Release from Developmental Arrest—Early Childhood Trauma: The Case of Mrs. E

INTRODUCTORY REMARKS

In 1980, Frank Lachmann and Bob Stolorow wrote a book entitled Psychoanalysis of Developmental Arrests (Stolorow and Lachmann, 1980). They described how psychoanalysis is changing from the treatment of classical psychoneurosis to the treatment of severe disorders caused by developmental voids, deficits, and arrests. I think there is a general consensus that psychoanalysis has gone through a major change in the last 30 years since that book was published and as a reminder, Kohut’s (1971) The Analysis of the Self is less than 40 years old. Thanks to those two authors, and to the many others who have brought to us in the recent past, new ideas for our practice: among others motivational systems theory, the relevance of infant research in our treatment of adults, attachment research, theories of mentalization, theory of the mind and affects, neural biology, relational theory, intersubjectivity theory, specificity theory and non linear systems theory, we are more able to treat such patients described by Stolorow and Lachmann.

I might have been able to treat Mrs. E, had I seen her thirty years ago, but I am truly indebted to the many theoreticians who have changed the scope of psychoanalytic technique and treatment.

Kohut’s last book, published in 1984, three years after his death and completed by Arnold Goldberg and Paul Stepanky, was entitled How Does Analysis Cure. It is a question that is extremely difficult to answer; in fact, Philip Reiff wrote that “psychoanalysis does not cure, it merely reconciles” (1959, p. 13). I am sure every psychoanalyst has had that question raised by some patient, at the beginning of treatment or during the analytic process. At times, I even ask myself, “How will I ever help to cure this patient? He or she really needs help.” There are so many things that are taking place in the clinical exchange, either explicitly or implicitly, that we can never give an adequate answer to that question. Why some patients with severe deficits, i.e., childhood trauma improve and others with a seemingly less traumatic past don’t, is a puzzle that often confounds me. An answer, a piece of that puzzle that is often found is the following: that there must have been some person, object, or selfobject experience from the past that the patient had that gave the patient a sense of self that could be characterized as having a feeling of coherence or wholeness. The three major selfobject transferences that Kohut differentiated in his lifetime and the many others that have been theorized since his death are examples of just such experiences.

This article discusses the two treatments of a woman, an ongoing treatment, whose development was almost completely shattered by her early experiences within her family and this nonholding environment has continued throughout her formative years. In this case, that of Mrs E, there are only small hints in her explicit autobiographical memory that can provide us with some understanding of why she has made such remarkable improvement. In her memory of her personal story, there is no good teacher, neighbor, or friend as we often find in our case studies, who provided a reliable selfobject experience, although she did not live in a vacuum and there must have been positive experiences in her life. In her immediate family, there was a grandmother who might have given her, on rare occasions, adequate selfobject experiences such as mirroring. In her relationship with her father, there was always a hope of a positive attachment and a wish for a bond. Perhaps the hope of mirroring and a small amount of idealization was all that she needed. She claims that she was the only one in her family who was not afraid of him. But in her family narration, she is mostly disappointed in his abandonment of her, his consistent disappointing of her expectations and in his using her in his financial and emotional battles against his wife, i.e., the mother of the patient. With her mother, the patient had someone who was almost always at home, but seemingly only in body and not in mind. Bernard Brandschaft wrote, “What particularly distinguishes resilient individuals from those who remain damaged and damaging is a capacity to reflect on mental experience” (2010, p. 180). Somehow, Mrs. E is far more resilient than I ever would have expected.

SIBLING RELATIONSHIPS

Mrs. E. made copies of a Super 8 film (in the second analysis) and gave them to me so that I could get a picture of her family and see some childhood interactions: with her mother and with two older sisters and with the father who is taking the films. There seems to be a caregiving and playful attitude of the older sisters toward her that the mother and father did not openly possess. In the film, we can see how both sisters play with the patient. Especially the oldest sister (the psychotic one) plays very warmly with the patient. She puts the patient on a blanket together with a friend of hers (Pt. ca. 2 years old) and swings her. She also pushes the patient on a swing, as does the second sister. Originally when I watched the films, I thought the second sister was more of the caregiver because in most of the stories that the patient told, it was she who helped the patient. When looking at the film, it appeared, however, that this sister did play with the patient, but often with a quick glance toward the mother, indicating in words “what I am doing is good; see how good I am.” The oldest sister was having fun with the patient. What was very apparent while looking at the pictures was the disengagement of the mother in her interactions with the patient. The patient, in one scene, was in a play pen, with almost no toys and looking very lonely; the mother was sitting next to her and knitting but never looked once at the patient or smiled. The mother’s face looked angry and unfriendly, not the face an infant would want to see. We never see the father, but when the patient sees him as he approaches her with the camera there is a smile on her face; a smile she never has on the film with her mother. There seems to be a relationship between the patient and her father. The movie pictures are often interrupted when a plane passes by or when the father zooms in on flowers in the garden. It gave me the opinion that flowers and planes were more important than the members of his family, although the father evoked the promise of a relationship as indicated by the patient smiling at him. After looking at the film, I asked the patient about her sisters and she told me that she felt that both were very important to her during her childhood and especially the oldest sister was important when she was very young.

I thus began to think more how sibling relationships can play a major role in the psychic development of an individual. It is a variant that has been too often neglected, especially when the relationship is positive. For the most part, we read about sibling rivalry and how jealousy, envy, and competition are often in the foreground of the life histories of the patients and what is often discussed is how it is enacted and repeated in the transference situation. We frequently read in case studies about malignant sibling relationships where, for example, an older brother abused his younger sister and an often given interpretation would look for similarities in the parents’ past, i.e., a transmission of abuse or sibling rivalry. In Freud’s compendium, listed under the rubric sibling, was: ambivalence, birth of, disappointment, incest love, rivalry, as object of beating fantasy, and death wish towards (Freud, 1968). The great child psychologist D. W. Winnicott (1989) hardly mentions sibling relationships. In fact, he even wrote that phobias may be good, such as in the case of rats or wolves, because these phobias may “safeguard a child against sibling rivalry, for instance, and the fear of the hated siblings” (1989, p. 69). In the index of the first 25 years of The Psychoanalytic Study of the Child (1975), in the table of contents under sibling, were references to the following articles: birth of, cruelty to, death of, development compared, different responses to same event, exaggerated protectiveness, jealousy of, reaction to death of parents compared, and sex play. The only exception was an article written by Anna Freud and Sophie Dann (1951) in which they did a study of orphans who were in concentration camps and they concluded how important their relationships were for each other and how much they cared for each other and their wish to be always together. These were, in fact, not real siblings, but children who had suffered traumatic experiences and had shared the loss of their parents.

However, the leading edge of the sibling relationships and how they are relived in the transference is an extremely relevant and often overseen phenomena. Surprisingly, in many fairy tales the good sibling relationship is prevalent, for example in the Brother Grimm’s collection there are “Hansel and Gretel,” “Jorinde and Joringel,” “Snow-White and Rose-Red,” “The Three Brothers,” “Brother and Sister,” “The Six Swans,” and “The Twelve Brothers,” and also in Hans Christian Anderson’s “Wild Swans.: Though again, we often think of the bad and envious sisters, as in “Cinderella” or in “Mother Holle.”

In the Psychoanalytic Inquiry, Sibling Relationships was the main topic of Volume 8, Number 1 (1988). But here too, and I quote from an article by Henri Parens: “In fact in some patients, siblings play a vital part in the analysis of their neurotic conflicts and symptoms” (1988, p. 31). In his article, Parens acknowledges that siblings have positive aspects as in helping each other enter into peer groups, or as a source of idealization, but for the most part he examines the negative features.

Clinical psychologists are, perhaps, more advanced in finding positive aspects of sibling relationships than what we usually find in psychoanalytic literature. They see sibling relationship as important for the child’s development. In a recent article by Laurie Kramer (2010), she quotes the longitudinal study of Judy Dunn: “Siblings engaged in social interactions that alternated rapidly between instances of conflict, teasing and threats and instances of shared laughter, affection and pride, often with a devastating lack of inhibition” (my italics). According to Dunn, “the continual interchange of intense positive and negative emotion makes sibling relationships a potent force in children’s development, helping to shape the development of social understanding” (p. 82).

According to Kramer (2010), “Cross-cultural research has reinforced the value of sibling relationship as contexts for extending nurturance, comfort, caregiving, teaching, and loyalty across development” “(p. 83). Other researchers have showed that sibling relationships can further the mentalization process and building up of a theory of mind (see Pernoff, Ruffman, and Leekman, 1994). In an article by Vaillant and Vaillant (1990), the best predictor of well-being among male Harvard Alumni at age 65 was their sibling relationship reported during their college years. Alessandra Piontelli (1992) showed in her pioneering work that even before birth, twins have relationships that, in some forms of behavior, repeat themselves outside of the womb. Kohut (1971) knew the importance of twinship or alter ego experiences and Michael Basch (1992, 1995) talked about kinship yet in their works there is no significant reference to sibling relationships in the development of the self.

In my work with Mrs E, I have come to believe that Mrs E’s trust and positive feelings toward me are an outgrowth of her early attachment to her sister. I say this because Mrs. E has shown me, in our work together, an ability to self-right and get on a developmental path that had been derailed for so many years or had never existed.

The importance of caregiving can’t be reduced to the older generation, i.e., parents, grandparents, teachers, neighbors, etc., but can be looked for in the sibling relationship. Caregiving in fact, is now a separate motivational system in the most recent book of Lichtenberg, Lachmann, and Fosshage (2011).

LIFE HISTORY

Mrs. E, who is now 42 years old, is the youngest of four children: three girls and a boy. Her brother is 15 years older than she is, and one sister was 13 years older than she and the other 7 years older. The brother left to join the army when she was 3 years old and she has very little memory of him from her early childhood. Her mother recently told her that he was punished by the father, in a similar manner to Kafka (1953), in that he was left outside the house and not allowed to come in at night if he did something wrong. He now suffers from severe depression, and he is in early retirement and in his second marriage. The older sister was often hospitalized for psychosis and died of an asthma attack when the patient was 15 years old. The second sister has been married three times, and has suffered physical abuse with each of her alcoholic husbands. She was the favorite of the mother and perhaps that is why she had some caregiving abilities. What is of interest is that the patient never really knows how much older her older siblings are and when the older sister actually died. Sometimes the brother is 15 years older than she is, and at other times he is 17 years older; for some reason she cannot remember the birth years of her family members, with the exception of her father, who was born in 1927. In her current family, celebrating birthdays is important.

Her mother, a housewife was over 40 at her birth. The mother would lie on the couch all day and complain about various hypochondriac ailments such as digestive disorders and not feeling well, leaving the patient to be alone in her own fantasy world. There were almost never any shared family meals where a sense of affiliation could grow. Mrs. E cannot remember her mother ever playing with her, but she can remember often being beaten by the mother. She feels as if she was an unwished-for child, and she can remember that when she was 5 years old her mother said to her that “it would have been better if you were never born.”

The patient went to nursery school at the German kindergarten at the age of 4, but only stayed for half a year because she did not want, or know how, to play with the other children. Instead, she stayed home with the depressive hypochondriac mother and she would often play alone in the family garden with a stick that became her horse in her self-created fantasy world. The mother forbade her to take the stick into the house because it was “too dirty.” The patient doesn’t remember playing with or owning dolls, or having any toys. She can remember that when she was 4 years old, she hurt herself when she fell out of a tree but nobody was there to comfort or help her. Another memory from this time is how she got her foot caught in the spokes of her sister’s bicycle while they were riding to a lake. The sister and she went by themselves to a doctor, who took care of her. Perhaps this is the first hint in the memory of the patient of the importance of this sister as a caregiver.

Her father was an illegitimate child and he was a prisoner of war in Russia at 17 years of age during World War II. His mother, the so-called good grandmother, married after the war and he had a step-brother who was the favorite of both parents. However, the father of the patient always spoke kindly of his stepfather. The patient never met her step-grandfather, because he died before her birth. Mrs. E’s father wanted to study medicine after the war but, according to the family story, there was no money to support him and he became a teacher, and later he was a principal in a public school. The father of the patient was seldom at home, and when he was there he was very strict and demanded his peace and quiet so he could work in his own office. Mrs. E says she was his favorite child, although she had very little contact with him. He always told her that “if you have a problem come and talk to me,” but if she attempted to talk with him, he would not listen or would say he was busy. He was extremely brutal, especially with the oldest sister, whom he would often beat. In fact, Mrs. E’s first memory, at the age of three, is that of her oldest sister coming home and how the father waited for her to arrive, so he could beat her up. She has memories of her sister screaming at night in the basement, where she slept. Years later, right before the second analysis began, Mrs. E’s mother told her that the father had abused, i.e., raped, her sister. To this day, she does not know if this is true or a fabrication of the mother.

In school, she was surprisingly a good pupil, although she felt very lonely and had no support from her family. When she was 9 years of age, the parents sent her to a boarding school run by nuns and, according to her description, it would fit all our prejudices on how harsh and desolate such a school can be. The reason for her being sent there was that her mother claimed that she was too difficult to handle and that she was aggressive. The patient has no recollection of being a difficult or aggressive child. There she was forced to eat everything that was served and suffered under this continuous strict and loveless attitude of the Catholic nuns. Later on in her biography, she developed an eating disorder and food was a major issue for her. When something was stolen from another girl and found near her bed, she was blamed, chastised, and punished by the nuns and other girls. She was mobbed, became an outsider and labelled “thief,” although she was innocent. After a year at the convent, she was so sad and despondent that the parents took her back home.

She was still good in school and got accepted to the German Gymnasium, which in Bavaria is no simple accomplishment. In Germany, after the 4th grade of public school, the children either get accepted to Gymnasium, which continues through the 13th grade; Real Schule, which ends after the 10th grade; or the Hauptschule, which ends after the 9th grade. To get accepted at the Gymnasium level, one had to get good grades in the 4th grade. It is a system that divides children at a very early age of life, and only children who attend Gymnasium can continue to the University. The patient accomplished this, but the father claimed that she was not smart enough to go to Gymnasium and should go to the Real Schule. The few friends she had were the ones who continued on to the Gymnasium. Up till this point, she still could maintain the fantasy that she was someone special for her father, but this idea was shattered, or at least put in question, by his lack of support and disdain.

At this time, her oldest sister was in a mental hospital and the father took the patient with him to visit her sister. She does not remember that the mother ever visited the sister. The fact that the father took her with him, and no one else, might be an indication why she thought she was someone special for him. The father terrified the patient when they went to the clinic, saying that all the patients were dangerous and would hurt her, although, once again, he ignored her while they were there.

The marriage of her parents was not good, and they separated when the patient was 12 years old. The patient had the choice to decide with which parent she wanted to live and she immediately decided to go live with her father. He promised her that when they would live together, he would finally have more time for her and painted a pretty picture of how life would be with just the two of them. Thus. her disappointment was even greater when they moved in together and she found out that, because he had a lover, he was at home far less than ever before. She was now all by herself in a new neighbourhood, without friends or her sister, and felt betrayed and used by her father. Because she lived with him, the father saved money because he had to pay the mother much less alimony. The patient only saw her father at breakfast and she had to take care of the household. She began to stay away from school and her grades sank rapidly. She was able to get an appointment with a governmental agency where she complained about her father’s abandonment. He was called in to testify and convinced the social worker that she was a pathological liar and had completely made up the story. She attempted suicide three times with pills, and began to drink alcohol, consume drugs, and engage in sexual relationships.

She had an Italian boyfriend, and when he went back to Naples to live, when she was 14 years old, she ran away from home and hitchhiked to his family home. On the way, she was picked up by an older Italian and abused by him. When she finally arrived in Naples, the police were waiting for her and held her till the father picked her up. He was ice cold to her, but she was relieved that he did not beat her. Upon returning, she moved in for a short time with her 7-year-older sister, but when the sister got engaged she again moved, this time to live with her older brother, who was married and had two children. Thus, within a year, she had changed addresses four times and went to four different schools. She had no contact with her mother, who refused to see her because she had chosen the father over her.

When she was 15, she was allowed to visit her boyfriend in Naples. She enjoyed her stay there with his family, but upon returning she decided to go back and live with her father. This time it was somewhat better with him, but because she picked the father’s house over the brother’s, he became insulted and broke off contact with her. She completed her Real Schule and wanted to do an apprenticeship as a business woman in the advertising branch. However, at the age of 16 she met her first husband, a Yugoslavian, and when she was 17 they moved together to Yugoslavia. When she became pregnant, they decided to move back to Germany where they could earn a living. She gave birth to her daughter and she was all alone during the birth, as the husband was in a gambling casino. She says for the first 3 years the marriage was good, but then the husband began to stay away from home and not come home at night. He was disappointed that they had a daughter and not a son. She had to work and take care of her daughter and the household all by herself. She did training as a nurse in an old age home and worked different shifts there, often leaving her daughter alone.

After another 2 years, she got divorced and moved in with her mother, who was the only member of her family who would take her in for a short time until the patient got an apartment of her own. As a nurse, the patient had access to medication at the old age home; she started stealing pills and became addicted to enemas and other pills. She developed bulimia and her condition rapidly got worse. This is the time when she went into the psychosomatic clinic and shortly before we began the treatment.

INITIAL TREATMENT WITH ME 1994–1996

Symptoms at the Beginning of the First Treatment

The patient, Mrs. E, first entered treatment with me, in our first round of psychoanalysis, when she was in her early 20’s. She was just coming out of a clinic where she had been diagnosed with a borderline symptomatic. She had a major eating disorder, had cut herself, and had attempted suicide more than once. The patient, a divorcee and single parent, had a 6-year-old daughter who was living with foster parents during her clinic stay and with whom she had a distant relationship. She was not sure if she wanted her daughter back, a repetition of her own story. Mrs. E had great trouble in expressing herself; her narrative self was not incoherent but she would lose herself while speaking, either entering a dissociative state or by searching for a correct word, which was often inaccurate in the current description she was giving me, and I, a foreigner, had to help her in her German vocabulary. She would, at times, use German idioms that did not fit the situation and were used incorrectly. I had to either fill in the gaps in her narration, i.e., free associations, or I would give her what I thought was the correct word. Many times I would go back to where she had lost her train of thought or entered her dissociative state.

The patient was referred to me by her boyfriend, Dennis, who she had met in the psychosomatic clinic. I had almost taken him as a patient but, because he suffered from agoraphobia and other panic disorders, we could not do an analytic therapy because he lived outside of Munich and could not come to my office. Interesting information is that when I graduated University and worked in a counselling service, he was in treatment by a good friend of mine, who continued to have a close relationship to him. Mrs. E was extremely self-destructive at the beginning of treatment. She would often take her enemas and said, “I have a deep wish in me to destroy myself with medicine.” She complained that her daughter was very fresh to her and called her names. She was very dependent on Dennis, with whom she lived. Because of his agoraphobia, he, too, was very dependent on her. Because she continued to often work at nights, he was able to take care of her daughter. When Mrs. E came to therapy, she often brought her daughter with her. I would provide the daughter with crayons, paper, and other toys, and she would sit in the adjoining room and occupy herself. Very rarely would Jane come in and ask for something. I liked the daughter almost immediately; she was one of those children where I have the feeling I could imagine adopting her. Many years later, when Mrs. E returned to therapy, I saw Jane once, when she was having problems, and she told me, to my surprise, that she thought I was always having sex with her mother while she was in the other room. I worked with Mrs E on her relationship with her daughter, explaining to her in many ways how and why her daughter reacted to her. In a sense, what Fonagy called mentalization or theory of the mind or what Sander stated in his paper on the recognition process “the specificity of another’s becoming aware of what we experience being aware of within ourselves” (Boston Change Process Study Group, 2010, p. 57). This was important to Mrs. E, who had troubles in empathic thinking and feeling because she had experienced so little herself and she appreciated my explanations. I was becoming for her an idealized selfobject who could explain different situations and ideas to her. She was a good listener and I had the feeling she could follow my thoughts, although she could not express them herself at this time. Looking back, perhaps that is why I did so much talking.

Mrs. E was very angry at her father at the beginning of treatment. He had visited Jane when she was with the foster parents and had given them money for Jane’s support, but once she had Jane, the father again ignored her. Once again, to the outside he pretended to be a good father and grandfather. She had fantasies of beating him and hurting him. Mrs. E was getting beaten, herself, by Dennis. He had started beating her out of jealousy and his fear of being left alone. He had wrenched her cervical vertebrae so that she had to wear a neck brace and didn’t go to work; she told her employers that she had fallen off a horse that, by the way, she had bought; she had made her childhood fantasy of the stick real.

Her first reported dream was in the 32nd hour. She dreamt that she was riding an elk (moose) and holding on to it with leather straps. The elk starting galloping and she had the feeling she could not stop it and it was dangerous. Her associations went to skiing when she was 13 and going down hill without knowing how to stop; to her father, who took her with him on a glider flight and her being terrified; and also to a memory of her first love affairs, always with older men, she being 13 years old and they being 21 or 23 years old. There was something I probably didn’t understand, because after this hour she reported that she once again had taken her enemas and felt self-destructive. Previously, she was very proud that she had stopped taking them for over 2 months. She also reported that, between our sessions, Dennis had choked her again.

As our work continued, Mrs. E was often able to tell me her inner feelings. They were mostly sad, despondent, and full of self-hate. She continued her medicine abuse, taking all the pills that she, as a nurse, could get her hands on, such as her enemas, thyroid medication, beta blockers, and lots of alcohol. We were able to understand her negative affects and it helped her to tell me but we could not stop the negative actions she took. I don’t know if I would call them enactments but I was certainly worried that she could commit suicide, which she almost did once with a cocktail of medicines.

I always tried to track the affects that Mrs. E had. Explaining to her why she needed to be so self-destructive and pointing out to her that she had learned so little self-regulation; that her form of regulating and avoiding pain was also now a way of inflicting more pain on herself, and that it often occurred when she felt attacked or abandoned by people, including me. In our relationship, vacation times were critical, though she could not acknowledge my significance for herself. In time, her drug taking ceased; we were almost able to nip it in the bud as she was becoming more aware of her own inner feelings and that she was no longer alone with them but could talk to me about them.

Toward the end of the first analysis, her relationship with Dennis came to a sudden end after he had hit her and broken her nose; he had then followed her in his car and bumped her from behind as they were driving. She was infuriated, broke off the relationship, and found an apartment for herself and her daughter. She brought him to court, which unfortunately he won, because he brought in phoney witnesses including my friend—which almost cost me my friendship with him. However, Mrs. E knew that I believed in her and supported her. Soon thereafter, she met her future husband, a shy and somewhat younger man than she was. He loves her very much and supported her, and together they moved with Jane to Northern Germany, because he was transferred there by his employer.

In the 12 years between treatments, Mrs E. visited me once with her husband and new-born son. She brought a present with her—a mirror in the form of a sun. She thanked me for the work we did together and made a good impression on me, though I noticed that the child seemed to cling to her and she was quite nervous.

Second Treatment

In 2008, she called me and informed me that she was back in the Munich area, as her husband was transferred by his company back here. They were living in an apartment above her parents-in-law, who owned the two-family house they were living in. We made an appointment to meet. She told me that she was very active in Northern Germany in Rudolph Steiner, i.e., Waldorf, education. She still suffered from dissociation. Her dissociative states were not confined to talking within the sessions, but she would describe to me how she would be driving a car and not know where she was or where she was going to and the surroundings seemed to be foreign and not recognizable to her as she drove along the streets and highways and country roads. Also, when she took trains she was not sure if she was going in the right direction and people in trains scared her, as they would stare at her or they seemed very weird.

She said she had trouble speaking when there were meetings in schools and that she wanted to speak but couldn’t. When she asked her husband to speak for her, which he sometimes did, she was often annoyed and ashamed that he too was shy and not very articulate. She told me she had a second child with her husband, a daughter, as well as the son that she had brought to me 7 years before. She also confided to me that she thought that the son was not from her husband but from an affair she had, but she never had a test done and her husband is very attached to their son and she didn’t want to disturb their relationship. Her eating was no longer a problem, but she was now a vegan and followed a strict diet. She was not working, but was a housewife. The parents-in-law were also a major source of trouble, as her father-in-law, a former policeman, was very paranoid and controlling and she hated living in the same house as him, but because they had 3 children—Jane still lived with them—they couldn’t afford an apartment in Munich. Both her parents were still alive, though the father was becoming demented, and she had almost no contact with the two of them.

I noticed that now the interest in the Waldorf education had given her a sense of pride and knowledge, and gained her some respect among her peer group, i.e., the parents who sent their children to the Waldorf schools. I was happy to see her again, because I liked her a lot, and also because I felt work that we ended 12 years earlier was not over. It was as if she returned to a parent who was happy to see her and could still remember her and her history. We decided to work twice a week in a sitting setting. There was now new information that caused the patient anguish and uncertainty: Her mother had just told her that the father slept with her psychotic sister and there was also a question whether the brother also had sex with his sister as well. This time, the brother was 17 years older than she was. There was now a positive memory about the father that when she had foot pain and woke up at night, she could go to his bed for comfort and not to the mother.

Our work concentrated now on her inability to talk and her relationship to her husband, children, and parents-in-law. Affects of shame, embarrassment, and disappointment were in the foreground of our work. She now brought her two children, and sometimes a dog, to our hours. The boy was 7 years old and the daughter 4. I commented on her mothering and it was easy for me to mirror her ability as a concerned and nurturing mother who cared for her children. She was able to give to her two children what she could not have given to Jane or never got from her own parents. I think what I do with Mrs. E is at least twofold: First, I provide mirroring, in the true Kohutian sense of the term, and also what Judy Teicholz (2008) called a near-synonym for mirroring: affective resonance. Teicholz wrote

Rather than reflecting back the symbolic meaning of an experience, resonance involves the sharing of affect in some way. Affective resonance can transcend meaning via attunement, expressed through tone of voice, body language, or bio-rhythmicity. Affective resonance has the power to validate the common humanity between two individuals, with or without the articulation of specific meanings. (2008, p. 14)

Second, I am able to provide an idealizing self-object experience for the patient. She trusts me and can now openly admit how important I am for her and how difficult vacations times are for her.

It is hard for me to define the exact point, but suddenly there were major leaps in her development or the cohesion of Mrs E’s self. Through our talking cure, she became more and more articulate. When her husband was not able to talk at parent-teacher meetings, in the Kohutian sense of transmuting internalization, she suddenly was able to talk: at first in shorter sentences but within time longer and longer. She became increasingly involved in the Waldorf school politics and organized lectures and even gave small lectures herself. She started reading good books and would discuss them with me.

Her dissociation has also disappeared. I explained to her how in the past the dissociation was a way of avoiding a conflict or a situation but now, in the sense of Donnel Stern (1997, pp. 36–39), she no longer needed to have an “unformulated experience“ but could formulate and express her feelings. She was able recently to tell her husband about the possibility of his not being the father of their son, and he responded positively without any accusation. We were able also to find a therapist for Jane, who also had a great deficit from her childhood, as she witnessed not only the assaults of Dennis on her mother, but had a mother who was often not there for her.

Mrs. E has begun to talk more about our relationship and how I look when she talks. She told me recently that I looked astonished when she came in recently in a dress. I could not remember right away, but looking at my notes and I saw that I had written in my notebook the word “breast.” Yes, I said I could now remember thinking to myself that she might talk about sex with me in that, our last session, explaining to her that I can remember writing this down before, when she confided her rape scene in Italy to me and also when she talked about a lesbian relationship during her marriage. I told her that sometimes I think the topic of sex might be in the air, based on how she dressed and perhaps that was why I looked like I did. I could verify her perception and tell her what went through my mind.

July 5, 2010

As an example of her ability to verbalize her affects and experiences as well as make associations to the past the following is given from the beginning of a session:

Mrs. E comes into the hour and seems upset. She begins immediately.

Mrs. E:	=	I just saw something on the street that really shocked me. A young girl, she was 4 or 5 and she was being held by an older man. She tried to tear away from him and she was screaming, but he held on to her tightly. Then I saw two other women, one was probably the mother of her. They wanted to leave the girl with the man, probably because they wanted to go shopping. At first, before I saw them, I was really scared for the girl until I realized that the man was not abusing her or taking her away. But probably that he was the father or grandfather of that girl. I really felt as if I were under great pressure. As if either I saw such a scene in my childhood or experienced such a scene and was screaming.
RB:	=	The way you seem so shaken now; I can imagine that there were some scenes from your past that were triggered in your memory and that you can still feel.
Mrs. E:	=	I am not sure. There are some scenes that I can faintly remember, screaming at age 2 or 3 when my mother beat me or perhaps it is the memory of my sister screaming and being so loud.
RB:	=	Or both.
Mrs. E:	=	Or both. I can recall that my sister was listening to music in the basement. She was listening to a cassette. My father came in and wanted to take it away from her. It was the only thing that she had. She started screaming and then she came upstairs and had a black eye. That was during the Easter holidays.
RB:	=	How old were you?
Mrs. E:	=	4 or 5
RB:	=	That must have been extremely threatening for you and scary.
Mrs. E:	=	It was excruciating for me. However, I experienced such scenes often. I had that thought while I was downstairs. I am not sure if it was threatening. My feelings were more of a tension, helplessness. As if violence was in the air, but yes, threatening is an important word.
RB:	=	And there was nobody there with you as a child with whom you could share these feelings when you experienced these horrible scenes.
Mrs. E:	=	Yes, mother always kept out of it. It was always so vehement. So loud and scary but other children experience worse things and aren’t so damaged.
RB:	=	Seems like you are telling me that you shouldn’t be so damaged from your childhood experiences.
Mrs. E:	=	I just feel so overwhelmed when I see violence and I feel so inhibited. As if I am in shock and can not move or take action.
RB:	=	You know now that you are no longer 4 or 5 and have the feeling that you should cope better in the situation. But still a 4-year-old is overburdened in such a situation when they have no one to share their feelings and other children who can cope better when they experience violence at home might have someone like a teacher or kindergarten teacher with whom they can confide.
Mrs. E:	=	I know what you are telling me that I shouldn’t be so disappointed in myself. My mother really wasn’t there. I tried to get close to her and tell her but there was always such a distance, such a deficiency in her responses. I think I gave up early on seeking her out for comfort.
RB:	=	When you need consoling and felt rejected by her. You know what just occurred to me. What we talked about last week. About Jane being accosted on the street and feeling threatened by the violence of her ex-boyfriend but how she sought you out for consoling. And in your situation it was also often the father who was threatening and your mother too. You could give your daughter what you didn’t get. But who could you turn to?
Mrs. E:	=	That is definitely true. There was so much violence and so much wild rage. There is so much danger coming from both parents. I think that there should be some kind of law that makes parents who are violent do training that is missing in our society. I know my father was a victim, himself, being only 17 years old and being a prisoner of War. After the war, he wanted to be a surgeon. I think there is also something violent in that job. Almost like a butcher. Do you agree?
RB:	=	I think you are telling me that you think your father wanted to be a surgeon, not just to save lives, but for him there might have been something sadistic as well. Is that right?
Mrs. E:	=	Yes you’re right. He didn’t become a teacher because he loved children, but because he loved power and control …

Mrs. E still has a lot that she wants to work on. She has no real profession, as she does not want to work as a nurse in an old age home. She sometimes has the fantasy of becoming a psychologist, but knows to do that she will have to get her high school degree (Abitur). She now works as a waitress in a café. She also has to work on her relationship with her husband because, in many ways, she has outgrown him and has a desire for a more dynamic and articulate partner. We would both love to see him in therapy as well, because he has major issues with his parents and lacks friends.

I also believe that what has helped in the treatment of Mrs. E is what the Boston Change Process Study Group (2010) called implicit relational knowing and moments of meeting. In our many years of working together, we have gotten to know each other very well. As Ed Tronick wrote, “Implicit relational knowing is constantly being updated and ‘re-cognized’ as it is accessed in day-to-day interaction” (2007, p. 413).

EPILOGUE

The patient ended her analysis in December, 2011 and has begun working in a medical laboratory as a technical assistant. There, she has informed me that she is doing very well and gets along with her fellow workers. Her husband entered psychoanalytic treatment and the couple are increasingly able to communicate with each other. They moved out of the house of the parents-in-law and are now living in a new community near the Waldorf School that the children attend.

Additional information

Notes on contributors

Ron Bodansky

Dr. Bodansky is Member of the MAP (Munich Working Circle of Psychoanalysis), Teaching and Training Analyst, Council Member of IAPSP, and Director of Munich Forum for New Developments in Psychoanalysis.