I used to replay meetings in my mind. I wouldn’t let them
go. This morning the meeting was a good one, and I want-
ed to replay the little moments: someone says this, someone
responds, it feels really good. But I know that the replaying is
not productive and is only for my gratification.
 E N A C T M E N T: O P P O R T U N I T Y F O R S Y M B O L I S I N G T R A U M A 63

Analyst: It feels important to be productive and fend off feeling

deficient.
Patient: I would want to listen to the tape of the hour just before my
next hour; and get that high state of feeling alive. It is a way
I could perpetuate the sense of being alive.

Mr T’s intellectualisation and splitting off of affect, both derivatives

of his character, made for his mode of communication in this ongoing
enactment of a mood of deadness. In the deadness Mr T disavowed the
analyst’s “otherness” and her vitality. The analyst’s separateness in her
analytic function represented a threat of despair for Mr T. He believed
he fell asleep only because he was tired, not allowing for consideration
of unconscious motivation. He wished to record hours only because
of his memory “deficiency”, not to stave off his “deadness”. He dis-
regarded any suggestion from the analyst of her separateness and of
the symbolic meaning to these events. Likewise, Mr T demonstrated
a fusion between his self and object representations in his relatively
undifferentiated ego-ideal; he behaved “as though he was his own ego-
ideal” (Reich, 1954). Mr T wanted to feel productive by recording the
hour, thereby capturing the steps of his insight. He wanted to savour the
exhilaration of his “productivity” by replaying an hour on tape, replay-
ing his professional meeting in his mind, reviewing his steps towards
an insight or professional success. Recording an hour served to disavow
the differentiating effect of time as if analyst and patient were never
parted. Mr T’s conscious concern was his deadness and aliveness, his
battle with his sense of “deficiency”. To “feel good” through productiv-
ity and accomplishment, to “perpetuate the high state of feeling alive”,
Mr T engaged in an ongoing enactment of preventing separateness. He
feared losing the analyst as she does not exist when they are apart and he
feels deficient, dead and vulnerable. Overwhelming affects associated
with the trauma of threatened and actual affective abandonments were
not yet symbolised in language. Mr T’s use of language as action, not
as symbolic verbal narrative, moved the dyad into the enactment.
The analyst’s countertransferential concreteness was manifested in
her interpreting the taping solely as a defence. The existence of mul-
tiple meanings was dead for both. She struggled with considering the
patient’s wish to take his analyst with him as she did not exist for him
when they were apart. Both patient and analyst were caught in the ter-
ror of aggression and annihilation. The patient’s effort was to fend off
the analysis and keep the analyst with him so that both could continue
64 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

to exist. The analyst was locked in her feeling of being kept out and shut
down. As she experienced the patient’s efforts to grip her, she freed
herself from the deadness of mood, extracted herself from her concrete-
ness, and asked “Is there anything else you are worried about losing?”
It was then that the patient related the exhilaration of the merger fan-
tasy, enacting a state of the dyad as not separate and distinct, and also
denying contact to stave off the anticipated terror of annihilation.
Through recognition of the ongoing transference enactment, the
derivatives of conflict around separation then became available to anal-
ysis, and involved Mr T’s seeing his creation of this mood of deadness
more directly. He said, “I am in a coffin,” as he lay on the couch gazing
ahead; or “I’m a rock on the ground as a stampede of animals trample
over,” “I am underwater and everything is motionless.” Each hour Mr T
hoped for something to happen; he yearned to create life, understand-
ing, meaning, and invigoration. When he believed nothing happened,
he left lifeless. He recalled times as the young boy sent to his room,
alone, lifeless. Through his language, Mr T enacted the unconscious
image of closing out the analyst and deadening the object relationship.
Contact only meant annihilation. Not to be overlooked is the layering
of Mr T’s castration anxiety in his associations of having his arm cut off.
Mr T was concretely caught between his longing to retain the good con-
tact with the analyst, “wanting to replay the little moments”, and his
fear of losing hold of something precious to him.
The struggle for the analyst included the effort to extract herself from
a concrete process and allow for multiple meanings in the patient’s
communications. Articulating the deadness of the enactment was the
first step of the analyst entering the patient’s inner world. Mr T’s strug-
gle to achieve his “sense of aliveness” came to be understood through
the analyst/patient dyad’s enactment as his dread of non-existence,
annihilation, and his longing for contact and permanence. All roads led
to Mr T’s reconstruction of trauma as the terrorised child of a rigid,
disengaged, and actively sadistic mother, thereby opening the way for
Mr T’s greater accessibility in his relations.

Case: Ms M
An enactment in the second year of Ms M’s analysis brought to life
major traumas related to childhood abandonments, sexual seductions
and betrayals, and additionally the traumatic death of her infant son
 E N A C T M E N T: O P P O R T U N I T Y F O R S Y M B O L I S I N G T R A U M A 65

after birth. In the last session before the analyst’s vacation, Ms M sat up
from the couch, started to walk away, reached the door, and brought
her hand to her head saying she just could not leave. As she told her
analyst about feeling dizzy, she seemed to be folding to the floor.
The analyst walked towards her, reaching out and Ms M collapsed into
the analyst’s arms. The analyst assisted the patient back to the couch
and Ms M sat down. She thanked the analyst for helping her. The ana-
lyst sat in her chair and asked Ms M if she could put into words what
was happening. She focused her gaze on the floor quietly speaking:
“I don’t know exactly. Everything was black and scary. I feel very very
small, maybe a baby. My whole body feels strange like I’m not even me.
I could not go. That is all I know. You did not push me away, you did
not act angry, you let me cling to you as I hugged you and felt your car-
ing for me as you held me up. I can trust that. I know you do not hate
me. Now I can leave and I know I can remember you and your help.”
Countertransference is often the catalyst by which enactments become
identified and enter a symbolising process. There is a communication
to the analyst that needs to be put into words. On vacation the analyst
was aware of feeling relieved that her patient stated so clearly she could
now tolerate the separation. The analyst recalled important hugs from
her own grandmother that had felt life-saving as a child. She also felt
annoyingly preoccupied with this treatment during her vacation. Along
with the feeling of comfort and of nurturing was a sense of worry as
the analyst wondered if this act of “helping” her patient was indeed
a transgression and risked the treatment’s viability. The analyst felt
guilty. Maybe she had unconsciously stirred up this activity and caused
a defect to enter the work. Labelling and symbolising her feelings and
ideas helped, as did a renewed interest in psychoanalytic enactments.
Ms M’s psyche was overwhelmed in reaction to the summer separation
and responded in the concrete actualisation of a collapse in body that
the analyst also responded to in real action. Ms M. had acted out with
the analyst the belief that she had to touch her analyst, emotionally and
actually, and activated the analyst to show her responsiveness in order
to be able to leave for three weeks. The concreteness in Ms M’s psy-
che relating to unknown trauma and the analyst’s response created the
enactment. The intensity of the countertransference opened the way for
understanding the multiply layered motivations for its creation.
After the summer vacation the patient spoke of her feeling of being
accepted and held, and labelled the interaction with her analyst as “the
66 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

hug” which was sustaining for her through the three-week separation.
The concrete event of the enactment was now a symbol, an image, carrying
meaning of referencing traumatic events and unconscious fantasies. What
was compellingly repeated, in order to not know, entered a process of
becoming known. As analyst and analysand viewed this sculpted image,
affects, memories, and wishes entered the analytic work with intensity
and conviction. Thoughts about “the hug” appeared to function for the
patient as a safety zone containing the idea of her analyst’s true concern
for her. Simultaneously, it functioned as a fantasy construction leading
to the uncovering of powerful affective experiences related to childhood
betrayals and the loss of the baby who had never been touched or held.
The feelings contained in the embrace led to the increasing availability
of affects related to these major traumas of childhood and to the lack of
a somatic bond with her infant. Her belief was that all good objects are
destined to disappear. An array of deeply held unconscious ideas con-
cerning her capacity to seduce and to murder emerged.
Sessions came alive as Ms M. spoke of traumatic events, not only as
a reporter of fact, but as a way to communicate to and explore with her
analyst. She first recalled a sense of closeness and security associated to
hugs and caresses from the kitchen help and nursemaids of early child-
hood. She recalled the sensory memory of playing and looking at books
in the crook of a tree behind the house. The capacity to experience the
holding represented in “the hug” allowed the traumatic affects of early
childhood to appear and be linked to her early life actualities. With this
linking she came to know early overwhelming experiences related to
abandonment and sexual arousal. Thus, the work at uncovering the
derivatives that created “the hug” oscillated between finding ways to
symbolise despair and to elucidate fantasies of merger with the analyst
either through erotic ecstasy or through death.
The narrative of childhood emerged with increasing clarity as she
put these traumatic affects into words. She sketched out in distilled
and fragmented imagery various experiences of childhood where she
felt psychic helplessness. She narrated being sent to boarding school
in the mountains at the age of five after a sexual seduction by an older
male cousin. She would be home only for summers from then on, often
alone with her depressed, withdrawn, and suicidal alcoholic mother.
Naps with her mother included arousing physical contact and intense
shame and guilt. She conveyed the despair of her childhood with poetic
words: “All I feel is cold, so much cold. I need to get close to you to
 E N A C T M E N T: O P P O R T U N I T Y F O R S Y M B O L I S I N G T R A U M A 67

feel warm. Where are my memories? I think of the tragedies on TV, the
faces of starving children in Rwanda, almost dead, unable to wave flies
away. That train ride to school, leaving, leaving, leaving … blank star-
ing faces, trains in Nazi Germany taking people to death. I wished to
be dead.” There were painful memories about forbidden deeds. “Some-
times I would crawl into bed with another girl, we would warm each
other. Maybe we were sexual: I had to feel alive and felt so guilty. Why
was I sent away?” She was amazed that she could find ways to talk, and
that she was not going to be sent away for what she feared and wished
she could do with the analyst/mother.
A deep depression of early childhood and a desire to die were
embedded in layers of erotic fantasies then present with the analyst.
In her fantasies and recollections it was unclear who did what to whom,
and what was pleasure and what was pain. In analysis she confronted
what she was sure she could not face—the death of her baby and the
ways she felt implicated because she had let herself trust a physician
who, she knew, drank too much. While the actualities of this event were
repressed, they continually appeared symbolically in repetitive pat-
terns of birth, guilt, and death. She would abort creative projects, or
if completed, she would bring terrible suffering upon herself. She had
never touched nor held her infant son during the few hours he lived
nor after he died. Her desire to hold her baby and her fear of being
a “death” machine were also elements of the enacted “hug”. She had
almost no memory of the days after the baby’s death and did not recall
grief, but instead she felt elation at the thought of her infant in a safe
pain-free place. Life and death, pleasure and pain, autonomy and sub-
mission were scrambled. She asked: “Who needs to be held, who did
not get held, who died?” The analyst asked if the overwhelming need
to make contact with the analyst contained knowledge of the need she
had felt to hold her baby, to feel his form. Every time the analyst spoke
to her about what it would feel like to hold him, she cried. The “hug”
with her analyst led to articulation of what the baby would have felt
like and a true somatically based experience of grief twenty years after
the event. She became clearer with the details of what happened, more
able to distinguish then from now, and less merged with the newborn
and with her analyst.
Accompanying the discovery and symbolisation of these traumas
were unconscious fantasies about her seductiveness and aggression.
Her psyche used the “not knowing” of trauma to “not know” her own
68 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

forbidden desires. She began to articulate her desire for more hugs, her
desire to change the analytic situation. She and the analyst were able to
understand how she wanted to do to the analyst what had been done to
her. If she could seduce her analyst, then the analysis would never end,
there would be no grief, and there would be an actual timeless forbid-
den embrace. If she died and did not thrive, she could make the ana-
lyst feel guilt and despair forever. She was able to speak of her desire
to attack the analyst through seduction, and to induce in the analyst a
state of feeling defective as she had felt from her mother’s seductions.
She wanted to have the analyst deliver a dead analysis; and like her, be
a mother lost in grief. This capacity to recognise her own aggression
was the final step in creating a symbolic narrative in the place of con-
crete re-enacted action sequences.
The actual hug entered the symbolic language of the analysis as
something that had to be talked about, something that was felt about,
something that related both to the past and to the here and now of the
analysis. The analyst’s unconscious mind entered a place of helpless ter-
ror that brought her into action with her patient. The relation of past to
present contained in the terror and the symbolic representations related
to trauma and to conflict became knowable through the actions. The ana-
lyst’s first inklings about holding, comfort, seduction, and defect, and
the analyst’s ability to name these internal reactions portended what
would come to be known in the analysand’s mind. As the hug became a
symbol and a connection to deep psychic experience, including Ms M’s
wish to create a defective merger with the analyst, working through
could take place. In the last months of the analysis she had dreams of
walking with the analyst sometimes arm in arm, sometimes hand in
hand, and sometimes side by side. She was both furious and grateful
that her analyst was actually letting her leave to have her own life and
to have wishes that did not have to be realised. The dramatic enactment,
a concrete thing that happened, led to the identification and labelling of
a symbol, “the hug” that was now both enacted and known by analyst
and analysand. Once “the hug” became a metaphor, the analysis could
discover both the trauma and the ways it had become instinctualised in
terms of wishes, fears, and defensive functions.

Discussion
The authors report two cases where an element of concreteness exist-
ing in the psychic life of each patient was due to the impact of trauma
 E N A C T M E N T: O P P O R T U N I T Y F O R S Y M B O L I S I N G T R A U M A 69

and gave rise to the tendency for enactments. Once the enactments
were identified in a transference and countertransference context they
gained symbolic meaning. Mr T was terrified that togetherness, even
through the exchange of verbal communications, would lead to anni-
hilation. He disavowed the multiple meanings of language and used
language to create a deadened object relationship. As he expressed his
desire for a tape recording of sessions and the analyst reflected on her
concrete responses, his use of language to deaden became known. Now
available for understanding was the way his character was structured
to avoid contact. Ms M and her analyst created “the hug” before the
summer vacation separation, awakening affects and fantasies in the
dyad. The patient’s collapse at the door and the analyst’s response to
go to her, to use her own body to balance the patient and then walk
her to the couch was a clear interaction event. The enactment gained a
name, “the hug”, and became a symbol that led to the understanding
of the patient’s traumas and their sequelae. In reaction to the “hug” the
analyst experienced feelings of comfort, transgression, damage, guilt,
and shame as the patient expressed new belief in togetherness and love.
Together they followed the associative path of physical contact and lack
of contact to discover past seductions, abandonments, and the death
of the baby she had never held. In both cases a symbolising process
developed from the enactments. Here, the unconscious motivations to
do to the analyst what had been done to them could be uncovered and
followed back to a greater knowing of the original traumas.
In Remembering, Repeating, and Working Through (1914g), Freud wrote:
“The patient does not remember anything of what he has forgotten and
repressed, but acts it out. He reproduces it not as a memory but as an
action” (p. 150). It is important to recognise that there are places in the
mind that have never been symbolised due to overwhelming trauma.
Terror enters the psyche and then appears in an enactment process
sometimes in a continuous flow: Mr T’s use of language to negate
contact; and sometimes in a dramatic interaction: Ms M’s collapse
and the analyst’s response. Stern (1983) elaborated on “unformulated
material” … “that has literally never been thought” (p. 84). The two
cases presented illustrate how experience of psychic trauma leaves a
residue of concreteness that then presents in analytic treatment through
action—in the form of a re-creation. Loewald (1980) wrote of “global
transferences” characterising the “enactive form of remembering” where
there is a substitution of the “… timelessness and lack of differentiation
of the unconscious and of the primary process …” (p. 165). In the cases
70 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

discussed here, the form of the “global transference” became apparent

when the analyst reflected on countertransference reactions. The analysts
in both cases were drawn into an action by becoming concrete in the
interpretive process and physically responsive to distress. The terror of
knowing the trauma resided also in the analyst’s mind and remained
unavailable until the enactments were recognised. Subsequently,
attention to the action sequences and to the patient’s compulsion to
repeat allowed for fantasy constellations, reconstructions, and construc-
tions of the unsymbolised. Enactments bring affect-laden fantasies into
transference/countertransference. While action sequences accompany
the narrative in psychoanalysis, this paper shows that where trauma
has been significantly formative, the identification and analysis of con-
crete action sequences engender the symbolising and working through
process. Under the press of affects, a mode of concreteness can be estab-
lished in psychic functioning and pushes for an unfolding of enactment
through which the traumatic affect and associated fantasies and events
become known and explored. Even language, typically a symbolised
function, can be an action annihilating its customary symbolic charac-
teristic. Both patients held in their psyches a traumatising object rela-
tionship and neither had developed a narrative that could allow for a
relating to their past and their present. As the analysands’ inner worlds
became less concrete and more knowable, the traumas and their defen-
sive organisations in character and compromise formations entered
a transformative process. In the beginning, the terror of trauma and
the instinctual play of these traumatic scenes in the analysands’ minds
could only appear through enactment. The analytic dialogue served to
unravel the unsymbolised action sequences that had worked their way
into psychic systems of defence and adaptation, thereby allowing for
the emergence of verbal symbolising narratives. As the symbolising
process developed, reflection and working through in the transference
and countertransference became possible.

References
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Chused, J. (1991). The evocative power of enactments. Journal of the
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Ellman, P. (1998). Is enactment a useful concept? In: S. Ellman &

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manifestations of listening. Psychoanalysis and Contemporary Thought, 1:
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CHAPTER FIVE

The bureaucratisation of thought and

language in groups and organisations
Laurence J. Gould

The map is not the territory

(anonymous)

We must understand that there can be no reconciliation without

remembrance

(von Weizsäcker, 1985)

Introduction
The idea of concrete vs. abstract (symbolic, metaphoric) thinking is
well-known and documented, both clinically in connection with schizo-
phrenia (e.g., Searles, 1962), and developmentally with regard to cogni-
tive growth (e.g., Piaget’s (1985) groundbreaking work on concrete and
formal operations). However, what is considerably less understood are
both the “thinking style” of groups and organisations, as distinct from
that of the individuals, within the normal range, who comprise them.

73
74 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

Early background
From its earliest days psychoanalysis has been interested in the nature
of group and organisational processes. For example, in Group Psychology
and the Analysis of the Ego (1921), Freud linked certain dynamic aspects of
the Church and Army to his earlier hypotheses regarding the origins of
social process and social structure—namely, in his analysis of the primal
horde (1912–1913). Indeed, in his very first sentence in the 1921 paper he
says: “The contrast between individual and social or group psychology,
which at first glance may seem to be full of significance, loses a great deal
of its sharpness when it is examined more closely” (p. 69). Fenichel (1946)
later noted that human beings create social institutions to satisfy their
needs as well as to accomplish required tasks, but that institutions then
become external realities, comparatively independent of individuals
that affect them in significant ways. However, despite this early interest
in group psychology, and some sporadic, modest additions to a theory
of group and institutional life, in for example, Freud’s later “sociologi-
cal works” (1927, 1930, 1939), neither he nor his colleagues carried this
line of theorising much further. While the reasons are many, the paucity
of psychoanalytic writings on the subject, especially early on, may par-
tially attest to the conceptual limitations of a predominantly intrapsy-
chic model of drive, and impulse/defence analysis for understanding
any but a few selective aspects of group behaviour. The beginnings of an
enlarged psychodynamic theory of group and organisational processes
had to wait for a more fully worked out object relational perspective,
which could provide the necessary interactive constructs.

Further developments
A radical and widely influential departure in group theory was not to
happen until the publication of Experiences in Groups (1959) in which
Bion put forward a psychoanalytic theory of group processes, based
largely on developments in object relations theory pioneered by
Melanie Klein (e.g., 1928, 1935, 1940, 1945, 1946, 1948, 1957) and her
colleagues. The essential element of Bion’s theory of group life was to
differentiate between mental states, behaviours, and activities geared
towards rational task performance, and those geared to emotional
needs and anxieties. Following Klein, he viewed the latter as mani-
festations of experiences and unconscious phantasies originating in
T H E B U R E A U C R AT I S AT I O N O F T H O U G H T A N D L A N G U AG E I N G R O U P S 75

infancy. In addition to noting the importance of Klein’s general theory

of development centering on the paranoid/schizoid and depressive
positions (see, Gould, 1997), Bion also explicitly set out to articulate
the relevance of other central Kleinian concepts for understanding the
human group, including: projective identification, splitting, psychotic
anxiety, symbol formation, schizoid mechanisms, and part-objects.
While there have been substantial advances since that time, Bion’s work
and the Kleinian concepts on which they are in part based, still remain
the touchstones of psychoanalytic group theory. For the purposes of
this chapter, however, it is only selected aspects of Bion’s views regard-
ing the nature of thinking and symbolisation, and their perturbations in
groups and organisations, that are the focus.

Contrasting individual and group psychology

This is a familiar theme in social and political thought—the relation-
ship between individual psychology and group psychology. In psycho-
analysis proper, Freud (1921) elaborated some aspects of this issue, by
pointing out, among others, how groups—in his examples, the Church
and Army—developed particular cultures of thought and language that
reflected underlying psychological processes. This chapter attempts to
extend this notion, especially with reference to the work of Bion (1959),
by placing it in the context of contemporary groups and organisations.
The suggestion put forward is that over time, largely as a defence against
the anxieties stimulated by increased complexity and rapid change,
a particular, collective form of concrete thinking has developed, which
is conceptualised here as “cognitive bureaucratisation”. It is argued
that many aspects of contemporary organisational life exemplify this
process, from the development of cognitively debased thought patterns
and forms of communication, to correlative schisms between groups,
parties, and countries. Examples of these processes, and their negative
consequences for group and organisational performance, and emotional
well-being, at all levels, are explored.

A note on the confusion of levels

Before proceeding, I would like to note parenthetically that the proc-
ess of cognitive transformations—in this instance the transformation
of symbolic thought to concrete thinking in collectivities, presumably
76 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

under the sway of regressive forces, like many psychoanalytic concepts,

is often defined and used either somewhat differently, and/or in more
restrictive versus inclusive ways. Further, Freud, for example, never
specifically considered anything like the notion of such transforma-
tions as an aspect of a collectivity responding to conflict, trauma, or
loss, except by implication in Group Psychology and the Analysis of the Ego
(1921), where his first line is, “The contrast between individual psychol-
ogy and social or group psychology, which at first glance may seem to
be full of significance, loses a great deal of its sharpness when it is exam-
ined more closely.” He also, picked up this theme, albeit again indi-
rectly, in Totem and Taboo (1912–1913), with the totem being a particular
kind of memorial, erected by the guilt-ridden sons in expiation for the
murder of the primal father. I put forward these notions since I hope
to suggest that linguistic transformations in collectivities, as a conse-
quence of conflict, trauma, or loss, serve the same defensive functions
as they do for individuals. However, it also seems clear that the concept
of concrete thinking in connection with individuals does not capture
either the processes or the manifestations of concretisation on a collec-
tive level. I believe, therefore, that conceptualising concretisation with
regard to collectivities, requires both a different level of analysis, as
well as a different praxis, since the work of restoring symbolic function-
ing takes place in forms and venues not at all like therapeutic work that
takes place in the consulting room. For example, the conditions under
which the processes of interpreting the defensive functions of concre-
tisation in the treatment situation take place under relatively control-
led conditions, with highly regulated boundaries. By contrast, none of
these conditions is likely to prevail in response to societal conflicts and
trauma that result in collective, regressive functioning. Added to this
are, of course, the differences of working in treatment with one indi-
vidual, with his or her unique history, compared to the complexities of
working in groups, with the needs, and preferred defensive styles of the
individuals comprising the group, highly varied.
From what I have stated up to this point, I think that you can begin
to see where I am heading. It is an attempt to grapple conceptually, and
with the enormous potential implications for understanding what hap-
pens in groups cognitively, as well as applying a psychoanalytic under-
standing to catastrophic, collective trauma and conflict, that groups,
organisations, and society increasingly face. Parenthetically this form
T H E B U R E A U C R AT I S AT I O N O F T H O U G H T A N D L A N G U AG E I N G R O U P S 77

of applied psychoanalysis, pioneered at the Tavistock Institute, has

a long, rich history, and in current usage is commonly referred to as
socio-analysis, or systems psychodynamics (Gould, 2003). To make
these terms explicit, perhaps the best short definition is offered by Bion
(1959), who notes in his introduction to Experiences in Groups that:

The term “group therapy” can have two meanings. It can refer
to the treatment of a number of individuals … or it can refer
to … an endeavour to develop in a group the forces that lead to …
cooperative activity. The therapy of groups [as distinct from group
therapy (author’s addition)] is likely to turn on the acquisition of
knowledge and experience of the factors that make for good group
spirit. (p. 10)

If we take this quote broadly, which I believe would clearly be in

the spirit of Bion’s thinking, the collective—whatever dilemmas,
conflicts, and traumas it may be grappling with—becomes the object
of enquiry and intervention. This constitutes the subject and praxis of
socio-analysis.

Bion’s conception of group psychology

Compared with Freud, as noted above in connection with the differ-
ences between individual and group psychology “losing their sharp-
ness”, Bion is quite explicit with regard to understanding group level
phenomena, emphasising that they cannot be reduced to individual
psychology. In this sense he departs quite markedly from Freud’s view
noted above. In fact, Bion is so scrupulous about making this point,
that the language of his group theory is comprised almost exclusively
of non-psychoanalytic neologisms, the most central being “basic
assumptions”.
Since Bion’s basic assumption theory is well known, it will not
be reviewed in detail. Suffice it to say, therefore, that the basic
assumptions—fight/flight (baF), dependency (baD), and pairing
(baP)—may be viewed as modes of group behaviour which coalesce
around different patterns of drives, affects, mental contents, object rela-
tions, and defences. These basic assumptions are aspects of group behav-
iour in which the aim, as well as the source, relate to emotional security.
78 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

They are contrasted by Bion with another mode—namely, the work

or “W” group—the aim of which is rational, reality-based, task per-
formance. It is in this connection that I specifically begin to consider
the question of language and cognition in groups and organisations,
and how they may be understood as an expression of social (collective)
defences, required to defend against anxiety.

Regressive behaviour and cognitively debased language

Alongside the work group, which functions in a way that draws on the
“mature” capabilities of its members, “ba group” functioning may be
considered a form of “groupthink”,1 characterised by a lack of critical
awareness, non-differentiation, and magical thinking. In Bion’s view,
such states of mind and their manifest corollaries in thought, language,
and behaviour can be viewed as defences against anxiety—with anxi-
ety viewed as having its origins in the emotional demands and com-
plex challenges the group must meet. It is in the face of these that the
group retreats into the socio-emotional patterns of denial described by
the bas. Further, in such groups an unconscious, collusive bond devel-
ops between the members that reinforces denial. The casualty of this
process is work. For in such ba states, the group is given to stereotyping
and simplifying external reality, and internally fostering a culture of
undifferentiated, uncritical mutual support. In this later process, aside
from the damage to required work, there is also collateral damage of
another sort—namely, powerful pressures to relinquish individuality.

The fate of the dissenter in ba groups

In connection with the above, one may also consider the fate of a group
member who questions the assumptive reality of the ba group. As
Krantz (2006) points out, the result is often severe and decisive con-
sequences. Differentiation within the fused, harmonised emotional
environment of the basic assumption group is experienced as—and in
a very real sense is—a betrayal. That is, the naysayer is viewed as a
threat to the ba group’s existence in a blissful state of denial, platitude,
and dogma. And it is precisely such linguistic forms—the group’s lin-
gua franca—and their enforcement by the group (the marginalisation
or expulsion of those with “foreign accents”), that function to main-
tain a “ba culture”. In sum, a cognitive/linguistic system exhibiting
T H E B U R E A U C R AT I S AT I O N O F T H O U G H T A N D L A N G U AG E I N G R O U P S 79

all the hallmarks of a bureaucracy: severely diminished discretionary

behaviour, inflexibility, and a literalist, “biblical” adherence to policies,
rules, and regulations.

Cognitively debased language and verbal communication

To further elaborate the view outlined above, it is useful to specifically
consider the nature of verbal communication in ba groups. As Bion
views it, functional, constructive communication is a property of the
work group. By contrast, the closer a group comes to operating on a ba
level, the less it uses rational communication as a mode of discourse.
Early on, Klein (1930) stressed the developmental importance of sym-
bol formation, and the consequences of this capacity breaking down.
Bion suggests that in ba groups, this is precisely what happens as well.
That is, the ba group loses the capacity for symbolisation, and in its
stead, as Bion suggests, the ba group uses existing language as a mode
of action, concretising thought in a manner, for example, in which the
group acts in relation to the “map” rather than the territory it symbol-
ises. Bion (1959, pp. 186–187) provides a powerful example, citing the
biblical account of the building of the Tower of Babel (Genesis xi. 1–9).
He postulates that the symbolism of a tower, which would reach heaven,
introduces the idea of Messianic hope. But as the group concretises the
idea of salvation, and acts upon it by building the Tower, it brings down
the wrath of Yahweh, who confuses their language, and scatters them
throughout the earth. This parable if generalised and put into ordinary
form, is a parable of a group destroyed by acting on a false (concrete)
belief. Further, and quite central, is that the particular form of destruc-
tion is verbal fragmentation, with Babel a metaphor for the multiplica-
tion of self-contained, hermetic linguistic systems. But what I would
like to emphasise here is that this idea can be framed succinctly as a
hypothesis about language and communication in groups, as follows.
Groups in a state of mind, characterised by consensual, concrete
thinking, and debased verbal communication, acting on the aims they
suggest, result in a catastrophic failure of communication, and the
demise of the group in fragmentation.
Put slightly differently, the point can be made that the obverse of
groups in the thrall of basic assumption life, marked by cohesive and
restrictive language, when acted upon, results (metaphorically) in
the fragmentation of language, and the group’s ultimate destruction.
80 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

That is, if a group is incapable of authentically communicating,

internally or externally, neither redemption, nor even a return to the
status quo ante, is possible.

Paranoid/schizoid and depressive positions

What I have just written about leaders and organisations driven by the
enactment of unresolved depressive position processes, is the obverse
of the more familiar forms of overt malignant leadership informed
almost exclusively by perverse paranoid/schizoid states of mind—the
Hitlers, Husseins, Milosovics of the world, with policies like the “final
solution” and “ethnic cleansing” being the extreme of violent, sadis-
tic, and destructive splitting. Or less malignantly, the Margaret Thatch-
ers, Bibi Netanyahus, or Richard Nixons. In such cases it is easy, on
the face of it, to literally see what it means to destroy the moral order
because the “centre” is a centre in name only—it is comprised of a lead-
ership cadre that perpetuates and stimulates anxiety and hatred rather
than containing it, resulting in violence, dehumanisation, and destruc-
tiveness that others enact on its behalf. But I would like to emphasise
that these leaders and their followers represent in important ways the
converse of what I have described as the perversions of depressive
position values—the psychically corrupted depressive position leader
is married to the sadistic psychopathic paranoid/schizoid leader: they
are a mutual creation.

References
Bion, W. R. (1959). Experiences in Groups and Other Papers. London: Tavistock
(PEP version).
Fenichel, O. (1946). The Psychoanalytic Theory of Neurosis. London: Kegan
Paul, Trench, Trubner.
Freud, S. (1912–1913). Totem and Taboo. S. E., 13. London: Hogarth.
Freud, S. (1921). Group Psychology and the Analysis of the Ego. S. E., 18.
London: Hogarth.
Freud, S. (1927). The Future of an Illusion. S. E., 21. London: Hogarth.
Freud, S. (1930). Civilization and Its Discontents. S. E., 21. London: Hogarth.
Freud, S. (1939). Moses and Monotheism. S. E., 23. London: Hogarth.
Gould, L. J. (1997). Correspondences between Bion’s basic assumption the-
ory and Klein’s developmental positions: An outline. Free Associations,
7: 15–30.
T H E B U R E A U C R AT I S AT I O N O F T H O U G H T A N D L A N G U AG E I N G R O U P S 81

Gould, L. J. (2003). “Collective working through: The role and function

of memorialization.” Presented at: Memory, Memorials and Collective
Working Through. Annual Meeting of the New York Freudian Society,
co-sponsored by Pace University, Downtown NYC, Psychology Depart-
ment. February 8.
Klein, M. (1928). Early stages of the Oedipus conflict. International Journal of
Psychoanalysis, 9: 167–180.
Klein, M. (1935). A contribution to the psychogenesis of manic-depressive
states. International Journal of Psychoanalysis, 16: 145–174.
Klein, M. (1940). Mourning and its relation to manic-depressive states.
International Journal of Psychoanalysis, 21: 125–153.
Klein, M. (1945). The Oedipus complex in the light of early anxieties. Inter-
national Journal of Psychoanalysis, 26: 11–33.
Klein, M. (1946). Notes on some schizoid mechanisms. International Journal
of Psychoanalysis, 27: 99–110.
Klein, M. (1948). A contribution to the theory of anxiety and guilt. Interna-
tional Journal of Psychoanalysis, 29: 114–123.
Klein, M. (1957). Envy and gratitude. In: Envy and Gratitude and Other Works,
1946–1963 (pp. 176–234). New York: Free Press.
Krantz, J. (2006). Leadership, betrayal and adaptation. Human Relations,
59(2): 221–240.
Piaget, J. (1985). The Equilibration of Cognitive Structures: The Central Problem
of Intellectual Development. Chicago: University of Chicago Press.
Searles, H. F. (1962). The differentiation between concrete and metaphorical
thinking in the recovering schizophrenic patient. Journal of the American
Psychoanalytic Association, 10(1): 22–49.
Whyte, W. H. Jr. (1952). Groupthink. Fortune, March.

Note
1. Groupthink was the title of an article in Fortune magazine in March 1952
by William H. Whyte Jr. He wrote:
Groupthink is becoming a national philosophy. Groupthink
being a coinage—and, admittedly, a loaded one—a working
definition is in order. We are not talking about mere instinctive
conformity—it is, after all, a perennial failing of mankind. What
we are talking about is a rationalized conformity—an open,
articulate philosophy which holds that group values are not
only expedient but right and good as well.

Whyte derided the notion he argued was held by a trained elite of

Washington’s social engineers.
82 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

Groupthink is a type of thought exhibited by group members who

try to minimise conflict and reach consensus without critically testing,
analysing, and evaluating ideas. Individual creativity, uniqueness, and
independent thinking are lost in the pursuit of group cohesiveness, as
are the advantages of reasonable balance in choice and thought that
might normally be obtained by making decisions as a group. During
groupthink, members of the group avoid promoting viewpoints out-
side the comfort zone of consensus thinking. A variety of motives for
this may exist, such as a desire to avoid being seen as foolish, or a desire
to avoid embarrassing or angering other members of the group. Group-
think may cause groups to make hasty, irrational decisions, where indi-
vidual doubts are set aside, for fear of upsetting the group’s balance.
The term is frequently used pejoratively, with hindsight.
CHAPTER SIX

Painting poppies: on the relationship

between concrete and metaphorical
thinking
Caron E. Harrang

Introduction
Wilfred Bion (1965) begins his book on Transformations thus:

Suppose a painter sees a path through a field sown with poppies

and paints it: at one end of the chain of events is the field of pop-
pies, at the other a canvas with pigment disposed on its surface.
We can recognize that the latter represents the former, so I shall
suppose that despite the differences between a field of poppies
and a piece of canvas, despite the transformation that the artist
has effected in what he saw to make it take the form of a picture,
something has remained unaltered and on this something recognition
depends. (p. 1)

In this deceptively simple description Bion shows us the relationship

between concrete reality and any symbolic rendering of that reality.
He uses this analogy to demonstrate how the analyst’s experience of
the patient’s production of unconscious thoughts and feelings is trans-
formed into psychoanalytic interpretations. I will use it in a slightly
different way to shed light on the relationship between concrete and

83
84 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

metaphorical thinking and show how it relates to Melanie Klein’s

theory of mental positions (1935, 1946) as elaborated by Bion (1963)
and later by Ronald Britton (1998). Concreteness as it is usually defined
in the psychoanalytic literature to describe a pathological condition is
amended in favour of a view that it is also a natural component of the
paranoid-schizoid position, just as metaphorical or symbolic thinking
is a natural component of the depressive position. As such, concrete
thinking is not overcome or outgrown as the individual develops the
capacity for metaphorical thinking. More accurately, I believe, in health
it is balanced with metaphorical thinking in a way that allows for ongo-
ing, unconscious oscillations between these two forms of thought nec-
essary for mental growth.
Furthermore, I concur with Britton (1998) who believes that there
are pathological and healthy forms of both the paranoid-schizoid and
the depressive position. Applying his model I suggest that it is possible
to observe instances of concrete thinking in the clinical situation that
are non-pathological and, as such, part of the normal paranoid-schizoid
position in which there is a transitory return to sensory-based perceptual
experience that is pre-symbolic. I will provide clinical material and
ordinary non-analytic conversation to illustrate these phenomena and
show how concreteness may either be part of healthy development or
indicate what Harold Searles (1962) calls “pseudo-concreteness”, where
ego boundaries are actively obscured and the individual’s thoughts
and feelings remain undifferentiated, neither genuinely concrete
nor clearly symbolic. I will also contrast non-pathological concrete-
ness with what Bass (1997), Frosch (1995), Grossman (1996), Jacobson
(1957), and Renik (1992) describe as an attitude of absolute certainty
about one’s perceptions that rigidly defends against the possibility
that “one thing might mean another” (Bass, p. 645). Implications of the
views expressed in this chapter for psychoanalytic technique are briefly
mentioned.

Background
Before proceeding to examine the relationship between concrete and
metaphorical thinking as it relates to Klein’s mental positions, it is
necessary to touch on terminology. Concreteness in common linguis-
tic usage refers to things perceived as real, because they can be seen
or touched as contrasted with, for example, thoughts or feelings that
 PA I N T I N G P O P P I E S 85

do not exist in physical form. Developmental psychologists such as

Piaget (1945, 1954) describe concrete thinking as a phase of cognitive
development that precedes the capacity for abstract or metaphorical
thinking characterised by literalness and lack of generalisation. Psycho-
analysts, on the other hand, have tended to focus on the unconscious,
dynamic roots of concrete thinking, linking it generally to difficulties
in differentiating concrete from symbolic communication. Hanna Segal
(1957, p. 391) illustrates this problem in her well-known paper, Notes on
Symbol Formation, when she describes a schizophrenic man’s inability
to play his violin because it has become for him indistinguishable from
masturbating in public. Harold Searles (1959, p. 305) notes something
similar in his work with schizophrenic patients, saying, “If his therapist
uses symbolic language, he may experience this in literal terms; and on
the other hand the affairs of daily life (eating, dressing, sleeping and
so on) which we think of as literal and concrete, he may react to as
possessing a unique symbolic significance which completely obscures
their ‘practical’ importance in his life as a human being.” Alan Bass
(1997, pp. 643–644) describes another form of concreteness evident in
non-psychotic, narcissistically organised individuals who are so utterly
convinced of the truth of their own perceptions that they are unable
to consider the analyst’s point of view when it differs from their own.
For example, the patient may begin the session refusing to talk because
she knows that the analyst will be disapproving or critical. Dramatic
as these descriptions are they serve well to illustrate the essence of
concrete thinking in its pathological forms. Non-pathological concrete
thinking associated with the normal paranoid-schizoid position will be
described later in this chapter.
A metaphor is a figure of speech concisely expressed by comparing
two things, saying that one is the other, as for example, in Bion suggest-
ing that the artist’s painting is the analyst’s interpretation. Metaphors
are not meaningful, however, unless the difference between the two
things being compared is also understood. The schizophrenic man Segal
described could not differentiate playing a musical instrument in public
from a private sexual act. Thus, playing the violin was not in any way
metaphorical because the two things being compared were experienced
by him as identical. In his introduction to Attention and Interpretation
Bion (1970) notes that what gives analogy [and perhaps all metaphor]
its communicative power is the relationship between the things being
compared and not the things themselves. From a psychoanalytic
86 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

perspective, metaphorical or symbolic thinking (these terms are used

interchangeably) implies the capacity for differentiation between self
and object. How this mental ability develops is viewed differently by
various psychoanalytic schools. For example, Klein (1930) viewed sym-
bol formation—and by extension metaphorical thinking—as resulting
from the ego’s efforts to deal with anxieties evoked by its relationship
to internal and external objects.
To summarise, terms such as “concreteness” or “concrete think-
ing” have generally been used in the psychoanalytic literature to
denote a developmental stage preceding the capacity for symboli-
sation and metaphorical thinking, or to describe a state of mind that
accompanies regression and defends against differentiation and mental
growth. Segal (1957) linked the symbolising process with achievement
of the depressive position. Conversely, she believed that “distur-
bances in differentiation between ego and object lead to disturbances
in differentiation between the symbol and the object symbolized and
therefore to concrete thinking characteristic of psychoses [my emphasis]”
(p. 393). In other words, concreteness or concrete thinking is used as an
antonym to symbolisation or metaphorical thinking. This view of the
relationship between concrete and metaphorical thinking is reflected
in the writings of Kleinian and non-Kleinian analysts alike. Although
I agree that this terminology does accurately describe an important
aspect of mental life, it ignores or does not account for another dimen-
sion of the relationship between concrete and metaphorical thinking
that is complementary. In the next section I will show how Kleinian
metapsychology as elaborated by Bion and Britton helps to illuminate
the non-pathological relationship between concrete and metaphorical
thinking.

An evolving understanding of the paranoid-schizoid

and depressive positions
Klein elaborated and greatly animated Freud’s concept of the ego
through her introduction of the depressive position (1935) and later
the paranoid-schizoid position (1946). Together they form the core
of Kleinian metapsychology. The paranoid-schizoid position is char-
acterised by part-object representations of the infant’s experience
of its relationships with primary objects.1 Self and object are initially
experienced as exaggeratedly “good” or “bad” with the aim of union
 PA I N T I N G P O P P I E S 87

with gratifying, good objects and expulsion of frustrating, bad objects.

The experience of separation between self and object in the first months
of the infant’s life is relatively undeveloped mentally such that distinc-
tions between internal and external, or hallucinatory wish-fulfilment
versus actual gratification are only vaguely recognised. A primary
defence against psychotic anxieties, such as the fear of being poisoned
or devoured (Klein, 1946, p. 2), is projective identification2 in which
unwanted parts of the self are unconsciously attributed to the object.
Similarly, qualities of the external environment including the parents
and others are introjected and treated as part of the self. Through an
ongoing process of projection and introjection part-objects are trans-
formed into whole objects where “good” and “bad” experiences are
gradually integrated.
According to Klein (1935, 1946) the depressive position forms because
of the infant’s capacity to differentiate self and object, thus allowing
for integration of libidinal and destructive impulses and furthering the
development of psychic reality. The ability to feel love and hate for the
same object, no longer split into excessively “good” and “bad” part-
objects, allows the infant to feel “states akin to mourning … because
aggressive impulses are felt to be directed against the loved object”
(1946, p. 14). This newly forming capacity to feel emotional pain over
phantasised destructiveness towards whole objects combined with
the impulse towards reparation fuels emotional growth. For example,
a six-month-old infant furious at mother for frustrating his desire to
be picked up and comforted may offer to share a favourite toy or a
bite of the half-eaten biscuit she gave him after feeling his needs ade-
quately recognised. Gestures like these signal the developing child’s
ability through symbolic means to demonstrate concern for the effect of
his thoughts, feelings, and actions on the object. Thus, as Segal (1957)
emphasised, achievement of the infantile depressive position is inti-
mately linked with symbol formation and the beginning of metaphorical
thinking.
Klein (1946) viewed the paranoid-schizoid position as preceding the
depressive position which will then consolidate in the first few years
of the child’s life. If persecutory fears associated with the paranoid-
schizoid position are not adequately resolved, they may interfere
with development of the depressive position, going on to form the
basis of later manic-depressive and schizophrenic illnesses. Once it
is reliably achieved, movement from the depressive position back to
88 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

the paranoid-schizoid was primarily seen as pathological. However,

as Britton (1998, p. 70) notes, a close examination of Klein’s writings
shows that “She described the paranoid-schizoid position sometimes as
a defense, sometimes as a regression and sometimes as part of [normal]
development.” This variability in Klein’s terminology may be one rea-
son why her highly original contribution is sometimes misunderstood
to refer exclusively to the initial formation of the paranoid-schizoid and
depressive positions as if they were solely developmental stages. Fortu-
nately, two of Klein’s followers, Wilfred Bion and Ronald Britton, have
made important revisions to her theory of the positions in ways that,
I believe, strengthen its viability, and provide a platform for my own
thoughts on the relationship between concrete and metaphorical think-
ing detailed in this chapter.
In Elements (1963, p. 3), Bion advanced the notion that Klein’s
paranoid-schizoid (Ps) and depressive positions (D) could be thought
of as proceeding from one to the other in either direction, which he rep-
resented in the equation Ps↔D. In placing the double arrow between
the two positions he inferred from Klein’s writings that movement
back and forth between the positions was at times part of develop-
ment. This he restated as a naturally occurring oscillation throughout
the lifespan. Bion left intact Klein’s descriptions of the positions, add-
ing that it was possible to experience “a state of mind analogous to the
paranoid-schizoid position” (1970, p. 124), characterised by unknow-
ing, frustration, and suffering as one waits, without memory or desire,
for meaning to evolve. He realised that the paranoid-schizoid position
was not only a pathological state as Klein had described but a source
of immense creativity as well—if the individual could bear what Keats
(1817) called “negative capability”, or openness to “uncertainties,
Mysteries, [and] doubts without any irritable reaching after fact &
reason”. He saw this non-pathological paranoid-schizoid position as a
necessary precondition for, among other things, analytic listening and
optimal receptivity to the patient’s emotional experience. Unfortunately,
rather than calling his expansion the normal paranoid-schizoid posi-
tion, he coined the term “patience” to distinguish it from the pathologi-
cal state. However, as Britton (1998, p. 69) notes, it was never accepted
as a psychoanalytic term.
Building on Bion’s revision of Klein’s theory, Britton (1998) wrote
a theoretical paper entitled Before and After the Depressive Position in
which he sought to clarify how movement between the positions
 PA I N T I N G P O P P I E S 89

reflects either psychic development or regression. His model clearly

distinguishes between the pathological paranoid-schizoid position
described by Klein and the normal paranoid-schizoid position that Bion
called “patience”. Additionally, Britton (p. 72) identifies a pathologi-
cal form of the depressive position, not explicitly recognised by Klein
or Bion, and characterised by a “ready-made, previously espoused
coherent belief system … prompted by a wish to end uncertainty and
the fears associated with fragmentation”. For example, the certainty
with which the Bush administration sought (erroneously) to connect
the attacks on 9/11 with the then Iraqi dictator, Saddam Hussein, typi-
fies the moralistic and self-righteous character of the pseudo-depressive
position. This state of mind results, Britton says, from an inability to sur-
render the security, moral sensibility, and self-reflective capacity of the
normal depressive position in order to re-enter the more anxiety-laden
territory of the normal paranoid-schizoid position necessary for emo-
tional growth. Psychic development occurs when there is uninterrupted
movement from the normal paranoid-schizoid position into the
depressive position followed by a return to the next paranoid-schizoid
position … and so on. This clarification of Bion’s formula underscores
the normalcy of the paranoid-schizoid position, indeed, the importance
of it for ongoing emotional growth. Regression,3 on the other hand,
refers to a shift into either the pathological paranoid-schizoid position
or the pathological depressive position.

Concrete and metaphorical thinking—a post-Kleinian view

Holding in mind Klein’s theory of the positions as elaborated by
Bion and Britton, the question remains: what does this tell us about
concrete and metaphorical thinking? Returning to the central thesis
of this chapter I suggest that there are both healthy and pathological
forms of concrete thinking, and that oscillation between concrete and
metaphorical thinking are part of an ordinary, non-pathological proc-
ess of development. My conceptualisation runs parallel to Britton’s
model; that is, mental growth results from ongoing shifts back and
forth between part-object and whole object relating. Non-pathological
concreteness is, in my view, a natural component of the normal
paranoid-schizoid position. This view implies that concrete thinking
is pathological only when it becomes fixed and impedes movement
between the positions. Concreteness as an obstacle to growth is seen as
90 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

belonging to either the pathological paranoid-schizoid or pathological

depressive position.
Logically it follows that there are also healthy and pathologi-
cal forms of metaphorical thinking. For example, applying the often
quoted phrase “God helps those who help themselves” (Sidney, 1698,
cited in Keyes, 2006, p. 79) to mean that it is ungodly or morally wrong
to depend on others illustrates pathological metaphorical thinking.
Genuine metaphorical thinking as previously mentioned (Segal, 1957)
belongs to the depressive position, whereas errors in symbolisation,
such as the “unique symbolic significance” (Searles, 1959, p. 305) which
schizophrenic individuals assign to ordinary concrete acts such as
eating or sleeping, may be thought of as belonging to the pathologi-
cal paranoid-schizoid position. However, it is beyond the scope of this
chapter to explore in any depth the pathological forms of metaphorical
thinking. Rather, I will elaborate what I mean by non-pathological con-
creteness, as compared with its pathological forms, and show how this
relates to the paranoid-schizoid position. As stated earlier, this healthy
form of concreteness is, I believe, complementary to the development
of metaphorical thinking and not its opposite, as is often implied in the
literature.

Concrete thinking in the paranoid-schizoid position

The essence of non-pathological concrete thinking is, in my view,
to be found in sensate experience. It is, for example, represented in the
infant’s visual experience of gazing at the mother’s face before he has
any conceptual understanding of what he is seeing. It is the feel of her
skin against his as she attends to his physical needs for feeding, bathing,
nappy changing, and dressing before he has a clearly formed sense of
the physical or emotional boundaries between himself and her. It is the
taste of warm milk entering his mouth as he suckles, and the sensations
associated with swallowing and digestion before he understands that
what he is doing is called nursing. It is hearing the sound of his own
voice as he cries—expressing a multiplicity of primitive anxieties—and
how this proto-mental experience changes as he registers the vibrations
of mother’s approaching footsteps and then her voice as she speaks
before taking him into her arms. Altogether these body-based, somat-
opsychic experiences form the substrate of what, in normal circum-
stances, gradually becomes symbolised in verbal thoughts and speech.
 PA I N T I N G P O P P I E S 91

This way of understanding the relationship between concrete and

symbolic or metaphorical thinking may have been what Ernest Jones
(1916, cited in Segal, 1957, p. 392) had in mind when he said that all
symbols represent experiences of “the self and of immediate blood rela-
tions and of the phenomena of birth, life, and death”.
Put another way, it seems to me unlikely that there is any such thing
as a symbol that is not rooted, however distantly or unconsciously,
in sensory experience. This, I believe, is what Bion was referencing
when he noted that any symbolically expressed creative impulse, be it
the artist’s painting or the analyst’s interpretation, draws upon “what
he saw”—that is, a sensory experience—which allows recognition of
the relationship between the symbol and what is symbolised. Along
similar lines, Searles (1962, p. 582) notes “the extent to which somatic
sensations participate in the development of metaphorical thinking in
the normal child”. That is, “Before the child can come to understand
such phrases as ‘gives me a pain in the neck’, or ‘turns my stomach’,
or ‘tears at my heartstrings’ in their metaphorical meaning, relatively
devoid of somatic concomitants, he must first have felt their meaning as
a partially, or perhaps predominately, somatic experience.” I agree with
this if by “devoid of somatic concomitants” it is to be understood that
metaphorical meaning contains the literal level of experience rather
than replacing it.
The significance of sensory experience to metaphorical think-
ing was also noted by the writer T. S. Eliot (1919, cited in 1950,
pp. 124–125), when he posited the “objective correlative”4 or “a set of
objects, a situation, a chain of events which shall be the formula of that
particular emotion; such that when the external facts, which must termi-
nate in sensory experience, are given, the emotion is immediately evoked
[my emphasis]”. This concept reflected his conviction that human
emotional experience is dependent on the ability to locate objects in
the external world which reflect the living power of our thoughts. Eliot
was quick to point out that it is not the object or image in isolation that
evokes an emotional response. Rather, feeling originates in response to
the combination of these phenomena as they appear together.
The relationship between non-pathological concrete and metaphor-
ical thinking may also be reflected in Freud’s (1896) ideas about the
origins of consciousness and the relationship between what he called
“thing-presentation” and “word-presentation”. Thing-presentation
is a visual image in the unconscious unconnected to a linguistic
92 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

signifier. Word-presentation is a conscious thought comprised of “the

presentation of the thing, plus the presentation of the word belong-
ing to it …” (1915e, p. 201). He believed that conscious thought arose
when thing-presentations become linked with language. Freud’s belief
that both thing-presentation and word-presentation are derived from
“sense-perceptions” (p. 202) is significant for my definition of non-
pathological concrete thinking. If we accept that thing-presentation
corresponds to concrete thinking and word-presentation to metaphori-
cal thinking, then Freud is saying that both forms of mental activity
are rooted in sensory experience. Thus, we can conclude that sensory
experiences meld with thing-presentations and gradually acquire lexi-
cal meaning in normal development.
The paranoid-schizoid position from infancy on is, in my view,
embedded in sensory-based perceptual experience. These sensory
experiences are represented concretely before they acquire full symbolic
value. Development hinges, of course, on the depressive position having
been relatively well established in the first few years of life. That is, the
infantile depressive position is the prerequisite without which the nor-
mal paranoid-schizoid position would be impossible. Once achieved,
the post-depressive paranoid-schizoid position bears the initial impact
of new thoughts and feelings. The capacity to think in literal imagis-
tic terms relatively unencumbered by reality testing accompanies the
necessary deconstruction of meaning found in previously achieved
depressive positions. If the disorganisation, lack of coherence, and
uncertainty associated with the normal paranoid-schizoid position
can be tolerated and contained, then a new experience, at first repre-
sented literally, acquires symbolic value as the next depressive position
takes shape.
As previously noted, by Segal and Searles among others, concrete
thinking may become distorted and part of disordered thinking evi-
dent in schizophrenia and borderline disorders. Before turning to
illustrations of non-pathological concreteness in the next section it is
important to note the distinguishing features of its pathological forms.
Concreteness accompanying psychosis obscures developing metaphor-
ical meaning or strips it away in a process Searles (1962, p. 580) termed
“desymbolization” where “once-attained metaphorical meanings” are
reacted to as literal or concrete. This denuding of symbolic significance
is one indication of a defence against the self-object differentiation nec-
essary for movement into the depressive position. Active destruction
 PA I N T I N G P O P P I E S 93

of metaphorical meaning for the purpose of evading growth is, in my

view, part of the pathological paranoid-schizoid position. By contrast,
concrete thinking in non-psychotic, narcissistically organised individu-
als evidenced by the conviction that their point of view is the abso-
lute truth, described by Bass and others, is more likely indicative of the
pathological depressive position. Concreteness in this state of mind is
used to defend against the perceived crisis of relinquishing the depres-
sive position and experiencing, once again, the emotional turbulence
and lack of certainty associated with the normal paranoid-schizoid
position.

Illustrations of non-pathological concrete thinking

An ordinary (non-clinical) example
The first example of non-pathological concrete thinking comes from an
ordinary, non-clinical conversation with actor Sidney Poitier in an inter-
view he gave to Renee Montagne, host of Morning Edition, and aired
on NPR (national public radio in the United States (May 19–20, 2009).
Poitier, now in his eighties, was describing his childhood in the remote
village of Arthur’s Town on Cat Island in the Bahamas where his fam-
ily lived without access to electricity, indoor plumbing, or motorised
transportation for the first ten years of his life. The interviewer asked
how under such circumstances he became interested in acting. Poitier
explained that around the age of ten his family moved from Cat Island
to Nassau where he was for the first time introduced to the world of
modern conveniences. One day a group of boyhood friends asked if
he wanted to join them in attending a matinee. Having no idea what a
matinee was, and perhaps too shy to reveal his ignorance, yet curious,
he agreed to go with them. Although he no longer recalls the title of
the film, he remembers that it was a Hollywood Western. Transfixed by
images of cowboys walking, talking, and riding around in horse-drawn
carriages, he wondered “How could they get all those people in this lit-
tle place, this little theater place …?”
Afterwards as Poitier and his pals were walking home he was over-
come with an irresistible urge to return to the theatre and learn about
this thing called a matinee that had so “shocked” his young imagina-
tion. Laughingly, he told Montagne that he stood at the back door of
the theatre “waiting to see who would come out”, not understanding
94 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

that what he had seen was on the screen and not in the theatre as he
had experienced it. That is, the overwhelming power of the visual and
emotional experience was such that he did not initially recognise the
distinction between internal and external reality. This transient lack of
differentiation between inner and outer, combined with an intensely
felt sensorial experience, in my view characterises non-pathological
concreteness in normal individuals. In a less healthy individual this
might have become the basis of a delusion; that is, an enduring con-
viction that the film characters were real in the external sense, indis-
tinguishable from a representation of that reality in film or in one’s
imagination. Or someone less curious might simply have dismissed his
unknowing as not worth pursuing. As it was, the emotional intensity
of the above-mentioned experience, initially felt as literal and concrete,
was eventually transformed into Poitier’s meaningful, reality-oriented,
professional career. How this transformation came about is also sig-
nificant for understanding the nature of normal concrete thinking and
how it relates to the shift from the paranoid-schizoid to the depressive
position.
Poitier (2008, pp. 4–5) describes how his first film experience was
transformed from a literal event into one that served as inspiration
for his eventual career as an actor through an interaction with one
of his siblings. His older sister, Teddy, asked him, after he had seen
the film, what he wanted to be when he grew up. Poitier spontane-
ously announced that he wanted to go to Hollywood so that he could
“work with cows”. It was then, he speculates, that she must have
figured “that since it was in the movies that I had seen cows, I must
have assumed that in order to be one of the heroic cowboys from
the movies, I had to go to Hollywood”. When his sister sensitively
explained that Hollywood was a place where they made movies and
not where one went to literally become a cowboy, the would-be actor
felt severely “disappointed” and concluded that his “future was to lie
elsewhere”.
Although the preceding vignette is not from an analytic treatment,
we can see that the sister functions much as a good analyst does by
careful listening and respectfully interpreting her brother’s phantasy.
Poitier’s disappointment indicates his recognition of the sister’s clari-
fying understanding helping him move from an idealised phantasy
(paranoid-schizoid position) to a more realistic appraisal (depressive
position) of the opportunities that lay ahead in Hollywood. These
opportunities included, ironically, his starring in two Westerns and later
 PA I N T I N G P O P P I E S 95

becoming the first African American actor to win an academy award

(1963) for his role in Lilies of the Field.
In considering this vignette, which by necessity omits important
details of the actor’s life, I am, nonetheless, left with the impression that
the concrete nature of his experience—thinking that the people and ani-
mals were three-dimensionally present in the theatre—contributed to
his development as an actor and richly creative human being. With the
help of Poitier’s sister, he could distinguish between what was on the
screen and what was in his mind, and thus could bear the loss of his
concrete phantasy, identifying with the actors as whole objects separate
from himself.

Clinical examples
A second example of non-pathological concrete thinking comes from
the written report of an analytic candidate (Parnes, 2009), looking
back on his year-long experience of infant observation. Although the
experience is described retrospectively using metaphorical language—
that is, from the depressive position—it conveys both the candidate’s
conjecture of the infant’s sensory-based perceptual mode of thinking
and his own ability to surrender to an analogous state of mind:

At first, like [the infant], I am awash in sensory experience. I notice

the mountain views, the feel of the home (quiet and orderly), the
sun coming through the window, the temperature of the bathwater.
And I can’t leave out the breast, which I take in with my eyes as
[the infant] does with his mouth. He is tongue tied5 and so am I. It is
all so much to take in and neither of us knows what it all means.

The candidate’s capacity to relinquish the depressive position and feel

“awash in sensory experience”, where “it is all so much to take in”
allows him to get closer to the infant’s experience, and learn about
psychic development in an emotionally meaningful way. This abil-
ity to temporarily forego knowing “what it all means” is as much a
part of psychic growth and development for the observer as it is for
the infant.
A third and final example of non-pathological concrete thinking
comes from my analysis of a married middle-aged professional man with
a predominately obsessive character structure and strong tendencies
to somatisation. At the time of the following vignette, the patient felt
96 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

emboldened to express his increasingly conscious ambivalence towards

analysis and the analyst with less trepidation than in the past, although
this often resulted in a flare-up of somatic symptoms, particularly dur-
ing weekend breaks and vacations.
The patient began the session talking about a friend’s behaviour
disordered child who hates being touched and has “learning difficul-
ties” at school. Further exploration of this material led to my patient’s
speculation that the child acts up at school when he feels ignored by the
teacher. Then he thought of three missed sessions in a previous week and
wondered if I would allow him to reschedule since “nothing had hap-
pened” during these hours. In exploring his feelings about the missed
sessions, it became possible to show him how he felt extremely perse-
cuted by the unconscious perception that he was a “no-thing” (did not
exist) in the analyst’s mind during these times. This had caused him to
feel both untouched and untouchable, which he reversed in the associa-
tion to the neighbour’s son who “hates being touched”. Unconsciously,
he also blamed the analyst particularly for his hateful feelings, which
added to his fears of being retaliated against. As his feelings associated
with these events were taken up, one by one in the session, the patient
gradually experienced a sense of relief and then, quite unexpectedly,
strong loving feelings arose. Spontaneously he confided, “After you
said what you just said I heard myself say in my mind, ‘I love you!’.”
This was said in a tone of voice conveying that he felt both appalled and
in awe of his positive transference feelings.
In the next instant, the patient’s leg jerked violently and, for a
moment, it seemed he might sit up (to regain a sense of volition over
his bodily movement?). However, as it happened, he remained supine
on the couch, motionless and silent for several minutes. When he spoke
the patient sounded shaken, saying he had suddenly remembered a
disturbing dream from the night before. He wondered why the dream
had come to his mind at this moment and seemed to be struggling to
orient himself to the occurrence in his dream and what was occurring
in the session. Haltingly, he said that in the dream:

A rodent was in my bed. I was terrified. I tried to call out to my wife

but I couldn’t make a sound. I guess I woke her up. I was looking
around for the rodent. I was afraid to look under the covers and it
took a while to realise that the rodent—or maybe it was a beaver—
wasn’t actually in our bed.
 PA I N T I N G P O P P I E S 97

By exploring the sequence of the patient’s libidinal transference and his

involuntary leg movement, it became possible to understand the dream
as an unconscious precursor to what was recapitulated in the session.
The patient associated the rodent or beaver to his wife’s leg, which he
thought had probably brushed up against him while he was dreaming,
resulting in confusion when he awoke about whether the animal was in
his dream (internal) or in his bed (external). It seemed that something
similar had happened in the session when he was sharing his loving
feelings and then felt as if we—that is, patient and analyst—had literally
touched, which both excited and frightened him. In this regard I felt that
my patient was not only remembering a dream from the previous night
but also having a dream in the session. That is, his involuntary leg move-
ment and the sensations related to feeling physically in contact with
the rodent/beaver/wife’s leg gave him to feel, momentarily, that the
analytic couch was the night-time bed in which he and his wife/analyst
were together sleeping.
When the patient is thinking concretely, and reflective thinking is in
abeyance (Britton, 1998, p. 73), technically it is important to avoid trans-
ference interpretations until the sensorial aspects of the experience are
well contained. As the patient, for example, was able to describe where
in the bed he thought the rodent lay, whether he saw it (he did not) or felt
it moving around under the bedcovers, and what it was that made him
think it was a beaver rather than another type of rodent, the sensorial
elements of his experience were slowly transformed into increasingly
complex, verbal thoughts and associations. The analyst’s genuine curi-
osity in the patient’s concrete experience is, I believe, containing and
supports differentiation between psychic and external reality neces-
sary for movement into the depressive position. In this regard I agree
with Searles (1962, p. 576), who cautions that “It is a mistake to respond
[to the patient’s communication] in terms of its potential metaphori-
cal meaning without first acknowledging its validity as a statement of
literal fact.” That is, the patient must first be able to successfully make
contact with the analyst at the paranoid-schizoid level of experience,
before facing anxieties attendant to approaching the depressive posi-
tion. Aspects of experience—for example, my patient’s wondering if
the rodent in his dream was a beaver—that may eventually acquire
symbolic significance, need first to be explored in their literal form.
With this particular patient, an unhurried exploration of the somatic
sensations experienced within the session and in his dream eventually
98 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

allowed for the interpretation that feeling loved or touched, literally or

figuratively, was as intense emotionally as feeling ignored (unloved)
or untouched.
In concluding, I would like to offer this summary: the terms
“concreteness” or “concrete thinking” are typically used in the psy-
choanalytic literature to denote a developmental stage preceding the
capacity for metaphorical thinking, or to describe a regression from dif-
ferentiation and mental growth. Concrete thinking, in this sense, is used
as an antonym to metaphorical thinking. Alternatively, I suggest it is
possible to observe a complementary relationship between concrete and
metaphorical thinking that spurs normal development. Melanie Klein’s
theory of mental positions, as elaborated upon by Wilfred Bion and
later by Ronald Britton, was utilised to show how psychic development
may be thought of as resulting from ongoing oscillations between the
normal paranoid-schizoid and depressive positions. Additionally, I pro-
pose that non-pathological concrete thinking can be considered part of
the normal paranoid-schizoid position. If the disorganisation, lack of
coherence, and uncertainty associated with this state of mind can be
felt and contained, then new experience, at first represented literally,
acquires metaphorical meaning as the next depressive position takes
shape. As such, concreteness is not something that is overcome as the
individual develops the capacity for metaphorical thinking. More accu-
rately, concreteness grounded in sensory experience underpins meta-
phorical thinking. Clinical and non-clinical examples were provided to
illustrate the essential features of this sensory-based form of thought,
and to show its vital relationship to development. Implications for tech-
nique, including the importance of differentiating between pathological
and non-pathological forms of concreteness and the containing func-
tion of the analyst’s curiosity in, and respect for, the patient’s concretely
conveyed communications, were briefly mentioned.
If space allowed, I would be able to furnish many more examples
of normal concreteness associated with the paranoid-schizoid position.
Hopefully, the vignettes provided illustrate the ordinary quality of the
experience and how it contributes to healthy development.

References
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Bion, W. R. (1963). Elements of Psycho-Analysis. London: Heinemann.

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1917–1932. New York: Harcort Brace, 1950.
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Notes
1. In using the term “object” I assume that the reader understands I am
referring to both external others, such as the infant’s primary cares, and
to the many evolving internal representations of these relationships.
2. Klein elaborated Freud’s concept of projection and offered the term
“projective identification” to describe both unconsciously attribut-
ing unwanted aspects of the self to the object (1959, pp. 252–253) and
unconsciously acquiring aspects of the object’s identity then treated as
part of the self (1955, pp. 141–175).
3. Britton (1998, p. 72) uses the term “regression” to refer exclusively to
a pathological state of mind that “reiterates the past and evades the
future”. Regression is contrasted with the disorientation, emotional
turbulence, and loss of coherence that accompanies relinquishment of
the depressive position as one re-enters the paranoid-schizoid posi-
tion. This latter experience is part of psychic development and as such
should not be labelled as regression.
4. American visual artist Washington Allston first used the term “objec-
tive correlative” about 1840, but T. S. Eliot made it famous in his essay,
Hamlet and His Problems, published in 1919.
5. Interestingly, the infant was actually tongue-tied and needed a minor
medical procedure to allow for normal feeding. Thus, the observer is
referring simultaneously to the concrete and metaphorical significance
of the infant’s and his own experience.
CHAPTER SEVEN

When words fail

Richard Lasky

T
his chapter will address how analytic treatment is facilitated when
the inevitable stalemate occurs with a very commonly encoun-
tered but particularly difficult category of patient—the concrete
patient who is not simply concrete but is also refractory to interpre-
tation. The focus will be on why an entire category of patients are so
concrete and are not helped by interpretation; about how the analyst,
and analyst–patient transactions, and the analyst–patient relationship
are internalised; and, on what specifically happens, within the broad
range of those conscious and unconscious processes, that facilitates
therapeutic action with this particular kind of difficult patient.

The patient: Mr V
Mr V came to treatment because he suffered from barely controllable
rages that caused him many social and professional difficulties, includ-
ing having turned almost all his friends, going back as far as he could
remember, into enemies, wrecking every romantic relationship he ever
had and, also, despite making a lot of money when he gets work, hav-
ing been fired from every job he ever held. He recognised that he had
a very serious problem, but he came with deep reservations about the
101
102 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

ability of psychotherapy to be of help. He described asking everyone

he knew for advice on how he might address his problem, and said
he was told by the people he respected that psychoanalysis was the
most comprehensive form of therapy. He was “willing to give analysis
a crack at me”, as he put it; “but I have to tell you”, he went on, “that if
this thing works it will be a miracle.” His expectation of frustration and
disappointment became understandable almost immediately.
Mr V’s portrayal of his parents, his history, and his life was simple
and it never varied. He was an only child and he described his mother
as an overly intellectualised and self-involved college professor who
was basically uninterested in him. She was a person who could not
properly relate to him “because all she cared about was her work, never
about people, and certainly not about me”. Although Mr V had many
such angry feelings about his mother, he retained few actual memories
of her prior to her sudden, and unexpected, death just before he entered
middle school. Mr V also claimed to have very few, almost no, memo-
ries of his childhood, and he found it difficult, when asked about his
childhood or about his parents, to bring specific recollections intention-
ally to mind.
It turns out that Mr V actually did have memories, many memories,
and some were quite vivid, in fact almost palpable, in their intensity.
It was because of the form they took and the purposes they served that
Mr V did not recognise, treat, or even experience his memories as mem-
ories. Mr V’s memories were couched in chronic complaints levelled
against his mother and, occasionally, his father. His inability to experi-
ence his complaints as a form of remembering was due, in part, to the
concreteness of his thinking; memories were memories and complaints
were complaints. Mr V also used these complaints as indictments, retal-
iatory denunciations that had the power both to injure and to redress
injury. In addition to his concreteness, he resisted thinking about them as
memories in order not to weaken their power as indictments. The litany
of complaints directed against his mother (and to a lesser extent, his
father) in session after session were, for Mr V, actual, not metaphori-
cal, character assassinations. His denunciations of her were imbued,
for him, with the retaliatory power to punish and destroy. Whenever
I brought up the possibility, no matter how gently or tentatively, that
his complaints might be more complicated than they seemed, Mr V
would become furious with me; at such times he would tell me, in a
voice tinged with steel, that he thought me a rather stupid person for
 W H E N W O R D S FA I L 103

not knowing the difference between a memory and a complaint, and

he wondered how someone like me ever got into the business of doing
therapy in the first place.
Mr V’s history, or at least his version of it, which he could not readily
convey as personal memories, emerged in the recounting of his com-
plaints. For example: “On the rare occasion that my fucking mother
turned her fucking attention to me, she found me always”, he said,
“to be just a great big fucking disappointment. That’s it. That’s the
whole fucking picture. I never did anything fucking right, or fucking
good enough, except, maybe, to take a fucking shit.” The constant and
repetitive use of the word “fucking” infiltrated almost everything Mr V
said; he used it as a noun, a verb, and a modifier of virtually anything
and everything. This illustrates another prominent and characteristic
facet, a consequence actually, of what I will discuss more thoroughly at
a later point, as Mr V’s inadequately developed, as well as his degraded
and defensive, use of language.
His furious statement that he could only do right by “taking a shit”
was his shorthand way of commenting on a V family “legend”: among
all “the cousins” (there were seven children in his generation of the
extended family), he was the one that was toilet trained the earliest; in
fact, as the legend goes, he was mostly toilet trained by his first birth-
day and fully toilet trained not long after it. Everything Mr V knew
about his toilet training he learned from the “legend”; it was not, as far
as he knew, something he remembered. Being toilet trained so early was
the only thing involving him that Mr V ever remembered his mother
acknowledging with either a sense of pleasure or a measure of pride.
As Mr V saw it, his mother boasted about his early toilet training as
an achievement of hers, rather than his, and he could never even men-
tion it without falling into a rage: “She always said that she toilet fuck-
ing trained me so young. Well, I was the one who was toilet fucking
trained, not her. What did she fucking do to get so much fucking credit,
huh? All she fucking did was make my fucking life fucking miserable
unless I fucking did what she fucking said!”
Turning now to Mr V’s father: he sounded like a chronically depressed,
possibly alcoholic, and generally unavailable man, who aspired to be an
artist but, after his marriage, was unable to make a successful living at it.
His depression and withdrawal appears to have markedly increased on
the heels of his wife’s death. Mr V had nothing but contempt for his
father, whom he described as “a schmuck, who wasted his fucking life”
104 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

in a series of meaningless and unrewarding jobs. “He was a fucking

failure,” was how Mr V summed it up, whenever the topic of his father
came up. Mr V also constantly felt misunderstood by his father, and
said once, “Instead of talking fucking to one another, we talked fucking
past one another.” Despite the anger with which he always spoke about
him, the lack of connection to his father seems to have been a source of
frustration for Mr V. It was a painful absence that turned into what felt,
to Mr V, like a complete abandonment of him after his mother’s death.
Mr V complained bitterly about how he “became an orphan” after her
death, despite his conviction that neither of them really paid him any
mind when she was alive. Mr V vehemently said, on more than one
occasion, “I will feel deep fucking resentment toward them both for as
long as I fucking live. If I live for-fucking-ever, that’s how long I will
fucking feel that way.”
From the material thus far presented, and from bits and pieces col-
lected over the course of his treatment, it appears that Mr V’s mother
was essentially as narcissistic with him during his infancy as she
was described to be during the later years of his childhood. It seems
quite likely that the scale of his rage, certain of his problems with
reality-testing associated with a tendency towards action (specifically,
an unconscious belief in the magical power of action), can be traced
to excessive oral frustrations that prevented, or at the very least inter-
fered with, the development of areas of the ego (and specific functions)
that, with a more attuned mother, would have made the modulation of
affects, frustration tolerance, and impulse control more possible. His
mother’s use of him, even as an infant, to regulate her own narcissis-
tic pressures evoked chronically heightened states of tension that, since
he was only an infant, he had no capacity to either regulate or dimin-
ish. That early experience may have been the template for his life-long
condition of heightened affect within a chronic state of general over-
stimulation, and it may also account for his chronic inability to manage
the escalation of internal pressures in later life.
It is no surprise that narcissistic parenting raised, rather than
reduced, conflicts and they then led to broad defects and deficits in ego
development. Those early conflicts as well as the various impediments
in function they caused were all greatly exacerbated, and the defen-
sive structure he initiated in the oral stage acquired their distinctly anal
colouration, when Mr V was driven, apparently quite traumatically,
into such untimely urinary and bowel mastery. What came to have
 W H E N W O R D S FA I L 105

equal and, in some ways, even greater consequence for Mr V’s current
condition (and for his attempt at analytic work) were the injuries that
further stunted and deformed his psychic development during the anal
stage. In addition to the centrality and the critical impact of toilet train-
ing, we know that other important maturational requirements must also
be mastered by toddlers, not least of which are the challenges of differ-
entiation, separation, and individuation. Mr V’s advancement into the
anal-rapprochement phase created newer and more difficult problems
for him. How to cope with the demands of this new phase when griev-
ously unprepared in so many ways? How to negotiate it with grave ego
weaknesses (with an ego that is deficient in some ways and defective
in others)? How to traverse it lacking the defensive organisation that
should have been available from a successful passage through the oral
stage? And above all, how to negotiate all this with a highly narcis-
sistic mother, poorly attuned to his needs? Many of Mr V’s difficulties
could be traced to the functional pathology that originated or was exac-
erbated during this period of his life. Among the many far-reaching
developmental casualties that came to permeate his life, one in particu-
lar was a matter of real concern in contemplating his ability to make use
of analysis. This was Mr V’s inability to make use of the symbolising
functions of words, speech, and language.
In the brief case material thus far presented, the anal-aggressive
character of Mr V’s language use is obvious as he inexorably infuses his
speech with curses (“fucking” this, and “fucking” that) which may look
either phallic or Oedipal because of their content but which are more
closely related to a kind of angry anal smearing than anything else. The
concreteness of his speech, and how very literal his speech is, is also
readily apparent. We can see how poorly speech is distinguished from
action by him, and also how much he seems to use speech as a form of
action itself. And we have also seen to how great an extent his speech
is used for gross tension relief and discharge purposes, rather than for
the purpose of establishing a kind of communication intended to lead
us together into a shared “analytic reality”. But let us return now for
some additional data, in order to focus on the disturbances in how Mr V
made use of words, speech, and language, and on the implications it
had for his treatment:

Not long after Mr V entered treatment he told me the most amazing

story. At some point between the ages of four and six, or perhaps
106 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

as late as seven, a paediatrician told Mr V’s parents that his weight

was on the high side of normal for a child of his size. The doctor
went on to say that they might want to keep an eye on how he was
eating, just to be sure that he remained within the normal range
as he continued to grow. According to Mr V, his parents reacted
dramatically to this information. They responded as if what they
had been told was not that he was in the normal range, even if a bit
near the high side, but that he was grossly, dangerously, disgust-
ingly obese. They immediately began to treat him as if that were
true; they commented negatively and incessantly on his appearance;
they radically changed his diet; and they began to weigh him every
morning and evening, and sometimes even in the afternoon, too.

Once during that time he was sent to live with his grandparents for
seven weeks while his parents were off on a pleasure trip. Mr V said that
according to an agreement between his parents and his grandparents,
and much to his shock and dismay when his first mealtime arrived, he
was to eat every meal separately from them, and they were to feed him
only one meal per day. And that meal consisted of one cracker and one
glass of water. He was to receive only seven crackers and seven glasses
of water for each full week of the entire seven weeks of his stay with
them. In all the times Mr V told this story he never described sneak-
ing another cracker or glass of water when no one was looking. Mr V
said that he never discussed this with his parents or his grandparents.
He knew that if he raised the subject they would only tell him how fat
and disgusting he was. He reported that when they returned from their
trip, his parents resumed treating the issue of his weight exactly the
way they did before they had left.
Mr V told that story over and over again in his treatment and no part
of it ever changed. Mr V never wondered whether it was true; he never
wondered whether he actually could have been fed a single cracker
and only one glass of water a day, for seven weeks; he never wondered
how he survived this without becoming ill; he never wondered why
he had no memories of having lost weight as a result; he never ques-
tioned whether his grandparents really would have agreed to treat him
that way; he never wondered how he knew what would happen if he
asked his parents, or his grandparents, about this; and never did he
express any doubt about the story or any part of it. In addition, he was
never interested in their motives; he never wondered how they arrived
 W H E N W O R D S FA I L 107

at one cracker or one cracker per day, or how and why they settled on
a single glass of water. Mr V never speculated about why his parents
understood the paediatrician’s information the way they did, or about
why they reacted to it the way they did. Mr V was not interested, never
even remotely curious, about the repetition of the number seven (seven
cousins all told; being between four and six but perhaps as late as
seven when the paediatrician spoke to his parents about his weight;
seven years old when he stayed with his grandparents; and, the sevens
that were repeated so frequently in the story itself—seven crackers each
week, and seven glasses of water each week, for seven weeks). And, not
least of all these, Mr V also never wondered why he brought that story
up in treatment so frequently, or why he brought it up just when he did,
or why he even brought it up at all.
Mr V’s story was like a fly trapped in amber—a prehistoric tale,
brought intact and unchanged from a frozen past, into a frozen present
and future. The story may have been like a fly in amber, but his use of it
was not. Mr V used his story like a multi-purpose tool or a “Swiss Army
knife”; one of those things that have so many blades they can be used
for anything and everything. For example: Mr V’s preferred approach
was to fill his hours with event reports, and the instant he caught him-
self drifting away from “hard facts” or if, in telling about something,
he became aware of even the slightest indication of needing anything
from me, he would immediately launch into the “crackers and water”
story. If he had a memory of the past, the instant he realised that it was
a memory in memory form, he would launch into the story. Complain-
ing about his parents and his childhood was fine, but if he caught even
the slightest hint of need or even nostalgia in what he was saying the
story was soon to follow. There were many other occasions for telling
the story but, to give just one more example, it was guaranteed to come
up when he came in for a session and did not know what to talk about.
Every account of his story was given fully charged with affect. And
Mr V never tired of it, nor did he ever have anything to say about how
frequently it came up.
Mr V’s story was basically the same each time he told it. To him, that
was the equivalent of telling it exactly the same way each time. If there
was ever any variation, no matter how small, that I chose to comment
about—for example, if he said “I was brought to stay with my grand-
parents” instead of the usual “sent to live” with them, and I wondered
out loud about the wording change—Mr V would first become quite
108 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

angry and then deeply confused about what I said. His behaviour
with interpretations about this or anything else, no matter how
non-confrontational, tentative, or well timed they were (from my point
of view), received exactly the same treatment. He would not be able to
remember exactly what I said or how I said it, and he would ask me over
and over again to repeat parts of it. Soon he could not remember any of
it, and he drew a complete blank when he tried to recall what I might
have been talking about. This often escalated into his being unable to
remember anything either of us had said, right from the moment he
entered the room. The day after something like this he was likely to come
in saying that just after he left yesterday, or just before he got here today,
he finally “got” what I was talking about. He then would invariably mis-
quote me, either in the main or entirely. Next, he would tell me his under-
standing of what I would have meant by what I said, if I had said what
he said I said, instead of what I actually did say. I often felt with Mr V
that I was forever trapped in the famous Abbot and Costello routine,
“Who’s on First”; and if this has become just a bit too confusing to easily
follow for you, too, that was exactly the point. Usually within about ten
minutes of Mr V’s having “gotten” anything I said, he once again lost the
memory of who said what and even what it was about. He would try to
try to remember what he said, what I said, or the interpretation he had
made of it earlier that session, but was never quite able to grasp it.
As is obvious by now, it would be something of an understate-
ment simply to say that Mr V made attacks on linking. The violence
with which he destroyed meaning, without seeming to suffer a formal
thought disorder or an outright flight into psychosis, was charactero-
logical in nature rather than a defence that he could chose selectively,
even if unconsciously, to employ. This was Mr V’s reaction to almost
anything I might say that went beyond a superficial comment with a
clear link to the manifest content of his event report. The annihilation of
meaning was by no means limited to potential conflicts I might stir up
in him by making an interpretive comment, and attacks on linking were
just as likely to appear in the most routine of our interchanges. Ses-
sions easily could, and regularly did, deteriorate into these disorienting
“Alice in Wonderland” kinds of interactions. It may not have hap-
pened with such prominence right from the start of Mr V’s treatment,
or I might not have been exposed to the repetitive nature of it enough
to recognise it for what it was right from the start, or it is certainly pos-
sible that some countertransference reaction caused me to turn a blind
 W H E N W O R D S FA I L 109

eye to it. However, at some point during the first year of our work,
the quantity and the tenacious adhesiveness of these reactions not only
became apparent, they reached the point where they came to entirely
dominate the treatment. Worse yet, when the nature of the problem did
finally become clear to me, we had no way to work on it. Not surpris-
ingly, at least in hindsight, Mr V would react in his characteristic way
to any attempt I made to examine this very thing with him. Often, it is
said, the simple fact of knowing what one is dealing with is more than
half the battle won. That may be true for all kinds of problems but, in
this case, because his reaction made it impossible for us to talk together
about it, it was the way his treatment went for years.
When not furious, and not annihilating and obliterating mean-
ing, Mr V was actually a very bright, articulate, and creative person.
Because of time limitations I have not presented the many observable
strengths that at first supported my thought that he might be able to
benefit from analysis even though he had expressed reservations; over
the years I have seen numerous instances of analyses that started with
reservations and finished quite successfully. And beyond the initial
strengths I saw, I have also left out other assets of his (and some were
considerable, despite his difficulties). Given some of the strengths he
had, if Mr V’s problem was only that he tended to take umbrage too
easily, that he often felt unfairly treated, that he experienced any differ-
ence of opinion as a personal attack (either on him, or by him), that he
expected the worst in any situation, that he felt disappointments to be
overwhelming, that he experienced frustration as torturously painful,
that he had significant problems with affect regulation, that his object
relations were essentially sadomasochistic, or that he had such a strong
narcissistic current in his personality that he felt completely entitled to
be brutally retaliatory with people he felt deserved it and did not give
it a second thought afterwards (all of which were, in fact, true of him),
there would still, even with that extensive list of difficulties, be no obvi-
ous or unequivocal reason why we could not, together, do the analytic
work necessary to address those problems. To describe him in those
terms alone actually would make him no different from many of the so-
called “more difficult” patients that we regularly see in analysis today,
and who do in fact end up getting considerable benefit from it.
Mr V’s inability to use analysis effectively, the thing that makes him
so different from those others, is because he was not just presented with
conflict in his childhood (as they, and we, all are) but because he was
110 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

overwhelmed by it; and not just inundated by conflict alone, but beset
by it at a very crucial and decisive time. Mr V was flooded by unrelent-
ing implacable conflict before, during, and after the crucial period in
childhood when toddlers begin to develop the capacity to use words,
speech, and language for symbolising purposes and as a symbolis-
ing process. I do not mean the simple acquisition of vocabulary, or the
capacity to properly employ syntax and correct grammar; they can be
learned and their uses are all possible even if the symbolising func-
tion of language is not present. And I do not simply mean the use of
symbols, such as a cigar may stand for a penis or a purse may stand
for a vagina, although that facility is certainly a part of the symbolising
process. By the symbolising use of language I mean, for example, when
words, when language, and when speech can be used to bind affect
rather than only for the expression of it; I mean the ability to go beyond
simply using them for discharge purposes; using words, speech, and
language beyond the simple reduction of tension so that they can
become instead the vehicle of genuine communication; I mean when
words and speech can take the place of action, instead of being used
as forms of action; when the use of language has the capacity to distil
bodily tensions and sensations into modulated affect, or into thought,
or into both modulated affect and thought simultaneously; and, above
all, I mean when the availability of the symbolising function of lan-
guage enables one to gain some degree of psychic distance from pure,
unadulterated, unmodulated, raw, experience.
In considering the treatment of patients like Mr V my focus will
be on the patient’s internalisations of the analyst, the analyst–patient
transactions, and the analytic relationship. I will describe how that
can be achieved only by continuing to use verbal interpretation, if not
directly for every intervention at least as the fulcrum for interventions
with these patients. And I will explain the value in doing this despite
the impediment these kinds of patients have with the functional use of
words, speech, and language. Finally I will explain why, despite how
paradoxical it appears to be, it is essential to engage in ongoing verbal
interpretation throughout the analysis despite the fact that interpreta-
tions will not be likely to have mutative value for these patients until
they are relatively close to the completion of the analysis. My focus on
internalisation processes is not unique. Dorpat (1974, quoting Loewald,
1962) tells us that, “all analytic patients internalize patient-analyst trans-
actions”. I agree that this is a ubiquitous process with every patient, no
 W H E N W O R D S FA I L 111

matter how “difficult” or “easy”, and I would only add the point that
the more pronounced the pathology of the patient, the more critical the
patient’s internalisation processes will be in the conduct of an analysis.
I am aware of the seemingly contradictory nature of recommend-
ing a treatment that is based, to a considerable extent, on the sustained
use of verbal interpretation with exactly the kind of patient who, at the
very best, may only be able to understand the words that are used in an
interpretation; who, if asked, could probably repeat the interpretation
word for word; but who, nevertheless, is refractory to interpretation.
I am also aware of how much more contradictory still it must seem to
suggest doing exactly the same thing with the more extreme version of
this kind of patient, that is with the kind of patient who cannot make
sense of an interpretation, who cannot even take it in, and who could
not repeat it back if his or her life depended on it; with the kind of
patient who, at best, finds interpretations useless and, at worst, experi-
ences interpretation not as a relief but as an active source of frustration
or as an outright attack.
My approach to such patients has been informed by many of
Loewald’s (1960a, 1960b, 1962, 1970, 1973, 1979, 1986, 2007) ideas about
what makes analysis possible, which I believe are equally applicable
despite the vast difference between most of the patients he had in mind
and the ones I am concerned with. I have also benefited greatly from
his ideas about what makes an interpretation mutative, despite the fact
that I am considering what kind of work can be done with patients for
whom interpretation is either meaningless or useless. Loewald’s views
on internalisation processes in psychoanalysis are rooted in a model of
the analytic dyad in which certain very critical ego identifications and
superego identifications are taken on by the patient. Those identifica-
tions are not simple imitations, and when the process is functioning as
well as we hope it will, those identification processes exist at extremely
high levels of abstraction. From Loewald’s point of view, identifications
are not what bring about a cure and they are not the equivalent of (or an
attempt to provide) a corrective emotional experience. He is suggesting
instead that these identifications—not with the personal ego and super-
ego of the analyst but with the analyst’s analytic ego and the analyst’s
analytic superego—are essential ingredients in making the therapeu-
tic environment (or what one might call the analytic situation) possi-
ble for patients. The safety of the analytic environment cannot be taken
for granted by anyone, and it is especially not a given for patients like
112 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

Mr V; it may be the starting point from which everything else proceeds,

but it requires extensive analytic work, often over many years, before its
safety can be established with patients at that level or with that kind of
pathology. The ability to bring in to treatment actively conflictual mate-
rial, to expose wishes that are unacceptable, forbidden desires, and ter-
rible, sickening fears, everything that is strenuously defended against
in order to block them from ever emerging into consciousness, is close
to impossible even for neurotic patients with fully adequate symbolis-
ing functions and complete mastery of verbal expression. It is an astro-
nomical order of magnitude harder for patients like Mr V; however, he
and all the others, no matter where they fall on the spectrum of psy-
chopathology, facilitate their experience of the analytic situation as safe
enough to confront these things not by reality testing but through an
unconscious process of internalisation. Loewald suggests that a partial
substitution of the analyst’s analytic superego can alter the patient’s
superego in much the same way that a teacher can assume the moral
authority of a parent when a child is first sent to school. And it is the
result of this identification altering the patient’s superego, not a takeo-
ver but a subtle retuning of the superego, that enables the patient to
allow material that is ordinarily disavowed and warded off to arise into
the preconscious and then, finally, to emerge into consciousness for
exposure to analytic work.
In considering the degree of attunement necessary to make inter-
pretations, Loewald draws on the mother-infant analogy. Loewald is
concerned with shaping the communication in such a way that, just
as happens with a mother and her baby, it accurately complements
the patient’s capacity to take it in. In his analogy the baby, experienc-
ing undifferentiated painful levels of tension, learns to differentiate
and identify the differences, for example, between wanting to be held
but not necessarily fed and wanting to be fed and not only held. I will
extend this analogy in order to suggest what I think happened over the
course of many years to have made analysis actually useful for Mr V
(and you must have guessed that it turned out to be, otherwise why
would I be writing this chapter?). When the baby recognises from its
mother’s behaviour that it wants to be fed, not picked up, or picked up
but not necessarily fed, we would say that the mother has communi-
cated the contents of her ego to the baby by getting what her baby needs
right, first through trial and error but after that, again and again, in a
systematic way. Over and over again, these experiences take place and,
 W H E N W O R D S FA I L 113

eventually, when the baby has learned the differences and knows what
it wants, we would say that the contents of the baby’s ego are reflecting
the contents of the mother’s ego. By the time the baby can imagine sat-
isfaction as a way of tolerating the time it takes for the mother to come
and actually satisfy those needs, among the many things we might say
about denial, hallucinatory wish fulfilment, magical thinking, narcissis-
tic omnipotence, the omnipotence of the wish, etc., we would also say
that an identification has taken place; we would say that the contents
of the baby’s ego exist through identification with the contents of its
mother’s ego.
There is, however, something else that is happening here which is
of even more importance; that is, through the baby’s observation of its
mother, another, different, and infinitely more important identifica-
tion is taking place. As the baby takes in what is happening, however
much primitive perception and immature cognitive processes permit,
the baby sees the mother at first struggling to figure out what is bother-
ing her baby, what her baby needs. This is not something she knows
automatically as a result of hard-wired signals between the two of them
that make it unmistakable. In fact, the mother makes mistake after mis-
take, getting it wrong at first much more often than getting it right, and
that is not just something the baby sees but something the baby experi-
ences, until finally the mother comes to recognise the cues in her baby
and cues in the environment that make the baby’s needs comprehensi-
ble to her. But this is not all; if the mother understands what the baby
needs but does not deal with it correctly, the baby does not learn what it
needs to, or what it is supposed to, from the interaction. For example if,
instead of feeding baby when that is what it needs (and not feeding
but holding baby when that is what it needs), she says to her newborn
infant instead, “You know Sweetie Pie, you have two kinds of cries, one
for being fed and one for being held, and this is the one you use when
you want to be fed,” there is no way imaginable that this baby will get
anything beyond intense frustration and increased agitation from her
behaviour. The mother has to respond properly for the baby to get what
it needs psychologically from this. But even when she is on the right
track she still will not get it right immediately or even all of the time.
The baby will witness the mother’s trial and error attempts to satisfy
its needs in a way that is appropriate not just to its needs but also to
its abilities, until she finally can get all of this right most of the time.
In this process the baby will be witnessing its mother’s ego at work;
114 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

not just the contents, held versus fed, but the struggle to comprehend
it all—what it is that is happening, what has to be done about it, how
does it have to be done for it to be done right—everything that needs
to be understood and done. The baby will not only identify with the
contents of its mother’s ego, it will also identify with the functions of its
mother’s ego, that is, with the ego as a structure that makes sense out
of things, that takes action when needed, that figures out what kind of
action is best. I am suggesting that patients with immature, damaged,
or deformed egos, in witnessing their analyst’s attempt to understand
and help them, are able to take in not only the contents of their ana-
lyst’s ego during that process but also can make use of the much more
important internalisation of their analyst’s analytic ego as a functional
structure, as a substitute and, over the passage of considerable time,
as the model for their own now repaired ego in much the same way as
I just presented in the analogy.
The analyst is never passive in the treatment. The analyst is con-
stantly struggling to understand what is going on, is working hard, all
the time, to make some kind of reasonable sense out of what happened
to this patient or is happening at the present moment in the treatment,
and why. The patient is unable to communicate sufficiently, so that the
analyst struggles constantly, and almost in isolation because it is so one-
sided, with what happened to this person to create such difficulties.
Where did this pathology start, why is it so severe, why this kind of
pathology in particular? What strengths does this person have; how
did the strengths develop, why these particular strengths? What does
that story mean: is it a memory of something that actually happened;
is it a memory of what the patient wished would have happened; is it a
memory that is the opposite of what happened; is it a memory of what
the patient was afraid would happen; is it a memory of something else
entirely; is it a screen memory; is it a memory that is changed specifically
to allow the patient to be in an active position instead of being forced to
be a passive victim; is it not a memory at all; is it pure fantasy, and, if so,
to what end; is it actually multiple fantasies or multiple memories rep-
resented by this single memory; is this the product of innumerable reor-
ganisations of fantasy? And, what is it that is behind these constantly
shifting, always larger than life, versions of me that the patient experi-
ences; or behind this impossibly static and eviscerated version of me
that the patient constantly experiences? And, what just took place in the
patient’s mind to cause what just happened between us; or is it because
 W H E N W O R D S FA I L 115

the patient registered the presence of something that just happened in

my mind, and misunderstood what it was; or is it because something
just happened between the two of us that I completely missed, let alone
made proper sense of? The analyst struggles with understanding in
this way, trying to make some kind of reasonable sense out of these
kinds of things, for years; and throughout all that time the analyst is
always doing this in the presence of the patient. It matters little whether
the patient uses the couch, sits up, or paces the room as the analyst
engages in this ongoing struggle because it is not just what the patient
sees, nor is it only what the patient hears, nor is it particularly what the
patient can read about the analyst’s unconscious at any given moment;
it is the apperceptive reception, everything that impinges from every
possible source that will register over time, the manner in which all
ways of experiencing become melded in the patient’s experience of the
analyst’s struggle to understand the patient that will come to have the
power to imprint something meaningfully different in the patient’s
mind. The patient is also the witness, the apperceptive recipient, of the
analyst’s constant struggle to find ways that will help the patient to
understand these things, to find a way to help the patient gain perspec-
tive, to examine inner experience, and to acquire a meaningful under-
standing of both current and past experience. And this is why a retreat
from talking to the patient analytically must not happen. Wishes, fears,
defences, transference, resistance, all that and everything else analytic
needs referencing as analytic throughout the work. It does not matter
what modifications in the traditional frame may have been necessary
in the course of the analysis, they must be talked about analytically.
It does not matter how much or how little support has been necessary,
nor does it matter what kind or for how long, it must all be talked about
analytically. It does not matter how damaged a patient’s functional use
of words, speech, or language may be, to turn away from analysis in
favour of uninterpreted support will, whatever immediate problem in
the treatment it is intended to solve, end up depriving the patient of
infinitely more than anything that could possibly be gained by it.
It took more than a decade, but Mr V eventually did make gains in
his treatment; in fact, gains that were as significant as any reasonable
person could wish from analysis. That was the evidence and the proof
of my assertion that continuous meaningful verbal interpretation was
not lost on Mr V, nor is it lost on patients like him; and, while it remains
undeniably true for most patients of this kind that interpretations
116 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

take on their greatest analytic power near the end of their analyses,
interpretations are, throughout, what enable the end of an analysis to
ever come into sight.
What is striking in Mr V’s positive outcome was his eventual abil-
ity to use interpretation. I have attempted to describe the kinds of
unconscious internalisation processes that allowed Mr V to acquire the
symbolising function of language, words, and speech; and the analytic
conditions that facilitated those internalisation processes, which led
to his being able to use at first my interpretations, and eventually his
own interpretations, thoughts, and ideas to better understand himself.
I see this as a transformative interpersonal experience that fosters intra-
psychic maturity; it is an internalisation process that affects a patient’s
functional capacities which then, through further sublimation, becomes
a dynamic property of autonomous unconscious mental life that ordi-
narily remains available forever. For Mr V this became possible because
I did not favour support (the attempt to manage indisputably prob-
lematic functioning) over trying to progressively understand him; and
because I accompanied whatever I thought I understood, always, with
a constant effort to find a way of using words, however difficult that
appeared to be, to express that understanding to him in a way that was
meaningful to him, not just to me. Support, as contrasted with inter-
pretation, employs action; and support does not exclude how one uses
words, because the supportive use of words means using them as a
form of action (for example, in reassurance designed to calm or soothe
rather than to convey deeper understanding). The necessity of support
is unquestioned in the treatment of many very disturbed patients, but
my point is that when the preverbal/nonverbal nature of the patient’s
mental processes, the deep impairment in the patient’s functional and
symbolising use of language, words, and speech, causes the analyst to
despair of interpretation, the necessary support then becomes an end in
itself; and the end having been achieved, there is no longer any reason
to talk further about it. In this, the very best one can possibly hope for,
even with the most positive outcome, is a transference cure. There are
many reasons why a person may not be able to develop the ability to
use insight, no matter how doggedly the analyst hews to interpretation:
severity of pathology (Mr V’s degree of pathology is by no means the
ultimate possible), overwhelming traumatic injury leading to ineradica-
ble psychic scarring or destruction, and low intelligence, are among the
most obvious. A transference cure is nothing to scoff at for people who
 W H E N W O R D S FA I L 117

are genuinely incapable of structural change. Let us make no mistake

about this: for many people in that position it can change a hellish exist-
ence into a life worth living. But I am trying to make a distinction here
between something intrinsic in the patient and something the analyst
does, that is, the analyst’s abandonment of consistent analysis, however
well meaning, that ultimately may limit the outcome to a transference
cure. As wonderful as a transference cure may be for some, the benefits
that structural change confers on those who are capable of achieving it
are vastly superior. Anything short of genuine structural change would
have short-changed Mr V. In current practice we are regularly presented
with pathology that seems so very deep and seems to so infiltrate the
patient’s personality that we are tempted to think of the modifications
that may be necessary rather than the analysis that may be possible.
That is certainly understandable, but it should not become so automatic
a response that it turns out to be us, rather than the patient, who are
unable to analyse.

References
Dorpat, T. (1974). Internalization of the patient-analyst relationship in
patients with narcissistic disorders. International Journal of Psychoanalysis,
55: 183–188.
Loewald, H. (1960a). On the therapeutic action of psychoanalysis. Interna-
tional Journal of Psychoanalysis, 41: 16–33.
Loewald, H. (1960b). Internalization, separation, mourning, and the super-
ego. Psychoanalytic Quarterly, 31: 483–504.
Loewald, H. (1962). The superego and the ego-ideal. International Journal of
Psychoanalysis, 43: 264–268.
Loewald, H. (1970). Psychoanalytic theory and the psychoanalytic process.
Psychoanalytic Study of the Child, 25: 45–68.
Loewald, H. (1973). On internalization. International Journal of
Psychoanalysis, 54: 9–17.
Loewald, H. (1979). Reflections on the psychoanalytic process and its thera-
peutic potential. Psychoanalytic Study of the Child, 34: 155–167.
Loewald, H. (1986). Transference–countertransference. Journal of the
American Psychoanalytic Association, 34: 275–287.
Loewald, H. (2007). Internalization, separation, mourning, and the
superego. Psychoanalytic Quarterly, 76: 1113–1133.
CHAPTER EIGHT

Some observations about working with

body narcissism with concrete patients
Janice S. Lieberman

I
n the recent documentary film Valentino, the Last Emperor, the great
fashion designer asked (as did Sigmund Freud a century ago): “What
does a woman want?” The answer was simple for Valentino, but not
for Freud. “A woman wants … to be beautiful.” I think that Valentino
had it right on many levels. The wish to be beautiful is true of many
women. Many men too want to be handsome, and many men want to
be with a woman who is beautiful. Psychoanalysis has had little to say
about the wish for beauty, yet it dominates the thoughts of so many.
In my private practice in New York I have found that increasing
numbers of patients present initially or after some months of psychoan-
alytic treatment with preoccupying concerns about bodily and/or facial
appearance. They do not understand their anxiety about these issues to
be “symbolic” of anything. Although they are intelligent and may be
able to understand other feelings about other issues in more abstract
ways, their worries and questions about the importance of their looks
are concrete, and so is the language they use. One university professor
confessed that: “When I look in the mirror, I am not sure of what I see
and I need someone to tell me what they see.”
Many of today’s patients suffer from developmental deficits linger-
ing from childhood. They were not really “seen”; they were incorrectly
119
120 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

“seen”; or they were falsely mirrored. They do not as adults really know
what they look like and are vulnerable to being shamed, humiliated
on a bodily level. The body image is not constant. (We have coined
the term “object constancy” but not “body constancy”!) These patients
come into treatment with enhanced body awareness accompanied by
enhanced shame, self-consciousness, and a profound need for attention
given to their bodies. Many do not have sexual relations or have sex
infrequently, shame being an inhibitor, or in some cases shame func-
tions as a defence against the experiencing of sexual feelings.
Disturbances in body narcissism are often reflected in more or less
temporary disturbances in the capacity for metaphoric language when
speaking about the body, its appearance, and its maintenance. It is my
thesis that psychoanalysts should not “rush to metaphor” as they have
been trained to do when making interpretations, but rather, they should
“linguistically attune” to such patients. Concrete responses from the
analyst about his or her observations of the patient’s body issue in ques-
tion, of what is revealed at the level of the skin and clothing, actually
facilitate the patient’s capacity for symbolic thinking. Such responses
repair the narcissistic deficit underlying the preoccupation, allowing
the ego to grow and further develop.
When Freud wrote in 1923 that the ego is first and foremost a bodily
ego, I believe that he was referring to an inner experience of the body.
The patients I speak of here refer to: (1) their external bodies as seen
from the outside by themselves in the mirror—the body’s size, shape,
muscle tone; and (2) from the inside, by their own critical internalisa-
tions. Freud’s neglect of the external, visually understood body was
explained by Gilman: “Freud’s intellectual as well as analytic develop-
ment in the 1890s was a movement away from the ‘meaning’ of visual
signs … to verbal signs, from the crudity of seeing to the subtlety of
hearing” (1995, p. 22). Gilman (1998) also wrote that “Freud stopped
seeing the outside to [sic] the body as a means of judging the inner
workings of the psyche and focused on the invisible and unseeable
aspects of the psyche.” He now saw the fantasy as the source for the
types of physical ailments that manifest themselves in sexual dysfunc-
tion and hysteria” (p. 93). Freud did not like his own looks. He did not
like to be photographed and he made faces when he was. His mother’s
vanity might have influenced his championing a “talking cure” rather
than a “looking cure”.
Another twentieth century intellectual, Jean-Paul Sartre, regarded
himself as the victim of the look. As Jay (1993) noted: “The body looked
 S O M E O B S E RVAT I O N S A B O U T B O DY N A R C I S S I S M 121

at was to Sartre a fallen object subject to the mortifying gaze of the other”
(p. 22). Mirrors were fraught with danger for Sartre and for Freud too.
In The Uncanny (1919h) Freud reported an overnight train ride in which
a mirrored door opened and an elderly man in a dressing gown came in.
Freud thoroughly disliked the man’s appearance. Then he realised that
it was his own image in the mirror. Freud never mentioned in the Wolf
Man case what Brunswik (1928), the Wolf Man’s second analyst noted.
According to Brunswik, the Wolf Man “neglected his daily life because
he was so engrossed, to the exclusion of all else, in the state of his nose”,
its supposed scars, holes, and swelling: his life centered on the mirror in
his pocket, and his fate depended on what it revealed or was about to
reveal” (see Phillips, 1996, p. 19).
Whether they did so in Freud’s time or not, many of today’s patients
come into psychoanalytic treatment feeling ashamed about the way
they look, whether the shame has to do with the entire body or it parts:
arms, legs, face, nose, lips, hair, body fat, acne scars, tallness, shortness,
etc. Others are ashamed of the way their lovers or spouses or parents
look. Most psychoanalysts, in classical Freudian tradition, pay little
attention to these concrete complaints, assuming that they are manifest
content and derivatives of inner dynamics, compromise formations.
I have found that working with patients who are ashamed of their bod-
ies by interpreting what I assume must be the underlying fantasies and
meanings of the shame either hits a stone wall of non-comprehension or
in some cases, meets with intellectual compliance with the interpreta-
tion, but little alteration of the shame experience.
I see shame as a painful and powerful affect suffered early on at a
time when the child lacked the words that would have made the shame
experience more bearable and metabolisable. In addition, the bodily
and social vicissitudes of early adolescence force one to revisit these
early affects and combine with them to produce the language-deficient
shame we see in our consulting rooms with adults. Jacobs (2005) has
recently postulated the “adolescent neurosis” as equal to or even more
important than the “infantile neurosis”. He speaks about early adoles-
cence and its bodily disharmony (ages eleven to fourteen) and notes
that it is quite difficult to retrieve memories of shame about the body
from this time, the teasing and exclusion by peers, because the young
adolescent does not have the capacity for metaphoric thought that the
later adolescent has.
As I emphasised in my (2000) book Body Talk: Looking and Being Looked
at in Psychotherapy, the body is a concrete object with an actual concrete
122 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

manifestation and actual physical feelings (as opposed, say, to an idea

or a fantasy). We have to begin to deal with our bodies well before the
emergence of abstract thought … therefore, psychological issues about
the body appear to require a concreteness of thought other issues do
not. I have found that concrete thinking is often connected with prob-
lems in the development of the bodily self and its boundaries, and is
connected with early deficits in attention to the body, its care, and main-
tenance. Such problems intersect and interact with the development of
inner fantasy, conflict, and defence from early childhood on.
It has been a decade since I published that book, and I have been
able to fine tune my thinking about the relationship between bodies
and language due to a plethora of articles and books recently pub-
lished that confirm and add to my theories. (Among them are Farrell,
2000; Lombardi, 2003, 2008; Mitrani, 2007; and Steiner, 2006.) When
I researched my book, I missed the important work of Rizzuto (1988)
who noted that: “Psychoanalytic theorizing has not paid enough atten-
tion to the function of language in the development of character struc-
ture, transformation of object relations, but most important, regulation
of affect and self-esteem” (p. 2). She has observed that “The avoid-
ance of communication seems to be a defence against the transference.
For these patients, that is the transference” (p. 4).
Several recent cases both in psychoanalysis and psychotherapy have
provided me with more insight into the underpinnings of body narcis-
sism. I have had to think more about the role of shame due to my pres-
entation on a panel on Shame and the Body in New York with Riccardo
Lombardi in March 2006. The writings of others have helped me to
analyse my countertransference reactions, potentially powerful and
disruptive to treatment. In my work with these patients, I have had to
tolerate exposure to abject bodily processes and have had to think about
and talk about them. I have had to tolerate constant cycles of need and
rejection, provocations to withdraw from the treatment in transference/
countertransference cycles that repeat the early relationship with the
mother.
I will present to you three case examples.

First case vignette

Amanda, a thirty-five-year-old marketing executive, was referred to me
for psychoanalytic treatment by the analyst she saw while in college.
 S O M E O B S E RVAT I O N S A B O U T B O DY N A R C I S S I S M 123

She had relocated to New York at the age of twenty-five, but had not
“psychologically” separated from her mother, with whom she was in
cell phone and e-mail contact many times a day. Her parents had been
divorced since Amanda was nine. Her mother was their “mainstay”.
Her father, considered to be quite “crazy”, was essentially unavaila-
ble. Her mother would stay in a hotel, visiting for a month at a time.
Mother’s visits (as well as phone calls and e-mails) involved constant
negotiations about money. I had the feeling that Amanda wanted to
suck her mother dry.
Although I had been told by the referring analyst that Amanda had
a serious eating disorder, an attractive, trendily dressed young woman
swept into my office. She may have seemed anorectic elsewhere, but
was more normal by New York standards. The referring analyst thought
she was a virgin still. Amanda reported living with James, an architect,
who adored her and who listened to all her complaints, soothing her
endlessly as he did his mother. He barely earned a living and Amanda
was angry that she was their main support. She also described James
as a “baby” who could not handle the simple matters of life; it seemed
clear to me that she wished that she could trade places with him as the
one who played “baby”.
Amanda told me that she sought treatment to keep her resolution to
do “good things” to her body. She wanted to become pregnant and had
been told that she might not be able to do so because she had not men-
struated in eight months, or very much before that, for that matter. She
told me that after a boyfriend jilted her at the age of sixteen she became
anorectic and had to be hospitalised for a while. Since then her diet was
vegetarian only and she had little appetite for many foods. She was an
internet addict, researching every food she ate for problems. I detected
considerable grandiosity (“I can only eat the best”) as well as paranoia
in this matter.
As treatment began, Amanda began to visit a series of dermatolo-
gists and was particularly upset by one who “assaulted” her by biopsy-
ing several small bumps on her chest. She experienced this as a kind
of rape. (The displaced negative transference was thus activated.)
On some level I believe that she was experiencing me as attacking her
and invading her, but she protected herself from awareness of this
through displacement.
Amanda had a slight case of acne and became obsessed with it. She
stood in front of the mirror for hours looking at and squeezing the
124 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

pimples, thus making the irritation worse. She tried all kinds of creams
on her face, then looked up their ingredients on the internet, concluding
that they were “bad” for her. She argued with each dermatologist about
the safety of the creams and antibiotics they prescribed. She came to me
as “referee” and spent countless hours with her mother on the phone
about whether these products would cause her permanent damage.
(Her mother seemed to share similar concerns about her own body.)
Amanda was concerned that with her anorexia and her treatment for
acne she had done “permanent” damage to herself, had caused perma-
nent scars.
A classic understanding of her problems would be one of castra-
tion anxiety and fears of genital damage. My treatment of her was
along the lines described in my (2000) book: I spoke with her quite
concretely, since she was unable to speak of her issues as if they had
any psychological meaning. She wanted me to see her face each ses-
sion and to let her know what I thought: was it better or worse? She
came in suffering. “I’ve had a miserable weekend. I have driven my
boyfriend and my mother crazy.” I thought that she wanted to drive
me crazy too. She burst into tears the way a two-year-old might do.
In addition to the dermatologists she visited, Chinese herbalists, acu-
puncturists, and cosmeticians were called on to look at her and give
their opinions. She challenged every suggested treatment. I was called
upon as another “mirror” to try to soothe the bad image she had of
herself. She would come in and confess (in a highly dramatic man-
ner): “I was BAD”, meaning that she had picked her pimples. It was
high drama, and I was quite aware of the role I had been cast in. I was
also willing to play that role, since it confirmed the hypotheses I had
developed about working with body narcissism. The kind of aversive
countertransference I might have had fifteen years prior (“I cannot
believe that I am listening to such rubbish!”) was quite muted due to
my experience with so many of these patients, what I regard as the
patients of our time.
A concurrent scenario was being played out on the gynaecologi-
cal end as Amanda sought treatment for what she imagined to be her
“infertility”. She had been told as a young girl by a doctor her mother
had taken her to that she would have problems conceiving a child.
She pitted several traditional medical doctors against several Chinese
doctors. This daughter of divorce trusted no one. She was afraid that
the hormones the medical doctor prescribed would damage her eggs
 S O M E O B S E RVAT I O N S A B O U T B O DY N A R C I S S I S M 125

and that the herbs given her by the Chinese doctor had aggravated
her acne.
I continued to look at her face as she came in and commented about
the redness or lack thereof of her pimples. I asked her if she had picked
them. My concrete interventions and my taking her complaints seri-
ously began to calm her down after many weeks. She needed reassur-
ance that she had not permanently damaged her face or body. I did not
offer it but did offer attention and talking. My task, as I saw it, was to
look, to be verbally descriptive, affirming, and to avoid any seductive
or personal, non-professional compliments or vocal intonations.
I used my psychoanalytic lens to understand what was going on
underneath. She was quite conscious of envying a pregnant friend,
the envy being so great that she could not see her friend any more.
As is my custom from time to time to test the current level of my
patients’ thinking, I tried a metaphoric statement: “The bumps on
your face may represent baby bumps.” She had no response to this,
as if it were nonsense. At another time, I interpreted, “Picking your
face is a substitute for picking on yourself,” but this too went nowhere
with Amanda.
Somehow the traditional medical doctor’s advice prevailed and
Amanda took antibiotics and then progesterone for a week. At her
check-up she was told that she was pregnant. (In the transference,
in which she was a needy child, no mention of sexual relations had
been made.) Fleeting moments of pleasure about this fact were soon
turned to pain and worry as Amanda feared she had already damaged
her baby with the various creams she was putting on her face for her
acne as well as whatever was in the little food she was eating. Her visits
to the dermatologists now included her obsessive questioning about
the safety of their products for pregnant women. They reassured her,
but she then found on the internet that they were not “safe”. Her fears
of damaging herself then morphed to damaging her baby. She stayed
in the house at the weekends because she did not want to be seen
with acne.
Concurrent with the treatment in which she was quite regressed,
Amanda was working in a very challenging job. She received a con-
siderable salary raise during this time. Her job required a high level of
interpersonal as well as other skills. She and her boyfriend kept appoint-
ments with the doctor who was to deliver her baby (although she had
a second one waiting in the wings.) She consulted with a nutritionist
126 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

about prenatal nutrition and brought in to her sessions bags of “healthy”

food to show me she was taking care of herself in this way. I believe that
the transference reflected a regression in body narcissism that had to be
worked through with me as a kind of verbal mirror, continually reflect-
ing back to her what I saw.
Although her mother seemed to be quite attentive to Amanda as an
adult, there is some evidence of severe neglect when she was a young
child. She has a memory of having broken a glass at the age of four. Her
mother did not have the resulting torn finger repaired properly. One
can only wonder what fantasies emanated from this, e.g., castration
fears. When in treatment with her former analyst, Amanda developed
psoriasis on that very finger, and the analyst interpreted her somatisa-
tion as due to that trauma. She remembered after many months having
to wear a metal bar that connected her shoes while she slept, a method
used to correct a slightly displaced hip. When she asked her mother
about it, her mother could not remember it.
From the transference I have concluded that Amanda was a needy
and annoying child who her mother tried to appease and then ignore.
Her pregnancy gave her the excuse to not return to her home town that
summer. She feared being seen with the acne.
Although she had quite a distance to travel to my office by subway,
Amanda came to her sessions until the week she was to give birth. Her
skin seemed miraculously better, for she had ceased aggravating it
with picking. She was excited and looking forward to the birth process.
“Squeezing the baby out” was my metaphor, a replacement for squeez-
ing her skin.
She sent me an e-mail and photos of her lovely baby daughter Emily
and was proud of having a quick delivery and natural childbirth. She
planned to nurse Emily. Her mother arrived to help her out for the
first month. Amanda enjoyed the breastfeeding, but Emily developed
colic and screamed for several weeks. When she was three months old,
Amanda brought the baby to my office. She seemed quite comfortable
caring for her in my presence, nursed her, and was very proud to dis-
play her skills as a mother, her child’s lovely outfit, and her own white,
unblemished face. She had to resume her job on a part-time basis and
hoped to continue sessions. I did not hear from her for several months,
somewhat of a surprise to me, since she had seemed so attached to her
treatment.
Prior to my summer vacation that year, I received a frantic call from
Amanda. She had hired a nanny to take care of Emily and the nanny
 S O M E O B S E RVAT I O N S A B O U T B O DY N A R C I S S I S M 127

was quite critical of her continuing to nurse at eight months. She felt
that the baby was not getting enough food. Amanda said that the
paediatrician was not unhappy—the baby was in the fortieth percentile
in weight. She was leaving in a few weeks for a month in her home
town. Her ninety-two-year-old grandmother might die if she did not
come, as she put it. Six weeks later, she returned, speaking in her ses-
sion as if she had never left. It seemed that the nanny had been the
recipient of strong negative (and some positive) transference feelings.
Amanda was hysterical over fears that a man she had paid $500 to put
in a water filter was not trustworthy. She feared that the water in her
apartment was not safe for the baby. Although there might have been
a slight reality to her concerns, it was apparent to me that the visit to
her family had reawakened her paranoid anxieties. As she reconnected
with me, she began to calm down. Her language was no longer con-
crete as she spoke about feeling that she had to respond instantly to her
baby’s cries and did not want to work to earn money so she could give
her good care. She was having difficulty dealing with her daughter’s
demands (as her own mother had), and her own greediness in demand-
ing money from her mother was coming to the surface. It seemed to me
that the anxieties about her acne were defending against the material
that was now emerging.

Second case vignette

Shame about her body affected my patient Wendy’s willingness to
engage in sexual relations. It became at certain times in the treatment
the predominant theme. Wendy at thirty began an analysis after her
brief marriage ended in divorce. She also had had relationship difficul-
ties with men, her parents, her brothers, women friends, and her bosses
at work. She hoped through the treatment to better understand herself,
to remarry, and to find a better job. Oedipal rivalry with her mother,
masochistic revenge and surrender to her mother, penis envy, and low
self-esteem about being a girl were strong components of her psychic
development. When she spoke about her relationship difficulties she
was highly articulate and able to grasp the meanings of her difficul-
ties in terms of her inner conflicts as we knew them from the analysis
of her infantile fantasy life, her early memories, her dreams, and the
transference.
I will tease out from these other issues the kinds of shameful issues
Wendy spoke of from time to time, focusing on them for weeks or
128 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

months: her body and bodily processes, of which she was ashamed
and contributed to her feeling like an outcast. An early dream made
it apparent that she experienced her body as a messy kitchen drawer.
When in this state of mind Wendy would walk into my office with her
head turned to avoid my eyes and left the same way. She feared under-
arm odour, sweated a lot, and wore dress shields, which made her even
warmer. Her sweat or odour were never manifest. Wendy was slen-
der with a boyish figure, but complained that she was too fat, that her
legs and thighs were thick and that her body had ugly cellulite on it
that no man would want to look at. Her breasts were too small—her
brothers got penises but the compensatory breasts she had hoped for
never grew.
She had numerous childhood and adolescent memories that but-
tressed the reality for her of her bodily shame. She told me these stories
over and over. As a child, when she sneezed, she honked and long snot
emerged. Her brothers called her a snot-nosed snotter (and as an adult,
despite this shame, or perhaps because of it, her behaviour could be
most aptly described as “snotty”). Her mother forced her to do exer-
cises to reduce her thighs when she was a teenager. At college the boys
hung up a ham hock in honour of her “thunder thighs”. It took years
in treatment for her to wear tailored trousers: there was little reality
to this shameful perception of herself, for she wore size six. Her other
chronic complaint was her shame over having “nothing to wear”. She
did not know what clothes to buy, spent her weekends in the stores,
bought clothes she loved for an hour, then hated them, and had to
return them.
Wendy recalled her mother, who died a few years into her treatment,
as always elegantly dressed and slender, taking her shopping, trying to
force clothes on her that she did not want. Her mother was not tuned
to what she needed for her body to feel right and therefore Wendy was
unable to do so for herself. She barely listened to my words for many
years. She could not bear to hear me speak and would shout that I was
interrupting her. It was apparent, however, that she needed me desper-
ately: she never missed a session and always came on time, never miss-
ing a minute, let alone a session. Nevertheless she denigrated me. I was
a “nothing”, just like her. Several years into the treatment and having
worked with a number of patients who were ashamed of their bodies,
I found a way to work with Wendy:
 S O M E O B S E RVAT I O N S A B O U T B O DY N A R C I S S I S M 129

W: I never feel that I look that great. I never know what to wear. I am
so uncomfortably warm today.

A: It is 90 degrees out. Yet you are wearing a wool cardigan and slacks.
What about that?

Wendy’s deepest dread of sweating and smelling was getting close to

realisation by her garb. I made a mundane statement that addressed a
concrete reality that I saw before me. I showed her that I was looking
at her bodily rather than thinking about the “meaning” of her words.
(Warm because of sexual feelings heating up? Wanting me to find her
looking great and fishing for a compliment? That is, the more classical
explanations and interpretations.)
Then:

W: I have to go to a business lunch tomorrow at the Four Seasons and

I have no idea of what to wear. I will feel humiliated.
A: You could pass by there today and see what people are wearing.

My interventions, concrete and mundane, and linguistically attuned to

the level of Wendy’s language in those sessions, were informed by several
years of analytic work with Wendy. I had come to the conclusion that
there had been a profound lack of loving and caring maternal attention
to her body and bodily needs and, especially, a lack of verbalising about
what was seen. My concrete statements addressed the consequent defi-
cits I had observed in Wendy’s capacity to care for herself. My comments
were available for understanding on two levels: the concrete one of
which she was at that time capable, and the historical/metaphorical one
(sexual heat in the transference; not looking at others due to the pain of
envy, suppression of curiosity) in which I had encoded my understand-
ing of her childhood experience.
A series of interventions such as these, in which my looking at her
was evident in my words to her, resulted in Wendy’s purchasing a styl-
ish wardrobe, feeling good about her body, and slowly she began to
return to working symbolically and metaphorically in the analysis.
We once again focused on issues of envy and revenge, punishment for
competitiveness, etc. Wendy’s fantasy life was Medea-like in the extent
of its violence.
130 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

The smooth course the analysis then took was threatened when
Wendy became involved in an automobile accident and badly injured
her neck and back. She barely missed a session, however. She needed
to talk about her body and what was happening to it. She reported in
assiduous detail her numerous hospital and doctor examinations and
tests and her numerous physical therapies. Any residual shame was
countered by the gratification she received having so many profession-
als look at her body and talk with her about every aspect of it. She then
came to her sessions and told me word for word what they said. A more
consolidated body image was thus reached by way of this unfortunate
event, the car accident. As Caper (1994) so well put it: “The mind needs
reliable information about itself—truth, if you will, just as the body
needs food.” I would add, so does the body need reliable information
about itself.
As I wrote in Body Talk: “I believe that children who do not master
this first level of language—the description of their own body parts and
those of others—along with its necessary intrinsic connection with body
awareness, vision and mother herself, are likely to suffer as adults from
deficits in the consolidation of the body image” (p. 67). Today I would
add: “and from proneness to shame”.
This is true of those in middle age, who experience a second ado-
lescence. How poignant was a session with my patient Robert, now
in his mid-fifties, who looked in the mirror one day and hardly rec-
ognised himself (like Freud). The white roots of his hair, for years
dyed, were showing and his shame about aging made him feel that
he could not recognise himself. To this owner of a business dominated
by twenty-somethings, a poet and master of Oedipal fantasy and
metaphor, I made the following concrete remark: “Your hair grows in
quickly, doesn’t it?” This odd moment for Robert of bodily shame had
its “roots” in having been mothered by a society lady who was always
“out to lunch”.
Most people experience some shame as the body changes and ages
and then learn to adapt to it. Extreme cases of those who do not have
been described by Phillips (1996) in her book The Broken Mirror. She
coined the term “body dysmorphic disorder” (BDD) and chronicled the
plight of patients she had treated who tortured themselves, like Sartre,
in their relationship to mirrors, feeling stuck to them for hours, com-
pelled to stand and look. One found it hard to function because of the
need to comb and recomb her hair. It was difficult for her to perform her
 S O M E O B S E RVAT I O N S A B O U T B O DY N A R C I S S I S M 131

work in a hospital because the patients’ rooms had mirrors. She tried to
conquer this problem by getting dressed without her contact lenses so
that she could not see and could avoid mirrors.

Third case vignette

Let me end with one last example: Robin, an elegant wealthy woman,
was plagued by her body, which seemed to me anorectic, yet she wor-
ried if she gained a pound. She was 5’5” tall and weighed 105 pounds.
She was constantly being shamed by others, who told her that she
was too thin. Robin was obsessed with her clothes and spent close to
$100,000 a year on her wardrobe. Yet she felt that she had nothing to
wear and spent hours in front of her closets in each of her four homes
not being able to decide what to wear or what to pack for the house she
was travelling to next. Her greatest dread was of the shame she would
feel if she went somewhere and confronted, all of a sudden, another
woman who was better dressed, who “really” knew how to put her
outfit together. If well-dressed women were wearing extremely pointy
boots that day, she was compelled to go to a store and purchase similar
boots. She was terrified of being the recipient of envy of the kind she
herself experienced and often would not wear her best clothes for that
reason.
Robin seemed to suffer from an internalisation of an envious critic
appearing in the guise of a harsh superego introject. Incidentally, a series
of women I have seen in psychotherapy with issues like Robin’s have
been endless talkers, are on their cell phones a good part of the day, and
lead frenetically busy lives. Robin endured ongoing humiliation by her
husband, who would not listen to her, she being a “motor mouth” who
invited his constant rejection. Robin maintained an exhaustingly busy
schedule filled with minutiae and chores. She defended against expe-
riencing feelings of shame by “not thinking”. At the beginning of treat-
ment she brought in lists of things to tell me, clippings from self-help
articles, sorting and shuffling among them in her Hermes handbag,
so that I would notice the bag. Once she told me what was in the notes,
she threw them away, nothing really being processed by her. She came
in once asking to use the bathroom and quipped that it was one of many
in the city she used all day. Robin’s problems are rather typical of a cer-
tain type of woman who seeks analytic treatment but needs a treatment
geared to her concreteness.
132 A B S O L U T E T R U T H A N D U N B E A R A B L E P S Y C H I C PA I N

Rizzuto (1988) noted that patients such as Robin “deal with the spo-
ken word as though it is an indispensable but meaningless nuisance
that they have no choice but to use. Frequently the affective tone of their
voice is a monotone pitch which may disclaim the significance of the
content of what they are saying … . When the analyst speaks trying to
help the patient to understand herself, he or she is frequently met with
an attitude of disbelief, scepticism, and rejection of what the meaning
might be” (p. 1).
Farrell (2000) decided on her book’s title Lost for Words, recognising
that words are problematic for women with eating disorders. “They are
either seen as a useless form of communication, or as tremendously
powerful, so powerful that they may drown in them, or be torn to
pieces by them. The pre-verbal, concrete way these women often think
and relate make words both a dangerous and unwanted commodity”
(p. xiv). Farrell sees the body for such women as a transitional object.
Their mothers have taken them as objects rather than the other way
around. “She wishes to use her baby both to confirm her own physical
boundaries and as a bridge toward whole object relations” (p. 44). This
certainly seems to be the case with Amanda.
To conclude: the analysis of body narcissism is a painful and difficult
task. It opens up all kinds of fantasies and memories related to shame
and humiliation and sometimes mental, physical and sexual abuse. Too
rapid a leap from the concrete can unleash a sadistic attack on the ana-
lyst, a therapeutic “bloodbath” from which it may be difficult to recover,
or more likely, without the words being expressed, an abrupt termina-
tion. The analyst’s countertransference must be constantly monitored.
It is very hard work.

References
Brunswick, R. M. (1928). A supplement to Freud’s history of an infantile
neurosis. International Journal of Psychoanalysis, 9: 439–476.
Caper, R. (1994). What is a clinical fact? International Journal of
Psychoanalysis, 75: 903–913.
Farrell, E. (2000). Lost for Words: The Psychoanalysis of Anorexia and Bulimia.
New York: Other Press.
Freud, S. (1919h). The Uncanny. S. E., 17. London: Hogarth.
Freud, S. (1923b). The Ego and the Ed. S. E., 19. London: Hogarth.
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Gilman, S. (1995). Picturing Health and Illness: Images of Identity and Difference.
Baltimore, MD: Johns Hopkins Press.
Gilman, S. (1998). Creating Beauty to Cure the Soul: Race and Psychology in the
Shaping of Cosmetic Surgery. Durham, NC: Duke University Press.
Jacobs, T. (2005). Presentation at the Psychoanalytic Association of New
York.
Jay, M. (1993). Downcast Eyes: The Denigration of Vision in Twentieth Century
French Thought. Berkeley, CA: University of California Press.
Lieberman, J. S. (2000). Body Talk: Looking and Being Looked at in Psychotherapy.
Northvale, NJ: Jason Aronson.
Lieberman, J. S. (2006). Presentation in panel on “Shame and the Body”.
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Lombardi, R. (2003). Catalyzing the dialogue between the body and the
mind in a psychotic analysand. Psychoanalytic Quarterly, 72: 1017–1041.
Lombardi, R. (2008). The body in the analytic session: focusing on the
body-mind link. International Journal of Psychoanalysis, 89: 89–110.
Mitrani, J. (2007). Bodily centered protections in adolescence: an exten-
sion of the work of Frances Tustin. International Journal of Psychoanaly-
sis, 88: 1153–1169.
Phillips, K. A. (1996). The Broken Mirror. New York: Oxford University
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Rizzuto, A.-M. (1988). Transference, language and affect in the treatment
of bulimarexia. International Journal of Psychoanalysis, 69: 369–387.
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INDEX

Abraham, K. 17 anxiety 3, 26, 29, 63, 87

Abram, J. 39, 54 near-traumatic 30
abstraction xx tolerance of 31
passionate xxvii Aron, L. 55
accusation 3 attunement 47, 60, 112
addiction 45 Austin, G. A. xxv
Adler, G. 36
adolescent neurosis 121 Bach, S. xxviii, 37
aggression 50, 63 ba group
aggressiveness 105 fate of dissenter in 78–79
Akhtar, S. 42 functioning 78–79
analyst Barroso, F. 57
and treatment 114 basic assumption theory 77–78
concrete responses from 120 Bass, A. 41, 58, 84–85
analyst–analysand relationship xxvi, Bion, W. R. 2, 12, 74–75, 77–79, 83, 85,
43, 110 88–89, 91
analytic object 43 Bion’s theory of group life 74
Anderson, M. 4 body dysmorphic disorder (BDD)
angst 26 130
anti-alpha function 4 body image 120

135
136 INDEX

body narcissism cognitive bureaucratisation 75

and concrete patient 119 cognitively debased language
disturbances in 120 regressive behaviour and 78
Bollas, C. 36–37, 39, 42 verbal communication 79–80
Bolognini, S. xxii, 55 communication 2, 39, 63, 65
Brandchaft, B. 36 cul-de-sac 40
Britton, R. 84, 88–89, 97 private 39–40
Broberg xxviii compromise formation 19–20
Brody, S. 54 concrete and metaphorical thinking
Bruner, J. S. xxv background 84–86
Brunswick, R. B. 121 concreteness, defined 84
Bucci, W. 57 depressive position 86–89
bureaucratisation of thought/ non-pathological concrete
language thinking (illustrations),
confusion of levels 75–77 93–98
developments 74–75 paranoid-schizoid position 86–89,
early background of 74 90–93
group psychology 75, 77–78 post-Kleinian view 89–90
individual psychology 75 relationship between 83–84
language, cognitively debased concrete mental states, clinical
78–80 aspects of 7–10
paranoid/schizoid states concreteness xix, 29, 60
of mind 80 and complexity xx, 1
regressive behaviour 78 countertransferential 63
verbal communication 79–80 defined 84
enactment in 68
Cancelmo, J. A. 35, 37, 44 non-pathological 84
Caper, R. 130 pseudo- 84
certainty 3, 9 psychoanalysis and xx, 1
character enactment 59 to symbolising space, movements
childhood of 43–45
deep depression of 67 concrete patient xx, 1
trauma of 66 treatment of see: content and
Chused, J. 58 process
clinical vignette concrete responses 120
Amanda 122–127 concretisation
dynamic formulation 46–47, 49–50 anxiety 3
Robin 131–132 concrete mental states, clinical
shifts in use of analyst 45–47 aspects of 7–10
subjective/objective paradox for deanimation of thought 4–5
47–50 debilitation 4
Wendy 127–131 dream, role of 10–13
 INDEX 137

lack of inner agency 5–7 ego 58, 63, 104–105, 113–114

mobilisation of concrete bodily 120
experience 13–14 splitting 19
reflective thought, capacity Eliot, T. S. 91, 100
for 2–3 Ellman, P. 57–58
conformity 81 Ellman, S. J. 36, 41, 57–58
content and process emotion xxiii–xxiv, xxvii
anxiety 20 unbearable 3
case study 20–33 emotional security 77
clinical problems 19 enactment
compromise formation 19–20 case study 59–68
dedifferentiation 18 character enactment 59
and Eros 18 concreteness 68–69
fetishism 19 deadness of 59
internalisation of differential 18 fantasy 70
interpretive process 17 global transference 70
possibility of meaning 19 psychic functioning 58
traditional forms of intervention in psychoanalysis 57–58
19 survivors of mass trauma 58–59
Coppolillo, H. P. 54 Eros
countertransference xxvi, 36, 65 counter-force of 18
cul-de-sac communication 40 self-preservative function 18
experience 94, 115
dead mood 62–63 inner 120
deanimation of thought 4–5 interpsychic 55
dedifferentiation 18 pre-symbolic 84
denial 78 sensory 2–3, 95
denunciation 102 shame 121
dependency (baD) theory 77 transformative interpersonal
depression 67, 80 116
depressive position 80, 86–89 external body 120
desymbolisation xix, xx, 1, 92
differentiated connection 23 fantasy 16, 114
disavowal 19, 22 source of physical ailments 120
disharmony, bodily 121 unconscious 66
Dorpat, T. 110 Farrell, E. 122, 132
dreams 9–10, 15–16, 30 Fenichel, O. 74
explosion 12 fetishism 19
role of 10–13 fight/flight (baF) theory 77
Dunn, J. 41, 43 Flavell, J. H. xx
dyad 35, 38 Fonagy, P. 40, 42
analytic 35, 37, 44, 47, 50, 57 Fossage, J. L. 41, 43
138 INDEX

Freedman, N. xix, 41–42, 57 Jacobs, T. 57–58, 121

freedom 7–8 Jacobson, E. 84
free floating anxiety 26 Jay, M. 120
Freud, S. xix, xxvii–xxviii, 18, 30, 36, Jones, E. 91
44, 69, 75, 120 Joseph, B. 18
Frosch, A. xxii, 44, 84
Katz, G. 58
Gentile, J. 43 Keats, J. 88
Gilman, S. 120 Keyes, R. 90
Goodman, N. 59 Kilingmo, B. 42
Goodnow xxv Klein, M. 74–75, 79, 84, 86–89, 98
Gould, L. J. 75, 77 Kleinian metapsychology 86
Grand, S. xxii, 57 Kogan, I. 58
Green, A. 43 Kohut, H. 36
Grossman, L. 84 Krantz, J. 78
Grotstein, J. 12
group(s) 79 language 110
group psychology 75 language, cognitively debased
Bion’s conception of 77–78 regressive behaviour and 78
group therapy 77 verbal communication and 79–80
groupthink 78, 81–82 Laplanche, J. xx
Grunes, M. 42 Lasky, R. xxi, xxv
Lateness 30
Heidegger, M. 26 Laub, D. 58
human mind 4 Lavender, J. xix
hypercathexis xxv–xxvi Lear, J. 58
hysteria 120 libidinal investments xxvi
Loewald, H. xxiv–xxv, 18, 36, 40, 42,
identification 111 69, 111
incremental symbolization 41 Lombardi, R. 122
individual psychology 75 love xxvi–xxvii
infantile neurosis 121
inner agency, lack of 5–7 Meltzer, D. 5
inner experience of body 120 memories 102, 107
internalisation process of patient mental functioning xxix
111, 116 metaphorical thinking see: concrete
interpretation 101, 116 and metaphorical thinking
traditional forms of 19 miracles xxvi
verbal 110 Mitrani, J. 122
interpretive process 17 Montagne, R. 93
interpsychic experience 55 Moskowitz 41, 58
intersubjectivity 43 mutual support 78
 INDEX 139

narcissistic parenting 104 reflective thought 2–3, 15 see also:

naysayer 78 concretisation
negative capability 88 Reich, A. 63
neurotic anxiety 26 Renik, O. 57, 84
non-pathological concrete thinking repression xxv
clinical examples 95–98 re-traumatisation 14
ordinary (non-clinical) example Rizzuto, A. -M. 122, 132
93–95 Rothstein, A. xxiv
normative concretising function 4 Russell, J. 41

object constancy 120 Sandell xxviii

object relations theory 74 Sandler, J. 47
Ogden, T. 12, 37, 43 Sandler, P. C. 4–5
organisations 73–75, 80 see also: Sanville, J. 36
bureaucratisation of thought/ Sartre, Jean-Paul 120
language Schimek xxii
schizoid states of mind 80
pairing (baP) 77 schizophrenic man 85
paranoid-schizoid position 80 Searles, H. xix, xxi, 73, 84–85, 90, 92
and depressive positions Segal, H. 58, 85, 87, 91–92
86–89 self, distress-based 2
concrete thinking in 90–93 self-neglect 10
Parnes, D. 95 self-object differentiation 92
Phillips, K. 121, 130 self-preservative function 18
Piaget, J. 73, 85 sense of aliveness 64
Poitier, S. 93–94 sense-perceptions 92
Pontalis, J. B. xx sensory experience 2–3
possibility of meaning 17, 19 separateness 63
pre-Oedipal world xxiv sexual dysfunction 120
projective identification 5, 87 shame 28
Proust, M. xxvii experience 121
pseudo-concreteness 84 language-deficient 121
psychic development 89 Silverman, D. 41
psychic reality 43–44, 59 social psychology 74
psychoanalyst 85, 121 speaking 59
psychoanalytic process xxi, 35 Steiner, J. 18, 36, 122
psychoanalytic theorizing 122 Steingart, I. xxiv, 36, 42
psychodynamics xxiii Stern, D. B. 48, 58, 69
psychologists, developmental 85 structuralisation 36, 51
subjectivity 43
Racker, H. 50 superego 6, 25
reality of castration 19 symbol formation 79, 86
140 INDEX

symbolic capacity development intersubjective framework 36

38–43 negotiating subjective/objective
symbolisation xx, 17, 38, 50, 110 paradox as 47–50
systems psychodynamics 77 overview of 35–38
shifts in use of analyst 45–47
tension 36 structural framework 36
thing-presentation xx, xxiv–xxv, symbolic capacity development
91–92 38–43
thought xxiii transitional realm 38–43
deanimation of 4–5 vignette 45–50
time control 30 transitional realm 38–43, 54
transference xxii, xxvi, 28, 36 trauma 7, 30, 41, 60, 64
cure 116 of childhood 66
transference–countertransference symbolisation of see: enactment
44–47, 50–51, 55 truth 3, 15
transference-interpretation 43 Tyson, R. 57
transformational object 37
transformations Van der Kolk, B. 36
cognitive 75 verbal communication 79–80
linguistic 76 vignette see: clinical vignette
transformative interpersonal violence 108
experience 116
transitionality 36–37, 54 Whyte, W. H. 81
transitional organising experience Winnicott, D. W. 18, 35–37, 39–40
from concreteness to symbolising word-presentation xx, xxiv–xxv
space 43–45