Conflict Theory,Nonlinear Development,and Mutative Action with Cases of Cumulative Trauma: Commentary on Fischer

Newell Fischer’s brief note on a time-limited psychotherapy with an eighty-year-old patient—a man suffering from a recurrent nightmare for over a decade—is intriguing given the many interesting questions it raises. In fact, it can serve almost as a Rorschach card, offering as it does inroads for exploration of whatever areas of interest a reader might have. Just as Fischer has a clear interest in preverbal memory, reconstruction, and trauma that guides his thought here, so my interest in conflict theory, development, pathogenesis, and mutative action will inform my comments. That they differ from the author’s conclusions should not be taken as a criticism. Rather, I am using his clearly interesting and apparently helpful treatment as an opportunity to comment on long-held interests of mine. From that perspective, my comments are meant to be heuristic and to highlight views from a different theoretical perspective.

In essence, Fischer suggests that the patient’s interesting nightmare reflects a pre-representational memory of cumulative trauma suffered during his breast feeding experiences. Clinical theories of trauma such as this one carry an implicit formulation different from more Freudian theories of trauma (see, e.g., Busch 2005; Sugarman 2008). “Clinical models formulated on this basis assume that real object relationships are stored in non-declarative implicit memory as ‘implicit’ or ‘procedural’ memories . . . or ‘implicit memory-objects’” (Bohleber 2007, p. 334). Such a model of pathogenesis carries with it the implicit notion of two qualitatively different memory processes, each unaffected by the other. Clearly Fischer advocates such an approach; he concludes that “the disquieting breast feeding left a kernel of the experienced trauma, a buried, preverbal memory that was activated by stimulating life events and evidenced by the recurrent nightmare” (p. 101).

A more Freudian perspective (modern conflict theory and contemporary ego psychology), embracing a developmental model based on nonlinear dynamic systems theory (Abrams 2008, 2011; Galatzer-Levy 2004; Gilmore and Meersand 2014; Harrison 2014; Knight 2011; Lament 2011; Mayes 2001; Olesker 2011; Olesker and Lament 2008), calls into question the plausibility of such formulations. This model of development emphasizes the hierarchical organization of multiple mental systems that interact and are transformed throughout the developmental process (Galatzer-Levy 2002; Harris 2005; Jaffe 2000; Kieffer 2007; Seligman 2005). It eschews the assignment of decisive etiological importance to any one of these systems, internal or external (Gilmore and Meersand 2014). Neither the external environment nor the internal world alone is thought to cause any single mental phenomenon (Sugarman 2017).

This understanding of development raises questions about Fischer’s basic assumption—that the patient’s nightmare (or any other mental symptom) can be caused solely by an external trauma. Bohleber (2007) has expressed reservations about models of trauma holding that traumatic memories are not encoded in the way other memories are, but instead are neither affected by already existing intrapsychic conflicts nor subject to revision by subsequent dynamic conflicts or tendencies of the patient. He believes that such models result “in a non-symbolic, inflexible and inalterable content to traumatic memories because the self is disengaged as the author of experience during the traumatic event” (p. 340). It can seem as if no agency or responsibility is attributed to the one being traumatized with regard to what is experienced as traumatic, or with regard to the specific symptomatic expression of the experience.

This approach to pathogenesis differs from a more Freudian one based on conflict theory. A traditional, conflict-based model “(1) assumes that trauma, even childhood trauma, is usually experienced and processed by an already more-or-less structured mind that will define what is traumatic, as well as try to make sense of it (Sugarman [1994b]), and (2) finds that feelings and fantasies generated by the trauma become components of intrapsychic conflict and compromise formation, including not knowing the trauma (Busch 2005)” (Sugarman 2008, p. 801). In contrast, models of pathogenesis like Fischer’s imply that the symptom reflects a memory of an actual trauma during breast feeding that has been unaltered by eight decades of life experience, developmental conflicts, unconscious fantasies, and multiple transformations of both the mind’s structures and its contents occurring between the breast feeding and adulthood. Most child analysts operating from the variants of contemporary Freudian theory (Sugarman in press) would question whether this is possible.

Instead they would emphasize the emergence of the dream some ten years earlier. Why did it occur just then? Had the so-called trauma occurred during early infancy, why would symptoms not have occurred at earlier developmental stages? What does it mean that the symptom occurred so late in life? What was going on in the patient’s life or psyche that led to the symptom’s appearance in his seventies? These are the sort of questions they would ask. They would dismiss as irrelevant to this case the research cited by Fischer, particularly the papers by Bernstein and Blacher (1967), Coates (2016), and Gaensbauer (1995). The patients that Coates and Gaensbauer describe, who experienced preverbal trauma and remembered it, were children only a few years removed from the actual trauma. In these cases, very few, if any, developmental transformations would have occurred. The patient Fischer describes has gone through many developmental transformations between breast feeding and old age. Further, the cases described in the literature involved shock traumas (Kris 1956) that can be objectively verified. It is not so clear that the subtle misattunement leading to cumulative trauma, hypothesized to have occurred with this patient, would be as indelibly etched in the patient’s memory. In fact, it is not even clear that such misattunement and trauma even occurred. These are just conjectures shared by patient and therapist, unlike the cases described in the literature. Modern Freudians are more apt to regard them as unconscious fantasies instead of veridical memories.

This last point leads to questions about Fischer’s thesis from the perspective of modern conflict theory (Smith 2003, 2005). From this perspective, symptoms like this nightmare involve compromise formations (Brenner 1982) that balance a variety of conflicting mental elements or forces. That is, most analysts using conflict theory assume that a symptom involves the mind’s attempt to balance unconscious impulses, defenses, superego pressures, and signal affects or feared consequences, as well as reality experiences (Brenner 1982). They would not view the symptom as simply or literally an unchanged residue of an infantile experience (Isakower 1938). At most, they might think that the symptom involves a regression of some sort. But contemporary conflict theorists (e.g., Inderbitzin and Levy 2000; Rizzolo 2016) and child psychoanalysts (e.g., Dowling 2004) no longer understand regression to involve a literal slipping back to earlier mental states or experiences. Instead, regressions are thought to involve defensive remobilizations of developmentally earlier residues of mental states that have been included and changed in subsequent developmental transformations. Conflict theorists’ clinical theory, different from Fischer’s, would lead them to focus on the defensive remobilization, not the concrete content, of the regressive symptom.

From a conflict perspective, there are many suggestions in the clinical process that the symptom and the analyst’s explanation of it are used defensively by the patient. Such a model would highlight the likelihood of defense because the patient came to the consultation with a firmly formulated belief that the nightmare was related to his breast feeding experiences. That belief then shaped the therapeutic discourse. Fischer reports that “M.H. and I spent the majority of our time talking about his early development and his family life. He took the initiative to contact several of his relatives and his four-years-older brother for more details about his formative years” (p. 95). Later he describes how they “speculated that [the mother’s] anxiety, disappointments, sense of abandonment, and anger overflowed into her breast feeding and that it was traumatic to the neonate” (p. 96). Conflict theory advocates might see the patient-analyst interactions as intellectualized. Indeed, they might question what it means with regard to the patient and the meaning of his symptom that he has come to therapy having already figured out its meaning by himself, that he controls the hours so that the participants engage in a logical, secondary process search of his history for confirmation of his own interpretation, or that he goes in search of further confirmation from those who might remember his childhood experiences.

An explicit tenet of conflict theory is that the mind is organized in a way whereby some mental content or process is being defended against while other mental contents or processes are used to defend and keep what is being defended against unconscious (Blum 1985). On this understanding, material presented early in treatment would tend to strike the analyst as defensive. After all, it is conscious. Why would the patient need treatment if his conscious explanation of his symptom is correct? Instead, the analyst would wonder why the patient is so invested in his own interpretation that he spends his time in therapy simply confirming what he already believes to be true. After all, he takes pains to structure the treatment in such a way that its frequency and brevity make it unlikely that anything might come up that might challenge his already well established explanation. Even the process of the treatment is kept at a conscious level, another sign of defensiveness to contemporary Freudians. From their perspective, one of the values of free association, as a technical tool, is to allow for the expression of unconscious mental phenomena in the therapeutic encounter. Treatments such as the patient’s, where the interaction is conducted in an exclusively secondary process manner, make the emergence of unconscious material highly unlikely.

The material and clinical process presented in the paper make it impossible to hypothesize what is being defended. But one might wonder about an aspect of the patient’s history that the author does not emphasize. That historical nugget is the report of the brother’s stutter and the parents’ explanation for it. The patient explains how the brother’s stutter developed after an evening in which the parents had gone out, leaving him with a baby-sitter during a thunderstorm with lots of lightning. When the storm arose, the parents rushed home, fearing their son’s experience could be traumatic. Later they readily attributed the boy’s stutter to his having being traumatized by the storm. Modern Freudian–trained child analysts would question whether a stutter could develop de novo after a one-time experience as normal as a thunderstorm. If that truly had been a trigger, they would assume that the brother had to be already dealing with intrapsychic conflicts that made the thunderstorm the tipping point. Again, it is impossible to know whether it was, indeed, the trigger or even if this was truly the parents’ explanation for the symptom. Fischer is entirely dependent on the patient for this bit of information, but it might simply evince the patient’s predilection to assign psychopathogenic causality to outside experiences. If his story about his parents’ formulation is accurate, he might have identified with their defensive use of externalization despite his training in the mental health field. Should his recounting of the parents’ explanation be simply a screen memory expressing his own compromise formations, the conflict theorist would interpret this as another instance of the patient’s simplistic attribution of causality as a way of defensively avoiding disturbing thoughts about his internal conflicts, the same strategy deployed in his explanation of his nightmares.

An approach to technique and mutative action different from Fischer’s follows from an understanding of pathogenesis based on a nonlinear dynamic systems understanding of childhood development and conflict theory. As I have mentioned, modern Freudian analysts would be struck by the patient’s initial presentation of a well-entrenched explanation for his symptom and his insistence on understanding it exclusively from that perspective. They would also wonder about the intellectualized search in sessions for evidence supporting his theory. Such an approach to his treatment would be seen to reflect a desire for premature closure and a tendency to be controlling in order to regulate anxiety. Hence their technical strategy would be to draw his attention to his seemingly defensive insistence on an explanation that blamed the environment. This approach follows from a contemporary ego psychological view of mutative action. That perspective asserts that psychoanalysis works by expanding the patient’s ability to look at the workings of his mind during the interaction with the analyst. These analysts, as well as some Bionians, aim to help their patients by showing them that their thoughts are only mental constructions, not veridical pictures of reality (Busch 1999, 2014; Sugarman 2003, 2006; Tuch 2007). As patients gain this perspective, they become able to see the various interacting contents and processes of their minds at work. Many analysts believe it most useful to first draw patients’ attention to their defenses and/or superego pressures as they manifest in the analytic interaction (Gray 1994; Portuges and Hollander 2011; Sugarman 1994a). Helping Fischer’s patient gain interest in looking at his own mind, in process, would be their reason for focusing on what seems his irrevocable insistence that the nightmare is due to his breast feeding trauma. To be sure, some patients can find such questioning to be narcissistically challenging. In these cases, the analyst would look for other areas of mental functioning as they manifest in the consulting room to interest the patient.

Analysts using these variants of modern Freudian thinking would not be comfortable allowing the patient to use sessions to search for confirmation of what they would see as his defensive rationalization for his symptom. If they caught themselves being drawn into such a role, without realizing it initially, they would assume the presence of a transference-countertransference enactment and look for ways to use their subjective experiences to draw the patient’s attention to the workings of his mind (Gottlieb 2017). Guiding their approach is the assumption that patients interpersonalize the many structures, processes, and contents of their mind into their construction of the analytic frame. Essentially, all mental structure and conflict is transferred into the analytic relationship, not just defenses or infantile object ties. From this perspective, analysis of transference allows one to show the patient the workings of his mind in vivo. Observing these workings and exploring their specific unconscious meanings lie at the center of the insightfulness that analysts operating from the variants of modern Freudian thinking believe to be mutative. Process knowledge (Busch 2014) is what they aim for.

Related to this issue is the difference in opinion between those who emphasize reconstruction (Blum 1994, 2005) and those who stress work in the “here and now” (Fonagy 2003; Sugarman 2006) as more valuable in bringing about structural change. Fischer’s approach clearly comes down on the side of reconstruction. It appears that he believes that what Busch (2014) would call state knowledge, what others would call insight into mental content, is what is most mutative. In this case, the content or state involves the reconstruction of trauma experienced during breast feeding. Some analysts worry that such analytic work can help the patient avoid the transference, the very place where underlying unconscious conflicts are most immediately available for scrutiny and analysis. Certainly the process Fischer describes does not report any attention to the transference. As a result, it is difficult to determine the degree to which underlying unconscious conflicts were addressed. As such, the therapeutic work reads very differently from the clinical reports of those emphasizing “here and now” exploration. To be sure, some advocates of reconstruction believe that it offers particularly valuable inroads to repressed, unconscious mental contents. That is because they see insight into such content as the most important mutative factor in psychoanalysis. But in this patient’s case, it is difficult to ascertain repression at work. He comes to treatment with a conscious reconstruction of his symptom, and the treatment is described as if it buttressed this reconstruction. No repressed memories, emotions, fantasies, or the like are reported. The case reads as if the unconscious was not addressed by either the analyst or the patient. This is an approach to reconstruction different from that of modern Freudians like Blum (1994, 2005) or Gottlieb (2017).

One can speculate that Fischer sees his mutative impact to lie in helping the patient elaborate or flesh out his narrative to reveal the meaning of the symptom. In contrast to this approach to narrative, a modern Freudian orientation assumes that narratives make use of and bring together a host of disparate conscious and unconscious mental contents and processes. In this patient’s case, it seems as if the treatment served primarily to support an already elaborated narrative that the patient brought to treatment, rather than one co-constructed by the analytic pair. In this way, the patient’s narrative is different from the narratives of patients treated by analysts Fisher cites as emphasizing the importance of narrative in mutative action.

The brevity of the case makes it difficult to know how impactful the treatment was in alleviating the symptom. And that impact is an important element when thinking about mutative action. Only time will tell. But the patient definitely seems to have valued the treatment and found it helpful emotionally. This valuation of the treatment by the patient is an important factor to be considered given the various technical views that differ from Fischer’s.

His interesting case report also helps us think about the difference between psychotherapy and psychoanalysis as treatment modalities. Two general perspectives appear in psychoanalytic discussions about this vexing distinction. On the one hand, many argue that psychoanalysis and psychotherapy are distinct treatment modalities. Those who think this way contend that psychoanalysis, as a treatment modality, is characterized by the facilitation of a process qualitatively different from that occurring in psychotherapy. Others, however, argue that the treatments are best viewed as on a continuum, each sharing, in varying degree, common elements such as transference, resistance, and interpretation. Those taking this view do not believe the two modalities are characterized by different treatment processes. Rather, they suggest that certain elements may occur in greater or more vivid detail in one or the other. For example, more direct transference phenomena may occur and be available for exploration in psychoanalysis than in psychotherapy.

Fischer’s psychotherapy with the patient in this paper raises the question of whether narratives that buttress a patient’s defenses may characterize psychotherapy and distinguish it from psychoanalysis. No one, including Fischer himself, would suggest that a psychoanalytic process occurred in the case he presents. Rather, the patient seemed to find the treatment useful because it supported and provided details he could use to consolidate his belief that his unpleasant symptom was caused by trauma experienced during breast feeding. From this perspective, it may not matter that he used that explanation for unconscious reasons that the therapy could not clarify. He came for symptom relief, not a deeper understanding of his psyche. Psychoanalysis would not be an appropriate treatment recommendation for such a patient unless the analyst believed that his internal and external circumstances warranted a deeper and more intensive treatment. Instead, the treatment described could be viewed as what an earlier generation described as a supportive psychotherapy (Gill 1951). In this vein, Fischer’s paper may help clarify one element that distinguishes psychotherapy from psychoanalysis—the degree of emphasis on narrative and the way in which it is used.

In conclusion, Newell Fischer deserves our thanks for offering such interesting and controversial clinical material. Doing so allows us to explore and sharpen our psychoanalytic understanding of many facets of our field. Debates and discussions such as this are the essence of what makes psychoanalytic education a lifelong endeavor.