( field: 2008 field: ).

field:hdgjrnltitle Journal of American Academy of Psychoanalysis field: , field: 36 field: :

field: 143-163 field:

Concreteness, Dreams, and Metaphor: Their

Import in a Somatizing Patient
field: Eileen A. Kohutis, Ph.D. field:
header end
field:abstracts One of the most challenging types of patients that psychoanalysts
encounter in clinical practice are those who are concrete and who also suffer from
somatic or somatoform disorders. These patients come for treatment, appear
motivated to change, yet they do not change in expectable ways. This paper
presents the case of a woman who was concrete and had numerous somatic
symptoms. Although she had little interest in talking about her feelings, she
expressed herself and her ailments through dreams and it was through her use of
dreams that she changed. Dreams were a type of metaphor where the concrete and
the symbolic functioned to promote growth. field:
Work with concrete patients is largely uncharted analytic territory, although they
do appear in our clinical practices. Concrete people tend to report events rather
than reflect on them; they experience emotions as something that happens to them,
rather than their own responses to what happens; they attribute meaning only to
things that can be touched or seen. Because they do not readily make the leap from
the particular to the general, they do not always develop the perspective that
enables us to learn from emotional experience, and concreteness is a constraint
upon psychological insight. These people do not take easily, therefore, to the
classic tools of psychoanalytic technique. The analytic literature has moving cases
in which concreteness over time gives way to more flexible ways of thinking
(Gottlieb, 2003; Shapiro, 2003). But this does not always happen. Some patients
can't tolerate the stresses of analysis and leave; this outcome may be encouraged
by an assumption that concrete patients are unanalyzable (Wurmser, 2003). But
concrete patients use or don't use analysis in individual and sometimes
unpredictable ways. This article is a study of an unconventional psychotherapy in
which the patient, who had multiple somatic complaints, never became a
traditional analysand. Nevertheless, she stuck it out in her
- field:pgn 143 field: -
own distinct fashion, and when her treatment ended after three and a half years,
she had made notable changes in her life. She never developed much interest, or
capacity, in talking about feelings. But she communicated through her dreams, and
it was through her dreams that I was able to communicate back.
Concreteness and Metaphor
While analysts are aware of the clinical problems posed by concrete patients, there
is no clear theoretical or technical analytic consensus on this style of thought. In
fact, concreteness has largely made its way into the analytic literature indirectly,
often through case studies of psychosomatic and eating disorder patients, in whom
concreteness is a common and well recognized characteristic. The term itself is
used inconsistently, and may refer to organic brain syndromes as well as
psychological disorders.
Several attempts have been made to bring some order to the field. Combining
concepts from developmental and interpersonal psychology,
psychoanalyst/psychologist Lawrence Brown (1985) classified concreteness along
a developmental continuum into a four-level hierarchy. More recently the literature
on concreteness has been elaborated in Symbolization and Desymbolization:
Essays in Honor of Norbert Freedman(Lasky, 2002), who established a four-level,
hierarchical conceptualization of symbolization.
Both Brown and Freedman believe that developmental defects in the area of
differentiation contribute strongly to concrete thinking, and this view has been
echoed, with variations, by other analysts. But their hierarchies suggest that both
fundamental ego defects and defensive regressions may appear clinically as
concreteness. They are not alone in their connection of clinical concreteness with
issues around self/object differentiation. In an important but overlooked paper,
Denial and Repression, Jacobson (1957/1975) suggests that concreteness is a
defense against the experience of the inner worlda regression to a concretistic
infantile stage where the child, though already aware of the difference between
internal and external world, between himself and objects, still treats both in the
same manner (p. 125).
Bass (1997), also dealing with defensive aspects, argues that concreteness
is a fetishistic compromise formation between any form of differentiation that
represents the threat of too much tension and a set of fantasies that replace this
unconsciously registered differentiation within consciousness (p. 646). He notes
that while concrete patients can distinguish the boundaries between self and object
intellectually, they do not do so affectively. Giovacchini (1972/1993), on the other
hand, argues
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that concreteness is not always an adaptive function enlisted as a defense against
affect or conflict, but that it may also reflect impaired capacities for abstraction,
symbolization, self-observation, and tolerating ambiguity.
Whether concreteness is primary and intrinsic or secondary and defensive, it is a
problem in clinical psychoanalysis, which relies heavily on the assumption that
people can and do think about things in terms of other thingsthat one concept
can represent another in our thoughts. The point of interpretation as a therapeutic
tool is to elucidate such representations for the patient. Since the most striking
aspect of concrete thinking is the absence of or lack of access to this symbolic
capacity, interpretation with concrete patients is often of limited use.
Transference and metaphor both mean exactly the same thing, says Arlow
(1979). They both refer to the carrying over of meaning from one set of situations
to another (p. 383). Ogden (1997)adds that Without metaphor, we are stuck in a
world of surfaces with meanings that cannot be reflected upon. Self-reflective
thought occurs when I (the subject) look at me (the object). Metaphor is a form
of language in which I describe me so that I might see myself (p. 7). These
metaphoric descriptions of metaphor tell us little about how it is used
psychologically. Borbely (1998) offers an interesting elaboration: Linguistically,
metaphor is to understand something in terms of something else.
Psychoanalytically, in terms of something else becomes in terms of another
time: the present is understood in terms of the past, the past is understood in terms
of the present (p. 925). For him, metaphor is a way of understanding the world:
when we encounter a new situation, we recognize it as a new category and try to
relate it to the previous categories of our experience (p. 927). New experiences
resonate with old ones through metaphoric connection, and are internalized in a
rich network of multiple associations and meanings. It is metaphors, therefore,
Borbely says, that create new insights, as it is metaphors that re-conceptualize
previously held thoughts and ideas (pp. 927-928).
The most provocative idea of all, at least in my study of the following case, is in a
statement by the linguist George Lakoff (1993), in his study of the cognitive work
of metaphor: Metaphor allows us to understand a relatively abstract or inherently
unstructured subject matter in terms of a more concrete, or at least more highly
structured subject matter (p. 245). Lakoff's comment implies that metaphor is not
a conceptual excursion into a more abstract realm, as Ogden suggests, or even a
link between equal abstractions. Perhaps, he suggests, the concrete aspects of
metaphor are as valuable as the abstract onesthat it is a bridge between the
abstract and the concrete. If so, it can be approached from either end.
- field:pgn 145 field: -
Clinical Case*
Lucy was 34 and single when her psychiatrist referred her to me. She was the
skilled office manager of a medium-sized law firm, a petite and attractive woman
who dressed fashionably but with a hint of bohemian flair. She was living with
Georgia, her partner of three years, but still yearned for a previous lover, Tina,
whom she had left because of intractable substance-abuse problems. She was
preoccupied with gastrointestinal (GI) and gynecological physical symptoms that
had engaged her in years of inconclusive medical consultations and tests. Lucy
focused exclusively on her physical symptoms, and maintained that the
medications offered by psychopharmacology consultants did not help. However,
when a psychiatrist referred her to me during one of her diagnostic
hospitalizations, thinking that she might feel more comfortable talking about her
emotional concerns with someone who had worked with many psychosomatic
patients, she agreed to an evaluative visit. After a few consultative sessions, we
began meeting three times a week.
In our first session, Lucy told me that she was being ripped apart by the
demands of work, family, and friends; she was tired of taking care of everyone
else and wanted to make herself her first priority. She could only imagine caring
for herself except in terms of fervent pursuit of the elusive GI complaints for
which she was being worked up when the hospital psychiatrist sent her to me, and
for which no conclusive structural explanation was ever found.
History
Lucy was the youngest of three children, with a brother three years older than she,
and a sister two years older. She described her parents as harsh and strict and
withholding. In that family there was no such thing as letting children be children.
The parents were unforgiving of ordinary childhood scrapes, and Dad was always
righteven when he wasn't, Lucy said.
There wasn't much room for self-determination as they grew older, either. Her
father believed that good girls lived with their parents until they married, and he
was so angry at Lucy's decision to live in a dormitory at college that he did not
speak to her for five years afterwards.

*field:footnotesNames have been changed and personal clinical material in this article
has been disguised. field:
- field:pgn 146 field: -
When she was raped at college, heand sheunderstood it as punishment for this
act of disobedience.
Lucy experienced her mother as cold, distant, and cruel. She told Lucy that she
had tried to abort her, an idea that was so traumatic to the child that Lucy carried a
copy of her birth certificate around with her for years, trying to convince herself
that she really belonged to the family. Her mother told Lucy that anyone who
could survive an abortion was too strong to need hugs and kisses. Both parents
used the silent treatment to control Lucy, treating her as if she didn't exist when
she wasn't sufficiently compliant. And in a way I didn't, Lucy said. There was
no one to hear what I had to say. The parents also tended to reject the emotional
in favor of the concrete. When Lucy graduated from high school, they did not
attend her graduation, stating that they would see her diploma when it hung on the
wall.
Lucy felt alienated from her family and everyone else. Her brother and sister were
athletic and outgoing, but Lucy mostly stayed home alone. She found
understanding in books, and did not participate much in the outside world. When
there were problems, I looked them up, she told me. Early reclusive tendencies
were reinforced by a bout of rheumatic fever when she was 7. When she first got
sick, her mother took her to a herbalist of her own religious background. Only
when Lucy remained ill after a week of the healer's prescription did the mother
consult a pediatrician, who scolded her for negligence. With his treatment Lucy
improved, but either as precaution or revenge, or perhaps out of unconscious guilt,
her mother forbade Lucy to play outside with the other children long after the
period of prescribed bed rest for rheumatic fever had expired.
Lucy reported having had stomach problems and almost constant diarrhea
since she was 8 or 9. The pediatrician told her that she had a nervous stomach,
and instructed her to take it easy and not worry. For these symptoms too Lucy's
mother took her to the herbalist, who performed rituals with oils, candles, and
chants. Lucy didn't like thisthe herbalist scared herbut she was aware early on
that her mother was inclined to concrete and magical thinking, and depended on
these rituals. When I got sick, she'd take me to these spiritualists. She still thinks
this way. To assure that I would marry Georgia, she put wedding figurines in a
glass jar, wrote my name and hers on paper, taped it to the feet of the figurines,
and put rice in the jar.
As an adult, Lucy consulted one physician after another about her somatic
ailments, and was told repeatedly that there was nothing physically wrong. In the
five years before she came to me, along with the diagnostic GI workup, she had
undergone four laparoscopies and a hysterectomy for endometriosis. Medications
for her gastrointestinal symptoms
- field:pgn 147 field: -
brought no relief, and she continued her fruitless search for cure. She didn't
understand, she told me, why no one could fix the problem. She had physical pain,
so there must be something wrong, and equally there must be something to make it
right. Like many somatizing patients, she rejected the notion that her symptoms
might mean something to her, that she might be feeling her emotional experience
in her body. What did I think she was, a hypochondriac? I learned quickly that the
idea of symptoms as psychologically meaningful didn't compute with her. She
continued to go from doctor to doctor while she was seeing me.
Course of Treatment
The most striking aspect of Lucy's treatment was the extraordinary concreteness of
her thinking, and its persistence despite all the usual analytic encouragements to
look at experience more deeply and broadly. She never developed much interest in
her psychological life, and her capacity to talk about it remained limited. She came
to analysis faithfully for over three and a half years, despite a 45-minute commute
each way; by the time we parted her life had changed significantly. The changes
were reflected not in her conversation, but in a series of dreams about houses
dreams that Lucy reported and then, characteristically, refused to discuss.
In the early months, Lucy began almost every session telling me how she felt
how she had slept the night before; if she were dizzy, nauseous, or suffering from
stomach pains. After her medical report, she recounted what had happened the day
before. It became clear to me that the worst of her symptoms occurred predictably
when she was upset about something in her life, she insisted from beginning to
end that her symptoms didn't mean anythingthey just happened.
Lucy described daily events in the same great detail as she did her symptoms, but
she evinced no curiosity about any of them. When I asked her something, she
responded pleasantly and continued her recitation. I tried every technique in the
analyst's book to awaken some attention to her thoughts, feelings, and fantasies,
but nothing penetrated her wall of concreteness. She seemed to think that just to
mention a topic was enough to neutralize ither version of writing its name on a
piece of paper and burying it. Except for this magical cure-all, her psychic life
held little interest to her, and on the rare occasions when I got her to think about it,
she regarded it as almost meaningless.
In contrast with her endless interest in things medical, Lucy rarely discussed
feelings. She concentrated on happenings. The one feeling she acknowledged was
guilt, which seemed to be the final common pathway
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of her affective experience. Here too, the admission of guilt was more of a magical
incantation to ward off punishment or control than the evocation of an acute and
unpleasant affective experience. When invited to explore her guilty feelings, she
had nothing to say. She knew the names of positive and negative affects, but the
feelings that usually accompany them were absent, and so were their physical
manifestations. It was as if affect was not hers, but a thing outside of heran
external force that she dealt with by naming and exorcism.
Lucy did not appreciate the merits of allowing a topic to develop and exploring it.
She preferred to reduce complicated emotional situations to equations: she was
good, virtuous, and helpful, and therefore could expect the same from others. I
tried to demonstrate that her symptoms tended to come upon her when she might
be expected to feel upset. She felt especially poorly on the days after Georgia, or
her mother, or her sister, had failed to live up to her equivalent goodness
standard. Although Lucy slowly came to recognize this association, she never
accorded it much interest.
I looked for ways to expand our discourse about feelings, but without much
success. I wondered aloud, for instance, about a particularly intense fight with
Georgia. Where was her anger? She hadn't been angry, Lucy told me; she had only
ever been angry five times in her life, and in her striking and concrete way she
proceeded to enumerate them. She said that she didn't have the words to get angry;
she hadn't been allowed them as a child. When I pointed out that not having words
didn't mean not having feelings, Lucy agreed in principle. If you were to say what
your feelings were, she objected, you might do damage that could never be
undone. In Lucy's concrete and magical thinking anger was a machine, rather
than a feeling which, like all feelings, could be subject to reflection and change,
both in oneself and in other people. Anger was not about her own feelings, but her
reaction to other people's feelingswhen people yell, she said, she felt like a
caged animal in a corner. Ready to pounce and attack? I asked. Lucy smiled at
me, but said nothing.
About three months after we began the analysis, Lucy and Georgia bought a house
in a town an hour away. Although the area increased greatly in value not long
afterward, at the time it was shabby and run down, and so was the house. Lucy
was interested in the renovations, but Georgia dreaded them. They decided that she
would live alone in the new house while the work was being done, and Georgia
would maintain their old house. Despite a much longer commute, Lucy continued
to come regularly to sessions, even as I wondered what it was in the analysis that
mattered to her, given her lack of interest in any internal exploration. Over the
early months we had developed a type of communication
- field:pgn 149 field: -
not unusual in beginning patients who are not psychologically inclined. Lucy
described her problems with her gut, her job, her family, and her lover; I wondered
aloud about what she told mewhat all these things meant, how they fit together,
how she felt about them. In many analyses, this sort of parallel discourse becomes
increasingly mutual and interactive as analyst and patient learn each other's
language and cooperate more skillfully toward their mutual goal of exploring the
patient's inner life. This did not happen with Lucy.
She added to her daily recitation the story of the renovations, including a growing
relationship with the contractor who was doing the building. Then the house
dreams began.
Lucy was a prolific dreamer. In a remarkable series of dreams,1 she elaborated a
growing spacehouse, body, selfin which emotional experience was
encompassed. This development was not reflected in our waking discourse, where
her characteristic concreteness and indifference prevailed, and where she talked
about her life while I talked about her feelings. The dreams connected our parallel
voices. And her life changed as her dreams changed.
Dream I
During our first September, about four months into her treatment, and a month into
the new house, Lucy talked about how rejected she felt in her relationship with
Georgia. She spent a session describing her endless criticism, and then began the
next one with this dream.
I'm looking at houses, but they're all burnt, dark, abandoned. They look
beautiful, but inside they're falling apart. They don't seem real.
This was Lucy's first house dream, and the second dream of the analysis. I asked
her what she thought about it. She didn't think about it, she said; she had reported
it because I had told her that dreams were a way of understanding what was going
on inside her. As usual, I tried to move beyond the operational to the experiential
with questions: Could she remember any feelings? Did she have any ideas about
the images? Could she say more about the damage? It's a dream about houses,
that's all, said Lucy.
But the dream recurred several times. Lucy herself wondered occasionally why
she kept having it, but she produced no associations. The context appeared to be
her unhappiness in the relationship with Georgia,

1field:footnotes Over the three years of her analysis, Lucy had 25 house dreams. I can
only discuss some of them here; I have chosen the ones that best delineate the arc of the
analysis. field:
- field:pgn 150 field: -
the constant criticism of her, her feeling inadequate and, of course, her physical
symptoms. I tried to connect those feelings with the houses in the recurrent dream
all of which were beautiful on the surface, but tragically flawed withinand to
explore with her how the dreams, her feelings, and the circumstances of her life
might be connected. She listened politely, but she did not join me in these
endeavors.
Lucy did not directly associate it with her dreams of burnt-out houses, but said that
her pain was the only part of her body that felt alive, and that she wished she could
separate her body from her soul. I want to not exist. I'd be invisible. You can't
be hurt if you can't be seen. People can't judge you. She added that her favorite
cartoon character had been Casper, the friendly ghost. I recognized this fantasy
and offered it back to heras a reflection of her experience with her parents, but
she dismissed it. I also pointed out that it was a double-edged sword. To keep mind
and body separate, you have to work twice as hard, protecting the mind from
bodily pain and the body from psychic pain. Maybe it requires letting oneself
reflect on all feelings, emotional ones and somatic ones, since we are both body
and soul, and more than both. She nodded thoughtfully and changed the subject.
Lucy kept herself busy so that she would not feel pain, she told me later. Once I
asked her whether she meant physical or emotional pain. She said archly, Oh.
There's a difference? It was clear and unusual that she was being playful; when I
asked her how she experienced the difference she looked sad, and said that
sometimes she couldn't. They both hurt as much. They do, I agreed, and that was
why it was important for us to understand her emotions. Psychic pain can be felt as
physical pain. Was there any chance that that might be happening with her?
They're just symptoms, Lucy said again.
Dream II
A few months later, Lucy and Georgia were having an especially turbulent time.
Her symptoms were worse: cramps and nausea had given way to throbbing
intestinal pain. She reported the following dream:
field:quotesI'm in a battlefield, and houses are blown out. Dying people are all
around. I see people as if I know them but I don't. Like they're trying to shoot or
hurt me. The houses are built into a mountain. field:
Lucy's chief association was that she was trying to hide, to get away from
someone who wanted to hurt her. She said that she was angry at Tina for all of her
unfulfilled promises, and that she wished she were dead. But she backed off
quickly from this, because anger destroyspeople, things, everything. Well, I
said, if you think about anger as an
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experience, rather than a force, it looks different. She rejected that idea in favor of
the turmoil in her gut, and I tried again, raising the possibility that her body might
be expressing for her feelings that she was afraid to express in other ways. I tried
to delineate the emotional landscape of the dream and pointed out that these
blown-out houses, unlike the ones in the earlier dream, were built into a mountain.
Perhaps Lucy was not exposed and unsupported as completely as she sometimes
felt. Might this have something to do with the analysis?
Dream III
About a year into treatment, in May, there was a crisis. Preparing for her
hysterectomy, Lucy had given Georgia joint access to her bank accounts and had
not retracted this arrangement in the over two years since the surgery. This was an
unusual forgetting for a gifted businesswoman like Lucy. When her bank
accounts were suddenly frozen by the Internal Revenue Service, Lucy discovered
that Georgia had not paid her personal or business taxes for three years. She
expressed no angry words and calmly explained the financial situation. Her body
responded with the fury that she did not speak. Her left side hurt and felt numb,
she had stabbing intestinal pains, her wrist and fingers were swollen, her eyes
were watering. She reported the following dream:
field:quotesI'm in the house and it's raining blood. Everywhere I looked out of
the window and I saw mutilated animals. I screamed, someone's killing my
animals. I opened the door and someone yanked the head of a cow off. When I
opened the door, my sister was there. She threw the head at me. I screamed and
woke up and felt full of blood on me. field:
Lucy did not associate to the dream, but talked about what was happening in her
life as I talked about what was happening in her dreams. Again I delineated the
affective landscape and the particular self-state that the house seemed to represent
her operational view of anger and the bodily mutilation that seemed to reflect
her sense of her somatic symptoms. This time, even amidst the carnage, the house
in the dream provided some shelter; it allowed for an observing part of her to look
outside and reflect on what she saw.
In this way, across many dreams, the months passed. One constant subject was the
masochistic relationship with Georgia. She was endangering her finances; she was
seeing other women. Why did she stay? I asked. Lucy returned to her final-
common-pathway explanation, that perhaps she deserved that kind of treatment.
If your own mother doesn't want you, who does? Mine tried to do away with
me. She had no access
- field:pgn 152 field: -
to any connection between the explanation she labeled as guilt, and any
fantasies, or thought-crimes, of her own.
Still, things were demonstrably changing. Lucy told me that Georgia and her
family had begun to complain about her therapy; she was behaving much more
assertively and they considered this a very unwelcome development. Their anger
frightened her. We approached this problem in parallel, too. To fulfill her concrete
needs, we looked for ways for her to express herself that might irritate the family
less; to fulfill my responsibilities as an analyst, I addressed Lucy's anxiety about
her own angerif I left Georgia she would be destroyedand her resulting
reliance on splitting. I encouraged Lucy to express her feelings to me so that I
could help her assimilate them for herself, and then we looked for ways to engage
with her family around them. Now for the first time she spoke of some
identification with me and some transference feelingsshe felt soothed and
comforted when she was with me, and being in my office was the only time that
she had to think about herself. But perhaps she was a burden to me. When I asked
if she was worried that I might get rid of her, as her mother had tried to do, she
quickly denied it.
Alone in the new house, Lucy was preoccupied with the renovations. She didn't
speak of the house in symbolic terms, nor mention any meanings it might have had
for heras a haven or refuge, or as a representation of her self or her body. A
house is a house, she said, with rooms that needed to be reconstructed, plastered,
and painted. The changes in the house were wreaking changes in Lucy's life. She
was spending a lot of time with the contractor, Hazel, and she thought, as did I,
that she was beginning to fall in love with her.
Hazel's sweet ways reminded her of Tina, and Georgia, still in the old house, was
becoming increasingly jealous; he once asked her angrily why she didn't just move
in with Hazel. But Lucy, like many concrete people, had trouble seeing another
person's point of view, and she was mystified by Georgia's attack. Hazel often
talked about wanting to go away with her, but she knew she wasn't in love with
her. Why should Georgia, or Hazel for that matter, fuss so much? She could not
recognize that in encouraging Hazel's confidences she might be contributing to
Georgia's unhappiness and thus to her anger at her. I tried another tack, wondering
if there was something in this level of relational chaos that felt familiar or
comfortable to her. She denied it, portraying herself as a victim who had no choice
but to do what women wanted lest she lose them, as she had lost Tina and the
woman before her. She admitted to having anger toward women because of the
way that they treated her over the years, and that perhaps was why she stayed with
Georgiafor payback. But she didn't hear the implications of her own
comment, or the irony in it.
- field:pgn 153 field: -
Lucy loved the renovation process and its endless decisionsa cornice here, a
molding there, colors, furniture. She commented on the decor of my office calling
it soothing. Surely she was expressing her desires and talent through the design
work, I said; she seemed to be getting stronger and firmer as the house did. Her
family had been noticing changes. Did she? Lucy denied it saying it was just work
that somebody had to oversee. She told me, with no apparent sense of
contradiction that she had once hoped to be an architect. She had been accepted to
study at a prestigious design school, but her parents had refused to pay
architecture was a man's field.
Dream IV
About 18 months into treatment, something new emerged. A dream:
field:quotesI had a confrontation with a contractor about the kitchen counters. I
dressed her in a Mickey Mouse suit to humiliate her. Then someone comes along
wearing a Minnie Mouse suit and it was like a competition. I was angry and that
was the only way I had to get her. Minnie said that she was better for her and I felt
bad for her because I had humiliated her. field:
The contractor in the dream was a real person (not Hazel) who had filed for
bankruptcy and left the state, leaving her work paid for but not done. In the dream,
she responded for the first time deliberately and effectivelyalthough guiltilyto
an affront to her house and herself. Shortly after this, she told me that she had
noticed that her actions were an attempt not only to please her parents, but also to
live the kind of life that they themselves would have liked to have had. For the
first time she was differentiating herself from them.
Lucy still showed little affect in our sessions, but she now expressed her feelings
more readily to the other people in her life. We talked about her right to do this,
and the possibility that while words are powerful, they do not in fact annihilate
people in quite the way that she fantasized. Progress came slowly, but it did come.
As she took less responsibility for other people's actions, she began to take more
for her own: I solve their problems because they can't. They're incompetent. It
drives me nuts to see something not done right. She began to think that maybe
she could let them live their own lives and make their own mistakes. She asserted
herself more often and admitted to herself, and to me, that it was not only her
family's demands that were a problem, but that she wanted to see herself as
everyone else's rescuer.
- field:pgn 154 field: -
Dreams V and VI
After a period of about two months of diminished somatic symptoms, Lucy had
another upsurge. This was a little less than two years into the treatment. The
renovations on the house were finished, and Georgia had moved in. She had been
helping her sister to obtain a divorce and establish herself in New Jersey. The
sister and her two children were living temporarily in Lucy's house. Lucy the
rescuer welcomed them and enjoyed the company, but she was envious of her
sister and what she hadchildrenand Lucy, without a womb, felt that in her
body. For the first time, real affect was palpable in the analysis. In one week she
reported several dreams, including the two that follow:
field:quotes I was in a women's prison, confined, and I didn't know why I was
there. Hazel came and got me out. I walked to the town where I lived with Tina. I
didn't know what I was looking for. There were hidden houses. You hit a button
and a house came up. I feel I was looking for my home. field:
I'm moving, and the houses are beautiful on the outside, but inside it doesn't
make sense. Different hues of yellow and the floors were tile. Like a hospital. The
floors had ramps. I was moving out of this house with Hazel to be with Tina. I felt
confusion and thought I should be leaving Georgia. The house had a sink on top
and a shower in one room. A pipe but no sink. Everything was so bare. Then I'm
driving through farmland that was luscious, but it was wet and rainy and dewy.
Felt anxious but a sense of serenity. The floors separated the rooms and the
windows were only on the outside of the house, but inside I couldn't see out.
Lucy began to recognize her inner restrictions, and that she was chafing against
them. She dreamed of confinementprisons, hospitalsbut the possibility of
windows, although she couldn't yet see out of them. She expressed in her dreams
the momentous idea that what goes on inside should make sense. Well, I said,
she was feeling trapped in her living situation. She and Georgia were living like
roommates. They had a houseful of guests. No wonder she was feeling
claustrophobic. All Lucy said was that she felt like the walls were closing in. I said
that I thought that was interesting, since the houses in so many of her dreams
didn't have walls. She laughed.
Dream VII
The next session brought another house dream:
field:quotes In a house with spirits or souls. Like a Hansel and Gretel house.
Exposed field:
- field:pgn 155 field: -
field:quotes wooden beams, rustic. Merv Griffin told me he lived there once. The
house seemed like a fairy tale. Some big, tall, black, angry man knocked on the
door and I panicked. I knew he'd hurt me. When I looked out, there was a
battlefield. The man turned into black smoke and was grabbing me. The windows
had shutters and a cozy fireplace. The battlefield looked like Harlem. Bombed
buildings. Houses destroyed. People walking with torn shoes and clothes and the
man pulling me out. Trying to pull me out of the house. People didn't care about
me. I felt this guy's anger and fury in the dream. field:
This time Lucy tried to talk about the feelings in the dreamI feel like a volcano,
ready to erupt. Like I want to hit someoneand then quickly said that she was
nauseated and might pass out. I was contemplating Lucy as the angry black man in
the dream whose fury terrifies her, and who handles it by turning into something
intangiblesmoke, or Casper the Ghost. Paradoxically, I noted, that her dreams
were becoming ever more detailed and less smoke-like. She approached some
feelings that had evoked the old wish to keep to the spiritual and away from all the
nasty stuff. As well as the fearsome bombed out battlefield, there is a house that
affords some protectiona cozy fairy tale house. I knew that a child-eating witch
often inhabited Hansel and Gretel houses; maybe someday Lucy would take her
on.
About two years into treatment, Lucy felt so trapped that one day she decided not
to go home and instead stayed at a friend's house for almost ten days. This was
Lucy's usual way of getting away from relational problems. She had done it
when things got rough with Tina, too. Lucy maintained that she was committed
to Georgia. Was she committed to her, I asked, or to the idea of being with
someone? She recognized the distinction, and said that she liked the freedom that
she had with her and that perhaps she was comfortable with Georgia's indifference
to her. This was another new piece of differentiation, this time between Georgia
and the other women with whom she had always previously conglomerated her.
She was recognizing her own contributions to her emotional environment, and
finding ways to stand up for herself, even such concrete ones as splitting for ten
days to a friend's house.
During our third summer break, Lucy met a woman who catalogued houses for
antique dealers and invited Lucy to work with her. This was a welcome
development to the house-loving Lucy, and she decided to take advantage of the
new opportunity while continuing her administrative work with the law firm.
A few months later we were approaching the three-year mark. Lucy had always
been competent about practical things, and so she was in this new pursuit. Soon
she was covering estate sales and auctions for her new boss. She enjoyed the work.
It kept her busy, and it was a way to avoid dealing with Georgia and her demands.
Like the decampment to
- field:pgn 156 field: -
the friend's house, this was a concrete way of handling feelings. But Lucy's life
was getting less constrained, and she knew it. A hobby was rapidly developing into
a potential vocationand Lucy was getting interested in real estate.
Still, she remained entrenched in her somatic preoccupations, and her indifference
to psychological thinking persisted. She came regularly to her appointments and
paid her bill on time, and I occasionally asked what she was getting out of therapy,
and what she hoped to gain. At one of those times, Lucy told me that she asked
herself the same questions. I come, and yet I don't know how this is supposed to
help. How can talking help? Yet, when I leave I feel better; sometimes stronger.
Some times when I'm really upset I think of you being with me and we talk in the
careven though I know you're not really there. I take you shopping or to church
or out when I'm running errands.
One day, frustrated with work, she said that she was going to quit. She wasn't
looking for a new job, and I learned that she had made a fair amount of money day
tradinganother example of Lucy's extraordinary financial competence, which
she was beginning to allow herself to use on her own behalf. She had decided to
use some of that money to purchase foreclosed houses in distressed but rising
areas, renovate them, and then sell them. As she successfully pursued this path she
developed another layer of self-confidence, and a deepening of her multi-faceted
and complex affective relationship with houses.
As our fourth year began, Lucy, Georgia, and Hazel bought three run-down houses
together. Hazel was renovating them, and they expected to share in a handsome
profit. One day, while Lucy was out, Georgia searched her drawers and found a
cache of cards and letters that Hazel had written to her. Georgia confronted her
with this evidence that things were not as innocent as she had proclaimed; she
confronted her in return, furious at this invasion of her privacy. She told me that it
was over between thema refrain I had heard many times. Now, Lucy was
actively contemplating leaving Georgia. Georgia would never move out of the
house, and if she left, she would have to give up all the possessions.
Dream VIII
Lucy's explorations continued. Some of them she shared with me; others, I learned
later, she didn't. As we approached the middle of our fourth year, she sought
consultation with yet another gastroenterologist. Another workup began, and she
dreamed:
field:quotes I go to see Tina. The house is sad, and she is sick, but struggling. As I
walk down the street to her house, these people are beating up on me. I run to her.
She field:
- field:pgn 157 field: -
field:quotes said she hasn't been out of the house for a long time because she was
waiting for me, and when she goes out, she gets attacked too. When I go to hold
her, it's spiritual. Enveloped as [if we were] one. Such a sense of comfort and fear.
I feel ecstasy and comfort. So powerful, but I fear the house and what lies beyond
it. I feel her sense of loneliness and at the end of the dream is a union of spirits. At
the end is worry, sadness, fear, but when I get to her there's such tremendous
happiness. Almost like being encased in the womb. field:
Lucy was still longing for the blissful unity that Tina symbolized for her, but in the
dream she recognizes that Tina hasn't the strength to give her what she hopes for.
She's sick, struggling, and fearfulas trapped in her own problems as Lucy is. She
longs for the union of spirits, and perhaps is having some beginning sense that she
might find it. But she will have to look for it beyond the housethe family and
the familiarand that grieves and frightens her.
Dreams IX and X
Lucy was aware of her feelings now and experienced some depression. The
renovation of her house which had brought her so much joy and kept so many
feelings at bay had begun to seem like a chore. She thought that she had to get
away from the endless carping of Georgia and her family, but the how of it eluded
her. As the GI workup continued, three and a half years into treatment, she
reported what turned out to be her two last dreams.
I was pregnant and puzzled. Excited but puzzled. In the hospital I was
saying it's time for the baby, and the nurse said I'm too tiny to be nine months
pregnant. Other women were giving birth and I wanted to see the baby. Finally the
doctor said he'd do a Csection. I woke up when I heard the baby cry.
Then I'm working, and looking for someone to help me. A woman brought a
dog in to be groomed, but the dog was sick. I heard someone scream. I grabbed
the dog and it was magical. It could fly. The dog and I went into a room with huge
pillars and it was dark. I saw a young girl being attacked by a monster and then
people in the office were attacking me because I wasn't supposed to be there. I ran
and saw my brother but he didn't know me.
Lucy felt the loss of her womb; she regretted having agreed to the hysterectomy,
but felt that she had made the best decision she could, given the information that
she had had at the time. She felt more hopeful about the second dream, in which
she told me that she felt she was helping the young girl escape from the monster.
I thought about Lucy being too tiny to be nine months pregnant. Was she really
ready to give birth to the new life she sought? Would her curiosity help her over
the hump? The more she acknowledged her great
- field:pgn 158 field: -
losses, the more she seemed to be recovering a sense of her own strength. The sick
dog turned out to have magical powers, and after her struggle with monsters, had
lost some of their terror. I associated the dark room with huge pillars and the
monster to a sacrificial temple. It seemed, though, that Lucy was finally managing
to escape. With the recognition that her family couldn't help, she was now free to
leave.
Lucy canceled her next appointment with me to proceed with the GI workup, and I
did not hear from her for several weeks. She eventually called saying that she was
in San Francisco for a vacation, and would call when she returned. When she
called, three months later, she was still in San Francisco. She had rented a small
apartment and bought some property there. She had often talked about leaving the
state as a way to avoid her difficulties with Georgia, her family, and Hazel, but
now she had done so, taking everyone in her life, including me, by surprise. Lucy
said that she was feeling no better physically, and that her therapy was going
nowhere. I suggested that those last two dreams had been both sorrowful and
challengingthe premature birth, the temple and the monster, the fearful escape
into the unknownand that she had been known before to run from frightening
feelings. But, Lucy voted with her feetshe had managed a bodily escape from
her family and Georgia, and this time she decided to stay away.
Lucy stayed connected with me for a while through some documents that I was
holding for her, and through periodic phone calls. She kept away from her family,
even in the face of some serious crises. She was making a life for herself in San
Francisco with friends and work. When the time had come for her to separate, she
did it concretely, the only way she knew.
Discussion
This case, like many, is less valuable for what it tells us than for the questions it
raises about the complexities of the human spirit and the limitations of the analytic
process. Lucy was referred to me for the treatment of a psychosomatic disorder,
but she never engaged with me over her physical symptoms the way my
somatizing patients generally do, and her bodily preoccupations remained with her
to the end. She was very intelligent, but she had no interest in psychological
reflection, and therefore little motivation to pursue it. Nevertheless, surprisingly,
she remained in treatment for a long time.
Lucy ended her therapy as she ended everything else in her life, including the
relationship with her beloved Tinaby walking away. The decisions of
unreflective people are often impulsive, and so were many of Lucy's. But this time
for the first timeher departure was more than
- field:pgn 159 field: -
a temporary escape or a leap from an old frying pan into a new fire. It came in the
context of her developing struggle to manage separation and individuation, and to
imagine how a person can leave behind unsatisfactory aspects of confining
relationships to give herself room for new ones. In taking the step of moving to
San Francisco, Lucy did in fact achieve a life of greater freedom and more
satisfaction.
Lucy and I never developed anything like a classic analytic dialogue. She
recounted her life and her dreams; I reflected on them to her. The dreams were a
bridge that gave us both accessme from my end and she from hersto a
metaphoric place where the concrete and the symbolic made common cause. Her
dreams reminded me of the cutlery drawers in old houses that can be pulled out
either from the kitchen or from the dining room, depending on who is working
where, and what task needs doing. The two of us used her dreams differently, but
there was sharing in the use. Somewhere between Lucy's rejection of the
psychological and my analytic preoccupation with it, Lucy could practice, as
Lakoff (1993) says, understanding a relatively abstract subject in terms of a more
concrete one. And so could I, as I worked on freeing my own understanding from
my habitual overdependence on the traditional analytic vocabulary. Lucy made the
dreams and offered them to me; I took them from her and gave them back
transformed; she studied the transformation, and then made more. It seems likely
to me that the series of house dreams was as much the result as the cause of the
parallel discourse it enabledthe more successfully the dreams allowed us to
communicate, the more frequent they became.
I don't know what made Lucy's concreteness so recalcitrant, and I could not
always distinguish to what degree her rejections of psychological experience were
defensive, and to what degree they were manifestations of a developmental or
structural defect. She came from a very concrete family; certainly she had had no
one to model useful ways of understanding unstructured experience, and this may
have discouraged her early efforts to learn to think symbolically. It was also true
that in her growing up the most feelingful use of words was in magical
incantations, where they were instruments of control, life, and death. Perhaps the
only way Lucy could make words safe was to strip them of their symbolic power.
A question may be raised about Lucy: was she alexithymic? Classically,
alexithymic patients are characterized by difficulty in identifying and describing
feelings and a sparse fantasy and dream life (Bach & Bach, 1996; Taylor, 1987).
They tend to view the world literally, and make little use of symbolic thinking
(Taylor, 1987). As Taylor (2003) notes, If we don't have a clear awareness of our
feelings, our emotions become very confusing; they remain as mostly somatic
experiences
- field:pgn 160 field: -
without psychological meaning (pp. 497-498). Similarly, Freedman suggests that
one component of desymbolization is a disavowal of meaning (Freedman &
Lavender, 2002).
Certainly Lucy did have a hard time labeling and identifying affects, and she did
perceive bodily sensations primarily as indications of physical illness; unlike most
classically alexithymic people, however, she was a prolific dreamer. Krystal
(1997) points out that although alexithymic patients may report dreams, they are
unable to associate to them. They are particularly unable to work with dreams,
which, as we now understand , are formed by associative linking of fantasies
and day residues around an affect (p. 137). Lucy too had trouble with association,
especially in the beginning. However, her capacity to make use of her dreams
suggests that she did not experience them as having only one meaning, a
characteristic of concrete patients for whom a thing can represent only itself, not
something else. Lucy's dreams seemed to act as a bridge between the aspects of
her life which she viewed concretely and aspects of her inner world that she was
not yet capable of considering. So was she alexithymic? Perhaps so, in which case
our experience with her dreams may suggest one way of working with alexithymic
patients. Perhaps not, in which case Lucy's dream work may be a way of helping
certain patients make a bridge between the concreteness that feels safest and most
familiar to them in the real world and the symbolic experience that allows us
access to our inner selves.
Lasky (2002, p. 19) has pointed out that desymbolization, as Freedman uses it,
implies something frozen in the psyche:
field:quotes Desymbolization is concrete and repetitive, with an insistence not
only on the sameness of things and situations but also on sameness of the self and
of others. Defensively, this mode of mentalization is based on profound disavowal,
implementing the wish not to know. It also guards against psychological
differentiation within the self and between the self and the other. Psychic space
can be said to be frozen. field:
Because of this, he goes on, there is a serious inability to use experience,
external, situational, and internal, to create complex and varied meanings. In
Lucy's case, dreams seem to have been a way of thawing out a long-frozen inner
psychic life, and allowing her a new access, albeit still tentative, to the experience
of complex meaning.
The final act of Lucy's treatmentwhat did it mean to her? Was it a flight, an act
of separation, a giving birth, a symbolic abortion? I speculate, but I'll never know.
She didn't give me answers to questions like that; she never asked them of herself.
She rejected to the end any conventional
- field:pgn 161 field: -
discussion of her emotional life. Yet as the houses in her dreams evolved over the
years from blown-out bomb ruins to structures in which people could take shelter
and weather their emotional stormsand sometimes even discover some human
helpher life changed slowly but steadily for the better. In her own way and on
her own terms, Lucy did work in her therapy that I respected. Her life changed and
grew, and so did she. I eventually realized that her final move (that is, to San
Francisco) was as much a symbolic statement of movement as an actual one. She
taught me that it is not always possible to distinguish where the actual ends and
the symbolic begins, and to be very wary of analytic value judgments about
concreteness. Symbol and actuality are more usefully conceived as dialectic than
as duality. And as clinicians we do well not to be too concrete in the definition of
either.
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Article Citation [Who Cited This?]
field:citationsKohutis, E.A. (2008). Concreteness, Dreams, and Metaphor: Their
Import in a Somatizing Patient. J. Am. Acad. Psychoanal. Dyn. Psychiatr., 36:143-
163 field: