Luke Ford

From a 2019 meta-analysis in the British Medical Journal: Conclusions: The benefits of antidepressants seem to be minimal and possibly without any importance to the average patient with major depressive disorder. Antidepressants should not be used for adults with major depressive disorder before valid evidence has shown that the potential beneficial effects outweigh the harmful effects.

Wikipedia notes:

[Harvard psychology professor Irving] Kirsch’s analysis of the effectiveness of antidepressants was an outgrowth of his interest in the placebo effect. His first meta-analysis was aimed at assessing the size of the placebo effect in the treatment of depression.[7] The results not only showed a sizeable placebo effect, but also indicated that the drug effect was surprisingly small. This led Kirsch to shift his interest to evaluating the antidepressant drug effect.

The controversy surrounding this analysis led Kirsch to obtain files from the U.S. Food and Drug Administration (FDA) containing data from trials that had not been published, as well as those data from published trials. Analyses of the FDA data showed the average size effect of antidepressant drugs to be equal to 0.32, clinically insignificant according to the National Institute for Health and Clinical Excellence (NICE) 2004 guidelines, requiring Cohen’s d to be no less than 0.50.[8] No evidence was cited to support this cut-off and it was criticised for being arbitrary;[9] NICE removed the specification of criteria for clinical relevance in its 2009 guidelines.[10][11]

Kirsch challenges the chemical-imbalance theory of depression, writing “It now seems beyond question that the traditional account of depression as a chemical imbalance in the brain is simply wrong.” [12] In 2014, in the British Psychological Society’s Research Digest, Christian Jarrett included Kirsch’s 2008 antidepressant placebo effect study in a list of the 10 most controversial psychology studies ever published.[13]

In September 2019 Irving Kirsch published a review in BMJ Evidence-Based Medicine, which concluded that antidepressants are of little benefit in most people with depression and thus they should not be used until evidence shows their benefit is greater than their risks.

Marcia Angell writes in the New York Review of Books:

It seems that Americans are in the midst of a raging epidemic of mental illness, at least as judged by the increase in the numbers treated for it. The tally of those who are so disabled by mental disorders that they qualify for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) increased nearly two and a half times between 1987 and 2007—from one in 184 Americans to one in seventy-six. For children, the rise is even more startling—a thirty-five-fold increase in the same two decades. Mental illness is now the leading cause of disability in children, well ahead of physical disabilities like cerebral palsy or Down syndrome, for which the federal programs were created.

A large survey of randomly selected adults, sponsored by the National Institute of Mental Health (NIMH) and conducted between 2001 and 2003, found that an astonishing 46 percent met criteria established by the American Psychiatric Association (APA) for having had at least one mental illness within four broad categories at some time in their lives. The categories were “anxiety disorders,” including, among other subcategories, phobias and post-traumatic stress disorder (PTSD); “mood disorders,” including major depression and bipolar disorders; “impulse-control disorders,” including various behavioral problems and attention-deficit/hyperactivity disorder (ADHD); and “substance use disorders,” including alcohol and drug abuse. Most met criteria for more than one diagnosis. Of a subgroup affected within the previous year, a third were under treatment—up from a fifth in a similar survey ten years earlier.

Nowadays treatment by medical doctors nearly always means psychoactive drugs, that is, drugs that affect the mental state. In fact, most psychiatrists treat only with drugs, and refer patients to psychologists or social workers if they believe psychotherapy is also warranted. The shift from “talk therapy” to drugs as the dominant mode of treatment coincides with the emergence over the past four decades of the theory that mental illness is caused primarily by chemical imbalances in the brain that can be corrected by specific drugs. That theory became broadly accepted, by the media and the public as well as by the medical profession, after Prozac came to market in 1987 and was intensively promoted as a corrective for a deficiency of serotonin in the brain. The number of people treated for depression tripled in the following ten years, and about 10 percent of Americans over age six now take antidepressants. The increased use of drugs to treat psychosis is even more dramatic.

Marcia Angell follows up in the July 14, 2011 issue:

One of the leaders of modern psychiatry, Leon Eisenberg, a professor at Johns Hopkins and then Harvard Medical School, who was among the first to study the effects of stimulants on attention deficit disorder in children, wrote that American psychiatry in the late twentieth century moved from a state of “brainlessness” to one of “mindlessness.” By that he meant that before psychoactive drugs (drugs that affect the mental state) were introduced, the profession had little interest in neurotransmitters or any other aspect of the physical brain. Instead, it subscribed to the Freudian view that mental illness had its roots in unconscious conflicts, usually originating in childhood, that affected the mind as though it were separate from the brain.

But with the introduction of psychoactive drugs in the 1950s, and sharply accelerating in the 1980s, the focus shifted to the brain. Psychiatrists began to refer to themselves as psychopharmacologists, and they had less and less interest in exploring the life stories of their patients. Their main concern was to eliminate or reduce symptoms by treating sufferers with drugs that would alter brain function. An early advocate of this biological model of mental illness, Eisenberg in his later years became an outspoken critic of what he saw as the indiscriminate use of psychoactive drugs, driven largely by the machinations of the pharmaceutical industry.

When psychoactive drugs were first introduced, there was a brief period of optimism in the psychiatric profession, but by the 1970s, optimism gave way to a sense of threat. Serious side effects of the drugs were becoming apparent, and an antipsychiatry movement had taken root, as exemplified by the writings of Thomas Szasz and the movie One Flew Over the Cuckoo’s Nest. There was also growing competition for patients from psychologists and social workers. In addition, psychiatrists were plagued by internal divisions: some embraced the new biological model, some still clung to the Freudian model, and a few saw mental illness as an essentially sane response to an insane world. Moreover, within the larger medical profession, psychiatrists were regarded as something like poor relations; even with their new drugs, they were seen as less scientific than other specialists, and their income was generally lower.

From the British Psychological Society:

* 5. Loftus’ “Lost in The Mall” Study
In 1995 and ‘96, Elizabeth Loftus, James Coan and Jacqueline Pickrell documented how easy it was to implant in people a fictitious memory of having been lost in a shopping mall as a child. The false childhood event is simply described to a participant alongside true events, and over a few interviews it soon becomes absorbed into the person’s true memories, so that they think the experience really happened. The research and other related findings became hugely controversial because they showed how unreliable and suggestible memory can be. In particular, this cast doubt on so-called “recovered memories” of abuse that originated during sessions of psychotherapy. This is a highly sensitive area and experts continue to debate the nature of false memories, repression and recovered memories. One challenge to the “lost in the mall” study was that participants may really have had the childhood experience of having been lost, in which case Loftus’ methodology was recovering lost memories of the incident rather than implanting false memories. This criticism was refuted in a later study (pdf) in which Loftus and her colleagues implanted in people the memory of having met Bugs Bunny at Disneyland. Cartoon aficionados will understand why this memory was definitely false.

* 8. The Kirsch Anti-Depressant Placebo Effect Study
In 2008 Irving Kirsch, a psychologist who was then based at the University of Hull in the UK, analysed all the trial data on anti-depressants, published and unpublished, submitted to the US Food and Drug Administration. He and his colleagues concluded that for most people with mild or moderate depression, the extra benefit of anti-depressants versus placebo is not clinically meaningful. The results led to headlines like “Depression drugs don’t work” and provided ammunition for people concerned with the overprescription of antidepressant medication. But there was also a backlash. Other experts analysed Kirsch’s dataset using different methods and came to different conclusions. Another group made similar findings to Kirsch, but interpreted them very differently – as showing that drugs are more effective than placebo. Kirsch is standing his ground. Writing earlier this year, he said: “Instead of curing depression, popular antidepressants may induce a biological vulnerability making people more likely to become depressed in the future.”

* 9. Judith Rich Harris and the “Nurture Assumption”
You could fill a library or two with all the books that have been published on how to be a better parent. The implicit assumption, of course, is that parents play a profound role in shaping their offspring. Judith Rich Harris challenged this idea with a provocative paper published in 1995 in which she proposed that children are shaped principally by their peer groups and their experiences outside of the home. She followed this up with two best-selling books: The Nurture Assumption and No Two Alike. Writing for the BPS Research Digest in 2007, Harris described some of the evidence that supports her claims: “identical twins reared by different parents are (on average) as similar in personality as those reared by the same parents … adoptive siblings reared by the same parents are as dissimilar as those reared by different parents … [and] … children reared by immigrant parents have the personality characteristics of the country they were reared in, rather than those of their parents’ native land.” Harris has powerful supporters, Steven Pinker among them, but her ideas also unleashed a storm of controversy and criticism. “I am embarrassed for psychology,” Jerome Kagan told Newsweek after the publication of Harris’ Nurture Assumption.

* 10. Libet’s Challenge to Free Will

Your decisions feel like your own, but Benjamin Libet’s study using electroencephalography (EEG) appeared to show that preparatory brain activity precedes your conscious decisions of when to move. One controversial interpretation is that this challenges the notion that you have free will. The decision of when to move is made non-consciously, so the argument goes, and then your subjective sense of having willed that act is tagged on afterwards. Libet’s study and others like it have inspired deep philosophical debate. Some philosophers like Daniel Dennett believe that neuroscientists have overstated the implications of these kinds of findings for people’s conception of free will. Other researchers have pointed out flaws in Libet’s research, such as people’s inaccuracy in judging the instant of their own will. However, the principle of non-conscious neural activity preceding conscious will has been replicated using fMRI, and influential neuroscientists like Sam Harris continue to argue that Libet’s work undermines the idea of free will.

Here are some excerpts from this 1998 book:

* One’s image of oneself or one’s self-representation originates in one’s bodily sensations and is a reflection of one’s body image.

* According to the Dictionary of the American Psychological Association: “affect n. any experience of feeling or emotion, ranging from suffering to elation, from the simplest to the most complex sensations of feeling, and from the most normal to the most pathological emotional reactions. Often described in terms of positive affect or negative affect, both mood, and emotion are considered affective states. Along with cognition and conation, affect is one of the three traditionally identified components of the mind.”

* conation n. the proactive (as opposed to habitual) part of motivation that connects knowledge, affect, drives, desires, and instincts to behavior. Along with affect and cognition, conation is one of the three traditionally identified components of mind. The behavioral basis of attitudes is sometimes referred to as the conative component.

* embodied cognition: the thesis that the human mind is largely determined by the structures of the human body (morphology, sensory and motor systems) and its interactions with the physical environment. This concept emerged from work in late 20th century linguistics, philosophy, and cognitive psychology.

* A potentially useful concept here is ’embodiment’: the processes whereby our physical bodies incorporate traces of previous experiences. … Embodiment may be physical, cognitive or emotional and refers to the processes whereby a person’s life experiences are literally incorporated into their body.

* reflexive behavior: responses to stimuli that are involuntary or free from conscious control (e.g., the salivation that occurs with the presentation of food) and therefore serve as the basis for classical conditioning. Compare planned behavior; voluntary behavior.

* The term cathexis is used to describe an investment of libidinal energy in an object or an idea. Sentimental attachment to a keepsake, a family heirloom, or a photograph would be an example of cathexis. Patriotism and other impassioned identifications with groups and systems of belief are also forms of cathexis. The word is derived from the Greek verb “to occupy” and is a translation of the German word Besetzung, “occupation.” The image suggests that the libido is sent out to “seize” the external object, as an army would seize and occupy a city.

* In attempting to understand the relationship between subject and object, psychoanalysis describes “objects” that have been cathected, invested with libidinal energy. These objects can be other people (the “object of one’s affections”) or anything else (including abstract concepts like “freedom” or “justice”) that serves as a focal point of desire.

* In psychoanalytic theory, the term “subject” refers to the sum of the physiological and psychological operations that sustain a human individual as a “person”. The human subject has both mental and bodily dimensions.

Psychoanalysis is critical of the Cartesian vision of the subject as a centered, autonomous “I” whose self-awareness can be taken as a foundation for philosophical inquiry. For psychoanalytic theorists like Freud and Lacan, the subject’s autonomy and self-awareness is constantly undermined by impulses from the id and steered by the pressures of the superego. In this sense, “individual” is an inaccurate synonmym for “subject” because the Freudian model of the subject is divided into at least three conflicting parts.

* mentalization: n. the ability to understand one’s own and others’ mental states, thereby comprehending one’s own and others’ intentions and affects. It has been theorized that this ability is a component of healthy personality development and is achieved through a child’s secure attachment to the parent. The concept has had particular application in the understanding and treatment of borderline personality disorder (BPD), characterized in this context as a disorder marked in part by an inability to mentalize due to poor attachment in early life.

* I remember that when I was in analytic training I would frequently hear (or tell) a joke along these lines: Students would say that, if you told a Freudian supervisor about a case organized around problems related to intimacy, then you would be told about the meaning of this in terms of the patient’s conflicted sexuality. If, on the other hand, you told an interpersonal supervisor about a case in which the patient’s sexuality played a central role, then you would likely be told to look at the underlying difficulties in the patient’s capacity for intimacy. There was, I believe, much truth to this joke. Both groups used theoretical structures, metapsychologies, to guide their analytic listening; and, whereas the Freudians tended to highlight bodily phenomena, particularly sexuality, as at the core, the interpersonalists tended to put interpersonal events at the center and to view sexuality as derivative of such interpersonal experience as intimacy. What was surface for one analyst was depth for the other.

* Sexual disturbances and problems [are conceived] as pointed reflections of wider and more general difficulties in living, reflections of the person’s outlook and orientation vis-a-vis himself as a physically independent unit and his concomitant outlook upon others. A person’s sexual behavior is then seen as a manifestation of his orientation rather than its cause.. . . Sexuality lends itself more readily than any other behavior to symbolic expression of attitudes toward oneself, others, and life itself.

* …four reasons why sexuality is a central organizer of childhood experience. First, because bodily sensations, processes, and events dominate a child’s early experience, bodily events are drawn on and elaborated imaginatively so that the child can construct and represent a view of the world and of the important people in it. Second, since sexuality involves both an interpenetration of bodies and desires and contact with the bodies’ boundaries and openings, it is ideally suited to represent longings, conflicts, and negotiations in the relations between self and others. Third, bodily, and especially sexual, experience entails powerful surges that are used to express the dynamics of conflict and interpersonally generated affect. Fourth, the very privacy, secrecy, and exclusion in one’s experience of one’s parent’s sexuality make it perfectly designed to take on meanings concerning a division of interpersonal realms, the accessible vs. the inaccessible, the visible vs. the shadowy, surface vs. depth. Sexuality takes on all the intensity of passionate struggles to make contact, to engage, to overcome isolation and exlusion [p. 103].

* I remembered one woman supervisor from whom I had learned a great deal, who told me repeatedly as we would listen together to a patient’s free associations to “think body, think sex, think dirty.”

* The interpersonal position stresses the formative impact of parental character.. . . the emotional life of the child is filled with and shaped by the contours of parental character and is constructed out of actual interactions. The parents’ issues become the child’s issues; the kinds of interaction they make possible determine the metaphors that ultimately are utilized by the child to constitute the intrapsychic.

* This book, Relational Perspectives on the Body; emerged out of this call for renewed attention to the place of the body and somatic experience within a relational paradigm. Psychoanalysis (across all of its various schools) has increasingly moved in a relational direction. Simultaneously with this shift from a drive-centered to a relational theory, the profession of psychoanalysis has undergone a demedicalization, which may have further shifted the attention of psychoanalysis away from the body. Nonmedically trained analysts may well have felt less sure of themselves in attending to and studying bodily based and psychosomatic phenomena. It is the intention of this book to bring the focus of psychoanalysis back to the body, to the bodily rooted self, to bodily based communication, to bodily and affective experience, and to somatic and psychosomatic phenomena, now all viewed in a relational context.

* In this chapter, I bring together these two broad areas of study: the role of the body in the psychoanalytic enterprise and the self-reflexive function of the mind: the clinical body and the reflexive mind. I focus our attention on the place of the body in the mind’s self-reflexive functioning, and the effects on the body when self-reflexive functioning is impaired. Extending this to the realm of the intersubjective, I will consider the mutual impact of the mind and the body on each other as the psychoanalytic situation entails two individuals jointly processing, experiencing, and reflecting on psychosomatic phenomena.

* Self-reflexivity (the capacity to experience, observe, and reflect on oneself as both a subject and an object) is at the very heart of the clinical psychoanalytic process, and in this chapter I explore the body’s role in self-reflexive functioning as well as the body’s involvement when self-reflexive functioning fails. The construction of a bodily self requires self-reflexivity, and self-reflexivity emerges through intersubjectivity. On the other hand, under normal conditions, intersubjectivity (and for that matter any subjectivity) is always embodied. Trauma is responsible for disruptions in the development of self-reflexivity, intersubjectivity, and embodiment.

* Self-reflection ordinarily connotes a cognitive process in which one thinks about oneself as if from the outside, that is, as if examining oneself as an object of thought. The way I am using self reflexivity here, by contrast, includes the dialectical process of experiencing oneself as a subject as well as of reflecting on oneself as an object. It is not, therefore, exclusively an intellectual observational function, but an experiential and affective function as well.

* [Sheldon] Bach (1985, 1994) suggests that a good deal of narcissistic and borderline pathology, including such structurally related conditions as perversions, addictions, eating disorders, and psychosomatic disorders, may be best understood in terms of the patient’s inability to maintain appropriate tension between these two perspectives on the self. When immersed in a state of consciousness of subjective awareness, the self is experienced as the agent, in Kohut’s (1977) words, as “a center of initiative and a recipient of impressions” (p. 99). At the extreme, this may lead a patient to experience grandiosity and a sense of entitlement and be unable to experience the self as an object among other objects or a self among other selves. When immersed in the state of consciousness of objective self-awareness, the patient can view himself or herself only as an object among other objects and cannot experience the sense of agency or vitality that comes with being a subject, a distinct center of thoughts, feelings, and actions. Although some patients (with certain forms of pathology) are more apt to maintain one side of this polarity over another (for example, overinflated narcissists tend to maintain states of subjective awareness, whereas depressives tend to maintain states of objective selfawareness), nevertheless, according to Bach, the real problem with all of these patients is that they have persistent difficulties moving back and forth between the two perspectives on the self and integrating them into their representational world.

Bach (1994) proposes that it is an important developmental achievement for a person “to integrate his sense of wholeness and aliveness (subjective awareness) with his parent’s and his own developing perspective on himself as one person among many others (objective self-awareness)” (p. 46). Accordingly, psychopathology is understood as a person’s inability to tolerate ambiguity and paradox, to deal with metaphor, or to maintain multiple points of view, especially about the self.5 Instead, in psychopathology, we find polarization, splitting, either-or thinking, manic and depressive mood swings, and sadomasochistic role reversals.

* Because one cannot simultaneously regard oneself as an object and immerse oneself in one’s own subjectivity, except perhaps during mystical experiences or states of ecstasy, and because these two modalities for self-knowledge can result in highly discrepant self-images, the capacity for reflexive self-awareness necessarily produces psychological tension and conflict, especially about one’s conception of oneself.

Auerbach, following Bach, goes on to elaborate narcissism as an attempt to escape the conflicts that result from self-reflexivity. He writes, “Kernberg’s narcissists, in their shameless grandiosity and entitlement, overemphasize subjective self-awareness; Kohut’s narcissists, in their shame ridden hypersensitivity, vulnerability, and submissiveness, overemphasize objective self-awareness.”

* “emotion is essentially psychosomatic”. Thus, when the psychological aspect of an emotion is ejected, the physiological part is left to express itself, leading to “psychosomatic explosions.”

* this development of “self-awareness of one’s affects as signals to oneself,” or, as he more dramatically calls it, of “owning one’s own soul”, that is the key step in the development of adult affect.

* Writing about dissociation resulting from trauma, Bromberg defines pathological dissociation as “a defensive impairment of reflective capacity” (p. 519). Conversely, as patients make the structural shift from dissociation to conflict, this movement is seen clinically “as the increasing capacity of the patient to adopt a self-reflective posture in which one aspect of the self observes and reflects (often with distaste) upon others that were formerly dissociated” (p. 525).
So, in the work of all the leading theorists of trauma and dissociation, just as in our survey of current work on psychosomatosis and alexithymia, we find an emphasis on the disruption of self-reflexive functioning at the heart of the pathology and the resumption of self-reflexive functioning as central to the cure.

* A long-established principle of psychoanalysis is that the analyst needs to form an alliance with the patient’s observing ego, which is split off from the patient’s experiencing ego.

* To become self-aware, a person must break the identification with any single aspect of self and engage in the internal dialogue of the multiple voices of subjectivity. Self-reflection, from this point of view, is based on the capacity for internal division and dialogue, healthy dissociation, standing in the spaces between realities, the transcendent,
oscillating, or dialectical function. Self-reflection is based on the ability to link up experiences, whereas trauma leads to dissociation as a result of “attacks on linking”.

* …one of Jung’s central contributions was the view of the unconscious as striving to compensate and correct for a one-sided conscious attitude.

* In summary, somatic symptoms, while pointing out the archaic connection with the primary object, highlight the failure or the inability to own the body and the mind. The body and the mind are not separate entities. Cartesian dualities have biased psychoanalytic thinking about the connection between the body and the mind, thus offering a schematic and fragmented perspective on their interrelationship. Rather, mind and body are better understood as operating within a dual track, a “Siamese twinship,” a “mind-body” that is one although it seems to be two (Grotstein, 1997).

Some specific conceptualizations by patients about the ownership of the body and the mind may be helpful to clinicians when listening to their patients from this framework. First, some patients actually physically tighten or tense their bodies in order to give the body boundaries, for fear that a relaxed body state would be equivalent to fusion with the powerful object. For example, Malcolm, a 45- year-old man, was preoccupied with tight, firm “butts,” both his own and that of the woman with whom he was involved. In the transference, he was preoccupied with the degree of firmness of the analyst’s “butt.” If two firm “butts” come together, there was no fear of fusion; but if one “butt” was not firm, even if his was, body boundaries would
disappear and he would fuse with the powerful object, the woman.

Second, affects that are localized in the body in a concrete way are real and therefore preferred. John, a 30-year-old single man suffering from ulcerative colitis, displayed the alexithymic trait of being unable to name affects and claimed ignorance when attempting to elaborate on his feelings. Inner life was practically nonexistent during the early stages of treatment. Only while talking about his illness did John become alive, as if the diseased body existed in ways his mind did not. To John, the body’s affliction was a sign of life.

Third, the psychic body exists if one does not admit loneliness. If loneliness or need for another person is acknowledged, psychic structure crumbles. Margaret, a 32-year-old woman, spent much of her time in analytic sessions caressing and stroking herself, particularly when the analyst was actively engaged with her (interpretations). Her attention was less on the interpretations offered by her analyst than on strengthening the boundaries of her own body. Fantasied relations with men were available to her 24 hours a day; she was never left in a state of loneliness or need for another person. Her ultimate desire to
remain in mother’s womb, and later to remain in analysis for the rest of her life, was the solution that warded off psychic disintegration.

Fourth, there can be a temporary mind-body dissociation when the body is experienced by the patient as failing him. Sam, a 48-yearold man, felt that his body had been weak since childhood. He described posture problems and not feeling balanced on his feet. He felt that his backbone could not keep him erect. During the analysis, Sam attempted various strenuous physical activities to try to correct this sense of his physical body. Each activity would start with hope and end in despair. His feelings about his weak body affected his feelings about his mind: weak body, weak mind. Unfortunately, during the course of the analysis, Sam developed a slowly degenerative physical condition that took away any hope of his having a strong body and, with it, a strong mind. Sam might have progressed if he could have separated the weak body from the strong mind. Instead, his anger at his weak body preoccupied him, and his mind was filled with attacks on his weak body. His mind was also filled with fantasies of his being an Olympic skier or a famous basketball player. He had two minds, one belonging to the weak body and split off from the other mind, which was full of potent, hopeful fantasies.

Several female patients who were experiencing physical difficulties felt that the body was their enemy, motivated to defeat them, that it was a “foreign body” with a mind of its own. Here we note a feeling of betrayal of the self by the body. This can, however, be a temporary state. Alice, a 52-year-old woman, and Margaret, 32 years of age, were enraged with their bodies when they experienced serious difficulties in their pregnancies and were unable to have their own children. They were particularly envious of their analyst’s body for being able to produce not only one baby but two (twins). They each had two bodies—their real bodies, which did not function as promised by their mothers, and their fantasied bodies, which worked perfectly and allowed for childbirth. For Alice, going through her pregnancy and childbirth in the analytic sessions led to her being able to buy a kitten to nurture. Margaret, who carried in her womb a baby who had to be aborted, was unable to mourn the loss. She continued to remain heavy—“pregnant”— even after the adoption of several children.

Fifth, the body realm is often used to avoid relationships. It serves to keep internal object relations a secret and ongoing while there is an actual avoidance of establishing new, real relationships. Andrew, a 41-year-old socially withdrawn single man, complained of an unusual sensitivity to temperature changes in the analyst’s office. He would remove his jacket and put it back on several times during a session. Andrew was convinced of the “biological reasons” for his condition, ignoring the analyst’s attempt to address his social isolation. Only at home, in the privacy of his bedroom, was he successful in regulating the temperature, which he maintained unchanged through the entire year. His preoccupation with his cold or warm body served as a buffer against relating. He ignored the analyst’s interventions and devalued both personal and professional relationships.

Sixth, psychosomatic concerns are often defenses against sexual and aggressive impulses, wishes and fantasies. Julia, a 27-year-old graduate student, tended to develop severe migraine headaches during sessions that she described as “heavy” or “difficult.” She would sit up on the couch, reach for her purse, and get her medication. She would then apologize, spending the rest of the session attending to her headache by pressing her temples with her hands or massaging her head. The analyst became a passive, useless observer, lacking the “touch” to soothe his patient’s pain.

John, whom we mentioned earlier, relates to his body as a physical object devoid of any meaning or fantasy elaboration. The early stages of his analysis were devoted to scientific descriptions of the vicissitudes of his illness. He reported his wife’s being unable to tolerate his demands for bodily attention, and his grieving about his illness in the middle of the night. Being alone with and within his body was too painful. He wanted the analyst to become familiar with the illness that perturbed his body and, keep him away from the contents of his mind; he hoped that the analyst would become la mere calmant (Fain, 1971).

A premature baby, John was placed in an incubator for several weeks. His mother, fearing that she might get too attached to him and then she would have to deal with a painful loss, refused to visit him in the hospital. She was convinced that her child was not going to survive. She refused to name her child, and only at the hospital’s insistence did the father name the child so he could obtain a birth certificate. Although John lived, his mother never overcame the fear of losing him. She became overprotective of John’s frail body. She used enemas, vitamins, and oils to assure herself of her child’s survival.

As an adult, John truly felt that he could not live without the assistance of others. He demanded from his analyst a complete recognition of his bodily illness. He wanted the analyst to care for his body, to listen to its noises, and to observe its movements. To John, the condition of his body was a matter of life and death. He was not sure whether he was going “to make it,” as his mother felt toward him.

* Several years into her analysis, my patient Iris said to me, “Our work will be done when I have had enough time with you, when I have been as comfortable in my body as one can be in an old sweatshirt.” When I asked her to tell me how that might feel, she said, “I would be able to be fully in my body, in your presence, and able to move freely around your room and touch and see things from my real self without fear. I would be able to give up the fear that comes with constantly overthinking and evaluating whether I really have or deserve your availability. I would be able to take for granted that it is fine with you that I can take you for granted.”

* Nearly all my patients suffer from some degree of disconnection from their bodies and, therefore, from their truest feelings and core sense of self. Patients complain of not being able to breathe naturally or to feel entitled to take up space or to move about the world propelled by authentic feelings and needs. They suffer from a deep conviction that they cannot occupy their bodies while maintaining mutually safe and intimate contact with the people they need most. I believe that these dissociative conditions are often the cumulative developmental sequelae of various forms of parent-child misattunement.

* During enactments of troubled relational patterns, analyst and patient will share or take turns feeling all kinds of disturbing experiences of psychosomatic disunity. These states of disconnection are powerful diagnostic tools that guide us to the places that need to be healed. I demonstrate through clinical examples that it is the analyst’s struggle to remain embodied consciously throughout these enactments that makes the patient feel, quite literally, held and, consequently, safe enough to
experiment with new relational patterns.

* When Freud removed his hand from his patient’s forehead and invited her to free associate, he empowered her mind but abandoned her experiencing body. He abandoned the body that remembers and carries meaning, and that, above all, seeks to connect her to others for the sake of connection. With the development of the structural theory, the primacy of the Oedipus complex and the call for abstinence, the actual body was eclipsed by the fantasized body and the intrapsychic fate of the sexual and aggressive drives. The touch taboo and the fixed postures of patient and analyst that we have inherited from the classical model inhibit not only what we do and say with our patients, but also even what we are able to imagine and feel? We have been taught to be quick to reflect interpretively, to impose rational order on bodily experience. We foreclose our opportunity to learn from the body and to connect it to both affect and abstract thought.

* Repeated failed attempts to connect with one’s caretaker can result in rage, frustration, and despair (Bowlby, 1973). Such despair becomes a dead space between mother and child and between mind and body, a space where defensive pathological thought processes proliferate. Andre Green (1993) explores this phenomenon and describes the child’s attempt to repair the psychic hole left by precocious body-psyche dissociation with compulsive sadomasochistic thought and fantasy. Eigen (1986) has provided a wealth of examples of the kind of “crazy” bodily imagery that can fill this dead space in psychosis. He says that in psychosis “what seems to be a spoiling process can be an attempt to put mind and body together in whatever ways are possible under the circumstances.”

Psychotic thinking is only one of many consequences of rage and despair about not having comfortable access to the mother’s body.
In our work we more often see patients who have responded to their mother’s psychosomatic disunity and unavailability with an avoidance of being fully alive. This fear is expressed through many symptoms, perhaps most commonly in psychosomatic, obsessional, or depressive illness. In all of these conditions there is a fear and avoidance of either loving or hating from an embodied place. The internal world is cut off from people, and the mind is cut off from affect and body.

In obsessional thought we try to control the past or the future with our minds by running away from the experience of the moment and from the body. Shabad and Selinger (1995) have described this flight from rootedness in the body and the spontaneous moment to an identification with vigilant mental activity as a counterphobic defense against disappointment by the environment.

In depression, the arms and hands, which would ordinarily reach out to touch and cling in hope, or gouge and penetrate in frustration, withdraw from the needed one and hang in limp despair. The mind of the depressed person is mostly involved in an attack on one’s own body and on one’s own body-based attachment needs.

* Both analysts believe that patients who are trapped in this cocoon of self-hatred must be helped to direct aggression toward the analyst in order to gain access to the interpersonal world. Bringing aggression, either loving or hating, into the relationship and bringing it into the experiencing body are major tasks of psychoanalytic treatment.

* working in the dissociative gap requires more than verbally based descriptions of the landscape on either side and of the terrors in the dark canyon below. It must include awareness of what it actually feels like in the body for both analyst and patient as they slip and fall and catch themselves and each other as they work in that gap. As Ferenczi (1912) said, “Conviction is felt in the body.”