Abstract
Levine’s short volume elucidates a psychoanalytic approach that is nothing less than a paradigm shift. The very nature of our psychoanalytic endeavor is recast in this collection of Levine’s writings, in that he directs our attention to the idea that much of psychic development can be understood by examining representation and its vicissitudes, and that attention to the functioning and dysfunctioning of the representational process is especially important in the treatment of patients whose difficulties lie beyond neurosis. He moves elegantly between models, referencing the classical metaphor of archeology but emphasizing a more contemporary metaphor of transformation/construction to represent the psychoanalytic work with non-neurotic patients. The primary focus in this book is on the patient who through developmental trauma, both episodic and cumulative, manifests weakness in psychical representation in such symptoms as affect storms, somatic illness, and structural failures in the capacity for thought.
The essays in this volume bring together the ideas of Bion, Green, Ferro, Winnicott, Alvarez, Aulagnier, the Paris Psychosomatic School, and several others to invite us to reimagine our work with non-neurotic patients. The early chapters follow the sweep of psychoanalytic thinking over the course of Levine’s professional life as an analyst, from a one-person to an intersubjective two-person psychology. At its heart, the central thesis is that our analytic work can attempt to strengthen or create psychic structure in patients in whom this structure is weak, missing or inoperative. This stands alongside and in contrast to the traditional therapeutic approach that involves uncovering the unconscious dimensions of suffering and closely examining the contents of conflict. He leads us to find the place “between the silence and the cry” and directs our attention to the movement from the preverbal, primal place of somatic sensations, through the primary process world of unconscious phantasy to secondary functioning of representational thinking. I first picked up this book to help me understand some of my patients more fully when my attempt to analyze unconscious conflict was not yielding results; for example, my severely eating disordered patient who was only able to communicate her pain through affect storms, restricting and purging food, suicidal attempts, and bodily disfigurement. Levine’s work calls for a turn of attention to helping the patient create and imbue the words with symbolic meanings so that associations could be formed in the first place. Levine calls this “weaving a patch” (p. 26).
The book is divided into 10 chapters plus an introduction. Levine has been a prolific writer over his professional years, and many of the ideas of the book find resonance in his earlier writings, particularly his work on trauma, unrepresented states, intersubjectivity, and the construction of meaning (e.g., see Levine 2009, 2012, 2014, 2016, 2018, 2021). Some readers may recognize aspects of the writings and case material. Unlike many who describe their work as intersubjective, Levine does not shy away from the concept of drive, although this is not explicit in the book. His work is grounded in Freudian metapsychology. Levine reminds us of Freud’s suggestion that a kernel of actual neurosis may underlie every neurotic conflict. Similarly, he leans on Freud’s (1937) paper “Constructions in Analysis” in asserting that some traumatic pathogenic events of childhood may never be able to be recalled to memory and that under certain conditions, an intuitive conjecture on the part of the analyst may stand in for the uncovering of a previously repressed memory.
Levine also leans on Freud in defining “representation.” Levine defines it thus: “‘Representations’ are organized, structured psychic entities that are potentially verbalizable as thoughts, ideas and images . . . the unification of word presentations and thing presentations” (p. 3). Despite a “representational imperative,” representation is not a given, but a developmental achievement “through which previously unbound and inchoate forces become bound and contained in the psyche” (p. 2). A major task of the human psyche is representation of the previously unrepresentable. Levine brings to us his basic assumption in the form of a question: “Is there experience, perhaps deriving from the soma, from the pre-verbal period of infancy or from traumatic states, that is inscribed . . . but not psychically represented?” (p. 19). Experience (with a capital E, to denote that it pertains to the as yet unrepresented) encompassing drive, affect, somatic sensation, and memory, involves incompleteness. Any stimulus, presence, thing that has the potential to produce an excitation needs to be bound or contained and can assume any number of possible ideational forms.
A cornerstone belief for Levine is that preverbal cumulative or massive psychic trauma leads to unsymbolized or weakly represented mental states. Drawing from the ideas of Winnicott, Bion, Green, and the Paris Psychosomatic School, Levine notes that traumatic disruptions of psychic organization can produce areas of psychic voids and other discontinuities. I find Levine’s definition of trauma extremely helpful: “the events to which we ultimately will refer to as ‘traumatic’ disrupt and disorganize the psychic processes through which meaning making occurs” (p. 97). Trauma is that which outstrips the psyche’s capacity for representation. That which cannot be represented, or thought about, or contained in the mind cannot enter into a reflective view of one’s history, and a helplessness follows from being overloaded with mental elements that cannot be contained and are fit only for denial, evacuation, somatization, or enactment. Levine notes that it is through the transference, with intersubjective assistance, that such states of helplessness can be articulated and a thought container can be built.
It is always fascinating to consider why an analyst is drawn to a particular area of study. Levine generously reveals his own theory about his early emotional loss—that he experienced a deadened, depressed mother after the death of her own mother when he was in his second year of life. What he has continuously been striving to recover and create is an aspect of self in addition to his early object loss. For him, object and self form an indissoluble pair. Arguably, Levine has always been searching for what is “between the silence and the cry” in his own world—the wordless pain of sensing the missing object/self and his attempts to language such amorphous pain. In one of the five brief case histories in the book, Levine describes a small self-disclosure to his patient Ellen, a personal story in answer to her query whether his eyes were blue. He tells Ellen, whose own mother was unreliable and abandoning, that he thought his eyes were brown but that his mother would tell him his eyes are hazel. He spontaneously reveals this warm, loving memory to his patient, calling up his own “loving, maternal introject” (possibly idealized) in the face of a “hostile or barren” relationship with his patient. In response to his comment, he notes, Ellen settles down and realizes that she imagined seeing the blue eyes of her mother transposed onto his face, reflecting an internalized transference representation. He notes that his comment provided to the patient a verbal “prop” to the “playset,” calling up a more facilitating, caring mother—similar to the analyst-engaged mother in the positive transference—than the patient’s abandoning mother in order to “patch a ‘micro tear’ in Ellen’s psyche” (p. 33).
Alongside the more traditional archeological work of uncovering and interpreting more fully formed but repressed or split-off mental elements, Levine relies heavily on his reverie with the patient in order to transform and construct the psychic capacity of the patient to think about the unthinkable. He describes a process in which the analyst unconsciously absorbs, resonates, and transiently identifies with the representational absence or weakness of the patient, and then re-presents to the patient the “unspeakable unspoken” in a more structured form for internalization by the patient. It is the analyst’s unconscious, spontaneous participation in an active, intersubjective process in which “we support, catalyze and co-construct affectively imbued, symbolically meaningful, plausible thoughts and constructions with and sometimes even for our patients” (p. 24). There is always more affect than can be fully represented, but the psychoanalytic project Levine proposes is one in which the intersubjective relational configuration between analyst and patient can help make a portion of previously silent, inchoate forces verbalizable and in so doing build a capacity for representation. The process is one that uses the analyst’s intuitive rather than deductive abilities, as psychic states can be accessed only indirectly. As with Winnicott’s transitional object, there is no way to answer, “whose construction is it, the patient or the analyst’s?” I wonder whether the psychoanalyst without this history of early trauma and loss would be able to resonate as deeply with the unspoken, wordless suffering of the patient.
The analyst’s project is thus to help the non-neurotic patient construct a narrative truth rather than uncover the repressed unconscious. This begs the question: What of truth, the analyst’s authority, and the matter of suggestion? Levine tackles these questions in a number of middle chapters. He concedes that the whole of one’s truth can never be known. He sounds a warning note: “Once we recognize that we must rely on the analyst’s creativity and construction in the form of intuition, we are in danger of submitting to the forces of countertransference, suggestion and compliance” (p. 72). But as analysts we have to accept that we stand on the shifting ground of psychic reality. We must abandon an absolute dependence on correspondence with historical truth and move to what is useful for the patient, Levine contends. This leads to a situation in which the boundaries of the analyst’s influence and authority may be impossible to determine. In the face of this, the analyst has to fall back on an ethical commitment to function in the service of the patient’s analytic and developmental needs. The analyst is to be the guardian of the analytic process, both within himself as well as between analyst and patient, in the attempt to aid in the positive trajectory of psychic development and subjectivization. This is a lot to ask of the analyst. As Levine writes in a footnote, countertransference is always unconscious. What of the analyst whose envy, hostility, and destructive impulses are stirred up in the intersubjective soup of the analytic encounter? Levine does not address these difficult dilemmas directly but asks us to thoughtfully stand in the uncertainties of negative capability.
Throughout the book, Levine emphasizes that the capacity to create psychic representations is not a given, but a developmental achievement. Unrepresented states reflect events, inscriptions of the preverbal period, and are the sequelae of massive trauma and associated states of terror, annihilation and despair. According to Levine, unrepresented states accompany disorders such as psychosomatic disorders, autism, perversions, addictions, and primitive character disorders. This is a bold assumption in the current health treatment zeitgeist where recent developments in neuropsychiatry suggest that both functional and structural deficits underly many of these disorders. Levine is at pains to note that constitutional factors often combine with environmental provisions to mediate development. He notes, “there may be an actual failure of environmental provision on the part of the object or some constitutional inability of the infant to make use of what is being offered” (p. 111). Nevertheless, Levine’s emphasis on the environmental failure underlying such disorders will understandably raise concerns of a return to parent blaming.
In terms of the autism spectrum disorders, Levine draws on Alvarez in outlining that the infant may find the object to be unreachable, “traumatic rather than containing” and resort to an encapsulated auto-sensuous state “blocking the wound and providing a seal to protect the endangered self.” One imagines that Levine is not referring to the completely unreachable, nonverbal, severe end of the autistic spectrum in his work with the autistic patient. In the accompanying case history, Levine talks about Tom, a fairly isolated young man who speaks almost inaudibly and who has trouble with daily routines, but who is able to attend sessions consistently and to achieve academically. Levine stresses the affective presence of his interventions and interactions in the analytic work rather than the analytic meaning, relying on reverie, “inter-affective and inter-subjective stimulation” to “prime the pump of the psychic apparatus” and “weave psychic patches.”
In the latter part of the book, Levine turns his attention to psychosomatic states. I read this section with great interest as some years ago, I lost my voice for several months. Over time, various medical investigations uncovered a paralyzed vocal cord. I had some sense that the vocal cord paralysis was connected in some way to a long period of agony in my life when my daughter was gravely ill. I communicated the connection when seeking medical help, but the medical investigators I sought out had little or no interest in my emotional and mental state. This limited view of physical ailments relies on the Cartesian separation of mind and body that is well entrenched in our western society. Levine adds his voice to a group of psychoanalytic thinkers who provide a welcome corrective to such ideas in terms of psychosomatic disorders. He is heavily influenced in his thinking by the Paris Psychosomatic School, Aulagnier, Winnicott, and Bion. He points out the centrality of the body in the development of mental functioning and that affect ties together the soma and psyche. The intertwined connection between mind and body leads to his question: “Is somatic illness a manifestation of the ‘speechless mind’ or the ‘communicating body’?” Levine returns to the running theme of the book here: “at the heart of the analytic treatment of psychosomatic patients lies the inevitable encounter with the vicissitudes of the processes and failures of psychic representation” (p. 138). Consequently, the discourse of psychosomatic patients is often a pseudo-speech, an evacuative discharge of concrete, raw elements rather than saturated with meaning, and is an attempt to avoid potential emotions. Somatization is also a cry for intersubjective help in resolving psychic regulatory problems, he notes. In contrast to neurotic patients in whom desire and the capacity for psychic elaboration coexist from the outset of treatment, Levine remarks that those with psychosomatic or “mechanical” functioning organize their psychic life against the very objects on whom they depend to help reinstate psychic development, even as they unconsciously call out for help. In terms of treatment, Levine highlights that the analyst must rely on careful attention to countertransference to find a way to help the patient contain, mentalize and diffuse the pressure of unbound, excessive excitation. His case study to illustrate this process is brief and left me wanting more in understanding the complexities in dealing with psychosomatic patients.
Levine writes that we should expect to find that unrepresented and unintegrated states are universal and will be encountered in all of us. In one case history he talks about “pumping the psychic apparatus of his patient so that the patient’s representational capacities could be said to have emerged or come back on line in the service of thinking” (p. 121). But the universality of unrepresented aspects of the self is underemphasized in the book. Rather, Levine seems to distinguish between those who have capacity to represent and those who do not. He makes a clear distinction in many chapters between neurotic and non-neurotic functioning, and links non-neurotic functioning to voids in representation. In the consulting room, this is rarely so clear a distinction, and functioning in terms of psychosomatic states is better represented by a continuum rather than a binary system (White and Flax 2023). There are fluctuations in patients’ states—sometimes the patient is able to represent and at other times the archaic, raw, unconscious bits are bound by somatic processes and thinking is concretized. On one end of the continuum are symptoms that are products of psychic conflict, replete with symbolic and semiotic meaning. This would correspond to “neurotic” functioning. On the other end of the continuum we see a somatizing process through drive unbinding, where there is a temporary or permanent incapacity to function symbolically and sorrows are expressed through bodily concretization even to the extent of possible organ failure. Most patients fall somewhere along the continuum. We are all more prone to becoming gravely ill under circumstances that call for great emotional reserves that are presently unavailable to us, even if we have some capacity for symbolization. I became aware over time that my own somatic symptom was an expression of the surfeit of affect in me, a kind of wordless paralysis in response to my family’s shared helpless despair, terror, and rage. Coincident with my growing ability to articulate and process the shock and distress, my vocal cord paralysis thankfully largely resolved. As Levine notes, it is the very act of being able to recognize, name, think, and talk about—to mentalize the previously unrepresented states—that is helpful. Whether or not we talk in terms of a continuum or either/or, Levine’s work on the struggles of representation in psychosomatic states is vital to the understanding of these patients.
Levine’s book is a remarkable collection and is not to be missed. It is an excellent addition to a growing literature that expands on how we are to approach the wordless territory and lacunae in the psyches of the kinds of patients we encounter more and more in our clinic.