Introduction to Primitive Mental States: Theory and Treatment

Meeting Time: Fridays, 8:30 a.m. – 11:00 a.m.

Meeting Dates: 9/20/19, 11/1/19, 12/6/19, 1/24/20, 3/27/20, 5/1/20

Hours of Instruction: 2.5 hour sessions x 6 meetings = 15 hours

Instructor: Lynda Chassler, LCSW; Ph.D (lyndaphd@aol.com)

Course Description

The term Primitive Mental States is difficult to define in positive terms.  As Tuters (2010) states:

Most of the authors who write of these states prefer to single out what seems to be absent in the clinical manifestations of primitive mental states with adult regressed patients: The capacity for symbolizing, fantasizing, having affects and thoughts, feelings and dreams; the capacity for projective identification, for making links; the capacity for living inside one’s body, for experiencing one’s experiences, for finding meaning in those experiences; the capacity to relate to another person. These are capacities that cannot be taken for granted. Not everyone has these capacities……..”

At birth, the mind has been described as a “formless real of infinite possibilities” filled with “perception of emotional experiences “(Meltzer,1998, p.92), along with “potentials for action and somatic sensations—out of which coherence of meaning and consistence of identity must be wrought .”(Eekhoff. 2019).  Eekoff stresses that prior to achieving psychic representation, the unrepresented, not yet formed mind is “in and of the body,” (Levine, 2019). The development of mental representations are not a given.  Its development relies on the presence and responsiveness of the “good-enough mother” Winnicott (1952) to her infants needs. The outcome relies on the meeting of the baby’s innate dispositions and the parental function. Gross failures in this function, the baby experiences early trauma, pre-conceptual trauma.     “As adults they have within their internal worlds an infant that was not called forth or met, an absent or indifferent mother, and a raging inferno of unmediated and undifferentiated needs”(Eekhoff, 2019). These unprocessed primal terrors remain unmentalized. Locked in primitive mental states, adult regressed patients have a weakened capacity for representation and a poor apparatus for processing their experience. The psychic struggle to exist, its pain, terror and rage is held in their body, an egoless state of being when only bodily experiences exist, before symbol, before thinking, whose function becomes a processor of emotional experience. In a world inhabited by sensation and urges of pre-affect states, language is used as action and behavior as communication. Bodily sensation and action fill the void.

Course Objectives

Beginning with Freud’s drive/structural theory, the impact of early relationships and the way they influence our psychological growth and development was seen by classical analysts as libidinal energy seeking object contact solely to achieve the gratification of the drives. Treatment focused on the analysis of symptoms which suggested the person had reached the Oedipal Level of development, a 3 party relationship, the child, the mother, and the father. Conflict and ambivalence were central and the resolution of these struggles was the primary goals of the analysis. People whose symptoms suggested earlier mother-child struggles during the phases of dependency (a 2 party relationship)were considered to be unanalyzable and when these issues emerged in treatment, were interpreted by the analyst as a defense away from the Oedipal struggle.

Psychoanalytic inquiry that was significant in the understanding of regressed preoedipal states came from the field of Object Relations and the consideration of the primary role of objects, the mother, a 2-party relationship, essential in the psychological/emotional development of the infant from birth. (The major thinkers that fostered these ideas were:(Melanie Klein, Fairbairn, Balint, Winnicott, Bowlby, and Kohut). Although each had a different language of explanation. all looked to the nature of this early relationship and focused on the essential question: Were the mother’s responses good enough to engender a sense of well-being and safety within the infant to promote psychological growth or were the deficiencies such that the infant experienced their survival needs of safety and protection threatened so that the specific felt anxieties of annihilation, dread, and terror, emerged. Attention was being paid to the way in which psychological growth contributed to the birth of mental life, its development and its significance in the origins of psychosis.

The essential objective of this course is to emphasize the complexity of the early object-relations experiences and how they affect the mind and psychic development. The goal is to advance the candidate’s ways of thinking about primitive mental states so that they will be better able to treat severely regressed patients. We will focus on the origin of thoughts and the way these thoughts enable the individual to become a thinker (Bion, 1965). Its focal point is to describe the process that transforms unrepresented, unmentalized experience, existential experience into represented, potentially verbalizable, ideational psychic elements (Levine,Reed, & Scarfone, 2013). We will present the theoretical foundation for the way in which unprocessed primal terrors remain unmentalized, locked in primitive mental states. Significant attention is paid to the challenges of psychoanalytic treatment with patients often thought to be unanalyzable. I will present clinical material and I encourage the candidates to present their work as well so that we can integrate these ideas clinically.  At the completion of the course the candidates will be able to:

Session #1:

1.     Describe the anxieties, and mechanisms of defenses, which are characteristic for the first year of life.         

2.      Summarize some of the disturbed object relations, which are found in the paranoid/schizoid personalities.

3.     Explain the concept of linking.

Session #2:

1.     Explain how curiosity, arrogance, & stupidity relates to a psychological disaster.

2.     Address the role of frustration in the development of thoughts.

3.     Explain the interpersonal neurobiology of the essential right-brain process of   affect regulation in development and trauma dissociation.

Session #3

1.    Describe the primal function of the skin of the baby.          

2.     Explain the complexities involved in patients who tend to somatize.

3      Define the term Alexithymia and its link to psychosomatic disorders.

Session #4

1.     Define the term psychosomatic collusion and the way in which it relates to psychosomatic disorders.

2.     Address the role of the body as a communicator of unmentalizable experiences in primitive mental states.

3.     Write about the psychic repercussions of the very early mother-child relationship, particularly in regard to the elaboration of affects.

Session #5

1.     Define the term “psychotic core”.

2.     Explore the language of absence.

3.     Describe the concept of the analytic third.

Session #6

1.     Explain the technique of treatment at the basic fault.

2.     Write the technical considerations of working with the countertransference.

3.     Explain how the concept of transference is used in treating patients with primitive mental states.

Readings:

Most of the readings can be downloaded from the Pep Web. The following readings are not on PEP:

Finell, J.S. (1997).  Alexithymia and Mind-Body Problems.

Campbell, E. F. (1997). Failure in the Mother-Child Dyad.

Little, M.I.(1982). Direct Presentation of Reality in Areas of Delusion.

Winnicott, D.W. (1949)/1958).  Mind and It’s Relation to Psyche-Soma.

These articles will be scanned and uploaded onto the ICP website.

Goals and Objectives Session-By-Session

SESSIONS #1: 9/20/19

We will begin our consideration of primitive mental states with the article by Melanie Klein, “Notes on Some Schizoid Mechanisms.”  Here Klein writes about the birth of mental life and how it relates to psychosis.  One of her main points is that in the first few months of life anxiety is predominately experienced as a fear of persecution and that this contributes to certain mechanisms and defences that characterize the paranoid and schizoid positions.  Outside among these defences is the mechanism of splitting internal and external objects, emotions and the ego.  These mechanisms and defences are part of normal development and at the same time form the basis for later schizophrenic illness.  She describes the process underlying identification by projection as a combination of splitting off parts of the self and projecting them on to another person, and some of the effects this identification has on normal and schizoid object relations.  She writes that the onset of the depressive position is the juncture at which by regression schizoid mechanisms may be reinforced.  Klein suggests a close connection between the manic-depressive and schizoid disorders based on the interaction between the infantile schizoid and depressive position.

Bion has considerably advanced our conception of the genesis of psychosis by postulating the occurrence of an infantile psychotic catastrophe or infantile psychosis as a breakdown in the maternal container function of her infant’s feelings.  The failure to do this disallows the sensory data of emotional experience from being able to enter the mind.  They thereafter exist as “the normal furniture” of the psychotic mind—not fit to be emotionally experienced, to be thought about, or even projected—-but rather to exist as dissymbolic painful elements of “nameless dread.” In most of his papers, Bion talks of the psychotic part of the personality and speaks of the destructive attacks, which the patient makes, on anything, which is felt to have the function of linking one object to another. His intention in his paper, “Attacks on Linking” is to show the significance of this form of destructive attacks in the production of some symptoms met with in borderline psychosis.

In his paper On Arrogance, Bion suggests that the appearance of curiosity, arrogance, and stupidity should be viewed by the analyst as evidence that he is dealing with a psychological disaster.  Bion suggests that in a personality where life instincts predominate pride becomes self-respect, where death instincts predominate, pride becomes arrogance.

Francis Tustin in her article A modern Pilgrim’s Progress: Reminiscences of Personal Analysis with Dr. Bion writes how she might have been left in that “twilight state of ‘”autism”’ in its normal and pathological variations had it not been for “Dr.Bion’s incisive insight, his patience and persistence.”

Readings:

Bion, W.R. (1959).  Attacks on Linking. Int. J. Psycho-Anal., 40:308-315.

Bion, W.R. (1958).  On Arrogance. Int. J. Psycho- Anal.,39:144-146).

Klein, M. (1946).  Notes on Some Schizoid Mechanisms. Int. J. Psycho-Anal.,       27:99-110.

Tustin, F. (1981).  A Modern Pilgrim’s Progress: Reminiscences of Personal      Analysis with Dr. Bion. J. Child Psychother., 7(2):175-179.

Session 2: 11/1/19

As a consequence of the shift of interest from later to earlier stages of infant development, over the course of the last several years, the tools of psychobiology and neuropsychology have offered us windows into brain functioning which have added to our understanding of its interface with mental phenomena.

Philip Bromberg, from his book Awakening the Dreamer published this article “Something Wicked This Way Comes: Trauma,Dissociation, and Conflict: The Space Where Psychoanalysis, Cognitive Science, and Neuroscience Overlap.” This speaks to an interpersonal/relational, psychoanalytic approach that works at the interface of dissociation and conflict.

Allan Schore addresses in his article “Review of Awakening the Dreamer: Clinical Journeys by Philip Bromberg” the way in which “Bromberg masterfully integrates psychoanalytic, developmental, trauma and neurobiological data to explore the bottom-line defense of dissociation.” Schore further writes: “Bromberg’s creative book is an excellent example of how effective clinical work with such patients incorporates the current paradigm shift from not only cognition to affect but also repression to dissociation.”

Thomas Ogden develops his concept of the autistic-contiguous position.  He states that this model, a primitive psychological organization, is a sensory-dominated, pre-symbolic mode of generating experience which provides a good measure of the boundedness of human experience and the beginnings of a sense of the place where one’s experience occurs.

We will consider a quality of psychic non-life (non-existence) as it relates to primitive mental states in the two articles: ‘Void Existence” as Against “Annihilation Existence’: Differentiating Two Qualities in Primitive Mental States by Irit Hameiri Valdarsky and Fear of Breakdown by Donald Winnicott.

Readings:

Bromberg, P.M.  (2003).Something Wicked This Way Comes: Trauma, Dissociation and Conflict: The Space Where Psychoanalysis, Cognitive Science, and Neuroscience Overlap.  Psychoanal. Psychol.,20(3):558-574

Ogden, T.H. (1989). On the Concept of an Autistic-Contiguous Position.  Int. J. Psycho-Anal., 70:127-140.

Schore, A.N. (2007).  Review of Awakening the Dreamer: Clinical Journeys by    Philip M. Bromberg.  Psychoanal. Dial., 17(5):753-767.

Valdarsky,I.H. (2015). ‘Void Existence” as Against “Annihilation Existence’: Differentiating Two Qualities in Primitive Mental States.  Int. J. Psycho- Anal., 96(5):1213-1233.

Winnicott, D.W. (1974).  Fear of Breakdown. Int. R. Psycho-Anal., 1:103-107.

The ego “is first and foremost a body-ego.” (Freud).

Sessions 3&4 bring to attention the role of bodily emotion as the arena in which traumatic emotional memory is stored.  We will read how somatic experience replaces self experience and reflects deep anxieties over fragmentation and disintegration and that psychosomatic syndromes tend to be associated with primitive layers of the personality and personality functioning.  We will examine the way in which the failures in the mother’s ability to receive and elaborate on the child’s affect communication can lead to psychosomatic expression.

Session 3: 12/6/2019

The central theme of Ester Bick’s article “The experience of the skin in Early Object- Relations” is concerned with the primal function of the skin of the baby and of its primal objects in relation to the most primitive binding together of parts of the personality not as yet differentiated from parts of the body.  The thesis is that in its most primitive form the parts of the personality are felt to have no binding force amongst themselves and must therefore be held together in a way that is experienced by them passively, by the skin functioning as a boundary.  In all patients with disturbed first-skin formation manifests itself in states of unintegration involving the most basic types of partial or total, unintegration of body, posture, motility, and corresponding functions of mind, particularly communication.

In her paper Further Considerations on the Function of the Skin in Early Object Relations: Findings from Infant Observation Integrated into Child and Adult Analysis, Ester Bick extends the findings in her 1968 paper and investigates them in greater depth.

Winnicott describes the integration of mind and body as a psychosomatic collusion; he also refers to the psyche indwelling in the soma”.  This describes the successful outcome of the process of “personalization” that occurs as a result of the mother’s “handling” of her infant during the holding phase.  This is the time of absolute dependence, when the (healthy) mother is in a state of primary preoccupation.

In Winnicott’s work, the use of the word “psyche” is described as the “imaginative elaboration of somatic parts, and is often synonymous with “fantasy”, “inner reality”, and “self”.  If the mother has not been able to provide good-enough handling during the holding phrase, then her baby may never feel at one within his body, and a mind-body split therefore occurs.

Psychosomatic illness is a symptom of something gone wrong in the individual’s early emotional development.

Readings:

Bick, E. (1968).  The Experience of the skin in early Object-Relations.  Int. J. Psycho-Anal., 49: 484-486.

Bick, E. (1986). Further Considerations on the Function of the Skin in Early Object Relations: Findings from Infant Observation Integrated into Child and Adult Analysis.  British Journal of Psychotherapy, 2(4):292-299.

Winnicott, D. W. (1949).  Mind and its Relation to Psyche-Soma.  In Collected Papers: Through Paediatrics to Psycho-Analysis (pp. 243-254).

London: Tavistock, 1958.  New York: Basic Books,1958.  {Reprinted as : Through     Paediatrics to Psycho-Analysis. London:Hogarth Press & the Institute of Psycho-Analysis, 1975; reprinted London: Karnac Books 1992}.

Session #4 1/24/20

Cates in her article Insidious Emotional Trauma:The Body Remembers speaks to “insidious emotional trauma”, a concept that is defined as the repetitive demonization of emotionality during development and beyond.

Finell examines mind-body problems in contemporary psychotherapeutic practice.We will be reading two of her chapters: In Chapter one she discusses the concept of alexithymia.  The term refers to psychosomatic patients who display asymbolic and identifying and communicating and feelings.

In Chapter Six, Failure in the Mother-Child Dyad Campbell addresses how problems with the mother’s attunement and response to the child’s affective experience can lead to psychosomatic expression.

Theaters of the Body: By Joyce McDougall is reviewed by Austin Silber.  He writes that Dr. McDougall never underestimates the complexities involved in trying to understand patients who tend to somatize.  “Making use of construction and reconstruction, of verbal and preverbal clues, she tries to lay bare all that can fortify her patients with increased knowledge of their functioning body and mind.”

Steve Posner’s article The Unconscious Motivation to Become a Murderer in Camus’ The Stranger speaks to the character of Meursault who is analyzed in terms of the diagnosis and dynamics of alexythymia as described by Joyce McDougall in her book Theaters of the Mind.  The murder committed by Meursault can be understood as unconsciously motivated by the desire to make an emotional connection to the father, a man he says he never knew, and who is mentioned in the book only once.

Moscato and Solano argue in their article Eating Disorders as Autisticlike Defenses: Unmentalized Experiences in Primitive Mental States that in primitive mental functioning, eating symptoms—both bulimic and anorectic—can be used as autisticlike defenses in which the altered body becomes an objectified protective shell providing shelter from intolerable anxieties that derive from unmentalized and unmentalizable experiences.  The role of the psychoanalytic third, rising from the analyst’s reverie, as a possible meeting ground between the concrete and the symbolic is discussed. Drawing on case material from the analysis of two patients with eating symptoms used as autisticlike defenses clarifies some of the theoretical aspects of eating disorders.

Readings:

Campbell, E. F. (1997). Failure in the Mother-Child Dyad  In J.S. Finell (Ed.), Mind-Body Problems: Psychotherapy with Psychosomatic Disorders (pp.12-131). Jew Jersey: Jason Aronson.

Cates, L.B. (2014).  Insidious Emotional Trauma: The Body Remembers….1. Int. J. Psychoanal. Self Psychol., 9(1):35-53.

Finell, J.S. (1997).  Alexithymia and Mind-Body Problems.  In J.S. Finell (Ed.), Mind-Body Problems: Psychotherapy with Psychosomatic Disorders (pp.3-18). New Jersey: Jason Aronson.

Moscato, F. & Solano, P. (2014).  Eating Disorders as Autisticlike Defenses: Unmentalized Experiences in Primitive Mental States. Psychoanalytic Review. 101(4):547-570.

Posner, S. (2000).  The Unconscious Motivation to Become a Murderer in Camus” The Stranger. Mod. Psychoa nal.,25(2):259-267.

Silber, A. (1991).  Theaters of the Body: By   Joyce  McDougall.  New York: W.W. Norton, 1999.  Pp. 192. Int. J. Psycho-Anal., 72:367- 370.

Treating primitively fixated patients is demanding  and rewarding.  Giovacchini and Boyer (1982) best describe this treatment: “Early preverbal orientations are reenacted with the therapist…..The intense therapeutic needs of these regressed patients may be overwhelming……..yet the treatment setting can provide them the holding environment they so desperately require and thus create transference readiness and later a firm attachment to the therapy.  In session 5 & 5 we will examine these treatment challenges.

Session #5 3/27/20

Clifford Scott in Primitive Mental States in Clinical Psychoanalysis speaks to the analysis of the “psychotic Core”, the unresolved infantile problem of development which may lead to inhibition, fixation, dissociation, splitting, disintegration.

The paper The Language of Absence by H. Gurevich describes a  continuum of non-responsiveness and misattunement of the environment in the stage of absolute dependence; it refers to concepts like lack, failure, neglect, ranging to mental, physical and sexual abuse.  Understanding the language of absence enables the analyst to recognize its intersubjective and its intrapsychic presence, to provide an environment that allows for its revival, and to facilitate and regulate the annihilation anxiety that awakens when dissociated self-states are experienced.

Thomas Ogden in his paper The Analytic Third:Working with Intersubjective Clinical Facts describes the methods by which the analyst attempts to recognize, understand and verbally symbolize for himself and the analysand the specific nature of the moment-to moment interplay of the analyst’s subjective, the subjective experience of the analysand and the intersubjectively-generated experience of the analytic pair )the experience of the analytic third.

Readings:

Scott,W.M. (1984). Primitive Mental States in Clinical Psychoanalysis. Contemp.        Psychoanal.,20:458-463.

Gurevich, H. (2008).  The Language of Absence. Int. J. Psycho-Anal., 89(3):561-578.

Ogden, T.H. (1994).  The Analytic Third:Working with Intersubjective Clinical Facts. Int. J. Psycho-Anal., 75:3-19.

Session #6 5/1/20

Technique at the Basic Fault/regression by Harold Stewart reviews Balint’s concept of the basic fault and examines some of the aspects of the technical problems encountered there.

On ‘Doing Nothing’ in the Psychoanalytic Treatment of the Refractory Borderline Patient Glen Gabbord writes about the analytic management of silence with regressed borderline patients’:the monotony, the helplessness, the frustration, the hatred and the wish to give up.

Speziale-Bagliacca writes in his article The Capacity to Contain:Notes on its function in Psychic Change that the main work of the analyst in promoting psychic change in the patient within the analytical process lies in his commitment to “contain” the infantile aspects of the mind.

Addiction to Near-Death is discussed by Betty Joseph as a malignant type of self-destructiveness. She presents how it dominates these patients’ lives; for long periods it dominates the way they bring material to the analysis and the type of relationship they establish with the analyst; it dominates their internal relationships, their so called thinking, and the way they communicate with themselves.  It is not a drive towards a Nirvana type of peace or relief from problems, and it has to be sharply differentiated from this.

In contrast to Freud, Betty Joseph discuss in Transference: The Total Situation how analysts use the concept of transference in current clinical work. Her stress is on the idea that transference is a framework, in which something is always going on, where there is always movement and activity.

Etchegoyen writes in the article The Relevance of the ‘Here and Now’ Transference Interpretation for the Reconstruction of Early Psychic Development that early psychic development is included in the personality and appears in the transference; the progress of the analytical process shows in turn that the changes achieved in treatment transform the text of the original conflict.

Daphen and Robert Stolorow in My Brother’s Keeper: Intensive Treatment of a case of Delusional Merger present an account of an intensive treatment of a young woman whose chronic suicidality derived from a delusional merger with a deceased brother. Although her manifest symptomatology would be seen as borderline to psychotic, she was nevertheless able to form a stable and analysable transference bond with her therapist.

Little’s paper Direct Presentation of Reality in Areas of Delusion focuses on technical issues in treatment.  She refers to an undifferentiated psychic state where differentiation between the psyche and soma is just beginning.  She is describing a presymbiotic state and believes that analysts have to relate to these patients differently, often in a somatic fashion than they would with patients with greater psychic differentiation.

Readings:

Etchegoyen, R.H. (1982). The Relevance of the ‘Here and Now’ Transference Interpretation for the Reconstrution of Early Psychic Development. Int. J. Psycho-Anal., 63:65-75.

Gabbard, G.O. (1989).  On ‘Doing Nothing’ in the Psychoanalytic Treatment of the Refractory Borderline Patient.  Int. J. Psycho-Anal.,   70:527-534.

Joseph,B. (1982).  Addiction to Near-Death. Int. J. Psycho-Anal., 63:449-456.

Joseph, B. (1985). Transference: The Total Situation. Int. J. Psycho-Anal., 66:447-454.

Little, M.I. (1982).  Direct Presentation of Reality      in Areas of Delusion. In P.L. Giovacchini  L. B. Boyer (Eds.), Technical Factors in the Treatment of the Severely Disturbed Patient (pp.169-185). New Jersey: Jason Aronson.

Speziale-Bagliacca, R. (1991).  The Capacity to Contain:Notes on its function in Psychic Change. Int. J. Psycho-Anal., 72:27-33.

Stewart, H. (1989). Technique at the Basic Fault/regression.  Int. J. Psycho-Anal., 70:221-230.

Stolorow, D.S. Stolorow,R.D. (1989). My Brother’s Keeper: Intensive Treatment of a case of Delusional Merger. Int. J. Psycho-Anal., 70:315-326.

Suggested Reading:

C. Brickman (2018). Race in Psychoanalysis:Aboriginal Populations in the Mind. New York:Routledge.

This book illuminates the manner in which our colonialists and enslaving past continues to reverberate within the construction of psychoanalytic theory and practice.  She examines that the use of the idea primitivity in psychoanalysis is so ubiquitous and taken for granted that it is difficult to recognize its function as the key to the code of racial difference embedded in psychoanalytic theory.  She demonstrates its psychoanalytic usage conceals within it an anthropological and racial meaning by tracing the colonialist contexts in which it had developed by the time it had reached Freud.