Why Psychosomatisation is Complex:
Going Beyond Cause-Effect.

This is a lecture given for Confer on

February 6th, 2002 , as part of a series  on ‘Working with Psychosomatic Symptoms’.

 

The body is both a representation and a reality, a manifestation of life, and life itself, what we are, and something we have, that through which we live and in which we live: it is raw material, tool and crucible. The body has a language with which it responds to life, and is itself a language constituted by the language it carries, which speaks through us and ultimately speaks us.”

There have been numerous theories about psychosomatic illness: the history of medicine has never completely excluded psychological explanations, and psychoanalysis was born out of an interest in dramatic bodily symptoms. But I am going to suggest no single theory can encompass the range of phenomena that attract the attribution of the term ‘psychosomatic’. Many theories, from the psychoanalytical to the popular psychological have seized on the idea of illness having symbolic communicative value – a repressed conflict or feeling whose meaning has not been consciously assimilated by the patient. Researchers have found that certain kinds of illness – asthma, ulcer, colitis, heart attacks – tend to happen in people with particular personality traits. Other psychosomatic theorists have proposed that all psychosomatic disease is precipitated by loss or fear of loss. More recent theories have focussed on illness linked to problems with affect regulation originating in object relational failures.

 Like the proverbial elephant felt by six blind men, all these models grasp significant facets of what appears to be a problem in psychotherapy: physical symptoms which go outside the bounds of verbal narrative, fantasy, and transference behaviour. I believe

we need a complex model of illness that takes into account environmental, genetic and lifestyle factors as well as psychological themes and conflicts – in fact all the realities of the body.

  In the first part of this paper I will introduce  a very recent model of illness developed by Graeme Tayor which focuses on the concept of dysregulation, and incorporates recent psychoanalytic theory, research into infant development, and advances in biomedicine. I will expand it by drawing on the work of the neuroscientist Damasio and by bringing in a body psychotherapy perspective on object relations. Whilst Taylor ’s dysregulation  theory is a useful for understanding the complexity of illness, his conclusions in terms of psychotherapeutic intervention fall very much within a conventional deficit-repair model. In the second part of the paper I will offer a therapeutic way of thinking about symptoms which extends Taylor ’s model and is oriented towards the client’s experience  of their symptoms. This in turn moves the emphasis to exploring shifts in the client’s bodily sense of themselves as a means to both short-term re-organisation and towards long-term work with psychological structure.

Taylor is a psychiatrist based in Toronto whose book called Psychosomatic Medicine and Contemporary Psychoanalysis is a landmark in the field. He  argues, along with an increasing number of scientists and therapists,  that linear models of causality for illness are inadequate. Even models that include multiple variables like biological and environmental factors or psychoanalytic  models which consider processes like repression and splitting  fail to address the complexity and chaos inherent in human functioning. He states categorically that the distinction between ‘functional’ and ‘organic’ disorders is an outmoded one. This view is echoed by the neuro-psychoanalyst  Allan Schore who insists that the attempt to differentiate between physical and psychosomatic illness is “meaningless and misleading” (440)

  Taylor ’s model stems from the New Science conception of the human being as a self-regulating system, comprised of a hierarchy of subsystems that interface with the larger social system. The system is hierarchical in the sense of having different structures  of organisation and different units of communication: thus, for example, the endocrine system operates via hormones,  and human speech operates via language, which itself operates within a cultural system. These mutually influence each other, for example, its well-known that the menstrual cycles of women living in the same house tend to synchronize – a good example of how a social system can have an effect on a. a physiological system, or is it the physiology having an effect on the social system? What cutting edge research is revealing is that the multiple systems of the body – immune, hormonal, neurological etc – are interconnected in very complex ways.

  In  a  departure from conventional medical models, Taylor suggests that “A transition from health to disease is likely to occur within this self-regulating system [ie. within an individual] when there are perturbations in one or more feedback loops which lead to changes over time in the rhythmic functioning of one or more of the subsystems. Perturbations can arise at any level in the system, from the cellular or subcellular level (as with viral infections, or variations in the gene) to the psychological and social level (as with intrapsychic conflicts, attachment disruptions, affect arousal and loss of self-esteem) Because the affected subsystem interacts with other subsystems, several physiological functions may become dysregulated and lead to somatic symptoms and, in some instances, also to changes in bodily structure. “( Taylor , 146)

  Feedback is the essential mechanism of self-regulation: it is information given back to a system about itself, in order that it can maintain balance. Feedback comes in many forms, often pertaining to different systems, but in loops which often interface with other systems, thus having a complex effect. .Feedback includes information from motor-sensory loops, from the vicera and from the nervous system about itself; it also includes feelings, thought and fantasises, and communications from others through word, look, gesture and behaviour. As therapists we are familiar with the ideas of psychological splitting, but what I want to get across this evening is that this always correlates with physiological splitting. Cutting off painful thoughts and feelings is the same as interrupting feedback loops in the body which tell the body (and the brain) about itself. Our bodies – including the brain - are changed on a micro-structural level by our dynamic interactions with the world. Some changes are very transient, others get embedded and embodied in the specific bodily structures that regulate and shape our experience.  Object relations are not merely psychological structures, they are bodily processes. .

Let me illustrate how  these micro-structural changes act as object relations in the body.. All feelings have associated gestures and body posture visible in the muscular structure of the body  - sadness, shame, fear etc. When any set of feelings is repressed, there is a corresponding split in the body. For example, where sexual feelings are held back, there may be a corresponding pulling back of the genitals, and a restriction of the blood flow to that region. Where reaching out has not been responded to, there may be a collapse across the chest and arms. Physiological defence  may involve increase or decrease in muscle tone, including breathing muscles. Often a substitute 'false' posture is left as well, such as a 'superior' expression which both hides and wards off, for example, a feeling of vulnerability. Reich called this muscular armour and equated it with character armour associated with different stages in development - oral, anal etc.. But it gets more complicated - a child may imitate and dialogue with an adult and learn to associate a physical expression with words and feelings. Or, failing sufficient experiences of relating, may instead make powerful unconscious bodily identifications, perhaps with unconscious feelings in the parent. (This is one of the ways that family behavioural and emotional patterns are handed down over the generations) Additionally  implicit or explicit parental injunctions may require the control or display of certain affects - this introject lives on as a muscular patterning as well as an image, memory, set of attitudes etc. So each individual's muscular structure will embody a complex history of defences and resources.

  But this is just one aspect, one facet, of the body which contributes to a dense and detailed though often unconscious sense of self. There are also the nervous, endocrine and immune systems, which though often treated as separate, are reciprocally linked through the recently discovered molecular messengers called peptides. Whilst muscle and bone provide a structural image, the peptides can be described as adding colour. Some scientists believe that each of the 60 or so peptides is capable of evoking its own unique emotional tone. Peptides include hormones, neurotransmitters, endorphins and growth factors, including ones we already associate with qualities of drive and feeling, such as  testosterone, oestrogen and progesterone, oxytocin - the 'bonding' hormone - and the stress hormones cortisol and adrenalin. This complex biochemical network constitutes when Damasio refers to as background mood. Again, the capacity of the body to self-regulate the production and distribution of these peptides has its origins in the infant's early object relations, which also mediate the cultural prescription of - or perhaps we should say stylisation of - mood management.

  Allan Schore demonstrates how the mother  functions to regulate this system via the infant's  autonomic nervous system, which manages metabolic energy in the body. I've mentioned how the body systems add structure and colour, well you could say that the ANS manages intensity or volume. It operates in cycles of arousal and relaxation: organising, dispersing or interrupting stimuli, enabling us to let go and recuperate, or preventing us from unwinding.

  Initially the mother's regulatory function is a direct extension of the life of the infant in the womb. Her bodily presence and state influences autonomic, endocrine and immune system, supporting homeostasis. This is achieved by physical contact, tone of voice, facial expression, in fact subtle attunement across all modalities."Attachment bonds fundamentally regulate physiological systems", writes Allan Schore, "via dyadic affect communications." In other words physiological and psychological processes are inextricably intertwined, and the achievement of emotional regulation directly correlates with autonomic regulation. Regulation here means the capacity to use, modulate and vary intensity. It  means being able to identify with an inner rhythm, and to harmonize with and separate from the rhythms of others. Words are by no means the only vehicle for this, though the ability to put feelings and needs into words is crucial. 

 For an illustration of how these subsystems interact to create a sense of self, an object relations of the body, let us turn to the neuroscientist Antonio Damasio. He describes how complex the interaction of regulatory systems of hormonal, immune and metabolic function are, each biochemical loop being influenced by others. These myriad changes in body state, he argues are the essence of emotion.  This is important: multiple micro interrelated changes in the body’s physiology do not cause feelings, nor are they caused by feelings. The feeling and the physiology are two sides of the same coin. Even when we’re not conscious of a feeling, it is via the body systems that the sensory, muscular, nervous and biochemical aspects of the  undesirable feeling is suppressed or interrupted.

 As a consequence of this, declares Damasio:

“the body, as represented in the brain, may constitute the indispensable frame of reference for the neural processes we experience as mind [  ] our very organism [the body] is used as the ground reference for the constructions we make of the world around us and for the construction of the ever-present sense of subjectivity that is part and parcel of our experiences    […] The physiological operations that we call mind are derived from the structural and functional ensemble [of endocrine, immune, autonomic etc components] rather than from the brain alone. “  The significance of his thesis provides food for thought, a reversal of the idea of the psyche as a self-enclosed system of images separated from the body. Rather, he states, “I believe that, relative to the brain, the body proper provides more than mere support and modulation [for psychological experience]: it provides a basic topic for brain representations.” [xix]

  Damasio is a neuroscientist writing about psychological experience from a non-psychotherapeutic process. He does not deal in the complexities of splitting and repression but rather with the unpredictability of human experiences which arises from what he calls "the sheer complexity of the system". I want to extend his account with a clinical vignette of Anya, a forty-two year old woman in her fourth year of therapy. Having acquired some embodied awareness of herself in relationship, she is able to explore sensation and gesture as both real and symbolic in an attempt to get to the deeper roots of her sense of self. She comes to the session complaining that her left shoulder is aching, and she feels tense and exhausted. The stillness in her body is broken by periodic sighs. Then she starts to move, twisting her upper body to try to get some relief from the tension. The movements convey both frustration and emptiness. With her right hand she grasps her left upper arm. She tugs at the arm with a sudden intensity. The left arm merely dangles. 'Come and play with me' she cries plaintively. She goes on wrenching at the arm, squeezing it, and starts to weep. Then she cradles the limp arm in her lap, and hangs her head.

  This sequence from Anya's therapy is quite condensed and complex, encapsulating many aspects of her history, and the history of our therapeutic relationship. She is working on the edge in terms of her symptoms, and in the transference with me. She is  experiencing the body as a thing in itself, a source of pain, discomfort and dissatisfaction. But she is also elaborating a process on an intricate physical  and psychological level where the body is used as a representation of parts of herself, her relationship with her mother and the transference relationship with me. Here I mean 'used' in the constructive therapeutic sense that Winnicott indicated. Later on I will spell out the contrast between this, and manipulation and attempts to control the body.  During this process, Anya is aware of resonant images and associations, and later we consider them together in the context of what she needs and wants from me. Physiologically there has been a complex process too: changes in  muscle tension and the chemistry of the connective tissue, changes in heart rate and breathing reflecting the autonomic cycle. Invisible but inevitable are the  subtle shifts and re-organisation of hormones, peptides and immunological agents. I am present in this process both as a good object who holds the space during her inward absorption, and as a bad object that cannot be made to 'come and play'. This powerful transference communication  will be and has been explored more directly in relation to me. But  it is equally bound up with self-objects, including a dead baby, present in both the deadness in the arm, and the cradling gesture at the end.

I will give you more of Anya's background later and will come back to the transference and countertransference when I talk about working therapeutically

 My aim so far has been to try to give you a flavour of the interconnectedness of physiological systems with self and object representational systems. Psychoanalytic psychosomatic theory has tried to differentiate symbolizing and somatizing, even seeing them as opposed processes. Other psychosomatic theories have seen the body's function as a vehicle of self-expression extending naturally into the creativity of physical symptoms. The first model pathologizes symptoms, the second model is often unduly optimistic about them.

 

Signs, symptoms and symptomization

Bearing in mind Taylor ’s thesis that perturbations can arise at any level in the system, from sub-cellular, to autonomic, to social, I want to propose a structure for thinking therapeutically about the client and their symptoms in terms of stages in a complex psychophysiolgical process. The four stages on a continuum are: signs, acute symptoms, chronic symptoms and what I am calling symptomization.

 A sign is any indicator of a process. My point in this paper is that all 'psychological' events have a corresponding physiological signs. In the account of Anya's process I focussed on physical signs, but I could equally have given you a more detailed account of the verbal narrative. Signs are part of a feedback loop simultaneously communicating outwardly towards the other and inwardly into the self. The flow of signs characterizes the operation of multiple interconnected feedback loops which organize our state of health and our sense of self. We can focus our awareness on any kind of sign – a breathing pattern,. a gesture, a phrase – and follow it through a process. There is always a surplus of signs because of our complexity as humans and often they are contradictory and confusing. The more intense the internal conflict, the more that physiological signs will reflect splitting. Heightening awareness of these tensions and complexities is one aspect of the feedback process in psychotherapy.

 A symptom is any sign that comes into the foreground, either by amplification or by its absence.  It draws attention to itself. I'm going to focus on physical symptoms, but obviously it includes any thought, feeling or behaviour which pushes itself forward, eg.  Suspicion of the therapist etc; or hides itself, is forgotten etc.

 An acute symptom may appear at the peak of an emotional-physiological cycle,  indicating a transition to another state. Often in therapy tears reflect such a critical juncture. A new physical pain, twitch, or a sudden restriction in breathing are often unconscious attempts to hold back a painful experience. Acute symptoms are a first line defence. They constitute a raising of the temperature in the therapy room, and sometimes literally in the client’s body. As the therapist focuses on  the client’s feelings, the physical symptom may intensify as if saying: keep out, don’t say that !! you’re cruel, I hate you, you don’t understand etc. In the crisis of the negative transference the client may leave the session convinced that the therapist’s intention is negative. But if the client feels some important issue has been identified, there is often a dramatic alleviation in symptoms. In challenging a client’s narcissistic defence, there is often a struggle in the client between the sense of a wound being re-inflicted, and the relief of being seen. Sometimes the acute symptom comes as a shock – it is spontaneous event in the body which people may instinctively want to control. One client who had frequent sore throats told me one day with great anxiety that he was scared to touch a knife because he was afraid of cutting himself with it.To his surprise I asked him where he wanted to cut himself and how. His image was of slitting his throat. By following through the impulse in fantasy, by elaborating it, it becomes less frightening and also became linked with other symptoms, such as his sore throat.

  From a  physical perspective  illnesses have typical symptoms – a temperature, excess mucous, coughing, rash, diahorrhea etc - which have a function. They are a physiological elaboration of a process. In a parallel way, illnesses happen all the time in therapy in the form of regressions, or episodes of feeling intensely, or feeling confused, or through dramas in the transference. Hopefully this allows a theme or conflict to be elaborated – emotional cycles completed or a narrative to become more coherent.

 Sometimes the crisis or intensification of the symptom is not sufficient to shift it into the next stage, and the symptom may then become chronic. A symptom becomes chronic when it has ceased to elaborate and be elaborated. It manifests a stasis of some kind. In illness it is typified by more fixed symptom - cysts,  ongoing aches and pains, tumours, rigidities etc. These symptoms act as stabilisers, initially a temporary boundary holding information. The symptom is often a physiological encapsulation correlating with a psychological enclosure around a painful issue. At this stage the symptom may be dull but persistent, or it may be intermittently painful.  The encapsulation serves a function – it protects – but it also restricts the feedback loop – it’s a blockage. The symptom then also acts as a reference point, because it intrudes on well-being,  it starts to function as a representation. It offers something to project meaning into.  The symptom often  contains a conflict or loss related to the specific site in the body,  and therefore seems to speak to the client if he/she will listen:The headache that occurs when the client finds a thought unbearable, the skin rash that erupts when the client is putting a brave face on a situation, the bladder infection that goes with being pissed off.  

  Some symptoms respond well to interpretation based on a metaphorical association to the symptom. Such connections may be valuable to the client and increase the resonance in the feedback loop, by operating in more than one modality. However some symptoms are not really alleviated by this crossword puzzle approach, either because the understanding needs to be more deeply anchored through insight into the transference, or because the dysregulation of the body is more complex and entrenched. My aim in this paper is not to suggest a simple one on one mapping of psychological and physical symptoms, a la Louise Hay, but rather to note that what we think of as psychological is an emergent property of the complex self-organisation of the body. The body is a both/and rather than  either/or.  A tumour may both encapsulate a specific dynamic conflict, or the conflict may be projected into the tumour and thus embodied through it. The two functions serve each other reciprocally.

  A client in her late forties who I’ll call Lisa came with symptoms of exhaustion, frequent migraine, sensitivity to light and severe tendonitis. Tendons attach muscle to bone, and in Lisa’s case, the tendons were so sensitised that everyday actions like putting the kettle on and opening the door, were beyond her. In the intial interview she told me how, 15 years ago she was on the verge of an impulsive and potentially very destructive act, which she managed to stop herself from doing. The cost to her of not doing what she wanted was pretty severe also, and she clearly identified the onset of her symptoms with  that dilemma and the huge losses connected with it. The phrase that came to me immediately was “you slammed the brakes on”. I had a vivid fantasy of a cartoon like scene: Tom being chased by Jerry and skidding to a halt, with all joints locked, eyes screwed shut, and the smoke from burning rubber coming from the  rigidly flexed heels. The phrase and the image carried an association for me  with a car accident, although she did not recall having been in one. I still wonder if some association to a  real car asccidenthad been repressed. But of course the mage of the car carries the idea of tremendous force and speed – the potential for instinct or drive to lead to damage in fantasy or reality. Anyway the phrase  ‘you slammed the brakes on’ resonated with her and seem to encompass the psychological conflicts and the physical symptoms.

  My third term on this continuum is symptomization. Here a symptom, or a set of symptoms, acquire a significant amount of conscious or unconscious collateral meaning. Extremely common is the feeling that the symptom is a punishment for some real or imagined sin. Or the symptom may stand for the persecuting object, for the feeling/object that can't be controlled. It becomes the focus of a vicious circle – frustration with or anxiety about the symptom makes it worse. Its prototype is the panic attack.  In a panic attack the feedback loop becomes self-reinforcing rather than self-correcting. So when a client notices symptoms of anxiety, the anxiety level immediately escalates, and the symptoms, such as hyperventilation intensify. The main difference between symptoms and symptomization is in the client’s reactivity to their own process. When the client is unable to become curious about and interested in their own condition, but merely antagonistic or despairing towards it,  then we need to understand the implications of this rejection of the body. The symptom has come to stand for a hated, feared, or envying object. The underlying dysregulation that produces the symptom is exacerbated by the displacement onto the symptom of feelings that originate in the early object relationship.

  Symptomization is a term I'm using as a rough equivalent to the word 'somatization'. I want to emphasize that what appears to be a somatic crisis is in fact a crisis in the client’s sense of self. The feedback loops which maintain a constant identity in the body have not just been interrupted, but have become severely distorted and dysregulated. Its equivalent to the howl that comes when the sound output of a speaker comes into the microphone. The loop is overloaded and our ears feel assaulted by it. When feedback escalates up, its end may be chaotically destructive, or, sometimes, creative – a breaking down and breaking through. Projective identification may be the client’s only way of managing the chaos. It seems like the therapist is forced to be directly in the feedback loop – feeling the client’s feelings and sensations and giving it back to the client in a more digestible form. In a more general way in the countertransference,  the therapist  resonates with subtle signs and amplifies them by giving them attention.

  A client who I’ll call Paul presented with tinitus. Tinitus is a ringing noise in the ear, which can be persistent and varying in volume. What the sufferer is hearing is the sound of their own blood circulating. It is exacerbated by stress, when in fact the blood flow is faster. Like many people who have chronic symptoms for which there is no easy cure, Paul had been on a search for any therapy or practitioner who might alleviate his misery. Tinitus is a very distressing symptom, but the panic associated with it seemed also to go with Paul’s story of the end of an important relationship and his search for a new partner. His terror of abandonment and of being permanently haunted by the ringing in his ears paralleled each other. And, just as he was always chasing several women at once, he would also pursue multiple treatments or therapies for his tinnitus, homeopathy, Chinese medicine, healing etc.  The need to get control of a feeling at all costs was effectively sabotaging the holding that he might have got from any one of these therapies or relationships had he been able to trust them. .

  Before going into further into this  categorisation of sign, symptom, symptomization and its implications, I want to suggest that what we are concerned with here is managing change. Our bodies mediate the reality both of the physical and emotional environment. Every minute there are changes and adaptations going on, including the processing of explicit external relational transactions, and internal fantasies and feelings. Change is present in the circadian rhythms of the body (of which there are at least fifty) , and most conspicuously in the autonomic nervous system which regulates the functioning of all the organs in the body. The autonomic nervous system, which thrives and matures with appropriate care during infancy, is highly involved in managing day to day emotional states.. If there are interruptions to emotional cycles – feelings get split off, thoughts repressed etc, there is a parallel in the body. The emotional charge remains in the body but gets held in a fragmented way, often via minute alterations in metabolic and hormonal process, and micro changes in muscle tension and tissue organisation..  If the emotional patterns are chronic – ie. there are fixed defences – then they become structured into the body as imbalances, distortions, tensions. These are not linear chains of cause and effect, but complex non-linear changes influenced by a variety of factors including genetics, lifestyle and overall stress level.

  Transference & the client’s relationship to the body

In psychotherapy transference is now recognised as one of the most significant forms of unconscious communication to the therapist. It is that part of the relationship this is governed by a relatively closed feedback loop because  it constitutes a repetition of a past pattern, rather than an open loop in the present. We could even say that tranference includes all the processes which maintain a closed system. The therapist needs to be able to feedback to the client the information in the unconscious behaviour. This is tricky because transference is precisely what blocks the  client from receiving feedback. And yet it is the essence of psychotherapy. In Anya’s process the impulse to tug at an arm is kept within the orbit of her own body, there for us both to know about, but not directly exposing her to the need to reach out to me.  It is important for me to help her know the physical need to reach for another, and what prevents it – in her case, originating in an experience of a mother severely depressed because of the death of Anya’s sibling as a baby. The dying, dead and depressed babies in Anya’s inner world come through again and again in gestures of cradling, in pain related to cradling, in heavy menstrual bleeding. At the beginning of therapy, Anya’s state would go into what I’m calling symptomization – she would bleed heavily and not be able to come to therapy, she would rage at my incompetence in not curing the symptoms,  she was so distraught that she wanted to kill herself.

  As a body psychotherapist  there are various ways in which I work to increase the client’s awareness of their body as a key to deepening their sense of themselves. In view of the obvious pent-up grief in Anya, the absence of crying, and the heavy menstrual bleeding were striking symptoms which seemed to be linked. By exploring movement and sensation in the body we soon found that she needed to get inot a particular posture in order to cry. Also important was the monitoring of physical distance between us. If I was too close she felt overwhelmed, if I was too far away she felt abandoned. By tracking her bodily sensations and impulses we began to understand how particular physiological states were related to her strong identifications. One day she sat in the chair extremely still. I felt chaotic in the countertranference. I was puzzled by the disjuncture between the stillness which seemed like a frozen traumatic state, and a slightly surreal feeling of pleasure. Anya said she felt loved and at peace, but she didn’t look relaxed to me. I asked her to describe the feeling of this in more detail. As she focussed on sensation, she became more agitated. I asked her to see what happened if she moved slightly. She started shaking her head and clutching her belly crying ‘no, no!’. From this it emerged that Anya had had an abortion five years ago about which she still felt guilty. She believed her mother had loved her dead sibling more. Through her body she came to feel the intense conflict between her desire to be the dead baby (who was at least loved) the pregnant mother (who had the loved object inside her). In the transference with me she had to overcome the self-hatred which prevented her from recognizing her  distress and need  for mothering in her own right.

  This is a familiar psychotherapeutic process where, as defences melt,  there are often bursts of regression, which become more intense  but also lead to differentiation and integration in the client. There is a clear parallel in the holistic model of illness where practitioners of alternative medicine recognize that healing chronic symptoms will  often involve  acute flare-ups of earlier illnesses. In psychotherapy  we  hope to be able to get closer to the experience of the symptom,  and even able to distinguish subtle signs which precede the onset of symptoms. In Anya’s therapy we came to realize that menstrual pain was tied up with loss. We both became alert to how a spasm in the uterus was an early sign of distress.

  M y categories of signs, symptoms and symptomization are paralleled by the way the client relates to their body in the context of the therapy. Where there is a well-established working alliance, signs can be traced, explored and associated to rather like dreams. In fact working with physical symptoms is very similar to working with dream material. We do not need to be the expert who knows what they mean. Rather we need to stay open to the resonance  of the symptoms,  to elaborate, to increase information  which can then be brought more explicity into the relationship. The client’s genuine interest in their own bodies as a subject (as opposed to an objectifying attitude to the body), reflects the capacity for both detachment and a sense of ownership,  which increasees with trust in the relationship

  There are of course lots of factors that make it difficult to listen to the body – when there is fear of the body itself, then the client invariably cannot make a sensory connection to it. The fear needs to be addressed directly. When there is a good therapeutic contact, the client may be able to differentiate the signs of fear in their body and tolerate them. Rage at the therapist also makes access to body signals difficult. So rather than ask the client to become aware of sensation, I might pick up a gesture of theirs, such as a fist, an involuntary kick, or a pushing away gesture and mirror it back to them. This can provoke further anger, but often it is wryly accepted as a rather incontrovertible sign of anger. Then the client may be able to think about the anger, or follow the gesture in more detail, either by doing it, or in fantasy.

  With chronic symptoms, there is often a state of psychological siege. Lisa, for example, was a client who was very committed to being honest and exploring issues in the psychotherapy process. Her recurring phrase was “I want to look at…”  and she would name whatever issue was present for her. I commented on the irony of this phrase, as her eyes were so sensitive to light that she had to wear dark glasses. She  always took off the glasses for the therapy but the curtains had to be drawn and the lights switched off. She was willing to talk about her symptoms but I always felt I had to tread carefully. But there was somewhere she would not go at all. She insisted that that her early life had been very good and she had been a very happy much loved baby. In the second year  of therapy I increasingly challenged this as a defensive idealization and and put it to her that she was ring-fencing, closing off the subject.  I shared my image of a circle of fire around her.

  These symptoms carried the paradox of Lisa’s management of her pain. She was forced to restrict herself to the half-light and yet she was very afraid of the darkness of the unconscious. We talked about this in a session at the end of the December as the natural light was fading and we were almost sitting in darkness. It was also  her birth date .

The imagery of fire was crucial too. Lisa came across as very contained, slightly wooden in her manner, but my perception of her passionate fireiness – glimpsed at through the underside of her words and stories – touched her deeply. In approaching the subject of her early life I felt the threat of her overwhelming rage and its association with fire. Fire is dangerous, and fire in the body is inflammation, which afflicted her tendons.

  These symptoms clearly contain tranference material but they also preceded her therapy, and were only partially alleviated by it.. Lisa moved to another part of the country after two years, a move designed to reduce the stress of her living conditions but also bringing to an end her therapy. . A few months before she left she had a very important dream, in which she turned her back on her husband and father and embarked on a voyage to a distant place. They wept as she departed.  What was most striking about this dream was its quality of it slowness; it had a mythical, epic feel – the opposite of the cartoon action of slamming on the breaks. It suggested to me that something was being assimilated at the level of the nervous system,  it was a palpable re-organisation of the experience of time. In this sense it was balancing out the past, a very deliberate gesture was replacing  powerful impulse that threatened to get out of control. Important dreams often how this quality of seeming to resonate in every cell of the body.

  Lisa’s dream was of renunciation, almost of martyrdom, turning her back on the world, just as her symptoms kept her in retreat from it. It was saturated with grief – she in the dream heavy with it, and the men awash with it. The dynamic is quite complex – it seems as if she maintains her dignity, and the vulnerability, the distress and the disappointment of loss is projected onto the father and the husband.. The dream anticipates her departure from the therapy and suggests a deep struggle  between mourning and revenge and pride. It really captures for me how deeply entrenched are our psychic positions and hence our physical symptoms. Lisa’s migraines did reduce considerably, I believe because of the grieving she was able to do, and the holding which allowed a great deal to be faced. The tendonitis did not change . In my view these symptoms like many others need to be understood as both linked to specific conflicts and originating in physiological dysregulation of a more complex nature.

  The transference when there is symptomization is characterised, I believe, by an overwhelming experience of object loss and separation anxiety. It may or may not be accompanied by a conscious sense of panic, but the intensification of the symptom seems to communicate intense distress. I suggested to Paul that his tinitus provoked intense anxiety because it was like listening to the sound of his own screams. Symptomization  is an indicator of a breakdown in self-regulation, prompted perhaps by a combination of stresses, not all of which may be object relational. Some illnesses in fact  are largely genetic or environmental. I think unconsciously the loss of health is experienced as  equivalent to the loss of the attachment object who helps regulate emotionally and physiologically. No wonder clients often experience such pessimism in the face of constant pain and illness, for it reflects back to them their own worst unconscious fear : the object seems to be irretrievable. Nothing is coming to 'make them better'. And when therapy fails to make them better, its like adding insult to injury. Perhaps this is why many people see their symptoms as a punishment. Where there is symptomization, there is a need to grasp the immediate crisis in the transference – what may have ruptured the client’s sense of being connected and held. With Paul I interpreted his constantly arriving late as a parallel enactment with his attempt to control the tinnitus. By not leaving enough time for his journey, he was repeatedly failing to master time, as he failed to master his physical symptom,and simply depriving himself of therapeutic time. And of course he was forcing me to be the one who waited.

 

  Conclusion

I want to end by repeating my main point that there is always a process going on in the body – sometimes its flowing and expressive and we feel at one with it. At other times we have symptoms which are obscure and troubling, and reflect back to us a splitting on both physiological and psychological levels. We cannot always say that a symptom has a communicative meaning – there may be a disruption of feedback loops in the body for many reasons, including genetic, lifestyle and environmental factors. However  I think we can say that the way clients relate to their bodies and to physical symptoms is information that is relevant to the process of psychotherapy.

  I have touched on some of the ways symptoms are explored in body psychotherapy. We don’t use the term psychosomatic because we assume every psychological event has its counterpart in the body. But every psychotherapeutic tradition has ways of including and relating to the body. Above all it is working with feelings in the transference relationship which helps clients make the internal connections which allow deeper self-knowledge. The creation of a narrative of ourselves with another helps establish a sense of identity which is intricately bound up with the subtle awareness of micro-details of bodily change constantly feeding  into the loop of self-regulation.Self-regulation, rather than absence of symptoms, constitutes the way to health.

Bibliography

 Key texts have been marked with an asterisk

  Psychosomatics

*  Broom, B (1997) Somatic Illness and the Patient’s Other Story (Free Association)

*  Erskine ,A (1994) ed. The Imaginative Body: Psychodynamic Therapy in Health Care  

   (Whurr, London )

    Lockhart, R (1983) Words as Eggs: Psyche in Language and Clinic (Spring 

    Publications)

    Mindell, A (1982) Dreambody (Sigo Press)

*  McDougall J (1989) Theatres of the Body – A Psychoanalytic Approach to  

    Psychosomatic Illness ( London , Free Association)

*   Scaer, R.C. (2001) The Body Bears the Burden: Trauma, Dissociation and Disease 

( Haworth Press)

    Schore, A.N (1994) ‘Vulnerability to Psychosomatic Disease’ in Affect Regulation and

   the Origin of the Self ( Lawrence Erlbaum, Hove )

Taylor G.J. (1987) Psychosomatic Medicine and Contemporary Psychoanalysis

    ( Madison , IU press)

*  Turp, M (2001) Psychosomatic Health: the body and the word (Palgrave)

*  Whitmont, E.C. (1993) The Alchemy of Healing: Psyche and Soma ( N. Atlantic Books)

 

Anatomy & Physiology

   Cohen, B.B. (1993) Sensing, Feeling and Action (Contact Editions)

   Hartley, L (1994) The Wisdom of the Body Moving (N.Atlantic Books)

   Juhan, D. (1987) Job’s Body: A Handbook for Bodyworkers (Station Hill)

   Kapit, W. (1987) The Physiology Colouring Book (Harper Collines , New York )

   Olsen, A (1991) BodyStories: An Experiential Anatomy (Station Hill Press, New York )

   A standard medical dictionary

 

Psychoanalysis

   Bowlby, J (1969) Attachment and Loss, vol 1. Separation vol2. Loss ( London , Hogarth   

   Press)

   Freud, S. (1950[1895]) A Project for a Scientific Psychology  SE.1

   Klein M. (1946) ‘Notes on Some Schizoid Mechanisms’ In Klein, M (1975) Envy and   

   Gratitude and Other Works 1946-1963 ( London , Hogarth)

* Krystal, H (1988) Integration and Self-Healing: Affect, Trauma, Alexithymia

  ( Hillsdale ,   NJ , Analytic Press)

   May, R. (1977) The Meaning of Anxiety (Simon and Schuster)

   Milner, M (1950) On Not Being able to Paint ( London , Heineman)

   Moore , M. S, (1998) ‘How can we remember but be unable to recall? The complex 

   functions of multi-modular memory’ in ed. Sinason, V. Memory in Dispute (Karnac) 

  Pines, D (1993) A Woman’s Unconscious Use of Her Body (Virago, London )

* Winnicott, DW (1949) ‘Mind and its relation to the Psychesoma’ in Collected Papers

  Through Paediatrics to Psychoanalysis (London, Tavistock, 1958)

  Winnicott (1958) Collected Papers: Through Paediatrics to Psychoanalysis ( London ,

  Tavistock, 1958)

 

Neuroscience

    Capra, F. (1996) The Web of Life: A New Understanding of Living Systems (Anchor  

    Damasio, A. (1999) The Feeling of What Happens: Body, Emotion and the Making of

   Consciousness (Heineman, London )

   Damasio, A. (1994) Descartes Error: Emotion, Reason, and the Human Brain (Putnam,   

   London )

   Pally, R (2000) The Mind-Brain Relationship (Karnac, London )

   Pert, C (1998) Molecules of Emotion (Simon & Schuster, London )

   Schore, A (1994) Affect Regulation and the Origin of the Self ( Lawrence Erlbaum,

   Hove)

 

Body Psychotherapy

   Boadella, D. (1987) Lifestreams: An Introduction to Biosynthesis (Routledge, London )

   Boadella, D. (1997)‘ Awakening sensibility, recovering motility: psycho-physical   

   synthesis at the foundation of body psychotherapy: the 100 year legacy of Pierre Janet   

   (1859-1947) in International Journal of Psychotherapy, vol 2, no.2

*  Carroll, R (2001) ‘The Autonomic Nervous System as a Barometer of Intensity and

    Emotional Conflict’ http//www.thinkbody.co.uk

   Boyesen, M.L. (1974)’Emotional Repression as a Somatic Compromise: Stages in the  

   Physiology of Neurosis’ Energy and Character, vol 5, no 2

   Eiden, Bernd  (2000) ‘Reich’s Legacy’  in Recent Articles (Chiron Centre Publications,

   London – http://www.chiron.org)

   Reich, W. (1973) The Function of the Orgasm (Reprinted Souvenir Press, 1983)

   Reich, W. (1972) Character Analysis (Reprinted Farrar, Strauss and Giroux, New   

   York , 1990)

* Rothschild, B (2000) The Body Remembers: The Psychophysiology of Trauma and

  Trauma Treatment (Norton, London )

   Soth, M. ‘Body/Mind Integration. AChP Newsletter, nos 17,18,19

* Soth M (1999)  ‘The Body in Counselling’ The Voice of Counselling Training

* Staunton , T (ed) (2002) Advances in Body Psychotherapy (Routledge)

   Totton, N. (1998) The Water in the Glass: Body and Mind in Psychoanalysis (Rebus

   Press, London )

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