Mind as the Thread: Weaving the Therapeutic Fabric
Dr Robin Chester
MBBS FRANZCP PhD Member Australian Psychoanalytical Society
Paper presented at the RANZCP Faculty of Psychotherapy 2025 Conference
“Weaving the Therapeutic Fabric” Integration of psychodynamic psychotherapy with contemporary therapeutic approaches for treatment of trauma
24th October 2025 Perth WA
Ladies and gentlemen
Have you noticed the quiet sense of indrawing relief that occurs when the psychodynamic – questions of mind – is parked in the background to cognitive behavioural treatments, avoidant of thoughts about suggestion of course, and somatic/neurological theories which with a bit of push and shove can explain the how of the phenomena experienced and observed. But what and why… So I must begin with a muted apology because as an old analyst I will be focusing on the what and its why of the psychological responses to trauma.
To begin to do this I will by necessity start with Freud, one of his, or perhaps the, most important concepts that psychological phenomena, i.e. those that pertain to mind e.g. to do with thoughts, mood, behaviour, the psychosomatic etc., have psychological causes. These may not be the sole cause but the mind has to be there for subjective and objective experiences to occur.
I appreciate that this is stating the obvious but…
The responses to traumatic experiences i.e. the hyperarousal, the reliving, the nightmares etc. are obviously all psychological phenomena as are those of PTSD including the fact that PTSD per se is occurring.
Continuing the beginning with Freud he introduced a symposium in 1920 which considered the aetiology of what was then called “war neurosis” following the tragedy of World War I. Two of the contributors, Abraham in Germany and Ferenczi in Hungary, in fact ran institutions in which the unfortunate sufferers were treated. Essentially the conclusions reached were that to explain why some patients developed symptoms and others didn’t in basically the same conditions that THE experiences of these patients touched on unresolved developmental conflict or as a Klein would put it aroused unprocessed unconscious phantasies.
This view of individual pre-disposition of course became buried, lost, with the introduction of the phenomenological concept of PTSD in 1980 but this does leave empty the explanation for why for example a third of American soldiers developed symptoms after severe or extreme combat experiences in the Vietnam War but 2/3 didn’t.
However, still staying with Freud’s ideas, in 1923 Freud introduced the concept of the ego as the essential integrating factor that sustained our psychic integrity. In this the idea is that the ego not only deals with the demands of the id, the expectations of the super ego, and the challenges of living in an interpersonal world, but also has to look after its own integrity such that it can go on going on being at the level of functioning required of it. To do this it has a number of functions including defences. With a bit of license the ego can be seen to have three challenges to its ongoing functioning with which it has to deal and accordingly three different groups of defences. If the ego, generally because of internal factors but also physiological, e.g. drug induced, is in danger of disintegration then it turns to splitting, projection, projective identification, etc. leading to symptoms classified as psychotic. If the challenges come from forbidden thoughts, feelings, wishes, fantasies etc. then it uses denial, repression, reaction formation, sublimation, etc., and we have neurotic and psychosomatic symptoms. If it is about to be smashed by a traumatic experience e.g. an imminent unavoidable accident, then it resorts to derealization, depersonalization, dissociation, splitting of consciousness etc., such that events happen in slow motion or are observed from outside of the body etc.
Freud, in one of his last works, suggests that there are different reasons why the ego may feel as though its integrity is threatened with respect to its defensive system and trauma.
One is that it can be caught off guard, the sudden accident you didn’t see coming.
The second is the quality and/or quantity of the trauma i.e. the trauma can be overwhelming e.g. an unrelenting artillery bombardment, because of the direct impact quality, or because it is unremitting – when will it end?
A third reason is the particularly personal nature of the trauma, the death in battle of somebody you have bonded with, or the extremely personal, e.g. witnessing of the rape and murder of your son as in the Balkans war.
Of course the three different traumatic pathways are understood and exploited by torturers who also use a fourth, that is using your physiological responses to cause unexpressable, overwhelming experience e.g. so-called water-boarding.
Freud lived and wrote a long time ago and so do we have more recent theories that may help us to understand the psychological in trauma?
As I trust that you will know the understandings, in particular, of Bion and Lacan have become the predominant focus of psychoanalytic ideas in recent years. Because of time I cannot introduce you to the essence of their ideas and will have to take for granted you understand these and will take up one idea from each.
With Bion the concept is that of what he calls the container/contained.
Very briefly what he is outlining is the process by which unthinkable psychic experience can be processed and therefore become able to be thought. The basis of this is that of the projection into the mother’s mind of the infant’s distressing, disturbing traumatic experience consequent of somatic experience, and these being processed by the mother in her thoughts about what the child is experiencing and why, and by doing so mastering the experience i.e. taking out of it the disturbing traumatic qualities.
In this concept Bion is indicating that stimuli arising within the body or from outside that cannot be thought cause a sense of distress, disturbance and proximity of psychic catastrophe, i.e. are traumatic, and what is essential is a mind that can contain the experience and in the containment-process move unthinkable experience to thought. Once there it can be processed further. As I trust you will know he categorized the unthinkable experiences as beta elements which are processed by an unknowable mental process into the rudiments of thought which then become what he calls “dreams, dream thoughts and myths” meaning personal myths or personal explanations for one’s experiences, leading onto memory.
The symptoms that immediately follow a traumatic experience and are almost universal can be seen as the mind’s efforts to contain in the Bion sense of containing i.e. to experience and process it such that it can become memory. These symptoms are at the interface between raw experiencing – reliving – and the processing of the experience that proceeds to the loss of the raw experience.
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The Lacanian perspective, that can be seen to be relevant, relates to his concept of the three registers of psychic experience.
Again, I have to trust that you know what I am talking about and will accordingly give only a brief overview.
Lacan proposes that all psychic experience can be considered within 3 registers the Imaginary, the Symbolic and the Real.
The Imaginary refers to the world of image and belief, illusion and expectation. It has an essential two-dimensional quality but is enthralling for example it leads you to believe that when you buy your new house, when we change governments, if you do more exercise etc. everything will be different and okay. That elusive happiness, satisfaction, sense of fulfilment will now be yours. Although it’s illusion it is what we often live our lives guided by because we want to believe it and it is where our beliefs come from which of course is a current world problem fed by the illusions that we are exposed to daily.
The Symbolic is essentially the registrar of pragmatic reality, the fact of the matter, if you want your life to be different then you have to change. Gaining your fellowship won’t do it. And the reality is that change involves work and often pain. Psychotherapy often involves the instating of the symbolic in the imaginary.
The Real is a true Lacanian concept.
It is what is left outside the world of the imaginary and what can’t be thought and represented in the symbolic. It is the core of our physical/psychic experiences and existences. It is in essence what is beyond thought and imagination but not experience and is experienced as shock, trauma, anxiety, mindless panic. The stuff creative torturers strive for and good horror movie makers achieve at the moment just before the evil strikes.
Relevant to our discussion the Real is the experience of the overwhelming sense of unthinkable mindless traumatic distress and even representing it in the imaginary is better which the mind attempts to do hence the symptoms of PTSD i.e. the imagery etc.
Achieving representation in the symbolic is the overall goal of treatment of trauma where it can be thought about and eventually mastered in one way or another.
Let me pause from a moment to summarize these ideas before I move on to discuss a couple of clinical cases of diagnosed PTSD in whom the psychological was central.
With respect to the experience of trauma there would seem to be two general outcomes. One is that seemingly the majority of people develop symptoms within a few days after having a traumatic experience. These symptoms, such as hyperarousal, flashbacks, difficulty sleeping, nightmares etc. appear to represent the ego’s attempts to restore its integrity by in retrospect mastery of the traumatic experience and possibly the sequelae. These efforts, especially if supported by a sense of held understanding security, are generally successful showing that the ego was bruised and has recovered accordingly. However with some either the symptoms persist, recur, or perhaps start sometime after the initial traumatic event. This leads to the diagnosis of PTSD.
Dynamically what is occurring is that the ego’s path to restoration has become obstructed but the ego has little choice but to continue trying even though its efforts cause pain and distress.
In the terms briefly discussed the ego has suffered significant disruption because it was caught off guard and/or the traumatic stresses were of an overwhelming quantity either upfront or ongoing and/or the stresses were of a particular quality. Or, there has been insufficient, inadequate or inappropriate holding and processing of the experiences such that the search for the necessary container becomes unending. Or, the experience continues to occur at the interface between the Real and Imaginary but it is impossible for it to be worked through in the imaginary and hence the futility of the recurrence of the symptoms. Instating of the symbolic in the imaginary is the challenge of successful treatment for trauma.
But in all this I wish to focus on one point, one reason for the failure of the ego to restore its integrity and hence the ongoing symptoms and this is because of the essential nature of the stressor. This was in essence the original analytic idea but one that has been pushed into the background as if it is no longer relevant. This refers to either the directly-confronting by its personal nature e.g. watching one’s child burn to death in a housefire, or where it touches on unconscious conflict e.g. phobic anxiety as in the film Brazil and rats.
I will take up this perspective by two clinical examples.
The first, Mr. A., was a man in his mid to late 30s who was referred to me for analytically informed therapy after a couple of attempts at treatment mainly by CBT for his diagnosed PTSD over the preceding two years. His story was that he was riding his motorbike on a major arterial road on a Sunday morning. His girlfriend was his pillion passenger. He confessed to possibly travelling a little too quickly but felt very much in control of the situation. A car pulled straight across in front of him– the driver later admitted to not seeing Mr. A. and his motorbike. But Mr. A. also didn’t see the car because his head was turned back to his girlfriend who had annoyingly been complaining about her hair being affected by the wind. He suddenly saw the car at the moment of impact. He and is bike went up and over the car he landed on his back and shoulders as he had turned in anticipation of the impact with the ground. However, as he looked back and up, he saw his girlfriend flying over him with a look he couldn’t really discern but later perceived as accusatory on her face. She landed on her head some 20m. down the road he said and was killed instantly.
He was in hospital for several weeks because of several broken bones but felt emotionally numb, out of it, which he put down at first to the medication but the emotional state of emotional absence persisted for 6 to 12 months after he went home. Then he began to have nightmares, flashbacks and became unable to ride his motorbike because of constant hypervigilant fear.
When I saw him, about three years after the accident, he said he would try anything even though he had been advised by several practitioners that analysis would make him worse by stirring things up. However, through the work of analysis he was able to focus the essence and nature of his flashbacks and symptoms. It was his girlfriend’s face and the look – the glance in analytic and existential terms – that haunted him. He perceived this as accusatory as noted and raised the question for him about whether this related in fact to an unconscious intention that he carried perhaps for her or perhaps focused on her. This quality of intention was explored and was seen by him as possibly related to his wish to be free of her and, to abbreviate a couple years analysis, to his mother‘s need to hold him to fill the space in her relationship with his father and the consequent claustrophobic feelings he experienced in intimate relations with women. His girlfriend’s look was linked to his mother’s look when he had started to bring home girlfriends. In practical terms his symptoms abated at the point at which the glance could be fully cognised and experienced and begun to be thought about.
Other PTSD patients I have seen include a 25 year-old woman who, in one of the bushfires, saw a burnt body in a burnt out ute, and thought it was her father; a man in his 50s, newly migrated, who was subjected to some Australian humour when a centrifuge he was in and cleaning was briefly switched on; and a man in his 40s who suddenly and seemingly inexplicably started having anxiety, flashbacks and nightmares related to his experiences in the Turkish/Greek war in his country as a child.
And a second motorbike man whom I will briefly discuss.
Mr. B., was riding his motorbike on a very wet night, the car in front of him braked suddenly, he couldn’t stop and threw himself and his bike sideways onto the road. He carefully disengaged himself from the bike, all this was happening in slow motion, he said, but he continued to slide amongst the car tyres, feeling unseen and potentially to be run over by the unseeing drivers. He was in fact physically unhurt and was able to ride his bike home but after it was returned from being repaired, he found he could not ride it. A few days after this he started to be invaded by the visions of the experience of sliding on the road amongst the unseeing car tyres, expecting to be run over at any moment. He couldn’t sleep, found that intimate close contact with his wife caused anxiety and anger and became intolerant of his teenage children’s what he called whingeing. His GP started him on an antidepressant which was changed after six months and he was referred on for counselling and CBT but they just left him feeling angry as if nobody understood what his problem was; as they simply saw the problem as something wrong with him, he said –that he was the problem.
He was referred to me for analytic therapy by the third psychologist he had seen in the two years since the accident with his wife saying that he had to do something otherwise she would have to leave him.
Very briefly, again the exploration of the visual experience and the associated meanings led to the remembering of and re-experiencing of being a young child of uncertain but very young age and crawling on the floor, he was sure he could walk but through fear and confusion had at that time lost that ability.
He experienced this as trying to find his mother amongst a sea of legs and being afraid of being kicked in dismissive distain, or, being trodden on by anonymous others. He, for a long time, believed that this must have been a recurring dream that he was now recalling. However he came to suspect that if it was a dream it could be based upon a real experience, or a fantasy arising from such. This was of a drunken party that his parents occasionally had. In this memory, or fantasy, he saw his mother sexually engaged with a man other than his father. At that point he had collapsed and had started to crawl away from his real mother, but to where? He believed that he was also crawling to his mother away from the unseeing mother to one that he believed must exist who would see his distress but could never find her.
This sense of traumatizing despair would seem to be what was reopened in the experience of the accident.
Once this distressing state of conflict was able to be experienced and considered his symptoms left but it took further analysis to fully explore what this meant and calm his hostility towards his wife.
So, to begin to finish with a brief overview and statement.
As introduced, I have attempted to indicate the continuing relevance of psychodynamic theory and practice within psychiatry in this case with respect to the immediate and long-term psychic consequences of traumatic experience. These can be understood with respect to the central role of the ego in terms of our psychic constitution and how the ego can struggle and the signs and the symptoms of those struggles and the ego’s efforts to reconstitute itself. Further developments in analytical theory offer understandings in terms of failures in containment in the fullest sense and the glimpse of the core essence of existence with the Real when we are unable to fully imagine or symbolize experience.
In this overview I suspect or, perhaps quietly hope, that I have only told some of you what you already know. So, I’ll add an idea or two.
With the cases I have discussed, except for the centrifuge man, the outstanding feature has been that of seeing, not - seeing and unseeing. In fact the general symptoms following trauma and PTSD point to seeing as being particularly important, e.g. flashbacks, nightmares etc. So it raises the question for us as to why seeing etc. is central to our reaction to trauma?
To answer this I will begin with another of Freud‘s ideas, that about regression, that when we find existing at that point of time is too difficult we fall back, regress, to a way of being that successfully dealt with the challenges we faced. He refers to an expeditionary force retreating back into an established fortress. So following trauma we retreat back into a way of being in which seeing is key. But still the question remains why seeing? To answer this I will loosely refer to the ideas of the philosopher Hegel who proposed that our sense of self begins when we bang into substance. Of course this will primarily be our sense of physical existence to do with our internal somatic processes and also touch. But that is not all. Once its somatic existence is assured a neonate or infant will look around i.e. it bangs up against the world by vision. And because of one of nature’s tricks its visual acuity is such that what it will focus upon is its mother‘s face and eyes especially her eyes when being breastfed.
The question is what does it see? Winnicott poetically tells us that it should only see itself, see its mother seeing it. In terms of its self this obviously helps it to gain a beginning sense of self, and a self in a secure world. However the infant may instead see the mother seeing problems to be dealt with, or hate because she hates the child’s father or her own mother, or a mother who is out of it. But what this means is that the child’s sense of self becomes lost from the start, trying to find a place for itself in an alien world. As most of us have mastered the psychotic parts of our character, this would presumably point towards the fact that in most cases the infant will successfully adjust to and find itself of sorts in the world but with a sense of fragility. Trauma would seem to expose this fragility and open a reminiscence of the initial traumatic experience when the anticipated continued security of the world was lost, shattered for some. We regress back to the initial feeling of hopeless, bewildered confusion when we looked in our mother‘s eyes and became lost and continue to search through vision for something that will help us make sense of the world we have suddenly found ourselves in.
Because of time I should finish there hoping that some of my ideas have been interesting for you.
Thank you.