Discussion Paper: The Application of Therapist's Maternal Capacity in Prerepresentational Body-Based Transference and Countertransference
Author: Ellen L. K. Toronto, Ph.D. Click here to view other discussion papers.
The Application of Therapist's Maternal Capacity in Prerepresentational Body-based Transference and Countertransference
Ellen L. K. Toronto, Ph.D.
“. . . our classical psychoanalytic models of mental functioning, to the extent that they are based on meaning, are insufficient for conceptualization of the manner in which psychic life is organized from the period before the infant becomes a verbal child . . .” (Joyce McDougall, 1989, p.36)
Theoretical development and clinical experience over the past 20 years have come increasingly to recognize a group of pathologies whose onset occurs in the early developmental period of the child, before language and before significant structural differentiation has taken place. These pathologies, involving developmental arrests and deficits in the core structure of the self, have necessitated a revision or certainly an extension of classical theory and technique. We have come to recognize that crucial reparative work must frequently be done and that this work must take place within the contest of a relationship which provides the kind of empathic attunement that was missing in the original mother/infant experience. The psychoanalytic therapist, like the good mother, must furnish a safe space, a holding environment, in which the patient\\\'s maturational needs can unfold. For those patients who evidence these early developmental deficits, the traditional tools of psychoanalysis, i.e. free association and verbal or representational exploration of the transference relationship, are not readily available. These patients must first experience the “being,” the holding, the affirmation of their continuous existence, much of which must be communicated nonverbally, before the symbolic conflict-based work can proceed.
Our work in this area, once thought to be outside the domain of psychoanalysis, has been greatly facilitated by the convergence of several lines of discourse which I wish to touch upon briefly. Our understanding of the early mother-child relationship, for example, has been greatly expanded by the explosion of research which has revolutionized our view of the infant. Observational research from many quarters has taught us that from the moment of birth the “intelligent” infant is an interactive, engaging, hard-working being, striving within the limits of its physical capabilities to interface with the caregiver and thereby influence its human environment . The notion of a passive, encapsulated, nearly autistic phase has given way to the realization that from birth on the infant has the capacity to synthesize experience and arrange an ever-widening and complex assortment of stimuli. What has emerged from our greatly increased understanding of this early phase of life is a realization of the extraordinary complexity of the mother-infant relationship. Though the communication is largely non-verbal, certainly on the part of the infant, mother and child are found to be engaging in a complex continuing social dialogue, one which is absolutely crucial in the formation of a human being. Insofar as we attempt to replicate aspects of this early relationship in the clinical setting, we must acknowledge that a significant part of the communication between therapist and patient, at least initially, will be in nonverbal form.
A second and related line of thought has been what Stolorow (1992) calls “the shift from drive to affect as the central motivational construct for psychoanalysis” (p. 26). As Stolorow points out, affective development is not a product of isolated intrapsychic mechanisms, but rather, a property of the child-caregiver system of mutual regulation. Viewed from this perspective then the effectiveness of the therapist/analyst becomes heavily dependent upon the ability to resonate with the crescendos and decrescendos of the patient\\\'s affective states, responding, often cross-modally, with affective crescendos and decrescendos of his or her own. In this type of emotional environment, again reminiscent of the original mother-infant bond, the patient may experience the kind of “vitality affects “(Stern, 1985) which generate a felt connection and, ultimately, a cohesive sense of self.
A third obviously related and highly influential line of thought and one which has the potential to increase abundantly our understanding of the therapist\\\'s “mothering” function is the relatively recent acknowledgment that the original mother is herself a subjective being with a perspective of her own. We have come to realize that the context in which the child matures, i.e. the “facilitating environment”, is indeed occupied by a person, a woman with wants, needs and desires which may or may not match those of the infant. As we shift our outlook to emphasize the relationship between mother and child, we recognize an interactive synchrony between two highly engaged individuals in alternating roles of subject and object, observer, and observed. It is an interconnection which,at its best, becomes the prototype of mutuality, spontaneity, and authenticity in all relationships to come. The analytic engagement then, insofar as it partakes of that primal bond, becomes a living, interactive drama in which two participants, therapist and patient, strive to co-create those experiences of reciprocity, mutual recognition, and intimacy which facilitate change.
The convergence of these three lines of discourse, i.e. our new understanding of the “intelligent” infant; the importance of affect in the development of the self; and the perspective on mothering as a subjective experience, has both widened the scope of pathology amenable to analytic treatment and altered our view of the analytic process itself. Work with those patients whose pathology involves developmental arrests and deficits in the core structure of the self becomes heavily dependent on the capacity of the psychoanalytic therapist to remain affectively attuned in ways that the original caregiver could not. The therapist is, in short, functioning in many respects as would a mother in providing a nurturing sustaining relational medium in which her child may grow.
Though there are of course important differences, the similarities between the relationship of infant and caregiver and that of patient and therapist are many, the comparisons, frequent and apt. The mother -child relationship indeed becomes the prototype for that between therapist and patient. As we attempt then to broaden our understanding of this critical aspect of our clinical capabilities, it becomes appropriate to comprehend and describe as fully as possible the actual experience of mothering from the mother\\\'s own subjective point of view.
It is this line of inquiry which I wish to undertake through examination of the following questions: What precisely are mothers experiencing when they are responding empathically to their infants? How are they doing it? The question of why they are doing it is also important but well beyond the scope of this paper. Given that it is near-universal that women have mothered, how and to what extent are men able to access this kind of nonverbal receptivity and what are the special complications they face in doing so? How is this maternal capacity applied clinically in working with prerepresentational body-based transference? How does counter-transference manifest itself in working with nonverbal material? Finally, I wish to present ongoing case material in which all of these issues have been particularly relevant.
Who Is Mother?
How do we comprehend the experience of mothering from the mother\\\'s own subjective viewpoint? I believe that we must begin by acknowledging that it is frightening to even attempt to do so. It is frightening because all of us, at some level, carry within us the memory and the mental image of ourselves as tiny infants, helpless in relation to mother\\\'s awesome power. Hirsch (1989) has accurately described this limitation within classical discourse.
Mother . . . remains absent even to herself. The place she inhabits is vacant. Although she produces and upholds the subject, she herself remains the matrix, the other, the origin...Is it possible to tell the untold tale of maternal participation in the psychoanalytic narrative, staying within psychoanalytic terminology? Can we invest with speech the silence that defines maternal experience? (pp. 168-169)
Yet the psychoanalytic imperative, i.e., to bring the unconscious into consciousness, impels us forward. We have traveled into forbidden zones before and can do so again as we explore, this time from both sides, the earliest bond.
With notable exceptions such as the work of Daniel Stern (1985), descriptions of the mother/infant relationship from the mother\\\'s perspective have focused solely on her symbolic and representational world, particularly as it affects her infant. Early work such as that of Winnicott (l957, 1965) and Wilfred Bion (1967) outline the fantasy life of the mother and her reveries, preoccupations and projective identifications involving the infant. Selma Fraiberg placed maternal fantasies of a pathogenic nature at the core of disturbed parent-infant relationships with her concept of “ghost in the nursery”(1975). In recent years an explosion of psychoanalytic research has also focused on the maternal representational world and,though these studies are highly illuminating, they do not tell us how these representations are translated into actual behavior.
Yet it is precisely the” doing “which interests us. The infant does not know or care what mother is thinking except insofar as it affects what she is doing with him or to him. For those of us who are trying to understand what is unique about mothering, it is the “doing”, manifest in moment -by-moment interactions of mother and child, which distinguishes it surely as much as the thinking. It is the mother\\\'s inner world as it is translated into hundreds of behavioral acts which ultimately communicate with the child. Again, Stern acknowledges the impact of maternal fantasy upon the infant but says that there is no “ether medium” through which fantasies of mother and infant could affect each other unless they take a form that is perceivable and discriminable to both.
One of the significant difficulties in describing this experience from the mother\\\'s point of view is that it is for her, as well as for the baby, a phenomenon which is largely nonverbal, physically encoded.. As described by Wrye and Welles (1994), it is mother and baby in close physical contact.
The infant, having once been literally encapsulated in mother\\\'s womb in amniotic fluid, experiences closeness postnatally through contact with skin and bodily fluids, through her caretaking in relation to milk, drool, urine, feces, mucus, spit, tears, and perspiration. A mother\\\'s contact with and ministrations to her baby in dealings with these fluids may optimally create a slippery, sticky sensual adhesion in the relationship; it is, so to speak, the medium for bonding. This sensuality, experienced by both parties, is key in their relationship. (p.35)
It is from within this slippery, sticky sensual and nonverbal bond that mother and baby create their dance of reciprocity and engagement. Yet as Stern (1985, 1995) has pointed out, the mother\\\'s experiences, as well as those of the nonverbal infant, appear to remain largely outside of consciousness. She seems unable to even begin to describe what she is doing, what it feels like, and how she accomplishes it. It has remained in that realm of human experience occupied by the poetic, the spiritual, the mystical.
Stern\\\'s pioneering work has represented a monumental effort to bring that realm of human experience into consciousness through his painstaking descriptions in behavioral terms of the hundreds of actions and interactions which comprise the mother/child relationship. He describes this early bond as characterized by an infinite number of lived moment-by-moment largely nonverbal experiences which taken together over days, weeks, months, and years form the individual representations of their life together. The mother\\\'s effective participation in this critical period in the child\\\'s life rests on her ability to read and respond appropriately to the cues which the child gives. Stern (1995) suggests that these daily acts of mothering evoke memories both of the mother\\\'s infancy and of the mothering she received from her own mother. It requires a kind of “empathic immersion and primary identification” (1995,p.181) which may never have been fully employed before.
The mother\\\'s stored memories include both sides of the interaction, i.e. the parts that she experienced directly as a baby, and the parts of her mother\\\'s experience that she felt empathically through imitation and primary identification. Except in pathological situations, this need not necessitate regression. Rather it involves access, possibly unconscious or preconscious, to the mother\\\'s own functioning in infancy and, through identification,to that of her mother. It entails access to a play space or transitional space into which she can enter, reside comfortably without getting lost, and eventually leave in order to return to her already highly organized representational world.
Through Stern\\\'s intricate descriptions however we are able to understand the mothering experience, previously thought of as intuitive or even instinctual, in terms of microevents. These are distinct from macroevents which occupy most clinical theories, such as the birth of a sibling, the mother\\\'s emotional availability and so on. The clinical analysis of microevents involves questions such as the following: What is the physical distance between the partners? What is the physical orientation, that is, turned toward the side or full-facing? Where are the eyes looking? Is there mutual gaze? How loud or soft are the vocalizations? Furthermore it clearly illustrates that it is not just the baby\\\'s reaction to the mother, but also the mother `s reaction to the baby,which creates their relationship.
Stern suggest that the mother\\\'s capability to respond to the needs of her infant arises out of a unique psychic organization which he calls the “motherhood constellation”. (1995) He identifies four central themes which emerge when a woman becomes a mother, in our culture, anyway. The first, called the life-growth theme, involves the following basic question: Can the mother keep the baby alive? Can she make her grow and thrive physically? He adds that this theme is unique in the life cycle and, I would add, it is unique to women There are no other comparable relationships or points in the life cycle where one person is responsible for the life and growth of another.
The second theme involves the mother `s social -emotional engagement with the baby and is called the primary-relatedness theme. Can mother love the baby? Can she feel that the baby loves her? Can she realize that this is truly her baby? Stern states that this concept of primary relatedness concerns the very essence of what it means to be human, including the establishment of basic human ties of attachment, security, and affection.
Again I would add that this type of relationship is also unique in the life cycle. The work of early mothering literally transforms a biological organism into a human being. I believe that it is the influence of these two themes which create the singular quality of the mother infant relationship. Furthermore, their primal urgency ensures the kind of avoidance and denial which has made it so difficult to explicate them in terms of simple human behavior.
Winnicott\\\'s concept of “primary maternal preoccupation”(1957) is similar to that of the motherhood constellation, particularly the primary relatedness theme. He states that soon after conception is known to have taken place the woman begins to “shift some of her sense of self on to the baby that is growing within her.”(1965,p.53) Through projective identification with the baby, the mother is able to achieve a powerful sense of what the baby needs. Interestingly enough, Winnicott also draws a comparison between the mother and the analyst who is attempting to meet the needs of a patient reliving these very early stages in the transference. He states that the analyst goes through changes in orientation which are similar to those of the mother but that “the analyst, unlike the mother,(italics mine) needs to be aware of the sensitivity which develops in him or her in response to the patient\\\'s immaturity and dependence.”(l965, p. 53)Thus while he acknowledges that it is important and useful to understand maternal sensitivity, he continues to overlook the subjective state of the mother.
It is my belief that while certain aspects of mothering may alter in intensity during crucial phases, the fact that women can,and universally have, mothered is a critical organizing factor in their psychic lives, one which prevails whether they have actually given birth or not .I believe furthermore that women\\\'s reproductive capabilities are a central organizing aspect of their psycho-sexual development. I do not wish to enter at this point the current debate about the contructivist versus essentialist, fluid versus fixed nature of gender. While I feel that it is a useful debate and relevant to this topic, my purpose for this paper is to explore those aspects of mothering which are pertinent in the clinical setting. In doing so I cannot ignore the obvious fact that it is women who have mothered throughout human history. Furthermore, “new” fathers notwithstanding, the experience for most of us and for most of our patients was that of being cared for as infants by women. . As Ruddick states, to assume that mothering is genderless,” trivializes both the distinctive costs of mothering to women as well as the effects, for worse and for better, of femininity on maternal practice and thought.”(1989, p. xiii). The survival of their children and of the species itself has depended on their becoming skilled at what they do. I believe that it is unreasonable to assume that this activity which has occupied the vast majority of women for the bulk of their adult lives for thousands of years has not greatly influenced their unique development.
Does this indicate that only women can mother? Does it mean that mothering is innate, biologically given, informed solely by the anatomical and hormonal differences between men and women? Probably not, but then again these are the very questions I am attempting to explore. Insofar as we can examine this aspect of human behavior and bring it into the critical light of day, we can apply our knowledge, not only in the clinical setting, but also in the de-construction of rigid and limiting gender stereotypes.
In summary then when we speak about mothering we are talking about a specific set of behaviors, performed historically only by women, and based upon their own experience of being mothered as infants. It is unique in the human life cycle and, when viewed in terms of the kind of skill and commitment required, it is truly an amazing feat. It is this unique constellation of attributes and sensitivities which we as therapists profess to bring into the clinical setting for those patients who are reliving very early stages in the transference. How do we accomplish this? Can we describe in a conscious and relatively systematic way our experiences in doing so ? Do we,for example, feel the kind of life-and-death urgency in regard to our patients which a mother, of necessity, feels for her child, and what are the costs to us if we do? How and to what extent are men able to provide the kind of attunement which mothering entails and what are the particular difficulties they face in doing so?
How Do Men `Mother\\\'?
All things considered, it seems to me that the analyst\\\'s bisexuality must be well integrated to enable the development of the baby, made by the analyst and the analysand in their work together, the baby which represents the analysand himself, recreated.(Chasseguet-Smirgel, 1984,p.175)
In this discussion we have been viewing aspects of the infant/mother bond as an analogue for the therapist/patient relationship. The therapist\\\'s capacity to provide the kind of psychobiological attunement that was missing in the relationship with the early caregiver is critical for those patients with ruptures in the affective core of the self. Yet in reality across human history it is women who have provided this. Father\\\'s relationship to the infants has typically been quite different. Furthermore, we who are therapists as well as our adult patients were, almost without exception, raised by women.
If we take the position that, given thousands of years of evolution, female primates(including women) may have a biologically based substratum of mothering responses, but that the complex interaction between mother and infant is still heavily influenced by social learning and individual experience, we may then assume that men can indeed access their maternal capacity. Their ability to do would, to a large extent, depend on their comfort with their own maternal and feminine identification. It is this point of view that I would like to discuss further in this paper.
Parenthetically I would add that there is a third perspective,one which I find both illogical and disturbing, which holds that while both men and women can access mothering skills and capabilities whenever necessary, it is only women who should continue to do the actual mothering.
From a developmental perspective, the male child begins to consolidate his gender identity at roughly the same time he is acquiring verbal and symbolic skills. He recognizes that the concept male, even as he dimly comprehends it, specifically states “not mother” as one of its defining characteristics. While the little boy may continue to share his internal feeling states with his mother, both verbally and nonverbally, he, unlike the little girl, must disavow that aspect of his mother which understands them.
Mother provides an emotional holding environment through which the child\\\'s own inner states may be reflected, understood, and shared. It is an atmosphere of safety which she provides for exploring, experiencing, and feeling in the world and which the child comes, through identification, to be able to provide for himself. When that identification is disallowed, the child or adult must search for and depend on others to provide the emotional holding. Thus the male, lacking in varying degrees this feminine identification, may be unable to access his own inner feeling states or attune to and share inner affective states with another.
In the clinical setting the male therapist or analyst may be called upon to provide the kind of emotional holding or attunement needed by patients who are reliving these early preverbal experiences in the transference. If he is without access to or heavily defended against his own maternal identification, the male therapist may fail to recognize or acknowledge this type of material in defense against what Wrye and Welles call “regressive immersion in boundariless erotic fusion”.(1994, p.85) Without recoiling in anxiety, the analyst must be able to permit himself to experience a range of primitive and sensual body states engendered by the patient\\\'s material. He must be able to tolerate the fear that overwhelming anxiety will flood him; pull him away from analytic composure; erode professional boundaries; and threaten his masculine identity. When the pathology is severe and self-other differentiation, not well-established, the threat of annihilation anxiety, and regression into the mother\\\'s body evokes sheer terror on both sides of the couch..
The Prerepresentational Transference
Transference as we traditionally think of it rests on the individual\\\'s ability to formulate mental representation. He or she can put into words various thoughts, feelings,and wishes, elaborate themes and patterns, and explore their connections and relationships. Oedipal transferences involve triangular conflicts around sexuality and aggression. Preoedipal transferences concern issues of anger, dependency, separation and control. The patient\\\'s ability to work with these issues, including the abstraction of emotion, in symbolic form, is the means for exploring it.
In prerepresentational transference however, the elements are far less obvious and are grounded in preverbal levels of development. Quite distinct from her verbal productions, she may be concerned with very basic issues having to do with self-regulation, safety, security and attachment. As Krystal (1988)and McDougall(1989) point out, affects may be in their early form in which they are experienced as bodily sensations, resulting in alexithymic and psychosomatic conditions and disorders.
The successful treatment of the prerepresentational transference rests with the therapist\\\'s ability to provide a holding environment, a safe space in which the patient\\\'s maturational needs can unfold. The therapist must function in many ways as a real object, one who can provide the kind of emotional validation that affirms the patient\\\'s continuous existence in ways that were not available in his early environment. In order for this reparative work to move forward, the patient cannot make do with the fantasy of empathy, but must experience real empathy. He must perceive the therapist\\\'s real emotional availability, affective attunement, and nonsterile holding. In the context of a relationship which acknowledges and addresses the deficits which the patient has experienced early in life, he will then begin to repair structural ruptures and will become increasingly able to ally with the therapist in an investigative attitude which will allow him to explore the meaning of his thoughts, feelings, wishes and behavior.
Of course in practice the theoretical differences which distinguish a prerepresentational transference from a more traditional one are often difficult to discern. The task of the therapist is, as Killingmo states, to
derive his therapeutic strategy from an understanding of the unique structural make-up of the patient and formulate and apply his interventions so that they match this very structure. (1989,p.66)
This is, after all, exactly what a good mother would do, i.e. match her responses and interventions to acknowledge the developing capabilities of her child.
I wish now to focus on three developmental levels of communication and relatedness which may present themselves in the prerepresentational transference and which must be brought to some resolution before the more traditional transference work may occur,
The earliest developmental level is identified by Greenspan (1989) as the level of engagement. It is drawn from the birth to two month period where the essential tasks of the infant / mother relationship are the organization and regulation of elemental sleep-wake cycles, feeding patterns, management of stimulus input, as well as soothing and self-soothing behavior usually involving contact with the mother\\\'s body, breathing patterns and heart-rate. The level of engagement also includes the period from two to approximately seven months where interaction becomes noticeably more social It is here that the individual is making vital connections to the human world as the source of comfort, interest, pleasure and joy as well as the provider of physical needs.
There are wide discrepancies in the extent to which engagement is an issue in the treatment setting depending, of course, on the level of pathology involved . Yet I believe that it is a significant factor in many treatments, particularly in the beginning stages, and that it is frequently overlooked because it is communicated largely at the nonverbal level. Of course neither the sociopathic nor extremely withdrawn individual frequently make it into the consulting room, at least voluntarily. We have all however encountered the very frightened or anxious patient, barely able to sit down in the chair or make eye contact. He or she speaks, often quite rapidly and in nonstop sentences, and we understand intuitively that our only task at the moment is to make it possible for that person to remain in the room and, possibly, in treatment .We sit in our chairs, ourselves barely able to move lest we scare them off, and struggle to interact in a way that is neither too intrusive nor too aloof.
I am reminded of such a patient, a twenty-six-year-old-woman, who had already been in treatment for over three years when I was forced precipitously to move my office when the clinic where I was working suddenly closed. I came to the waiting room of the new office to pick up the patient and indicated that she should follow me down the hallway to the consulting room. I walked down the hallway, assuming that she would follow,but she did not appear. I went back and found her frozen in the spot where I had left her. We then walked slowly together back to my office and it was only after she had visually examined the hallway, the office, and virtually every object in it that she was able to speak at all.
The second developmental level, that of gestural communication, comes from the childhood period of about nine to eighteen months. Infant researchers and observant parents are keenly aware of a dramatic shift which takes place in the infant at around nine-months. Stern (1985) states that it is at this point that babies seem to sense that they have an inner subjective life of their own and that others do as well. It is now not enough for mommy to do things for them . She must also be able to share the focus of their attention, interest and pleasure. The infant is, of course, still unable to communicate verbally so, as Greenspan points out(1989), she and the mother develop an elaborate system of nonverbal signaling. The infant is moving from the primarily proximal mode of relating based on physical holding and bodily contact to the distal mode involving nods, gestures, and eye contact, even across the room. Stern and Greenspan both emphasize that this ability to signal and communicate about inner feelings and intentions is a vital precursor to representational communication.
Greenspan further points out that some of the most basic emotional messages of life are communicated at the gestural level. Critical information such as safety versus danger, acceptance versus rejection, concern versus indifference, acceptance versus control, respect versus humiliation are communicated presymbolically. When this particular mode has not been mastered, a person who seems to be communicating verbally may in fact be assessing issues of rejection, danger, or safety at a nonverbal level.
Stern states that much of the attunement which goes on at this developmental level is not about categorical affects such as anger, surprise, joy, etc. Rather it is an apprehension of what he calls “vitality affects” qualities which he describes as “surging, fading away, fleeting, explosive, crescendo, decrescendo, bursting...and so on”(1985, p.54) A patient of mine who has struggled for long time to articulate her feeling states recently described what she said was a “whoosh” feeling. I believe it is often these vitality affects that we are trying to comprehend when we feel particularly confused, muddled, and befuddled by our feeling experience with a patient.
Our lack of attention to the importance of the gestural level of communication is often, I believe, a contributing factor in failures in empathy, abrupt terminations, or therapies which never get going at all. I recall a man in his late twenties who had entered treatment largely at the urging of his wife who was about to leave him. He lacked verbal skills but seemed to be making a genuine effort to enter into treatment . After only a few sessions, he came into the office on a very warm day, both inside and out, wearing a black leather jacket elaborately decorated with silver zippers and grommets. It appeared to be brand new and very expensive. Toward the middle of the session in which he must have been sweltering he said, “I guess I\\\'ll take this thing off.” He then slowly and deliberately removed the jacket. The session ended and he did not return to therapy. With hindsight I realize that, while there were surely other contributing factors, a significant reason that he did not return was because I had missed the nonverbal statement that he was making with the jacket. He was telling me something about himself, his unique characteristics,perhaps his masculinity, the way in which he loved himself, which I failed to affirm or acknowledge. Had I picked up on this nonverbal communication and responded empathically, the outcome might have been different.
Finally I believe that the gestural level of communication must be attended to even with those patients who are communicating at predominantly verbal levels. We must keep in constant awareness questions such as the following: Where does the patient wait in the waiting room? How does he walk? What does she communicate with posture or manner of dress? As he enters the consulting room does he make eye contact before lying down on the couch? Does she make eye contact when she talks in face-to-face therapy? When the timing is appropriate to bring into conscious and verbal awareness this very significant nonverbal communication, the patient is far better able to understand the meaning of his or her behavior and make informed decisions about how to change its problematic aspects.
The third and final level of development which I want to consider draws from the period beginning around eighteen months when the child is becoming verbal. In ideal circumstances he would begin to communicate in symbolic ways about shared meanings and feeling states and would be increasingly able to distinguish fantasy from reality, differentiate inner subjective experience from external occurrences, sequence or connect events and feeling states and put them into context. But because of problems in earlier phases of engagement and gestural communication this capacity may be greatly compromised so that the person is actually functioning at a level that we might term behavioral description. He can describe physical events or behavioral events but cannot abstract emotional states . The therapist might mistakenly believe that the person understands the appropriate feeling state and might in fact supply it. If, for example, the patient says, “I hit my boss.”, the therapist might respond, “You must have felt angry.” If this interpretation is premature and the individual is not functioning at a truly representational level, he will be mystified by the comment. If he is being compliant, he may even agree but this will not move the process forward. If the whole procedure appears stagnated; if descriptions of external events are repeated over and over in unchanged form; and particularly, if typical kinds of transference interpretations fall on deaf ears, it is likely that the individual is using language in a purely descriptive way, without the capacity for interpersonal emotional exchange.
This was clarified for me in my work with a very intellectualized man in his early thirties who has been in once-a-week treatment for about seven years. He is extremely logical, verbal, and intelligent, and has an advanced degree in a highly scientific field. When he first began treatment he was able to describe detailed sequences of events which had transpired between him and his wife in particular. He was however unable to talk about or apparently understand the feeling states,either in himself or others, which might accompany those events. Over time as we have gone over behavioral sequences in minute detail, stopping the action at many points to ascertain what he or another person might have been experiencing, this has changed. He has, in the context of an environment where he feels increasingly safe to reveal himself,been able to abstract emotion. Recently he described how in the past he had been paralyzed into inaction because he knew in advance how his wife would react to what he might say or do. He said that he had previously thought of emotions as if they were the solution to a math problem. Once one had arrived at the solution it could never be changed. He now realizes that emotions are fluid and changing--like human beings. He has evolved to a new level of representational thinking where the possibilities for interpersonal exchange are indeed infinite.
Early developmental issues, as they evolve from tasks of self-regulation and engagement through gestural communication and behavioral description to true symbolic expression, are, of course, transacted through close, continuing, and intimate contact with the mother figure. As the patient reworks these issues, he or she does so within the maternal transference. Wrye and Welles(1994) have coined the term maternal erotic transference to capture the highly sensual nature of this relationship, arising as it does from a time before words when the medium of communication was actual physical contact with the mother\\\'s body as well as ministrations by her to the body of the infant. Not only is this communication nonverbal, but it is also messy, sticky, and slippery, comprised as it is of the various bodily fluids--milk, saliva, urine, mucous, feces--around which the mother-infant relationship is, of necessity, organized. Moreover it involves the kind of rocking, nursing, patting, holding and stroking through which the infant\\\'s needs are met. It is these largely repressed experiences, both painful and pleasurable, which a patient, in the throes of a maternal erotic transference, attempts to recreate in an attempt to re-work prerepresentational developmental issues. I believe it is noteworthy that, although numerous male analysts have written with great accuracy about the mother-infant bond, it is two women analysts who have, at least to my knowledge, first addressed this particular messy, sensual aspect of it as it appears in the clinical setting.
The development of a maternal erotic transference is impelled by the patient\\\'s desire for a transformational experience in and through the body of the analyst. He or she feels invisible, perhaps dead inside, or to use Wrye and Welles term, a “horrible dry hollow”.(1994).
For these patients the transformational aspect of the maternal erotic transference represents a creative attempt to “make the mother/therapist into a living, more dimensional whole person”(Wrye and Welles, 1994,p.40) and thereby become alive himself.
As the maternal erotic transference begins to develop, the patient `s material may take on a monotonous, concrete quality. Killingmo(1989) describes qualities of both” monotonous persistence”(p.72) and directness in the patient\\\'s way of demanding. The free flow of associations, even from verbally articulate patients, becomes blocked, filled with `pregnant\\\' pauses, or stuck .Words have the impression of being expelled rather than spoken. Bodily concerns become central and, if the patient is verbal enough, associations are filled with vivid body imagery . Wrye and Welles, for example, (1994) describe a patient who would report the sensation of feces running down her leg or her analyst\\\'s leg. For patients who are not able to work symbolically, concern with these issues may take a variety of concrete forms of enactment, e.g., preoccupation with the therapist\\\'s office, furnishings, car, or clothing ; bringing items into the consulting room to be “stored” or “safe”; bringing gifts; showing rather than telling. The patient may attack the analytic frame, missing sessions or refusing to pay. Though there may be many meanings to these enactments, Wrye and Welles stress the concrete quality as a common denominator. The patient, and perhaps the therapist,is experiencing something at a preverbal level that cannot be verbalized. The task of the therapist is to recognize the enactments for what they are,and remain in touch with his or her own responses without either distancing or acting out . He or she may then endeavor to bring into conscious awareness the underlying issues in whatever form the patient is able to tolerate.
The Prerepresentational Countertransference
As we consider the prerepresentational countertransference we now focus on the subjective experience of the therapist as he or she works with preverbal body-based material in those patients who, due to developmental arrests, have limited capacity to express themselves in verbal abstract form. In order to expand our understanding of the experience of the therapist we must return then to our original inquiry: What are mothers experiencing when they are responding empathically to their infants ?
Again, of course, the usual caveats apply. We are not really responsible for raising our patients . Their lives don\\\'t literally depend on us(even if sometimes it feels like they do).Yet we acknowledge that there are important similarities. In order for this reparative work to occur we must respond empathically . We must reach out with our feelings, becomes involved. Yet as with the attuned mother we must continuously ask ourselves: How do I do this while still respecting the child/patient\\\'s autonomy ? For us as psychoanalytic therapists the questions become very specific: How do I become empathically involved without eroding professional boundaries? How do I do this and still maintain the psychoanalytic frame? These are very difficult questions . We tread a fine line and there are no easy answers.
Again I believe the solution lies in trying to comprehend what it is we are doing . We need to make as explicit, conscious, and systematic as possible the nonverbal body-based sensations, responses, and interventions which are necessitated by this type of material. We do this by closely monitoring both ourselves and our work, consulting with colleagues when needed,and listening to our patients and their responses to our interventions. When we take risks, we will inevitably make mistakes. But then again, if we don\\\'t take risks we won\\\'t be successful with this kind of work at all. As in the mother-child relationship, it is the empathic failures on the part of the therapist which provide the opportunity and motivation for needed internalization on the part of the patient. Mistakes and even enactments are unavoidable. As Wrye and Welles state,” it is not possible to experience a countertransference fully without minimally enacting it in the treatment.”(1994,p64)
In their discussion of countertransference Wrye and Welles also point out that the therapist\\\'s responses may or may not match or mimic those of the patient. It is likely however that, at least initially, countertransference reactions will occur in nonverbal form. Unusual bodily responses, sleepiness, boredom, disinterest, apathy--all may signal that nonverbal material, outside of conscious awareness of both patient and therapist, is emerging. The therapist may even be responding verbally,and yet, an outside observer or video tape recording would reveal rapid speech, angry tones, confusing gestures and body language, i.e., a parallel response to the chaotic nonverbal material presented by the patient. It is the kind of parallel nonverbal communication one might observe in parents\\\' unwitting mimicry of the gestural language of their eight-to -twenty-month babies.
In their own work Wrye and Welles (1994) have identified four types of countertransference reactions. The first involves grandiose fantasies which emerge as feelings on the part of the therapist that the patient will be totally remade or reborn as a result of therapy . This may include the belief that some type of physical contact with the patient will magically cure him or her. A second reaction which they have identified involves a depressive response to the patient\\\'s need either for fusion or separation. Where the patient seeks fusion through regression, the therapist attempts to ward it off with crisp insights and penetrating interpretations, defensively refusing to be consumed. Conversely, when the patient is ready to separate, the therapist holds onto a view of her as infantilized, depressed, and needy. A third type of response occurs when the therapist distances from the patient\\\'s all -consuming needs which threaten to swallow up her office, home, and body with messy demands and treacherous oral greed. The therapist\\\'s disavowal of this type of material may in fact render the treatment lifeless.
In addition to these countertransference responses which block transformational work, Wrye and Welles also identify some aspects of therapist gender which may make it more difficult for therapists of one sex or the other to work with certain types of erotic transference material. They posit that female therapists may be able to identify and enter more easily into the patients\\\' wishes for boundariless fusion since it is less likely to threaten their own female identity. Males, on the other hand, while finding it more difficult to tolerate the regression necessary for working with the maternal erotic transference, may more readily recognize the patients\\\' oedipal sexual strivings toward them.
I would like to propose an additional factor, which is implied by a number of authors but nevertheless not explicitly spelled out,as a significant, even necessary, element of a therapist\\\'s response to a patient with early developmental deficits. I am referring to that aspect of mothering which Winnicott called “primary maternal preoccupation”(1957)and which Stern referred to as the “motherhood constellation”(1995). Though there are many elements to these concepts, the key feature which I want to address has to do with the mother\\\'s investment in the child. In order for the child to grow and thrive he or she must become “the apple of mother\\\'s eye.” The mother must think about the child, indeed become preoccupied with it, unreasonably so .This investment, almost by definition, has a narcissistic quality to it. This must, of course, be monitored for the child\\\'s best interests, but it means that the child\\\'s delight is the mother\\\'s delight. Lacking this aspect the caregiving is perfunctory, even custodial. In the clinical setting without this element of concern, investment, unreasoning delight in the patient\\\'s growth and transformation, the treatment also becomes custodial, perhaps technically correct, but ultimately lifeless.
Finally I would like to suggest some ways in which this particular feature of countertransference has become identifiable to me. First of all, in working with patients who are particularly regressed, I have become aware of the sensation of holding them inside me as if they were literally a baby in the womb. This concept, which was clarified for me by Koeple (1996),. recognizes the mother\\\'s original investment in the child as a part of her own body. I believe that this facilitates in ways which are not as yet clear to me, the kind of emotional holding which I can provide. As Koeple pointed out this kind of holding is possible,at least for women analysts,without overwhelming fears of regression or fragmentation. This may indeed be a key point in which men and women differ.
A second element which I believe to be critical in the therapist\\\'s investment in the patient has to do with a function which Stern named “interpersonal communion”(1985,p.148). This factor was identified by those mothers whom he studied as their primary reason or motivation for wanting to be attuned to their infants. It was their desire to “be with” the infant, to share the infant\\\'s experience with no attempt, at that moment, to change, restructure, or modify in any way what the child was doing or believing. By the same token the attuned therapist must convey to the patient that there are times when they are doing nothing more nor less than being together in the moment.
A third aspect of this quality of investment in the child/patient is something I have identified as I have been working on this presentation. This is not the first time that a patient has made rather remarkable gains during the time that I have been preparing a paper or presentation about him or her. I have observed this phenomenon in the patient I will be presenting below and in others as well. There may, of course, be many factors involved here. I may be conveying at some unconscious level that I need her to improve in certain ways so that I can appear in a favorable light to colleagues. The additional work that I do in preparing the case, e.g. extraordinary efforts at formulation and clarification, may bring to light important features which enhance the treatment. But I believe that there is another factor which relates to the quality of investment which she experiences from me. This patient longs for me to think about her during vacations, or even during the time between sessions. She expresses this sentiment frequently and very directly. During the time that I have been preparing this paper I have indeed been thinking about her an unusual amount.. At times I have been nearly obsessed with her, with the case, and how I will present it. Isn\\\'t this the kind of unreasoning preoccupation and involvement that children long to have from their mothers? Children want and, in fact need, their mothers to hold in mind a mental image of them during periods when they are separated. It actually helps them, as I believe it does my patient, to maintain a continuous sense of themselves. Other patients express this sentiment, though perhaps more circumspectly than my patient. I\\\'m sure many of us have been asked, “Are you going to write a book about me?” I surmise that this is a wish that all of us hold,i.e., to be kept in the mind of a beloved other as we once existed in the mind of our mother, and I believe that it has a reparative effect in the treatment situation.
For reasons of confidentiality the details of the case study have been omitted.
The story of Sarah illustrates many elements of the prerepresentational transference. Initially her limited capability in either understanding or expressing her experiences verbally made it necessary for us to communicate in nonverbal ways. Through data gleaned from facial expressions, body language, manner of dress, and other less readily identifiable bits of information we created a kind of nonverbal signaling which has gradually evolved into abstract symbolic form. I believe that in certain important respects I functioned as a real object for her, literally supplying the verbal scaffolding and emotional holding which, under more benign circumstances, her mother would have been able to provide. Through the enactment which occurred and Sarah\\\'s subsequent experience of my limitations and empathic failures, she has gradually been able to achieve the necessary internalization of object which will result in enduring structural changes.
In conclusion, the prerepresentational transference emerges from a period of life which makes a rich contribution to our existence as human beings. It comes from a time when we experience life totally, globally, outside the bounds which language places upon us. As such it is an abundant source of creativity, artistry, religion, intuition, and love. It is ours to use insofar as we are free to draw upon our early memories of those experiences within us.
To recall our experiences as infants, however, is only half the story. The woman, the mother, who lived and shared that with us is also stored within our memories, for good or for ill. She who could enter into that world of global, body-based, sometimes chaotic, experiences, sensations, and emotions, and make some sense of it for us, that woman is also within each of us. In our work with those patients who are still grounded in that nonverbal, often chaotic place, we must be able to draw upon the mother within us. Insofar as possible we must understand these mothering capabilities and render them explicit, conscious, and systematic. For women therapists this may entail, among other things, discussing and using unashamedly our maternal capacities. For men it may involve the exploration of fears related to regression and loss of gender identity. For all of us it will widen the scope of treatment possibilities and greatly enrich our work and our lives.
Bibliography is available upon request from: Ellen Toronto, 328 Thompson Street, Ann Arbor, MI. 48104..