Psyche-Soma in Psychoanalysis � Course Proposal

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Psyche-Soma and Soma-psyche: The Foregrounded Body in Psychoanalytic
Theory and Practice
1-Credit, 8-Weeks

Sharone Bergner, Ph.D.
sbergnerphd@yahoo.com
212 787-4577

From its inception, psychoanalysis accorded primacy to bodily experience, expressed through the
focus on drives, psychosexuality throughout development, and in Freud’s view that the ego is first
and foremost a body ego. However, since the decentralization of drives in psychoanalytic thinking
and the ascendancy of ideas about the object relational world, the place of the body in
psychoanalysis has become less clear. And yet, in our consulting rooms today, we continue to be
presented with patients’ bodily reality and body-related fantasies. Our patients bring ongoing
bodily life – via the commonplace yet central subjects of eating, sexuality, body image, as well as
via acute and chronic, disrupting and habitual crises and dysfunctions that arise and intersect with
aspects of self and key life experiences. There are endless instances of the foregrounding of bodily
experience in the clinical setting, whether patients seek treatment with bodily-related concerns or
develop them in the course of an established analytic treatment. Commonly encountered in
today’s clinical practice are the range of transformations presented by pregnancy, breastfeeding,
pregnancy loss, infertility, skin and intestinal conditions and syndromes, unexplained clusters of
medical issues, pain, cancer, chronic fatigue syndrome -- to name a few. As we work, we are
embedded in clinical theory, including psychoanalytic psychosomatic theory, which guides our
listening and contributes to interpretation and countertransference. We are rooted in
psychoanalytic conceptualizations of psychosexuality, development, somatization,
psychosomatosis, conflict and deficit. These shape our understanding of patients’ symptoms and
difficulties. We are also always embedded in our current cultural context, which shapes
expectations regarding the mind-body relationship. Our contemporary cultural context is
characterized by, on the one hand, cutting edge medical technological advances, alongside with,
on the other hand, integrative medicine and other alternative practices and models – both
presenting demands for renewed investigation of ideas about etiology, and treatment, of bodily
dysfunction.

Inscribed in this cultural surround and in the context of available psychoanalytic theories about
the psyche-soma relationship, this course aims to push us to reconsider what we know and how
we understand the term “Psychosomatic,” as well as to re-ask core questions, such as: what is
somatization; what is a (somatic) symptom; are somatic symptoms vehicles of meaning; how does
the nature of psychic functioning relate to somatic events; when we work with psychic
functioning via the analytic process, what is our relationship to the bodily?

The purpose of this course is to evaluate theory to the extent that is needed in order to open the
field for working clinically from a fresh position that takes into account current bodily
presentations and medical as well as alternative physical practices and approaches. We will focus
especially on the countertransference and reverie, on classical and object-relational versions of
theories of psychogenesis and the psyche-soma relationship, on patients’ related unconscious and
conscious fantasy, and on the question of the relationship between the singular body and the
object-relational world.
The course is organized around units of psychosomatic and mind-body theory, and units
addressing the bodily from several directions. The “body” units will provide opportunities for
examining the interplay of theory, the transference-countertransference field, fantasy, and the
relationship of the body and the relational matrix. Clinical material from my own practice (and
from students’, when available) will be used to flesh out these ideas and bring theory close to
practice in an effort to open new dialogue and to characterize a clinical stance that embraces
complexity and uncertainty.

(For a bit more background about the history of our field’s relationship to the field of
psychosomatic medicine, please see the description at the end of the course outline, which is
followed by an annotated list of suggested additional readings that we could not possibly cover in
an 8-week course.)

COURSE OUTLINE

I. SEMINAL PSYCHOANALYTIC IDEAS ABOUT PSYCHOSOMATICS,
SOMATIZATION, AND THE PSYCHOPATHOLOGY OF PARTICULAR KINDS OF
PSYCHE-SOMA RELATIONSHIPS

Week 1: Theoretical perspectives, introductions

Case vignettes from my work (IBS; infertility; unexplained medical symptoms); setting up
organizing principles

Groddeck, G. (1977). The Meaning of Illness. IUP.; Chapter 2: Psychic conditioning and the
psychoanalytic treatment of organic disorders (1917); Chapter 7: Clinical communications
(1928).

Alexander, F. (1950). Psychosomatic Medicine: Its Principles and Applications. NY: Norton.
Chapter 5: Conversion hysteria, vegetative neurosis, and psychogenic organic disturbance;
Chapter 6: Progress in etiological thought; Chapter 7: Methodological considerations
concerning the psychosomatic approach; Chapter 8, sections 3 - The problem of the
specificity of emotional factors in somatic disturbances, and 4 – Personality type and disease.
(We will select from and divide these chapters.)

McDougall, J. (1989). Theaters of the Body. NY: Norton. Introduction: The psychosoma and
the psychoanalytic voyage; Chapter 1: Mater; Chapter 2: The body-mind matrix.

Week 2-3: Critical appraisal and updates on traditional psychoanalytic psychosomatic theories

Through these readings, we will characterize the most dominant (and seductive) ways of
thinking about the psyche-soma relationship and conceptualizing psychosomatic
presentations. We will discuss the need for multiple models that can be more particularly
attuned to specific body-self-other configurations, taking into account varied physiological
realities, developmental histories and psychic experiences. Emphasis will also be placed upon
the need for complexity that results from recognizing uncertainty and the unknown.

Aisenstein, M. (2008). Beyond the dualism of psyche and soma. Journal of the American
Academy of Psychoanalysis, 36:103-123.

Bergner, S. (2009.) The analytic environment in times of bodily dysfunction: The effect of
psychoanalytic psychosomatic theories. Psychoanalytic Psychology, 26:362 -378.

Bronstein, C. (2011). On psychosomatics: The search for meaning (Education Section).
International Journal of Psychoanalysis, 92:173-195.

Gottlieb, R. (2003). Psychosomatic medicine: the divergent legacies of Freud and Janet.
Journal of the American Psychoanalytic Association, 51:857-881.

FURTHER PERSPECTIVES ON THE SETTING UP AND MANIFESTATION OF
PARTICULAR PSYCHE-SOMA RELATIONSHIPS

Week 4:

Edgcumbe, R.M. (1984). Modes of communication – The differentiation of somatic and
verbal expression. Psychoanalytic study of the child, 39:137-154.

Lombardi, R. (2008). The body in the analytic session: Focusing on the body-mind link.
International journal of psychoanalysis, 89:89-109.

Lombardi, R. (2002). Primitive mental states and the body: A personal view of Armando B.
Ferrari’s Concrete Original Object. International Journal of Psychoanalysis, 83:363-381.

For those with extra time, see also the Winnicott papers in the recommended additional
readings list.

II. THE SPECIFIC BODY IN THE CONSULTING ROOM:
CLINICAL DOMAINS AND BODILY ARENAS

Weeks 5 and 6: Pregnancy, Breastfeeding, pregnancy loss, infertility

This arena brings together central issues of sexuality, development, intergenerational trauma
and transmitted meanings, and the need for experiencing the control of psyche over soma. It
is also a useful arena for studying the interplay of fantasy and psychic functioning with the
real body, omnipotence, repetition, and the nature of the psychoanalytic context in which
these are explored while the related somatic events unfold.
Balsam, R.H. (2003). The vanished pregnant body in psychoanalytic female developmental
theory. Journal of the American Psychoanalytic Association, 51:1153-1179.
Friedman, M. (1996). Mother’s milk: A psychoanalyst looks at breastfeeding. Psychoanalytic
Study of the Child, 51:475-490.

Leuzinger-Bohleber, M. & Teising, M. (2012). “Without being in psychoanalysis I would
never have dared to become pregnant”: Psychoanalytical observations in a multidisciplinary
study concerning a woman undergoing prenatal diagnostics. International journal of
psychoanalysis, 93:293-315. (This article addresses pregnancy loss and the effect of
technology and knowledge of genetics in the context of a psychoanalytic process.)

Pines, (1990). Pregnancy, miscarriage and abortion: a psychoanalytic perspective.
International Journal of Psychoanalysis, 71:301-307.

Apfel, R. and Keylor, R. (2002). Psychoanalysis and infertility: myths and realities.
International Journal of Psychoanalysis, 83:85-104.

Zalusky, S. (2000). Infertility in the age of technology. Journal of the American
Psychoanalytic Association, 48:1541-1562.

Week 7: Oncology

Here our focus will be on specific clinical cases, and especially on the way that
countertransference and the patient’s conscious and unconscious fantasy combine to shape
the clinical process.

Bergner, S. (2011). Seductive symbolism: psychoanalysis in the context of oncology.
Psychoanalytic Psychology, 28:267-292.
We will expand upon and discuss a clinical case described in detail in this paper.

McDougall, J. (2000). Theatres of the psyche. Journal of Analytical Psychology, 45:45-64.
This is entirely a clinical paper about one case, and is critiqued in Bergner article.

If you have time, also read either a) or b), both entirely clinical papers:

a. Adams-Silvan, A. (1994). “That darkness – is about to pass”: The treatment of a dying
patient. Psychoanalytic Study of the Child, 49:328-348.

b. Lloyd Mayer, E. (1994). Some implications for psychoanalytic technique drawn from
analysis of a dying patient. Psychoanalytic Quarterly, 63:1-19.

Week 8: Reaching for complexity and embracing uncertainty: towards holding in mind
a non-linear, multi-directional interplay of the physical and the meaningful

In this week, by way of beginning to synthesize, we will articulate a clinical stance
characterized by openness to multiple models and possibilities regarding the specific psyche-
soma relationship, and the meaning of particular somatic events, within the context of work
with individual patients. We will return to previously discussed cases, in addition to the
complex case presented in the Shapiro paper.
Shapiro, B. (2003). Building bridges between body and mind: the analysis of an adolescent
with paralyzing chronic pain. International Journal of Psychoanalysis, 84:547-561.

Optional: Gerson, M.J. (2002). Psychosomatics and psychoanalytic theory: the psychology of
ulcerative colitis and Crohn’s disease. Psychoanalytic Psychology, 19(2):380-388.
This is not a clinical paper, and our focus this week will be clinical, but it does offer a very
valuable consideration of the place of uncertainty in conceptualizing theory and practice in
relation to intestinal/gut issues. I also strongly recommend the Fonagy and Moran paper in
the additional readings list, which articulates a highly complex conceptualization that is not
based on linear psychogenesis.
FOR FURTHER THOUGHT:

Psychoanalytic ideas about the mind-body relationship in illness and in health were highly
influential in the early days of the consolidation of the field of psychosomatic medicine, and
psychoanalysts such as Alexander were central figures in the founding of the flagship journal
Psychosomatic Medicine. At the same time, the field of psychosomatic medicine itself has
evolved, and the pages of its flagship journal are no longer filled with psychoanalytically-derived
ideas. Instead, psychobiological research, psychoneuroimmunology and social psychological
studies now shape the understanding of mind-body links. Medicine and psychology have begun
new clinical collaborations via the arenas of health psychology and consultation-liaison
psychiatry, but there, too, there is virtually no psychoanalytic presence. There is heightened
interest in our culture in various integrations of mind-body approaches, a trend or renewed vigor
whose historical underpinnings – including its relationship to older ideas about psychosomatics to
which psychoanalysts crucially contributed - is investigated in historian of science Anne
Harrington’s fascinating (2008) book The Cure Within: A History of Mind-Body Medicine.

Suggestions for background and further readings: I will recommend these more
specifically as we go along, linking particular readings to those we cover in class, to
facilitate more in depth exploration according to students’ individual interest

I. Sampling from other fields:

1. Harrington, A. (2008.) The Cure Within: A History of Mind-Body Medicine. New York:
Norton. (Excellent overview, not theoretically dense, by historian of science.)

2. Sapolsky, R. (2004). Why zebras don’t get ulcers: The acclaimed guide to stress, stress-related
diseases, and coping. New York: Henry Holt and Co. (Excellent, not theoretically dense,
entertaining, but complex.)

3. Kiecolt-Glaser, J., McGuire, L., Robles, T., & Glase, R. (2002). Psychoneuroimmunology and
psychosomatic medicine: back to the future. Psychosomatic Medicine, 64:15-28. (A sample of relatively
current research-based thinking about nervous system and immune system links.)

4. Brown, T. (2000). The rise and fall of American psychosomatic medicine. Lecture given at
the NY Academy of Medicine. (Very helpful history, tying the field of psychosomatic
medicine to historical/cultural context.)

II. Psychoanalysis: (To round out understanding of the historical theoretical context of
psychoanalytic psychosomatic theory, this list also includes central-to-the-literature articles that
represent theoretical positions critiqued in class.)

Theorizing the psyche-soma relationship:

Bucci, W. (1997). Symptoms ands symbols: a multiple code theory of somatization.
Psychoanalytic Inquiry 17:151-172.

Solano, L. (2010). Some thoughts between body and mind in the light of Wilma Bucci’s
multiple code theory. International Journal of Psychoanalysis, 91:1445-1464.
Taylor, G. (2003). Somatization and conversion: distinct or overlapping constructs? Journal of
the American Academy of Psychoanalysis, 31:487-508.

Pollock, G. (1977). The Psychosomatic specificity concept: Its evolution and re-evaluation.
The Annual of Psychoanalysis, 5:141-168. For further insight into previously prevailing
American psychoanalytic theories of psychosomatics, especially Alexander’s.

Schur, M. (1955). Comments on the metapsychology of somatization. Psychoanalytic study of
the child, 10:119-164.

Aron, L., and Anderson, F. (1998). Relational Perspectives on the Body. New Jersey: The
Analytic Press.

Infertility: the first 3 of these are classic papers that exemplify a position critiqued in the
course regarding etiology, but note also fantasy material:

Benedeck, T., Ham, G.C., Robbins, F.P, & Rubenstein, B.B. (1953). Some emotional factors
in infertility. Psychosomatic Medicine, 15(4):85-98.

Jacobson, E. (1946). A case of sterility. Psychoanalytic Quarterly, 15:330-350.

Langer, M. (1958). Sterility and envy. International Journal of Psychoanalysis,
39:139-143.

Pines, D. (1990). Emotional aspects of infertility and its remedies. International Journal of
Psychoanalysis, 71:561-568.

Developmental perspectives on psyche-soma and body self:

Bick, E. (1968). The experience of the skin in early object relations. International journal of
psychoanalysis, 49:484-486.

O’Shaughnessy, E. (2006). A conversation about early unintegration, disintegration and
integration. Journal of child psychotherapy, 32:153-157. Disagrees and argues against Bick.

Winnicott, D.W. (1949). Mind and its relationship to the psyche-soma.

Winnicott, D.W. (1960). The theory of the parent-infant relationship. In: The maturational
processes and the facilitating environment, 37—55. London: Hogarth, 1965.

Pregnancy:

Lester, E.P. and Notman, M.T. (1986). Pregnancy, developmental crisis and object relations:
Psychoanalytic considerations. International Journal of Psychoanalysis, 67:357-365.

Oncology:
Renneker, R. , Cutler, R., Hora, J. Bacon, C., Bradley, G. Kearney, J, & Cutler, M. (1963).
Psychoanalytical explorations of emotional correlates of cancer of the breast. Psychosomatic
Medicine, 25(2)106-123.

Renneker, R. (1957). Countertransference reactions to cancer. Psychosomatic Medicine,
19(5):409-418.

Gastroenterology:

Chessick, R. (1995). The psychoanalytic treatment of ulcerative colitis revisited. The Journal
of the American Academy of Psychoanalysis, 23:243-261.

Pain:

Engel, G. (1959). “Psychogenic” pain and the pain-prone patient. American Journal of
Medicine, 26:899-918.

Anderson, F. (1998). Psychic elaboration of musculoskeletal back pain. In: Relational
Perspectives on the Body, L. Aron and F. Anderson, eds

Grzesiak, R. (2003). Revisiting pain-prone personalities: combining psychodynamics with the
neurobiological sequelae of trauma. American Journal of Pain Management, 13(1)6-15.

Skin:

Pines, D. (1994). Skin communication: Early skin disorders and their effect on transference
and countertransference. In: A Woman’s Unconscious Use of Her Body. New Haven: Yale
University Press, pp. 8-26.

Schechter, M.D. (1972). Psychoanalysis of a latency boy with neurodermatitis.
Psychoanalytic Study of the Child, 27:529-564.

Biven, B.M. (1982). The role of skin in normal and abnormal development with a note on the
poet Sylvia Plath. The International Review of Psychoanalysis, 9:205-229.