Metaphoric, metonymic and psychotic somatoform dissociation

Abstract

The present paper seeks to propose, using a combination of psychoanalytic and linguistic thinking, a distinction between three degrees of symbolicity across the somatoform dissociative continuum: the metaphorical, in which there is a symbolic connection between the somatoform phenomenon and the traumatic content, the metonymic, which constitutes a revival of the traumatic experience without the ability to reflect on it, and the psychotic, in which the somatoform phenomenon is experienced as ego-syntonic, thus neither causes distress nor evokes thinking. Three clinical vignettes demonstrate how the higher the degree of symbolization, the more effective the therapeutic process. Finally, a fourth vignette demonstrates how acoustic association in the therapist's countertransference can constitute an antidote to the patient's acoustic dissociation, allowing the reclaiming of the capacity for linking.

Keywords:

• Trauma
• dissociation
• somatoform
• metaphore
• metonimy

One of the questions that bother psychoanalytic clinical and theoretical thinking for decades is the question concerning the recording of traumatic memories. Traumatic experiences often activate a psychic process of self-annihilation. Their acidity creates a type of psychic hole that absorbs the unbearable traumatic substances along with the subject who contains them (Laub, 2005; Modell, 2006; Moore, 1999; Oliner, 1996; Stern, 2012; Van der Kolk et al., 1996), leaving the subject imprisoned in a territory of negative possession (Amir, 2012) in which the traumatic contents are neither digested nor worked through. The earlier the traumatic events are, and the more severe their intensity, the more they are prone to create an inner enclave that on the one hand allows no way in – and on the other hand allows no way out (Amir, 2016a, 2016b, 2019a). This enclave is the traumatic lacuna (LaCapra, 1994).

Caruth (1996, pp. 91–92) writes about the traumatic paradox in which the most direct contact with the violent event may occur only through the very inability to know it. Trauma is not only an experience, but also the failure to experience that experience: not merely the threat itself, but the fact that the threat was recognized as such only a moment too late. As it was not experienced in time, the event is condemned not to be fully known (Caruth, 1996, p. 62). As such, it returns to claim its presence, trying to cover the experiential void through various symptoms. This reclaiming can take diverse psychological as well as somatic forms, which simultaneously preserve as well as prevent contact with the traumatic materials. This deeply touches on the subject of dissociation in general, and of somatoform dissociation in particular.

Dissociation & somatoform dissociation

Traditional understanding of dissociation considers it a mechanism that is both defensive and adaptive: a process in which traumatic memories and feelings become disconnected from each other and get displaced in different parts of the personality (Bromberg, 1998; Chefetz, 2015; Kluft, 2000; O’Neil, 2009; Schimmenti & Caretti, 2016), preventing in this way from the traumatic experience, or certain aspects of it, to enter consciousness, thus allowing the individual to avoid processing or integrating information that is intolerable and inescapable. The more extreme the traumatic experience, the more massively the dissociative mechanism will be deployed (Bromberg, 1998; Chefetz, 2015). Van der Hart, Van der Kolk, and Boon (1996) suggest that pathological dissociation can be divided into three forms. In primary dissociation, a traumatic experience is processed in parts, rather than as an integrated whole. Secondary dissociation involves the individual perceiving an event without experiencing its full emotional impact. Tertiary dissociation involves the development of separate identities, each of which contains emotional and cognitive material that is unavailable (or only partially available) to the other identities. This distinction has later been refined (Nijenhuis & Van der Hart, 1999) to focus on the psychological dysfunctions involved in each form: while primary dissociation involves traumatic experiences being seen as isolated from the individual rather than as isolated from each other (as suggested by Van der Kolk et al., 1996), in secondary dissociation there is a division of the components of an experience (e.g., remembering a trauma without the affective component). Finally, tertiary dissociation involves the formation of distinct ego states (Waller et al., 2000).

Somatoform dissociation includes dissociative symptoms that phenomenologically involve the body and are related to the sensory and motor components of experiences, such as hearing, feeling, seeing, speaking, and moving, including conversion symptoms (Ellert & Nijenhuis, 2001; Nijenhuis et al., 1996). Although the tendency is to treat dissociation as a mechanism related to psychological symptoms and factors, patients with dissociative disorders report many somatoform symptoms, and many meet the diagnostic criteria of somatization disorder or conversion disorder (Ellert & Nijenhuis, 2001; Pribor et al., 1993; Ross et al., 1989; Saxe et al., 1994). In addition, patients with somatization disorder often have amnesia (Ellert & Nijenhuis, 2001; Othmer & DeSouza, 1985). Although somatoform disorders are not conceptualized as dissociative disorders in the DSM, the strong correlation between dissociative and somatoform disorders indicates that dissociation and conversion symptoms, particularly somatization symptoms, may be manifestations of a single underlying principle (Ellert & Nijenhuis, 2001). Among various types of traumas, physical and especially sexual abuse, best predicts somatoform dissociation (Coons, 1994; Ellert & Nijenhuis, 2001; Hornstein & Putnam, 1992; Kluft, 1995; Lewis et al., 1997).

Psychoanalytic thinking, beginning with the study of hysteria, strongly coincides with these data. The concept of somatization has its origins in the work of Freud (Breuer & Freud, 1893–1895), who proposed the idea of conversion as a main defense mechanism. The nineteenth century symptoms of hysteria are very characteristic of the twentieth century dissociative disorders. In fact, the items of the Somatoform Dissociation Questionnaire (SDQ-20) comprise many of the symptoms that mark hysteria as described by Janet, whose clinical observations suggested that hysteria involves psychological as well as somatoform functions and reactions (Janet, 1889/1973, 1893, 1901/1977/1907/1965).

Ferenzci (1932) argued that the human individual has two memory systems: while the subjective memory system includes feelings and bodily sensations, the objective memory system includes external events and sensations ascribed to one’s surroundings. The earlier an event, the more likely it is to have been encoded in the subjective memory, that is, as a bodily sensation or response. Having been inscribed in the body, certain types of memory can only re-surface in the body. Ferenczi considered the occurrence of bodily symptoms during psychotherapy as evidence of the return of this type of memories – a return made possible because and as part of the process of therapeutic regression. Winnicott (1954), too, regarded bodily experience as the substrate of psychic formation. He described the developing individual as a mode of being within which psyche and soma are inextricable and become distinct only as a function of the observer’s viewpoint. In his article ‘Ego distortions in terms of true and false self’ (1960) he focuses on the stage by which the patient allows contact, however partial, with hitherto inaccessible regions associated with his or her true self. It happens often that the patient falls ill during this process, thereby giving the therapist the opportunity to assume the role previously taken by the false self.

French thinkers linked the psychosomatic drama with difficulty in transforming body into language, or the raw primary data of experience into words and symbols. When the mother-infant relation is dysfunctional, the infant finds it hard to internalise the maternal object enough to dare losing and recreating it as a symbol, thus form a representation of its absence (Green, 1998; Kristeva, 1987). In such cases the infant goes on generating physical symptoms as a way of keeping the mother close as well as expressing his inability to mourn her in the process of internalisation Amir, 2014). MacDougall (McDougall, 1989) argued that where experiences are not successfully repressed, thus gaining no internal representation, they cannot even serve to generate neurotic symptoms. When temporarily, or for a longer stretch of time, the psyche is unable to restore what has been expelled from consciousness in the form of symptoms, the release of dreams or any other type of mental activity, it enters a state of deprivation. It is likely, in such a case, that the psyche will respond by somatisation. Like in early pre-linguistic childhood, the somatically reacting psyche will directly access the ‘thing’ – not the word that represents it. The bodily reaction is a primitive representation of the experience – but one that cannot turn it into a meaningful experience or enable release. MacDougall mentions in this context a phenomenon she calls ‘archaic hysteria’. Unlike its neurotic counterpart, which is a more developed form mainly related to anxiety associated with sexual satisfaction and desires – archaic hysteria concerns the very desire or right to exist. These are not anxieties of the more ‘developed’ kind, but ones that occur where personal identity or life itself are under a threat of extinction. These states are marked by damage to a body part or bodily function without organic reason. Since the anxieties involved are unavailable to symbolic, reflective, verbal representation – no neurotic symptoms evolve. What remains is the thing itself, without any possibility of distancing.

In ‘A question prior to any possible treatment of psychosis’ (1958/2007) Lacan writes about the notion of ‘forclusion’ in the context of psychosis. Repression and forclusion differ in that while the former aims to remove a thought or an image from consciousness, the latter removes it from the unconscious. In other words, while repression strives to fix the materials in the unconscious, forclusion casts them out of it. While repression is part of normal psychic functioning, though under certain conditions it has neurotic outcomes that impair functioning – forclusion consists of a violent rejection of psychic reality and its implications are catastrophic. It leads to psychosis rather than neurosis.

I would like to differentiate now between three states of somatoform dissociation which are located between the pole of repression and the pole of forclusion: The metaphorical, in which there is a symbolic connection between the somatoform phenomenon and the traumatic content, the metonymic, which constitutes a revival of the traumatic experience without the ability to reflect on it, and the psychotic, in which the somatoform phenomenon is experienced as ego-syntonic, thus neither causes distress nor evokes thinking.

Metaphoric, metonymic, and psychotic somatoform dissociation

Metaphor and metonymy are two forms of semantic shift, that is, two modes of transition from one semantic field to another. Metaphor is the use of a word or expression in a borrowed rather than simple sense, or rather the use of the characteristics of one concept to illuminate another. Metaphor is based on analogy, namely on a relationship of similarity between two semantic fields. The sentence ‘My love is a rose’ does not imply that the rose itself is the beloved one but that something in the beloved one’s features resembles those of a rose.

Metonymy, by contrast, is a figurative tool that illustrates something by replacing it with another that is situated close to it in time or space, or that belongs in the same context. The result is not logical in the simple sense, thus can only be understood through the proximity between the two elements. This is how the expression ‘the White House’ comes to stand for the notion of ‘the President’s spokesperson’. As opposed to metaphor, in metonymy there is no transfer of characteristics between the two elements (the President’s spokesperson is not meant to share features with the White House). The connection between them is associative only in a way that allows us to perceive the one as representative of the other (Amir, 2014; Efrati and Israeli, 2007).

In his article ‘Two aspects of language and two types of linguistic disturbances’ (Jacobson, 1956/1971), Roman Jakobson presents metaphor and metonymy as opposites rather than parts of the hierarchical order in which they are more commonly seen. He stresses the similarity that metaphor installs between its signifiers versus the contiguity typical of metonymy. Each of these modes of transposition, he argues, relies on different cognitive skills. While metaphor is based on the cognitive ability to convert, metonymy implies the cognitive ability to connect and contextualise. Jakobson divides the aphasic patients with whom his article is concerned into those who suffer from impaired identification of similarities as opposed to patients whose ability to combine and contextualise is affected.

Lacan’s distinction between metaphor and metonymy diverges from Jakobson’s. Though, following the latter, he associates metaphor with the axis of linguistic selection and metonymy with that of combination, metaphor for him acts to constitute meaning while metonymy resists meaning: the metonymic drive is related to the desire to recover the lost Real. Metaphor, by contrast, is associated with the symptom whose creation is a constructive process in which new meaning is generated.

What is a metaphorical somatoform dissociation versus a metonymical one?

Symbolic somatic phenomena, those which while resisting consciousness nevertheless participate in the symbolic order – can be considered ‘metaphorical somatoform dissociation’. The metaphorical somatoform dissociation is an estranged formulation, in a ‘foreign language’, of something a person either cannot or is not willing to fully recognise. It resembles the conversion phenomena typical of neurotic hysteria. The more primitive somatic phenomena may be seen as ‘metonymic somatoform dissociation’. Here there is no rich expression – not even in a different language – of repressed material, but rather a limited shift from the psychic scene to that of the body, or from one physical scene to another physical one (Amir, 2014). It creates a continuity with the traumatic materials, resurrecting them in the vivid present, in a way that is more reminiscent of what MacDougall called ‘archaic hysteria’ (McDougall, 1989). One can think of the metaphorical somatoform dissociation as a layered structure in which what is located on the surface (the somatic phenomenon itself) is perceived, consciously or unconsciously, as covering another level of consciousness. In contrast, the metonymic somatoform dissociation is a transverse structure. It is not a structure in which one level covers another, but rather a structure in which one phenomenon is connected to another in a more primitive way, where, as mentioned, association replaces analogy.

Finally, there is a third type of somatoform dissociation which I term ‘psychotic somatoform dissociation’ (Amir, 2014, 2016a, 2016b, 2019a. This phenomenon neither allows for reflection nor does it resurrect the traumatic experience as is. It is a massive attack on thinking and linking. Unlike metaphoric and metonymic expressions which through the distress they cause make a connection, even if a primitive one, with the excluded content – psychotic somatoform dissociation does not only fail to hold meaning (as metaphoric somatoform dissociation does) or preserve continuity (in the way of metonymic somatoform dissociation), but also simply numbs the distress itself, thereby turning any thinking redundant.

And yet, why psychotic?

In both the case of metaphoric somatoform dissociation, where the severed part symbolizes something directly associated with the traumatic memory, and that of metonymic somatoform dissociation, which consists of a vague resurrection of the traumatic experience by producing a kind of contiguity with it, somatoform dissociation is felt to be ego-dystonic (foreign to the self) with the resulting mental distress that accompanies it. These two types of somatoform dissociation, therefore, re-kindle the amputated traumatic contents through the distress they arouse, constituting a kind of invitation, even a demand, for thinking. Psychotic somatoform dissociation, on the other hand, is felt to be ego-syntonic rather than ego-dystonic. What we observe here is neither a symptom demanding meaning (as in the metaphoric somatoform dissociation), nor a contiguity which revives the traumatic real in the here and now and connects to it in this way (as would be the case in metonymic somatoform dissociation), but rather a somatic formation that stays transparent to the subject and hence arouses neither distress nor curiosity. In Bion’s terms, this type of somatoform dissociation constitutes the most serious attack on linking (Bion, 1959) not because it blocks the way to the traumatic material but because it does not evoke any mental movement in relation to it, leaving the subject in a state of terminal apathy.

Even though these three types of somatoform dissociation are described here as distinct formations, every single somatoform-dissociative phenomenon might display various combinations of the three types, with each acting as a different dimension of the same phenomenon (see the 4th clinical illustration). While the two first formations are responsive to in-depth interpretations (in the case of metaphoric somatoform dissociation) or experience-near interpretations (in the case of metonymic somatoform dissociation), the psychotic formation remains unresponsive to either form of interpretation. It is this psychotic element which produces a ‘negative therapeutic reaction’ (Riviere, 1936) in cases of somatoform dissociation, because in relation to it any linking is felt as unbearable threat. And so, chances of a successful psychodynamic psychotherapy depend on the extent to which the metaphoric and metonymic dimensions dominate the somatic dissociative register, indicating that the therapeutic alliance must be made with them.

Clinical Illustrations¹

Metaphoric somatoform dissociation

A., a man about 30 years old, seeks therapy following a traumatic event in which he forgot his son in the car. The baby lost consciousness and A. was alerted by passers-by who noticed the unconscious child, smashed the window, and activated the car alarm. During the long hours at the intensive care unit, A. began to feel an intense tingling in his right arm. This condition, which remained without any neurological indication, deteriorated, growing so bad that he would suffer severe pains in his arm for days on end (the kind of pain one feels when one’s arm goes numb). At other times he lost all feeling in this arm. He sought therapy after medical examinations came up with nothing and the doctors suggested that the origins of his complaint might be emotional, pointing to the fact that the problem had started immediately upon the traumatic event of his forgetting his son in the car. The patient told me, in response to my question, that it was his right arm with which he usually reached back when he was driving and wanted to caress the feet of the baby who was strapped in his baby seat in the back of the car. The tingling in his arm came and went for months. Gradually it stopped, but tended to return when he was somehow in transition. We understood this as related to the fact that in such situations (say moving from car to playschool) he was prone to repeat the traumatic failure of leaving his child behind. In time, as our processing of the traumatic event deepened, the tingling in his arm disappeared. I offer this as an illustration of metaphoric somatoform dissociation because it involves two examples of symbolicity. First, the loss of sensation was in the arm that connected the father with the child, symbolizing the moment in which this connection was ‘numbed’ enough to enable the father to leave the child behind. Second, the numbness symbolized the state of mental numbness in which the father found himself on the morning of the incident, and which, probably, caused the traumatic forgetting.

Here is an example of a ‘metaphorical interpretation’, in this context: ‘Your numbness is a bodily recording of what happened in your mind, namely the dimming of consciousness, which made it possible to leave your baby in the car. And it is placed in the right hand, the hand you describe as connecting between you two, at the same time as an indication of the traumatic wound and as a warning signal’.

Metonymic somatoform dissociation

B., a woman about 30 years old, was raised by a depressed and dysfunctional mother. Though she did not experience intended abuse, she spent her entire childhood being severely neglected, both physically and emotionally. According to what a few relatives told her after her mother’s death from cancer (when the patient was in her twenties), the mother, who was suffering from extreme post-natal depression, could have for instance changed her diaper, on the one hand, yet forget to feed her on the other; or might put the child to sleep while she was crying with hunger, or alternatively feed her but fail to notice that the baby’s entire body was covered in an itchy nappy rash because she was leaving her diapers unchanged. The patient developed a habit of ignoring her hunger and pain. The dissociating function she internalized was activated whenever she experienced either distress or arousal. For instance, she may walk for miles without noticing that her feet are bleeding into her shoes, she forgets to eat for entire days, and one of the things that distresses her the most is her falling asleep during sexual activity.

The reason why this illustrates metonymic somatoform dissociation is because the phenomenon does not symbolize the patient’s mother’s detachment by means of creating a metaphoric distance, but rather revives it in its raw form, creating in this way an experiential contiguity between daughter and mother through the resurrection of the primary maternal environment. And yet, these dissociations are attended by clear distress that opens a window of opportunity for working through.

Here is an example of a ‘metonymic’ interpretation following the patient’s report of an entire day in which she forgot to eat and drink and ended it in a state of nausea and dehydration (the patient stated that alongside the physical distress there was also a feeling of ‘familiarity’, even a sense of ‘being at home’): ‘Being dehydrated, or neglected, is a familiar physical feeling. That’s why it’s a bit like feeling at home. And maybe this is also your way, when you miss your mother too much, to call her back’.

What is the difference between the ‘metaphoric’ and the ‘metonymic’ interpretation?

The former is based on the metaphorical connection between the physical and mental numbness: the hand symbolizes the parental connection between father and son, and the numbness located in this hand is a physical record of the catastrophic rupture of this connection. The interpretation uses, therefore, relatively developed symbolic capacity from the patient’s side. The metonymic interpretation, on the other hand, links one thing to another not symbolically but in a way that is experience-near. The dehydration does not symbolize the neglect, or is analogous to the neglect, but is a reproduction of the neglect itself: the experience of the physical distress caused by the dehydration is a kind of memory in action, a revival of the early childhood environment.

In both cases, despite the differences in the level of symbolism, the interpretation was part of prolonged process of working through of a traumatic content that the somatoform symptom allowed access to.

Psychotic somatoform dissociation

C., a woman of about 40, known to the social services for years, is introduced to me by her therapist who comes in for supervision. The problem at hand is C’.s inexplicable somatic phenomenon: a muscular rigidity which breaks up her movement, so that both arms and legs move in a manner reminiscent of what one would call staccato in music, as opposed to the legato of more naturally flowing motion. The patient herself seems to have no obvious awareness that she is moving in this way, and she does not seem troubled by it. The neurological tests she has done over the years yielded no significant results.

C. was diagnosed with one psychotic-paranoid episode in her early twenties. This diagnosis was based, in part, on her claim that her father was a secret agent who pretended to be a gynecologist (which he really was) to implant ‘chips’ illicitly collecting information about his patients.

This accusation was related to another complaint C. expressed about having suffered long term sexual abuse from her father. She reported that he would make her recline in his gynecological examination chair every time she was menstruating, penetrating her with his penis, pretending he was carrying out an ultrasound of her ovaries. She told her mother about it on several occasions, but the latter silenced her by explaining that he ‘was only checking her to make sure she was developing properly’. The psychotic episode drove the last nail into the coffin of this accusation: now that she was diagnosed with psychosis, any validity her reports might have had becomes compromised in both her mother’s and her therapists’ views, as well as in her own.

The beginning of her fragmented motor movement can be traced back to her first psychotic breakdown. She was put on medication during a two-month hospitalization and then released. No more episodes of this type occurred, and medication was discontinued. The motor symptom, however, did not vanish. None of the behavioral therapies to which she was referred in the passing years was effective. Presently she is living with her sick mother in what used to be their family home. Her father, apparently taken aback both by the intensity of her psychotic breakdown and her accusations, left home for good while she was hospitalized. She looks after herself physically, and assists her mother with simple chores, but does not maintain relations with anyone other than a few close relatives. Her case was presented to me for supervision, as part of a supervision group for social workers, run by the social services.

I mention it as an illustration of psychotic rather than metaphoric somatoform dissociation (representing, for example, the mental attack on linking through the physical attack on motorial continuity) because of the patient’s own attitude to the physical phenomenon, or rather: her non-attitude to it. She treats it as something in need of neither diagnosis nor treatment, something transparent to her, and therefore arousing neither curiosity nor distress. When the examining neurologist asked her whether it did not hinder or trouble her, she answered – ‘it troubles my mother’. Upon being asked whether she understood what it was that troubled her mother, she replied she had no idea. Her bizarre motor behavior seems to have erected a barrier between herself and her past trauma, now contained in an untouchable psychosomatic capsule. As long as psychotic somatoform dissociation endures, she is protected, if not entirely from external impingements – than at least from internal seepage in the form of her traumatic memories.

As opposed to the two earlier mentioned types of somatoform dissociation, which produced ambivalent contact (both distancing and beckoning) with the dissociated material, thereby enabling psychic movement in relation to it, psychotic somatoform dissociation not merely thwarts contact with the excluded material, but also neutralizes all motivation to search for meaning.

When it comes to areas of psychotic somatoform dissociation alongside which one can also identify areas of somatoform dissociation that have a metonymic or metaphorical quality – one can work dynamically with the other areas, attempting to increase their surface area in relation to the psychotic surface area. But in cases like the above one, where the dominant area is of psychotic somatoform dissociation, psychodynamic therapeutic work will be much less effective in the absence of any motivation for encounter with depth and meaning.

Vocal Association as Antibody to Vocal Dissociation: Reclaiming of Linking in the Countertransference

D., a woman in her forties, seeks psychoanalysis following continuous traumatization. Between age three and thirteen she was repeatedly raped by her older brother, to whom she felt deeply attached. It happened behind closed doors while her parents were downstairs watching TV.

D. developed a vocal somatoform dissociation, characterized by episodes of either voice-loss or alterations in her voice. She describes episodes during which she is unable to produce any sound, along with episodes in which she wakes at night terrorized at having heard herself speaking in a low male voice (this may suggest dissociative identity disorder, but other than these voice alterations there is no indication of it). One may think of the voiceless episodes as well as the male-voice episodes as two formations where traumatic material is being displaced to the body. Thus, the shifts between her nocturnal male voice and the stretches of daily non-speech were interpreted in analysis as oscillations between metaphoric identification with the (male voice of the) aggressor (Ferenczi, 1932/1988 and the metonymic reenactment of the silencing, which was imposed on her both by external as well as internal origins. While the male voice can be considered a manifestation of metaphoric somatoform dissociation (symbolizing the abuser’s voice forcing itself on her voice), the loss of voice has a more composite, metaphoric-metonymic quality: the metaphoric part is associated, as said, with the silencing imposed on her by herself as well as by her family, while the metonymic quality is related to the creation of contiguity with a long-term experience of helplessness; contiguity with the inability to transform what was physically and emotionally intolerable into speech.

The session I will describe now took place some years into analysis. D. was trying to recollect a lullaby of a Scottish origin her brother used to sing to her when she was a little girl.

She remembered loving the tune even though the words made her sad. Then she recited, her voice rather mechanical, the lullaby’s lyrics, which one can understand as both seductive and cautioning. It was not surprising she recited these words in a mechanical voice. I understood it as her way of creating metonymic contiguity with the experience of being made into a silent, inanimate object used to gratify her brother’s needs. It housed, in the form of a phantom object (Sopher, 2018), her absent, amputated voice – as if marking the site of its burial. Maybe this was what led me to ask her, almost inadvertently, whether she would like to sing the song in her own voice. To my surprise she sat up on the couch, facing the open window, and sang it in a clear voice I had never heard from her before. When she finished singing, she began to weep. Seated behind her, I, too, teared up:

The water is wide, I cannot cross over

Nor do I have light wings to fly

Build me a boat, that can carry two

And both shall row, my love and I

Love is gentle, and love is kind

The sweetest flower when it’s first new

But love grows old and waxes cold

And fades away like morning dew

There is a ship that sails the sea

She’s loaded deep as deep can be

But not as deep as the love I’m in

I know not how I sink or swim

Botella (2014) writes about what he calls ‘acoustic figurability’ (pp. 919, 927): a moment when a melody playing in his own head allowed contact with a certain content belonging to his patient, and which completely escaped representation. Listening to my patient at that moment, reciting the song’s lyrics in a way that dissociated both lyrics from music and lyrics from vivid experience, I remember holding the music, even singing it, in my head. With a hindsight, I understood that what I stored at that moment was not the melody – but rather the possibility of a link between melody and words, as representing the very possibility of linking. As opposed to the patient’s dissociative mechanism of silencing, which was rendered both through the formation of no-voice and the voice’s transposition to a male register, my singing, and the patient’s singing following it, acted as antibody.

Novalis writes beautifully: ‘Disease is a musical problem. Cure is a musical solution’.² What stood up at that moment against the ‘musical problem’ of the acoustic dissociation was the ‘musical solution’ of the acoustic association. This unique example represents a central guiding principle in the treatment of somatoform dissociation: the therapist must be alert to any cue that allows for the restoration of the patient’s capacity for linking, whether located in the patient – or in the therapist’s own countertransference.

Caruth, in her book ‘unclaimed experience’ (1996), suggests that sometimes we speak in a voice that anticipates us. That voice, as D’.s singing illustrates, is a miracle of life preserved inside the inferno: a testimony to the human psyche’s capacity not only to bypass that inferno, as in the case of dissociation, but also to pass through it; not only to find a way out, but also to reclaim a way in.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1. All the details that may reveal the identity of the patients described in this paper have been disguised in a way that does not allow identification.

2. https://quotefancy.com/quote/1346880/Novalis-Every-disease-is-a-musical-problem-Its-cure-a-musical-solution-The-more-rapid-and.