The Secret Life of Secrets: Deleterious Psychosomatic Effects on Patient and Analyst

Elina: “I Can’t Say It”

Elina, age seventeen, was referred for consultation by her residential treatment team. Elina’s protracted course of anorexia (five years and more), with no significant period of remission despite stays in inpatient, day hospital, and residential treatment centers, left her current providers with a sense of hopelessness. Moreover, she had recently developed psychosis, a rare comorbidity of anorexia; the psychopharmacologist at the treatment center was considering antipsychotic medications and wanted a second opinion.

In our first interview Elina shared that she heard a voice in her head that she believed was a brain tumor. Day and night, it repeated the phrase, “Don’t say it. Don’t say it.” This monosymptomatic hypochondriacal delusion was Elina’s only psychotic symptom. A thorough medical and neurological investigation, including neuroimaging studies, revealed no cause for her rapidly deteriorating physical and psychological condition. With encouragement she agreed to come for twice-weekly psychotherapy sessions as long as I agreed to be neither “too silent” nor “too bossy” regarding her need to gain weight. Apparently Elina wanted something to be noticed and other things to be left out completely. I immediately felt I was on an emotional precipice, needing to say just the right thing from the beginning lest the patient fall into an emotional void or regressive collapse; I grasped her team’s frustration, exhaustion, and desire for relief via some magic potion, be it medication or psychodynamic insight.

Naturally, I wondered what Elina held in her mind that she was not supposed to reveal. Believing that her secret would be given up only over time, if at all, because it served as a defense against a more integrated experience of self, I cautiously interpreted how difficult it must be to live with a voice inside one’s head, a voice that wanted and needed to be heard but was not ready to make its presence known.1 In my reverie I experienced a cordoned-off, ghostly figure that Elina had managed at great emotional cost to hold under substantial control. I worried about how long this could go on without further deterioration, physical and psychological.

Suspecting some history of abuse or unresolved mourning as the likely etiology of the voice, I began reviewing the copious psychiatric records of the patient’s five years of treatment. Quickly my initial hypotheses proved wrong. Sprinkled throughout the documents, like pebbles left on a trail to mark one’s tracks, historical footprints came into view. Elina had been conceived by in vitro fertilization with the gametes of extended family members, a fact her adoring parents sought to hide from their daughter with a false narrative of her birth. They and their donors had made a pact to never reveal the true story to her. With the hallucination now understood as an encryption of the patient’s secret knowledge of herself, segregated from consciousness and creatively transformed, I proceeded to solidify an alliance for short-term dynamic treatment with Elina and to share with the multidisciplinary team working with her family my belief that she held within her psyche, at considerable emotional cost, the “known known” of her conception. Couples therapy then assisted the parents in confronting and working through their deception and shame about the infertility, so that Elina would be able to speak directly to “what had been hidden, but in plain view” (Zerbe 2008). Once Elina was told the circumstances of her birth, her hallucination stopped, though her struggle with weight and body image persisted. After she told staff members and me that she was not surprised by her parents’ revelation, the therapy saw a burst of affect-laden narrative. While Elina spoke with prompting of her anger, bewilderment, and sorrow regarding what had been withheld, she also opened up about her aspirations and was particularly eager to bring to session the tentative results of her self-study. This precocious adolescent was unusually empathic toward her parents despite their deceit, a facet of her character that facilitated dialogue and understanding within the family. Her development now substantially back on track, and having gained some weight, Elina was eventually released from the residential center to outpatient care.

This case shows that secrets are not always as out of reach or as multilayered as the analytic literature suggests. Elina’s determination “not to say it” led to the hypothesis that her anorexia was in part a bodily manifestation of pertinent observational facts (Bernfeld 1941) that she was refusing to swallow. The detective work of reviewing her records, but primarily the therapeutic work of psychodynamically informed staff with Elina’s parents, allowed the family’s acknowledgment and working through of what had intersubjectively been communicated as mortifying and devastating. As the meaning of the secret to Elina came under greater scrutiny in the psychotherapy, her innate ego capacities flourished as she came to grips with the circumstances of her conception.

In contradistinction to the widely held psychoanalytic axiom that psychosomatic and eating disorder patients are alexithymic and consequently “cling to unconnected facts, things, and persons” (McDougall 1980, p. 369), Elina’s case demonstrates the opposite. Her story was longing to be told, but the energy it took to conceal it, to “not say it,” appears to have completely shut down her capacity to tell it. Once released and before further encroachment on normal development could occur, the secret lost its power to “obstruct” by virtue of the shared psychotherapeutic “conversation” (Bernfeld 1941, p. 342), in which Elina’s unconscious identification with her parents could be addressed. She began to acknowledge her own desires, freed to begin a deeper negotiation with symbolic process and, most important, her self.

Thus, not all persons with psychosomatic illness may be examples of what the French psychoanalytic school has called operational thinking (la pensée opératoire), a highly restricted, affectless, delibidinalized form of relating believed to be characteristic of the “psychosomatic personality” and addictions (Marty and de M’Uzan 1978; McDougall 1974, 1980, 1989). However, just as French psychoanalysts first observed that psychosomatic patients must be helped over time to bear the unbearable lest their “tendency to eliminate any recognition of the overwhelming emotion” increase their “psychosomatic vulnerability” (McDougall 1989, p. 24), clinicians who become privy to what the patient has been concealing must see this as the opening of a new chapter and not the quick turning of a page that leads to cure. Elina needed considerably longer-term psychodynamic psychotherapy to forgo symptom substitution, assist in further remediation of her anorexia, and tackle problems of living that were impairing her quality of life. This process was greatly facilitated by the astute psychodynamic family therapists who helped Elina’s parents articulate their hidden shame about the infertility and making unspeakable secrets a subject of open discourse, attenuating the adolescent’s present suffering and preventing transgenerational transmission of the trauma (Leuzinger-Bohleber 2015a,b).

Octavian: “I Can’t Say It Yet”

Octavian, forty-four years old, was married with four children. An accomplished musician and aspiring composer, he did not give up his secrets easily. For this, his third attempt at psychoanalysis, he traveled a significant distance several times a year or when work brought him close to the city where I practice; otherwise we spoke on the phone three or four times a week. Despite access to analysts closer to home, Octavian’s sister, Clemence, found me through an internet search and insisted that her brother seek consultation. I incorrectly assumed that Octavian suffered, like a growing number of middle-aged people, from a long-standing subclinical eating disorder, body-image disturbance, or addiction that was beginning to manifest itself as an anlage of physical illness. The perturbations that accompany normal aging are exacerbated in these patients, and an illness directly resulting from an addiction is often what brings them to medical attention. Even then the patient may withhold the problem unless asked about it specifically and repeatedly. I suspected that Octavian’s comment about his sister and family dynamic was a ruse for reaching out now and that it helped him maintain the defense of omnipotent control over what he experienced as a deeply shameful personal shortcoming. Indeed, it is common for addictive pathologies to remain secret among accomplished professionals in many fields.

For over a year of analysis, nothing seemed to provide traction or to make any notable difference for Octavian. Silently worried that I was the wrong analyst, I sought out several senior consultants for help. I noted to each that I was more antsy and restless than is usual for me and often, especially during phone sessions, found myself shifting in my desk chair, stretching, fidgeting, or doodling. While advice from consultants was often useful to my growth as an analyst with other patients, only one comment scratched the itch when it came to Octavian. This consultant strongly advised forbearance and continued self-observation. She simply and repeatedly said, “This one sounds tough. Hang in there. Be respectful of the process. Sometimes it takes years. He’ll tell you only when he’s ready.”

Meanwhile, Octavian intermittently showed up in person or kept his appointments by calling in, always paid his bill on time, and began every session with something interesting to say about his career or his family. Dreams and fantasies were forthcoming; he linked themes to our relationship and the developing transference. He was a model analytic patient for about twenty minutes of every hour, but would then suddenly stop, collapse into tears, and sob for the remainder, sidestepping but not disavowing the entire experience at the next session. Uncannily preempting the perceptive consultant, Octavian pleaded, “I’m just not ready to go there with you. Not yet. Please don’t push it.” I decided to take his prompt as excellent co-supervision and wait it out.

Over the course of the next two years of analysis, the patient languished in the details of how he suffered from a rare, systemic disease diagnosed when he was a little boy. Just before a flare-up, a severe rash would break out over his torso. I also learned that Octavian had not lied about his sister’s having directed him to my office. His biographical narrative circled back to the physical illness, but he did not have any of the hallmarks of addiction or body dysmorphia. As siblings only a year apart, he and Clemence were competitive but uncommonly close, still speaking frequently; by his account, Clemence knew him better than anyone, including his wife. A shared aspect of their youth was the ongoing rounds to various specialists for diagnosis and ensuing painful treatments of the mysterious ailment. Octavian and Clemence were accompanied by their live-in nanny to these appointments, which interfered with after-school activities throughout latency and middle school; he said he felt guilty because due to his malady he got so much more attention than she did. Like her brother, Clemence had a career that often placed her in the public eye, and she made the insightful link that in adulthood Octavian’s physical problems became worse whenever he was inspired by a new project that would require “an appearance that puts you right in the center of things.”

Octavian’s secret emerged when a family crisis occurred. His youngest son, Geoff, age nine, developed a severe case of psoriasis. The plaques, spread over the youngster’s arms and legs, became stigmata that kept him from socializing, and the scabs that resulted from scratching and picking made him something of a pariah at school. This once lively, physically agile, and socially adept youngster now refused to go outside to play and pleaded to be homeschooled.

Given Octavian’s kneejerk resistance to reflection on emotional and physical states such as crying, I added a didactic statement to an interpretation. I told him the skin is a reactive bodily system that often signals psychological conflict or buried trauma. Perhaps father and son shared a biological or genetic vulnerability, or a family concern was lurking that was too much for Geoff to bear alone. I told Octavian that he and his wife should actively inquire about what Geoff might be experiencing that, even if not psychological in origin, was causing him emotional strain. I went so far as to say I wondered whether Geoff might know something about the family that he thought he couldn’t or shouldn’t openly share with them. I linked this statement to the fact that Octavian shut me out for over half of every session; I told him I suspected that Geoff might feel similarly isolated and perplexed. Much to my astonishment, Octavian did not falter this time. “That may be true,” he said. “It’s time to tell you. I am a man but I am also a woman. I am both. My wife knows about it. Clemence has known about it since we were kids. I am sure my older kids get it, too, although we never discuss it as a family. I tried to talk about it with the other analysts, but I just couldn’t let it out. Clemence felt I might have a better shot at talking about the ‘female me’ to someone out of town. She read somewhere that you have an interest in the mind and the body. Next time I come to your office, I might be able to finally talk to you like I’ve always wanted to—as both man and woman.”

This revelation led me to reconsider the cause of my long-standing restlessness and disquietude as an embodied countertransference reaction. At first I was not at all sure what I had heard, and it took time to draw any conclusions. Could I really be sure of what I had just heard after having formed, over many months of analytic treatment, a nuanced yet quite definite set of perceptions about Octavian as male? Such revelations are meant to shock, to throw the other person off balance, unable to think. They also, at least momentarily, give the secret-keeper a pass on any shame or guilt as the analyst begins to register in consciousness and attempt to pull together threads of the patient’s individuality heretofore unseen and unheard. Octavian’s pitch that he was finally going to speak as both “man and woman” at the end of his soliloquy came with perceptible relief, suggesting that his moment of narcissistic disequilibrium had been swept aside; an audible gulp could be heard over the phone from miles away. I, on the other hand, was left with self-inquiries similar to those Bok (1983), Ehrlich (2013), and Petrucelli (2010) found in their deconstruction of collusive, withheld, dissociated, or otherwise split-off secrets. What did I miss that now took me by surprise, and why did I miss it? The congeries of negative transference implications (of being called out as an expert on the body who had totally missed a prototypical female gender identity all this while) did not wash well. Revelation of the secret created, via projective identification, the occasion for me to experience the shame once housed in the body of my patient, another feature of somatic countertransference.

Other silent queries gradually came to mind: Why did the patient decide to bring this issue into the treatment at this moment? (Petrucelli 2010). Were there subtle shifts in the transference/countertransference mix that had nothing to do with the patient’s anxiety about his son’s illness that allowed his secret to be spoken out loud? (Jacobs 1980, 1987). And, now that new information entered the analysis, what would change between us that could further Octavian’s treatment and assist consolidation of his sense of self? (Adelson 1998; Avery 1982–1983; Gross 1951). A pertinent clinical fact could not be ignored. Attaining psychic equilibrium and the capacity to think a few days after the discombobulating, deflating declaration, my body was considerably less reactive in the sessions. Anxious squirming and adventitious movements gave way to a more relaxed state of being as I eased up and turned down the speakerphone. Unceremoniously, a sense of safety enfolded us. These embodied countertransference phenomena were the first signs that we may have weathered an impasse and that greater mind-body integration might now occur within analytic reverie (Ferrari 2004; Lombardi 2008a,b).

Unsurprisingly, Octavian had little immediately to say over the phone or at our next vis-à-vis session, a few weeks after the revelation. I was nonplused by his casual dismissals that “yes, a plank, something in the way” had been removed as I challenged his defense of having no understanding of the timing, meaning, or impact on either of us of his confession; moreover, there was no dramatic change in his demeanor or any natural dialogue that might otherwise announce that we were now speaking together “woman to woman.” For weeks I endured his repetitive narration, until I could barely contain my annoyance. Then, in a face-to-face session before he returned home and resumed phone sessions, new details finally surfaced, leaving us both with much to ponder. According to Octavian, he heard “some real worry . . . maybe it was your breathing . . . when I told you over the phone about what was going on with Geoff. . . . It was real though . . . then you as much as told me that my wife and I had to talk to him. . . . You can be firm but this was different. You meant business. My parents never once—never once—sat down and talked about what was going on with the doctors, although I did know they cared. They sent me to them with Clemence and Nanny.” By the fortuitous but sad breakout of Geoff’s skin disorder, the analytic relationship, with Octavian’s mind/body relationship consolidating, now moved on from my bearing his inaudible gasps and anguished weeping. He had entirely stopped crying midway through sessions.

Over time I formulated that as a boy Octavian unconsciously attempted to peel off his masculine self by means of the psoriasis, so that the female self might breathe and be seen; the illness—intermittent, mysterious, and painful—mirrored in all these respects Octavian’s recognition that he inhabited a male and a female self (Kubie 1974).2 This female self clamored for life but did not wish to extinguish the male self. The ministrations of medical professionals, though well intended, were paltry balm and did little to help these two selves live in harmony. Neither did Octavian experience his primary caretakers as present, available, and interested in understanding him. Before he achieved the capacity for abstract thinking and could lay claim to the benefits of Western culture (such as a library) to learn that others have struggled with gender identity, Octavian felt alone save for his relationship with Clemence, who kept his secret for years. The siblings essentially raised themselves with the help of their nanny. The lack of parental attunement that Octavian remembered from latency age likely had roots in infancy, perpetuating an enduring sense of void and loss of connection; the decades of secret-keeping with Clemence sustained a private, alternative life narrative wherein the two subjectivities held and housed Octavian’s male and female selves, thereby co-creating an intersubjective third on the conscious-unconscious continuum (Benjamin 2004; Kieffer 2007; Ginot 2015).

Geoff, on the other hand, developed a skin condition that signaled to the outer world an altogether different psychological situation. The raw, unmetabolized feelings of maintaining a family secret took a toll on his body and every area of his life. Pressure to stay silent about what was considered unspeakable led father and son at the same period in their developmental history to make psychological use of their bodies to contain powerfully affect-laden self-experience, all the while navigating as best they could a sense of themselves as pariahs. Aspects of my countertransference experience of restless inertia, twitching, and despair in the analysis, I believe, were brought on by Octavian’s successful deposit of fragments of himself into my psychosoma—visceral, nonverbal psychic pain too threatening to allow into the analysis or be spoken about until this moment. In retrospect, my embodied countertransference reaction served as a signal and fragile container for the tension and distress Octavian had earlier released by sobbing while maintaining his secret.

Bion’s concept of normal projective identification of penetration into the maternal mind and body cavity (1962, 1963) offers a way of understanding my somatic reaction: Octavian’s physically evacuated beta elements into my maternal container, bits that went unmetabolized (and hence unmentalized and unspoken) by his primary caretakers, were likely rendered in part thinkable by his attuned and emotionally resonant sister. Their physical proximity and shared subjectivities as siblings likely saved Octavian from more severe ego disintegration; Clemence came to realize that both she and her brother might benefit if his mental life were in part turned over to a person (i.e., a psychoanalyst) who would not be deterred from psychologically working with the corporeally experienced secret of being simultaneously male and female. The sequence of interventions from my nonverbal breathing acceleration to the actual confrontation regarding Geoff’s state of mind and body announced an unconscious shift in the transference/countertransference matrix, in which Octavian felt safer to express his long withheld emotional and physical sensations to a newly imagined, co-created parental presence.

Octavian’s terror at releasing his self-knowledge into the maternal container of the analysis had to be repeatedly tested; his breakdowns, followed by pleas to withhold inquiry, were both cathartic and aggressively exploratory: Would I be frightened by the intensity of his affect and what lay beneath it? In addition to the welcoming and receptive attitude akin to the mother’s capacity for reverie, as elaborated by Bion (Ferrari 2004; Lombardi 2008a; Miller 2001), the analyst who hears a secret must find verbal and nonverbal ways of signaling to the patient that the material has registered and he will not be abandoned as he projects outwardly, particularly facets of his aggression, negative transference, and somatically expressed needfulness. Although guilt and shame had rendered Octavian virtually helpless until this moment in our relationship, a new level of narrative biographical synthesis could now begin as the embodied memories of harboring male and female self states were brought to fuller consciousness in a manner that made his life more bearable.

Phineas: “I’ve Said It Before . . . Just Not This Part of It”

Phineas, age thirty-one, appeared to be nearing the end of what seemed to both of us a moderately successful analysis of five years. When Phineas entered treatment he was grappling with the terminal illness of his wealthy father and had put career plans on hold in order to care for him. Soon after the treatment began, the father died, after which the patient struggled to complete requirements to enter dental school despite excellent grades and professional references. After what seemed an interminable period of working through conflicts related to success neurosis, Phineas decided to become engaged to Renee, his long-time girlfriend; at about the same time, he was admitted to a prestigious dental school on the East Coast. Though an official date had not been set, we both knew termination was in the offing. Phineas was already preparating to move, having placed his condominium on the market. He and Renee had planned a vacation to the university town where they would relocate and marry within the year.

Separation from significant women had been a central dynamic for Phineas that came to light early in our work together. Feelings of abandonment and attempts to minimize a catastrophic fantasy of being left surfaced around vacation breaks or when significant steps were contemplated. Expecting that these issues, which we had worked through to a degree, might resurface with the anticipated move, I began to interpret the ensuing loss of the analysis before weekend breaks and when dream and fantasy material seemed to indicate the dynamic. Seemingly out of the blue, Phineas began to complain of insomnia. This usually lively patient fell silent on the couch and appeared to hold motionless vigil. He said he got headaches when he reclined and claimed that nothing was coming to mind. He had never had sleepless nights before and worried about the wakefulness. Meanwhile, I found myself sleepy in his sessions and fought hard some days not to doze off.

Feeling shut out by Phineas in a new and disturbing way, I made stabs at interpreting what might be going on between us. They went absolutely nowhere. I began to wonder if Phineas’s rigid, lifeless posture on the couch was an enactment of some aspect of unmourned loss of his father, intersubjectively shared between us but not yet touched on despite the time we had spent processing his father’s death. Might both analyst and patient be shut down and mutually influencing each other rather than risk delving more deeply into a loss that had been painful, dysregulating, and developmentally profound? I registered that my own father had died just a few years before I began the treatment with Phineas, a fact that lent credence to the avoidance, embodied simulation, and enacted unconscious (Ginot 2015; Leuzinger-Bohleber 2018a) I had hypothesized as underlying our synchronicity in the motor and verbal realms.

Phineas’s mother had been riddled with psychosomatic complaints for much of her life. He felt she ignored him and his older sister, Rose, a brilliant scholar who went on to become a literature professor. Phineas credited their devoted, nurturing father for his having had a reasonably happy childhood even though, from his point of view, “Mother’s well-being always came first. My father doted on her like she was a baby.” His having reclaimed this central dynamic of the analysis, I wondered if he was shutting me out with his silence, just as he had felt shut out, the insomnia an identification with his mother that he needed me to more fully experience before taking his leave. I interpreted that I thought he was trying to blow me off by going silent, just as he had felt blown off and ignored as a boy, especially when he was about to be promoted to a new grade or had something special happen to him. The insomnia and headaches were unconsciously designed to sap his vitality and keep him in an emotional cocoon; neither of us was supposed to feel that anything in the analysis was sticking or worthwhile. As much as these interventions appeared to make sense based on previous work, Phineas remained remote and silent, except to tell me that Renee was getting fed up with his nightly pacing and ruminative thinking; she felt that he needed medication and that the analysis was making him worse when she wanted him to start packing up and get ready for their impending move.

For much of the analysis Renee was a cipher into whom Phineas attempted to displace the negative transference. He reported that she was critical of the time, energy, and money he was spending on the analysis. I attempted to maintain neutrality by bringing my patient back to how he felt he needed to protect me from his anger and disappointment, as he was expected to do with his mother. While I interpreted the repetition compulsion of what had been sacrificed and split off to carve out an existence with his eternally ailing mother, the truth of the matter is that I was never fond of Renee, from the day she took her place on the analytic stage. Phineas reported that he felt he could not please her and, in a rather typical concordant countertransference, I felt the same. Now she returned in this late phase with a vengeance; I was left in silence to struggle with my feelings about his choice of a life partner.

Meanwhile I noticed that I began to associate in sessions to family vacations Phineas had taken with his parents when he and Rose were children, memories he had not brought up in analysis for several years. These were some of the best memories of his childhood. Early in our work I found myself romanticizing these travels and had to confront Phineas’s idealization to help him toward a more integrated self-experience. Now my reaction was different—I experienced sorrow and loneliness. According to Phineas, his mother always did better when they were away from home. Largely because of the father’s job, the family had the opportunity to explore much of North and South America. Associating to a hiking trip they had taken in Patagonia when Phineas was fourteen, I thought to myself that it was good that he “now had a sibling like Rose” in his life. I caught my silent parapraxis immediately and tried to ignore it. As much as this might seem like a natural glitch of a brain in middle age, in truth it was going to be Renee—and not Rose or me—who would accompany Phineas on the next stage of his life’s journey. I had transposed Renee with Rose in my thoughts, and the harder I tried to override my slip, the more the question lingered as to why this would happen at this moment. Oddly, waves of nausea and vertigo suddenly swept over my body; I felt I might have to stop the session. In a speculative leap that served the additional purpose of settling my stomach, I asked Phineas to tell me again about the Patagonia trip and if he recalled anything in particular about it.

He complied and then, in a blasé manner, said that this was the time he and his mother had the “special talk,” one he would never forget, though he wished he could. Still fighting the nausea, I told Phineas that I did not recall the “special talk” he referenced and apologized for my lapse. “No need,” he said. “I don’t think I ever told you the particulars about what happened there. We’ve talked many times about how I sensed that my mother never really wanted a daughter. But it was by Lake Traful that she told me the particulars. She and my father had been drinking that night. She needed to take a walk to get ‘some of it out’ of her system, and my father asked me to go with her to make sure she got back to the lodge. As we crossed over a small stream on our way, she told me to sit down. Right there she said that she had always wanted a boy but two kids were just too much for her. Wow! She ‘got it out of her system’ all right. She told me I could never tell anyone. I should ‘just forget this conversation’ when we got back to the lodge. Her pregnancy with Rose had made her sick. She never got over it.”

I believe that the nausea, vertigo, and dyspepsia I experienced are further examples of somatic countertransference phenomena that may signal to the analyst that she has stumbled upon a significant historical moment for the patient, one that had lain dormant in the midst of otherwise rich and productive narrative development in the analysis. Integrating Heinrich Racker’s classic concept of concordant and complementary identification (1957) with that of embodiment within the analyst, I would say my concordant bodily countertransference came about by Phineas’s projecting into me his disgust, anger, and anxiety about his mother and the withheld secret. On the other hand, my complementary somatic countertransference reactions reflected the split-off aggression he harbored toward Renee and his mother—his inability to process in words the admixture of feelings about the secret he held for his mother concerning his unwanted sister. Perhaps he had even induced in me a concrete experience of morning sickness, the beginning labor pains, and indigestion—embodied countertransference phenomena of pregnancy similar to phenomena noted recently by Leuzinger-Bohleber (2015b; Leuzinger-Bohleber and Teising 2012).

I found myself formulating that an uncanny confluence of events and unresolved dynamic issues had led to this timing. As the analysis neared its close, Phineas and I had the developmental task of bringing forth the viable analytic baby while propelling him on to the next stage in his development. This task would be aborted if he did not find a way to tell me about the long-concealed burden he carried—a burden that needed to be spoken and mourned. The oedipal enactment we engaged in, tendered by my embodied countertransference, placed both of us in the fantasy roles of being healthier parents to Rose and the younger Phineas, who would “welcome” both children as separate human beings and willingly undertake the responsibility of parenting without psychosomatic collapse. The induction and experience of embodied countertransference in this context take on the meaning of a transference query: Can my analyst face, know, and withstand the pain of my psychological birth and leaving her? Will she turn to me for support (as my mother did) at the cost of my emancipation? My indigestion may also have reflected Renee’s experience, projected into my body via Phineas; she frequently told him she “was just plain sick” of hearing about his analysis. I certainly found myself entertaining similar thoughts about her complaints.

Such somatic countertransference reactions are not new phenomena but lately have received greater attention in the literature (Zerbe 1995, 1998; Gubb 2014). They require that the analyst ultimately speculate about their meaning in the transference, but in the immediate moment it is enough to try to hold on to them and not sweep them away in a rush to nullification. “I personally do my work very much from the body-ego, so to speak,” Winnicott wrote (1960, p. 161), while emphasizing the importance of the analyst’s slowing down in order to examine and understand specific feeling states before an interpretation is verbalized. As Miller (2001) further explains, the free-floating attention of psychoanalysis leads to “more bodily availability and permeability . . . that give rise to temporary psychical experiences that are on the verge of hallucination, enactment, or somatization” (p. 67) for both patient and analyst. He advises great patience on the analyst’s part to tolerate these strange phenomena to give the patient a sense of security that sets up “the basic conditions, the stimuli towards life that enable mental life to emerge” (p. 69).

Phineas’s secret emerged on its own timing, as secrets always do, leading me to examine my own bodily reactions for clues, to risk becoming bored for long periods, and to dial back any therapeutic zeal to bring closure through verbal intervention, particularly when talk of ending is on the table. Better to terminate knowing more needs to be done in the future, likely with another analyst, than to provide soil for more secrets to take root by way of saying too much, thereby repeating the trauma to the patient, who had been forced to listen to and contain so many of his parents’ thoughts, split-off feelings, and somatic reactivity. Yet, as our work together came to a close, the release of this preconscious secret helped us grapple further with the anxiety Phineas had always experienced when separated from significant women in his life. This anxiety had the defensive function of staving off the unconscious anger (Zetzel 1970) he held toward his sister and mother, whom he felt beholden to protect or to mollify. That anger could now be spoken and tolerated in the transference (Krystal 1975), and that led him to undertake further analysis in the city he was moving to. There he would continue to work through its lifelong stultifying effect on his relationships and creativity.