| Psychoanalysis
and the Body-Mind Problem
by Michael Brearley Introduction One of the hardest aspects of our work as psychoanalysts is knowing what to make of persistent reports by patients of somatic symptoms, especially when they are isolated from further comment and associations, or when there seems no capacity (or willingness) in the patient to go further towards his or her emotional and mental reality than by referring to bodily states - pounding heart, stomach-ache, head-ache, and so on. As psychoanalysts we aim at a psychological understanding, and I imagine most analysts know the incipient feeling of helplessness - which it is our job to reflect on - when certain patients present this kind of material. We can easily feel that we are inadequate. We may too quickly lose confidence in ourselves or in the analysis, negating our understanding of the inevitable struggle involved in moving towards knowledge, especially in such cases. So, one counter-transference problem that such patients tend to evoke in us is the need think we know. We may thus be tempted to be wild analysts, constructing, and offering, heroic, magical and omnipotent interpretations. Along with this, we may make the error of failing to take seriously the physiological aspects and the possibility that what the patient needs is a medical check-up. Analysts who are also doctors may, on the other hand, revert to their former, knowing medical standpoint, and lose touch with their analytic stance. It is not surprising, in fact, that this is so difficult an area, because as our analytic understanding should remind us, somatisation is the outcome of the subject's repudiation of meaning. And it is often only after we have managed to understand and tolerate our not-knowing that we can begin, through careful and prolonged work with the patient, to get an often tentative idea of what these symptoms, and the reports, might mean in more psychological terms. With such an attitude we are able to be particularly alert for changes in the patient's manner or speech that indicate intrusions of unconscious material, such as parapraxes, hesitations, or the reporting of a rare dream (Aisenstein 1993). From such small openings we may be able to initiate small movements in the analysis, which may in time enable the patient and ourselves to grow towards a fuller psychic elaboration. However, as psychoanalysts we may, as I have suggested, slip from the view of body-reports as particularly difficult to understand into varying degrees of helplessness. We may even fall into a state of paralysis in which we are unable to reflect psychoanalytically on our feelings or on the patient. Then psychoanalytic perplexity about body-mind links in relation to certain patients at certain times can merge into a more generalised, quasi-philosophical perplexity; for a philosopher may put the sceptical argument in terms of the impossibility of a purely mental event, like an unconscious phantasy, ever producing bodily changes. In this paper I will first try to clarify some of the differences between ordinary doubts and uncertainties that are part and parcel of the psychoanalytic process, and the sort of doubt that Socrates called 'aporia', that is, philosophical and conceptual. Secondly I will describe one point at which aporia may creep into psychoanalytic thinking. Third I will raise a clutch of questions about the impact of a certain kind of psychoanalytical account of what thinking is. Does such an account, when fully digested, offer reason for the philosophical sceptic to think differently? Specifically, is the psychoanalytical model derived largely from Bion and Anzieu, in which mind is seen to be emergent from a body-mind nexus, to which we can under pressure regress, relevant to the philosophical arguments? I don't of course mean anything so hubristic as that it could solve them; philosophy has its own methods and paradigms. But if through psychoanalytic thinking we enlarge our notions of mind and body, so that mind is seen as emerging out of body-mind, could there be less need for the philosophical aporia? Would we be likely to ask different questions? I am not sure of the answer to these questions. More confidently, I do suggest that when we have more understanding of the origins of mind from the body and from body phantasies, we become able to understand our inevitable unease in this area. Fifth I will elaborate this approach by reference to an example of my own somatisation, and, sixth, to Anzieu's theory of a skin ego. 1. The relation of mind to bodily symptoms, or more widely between mind and body, seems to have something deeply mysterious about it, an attitude which can lead into philosophical scepticism, and thus into wildly implausible 'solutions', and half-baked compromises. With his notion of a pineal gland in the brain as the site of the body-mind link, Descartes had to resort to pseudo-science in order to escape a more deeply paradoxical mind-body parallelism, in which there can be no connections at all between events in the two realms. Another 'solution' is Leibniz's, that matter is fundamentally mental, the universe being made up of an infinity of 'monads', each containing within itself, and at whatever level of unconsciousness, its own partial viewpoint of the universe. Yet another philosophical solution is that mental phenomena are mere epiphenomena, thrown off like shadows by physical or material events. What are the features of the philosophical doubts that seem to necessitate such implausible solutions? As I have said, philosophical aporia is confusion of a purely conceptual kind.The philosopher Ludwig Wittgenstein said of philosophical sceptics that they don't doubt that under their trousers they wear pants. To give another example, the Idealist philosopher Bradley was reported to have ended one lecture with the following words: 'In this lecture I have proved that Space does not exist. In next week's lecture I will show that Time does not exist. Next week's lecture will be in room 6 at 10 o'clock.' Philosophers are not, that is, deluded, and their doubts are not really about the actual contents of the world. Their doubts do not, or need not, interfere with ordinary criteria for evidence, science and knowledge. But at times, and especially when doing philosophy, they, we, become puzzled and confused. In philosophy, doubt takes the form 'such and such cannot exist', where the 'cannot' is logical, not factual or causal. The puzzle is not about this or that particular hypothesis or claim, but about whole categories of statements or concepts. To return to the mind-body issue: a philosopher like Descartes is not concerned with particular mental states and their effect on particular body states or vice-versa, but with the whole category of mind-states as compared with the whole category of body-states. This perplexity is also related to the old issue of free will. We want to give a full place to the inter-related ideas of freedom, choice, responsibility and so on. Yet bodily actions, and the neural events that occur during mental activity, take place in a whole system of physical events and causes. What place is there for the soul, or the mind, or the self, in this chain? How are we to account, rationally, and with due recognition of the unconscious, for this experiential fact of life, this central element in our concept of a person? In our analytic work in the consulting room, such questions might be thought to be alien to us. We are concerned, one might think, with matters of fact, with what is or is not the case. We may have grounds for believing that certain bodily reports have - or don't have - particular psychological and emotional meanings. On other occasions we may think that, whatever the psychological complications in the situation or in how the patient talks about it or what he/she tells us about the transference, the patient may well be physically ill and needs to see a doctor. Often we may not know what to believe. But whether or not we think we understand something, we have an idea of what would count as evidence, and we know that further evidence, including the patient's responses, may lead us to revise our earlier ideas. However uncertain we are, we have our psychoanalytic experience to help us be open to the patient's vibes or projections, and to know that we may have to do a lot of internal work on our own thoughts and feelings to get closer to what is really going on in and from the patient. With patients whose presentation is full of somatic material, there is a range of possibilities. The patient may be alexithymic, (McDougall 1989) that is, unable to experience and conceive of what happens in him emotionally in a more or less articulated form. Or he may in more subtle and perverse ways be provoking us to omnipotent stances, which he is then in a position to repudiate, politely or otherwise. There may be some mixture of the two, or again, there may be a split between two parts of the self, one operating in concrete, evacuatory mode, with no detachment from or reflection on raw feeling, the other capable, within its range of comfort, of symbolic thought and a more emotional rather than sensation-based, concrete level of functioning. Again, there are understandable, evidential criteria to base such understanding on, whether or not we get it right on a given occasion. Doubt of this kind is very different from philosophical aporia.
I will start with natural expressions of emotion, a places where, as Wittgenstein also said, 'we touch rock-bottom'. We blush from embarrassment, flush with anger, go pallid when afraid, and cry from grief. Sweating, crying, blushing, shivering, going pallid, mouth open, eyes wide open, panting, tachycardia, tension - natural expressions of emotion. These physiological changes merge into action, doing. We strut or cower. The physiological expressions of fear merge into cringing or fleeing, those of anger into striking out, of disgust into vomiting. Fainting and becoming dizzy merge into falling asleep, which is something we can do, or try to do, or try not to do. Some patients, for example, suddenly become sleepy, or even fall asleep, at points of extreme anxiety in a session. 'Manageable' means that if I occupy this position I have conveniently set aside the most fundamental, sceptical, Cartesian worry about the causal interaction between the two worlds. For, in relation to the link between the first-person experience of emotion and the body changes, such worry must arise equally in the most obvious cases. I have shifted the locus of the problem. As a psychoanalyst, I want to give credence to more integral links than merely causal ones like, say, that between adrenaline and arthritis. I want, firstly, to be able to find a coherent system of ideas that allows house-room to hypnotic effects, hysterical paralyses, and to hypochondria. Here the link between (unconscious) thought and emotion, on one hand, and (partly) physical manifestations like paralysis, on the other, is not simply causal. There is a link of meaning; one might say that the paralysis is one way, or perhaps the only way, the subject has at that time of expressing unconscious feeling. To give one brief example. I have reason to believe that X's apparently inexplicable onset of an inability to play right handed at tennis, golf and other sports is an inhibition whose meaning is related to his fear of using this hand to kill someone, a crime his brother had been convicted of just before the quasi-paralysis began in X. I want to be able to say, without incoherence or unease, that to explain the paralysis along such lines is to offer a totally different kind of explanation from simply causal, chemical explanations. Here his phantasy ('I might kill my opponent but I must not') is at work through and expressed in the paralysis. So: my aporia tends to emerge in relation to psychosomatic conditions, in which there are obvious chemical changes. The person with colitis really does have changes in his gut, which operate at the cell level, at the enzymal level, and at the perceptual level. The locus at which my aporia tends to appear is here; sometimes I feel troubled by the question: how can unconscious mental events alter one's physiology in such permanent syndromes? And how can we ever know? For the most part, I am not prevented from thinking analytically in these areas. An example. A patient Y who is liable to colitis is afflicted by phobias. When the phobia becomes intense, or when she is phobic about the likelihood of intense phobic states, her colitis recurs. She feels horrible cramps in her stomach, and is likely to have diarrhoea. I believe that this has to do with her compulsive wish to evacuate everything from inside her. Yet the wish does not take the form of, say, a dream of evacuation, as with another patient (in four times weekly analysis) who dreamed of putting four bags of rubbish outside the door of his house; nor does she dream of internal conflict or war; Y actually has to go to the toilet. A related case concerned a male patient, Z, who came to suffer increasingly from constipation alternating with occasional diarrhoea. In the past, in the early part of his life, and in the first part of the analysis, the latter was the main symptom. At the time I refer to, we were able to see that there was a more complex psychological process. He wished to evacuate his bad stuff into another person, but this presented him with a double fear: would he damage the other as a result? And would he lose things of value to himself? So the spasm of pain seemed to express precisely the ambivalent anxiety that he felt psychologically. Either way - whether he let loose, or whether he was blocked up - he was exposed to extremely critical internal voices, one saying 'So you think you're so careful!' and the other 'So you think you're brave!' In a third case (in which the therapist was in supervision with me), the power of the projective identification into the body had a surprising further effect. This patient suffered from distressing colitis. She did not turn up for her last session before a long break. There was no telephone message. Half way through the session time, the therapist - who had gone through a range of feelings from worry and concern to anger - suddenly had a bout of violent diarrhoea. Since this was not a general problem of hers, and she felt no further discomfort subsequently, it seemed likely that she was the recipient of a powerful projective process from the patient. Patients who are functioning at X's or Y's or Z's level are bound to find insightful interpretations hard to make use of. And on my side, despite my belief that such interpretations are on the right lines, I can become radically uncertain. I can feel helpless; or in aporia; or paralysed; or, again, bereft of all belief, like a religious person experiencing a loss of faith. In my more in-touch moments I would understand the more extreme of such states as the outcome of my intolerance of partial understanding, and of an arrogant spitting out or negation of hope. The difficulty of establishing such connections can lead me to feel at a loss about all claims about, or even of, psychosomatic illness. If I ask myself why I am liable to such reactions to these conditions but not to 'natural expressions of emotion', I think I might first note the former conditions persistence over time, whereas the latter are relatively short-lived. Moreover, from what I regard as a proper psychanalytic point of view, I see the psychosomatic conditions as organised defences, which have a life of their own in the body. As the brief example of Y suggests, they may, at least sometimes, be seen as asymbolic expressions of primitive object relations
The second, and related, tendency is to make use of a model which acknowledges the way our sense of ourselves begins with, and is rooted in our emerging sense of ourselves as encased by skin, as existing in and through our bodies. 'The first Ego is a Body Ego'. And again: 'The idea is that there is a proto-mental level at which … emotional elements are undifferentiated from physical ones.' (Meltzer on Bion pp 9-10). At the raw, primitive level, we are absolutist, concrete and ruthless. The capacity for symbol-making is limited. A brief example of a colleague's: A patient is told that there will be no session next day, and says, in panic, 'My arm has gone. Something went.' This suggests that he experienced the other as part of himself, in a concrete bodily way; he was not at this moment able to conceive of a separate person whose prospective absence could be experienced as painful. Another brief example. A very young child vomits when parents leave her with someone else. Here she throws out the bad feelings and the bad objects, and also perhaps tries to put the stuff into the other. A few months later, the same child allows parents to go out, but requires a ritual 'good-bye' and a small material token from each parent, and which stands for the parents. Later still she can tolerate the separation without somatisation, and without material tokens or symbols. She can expect that they will return, trust them to remember her, and hold them in mind herself. Psychoanalysis expands the meaning of what may start by being thought of in a restricted physical sense. The concept of sexuality is one such example. I suggest that if we can grasp both these aspects of mind and body we may be less tempted to fall into, or slide towards, Cartesian dualism, and the question we will want to ask will not be 'how can we understand the connection between mind and body?' but rather, 'how can we understand the developmental moves from body-mind to mind?' We may also come to understand also how inevitable it is that we are all liable to fall back to earlier ways of functioning when we become anxious. This position may be criticised as a case of a genetic fallacy: that is, the fact that for a mind to exist there needs, causally, to have been a certain history (of body experience, and of containment by others, say) does not necessarily influence the meaning of the concept. This counter-argument goes: whatever the origins of our minds, it is the fully psychological meaning that gives us the sceptical aporia. However, I am not speaking simply about origins in a historical sense. I am talking about our deep sense that body and mind are not so separate. And I am suggesting that when this is understood and integrated more fully, then something might shift conceptually, philosophically. Our understanding of the growth of a mind, which involves our bodies, and the containing functions of other people, loosens the Cartesian notions of a purely psychological world on the one hand, and of a body for which the only explanation that has any reality is a chemical (or pseudo-chemical) one on the other. [I am not of course suggesting that a philosophical sceptic will as a result of reading this no longer want philosophical solutions for his aporia, or that the working out of the problem in these terms is otiose or inappropriate. In parenthisis, I do find persuasive the type of philosophy practised by Wittgenstein in his later work, and by John Wisdom. Both these thinkers offer dissolutions of aporia by means reminiscent of that of psychoanalysis. In each field there are manifold reminders of what is already known but not realised, and a subsequent process akin to working through. In philosophy the arena of 'treatment' is the pictures that are felt to be 'behind' the shared conceptual activities of all; in psychoanalysis, the treatment is of the pictures, phantasies of individuals.] 4. I will now offer a personal example of the struggle to move from one level to the other. Feeling anxious about the task of writing this paper, and of having something interesting to say to you, I can't sleep. Half-formed thoughts are racing around. In retrospect, I might describe my state as a mixture of fear and excitement. In the middle of the night I feel more than usually perplexed about body and mind questions, and the hopelessness of any possible solution. In the middle of this confusion, I get cramp in my calves and feet. I have to jump out of bed, and arch and press my feet to the ground. Here I am, with a somatic symptom of the very process that I am intellectually stuck in, the kind of intellectual cramp Wittgenstein refers to. The wretched body won't stay out of the picture. These cramps are, without doubt, physiological events. There are presumably changes in the chemistry of the muscles. Drinking water might help, or taking salt pills. They might be treatable by a medical doctor. Yet I believe that such an explanation, and possible cure, is only part of the truth. I have a sense that my cramp results from my tension about writing the paper. How am I to account for it? I am not able - or willing - to give a full account of all the emotions that enter into such nocturnal states, or keep me from sleeping. I am aware that by offering you this small item of personal history and my own thoughts on it I lay myself open not only to your supervision but to your interpretations. I am aware too of how likely I am to be prone to self-deception or over-confidence in my mini-self-analysis. However, one reason for including this is to underline my claim that psychosomatic tendencies exist in us all. Another is that in a public lecture issues of confidentiality are problematical. So I will say something. I know myself well enough to suspect that when I feel inept, or incompetent, in anticipation of giving a paper, this kind of anxiety is often an attempt at a solution to a personal problem. The problem is that 'behind' the felt, and sometimes enacted, incompetence is a phantasy of omnipotence. According to this other part of me, my ego-ideal, I should be giving the definitive answer to the mind-body problem that has led philosophers and others to such counter-intuitive and implausible answers. I must, at one fell swoop, clear up all the confusions and falsehoods not only in psychoanalysis but in philosophy too. However, I also know that this is, to say the least, a tall order, so, rather than be seen, by myself or others, as arrogant or grandiose, I make myself more stupid than I actually am. The cramps represent, I think, this painful and conflictual self-restriction. What's more, these painful psycho-physical events could represent the punishment of the cruel internal superego, which regards my self-importance with self-righteous scorn. Shakespeare was psychologically right when he talked about the cramps that Prospero causes Caliban; the base side of ourselves is constantly being pinched, cramped, inhibited by the mind's magic-working despot. Another idea of Wittgenstein's is useful here: a picture holds me captive. I am held in painful inner chains by my conflictual pictures or phantasies. One picture is that I can offer the best ever answer to the thorny and perpetual problems of free will and the mind/body problems; the other that such pride needs to be curbed, and deserves punishment and persecution. As I began, in the night in question, to calm down through thinking along these lines, I fell asleep. I woke at my usual time, having had a dream. I am captain of the England cricket team. England are batting, facing a small target. We have not lost a wicket. Geoff Boycott is struggling. His partner, who is a left hand batsman, has recently been in good form. There is a mix-up between the batsmen, and instead of completing an easy single, the left hander is run out. Boycott seems to be responsible. I am outraged with him, and have the thought: 'he must never again be picked for this team'. But I then think, still in the dream, firstly, that, far from scoring slowly, he has in fact scored most of the runs so far in this innings. And secondly, I wonder what he had to suffer in the way of learning in a hard school, of being put down, and run out when he was a boy? On waking I try to think about the dream. I can't link it with any particular event of the previous day. I wonder if the two batsmen represent part-selves, and if the dream says that I am running out, that is dismissing, excluding, another part of my inner team, of myself, the less orthodox, left-handed part of myself. Then my subsequent outrage against Boycott may be understood as self-hatred. But I go on, still dreaming, to moderate this pejorative view of myself. Only then is it possible for me to tolerate and forgive this selfish part of me, this 'player' in the team that constitutes myself, faults and all. It seems that another part of me which comments and thinks within the dream can allow that I/Boycott am selfish but that this has antecedents, and has not prevented me from scoring runs, even, perhaps, being capable of producing ideas in the present 'innings', the task of writing this paper. No doubt there are other many elements in the dream, including ambivalence towards the left-hander - running him out - and the aggressive aspects of legs and feet like kicking and treading on. This is not meant to be an exhaustive analysis of the dream.) As I thought about the dream later, I concluded that it was only after my period of reflection in the night that I was able to have the dream that actually gives a fuller meaning to the cramps. Previously, I had been unable to represent my situation psychically, in a dream. Rather, at the beginning I simply had this painful feeling in the body, itself both a cramping of thought and feeling, and, as the dream suggests, potentially a representation of my refusing to run, to exchange views productively with the side of me that is identified with the despised body. Thus by means of my reflections and then the dream I had reclaimed part of my psyche that had been temporarily lost. I found a means to move myself from the merely physiological to a more representational, symbolic way of experiencing. I have to acknowledge the fact that this growth in my capacity to evolve a fully emotional awareness, to generate a psychic register for what had been experienced as bodily, was an achievement. To generalise, for each human being it is a development worthy of amazement and pride were it not that we all, more or less, manage it in our first years of life. This development is the work of chiselling out a mind from a matrix of body-mind. For whatever account we give of the earliest psychological states of the infant, we all agree that there is a struggle, which is in fact life-long, to develop fuller mind-body discriminations. My small-scale reclamation of mindfulness, mind-full-ness, presence of mind, is presumably a repetition of the initial chiselling out; we need a concept of 'clamation'. 5. What account can we give of this development, and of the place of mind/ body in a theory of mind? And can this throw further light at the same time on the philosophical cramps that I referred to at the beginning? One account of the development of mind in the baby and small child offers an explanatory model of the acquisition of a psychic space, that is, for what we mean by the containing, holding, reflecting capacities of mind, and for the growth of a sense of separated, first-person identity. In his book The Skin Ego, Didier Anzieu posits a complex development en route to a fully psychic self, arguing that a crucial part of that development is the growth of a containing skin for thought. At first, he suggests, the baby is a 'bodily pre-Ego'. The baby 'has a disposition to integrate the diverse sensory data, a tendency to move outwards towards objects and to establish object relations with persons in the mothering environment. It is on the base of these abilities that the baby moves towards what he calls a Skin Ego, for which manifold experiences of being held are necessary. Feeding too contributes; this gives the baby the 'first experience, brief and vivid, of a differentiating contact, of a place of passage and an incorporation; while 'repletion brings the infant the more diffuse and more durable experience of a central mass, a fullness, a centre of gravity'. (p 36). At this first stage the baby feels inside the mother, and experiences the mother as inside itself, a notion that sounds identical to Fairbairn's of primary identification. At this first stage, p64, the baby experiences itself as liquid, Anzieu suggests, and is in danger of leaking out if it feels 'unpropped' by the maternal background. If all goes well, however, the baby's first thoughts (p64) 'render tolerable the dehiscences that have been opened up in the envelope by frustrations'. This is in line with Freud's and Bion's theories of the origins of thought, that its function is to deal with unpleasant realities. Then, Anzieu continues, the baby's interface with the mother 'transforms the psychical functioning into an increasingly open system, a process which leads mother and child to function more and more separately. It is at this point that a phantasy of a skin shared by mother and child' develops (57ff). At this stage there is a sense of an 'encompassing volume' p 37 provided by the mother which surrounds and contains the baby, but also of a shared skin or interface, which is the plane or axis with mother and self symmetrically placed around it. Hence the experience, and also the phantasy, of being understood instantaneously. There is also a developing sense of inside and outside. It is, he says, a 'two-dimensional psychical space (64) in which the meaning of objects is experienced as inseparable from the sensual qualities that one can perceive at their surface'. The 'interface keeps the two partners in mutual symbiotic dependency' (p 63). The next stage requires the suppression of this common skin, and the recognition that in fact each partner has his or her own skin, a process which p63 'does not come about without resistance and pain'. Thus the baby gradually achieves a properly psychic ego, 'by a process of interiorization'; (63) The skin ego 'underlies the very possibility of thought'. The skin ego has as functions, first, to keep its good things in; second to keep the outside out. And thirdly it is a means of communication; it is 'an inscribing surface' for others. There are of course various possible failings and distortions in this developmental process, which Anzieu describes at length. 6. To conclude: when we cannot contain in the skin of our minds whatever disturbs and affects us, this disturbance is likely to be experienced in our bodies, in ways that may change our physiology. One way in which primitive states of emotion are naturally expressed is through our bodies. Bion and Anzieu have given us a model which helps us to understand how we create and discover mind and self out of a more confused state of body/mind, and out of a self/other amalgam. As we progress emotionally, and can bear anxiety, guilt, and extremes of feelings with the help of symbolisation, we gradually modify them, and are less stuck in rigid, damaging and meaningless 'solutions'. My experience certain patients tends to confirm the idea that our body has from the start entered in to the growth of the sense of self as an autonomous and integrated being in world, and that the body self, the skin self, remain core elements in ourselves. When these achievements have been only partial, the person lacks, in layers of herself, capacities to register events through the symbolisation of thinking. Yet the achievements of a psychic skin, and of the capacity to bear separateness and separation, are always partial. Wisdom is also a matter of having the humility to hold on to the fact that the primitive is with us throughout our lives. No man is an island, entire unto himself: similarly no mind is mind, entire unto itself, and separated like an island from the body. Human bodies cannot be reduced to mere collections of chemicals. Mind permeates our bodies, and vice versa.
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