Following in the Footsteps of Ferenczi, Balint and Winnicott
Love and Hate in a Setting Open to Body- and Action-Related Interventions
Paper Febr. 2001
In the present contribution I would like to shed light on a field of psychoanalysis which has become increasingly important in the German-speaking countries in the past ten years. It was not least due to the influence of modern baby and infant research that a discussion long considered taboo in analysts' circles was resumed: engagement with the technique-related experiments of Ferenczi and the object-relations theorists Balint and Winnicott. A small but growing number of psychoanalysts is again opening the analytical approach to experience-activating and body-related techniques, daring to break new ground in psychoanalysis. In Germany it is mainly the Freiburg-based psychoanalyst and body psychotherapist Tilmann Moser who made a name for himself in the field.
This tendency comes as no surprise: after all, and for various reasons, psychoanalysis is in a serious crisis, at least in the German-speaking countries. New types of developmental psychology force practitioners of psychoanalysis to examine, and at times to revise, familiar theoretical concepts to avoid a widening gap between the "reconstructed" and the "observed" baby. Babies turn out to have a large number of innate abilities which they use to actively shape early baby-parent interaction. The growing importance of interactive processes and the way they are reflected in representations have increasingly drawn attention to interactions in the therapeutic and psychoanalytical process. Given the resulting concept of interactive transference, it seems justified to re-think the possibility of introducing concrete interaction into a notion of transference and counter-transference. Today, we have a much better understanding of counter-transference than in Ferenczi's days so we can base our ventures into new experiments and setting variations on much sounder foundations today.
Thus, it comes as no surprise that the Second Vienna Symposium on Psychoanalysis and Body, which the editor of this book was also invited to as a speaker, was held in September 2000. Traditionally, the Vienna Symposium is a forum for open discussions and controversial statements about these new developments in psychoanalysis. Amongst others, the list of participants at the last symposium included David Mann, Joseph Lichtenberg, Tilmann Moser, Günter Heisterkamp, Jörg Scharff, Gisela Worm and Hansjörg Pfannschmidt. The present contribution ties in with the discussions in Vienna.
Early Object-Relations Theorists
Early on, analysts started to consider the classic setting of psychoanalysis as not effective enough for some of our patients, denying too much, or unsuited for other reasons. Even during Freud's era, pioneers such as Wilhelm Reich and Sandor Ferenczi pondered over the problem but their models of theory and treatment technique raised much scepticism, which eventually led to their exclusion from the psychoanalysts' community. I would like to present a very brief overview of the criticism and attempts at innovation dating back to those days.
Ferenczi (1939), who considered the classic setting of psychoanalysis as strict, denying and even potentially re-traumatising, was one of the first pioneers and object-relations theorist. He strongly advocated a motherly principle of indulgence, even pampering, vis-à-vis his patients, some of whom suffered from serious personality disorders; he wanted to enable his patients to have a certain degree of need fulfilment, a reparative new experience, which was the reason why his attitude towards the patient's regression – considered more of a detour than a road to success by Freud – was highly indulgent. Thus he arrived at entirely new conclusions concerning technique while the failure of many of his experiments was due to the fact that the concept of counter-transference was in its infancy at the time. He wanted to give as much love as possible to his patients but had no suitable instruments to cope with their destructive hate and the way they acted full of hatred. At that time, it was not possible to allow for such hatred in the shape of fantasies in counter-transference, and to return it to the patient as interpretations. Instead, Ferenczi let himself in for mutual analysis which resulted in hopeless entanglement.
Balint tried to find a compromise between the attitudes of Freud and Ferenczi since he was against an exaggerated position of neutrality and abstinence but never went to the same extremes as his teacher Ferenczi. His concept of "primary love" and his view of the baby, revolutionary in his day and age, anticipated insights which seem to be fully confirmed by modern baby and infant research. When engaging with regressing and "fundamentally deranged" patients, he made it clear, notwithstanding the dubiousness of technique-related guidelines, that there are certain do's and don'ts an analyst must observe. For example, when dealing with fundamentally deranged patients, he/she is not allowed act in a denying way, but should grant them "satisfaction for the purpose of recognition," which, in certain circumstances and within limits, might include physical touch. At the same time, the analyst is forbidden to satisfy the wishes of patients suffering from "malignant regression", i.e. patients which insist on the satisfaction of drives. Thus, Balint drew a distinction between the patient's primary needs for love/being loved on the one hand and the satisfaction of drives on the other; the later would be understood as needs at a level of defence today. Concurrently, his statements about the mutuality of behaviour and influence in the analytical situation prepared the ground for a modern notion of interactional transference (Balint, 1973).
Winnicott, too, recommended that the distance required in the treatment of neurotic patients should be given up for psychotic patients and borderline cases, and that patients be given the leeway they need for regression. For him, it was more important than interpretation to give these patients the right atmosphere, loving, motherly warmth, as an analyst. In Through Paediatrics to Psycho-Analysis (1976), he wrote something to the effect that the couch, the warmth and comfort could be a symbol of a mother's love for a neurotic analysand while it would be more appropriate to say that these things were the physical expression of the analyst's love for a psychotic patient. The couch would be the analyst's lap or womb, and the warmth of the surroundings would be the bodily warmth of the analyst. However, Winnicott also said that in spite of all the motherly attitude the tremendous hatred and destructiveness of these patients should not be overlooked. In counter-transference the analyst's hatred should not only be allowed to come out as intensely as possible in the analyst's own fantasies, it should also be included in the interpretation given to the patient in a well-dosed and tactful manner so that he/she becomes aware of the extent of hatred and destructiveness. Another important notion developed by Winnicott was the psychoanalytical situation as a potential space or "playground".
Condensed Physical-Sensual Experience: The Psychoanalytical Situation as a Potential Space
Winnicott's concept of the psychoanalytical situation as a potential space or "playground" was taken up by H. Pfannschmidt, a psychoanalyst and former bioenergeticist at the Second Vienna Symposium (2000), which focused on sexuality. The title of his paper given at the symposium was "Sexualität im intermediären Spiel-Raum" (Sexuality in the intermediary potential space/playground). Pfannschmidt referred to Winnicott when he said that for any ability to develop, a space is required where these abilities can be discovered and mastered in a playful way. "By playfully using this space, the child gradually develops its own internal space, a feel for its own body, the world and potential relations... For example, a little girl may wish to possess the father, and having his child, and she may experience this in her imagination as long as it is clear that the father must not depend on the affection of his daughter in his erotic-sexual identity, i.e. as long as he is able to provide, together with his partner, the need-free space for the desire of his daughter that is fantasised and experienced physically."
To further this space for feelings of love and desire in an optimal way, Pfannschmidt believes that it is required to advance the development of all senses of the patient while not touching him/her physically "since physical touch is a massive manipulation of the patient's imaginative space, in such a way that his/her physical fantasies cannot unfold freely and undisturbedly any longer." Or, to say it in even more pointed words: "My claim is that the physical experience of sexuality and thus corporeality itself is only enabled when erotic touch is not physically performed in analysis. Conversely, a reduction in experiencing sexuality and eroticism reduces corporeality. If we allow for corporeality in analysis, we will very quickly feel that this type of abstinence is not renunciation; on the contrary, it is a very specific kind of satisfaction."
The experience made possible in this intermediary state is thus highly corporeal and sensual but not an experience in the sense of the satisfaction of drives: "This kind of pleasurable experience of eroticism and sexuality in the intermediary space of sexuality does not correspond to the satisfaction of drives in the genital-physical sense but an initiation successful in itself as a whole but also transcending its boundaries as a whole and pointing to the adult and independent sexual identity of the individual."
Pfannschmidt underscores that erotic and sexual issues can be dealt with in transference just like other issues; he considers the specific difficulties arising from it as "perceiving that one has touched the other with one's own erotic-sexual feelings and having received an emotional response that can be felt physically", a process which also applies to the therapist. In other words, if the analyst wants to be able to respond to the loving and erotic-sexual needs of the patient in an affective-physical way he/she has allow him/herself to get involved. He/she must be able to have an erotic-therapeutic relation with the patient. He/she must let him/herself in for the process with all his/her feelings; from this angle, a neutral and abstinent attitude would have to be seen as counter-transference resistance on the part of the therapist. This act of letting oneself in for the relation does not call the division of functions between therapist and patient into question, on the contrary, this assignment of roles is actually required (cf. also Ware, 2000).
The therapist's involvement in the psychoanalytical process applies not only to erotic-sexual experiences but all feelings developing between patient and therapist – including feelings of hatred. In this context hatred is to be understood as the defence of love, and the patient fears these loving emotions because they led to serious traumata in his/her early experiences. If the analyst tries to gradually approach the loving feelings of the patient, it will not be uncommon for him/her to be exposed to the patient's caustic mockery. When interpreting the re-staging of the traumatising situation, the analyst can feel the patient's original fear very clearly: he/she is deeply humiliated in the understanding approach to the patient, and thus the beloved person, in transference. An analyst understanding this situation, overcoming his/her own fears and really allowing him/herself to be drawn into the setting built together with the patient will create the prerequisite for the development of a "loving relationship" between analyst and analysand – without any physical touch.
However, transference love is no longer a one-way street and the analyst cannot simply hide behind interpretations any longer: the patient will feel that he/she is a person with emotions of love and hate, with fears and erotic feelings of his/her own. For this reason, we need a different type of transference that is more appropriate for this interaction.
Excursus: Modern Baby and Infant Research
At least implicitly, offences and early traumata play an important role in the psychoanalytical view of the way in which the structure of the human psyche is formed; in this context, the term "high-tension learning" is used. However, modern baby and infant research has emphasised that we must also pay attention to atmospherical elements and learning processes ("low-tension learning") and that entirely unspectacular experiences, repeated thousands of times in the every-day life of babies and infants, are represented mentally – as experiences of interaction or "rigs" (representations of interactions that have been generalised), as Daniel Stern (1992) calls them.
Such contemporary research is gaining importance, causing us to rethink constructs of psychoanalysis, such as the psychoanalytical theory of affects. Without wishing to go into detail here (I would rather refer to the overview in Dornes, 1992), I believe it is important to underline that the psychoanalytical view of undifferentiated affects in babies and the dependence of affective development on ego growth seems one-sided from the perspective of new currents in developmental psychology. In view of the evident perceptivity of babies, which has been proven in experiments, the inability of the baby to perceive the self as separate from objects, as we find it in Mahler's symbiosis theory and other theories, from Spitz to Jacobson and Kernberg, has at least to be reconsidered. Thus, it has meanwhile become very likely that infants are able to perceive seven categories of affects in their first year: interest, surprise, disgust, joy, annoyance, sadness and fear. Apparently, these affects are part of the innate abilities human beings are equipped with. Moreover, babies perceive time and intensity in a very accurate way so that they are most probably able to grasp affects of different degrees and as "contours of vitality" (Stern, 1998). They are able to differentiate between slowly building and explosive anger. Vital dimensions of human beings and events are thus taken in, and a range of feelings and sensations rich in nuances is experienced and represented mentally.
The extraordinary significance of early interactive processes and their mental representation compel us also to rethink and re-evaluate interaction in the therapeutic setting, in the form of concrete and physical interaction in the psychoanalytic space. This interaction takes place at all times in non-verbal dialogues of actions. The psychoanalytic space is no longer a language space only – it is also a space of action – or playground.
The Notion of Interactional Transference
The traditional psychoanalytic notion of transference assumes that transference is first and foremost a projection of internal conflicts and object fantasies of the patient onto the therapist and results from the fact that the therapist gradually identifies and interprets the fantasies of the patient through an attitude of neutrality and abstinence. From this perspective, transference is a "one-way street".
Just like babies and their parents continuously exchange affective-physical signals from the moment the child is born, the psychoanalytic relation is increasingly seen as a circular process of exchange and negotiation based on reciprocal and complementary responses from the respective other party. Today, we recognise to a growing extent that we as analysts/therapists with our own subjectivity are directly involved in this process of exchange. The non-verbal dialogue of actions always takes place even though the couch setting prevents any visual exchange. The reduction of non-verbal exchange at the visual level, which gives the patient less control over the process of exchange, may be justified in certain cases but many of our patients make up for the lack of eye contact caused by the setting by more auditory attention; in the course of the analytical process they have a keener ear for subtle noises coming from the analyst. Hence, it is impossible not to communicate, not to act. Object-relations theorists such as Ferenczi, Balint, Winnicott and others have always said this, and from the angle of new currents in developmental psychology there are many arguments supporting this opinion and this view of human beings.
Hence, the notion of transference I consider adequate is a concept assuming that there is a readiness to interact on both sides – on the part of the patient as well as the analyst – and that the readiness of the therapist to act is a significant element in the scene established together. At the Second Vienna Symposium Bettighofer emphatically advocated such a notion of transference. An interactional notion of transference "claims that both of us personally contribute to the way in which transference is shaped. Apart from the usual projects, basic situations of the patient are staged. And these also contain the contributions I have made as a therapist... Projections are not the only things concerned, in fact, real interaction takes place... neutrality and abstinence no longer mean that I am e.g., not allowed to touch but that I have to be aware of my motivation for touching and that I have to keep an eye on what this could mean for the scene. Against this backdrop, it is quite possible to use a variety of methods. The point is then no longer what speaks in favour or against this method but the question will be: what is it that I stage with the patient if I work with him/her the way I am working now?"
Such an interactional notion of transference is the prerequisite for the analyst letting him/herself in for the process a little more unreservedly and allowing him/her to become involved to a certain extent. From my own experience as a patient and therapist, I would now argue that this involvement into the shared interaction makes the psychoanalytical atmosphere more open, more lively and also more enjoyable so that it has a positive impact on the affective experience of the patient. When patients notice that I, as a therapist, act in an unconstrained way, that I show my personality the way it is and do not hide behind utterances reflecting detachment, they are also able to let themselves in for the therapeutic process in a more direct way, overcome their anxieties and sense of shame, and allow for loving feelings and hatred to happen with more intensity.
Setting and Experiential Space
The therapeutic relation is a space emerging in the framework of a psychoanalytical process and it is shaped by contributions of patient and therapist alike even though their positions are different. Certain modalities of the setting favour certain experiences with oneself and with others to a greater or lesser extent. Even though there is no compelling reason why the setting and the patient's experience should be connected, we can safely assume that a certain connection exists between the two (Scharff, 1998, p. 45).
Having made my own experiences as an analysand, I am in a position to comment on this. After having dropped out of psychoanalysis in a couch setting after one year, I did five years of bodyenergetic analysis according to Lowen which created the emotional prerequisites enabling me to approach deep emotional experiences and being touched by love and hate in a way I had not experienced for decades. My third therapy, seven years of psychoanalysis, eventually made it possible for me profit from the analysis because I had acquired the ability to open myself to emotions.
I would like to describe the difference in affective experience in terms of a caricature: whereas I mourned in the analytical setting, I frequently cried like a little child in the course of body-related therapy. Whereas I felt the physical tension of subdued anger in the analytical setting, I had the opportunity occasionally to express that anger through my whole body, which not only meant short-term relief but also gave me the comforting certainty that I was even able to cope with extremely heavy affective loads. Work with affects in body-related therapy is based on an immediacy of experiences that can hardly be achieved in a purely verbal setting. To my mind, this immediacy of experiences is not only linked with an opening of all sensory channels as described by Pfannschmidt but also with the physical-motor innervations one experiences in the course of physical contact or in motion.
Let me summarise the benefits and risks of body-related approaches and their impact on affective experience:
1. Body-related work gives much more immediate access to affects than this would be the case in a purely verbal setting. Of course, this comes with certain risks, e.g. the possibility of shifting defences of the patient, manipulated transference by instructions for body exercises, and the risk of a positive correction of experiences while negative developments in transference are overlooked. Moreover, the more directing body-related approach does not foster the patient's fantasy space quite as much as the psychoanalytical setting. Even though the approach is different, the result is the same as in psychoanalysis: traumatic positions of the patient gradually rise to the surface and can be worked through.
2. In the patient-therapist relation, while working "in transference", the affects experienced by the patient are more intense and dense, they also have a different quality, different "states of aggregation" (Moser, 1989a). Love and hate can be felt more strongly than in a purely verbal therapy space, they are quasi embodied. The opening of all sensory channels leads the way towards a comprehensive experience of emotions and body while also occasionally requiring concrete physical interaction with the therapist, which may but does not necessarily have to include physical touch.
3. This method broadens the range of indications of patients with whom we can work in psychoanalysis, so as to e.g. include patients with "traumatic affects": as a defence against their dangerous affects, which they fear might break out like an explosion, thus flooding their ego, they use a high degree of verbal and intellectual detachment which may even border on a state of unreality. It is practically impossible or very difficult to approach such patients verbally, the psychoanalytical process is often halting whereas more direct access to their affects – always taking into consideration their anxieties and resistance – would be advantageous because the analyst is "on site" then. However, there is a risk of the self being flooded when doing body work "in transference" so that occasionally one might better switch to scenic interventions (e.g. role play) that are easy on oneself.
4. By fostering body perception – in affects such as love and hate, but not only these – a "body space" getting ever more differentiated gradually emerges in the patient. Thus Freud's idea that the I is primarily physical in nature (Freud, 1923) continues to be valid. In times such as our post-modern age that is hostile to the body, increasingly turning to virtual contacts as a substitute for real ones, a time of alienation from corporeality and sensuality, when the feeling of being part of nature is lost, it seems to me that a body-friendly basic attitude is an indispensable corrective in psychoanalytical therapy.
Description of a Case
The following description of a case (Scharff, 1998, p. 46 et seq.) shows exemplarily how body-related work – in the present case it is an intervention by touch– can be introduced into a psychoanalytical situation in a discerning manner, and what kind of impact such an intervention has on the way in which the patient experiences her affects. In this context, the term "psychoanalytical situation" is used as a heading for situations "where the methodical use of transference and resistance makes it possible for a psychoanalytical process to develop" (ibid., p. 45).
"In my practice, the ... patient ... a borderline case with autistic traits, is in an experiential space which also includes the possibility of a staging interaction. She suffers from a severe organic visual disorder but primarily sought treatment for feelings of vacuity and depressions. Earlier, analysis had come to a standstill for a long time, and even now, the relation between the patient and myself was characterised by rigidity, mask-like stiffness and ritualisation. We changed the setting from her lying down to sitting face to face. This patient also talked about dreams she was unable to finish because she woke up in a panic. For example, she is afraid of being submerged in water even though a swimming instructor is close by and tells her what to do. Or she dreams that she is a little girl in a children's home and I tell her all of a sudden that the treatment is over. In her dream, she falls silent and holds on to a spoon before she wakes up. I will say more about the background of her disorder below and also explain why I eventually suggested a staging interaction to the patient in one session: I said that we could just wait and see what happens when she lies down on the couch and I sit beside her and perhaps put my hand on her shoulder for some time if she wants me to. When we really did that in the following session, the room fell totally silent and like a little child, the patient seemed to feel in good care in my presence for long, almost timeless moments, even though she was not entirely free from anxiety. Finally, we exchanged a few words. When I withdrew my hand after announcing that I would do so, the patient recoiled as if she was experiencing something very dreadful. We sat face to face for a while and spoke about what was experienced."
In contrast to conventional body-related therapies (bioenergetics, biodynamics, Hakomi, Radix, Reichian therapy etc.) the guiding principle of all interventions – including those at the level of body and actions – is the dynamic of transference and counter-transference. In spite of all differences, this guiding principle as well as work with internal, unconscious ideas, so-called representations, is shared by all analytical approaches. This also applies to processes which deliberately include times of (inter)action by gestures or movements, with or without touching. In terms of structure, such actions should be considered "testing actions", an "intended model scene expressed in movements" (Scharff, 1998, p. 47). Usually, the analyst's intervention takes as its point of departure a certain aspect of the relation which spontaneously develops between patient and therapist while they are speaking. In view of this, the method is not rooted in the body but in the relation while attention to bodily, i.e. non-verbal, dialogue processes plays a major role. Relations are always also articulated at this basal non-verbal level forming the communicative backdrop without which the transmission of verbal messages would not make sense. The communicative backdrop ensures a fine-tuning of closeness and distance that is negotiated unconsciously, and a specific atmospheric colouring of the therapeutic situation that it usually easy to feel and difficult to express in words. If we consider the quantity of information exchanged, the backdrop accounts for some 80% of communication on the whole (Fivaz-Depeursinge, 1998). It is also present but hard to articulate in purely verbal settings because the exchange of information does not so much take place in the realm of declarative knowledge but of implied procedural knowledge. Settings which include body perception and occasional opportunities for body experiences by action and touch facilitate the conscious perception of implied procedural processes because of their closeness to body and action. In the present case, the setting helped the patient out of the deadlock she had found herself in verbal analysis.
The Biographical Background of the Case
Over time, the following description of the patient's early relationship to her mother emerged through reconstruction, elements from transference and counter-transference, dreams and biographical details: the patient's mother had apparently had little tolerance for insecurity, anxiety or dissension vis-à-vis her baby. "She did not let herself in for the venture to turn the child into her baby by trying to empathise but entrenched herself behind a wall of regulations derived from her own mother about how she and the baby would have to behave. The baby's vivacity was a threat to the mother so that the actual unconscious motivation behind all her actions was to keep the baby quiet before she actually let herself in for any internal engagement with the child. Breast-feeding and feeding was thus tantamount to taking all vivacity away from the child, a way of putting it off and thus preventing herself from becoming involved with it. However, this mode of behaviour was not at work all the time, there were moments when the mother briefly engaged with the child but then broke their togetherness off again. In response to this experience, the patient withdrew to an autistic-contagious position (Ogden, 1989). Premature sham autonomy in the presence of a relationship characterised by clinging and psychic non-separation from the object, permanent hypervigilance, almost delusional omnipotent control over everything, those were the characteristics of their relationship. The patient felt deep-rooted anxiety and aversion to any affective movement and real affective experience because she feared a traumatic slip of the mechanisms regulating her affects in case the experience suddenly stopped. Her relation to the object was characterised by a deep-seated ambitendency, the object was at the same time good and bad, seducing and repudiating ... This was exactly the configuration of the relation in which treatment had been stuck for a long time. The patient was neither able to leave nor was she able to develop something new with me as she stayed on." (Scharff, 1998, p. 53).
Details of the Intervention by Touch
The first thing to do is work with the anxieties and resistance which the patient starts to feel when the analyst offers to touch her; after all, her resistance must not be overruled. Once the analyst has suggested to the patient to try a clearly delineated intervention by touch, advance work on the scene will start in the patient's fantasies, before the interaction actually takes place. This also happened with the patient in the case described above. "She is afraid that she will lose her footing, to fall, to surrender, and also to become too heavy for me." (Scharff, p. 53).
The analyst does not urge the patient, leaving options for the suggested intervention open – this can be compared to offering an interpretation which the patient may accept or reject. "When the patient lay down on the couch on her side the next day, I remained seated on my chair first and then sat down beside her after some time of asking questions and co-ordinating." (ibid., p. 53).
When the patient lies down and before the analyst places his hand on her shoulder, both pay attention to the atmosphere that materialises and the non-verbal quality of the emergent relation. "She is lying there silently, her hand at her mouth, and I experience from a different angle close up what she told me earlier: on the couch, she would sometimes feel like a little child, or actually was a child. As she does not move and her face is slightly flushed, I presume that she is still not entirely free from anxiety and tension. However, at the same time a surprising feeling of calmness is conveyed." (ibid., p. 53).
After the patient has adjusted to the new situation triggered off by less of a distance between herself and her analyst, he says "after a while that I could also imagine putting my hand on her shoulder the way we had discussed. Eventually, the patient asks me to do that." (ibid., pp. 53-54).
At the level of a non-verbal exchange of signals, the patient's response to the act of touching is directly perceivable for the analyst, and the non-verbal dialogue in the form of bodily signals and messages guides the complete interaction when this technique is applied: "The state of peaceful arrival is reinforced, perfect calm sets in. I can also feel this in the changing tonus as the patient accepts my hand. It is only the slightly flushed face that seems to signal some continuing tension." (ibid., p. 54).
The end of the intervention actually causes a drastic change in the affective state of the patient: "When, some time before the end of the session, I announced that I had to lift my hand, the patient responded by convulsively recoiling and withdrawing, dissociating and disconnecting herself in an embittered way. I commented on the change and said that this would perhaps be like retreating from unbearable pain caused by the change in our relation due to the separation. Then the patient sat down on her chair again and we continued to talk for a while." (p. 54)
"When the patient arrived the next day she had obviously changed, she was lively, full of interest in the session. She told me she was astonished on what one could experience on the couch – I had always said that but now she knew, too, and she would be curious about what would lie ahead. While she had been lying on the couch yesterday, she had felt like a small child, all delighted and she had totally lost her sense of time. However, it had been absolutely horrible when I "suddenly" announced that I would have to take my hand away. For a brief moment she had realised that something in her was crying out: 'If it hurts so much when you leave, I don't want anything from you anymore.' What preoccupied her most was that she had the feeling the whole thing had not been true and real when she rose from the couch." (ibid., p. 54).
The affects triggered off in the patient – probably a combination of love and hate – are very intense and assume a different "state of aggregation": "Even though the patient's affects take on a traumatic quality, especially as I lift my hand from her shoulder – and we were both surprised at the intensity of what was happening – the affective process also has certain characteristics of a testing action as it is grounded in a sequence that had been discussed and agreed earlier." (ibid., p.55). The scenic work "in transference" may have affectively flooded the boundaries of the patient's ego briefly, not sustainably. "At best, the creation of a scene with the mediating structure of a planned "third element" furthers optimal distance and optimal proximity in the therapeutic situation." (ibid., p. 55). Without the mediating structure, the therapeutic situation would be too close and too immediate, and the boundaries of the patient's ego would be flooded sustainably, which would be tantamount to a re-traumatising experience. A sufficient degree of the analyst's own experience and long-term supervision in body-related work "in transference" give the analyst a feel for the rhythm, dosage and tact that is not only required for verbal interpretations but also for the technique of using physical interventions.
In the present case, the patient's response shows that the intervention by touch had a releasing effect: "Previously (in the couch setting, P.G.) my patient's experience was always characterised by a simultaneity of 'no distance' in the sense of naked traumatic immediacy, and 'absolute distance' in the sense of affective negation" (ibid., p. 55). It was only possible for the patient to find a way out of the deadlock when she made the concrete physical experience. "Via the line linking the doctor at the bedside, the mother at her child's bed, the soothing-accompanying presence of an early part-object" a sensual-gestural relation comes to bear, taking up pre-verbal communicative moments and giving the patient "support....at a concrete-symbolic level." Such "closeness" – at least in respect of the spatial configuration, with the analyst entering the protected area around the patient – does not usually exist in psychoanalysis, with the exception of Winnicott (Little, 1985), or "it is not used methodically." (Scharff, 1998, p. 56).
Why is it that this experience was so important for the patient, and why was she unable to make such an experience in the classic psychoanalytic setting? For Scharff, the reason for the impact of the concrete intervention by touch lies in a specific quality of regression: "Here, the result is that the patient feels like a little child, her sense of time changes and for a few moments she feels safe even though the experience is not clearly positive throughout. The patient also reached early somato-psychic states in the classic setting on earlier occasions but it happened in the context of a negative object configuration which she/we were unable to correct for the time being: she felt totally abandoned, isolated, and I was perceived as inaccessible, as if behind glass. The ambitendency (1) of simultaneous seduction and repudiation, so deeply engrained in the patient's experience, is now taken at least one step towards an understanding of successive stages in time. This is due to my offering discernible shapes of events in the fields of positive and negative object experience alike, including the sensomotor level and thus also the feedback loops of physical experience, e.g. sitting very close to her, linked with the warmth and slight pressure of my hand on the one hand, and then severing the connection and leaving on the other. The patient will later on undermine these shapes fantasmatically by anticipating the ending at the beginning and in the end believing that she never started in the first place – but the shape of the process experienced haptically will be something that cannot be pushed aside permanently, primarily because it is at the same time the object of our attention." (Scharff, 1998, p. 56).
Scharff concludes with a comparison between the verbal-analytical setting and a setting open to body-related interventions: "Some patients ... may use parameters of the classic setting, such as the regularity of sessions and the surrounding environment, the act of lying on the couch, the analyst's voice, to name but a few possibilities, to make sure of precisely that quality. Other patients do not succeed in doing so for a long time or even not at all due to their specific traumata." (Scharff, 1998, p. 56). Thus it seems "that certain patients are only able to face their anxieties of impending doom to the full if a concrete environment is available to affirm the bodily ego senso-motorically so that an oscillating motion between support and catastrophic experience can emerge" (Scharff, 1998, p. 56).
The patient's affective experience is in the centre of the therapeutic process of change. Without affective engagement of patient and therapist alike, the therapeutic effects obtained will be unsatisfactory. Without a "fire that needs to be burning" in the therapeutic process, changes will remain superficial or stuck at an intellectual level. Love and hate are thus indispensable ingredients of any psychotherapeutic treatment.
Due to its very discerning approach to transference and counter-transference, which has meanwhile started to put an emphasis on interaction, the psychoanalytical process offers a methodological framework in which impulses of love and hate can be given free rein and worked through in transference. In many cases, it is helpful to allow the space of imagination to unfold so that affects such as love and hate can be felt in their full intensity. The more senses are allowed to be involved, the more intense and ultimately beneficial will the development of the therapeutic process be. In certain circumstances, it will not be enough to open up the patient's imagination; additional interventions will be required, including the dimension of acting through transference and counter-transference. After all, modern baby research makes it clear that the development of all affects, including the stages leading up to love and hate, starts very early on; initially, it is strictly and closely linked with sensomotor experiences. Some patients only will feel that the therapeutic process touches them sufficiently when they can directly tie in with that level of sensomotor experience.
In some patients, certain specific characteristics of the psychoanalytical setting cause them to see the setting in itself as identical with a central injury of theirs. This may lead to a therapeutic stalemate which will be very hard to break. It is especially the simultaneity of highly contrary tendencies such as seduction and renunciation, as well as love and hate, that may lead into a quandary where there is no more leeway.
In such cases of regression to what is usually a very early traumatic position, the use of modes of sensory perception corresponding to development (Heisterkamp, 1993), i.e. concrete body-related interaction such as conveying physical support, is often a useful way to break the stalemate. A "concrete-symbolic" level (Moser, 1989b) comes to bear through a sensory-gestural relation which thus introduces pre-verbal communication into the psychoanalytical setting to a greater extent than is usually the case, eventually setting the ball rolling again. This way, the direct physical experience of emotions within clearly structured therapeutic sequences may give the feelings of anger and love - originally experienced as something dangerous by the patient due to their simultaneity - a chronological order, turning them into defined sequences of interactions or processes of tactile experience, and making the patient's ego more flexible again.
Hence, working in an open psychoanalytical setting would be specially indicated in patients with traumatic affects. It is not a setting where emotions are acted out blindly. The space of action and the body is systematically incorporated in the analytical process while keeping an eye on transference, counter-transference and resistance.
Moreover, experience-oriented, body-related intervention techniques are meaningful as they complement the classic analytical repertory of interventions due to the fact that they counteract the physical and emotional alienation many patients suffer from in our post-modern days. Love and hate can be experienced in a very elementary way, near-physically, when the analytical setting is open to body-related interventions. Patient and analyst will again get a feel for the early experiential world often buried deep down in an adult, a feel for the different experience of time, wholeness and force linked with it, and for a feeling of power that is rooted in the body – an experiential world which in all of us forms the primary rock which all experience is grounded in.
1) "Ambitendency" denotes a state of ambivalence including the aspect of action, i.e. contrary physical impulses.
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