Transforming Trauma

Early Phase

When I first met Mario he was lying on his stomach on a stretcher, a white sheet covering his frail body with only his thin pale face and black eyes peering up at me. He might have had a cigarette dangling from one hand, but I’m not sure. I remember wanting to appear calm and receptive, while inside I was feeling shocked and overwhelmed. I was in touch with a traumatic world of utter helplessness and dependency and the near-death implications of a white sheet and catastrophic loss. ¹ I do not remember the department chair (or anyone else) preparing me for such an emotional confrontation. The young man on the stretcher was in his early thirties. We were close in age.

Two recollections stand out from the early phase of therapy. The first is the unexpected feeling of elation I had when I initially saw Mario in a wheelchair. His mobility made a world of difference. As I later learned, the stretcher was being employed only temporarily, so that the bedsores that periodically developed could heal. It was a relief when Mario, a thin-bodied man, began to roll his chair into our sessions, wearing shirts and pants and smoking a cigarette, flicking the ashes into a small metal can at the end of the chair’s side bar. I can still see him using his wrists in a rather fast and deft way, pleased that he could show me that he could get around on his own. I was also—on an unconscious level—experiencing an attribute of Mario’s, his sense of power and masculinity. I now believe that it was there in his seductive glance at our first meeting, where some aspect of mine may have responded in an unknowingly reciprocal way (Bromberg 1998, 2006; Bateman and Fonagy 2012; Gill 1983; Kantrowitz 1986; Laplanche 1999; Sandler and Sandler 1978).

The second memory is of the actual treatment process, the fact that my immediate supervisor had instructed me to provide supportive therapy only. As I look back, I believe he might have meant some form of cognitive-behavioral therapy. As I mentioned, I was in my own analysis at the time and was studying at an analytic institute. So I made the decision to follow my own inclination. I asked my supervisor to let me work with Mario twice weekly. Silently opposing the supervisor, I chose an insight-oriented approach that continued throughout the year. I can now imagine how, in that dark atmosphere of old men suffering the effects of strokes, I was motivated by having a young patient with an intact brain and a mind that could work. We could talk.

As I search my memory, it is impossible to recall much of Mario’s personal history or even the actual content of our sessions. He came from a small family (I never met any of them) and spoke about his engagement to a young woman who ended their relationship a few months after his hospitalization. I have a recollection of addressing his self-critical thoughts, perhaps referring to a harsh superego or a punitive, self-blaming voice that preceded the accident. As I think about it now, we might have been working on the self-flagellating thoughts that contributed to his depression and low self-esteem. I can imagine myself challenging his attacks on the horror of his dependency and damaged body/self, the crushing devaluations prohibiting a broadened appreciation of who he was—and could be. I am fairly certain that I was working in an empathic as well as ego-oriented way, using language for understanding and meaning making. I am reminded, in this regard, of Loewald’s appreciation (1979) for the analytic role of understanding: “while understanding does not spell out a cure, it is a therapeutic step . . . when the patient feels understood . . . an act that involves some sort of mutual engagement, a particular form of meeting of minds” (p. 381). Loewald believed that psychoanalytic interpretations are based on the analyst’s self-understanding and “the mutual engagement of different mental levels” (p. 382).

The Therapeutic Relationship

[The analyst] must recognize that the patient’s falling in love is induced by the analytic situation. . . . the patient’s need and longing should be allowed to persist . . . they may serve as forces impelling her to do work and to make changes, and . . . we must beware of appeasing those forces by means of surrogates.

What I clearly recall about our therapeutic relationship is that it seemed to take on a life of its own, an experience resonating from the affective quality of our work together. I can remember Mario beginning to wear bright flowered shirts and sometimes wheeling himself into our sessions with his head tilted to one side, a wise-guy seductive kind of smile on his face. On at least one occasion he teasingly challenged me, rolling the wheelchair around the desk, as if trying to pin me in. It was sexual, yet by cutting off my mobility he was inducing in me some of the feelings of helplessness and vulnerability he knew so well. I remember trying to hold a serious, professional countenance. I was not sure what to do. I believe I was silent. (I wonder if I smiled in an embarrassed or self-conscious way or maybe blushed.) I do know that I didn’t want to hurt him or cut off these masculine (if somewhat provocative) behaviors. These sexual and emotionally charged images remain fresh, along with my reckoning of how to move sensitively through the tangle of erotic advances that felt so out of place, yet so relevant. This transmission of potency and power seemed to be bringing him back to life. (I now believe that this erotic enactment or seduction scene served a critical nondefensive function, aiming at psychic reparation and testing the analyst’s receptivity and validation).

The Contract

At some point during the early months of the internship, I had an unexpected thought. I told myself that I would get Mario out of the hospital before my internship ended, that is, by the end of the following summer. I was not ambivalent. To this day I have no inkling of how this far-fetched idea developed. After the internship was over, I shared my private “contract” with a supervisory family psychiatrist who believed that this sort of unconsciously informed determination held a purposive motivating meaning. Today I believe that my vision—a wish for Mario to make it—came from a side of myself rooted in complementary identifications, supporting a somewhat omnipotent narcissistic need to take on near-impossible battles and succeed. Seen this way, my wish to rescue Mario fit with my own formative struggles with autonomy and freedom, my need to overcome enmeshing maternal internalization (Varga 2010) that prohibited higher levels of independence and oedipal possibility. To this day, in some ego-syntonic, Man of La Mancha way, I believe that human beings can perform remarkable feats when unconscious conflict is not a barrier. Now I wonder if this side of my personality was unconsciously stirred when I saw Mario in the wheelchair. I could empathize with Mario’s masculine, somewhat omnipotent presentation—as a fighter, a man seeking to live, to go out into the world—experiencing it as a significant and authentic part of his identity (Schwaber 1981).

Here was a guy who wanted to fly—to touch, to contact, to have sex—and I unconsciously, in a complementary way, connected and identified and needed to make it happen.

The Relational Unconscious

From its inception, psychoanalysis has tended to idealize the curative value of insight while devaluing the mutative significance of the analytic relationship . . . transference and countertransference provoke a continual intersubjective/interpersonal enactment.

As the treatment progressed, I continued a classical or more traditional approach, investigating Mario’s history and fantasy life and the meaning of the accident, the loss of his girlfriend, and so forth. Perhaps I worked with some dreams as well. I also modeled myself on my own analyst and his empathic and reflective way of listening (Schafer 1983). I cannot recall discussing or interpreting any aspect of our relationship. There was much that was left unsaid. This might have been intuitive or from a lack of experience on my part.

I do not underestimate the curative aspects of the expressed understanding taking place between myself and the patient (Greenson 1967; Loewald 1979). Yet, as I look back, I believe that the silent world—the relational unconscious—was doing much of the work that was bringing him back to life. I suggest that it was there in my mirroring of some intact psychic aspects of the patient, connecting to split-off instincts, images, and fantasies of his premorbid self and narrative (Bromberg 1996, 1998; Kohut 1984; Schafer 1992). It was active too in the mix of unconscious identifications and communications making their way between us and into the higher levels of his psyche, transforming affect into thought and self-representation for the future (Bion 1962; Fonagy et al. 2002; Loewald 1960). The relational unconscious also carried the chemistry between us, conveying a sense of emotional and erotic understanding and fit (Schore 2011; Bateman and Fonagy 2012; Goldklank 2009; Kantrowitz 1995, 1986; Kernberg 1974; Mitchell 2000; Scharff and Scharff 1987; Winnicott 1971).

During a session one spring afternoon, Mario reported unexpected news. He was attending a daily recreational rehab program and one of the female therapists had fallen in love with him. The couple were planning to take an apartment outside the hospital grounds. I was taken aback. I am embarrassed to admit that at first I did not really believe him—or was concerned he might be imagining or embellishing some wish-fulfilling interchange.

Mario had not said much about this woman, or, if he had, I missed the import of their relationship. (As a more seasoned analyst, I now ask whether he was protecting his self-esteem by not sharing more with me until he was more certain, or whether he was working through an unconscious struggle between the new woman and his dark-haired fiancée or, perhaps, his therapist, or whether I had not heard him because I was possessive or jealous.)

At the end of the hour, we planned a session for the couple later that week. I was unsure what might emerge, and then, finally, there they were before me, Mario in his wheelchair and a young woman sitting at his right side. They were calm and smiling. An attractive blonde, she had graduated from a prestigious college a few years earlier. While to myself I questioned the meaning of her decision and the unusual path she was choosing, I surmised that she meant business. I did not want to delve too deeply into her personal history, most likely afraid of upsetting the applecart.

A few weeks after this session, approximately two weeks before my internship would be over, they left the hospital together.

The Analyst and Trauma

As mentioned, clinical emphasis on the relational unconscious (Wolson 2012) requires that the analyst resolve formative complementary identifications (Varga 2010), particularly where the analyst’s own internal struggles can interfere with empathic alter ego functions and transformative possibilities. Thus, it is important to examine the psychological impact of my working in a hospital for neurological diseases and, on an affective and clinically relevant level, of treating a patient with a severe physical trauma.

In this regard, I believe that I perceived Mario’s severe and sudden injury as a massive assault on his identity and sense of self-continuity. Along this line, my anxiety and dread on meeting Mario appear to have a source at two levels of self-concern. The first relates to body/self experience, particularly the importance of ongoing psyche-soma representation and integrity; and the second to narcissistic self-experience, including affect and self-esteem regulation (Kernberg 1976) and self-affirming, motivating, and ambitious functions (Kohut 1977). ³

Clinical work with Mario meant that I would have to reckon with the catastrophic effects of bodily trauma on self-formative identifications related to who I am—and who I will be. The accident and its powerful psychological disruption triggered my own anxiety about psychobiological boundaries and intactness, and about regressive experience related to dependency and helplessness, as well as gender and social inadequacy and/or humiliation. Schafer (1992) describes psychoanalytic disruption as “the destabilization, deconstruction, and defamiliarization of the patient’s narratives” (1992, pp. 156–157). Similarly, trauma impinges and “deconstructs” fixed stories of the self in past, present, and future time.

Therapeutic relationships reveal how the analyst’s personality and “mind” are alive in the mutual influences of the bipersonal field (Bion 1959, 1962). In this regard, Mario’s therapy was a lightning rod that triggered a journey into my own psychic arrests and struggles (Stolorow and Lachmann 1980; Varga 2010). The therapeutic relationship could be understood as a working through of my trauma of being with Mario—and of being with myself—meeting some split-off, frightened, and insecure voices within my own psyche.

I too grew up in Brooklyn, in a Jewish middle-class family, not far from where Mario had his accident. As a child I struggled with dependency issues stemming from an overly enmeshed mother-daughter relationship with heightened anxiety around separation and narcissistic, perfectionistic expectations. I was also a flirtatious dark-haired, dark-eyed “Daddy’s little girl,” with an idealizing mother who actively reinforced the ideals of social acceptance and popularity. I became involved with the opposite sex in my early preteens. As an example of my precarious self-regard, I can remember trying to soothe my social anxiety by telling myself, “I will be okay no matter what I wear,” a few days before my birthday party when I turned eleven.

When my mother died suddenly of cancer when I was sixteen (the same age Mario was when his life was shattered by the accident), I was at the height of an adolescent struggle marked by overzealous dating and beauty competitions. Her death compromised possibilities for individuation that I very much needed (Blos 1979; Erikson 1950).

In a memory that depicts my emotional vulnerability in my early twenties, I can remember being away with friends when I asked to borrow a shawl from an attractive young woman crippled from childhood polio. I can still recall my dread at actually wearing the shawl—an object that in fantasy had absorbed the deformity. I returned the shawl quickly. It seems to have challenged my boundaries, my sense of secure selfhood or identity. As I look back, I believe that a pseudo-mature and grandiose persona or “false self” (Winnicott 1971, p. 68) was protecting another version of myself, a frightened and insecure being.

The shock I felt upon seeing Mario for the first time came from a pivotal place in my own psyche. This was the trauma of total dependence and impotence—and the image of an unacceptable and devalued self.

The clinical work with a highly compromised paraplegic man close to my age challenged my vulnerable feelings about physical attractiveness, social desirability, and competitive possibility. Thus, the treatment required me to dig into a number of dreaded places. I would need to confront the critical and perfectionistic mother-daughter constellations, battles between inner and outer, perfect and imperfect, assertive risk-taking and dependent-compliant. And, like Mario, I was self-critical and self-devaluing. The treatment would open up a path for my own growth—an analytic rebirth and discovery (Varga 2010).

The Co-created Drama and Chemistry

I believe that in the earliest moments of our meeting, Mario’s imploring and seductive eyes kindled my unconscious interest and identifications. Years later, I wonder whether these were my father’s black eyes—or even my own—so familiar to me and reflected in this first encounter. I remember the look in Mario’s eyes as he searched my face, hooking on to some part of me that might have unconsciously responded to his engagement (Sandler and Sandler 1978; Laplanche 1999). I wonder why I didn’t fold or go into hiding as I did with the young woman with the shawl. Why did he manage to strike a chord that pulled me in, making me feel so bold? Why did I decide to rescue him?

In a fantasy that takes place well after the treatment ended, the patient and I are in some mutual space—teens together, sharing social and sexual identifications, playing hooky where the parents, teachers, and administrators would not tread (see Ferro 2009; Mitchell 1986; Ogden 1994; Racker 1957; Schafer 1985, 1992). (I now wonder whether this “teens alone” fantasy expressed an additional meaning, an implicit one, that emerged in the therapeutic context, where I experienced the treatment as a secret and somewhat rebellious act: doing my own thing removed from the chair’s advice and watchful eye.)

Developmental Stories and Identifications

In an uncannily parallel way, a constellation of my own developmental strengths and vulnerabilities enabled me to identify with Mario’s plight. I knew the meaning of wishing to go out, to go forward, and the horror of being frozen and stuck. The need to move on and make my own choices, and to feel safe in my own psychic skin, were recurrent themes in my personal analysis.

Mario’s assertive self-representations, like mine, met challenges. He was caught in a damaged body, where helplessness and dependency foreclosed the formative masculine imagoes of his premorbid existence. Although I experienced a different form of incapacitation or arrest. Mario’s struggle resonated with my own dread of dependency and immobility. I understood his self-attacks and feelings of rage and shame. I could identify, coming from my own fear of social isolation, a wallflower who could lose out, unable to blossom and grow (Atwood and Stolorow 1984; Kernberg 1976; Mahler, Pine, and Bergman 1975; Schore 1994; Winnicott 1965).

On the other hand, as reflected in the teens-alone fantasy, my developmental story could present resolutions with healthier possibilities. I held feisty social and gender-related identifications with more individuated oedipal-level features. These maturational achievements could offer support for individuating alter ego functions (Varga 2010) and reverie for Mario’s treatment (Ogden 1994; Schafer 1978).

From my point of view as the analyst, the treatment challenged inhibiting mother-child constellations, requiring me to build on healthier, self-enhancing oedipal imagoes. These included developmental strengths found in the charismatic self-representations of the relationship with my father, as well as the more autonomous and admiring features of the relationship with my mother. In an adaptive multifunctional way, I was able to engage my autonomous oedipal identifications to resonate with Mario’s pretraumatized self, validating his assertive and masculine projections (Bromberg 1996, 1998; Kernberg 1984; Kohut 1977; Loewald 1960; Varga 2010).

Ultimately, Marios’s treatment would touch upon my own personal narrative, emboldening a desire to fight for my own psychic survival, to break free of an ambivalent mother-child constellation and live my life. I remember my analyst at the time saying, “Even a fly fights for its life.” Although he was referring to my own internal struggles, his voice was there in my relationship with Mario. I believe that my private contract, with its unwavering conviction (“He will leave the hospital before I do”) meant that Mario would—and must—get out. In a positive and complementary way, I was intrapsychically ready for his phallic wishes and mobilizing projections (Laplanche 1999; Sandler and Sandler 1978). The contract held a “viewpoint of the future” (Loewald 1960, p. 230).

The Analyst’s Contributions

The analyst’s contributions include (a) her alter ego functions, including the transformation of complementary pathogenic individuating and narcissistic internalizations (Varga 2010); (b) a view of future growth and possibility for the patient (Loewald 1960); and (c) a capacity to contain and mentalize affectively charged traumatic states (Bion 1959; Fonagy et al. 2002). ⁴

An expansive holistic appreciation of the bipersonal field includes “nonlinear dynamic systems” (Boston Change Process Study Group 2013, p. 733), context-relevant communication, and the role of fantasy, metaphor, and unpredictable states (Baranger and Baringer 1969; Bromberg 1996; Ferro 1999, 2009; Katz 2013; Ogden 1994; Stern 2013). This multilevel systems consideration implicates a broad (macro) sphere of influence in novel self-relational (micro) perceptions and motivation.

A classical view suggests that instinctual and affective experience is embedded in the analytic transference (Freud 1914, 1915), where the analyst’s healthy libidinal investment ignites and reawakens the patient’s fixated erotic instincts and secondary narcissism. From this perspective, the patient’s disability and psychic trauma have led to overwhelming anxiety, with ego destabilization and narcissistic and libidinal regression, including a withdrawal and drawing back of libido from the object world (Freud 1914, p. 76). In the developing transference, the analyst, as an idealized as well as idealizing object, fosters the patient’s erotic identifications and object-directed libido.

In Varga’s view (2010), which is both classical and relational, the analyst’s transformative role depends on a capacity to work with the ongoing transference enactment in terms of resolving his or her own pathogenic individuating identifications. In this way, the analyst’s positive, nonpathogenic contributions help to free up spontaneous libidinal and narcissistic states in which the patient’s premorbid masculine and assertive representations enliven the bipersonal world (Stern 2013). It is only when the analyst is able to join the patient in a less frightened and inhibited way that change takes place.

In this treatment, the relational chemistry relates to a “co-created infantile drama” (Wolson 2010, p. 211) that encompasses complementary struggles, defensive resolutions, and projective identifications (Dicks 1967; Goldklank 2009; Kernberg 1974; Mitchell 2000). The relational chemistry serves transitional purposes (Winnicott 1965, 1971), a holding environment that helps the transference enactment shift toward higher levels of psychic development and transformation (Bion 1962; Kernberg 1984; Loewald 1960). Ultimately, the patient connects with—and reorganizes—affirmative and mobilizing masculine self-representations. He is able to use the transference in a healthy way, creating a match with a new and available partner (Freud 1915). After proudly introducing his girlfriend to the analyst, Mario leaves with gratitude—a positive libidinal and postoedipal resolution (Klein 1935; Kernberg 1974, 1984).

A Broad Systems View

I am a field, an experience—a system of relationships.

I have presented an open-systems account of bidirectional dynamics that incorporate a relationship between the self and the interpersonal world, including the sensory, spatiotemporal environment (Baranger and Baranger 1969; Ferro 1999; Green 1975; Katz 2013; Merleau-Ponty 1945). ⁵

In this context, the relational unconscious is broad and interactive and expressed in a multimodal way throughout a treatment. It is found, for example, in symbolic form in the silent contract I made with myself in Mario’s treatment, as well as in the image of the Man of La Mancha, a libidinal, hope-filled character who arose spontaneously as I looked back on the treatment. The “contract,” the Quixote character, the “shawl,” and the “wallflower” in Mario’s treatment can be understood as objects or things or metaphors that contain significant affects, fantasies, memory-traces, and developmental wishes and identifications. They are alive with motivational and transformative meaning (Bion 1962; Civitarese and Ferro 2013; Ferro 1999; Fonagy et al. 2002; Katz 2013; Stern 2013). Ultimately, it was Mario himself who fulfilled the terms of the unspoken contract. In effect, the contract was the analytic couple’s unconscious agreement, fueled by complementary wishes, dreams, fantasies, and individuating, narcissistic, and erotic identifications.

The bipersonal field includes diverse internalizations related to the participants’ personal histories and stories, including parental demands and expectations and a range of ethnic, gender, and sociocultural constructions. It also encompasses institutional and organizational dynamics, including in this case the multifunctional meanings surrounding the hospital setting, administrative and staff communications (e.g., the chair’s meager description of the patient), the repetitive assignment of psychologists and interns (opportunities for optimism and/or disappointment and loss), the limited internship period (one year), and the analyst’s relatively young and inexperienced self—the naive wayfarer on a road not yet taken.

I believe that this contextual framework does not detract from the in-depth intrapsychic focus required for transforming a pathogenic transference enactment. On the contrary, I find that it strengthens the opportunity to explore positive as well as restrictive identifications and facilitates attention to the wide range of unconscious elements that dart in and out of the relational field with all its therapeutic potential.