Reflections on Therapeutic Action and the Origins of Psychic Life

Working at the Limits of Analyzability and the Foundations of Human Relatedness

Although psychoanalysis remains a “talking cure,” most analysts today recognize that the work of the analytic process goes beyond the semantic meanings of ideas communicated by interpretation. In addition to information exchanged via language-based communications, complex nonverbal factors—bodily states, emotions, and actions—are involved (see Levine 2019). These take place unconsciously—individually, inter-affectively, intersubjectively—and can only intermittently be tracked in an approximate and provisional sense, usually in retrospect.

A corollary to this recognition is that the semantic, word-based meaning of the patient’s associations and the analyst’s interventions, especially when working with non-neurotic patients or those moments dominated by the non-neurotic portions of the mind, are not necessarily the whole—or even most important part—of the story. Hence, various psychoanalytic theories may talk of the evacuative, “doing-to” or other performative components of speech as act. The latter may be especially important when working with autistic patients and autistic nuclei and defenses.

Alvarez (2010), for example, describes three levels of analytic work: explanation of meaning; ascription or amplification of meaning; and reclamation of meaning. The last seems most analogous and therefore relevant to the question of psychic origins, because it is required in situations where the patient is severely “withdrawn” or “undrawn,” because of maternal object failure (e.g., Green’s “dead mother” [1980]) and/or constitutional factors (e.g., biologically determined autism).

Since Alvarez derives her theory in part from Klein, Bion, and Tustin, her Kleinian roots often lead her to formulate her theory in terms of unconscious phantasies concerning internal objects and the relations between them. Thus, she reminds us that “what is at stake is not simply a weak ego, or even major defects in the sense of self; it is a matter of defects both in self and internal object, where both are experienced as dead and empty or useless. There is often a chronic apathy about relating which goes beyond despair. Nothing is expected” (Alvarez 2010, p. 865).

The latter account reads like a theory of presences: phantasies involving specific representations of dead, empty, or useless objects. And yet, when considering autism, Alvarez’s theory also approaches a formulation of deficit rather than conflict, a theory of absences, which may reflect the patient’s failure to possess or develop the capacity to represent or create three-dimensional internal objects of any kind. ⁶ Thus, the “desertification” Alverez (2010) encountered in her autistic patient, Robbie, may well have reflected a “blank space” due to constitutional factors or object failure rather than the internalization of a dead or unhelpful object. It was the desertification that elicited “a powerful countertransference sense of urgency” in the analyst that she suggests “may be an extreme form of the mother’s normal activity of awakening and alerting the normal, mildly depressed, or distracted infant” (p. 865).

This “awakening,” which is an inter-affective “priming of the pump” of psychic development, can be assumed to be essential from the first moments of extrauterine contact and care—if not even earlier, during intrauterine life—in building the framework for the development of psychic functioning and in initiating the origins of psychic life. This process of exchange involves the combination of the infant’s perception, satisfaction or gratification, tension reduction, registration of affect of self and object, and the internal representation that will memorialize for the infant and mark the fact and emotional quality of the event.

As with the neonate, so too with the withdrawn or “undrawn,” autistic or autistically encapsulated child or adult patient: helplessness, absence of autonomous regulatory capacity, and various signs of distress may evoke a sense of urgency in the feelings of the analyst (countertransference) that mobilizes the analyst and presses for an active response. This may result in—and require—not only interpretive descriptive attention to the patient’s state of rising discomfort, withdrawal, and despair, but a spontaneous insertion of affect or other act of reclamation needed to awaken and enliven the patient and make contact.

As I hope to illustrate in the clinical example that follows, when we are working at the extreme limits of what is reclaimable and analyzable, it is the affectively imbued action supplied by the analyst that is often a necessary stimulus for the patient’s affective recognition of the analyst’s emotional presence as object. The analyst’s affect and action are needed to awaken and enliven the patient and serve as a stimulus to the patient’s intersubjectively derived or autonomously produced psychic functioning, eventuating in more meaningful and robust psychic activity, representations, and engagement in life.

In the case of Robbie, an autistic boy who “seemed more undrawn than withdrawn, more lost than hiding,” a boy “whose passivity was not the result of a defensive retreat . . . he had given up rather than turned away.” Alvarez (2010) concluded that “receptive containment of a too passive nature seemed not to be helping him. . . . I despaired for years about how I was to become dense enough, substantial enough, condensed enough to attract his attention and concentrate his extremely flaccid mind” (p. 873).

What was needed was a kind of analytically informed, spontaneous, intuitive affect and action that included Alvarez’s noticing Robbie’s withdrawal and intervening by up-regulating his affect. This proved successful in “priming the pump” of his stalled or perhaps unassembled psychic apparatus, recalling Robbie “both to himself and to the human family . . . [involving] a kind of awakening from autism or life-long dissociation—or both” (p. 873).

As Alvarez concluded, “It is not easy to strike a balance between being too intense and therefore intrusive, and being experienced as too remote or too weak. Yet long before certain patients process their hatred and find their capacity for love, they may have to develop the ability to be interested in an object with some substantiality and life. Something and someone has to matter. This is work at the very foundation of human relatedness. . . . Once this is achieved, the work can move to higher levels, sometimes in the course of a single session” (p. 875).

Alvarez’s comments are reminiscent of a remark made by Green (2005): “Sometimes, paradoxically, it will be less damaging to the process to allow a lively countertransference reaction to be expressed, even if negative, in order to gain access to the internal movements animating the analyst. These are all evidence of . . . spontaneity . . . having more value for the patient than a conventional pseudo-tolerant discourse which will be experienced by the patient as artificial and governed by technical manuals” (p. 35). They also resonate with Roussillon’s description (2011) of the “signal function of the drive” and the object’s need to recognize, accept, and respond to that signal, so as not to have it weaken and languish to the point of extinction. They resonate too with Patrick Miller’s discussion (2015) of the work of Auglanier, whom Miller describes as exhibiting a “relentless endeavor to deepen and enlarge Freud’s metapsychology in order to forge representations of the origins of psychic life . . . [to] help us better understand what psychotic patients need . . . to come to terms with the “blancs” (blank spots) in their early development” (p. 1357).

What Miller also emphasizes in the earliest infant-mother interaction that is foundational for the origins of the psyche is that the infant absorbs not just “a physical element, but . . . an element of information coming from the senses” (p. 1358; emphasis added). That information includes a quantity and quality of emotion, pleasure or unpleasure, belonging to the object that is experienced during the first relational interactions. And although the assumption is that self and object are not yet discernible in the infant’s experience as separate, the affect that the infant experiences is a combination of the affect produced and felt by the mother’s psyche as well as the infant’s soma. Thus, Miller (2015) writes, “Meaning is conveyed and constructed through the quality of shared bodily experiences within a topography implying the blurring of body boundaries. The mother’s past, her libidinal history, her unconscious motives are transmitted first through the non-semantic way in which she bodily responds to her infant’s needs” (p. 1366).

In this way, the “shadow of the object,” including the quality of the mother’s emotional presence, is conveyed to the infant and becomes inextricably entwined in the initial development of the infant’s psyche and self. What I wish to emphasize is that in addition to the more usually recognized and vitally important issues of maternal physical care and emotional receptivity, the matter of maternal responsiveness, pleasure or displeasure, and vitality, is also crucial and joins with the infant’s own response in qualifying the inscriptions and representations produced by these earliest interactions. ⁷ This dynamic—or its later analogue—is repeated endlessly in the analytic situation and is the explanation and driving force behind the power of construction, here-and-now transference analysis, and the work of après-coup.

Case Example

Thomas, a tall, thin man in his mid-twenties, contacted me just before returning to school to resume his sophomore year pursuant to his university’s readmission requirements. Four or five years earlier, he had stopped going to classes and dropped out of school. He had had some analytic therapy in the intervening years, tried medications with limited success, worked in a desultory and unsatisfied fashion at a low-level job in a family business, and was now ready to try returning to school.

In our first interviews and throughout most of his first year in thrice-weekly analysis on the couch, Thomas dressed poorly in torn t-shirts, jeans, and sandals, was barely audible, and spoke endlessly about his fatigue, trouble establishing a basic routine of personal hygiene, doing laundry, grocery shopping, and the like, and difficulties regulating his sleep and eating patterns. His speech was relatively two-dimensional and flat and often evoked very little associational response. Although Thomas had been readmitted to college, he had neglected to register for courses or arrange living accommodations. So in effect he presented as “unregistered,” isolated (the few friends he had made in his first year of college had all graduated and left the area), and virtually homeless. A good deal of our first sessions was spent with my “noticing” and talking with him about his situation, until he completed the necessary administrative arrangements and became somewhat settled.

Thomas did not easily associate to a meaningful life history and could not generate a cause-and-effect narrative of his immediate circumstances or of what had led to his flunking out of school. To what extent was this repression, suppression, defense, or a weakness or absence of representation and an incapacity to produce and link thoughts into emotionally meaningful narratives?

The story that slowly emerged was that of divorced parents, whom he referred to by their first names rather than as Mom and Dad and who he felt were remote, self-involved, and inadequate as parents, paying him little attention and giving little credence to his needs. He had an emotionally disturbed, dyslexic older brother, who could not adapt socially to schoolmates and so was home-schooled by their mother when Thomas was about to enter third grade.

At that point, Thomas too was removed from school and placed in home schooling, “for the convenience of Michelle” (his mother), he bitterly told me. Eventually I was able to inquire about and suggest to him that this removal isolated him from peers at a crucial period of his life—he did not have play dates or otherwise keep in touch with his friends from school—and contributed to his withdrawal and asocial tendencies, which included sleeping all day and staying up all night playing fantasy games on his computer. However, while such interpretations made sense to me, they seemed to mean little to Thomas, and he did not elaborate on them in a more enlivened way or use them to deepen the analytic process.

A surprising feature of the first year of our work together was that Thomas was diligent about keeping appointments and always ended with a handshake. I did not comment on this, but noticed and silently wondered if he needed the concrete connection of physical touch to reaffirm something of our existence and contact; to know or signal that each of us was there.

In the first year, of course, I tried to talk with him analytically about many things, including his fear that he was really not ready to resume school, his shame at being a much older student who had previously failed, and his isolation, disappointment, and bitter anger at his parents that seemed to extend to everyone and everything. Nothing seemed attractive or of real interest to him. While these interventions seemed to follow from the flow of his discourse, they did not seem to be of use to him and did not seem to deepen the process.

But I also sometimes took a more active role, when I felt he needed some concrete input or signs of being noticed and taken to be of interest by me as a potential object. For example, when his father was coming to town for a business meeting and expecting to spend the night in Thomas’s dorm room—this would have displaced Thomas to an air mattress on the floor and disrupted his study schedule during exam week—I responded to Thomas’s complaints (and my building countertransference irritation) by short-circuiting the more usual and expectable analytic exploration of his passivity, feelings, and possible denial of anger and suggested he think about why he wasn’t telling his father that this was not a convenient plan. Thomas responded by confronting his father, and other, more adaptive arrangements were made.

Initially, ours was a very slow-going, deadened analytic encounter, and I dealt in part with my restlessness or impatience with the thought that whatever else his dull recitation of sleep patterns, missed meals, unbrushed teeth, etc. might contain or imply in more classically defensive or object-relational terms—e.g., acting out his sense of worthlessness, identification with parental neglect, masochistic self-punishment, attacking his parents for their neglect—he was describing trying and slowly succeeding in working out a better connection to his neglected body and working to some extent on repairing a form of body-mind dissociation (Lombardi 2017). That is, in response to my noticing and attending, Thomas was noticing and attending to the fact of his own existence through recognition of basic bodily needs and functions.

One “fact” that persisted throughout this first year was his claim that no one at the university “interested him” or was worth trying to make friends with or hanging out with. Nothing in Boston was interesting enough to get him to leave his room. I say “fact,” because “complaint” would imply that Thomas might hope, want, or expect it to be otherwise. Although not constitutionally autistic like Alvarez’s Robbie, Thomas seemed to have given up or else had collapsed into a miasmic state of withdrawal. Was he, perhaps, avoiding trying to make contact with anyone or anything because he was so used to disappointment that he didn’t believe anything else was possible for him and he didn’t want to face further disappointment, or had he simply given up on life and people in exhaustion and defeat?

Much to my surprise, despite the seeming emptiness of his life, inner and outer, Thomas passed his courses in his first semester and made dean’s list in his second. As he prepared for his summer break and return to his mother’s home out west—which did not include mentioning or feeling very much about the interruption of treatment and our relationship—he began to lament the fact that he would be isolated in a suburb without public transportation or his car, which he was leaving behind at school. I felt that this isolation would be a potential setback. He had begun to become interested in and excelled in one course, had been offered and accepted a small job doing research the next fall by that course’s professor, and begun a project with a classmate, and for the first time expressed looking forward to working with someone.

Feeling some urgency at the possibility of Thomas’s losing whatever small progress he had made, I expressed with surprise that he had not made plans ahead of time for something to do over the summer. I asked why, if he had driven across the country to school and was concerned about being shut in and isolated without his car over the summer, he wasn’t driving it back home. As I did so, I had the image of a shoehorn levering a foot into a shoe and the thought of pushing a baby bird out of its nest so that it might begin to fly. He began to tell me about the trip east, how he had slept in his car, or in a sleeping bag under the stars, how it reminded him of camping out alone and on his own, and how much he had once enjoyed that.

Somehow, this exchange sparked more positive feelings and a rush of associational life in me, as it brought to my mind memories of my own backcountry adventures out west. And I spontaneously asked if he had ever seen the big parks. He hadn’t, and I suggested that maybe, if he wanted to and felt comfortable, this could be an opportunity to take a more leisurely drive across country and visit some of them. He came back two days later, and there was a palpable shift in his mood. He reported feeling excited and had done some research. He had downloaded and studied auto routes and hiking maps and decided that he would do it. Along with the decision to refuse his father, his beginning interest in the school course, and the project with a fellow student, this was one of the few manifest “signs of life” of our first year’s work.

While it cannot be concretely demonstrated or “proven,” what I wish to suggest is that the work with Thomas went on at multiple levels, one of which involved the inter-affectivity of our object relationship. That is, his desertification and need mobilized some urgency and alarm in my mind, spurred me into action, and led me to the proactive intervention about his car. Thomas’s response included associations about sleeping under the stars, and these then triggered a cascade of memories and feelings in me about my own backcountry travels. For a moment, my own endless—and often seemingly fruitless—“trekking in the desert of Thomas’s analysis” was transformed in my mind (surely reactively and defensively, as well as affirmatively) into the memory of camping with friends and more pleasant associations of hiking in the American West. The fact that backcountry hiking was such a pleasurable memory for me must in some way have been communicated to Thomas in the emotion, cadence, music, and tone of how I said what I said to him when I suggested he think about seeing the parks.

This surge of positive emotion in me seemed to have enlivened something in him. My hypothesis is that it was not just the semantic content of my intervention, the reasonableness of the idea of relying on his own car, but the concomitant emotions with which it came that helped jumpstart something in Thomas that in the larger context of our relationship and history took hold. That this was analogous to the Miller/Aulangier description of the need for the interested and pleasurable, emotional presence of the object that is presumed to unite with the infant’s own somatic pleasure at being noticed, responded to, satisfied, and cared for, in the process of creating and marking the first psychic representations.

Events in the second year of our work followed a similar trajectory where the affective presence of my interventions and interactions rather than their “analytic meaning” as content seemed to be key in providing a spark for orienting Thomas back to vitality and engagement with objects, the world, and his own desires. Like the concrete warmth and touch of the handshake at the beginning and end of our sessions, the emotional quality and presence of my interventions seemed to be just as important as the content of what was said, and often more so.

By the second year of our work together, Thomas was a more enlivened and engaged patient. His speech was more discernible and emotionally inflected, his routine had become more regularized, and he had even begun to date a girl he found interesting and attractive. He still had a tendency to lose track of himself and lapse into states of deep withdrawal, but our exchanges held more associational resonance and our work turned a bit more traditionally to the exploration of the cause-and-effect, object-relational, and emotional determinants of his ups and downs. For my part, however, I continued to allow my feelings to silently play free, as I paid attention to what I felt at times was the need for me to affectively establish my presence as a noticing and involved object, allowing myself to use intuition, affect, curiosity, and humor as accompaniments of my analytic inquiry and interpretive presence. That is, I was aware of the need to be sure I was for Thomas, as Alvarez said she was in relation to Robbie, “dense enough, substantial enough, condensed enough to attract his attention and concentrate his extremely flaccid mind.”

Of course, unlike Robbie, Thomas was not autistic. But he was deeply disillusioned and withdrawn, and what seemed required to reach and restart his emotional engagement in life was similar. This was not work at the literal origins of the psyche, but I believe the metaphor of what was needed and what was useful proved apt.

Further Considerations

In Learning from Experience, Bion (1962) asserted: “The problem presented by the psycho-analytic experience is the lack of any adequate terminology to describe it” (pp. 67–68). His later work underlined his belief that “the human mind does not operate through predictable relations, such as that of [linear] cause and effect, but through nonlinear processes of growing complexity” (Bergstein 2019, p. 3) and that the subjects of psychoanalytic inquiry—psychic reality, the emotions, psychic states, and the contents and forces of the unconscious mind—are not easily or directly accessible via the data of the senses. ⁸

There is an uncertainty inherent in the infinite complexity of human development and personal relations that renders emotional truth fleeting: transient and always in transit (Bergstein 2019, p. 4). ⁹ Following in a long epistemological tradition that includes Plato, Kant, and Hume, Bion’s explication (1970) of the domains of O (raw existential Experience) and K (the subset of O that can come to be known) underlined the extent to which our comprehension of the phenomena and movements of psychic reality inevitably remains limited. Consequently, efforts to report or describe the experience of the psychoanalytic process, such as I have attempted to convey in this paper, and the claims of psychoanalytic theories in general, inevitably challenge and may appear to fall short of our everyday views of causality and evidence. The latter are limited by and appear in a context of the three-dimensional perspective to which human consciousness is restricted, while the realm of psychic reality and the unconscious, especially the unrepresented, unrepressed, and inaccessible unconscious, is multidimensional, perhaps infinitely dimensional (Bion 1970; Bergstein 2019).

Added to this fundamental limitation in the extent to which any of us may be able to come to know the domain of the psyche is an all-too-human foible shared by all of us. We tend to hate any limitations in what we can know and so create “explanations” that attempt to negate and deny the painful fact of our ignorance.

In his Tavistock seminars, Bion (2005) put it this way:

when we are at a loss we invent something to fill the gap of our ignorance—this vast area of ignorance, of non-knowledge, in which we have to move. The more frightening the gap, the more terrifying it is to realize how utterly ignorant we are of even the most elementary and simplest requirements for survival, the more we are pressed from outside and inside to fill the gap. . . . in a situation where you feel completely lost . . . you are thankful to clutch hold of any system, anything whatever that is available on which to build a kind of structure. So from this point of view it seems to me that we could argue that the whole of psychoanalysis fills a long-felt want by being a vast Dionysiac system; since we don’t know what is there, we invent these theories and build this glorious structure that has no foundation in fact—or the only fact in which it has any foundation is our complete ignorance, our lack of capacity.

However, we hope that . . . psychoanalytic theories would remind you of real life at some point in the same way as a good novel or a good play would remind you of how human beings behave” [p. 2].

In this paper I have tried to show how over and above any content-related interpretations, the inter-affective, intersubjective responsiveness and vitality of the analyst seemed to play a key role in the reclamation (Alvarez 2010) and reanimation of a deeply withdrawn, perhaps regressively undrawn, desertified young man. The question of whether the kind of interventions described are analogous or identical to what has been proposed as essential environmental provision in the mother-infant relationship are moot and probably unanswerable.

So too, the relationship between inter-affective reclamation and activation of the psychic capacities for representation, symbolization, affective and associative linkage, and objectalization. The achievement and consolidation of each of these capacities have been described in numerous analytic theories as following from interactive, inter-affective, and/or intersubjective relational experiences with primary objects. Each has been indicated as playing some role in the lifelong process of binding excitation, both internal (e.g., drives and their derivatives) and external (e.g., perception and sensation) and making sense of and creating meaning from one’s own knowable experience. Bion’s description (1962, 1970) of alpha function and container/contained is but one of the many available theoretical formulations that attempt to put these processes into words.

In the case of Thomas, I would propose that the inter-affective and intersubjective stimulation afforded by the affect-laden memories that underlay my question and suggestion about visiting the parks—memories that were probably defensive and self-restorative for me in the face of Thomas’s barrenness and despair, as well as hopeful conveyors of my positive parental countertransference toward him—helped enliven Thomas and spark into action his own capacities for thinking, imagining, and dreaming. Once the “pump” of his psychic apparatus had been primed, his representational capacities could be said to have emerged or come back on line in the service of thinking through what a Western trip and access to a car at home over the summer might be like for him. This restored capacity for “thought as trial action,” a capacity heavily dependent on processes of representation and figurability, enabled him to do the research, think through the possibilities, and make the actual decision to follow up on my suggestion. I present this formulation with full knowledge that it is a working and, I believe, workable metaphor for what might take place and be helpful in an analytic interaction. As such, it is a construction or myth whose pragmatic value may or may not be apparent to clinicians who read this, depending on their personal experience. My hope, like that expressed in the long quote from Bion, is that my description may remind some of you of “real life” and of how humans behave, as a good play or novel might, and in so doing help you to negotiate a useful path in a future encounter with a patient.