What sort of patients do we have in psychoanalysis now, at the beginning of the third millennium, and what sort will we have in the future? In the authors clinical experience, the patients who are currently seeking help from the psychoanalyst use primitive defence mechanisms alongside neurotic ones. Most of them do not explicitly request psychoanalytic treatment, but this does not mean that they would not want it if they knew what it was. She argues that is the psychoanalysts task to identify the latent request behind the non-request. To conduct a psychoanalysis with such patients, the psychoanalyst has to identify and interpret both primitive and neurotic psychic mechanisms; moreover, he has to use not only language that speaks to patients but also language that touches them, because these patients are difficult to reach through verbal symbolism. This implies that the psychoanalyst must be attentive to the bodily manifestations and bodily phantasies accompanying his countertransference feelings. The author shows through clinical examples what she means by language that can touch patients. The psychoanalyst gradually builds up this language while, at the same time, daring to discover in himself his own mad aspects and giving himself enough psychical freedom to accept them.
Wisdom often consists in following ones madness rather than ones reason.
_E. Schmitt, Le visiteur (1994, p. 26)_.
At the beginning of the third millennium I have been reflecting on my clinical experience as a psychoanalyst. Two questions I have been asking myself are: first, in my daily practice with patients in analysis today, what path is the unconscious using to manifest itself; and second, how can we recognise it?
Youre mad! I then found myself thinking, Today, you have to be mad to be a psychoanalyst! Then I recalled the moment when a transsexual patient, a man who had undergone a sex-change operation (vaginoplasty) several years before and who was suffering from a serious sense of a lack of being, asked me if I could take him into analysis (Quinodoz, 1998). By having this operation, this patient had done something mad that put her in a situation that was irreversibly mad; yet, in many respects she seemed well-adapted, particularly in her professional and social life. On the one hand, this patient was disavowing reality; and, on the other, she was able to take reality into account: she presented a splitting of the ego. I had serious reservations about accepting her into analysis, which was why I discussed the matter with colleagues.
For once, my colleagues opinions were unanimous: Youre mad!, they said to me. The mere fact that I had even considered taking on this analysis already seemed to be a sign of madness. Could the mad part of the patient evolve in analysis? Would it not be dangerous for this patient to develop psychically, since in reality her castration was irreversible? But it was precisely the latter question that troubled me. This patient wanted to develop; should she be refused the help she was asking for on the pretext that the consequences of her madness, in reality, could not be undone? Would she find herself ensnared in concrete reality? This was what seemed mad to me; for I was convinced that if it was possible for a patient to develop, he or she would be able to find a solution.
The unanimity of the comments made me realise that the condition for my taking this patient into analysis was, perhaps, that I myself would have to accept being mad not mad in a general way, of course; that is, it was not a question of believing that I was omnipotent and that I was capable of achieving anything. It was a matter of becoming aware of the mad aspects of myself, without making a drama out of it, and while keeping my feet on the ground. If, as psychoanalysts, we are to be able to work with the patients of the third millennium who turn to us for help, we will undoubtedly need to be aware of the archaic side of ourselves, our own splits, our psychotic mechanisms; in short, the mad aspects of ourselves. If we hope to understand our most disturbed patients, we have to be prepared to expose ourselves to troubling and uncomfortable countertransference experiences.
I had this patient in analysis for several years. Now the analysis is over, and the quality of life obtained by my patient has convinced me that psychoanalysis can be an invaluable resource for patients such as these, who suffer from a lack of ego unity.
Reproduced with the kind permission of the Institute of Psychoanalysis.
Originally published as Int J Psychoanal 2001; 82:235-248
This patient may seem to be a rather extreme case, owing to her transsexualism. Yet I feel she is representative of many of the patients I have in analysis, as well as of many of the patient s that training candidates whom I supervise have in analysis. With her and with them, we can observe the coexistence of contrasting aspects: a more developed aspect and an archaic aspect . These patients, whom I would call heterogeneous, suffer from experiencing incompatible attitudes within themselves; on the one hand, they are capable of symbolising and of using secondary psychical mechanisms, and on the other, they resort to primitive psychical mechanisms such as disavowal, project ion, massive projective identification and different forms of splitting. The extent to which these mechanisms are employed may hinder the functioning of their symbolic capacity, which they could otherwise make use of. I have chosen the term heterogeneous patients in order to avoid using psychiatric diagnostic labels; and I have tried to find a term that simply refers to the patients drive and defensive organisation as it can be observed by a psychoanalyst in the relationship that develops between himself and these patients. This is why I do not use the term borderline patient in the sense in which it is used by Kernberg (1984). Nor do I speak of borderline states, a notion introduced by Green who, from a different perspective, proposes that the borderline be considered as a concept (1999, p. 33) and is interested in this frontier, which is not just a frontier line but rather a frontier zone between two territories with its own characteristics (1986). I am purposely using a general descriptive term that is not part of a particular conceptual framework, but with which clinicians with different personal references may be able to identify. This heterogeneity can be found in each one of us in proportions that vary from person to person and can evolve over time: there is a psychotic personality concealed by neurosis as the neurotic personality is screened by psychosis in the psychotic, that has to be laid bare and dealt with (Bion, 1967, p. 63). Personally, I tend to speak of different parts of the patient when splitting predominates, whereas I speak of his different aspect s when unity prevails. But the patients whom I call heterogeneous all have the particular feature of suffering from their heterogeneity; not that they are aware of the heterogeneity itself, since it originates in unconscious splitting, but they suffer from its consequencesthat is, from the discomfort, which is often difficult for them to define, of having attitudes and forms of behaviour that are in conflict with each other, as well as discordant feelings. These patients are therefore the victims of an unconscious struggle between, on the one hand, the force driving them to split off, and keep frozen, certain parts of themselves and, on the other, a force driving them towards reunification. What can we offer these patients who, without being psychotic, nonetheless sometimes use psychotic mental mechanisms? Psychoanalysts have different answers here. Some psychoanalysts prefer to take them into psychotherapy. They think that the patient will be in less danger of disorganisation, or malignant regression, in a non-analytic sense (Gibeault, 2000) if he can relate to the reality of his therapist in the face-to-face sessions. Why not? Many fascinating things happen in psychotherapy. But a note of warning: if by preferring psychotherapy we think we are leaving madness undisturbed, it should not be forgotten that even if we let it sleep, it still does not go away.
This is why I think that, as psychoanalysts, we find we are being led to take heterogeneous patients into psychoanalysis and that this will increasingly be the case in the future. But this being said, it is a matter of evaluating not just the patients analysability but also what the analyst feels he or she is capable of offering the patient in a psychoanalysis. If we are ready to take on these patients for whom analysis can be an invaluable source of help, I think there will be no danger of analysts couches remaining empty.
FREUD HAD ALREADY FORESEEN THESE PATIENTS OF THE THIRD MILLENNIUM
In 1940 Freud described the splitting of the ego as follows:
Two psychical attitudes have been formed instead of a single oneone, the normal one, which takes account of reality, and another one which under the influence of the instincts detaches the ego from reality. The two exist alongside of each other. The issue depends on their relative strength. If the second is, or becomes the stronger, the necessary precondition for a psychosis is present The view that postulates that in all psychoses there is a splitting of the ego could not call for so much notice if it did not turn out to apply to other states more like the neuroses, and finally, to the neuroses themselves (p. 202).
The more I practise psychoanalysis, the more I notice both in my analysands and in myself the perspicacity of Freuds remarks describing the presence in each of us of these two attitudes in varying and fluctuating proportions. Moreover, in addition to the splitting of the ego discussed by Freud, we can also observe multiple forms of splitting, and I think an analysand may feel extremely ill at ease, without knowing why, if he (or she) finishes his personal analysis without having taken into account his own most important splits. Even if everyone, however well-analysed they may be, always retains some shadow zones, we cannot minimise the importance of the return of what is disavowed: Probably in a psychosis the rejected piece of reality constantly forces itself upon the mind, just as the repressed instinct does in a neurosis (Freud, 1924, p. 186).
THE NON-REQUEST IN PSYCHOANALYSIS
Should we only take into analysis neurotic patients and, specifica lly, neurotic patients who explicitly ask us for psychoanalysis, or patients who have been referred to us by a colleague who has already suggested that psychoanalytic treatmen t is indicated? Such situations are exceptional nowadays. We rarely meet a purely neurotic patient, especially as a neurotic person is sometimes a borderline case without knowing it. Furthermore, if a patient is already familiar with psychoanalysis, he will choose to have his analysis with a psychoanalyst of long experience. If these were the only patients who were accepted into analysis, psychoanalysts would psychoanalyse amongst themselves and we would then only be dealing with des psy de psy [(2)] as Mauger & Monette (2000, p. 28) call them, which would really be a pity. I think that as a result of extending the heritage left by Freud, the current state of our of psychoanalytic knowledge allows us to undertake analyses with patients who are not purely neurotic, if they exist at all. Freud was the first to take the risk. Personally, I have always made sure that at least half of my patients in analysis belong to a professional world other than that of psychiatry or psychology and have no prior knowledge of psychoanalysis.
If heterogeneous patients do not ask us directly for psychoanalysis, in most cases it is because they do not even know what it is. Yet they turn to us, as psychoanalysts, for help, and their decision to do an analysis or not will generally depend on the att itude of the psychoanalyst whom they see. It is for us to recognise their unconscious or preconscious request, to know how to welcome them and to propose this adventure to them. They make me think of Brassenss song entitled La non-demande en mariage (The non-proposal of marriage): I have the honour of not requesting your hand. When, during prelimin ary interviews, I am thinking of proposing psychoanalysis to a patient, my first concern is not to know whether I am dealing with a neurosis, psychosis or borderline state, or even to rely on an evaluation which often proves to be mistakenof their capacity or incapacity to symbolise, but to discern whether the patient has an unconscious or preconscious desire for the unificat ion of himself, and whether he shows at least the beginnings of a capacity to use a transference object constructively. In my experience, more patients could benefit from a psychoanalysis than we think. It would be a pity to respond to the manifest request for psychotherapy without noticing that behind it there may be a latent request for the kind of work that can only be done in psychoanalysis. Further, with the aim of helping new candidates to find analytic cases, I ran a clinical seminar for several years on the theme: how to enable a patient to become aware of his eventual wish to have psychoanalysis. I shall now try to mention a few points that may facilitate such awareness.
HOW CAN A PATIENT DECIDE TO UNDERTAKE AN ANALYSIS WHEN HE DOES NOT KNOW WHAT IT IS?
During preliminary interviews, when we want to propose psychoanalysis to a patient who knows little or nothing about it, even if he (or she) sometimes thinks he does, we can of course explain to him rationally what the unconscious is, or make a fine comparative description of the scope and limits of psychotherapy and psychoanalysis; and the patient will listen to this as if we were telling him a nice story, but without being ready to embark on the journey we are proposing. What matters is not to explain rationally, or to awaken an intellectual interest, but to arouse conviction. To discover what psychoanalysis is, the patient needs to experience it for himself from within. This insight may then bring with it the adherence of the whole person, allowing him to make a vital decision. This is also true for patients who have an intellectual knowledge of psychoanalysis through their profession. What sort of interview is likely to allow a patient to gain such insight? If the psychoanalyst shows the same reserve towards his heterogeneous patient s as he adopts with neurotic patients who, with full knowledge of the facts, have asked him for an analysis, nothing will happen. A patient cannot embark on an adventure about which he has not the slightest idea, with the aim of discovering a world whose existence is unknown to him, or of which he only has rational knowledge. This patient needs the analyst to interpret what happens between them at the level of the transference relationship emerging during the preliminary interviews, in a sufficiently suggestive way and in a language that speaks to him, so that he is then free to make a choice.
The patient who cannot imagine what the unconscious world or phantasies are will have considerable difficulty in understanding what the analyst is offering him, for he cannot perceive the world that the analyst is speaking to him about. For his part, the analyst sometimes has great difficulty in realising that his patient cannot perceive this world of phantasies or the world of the unconscious that he is speaking to him about, but with which he himself is familiar. The analyst sometimes infers too quickly that the patient is not interested in it or cannot get in touch with it. Yet I have often been surprised to observe that when a patient gets a glimpse of this world of which he previously had no inkling, he can show great interest in it. Indeed the patient often finds himself in a situation that is all the more anxiety-producing because he is enclosed within a real world, every aspect of which he has gone over in his mind in vain, without being able to see a solution. When, during the prelimina ry interview, the patient has even a fleeting revelation of the reality of this psychical world, of whose existence he was unaware, he may hope that his internal and external situation will perhaps become clearer and take on meaning, and that an unexpected solution, previously invisible to him, may exist for his problems. He will want to explore this space that is new for him and perhaps to accept the means that the analyst is offering him to try and get there. At times, he will also be afraid of going there. But, even in this case, the patient will know from then on that he has had a glimpse of a space of which he was previously unaware.
THE PERIOD OF UNCERTAINTY FOR THE ANALYST
Of course, if a patient is to be able to get a glimpse of his own world of phantasy, of whose existence he has hitherto been unaware, the psychoanalyst must already have discerned it himself; but, the latter will only have been able to do so if he has adopted an inner attitude of floating attention. If the analyst adopts any other attitudefor instance that of a psychiatric interviewhe will be able to notice interesting things, make an excellent anamnesis, but he will not be in a position to help his patient get an inkling of his unconscious phantasy world. There is a period of uncertainty for the analyst, since the representation of the patients phantasy world does not emerge immediately, and it requires patience, confidence and serenity. In any case, for the heterogeneous patient, to be listened to actively and with the utmost attention, over and beyond the manifest discourse, is a precious experience, for it enables him to feel that he exists as a whole person for the analyst. Sometimes, it is true, the patients world of phantasy does not take on any meaning for the analyst; nothing emerges, the way in cannot be found, and the analyst in this case cannot offer psychoanalysis. Perhaps psychoanalysis is not suitable for this patient . Moreover, it is also possible to imagine that a different psychoanalyst would be able to conduct an analysis with this patient.
A CLINICAL EXAMPLE: THE EMERGENCE OF INSIGHT DURING A PRELIMINARY INTERVIEW
Let us look more closely now at how Albert found the convict ion to do an analysis. Albert did not ask for an analysis; he did not even know what it was. He simply came to see me because things were not going well. He wanted to resign from an important job because he was feeling so anxious. In particular, when his wife was away for a few days, his anxiety reached dramatic levels. His psychiatrist, who felt at a loss as to what to do, told him to come and see me: medication had had no effect; in the face-to- face sessions Albert had been unable to speak about himself and in the sessions lying down he had been completely blocked. Albert obeyed, very sceptically, for he could see no other option but to go into a psychiatric clinic. In the initial interviews, Albert spoke very little and only through third parties, as if he only existed by procuration. Instead of speaking about himself, he spoke to me a bit about his children and his animals, and, noticing that this interested me deeply, he became more lively and talked more. But then he stopped suddenly, You see, Im blocked, Im not speaking about myself Yet, for me, as an analyst, Alberts psychical world was beginning to take shape: Albert felt he existed not where he was but elsewhere, through others, even animals. I could well imagine that he might feel empty when a partner went away, since he projected his ego so much into the other. With conviction, I said something quite simple but which had a very powerful meaning for Albert : When you were telling me that your son was a bit of a savage, dont you think you were also telling me about yourself ? I felt that for Albert a door had half-opened: he had found himself again, projected into his son. My question, which touched upon his projection and his identification, gave him a glimpse of a world that he wanted to know; Albert was beginning to show interest but was still a long way from psychoanalysis. Albert then told me, without attaching any importance to it, that he had had a happy childhood. From the age of 18 months he had lived with a couple who loved him a lot, his aunt and uncle, as his parents were divorced and his mother was too involved in her profession abroad to have time to take care of him, even if she said that she would have liked to. Then after talking about the unhappy childhood that many delinquent adults have had, followed by a long silence, he said to me, I would be very interested in doing an analysis with you, but Im so tied up professionally and have so little time that I would never find the time to come and see you several times a week. Its impossible. At this point I felt pervaded by a great feeling of sadness and disappointment. I then wondered: this sadness, could it be due to projective counteridentification ? Could this be the sadness that Albert, as a child, had disavowed and split off, and consequently could not speak to me about? Was he sharing it with me unconsciously by projecting it into me? After a period of silence, I said to him in a tone that probably reflect ed the sadness I had felt, Your mother was very interested in looking after you when you were a child, but she was so involved with her profession and had so little time that it was impossible for her to find the time to come and look after you A heavy silence, charged with emotion, set in. Albert recognised his mothers discourse in what he had said to me and he also recognised in the tone of my response what he had never been able to admit to himself. He had just had the experience of what could happen during an analysis in the transference relationship between us. We had both just experienced an exchange that reminded him of the exchange that had once occurred between him and his mother and that now acquired new meaning. A door had begun to open for Albert on to the world of the unconscious; he was now convinced that with this new dimension there was still perhaps a way forward. He agreed to undertake the work that I felt I could offer him, i.e. an analysis .
THE ANALYSTS CONFIDENCE IN THE PATIENTS OWN CAPACITY TO FIND A SOLUTION
It is my experience that in order to take the plunge with a heterogeneous patient, the presence of this confidence can prove to be an important factor both for the patient and for the analyst. To return now to the example of my transsexual patient: initially, I really could not see what solution this patient would be able to find at the end of her analysis. Reality seemed to block the situation: if at the end of the analysis the patient remained convinced of her identity as a woman, it would be the sign that the delusion had been reinforced; if, on the contrary, the patient rediscovered her identity as a man, she would be in despair, as she would not be able to find again either a male body or a male role in society. However, at the end of her analysis, the patient, who no longer disavowed reality, adopted an attitude I had not imagined; she said to me, I have accepted now, as far as is possible, to live with the paradox; I know that I am not a woman and that I will never be able to be one. Neither will I ever be able to be a man like other men. What I can say is that I am a transsexual, who has a womans position. By recuperating the part of herself that had been split off she had allowed her phantasies to evolve: Ive definitely changed since the time when I detested my masculine aspects; I wanted to be a woman out of my loathing for men; now, for me, being a woman means being a woman who likes men. The patient had found a realistic and integrative solution that, by escaping the dilemma that we had seemed to be caught in, appeared to me to be the best possible solution in a situation that nonetheless remained difficult. It was now possible to end the analysis. Initially I had made a seemingly mad gamble, because I was convinced that if the archaic phantasies and the psychic functioning of a patient could develop, the patient could find an answer that the psychoanalyst could not have imagined at the outset.
CERTAIN SPECIFIC ASPECTS CONCERNING THE ANALYSIS OF HETEROGENEOUS PATIENTS
The analyst who accepts a heterogeneous patient into analysis is led to analyse aspects that he would not have to analyse in a patient who was merely neurotic. Equally, he finds he is led to use language that does not merely speak to these patients but which touches them. These patients have difficulties in having access to the symbolic meaning of language, and they need the analysts discourse to awaken or reawaken bodily phantasies in them so as to be able to find emotional meaning in forgotten sensory experiences. They will then become a point of departure for mental representation.
The analyst as the guarantor of the patients desire for integration
It is sometimes the case that a psychoanalysts train ing has been based primarily on knowledge of neurotic patients and that, as a result, he has a great deal of experience of neurotic defences and can easily detect them in his patients. A special effort of attention may then be required for him to be able to detect the eventual presence of primitive defences in a patient and to understand the link (or absence of link) that exists between the two aspects of the patient. Freud presented the world of phantasy as a storehouse that the patient can draw on to feed both his neurosis and his psychosis. I quote:
It is from this world of phantasy that the neurosis draws the material for its new wishful constructions the world of phantasy plays the same part in psychosis and there, too, it is the storehouse from which the materials or the pattern for building the new reality are derived (1924, p. 187).
Thus, by putting the patient in contact with his phantasy world, psychoanalysis offers a special setting for a patient who is oscillating between the psychotic and the neurotic aspects of himself.
Generally speaking, depending on the analysts listening, the patient will put more emphasis on one aspect or the other. But for a heterogeneous patient to agree to undertake an analysis and for a process to be established, he needs to feel that the psychoanalyst is aware of the presence of these two aspects and that he is listening to both. To illustrate this I will make use of an old example (Quinodoz, 1966): Laure had begun the first preliminary interview by saying to me, I was born when I was 6 months old. This first statement could be understood in different ways: it could simply be a tribute to her adoptive parents who adopted her when she was 6 months old; but it could also be a disavowal of the existence of the first months of her lifethe one did not exclude the other. I want to emphasise, then, that an analyst can consider the same statement of the patient from either the angle of neurosis or that of psychosis, or again he can take both into account at the same time. Generally speaking, heterogeneous patient s need to hear that, even if he has chosen to interpret at the more developed, neurotic level, of the patient, the analyst has not forgotten the existence of the primitive side, and vice versa. Similarly, if the patient leaves an aspect of himself outside the session, the analyst can draw his attention to it. The analyst is, so to speak, the guardian of the patients desire for integrity and the guarantor of the possibility of achieving it .
Verbalising the shame of a patient upon discovering an aspect of himself that seems to him to be mad
While expressing in a latent way the wish for the reunification of their ego (self), heterogeneous patients are afraid of discovering archaic aspects of themselves that feel mad to them. In particular, they fear that this mad side may contaminate the rest, as was described by Klein. But the patients anxiety begins to lessen if the analyst can verbalise the shame that the patient feelseven though the latter cannot admit it to himselfwhen he begins to become aware of his mad attitudes, even though in other respects he rightly sees himself as being a responsible adult. The analyst de-dramatises what the patient is experiencing by verbalising the anxiety that the patient experiences at the idea of getting more in touch with aspects of himself that he has hitherto unconsciously and carefully kept separate from each other. The simple fact of making this anxiety explicit implies that, for the analyst, it is obvious that in each of us the presence of one aspect does not exclude that of another. The heterogeneous patient needs to identify himself with a psychoanalyst who dares to verbalise mad thoughts and who is able to look not only at the patients madness but also at his own without being scandalised.
I shall now return to the example of Albert . When we began to make connections between his current anxieties concerning separation and the apparent insensibility which, according to him, he had experienced when his mother had left when he was 18 months old, I said to him: It might be very disconcerting for you to feel like a small child who suffers so much if his mummy goes away, while at the same time you have to take such important decisions for an entire population. Albert then exclaimed, I want to kick this child in me out! His reaction consisted, then, in wanting to evacuate the disturbing part of himself. In reality, he had always fulfilled this wish unconsciously. On hearin g himself say this, Albert had become aware of his tendency to expel and abandon the side of himself of which he disapproved. But to be able to adopt and reintegrate in oneself a split-off part, one first has to realise that one has expelled or abandoned it. I said to him, You would like to kick this child in you out? Just as you reproach your mother for doing so when she left you to go and work abroad? Albert then had the surprise of finding himself identified with a mother whom he consciously believed he detested. So he began swinging back and forth between an abandoning ego and an abandoning object; persecution anxiety then diminished thanks to a better knowledge of the object through phantasy and an increased capacity to put himself in her place in phantasy. His mother could begin to be a internal object with more nuances for him internally, just as in the transference the analyst could appear as a more tolerant object and be regarded more tolerantly. With heterogeneous patients, I think that it is important for the analyst to draw attention to the difficulty that the adult side of the patient may have in accepting the child in him. These interpretations show implicitly that although the patient has a tendency to reject an aspect of himself, the analyst will be able to remember its presence.
Heterogeneous patients harbour a desire to get better and a dread of doing so at the same time; particularly because it would bring them nearer to the end of their analysis and therefore separation from the analyst. In order to be able to get better the patient is led to trick the part of himself that unconsciously wants to sabotage the progress that has been made, sweeping it away as soon as it is noticed. The analysts task is a delicate one; for, on the one hand, these patients are led to hide their progress from themselves in order to preserve it, and yet they need the positive points to be pointed out by the analyst so that they can gain confidence in their capacity for reparation and identify with an analyst who treats his objects well. The patient needs to understand that if the analyst mentions a positive point, he has nonetheless not forgotten the negative points, and vice versa; it is as though the patient had an unconscious wish to encounter in his analyst a concern to bind the forces of destruction and construction in order to put them at the service of vital life processes. In any case, it is when the destructive force of the patient is silentthat is, inaudible for himthat his destructivity has the greatest effect; and, by verbalising it, the analyst tries to prevent it from acting in silence.
What kind of language touches patients? A clinical example from Elises analysis
Elise, who was single and rather charming, but had never been able to make the most of herself in her professional plans or in her love life (her relationships had led to impasses), had made a very vague request for help; I will summarise it by saying that she wanted to feel she was alive: it was as if, for her, life was going to end without ever having begun. From the first preliminary interviews, Elise had appeared to me two-sided. On the one hand, there was a lively and generous side to her, which was perfectly visible to those around her; and, on the other, a dead and greedy side, well-hidden, harbouring suicidal ideas. Elise spoke in a factual way and she cut the links I tried to suggest. In the analysis, Elise talked to me as if I was a useless object, unable to understand her despair, but she had no awareness of the transference meaning of my role. On the other hand, the sessions were filled, in accounts impregnated with unconscious phantasies, with the presence of a man (who, in reality, was far away) who had dropped her. At the beginning of a session, Elise recounted a dream: In a covered pool, there was a big dog, with a broken leg, being dragged round and round in the current. It had a dull look in its eyes and was going to die. I left feeling helpless; then I came back because I couldnt let this dog drown like that, but I didnt know what to do. Elise associated: Once, when I was travelling, I saw an injured dog dying under the indifferent gaze of passers-by. I would have liked to ask for help but I couldnt speak as I didnt know the language of the country. The look in the dogs eyes in the dream made Elise think about the look in her mothers eyes, an old lady who was dying slowly. Elise had further associations: This makes me think of a drama which occurred near the place where I used to go on holiday as a small girl. There were holes in the torrent, hollowed out by the current; this made whirlpools which pulled you towards the bottom; we called them pots. A couple was out walking with a dog. The dog fell into one of these holes; the man dived in to save it and he drowned with the dog. As I listened to the account of the dream and the associations, I heard Elises plea for help as well as her fear and unconscious wish to drag me into the deadly whirlpool. I then felt a moment of intense relief: at last Elise had brought a dream and associations; she seemed to be elaborating her conflicts. The lively side of Elise was definitely present. But suddenly the other side of Elise reappeared: in a flash Elise had adopted her distant and cold tone again: Analysis, its just words; analysis is useless. I was then submerged by a sensation of collapsing; I felt myself falling into one of the pots in the torrent. In my countertransference I thought that perhaps my sensation of collapsing was linked with the massive projective identificatio n used by Elise and that it thus corresponded to a projective counteridentification. Elise had certainly had an unconscious need to communicate an early pre-verbal experience to me so that I could help her to find meaning in it: I couldnt speak
If Elise unconsciously projected into me her feeling of falling into the whirlpool, just as in the analysis she had been going round and round for months, it was no doubt so that I could help her make sense of it. I had already noticed that Elise had the tendency to act out instead of representing her conflicts mentally. Accordingly, during the preliminary interviews she had broken her leg like the dog in the dream and had said to me: I forgot about the step in the middle of the living-room, even though I knew it well; the ground went from under me and I fell. At the time, I did not make an interpretation. Now I thought that Elise was projecting the emptiness outside so as to avoid feeling it in herself, and that she unconsciously wanted someone to drop her to confirm the presence of this external emptiness. By making a displacement on to a man who would drop her, she had unconsciously protected the analyst. How could Elise be helped to feel that she had unconsciously projected a deadly emptiness outside of herself in order to avoid feeling it within herself ? I imagined that, even though she had always denied it, as she had no direct memory of it, she must have already experienced this emptiness when she was 8 months old; that is, when she had had to spend several weeks in a clinic because her mother, who was ill and contagious, was unable to take care of her. According to family accounts, when they met up again, Elise had turned her head away, refusing to look at her mother. I had sensed all this myself when I had the bodily impression that everything was collapsing. How could I use my projective counteridentification to interpret Elises excessive projective identification? I refrained from interpreting the projection directly to Elise by saying, for instance, that she may have unconsciously put into me what was causing her anxiety. I feel that this kind of interpretation can be experienced as being extremely intrusive, rather as if I had said to Elise that I knew what she was feeling better than she did. I reserve this type of interpretation for analysands who will be future analysts, when they are particularly interested in gaining insight into their psychic functioning. It seemed to me that what Elise needed was for me to help her to picture the bad internal object that was present in the depressed side of her. Not the missing good object, the absent good mother, but the presence in her of the bad object; i.e. the absence of the good object that had become the presence of the bad object. How was I to get her to feel that in the transference? I thought that I could make interpretations about myself, in the transference, as a representation of the unrepresentable internal part-object. This is why when I heard Elise say, Im really wondering whether you have any use for me in the analysis! I replied with deep conviction: Perhaps I am the pot. Elise gave a start, and said incredulously, What? I added: Yes, the pot which could contain good things to eat but instead of which is a hole sucking you to the bottom of the torrent in which you go round and round and drown Elise remained silent, concentrating hard, and calm. And as it seemed obvious to me that if I offered myself to Elise as an object, she would be able to experience the corresponding affect, I added: And you turn your head away in order to tell me about all your feelings of sadness and anger and how much I disappoint you. To help Elise discover what was happening inside her at this early level, I tried to start with her gesture so that, through rediscovering sensation, she could then discover its emotional significance. She asked: I turn my head away? I replied: When you tell me that I cant help you, its a bit like turning your head away from me, rather like when your mother came to collect you after your stay in the clinic. There was a silence and then Elise said emotionally: No one has sensed before that I really have a hole at the bottom of myself (silence) I think thats why I cannot take care of my mother properly; I do it out of a sense of duty. My brother, he really takes care of her (silence). Before the analysis, no one ever knew that there was this sadness within me. My mother has always been the presence of an absence. I had offered myself as the negative of a part-object. In the transference I was the breast that was lacking, the hollow form of the breast, as it were. The next time I saw her, Elise told me that after this session she had felt like vomiting and had dreamt of a caged panther (her cannibalistic aspect). She had also thought again about a separation that occurred when she was older, involving her brother. She then associated by talking about sexual differences and conflicts of rivalry with her brother situated at a secondary level: if one point in the network of associations is affected, it has repercussions throughout the network. After this session the phantasy construction of Elises love life was no longer so invasive.
WHAT WAS IT, IN THIS SESSION, THAT TOUCHED THE PATIENT? CERTAIN CHARACTERISTICS OF A LANGUAGE THAT HAS THE CAPACITY TO TOUCH
The analyst as the representative of the bad object
Often for heterogeneous patients either the bad object is either unrepresentable or it has to be repudiated. This is why, by daring to offer them a representation of the bad object, the analyst is able to touch them. As there is a correspondence between the ego and the object, de-dramatisin g the bad character of the object results in de-dramatising the bad character of the ego; consequently, the patient is better able to tolerate aspects of himself that he considers bad and so can re-own them. Moreover, once the patient is able to imagine the bad object, he will also, by way of contrast, have a better idea of the good object , even if it is simply to deplore its absence; and, owing to the correspondence between the ego and the object, he will also acquire a better idea of what is good in himself. The patient can then begin to realise that once a non-idealised (ambivalent) good object has been established in himself, the ego will prove capable of sharing its richness without feeling impoverished and can thus begin to feel gratitude towards the object. On the other hand, when he unconsciously sets up a bad internal object within himself, he feels dispossessed by other people of his own richness.
Listening to the bodily manifestations that accompany countertransference affects
Heterogeneous patients often make use of projective identification; the analyst is thus led to interpret it, and, in order to do this, he needs to make use of his projective counteridentification. I have noticed that in order to become aware of his projective counteridentification , and to be able to use it, the psychoanalyst needs to listen not only to his countertransference affects but also to the bodily manifestations and bodily phantasies that accompany them. Indeed, in the case of early affective experiences, it is through bodily experience that the patient can rediscover his affects and bodily phantasies. In order to gather the patients feelings that are projected into him, the analyst needs to notice the manifestations accompanying these feelings, which he may experience in his own body. He will then be able to give them back to the patient by trying to give meaning to the patients sensations and by helping him make the transition from sensation to affect, and then to representation and symbolism. Bodily phantasy can constitute a starting point for mental representation. The analyst may also have the opportunity of drawing the patients attention to a gesture he or she makes without being aware of its emotional significance. We have seen, in particular, how important it is for a patient to become aware of repeating a significant gesture and to move from the gesture itself to its meaning, as well as to the feelings which have given rise to it. It is by reconstituting the chain of sensations that the emotional significance of the gesture can be recovered by the patient; for it is often by getting in touch again with the bodily manifestations that accompany the affect that the patient will become aware that he or she has experienced the affect. For example, by rediscovering the emotional significance of turning her head away, Elise made contact again with a whole emotional context and the possibility of representing it mentally.
The absence of visual support in psychoanalysis can be invaluable
I have often found during analytic sessions that the absence of visual support can facilitate awareness of bodily experience, especially if the latter is barely differentiated; and, it can bring into play internal sensations that are difficult to locate as they are connected with the body as a whole, sometimes being linked to attitudes or to positions. My point of view relativises the opinion often expressed by psychoanalysts (Gibeault, for instance, quoted above) who recommend the face-to-face situation for patient s of this type because of the importance for them of visual experience. I think that for these patients the phantasies linked to the earliest internal bodily experiences can be more important than those linked to visual experiences: ... the hallucinated breast is not to begin with a visual experience, but a bodily one. Early experiences, such as hunger or satisfaction, are experienced and interpreted by the infant in terms of object-relationship phantasies Such primitive psychosomatic phantasies can still play a dynamic part in later development (Segal, 1993, p. 20). For example, for Elise, the gesture of turning her head away was felt throughout her entire body; the fact of being deprived of visual support in the analysis had facilitated awareness of the bodily experience corresponding to this gesture and the related relational phantasies. On the couch, these patients, who need to get back in touch with early bodily experiences, often shut their eyes in order to be able to focus better on what they are feelin g in their bodies and to find emotional meaning in it. The patient who recognises a lost early bodily experience during the analysis can rediscover its emotional significance and reconstitute a bodily phantasy, which serves as a point of departure for mental representation. Sometimes, moreover, it is precisely because of the absence of visual support that psychoanalysis can on occasions be an invaluable asset for patients who have difficulty in symbolising; provided, however, as I have already pointed out, that they show an aptitude, even if it be minimal, for using the transference object, as well as a desire, albeit hidden, for inner unity.
The effect of surprise
As the development of the patients I have called heterogeneous is not linear, interpretations have to be found which, by creat ing an effect of surprise, cause the whole network of the patients associations to vibrate. Interpretation thus creates a disequilibrium in the patients psychic system, helping him to get out of the circle in which he is turning endlessly and to open himself to symbolisation.
Using a language with double meanings
These patients who are disconcerted by the paradoxes within them are touched by the use of a language that is capable of uniting different meanings within the same expression, thereby showing that the combination of opposites is possible. In his commentary on the Gradiva, Freud noted that Zoe-Gradiva, presented as Hanolds therapist, successfully used a double language to touch Hanold: a language which had one meaning in the context of Hanolds sporadic bouts of delusion but also another meaning which took reality into account. For example, when she asked Hanold: I feel as though we had shared a meal like this once before, two thousand years ago; can you remember? (1907, p. 26) she could have been referring to the period preceding the eruption of Vesuvius, but equally to their childhood. Now I think that Hanold can be taken as an example of a heterogeneous patient: a person who is adapted to social life but who, with his sporadic delusions, shows a psychotic part, while nonetheless wishing to reunify his ego and showing he is capable of using the object.
There are various ways in which language can operate on dual levels. It can be at the level of the words employed or at the level of discourse. Thus, pot was a word with two meanings; it evoked several transference part-object representations: for instance, a saucepan used for preparing food which can represent the full breast, but also the fluvial pot, a deadly hole that can represent the empty breast, hollowed out by the patients cannibalistic aggressivity. A different aspect of the ego corresponds to each object-representation; for example, the dog corresponded to the deadly hole, but the panther corresponded to the hole created by erosion. Language can also have a double meaning at the level of discourse. When I said: Perhaps I am the pot , I used a formulation corresponding to that of the symbolic equation since I did not say that I represented a pot, which would have been less mad. But it is only the formulation that evoked the symbolic equation; the general meaning of the sentence was open to symbolism. It was a way of taking both parts into account, the archaic and the more developed part of the patient. The double meaning of language obliges the patient to decentre himself, to differentiate himself from the object; for the patient thinks he has heard one thing and then realises that the analyst has been saying something different. This discrepancy creates a disequilibrium that mobilises thought and prepares the way for symbolism. This gap can make it possible to get out of the circle in which the dog goes round and round in the washtub of analysis.
PSYCHOANALYSIS IS SOMETHING LIVING
I believe that future psychoanalysts will continue to do psychoanalyses if they are ready to take into psychoanalysis patients whom I have called heterogeneous; that is, patients who use both neurotic psychic mechanisms and primitive mechanisms, even though these patients have at least a latent wish for integration and a capacity to use the transference object. This implies that the analyst should not confine himself to the domain of neurosis but needs to recognise the primitive psychic mechanisms used by the patient and know how to analyse them. It also implies that the psychoanalyst, who will be listening attentively to bodily phantasies, needs to speak a language that touches the patient. This language will be built up gradually, at the same time as the psychoanalyst discovers his own mad aspects and allows himself enough psychic liberty to accept them. Taking these heterogeneous patient s into psychoanalysis corresponds neither to a stopgap measure, nor to a distortion or a concession with respect to the psychoanalysis discovered by Freud, which would be the case if Freud had passed on to us a rigid and dead object . Freud handed down to us a psychoanalysis that is living, and in order to remain faithful to him, what matters is not simply to respect its permanence but also its internal potential for development.