מקומו של הגוף בדרך לבניית מכַל לפי ביוןעבודה פסיכודינמית בשילוב עם החוויה הסומטית (Hebrew)

THE ROLE OF THE BODY EN ROUTE TO BUILDING THE BIONIAN CONTAINER: INTEGRATING SOMATIC EXPERIENCE AND PSYCHODYNAMIC PYCHOTHERAPY. (English)

Despite Freud’s (1856-1939) belief in the centrality of the body as the germinus or source of mental life (Freud 1923), psychoanalytic theory over time has evolved towards relating to the body as a metaphor, investigated and appreciated by exploring fantasies about the body and by achieving heightened levels of symbolic meaning of the body (Ben Atar Cohen, 2017). Contemporary psychoanalysis, both clinical and theoretical, show renewed interest and recognition of the importance of the body and bodily sensations in therapeutic work, particularly with patients who suffer from early, often preverbal psychic trauma and developmental pathologies that involve a lack of integration between sensory experience and symbolic processing. This evolution has encouraged the search for ways to work with experience that has not been mentalized. This focus is concerned with experiences that lack mental representation, or that are encrypted in very poor mental representations, experienced in the earliest stages of life before the development of language or mature thought. Early psychoanalysts such as Ferenczi (1873-1933) and Winnicott (1896-1971), each in their own language, claimed that such memories were nevertheless registered and stored in the body waiting a time when they might experienced and known (Winnicott 1958; Ferenczi 2013). Other analysts related to such early unformed experience, referring to it with different nomenclature: Wilfred Bion’s (1897-1979) beta elements (1962), the unthought known (Bollas 1987), unmentalized experience (Mitrani 1995), unformulated psychic experience (Stern 1997) and unfigured mental activity (Botella & Botella 2005). Recent developments in neuroscience have provided a neurological basis for the above phenomena by applying the important distinction between implicit memory and explicit declarative memory (Lazar & Zohar 2010). Explicit memory, primarily responsible for conscious memories, is mediated in the brain by the hippocampus which reaches full maturity at the age of a year and a half. Implicit or tacit memory, organized in the brain by the amygdala, is present at birth (Joseph1995). It is widely accepted among psychoanalysts that implicit memory is an unconscious, sensory-bodily memory system that registers our earliest sensory experiences and relationships. Mancia (1929-2007) referred to this range of experience as the ‘unrepressed unconscious’ (Mancia 2006) and they are expressed through body behavior and in certain kinds of dreams. Carla De Toffoli (1938-2011), in her essay “The living body in the psychoanalytic experience,” writes that we must recognize “in somatic and sensory elements and in body functions the potential for meaning …appreciating their status as precursors of representation” (De Tofoli 2011, p. 597). Despite the recognition that these kind of raw experiences often manifest in sensory and nonverbal ways in both the patient as well as the analyst (Gaddini 1987; McDougall 1989; Rik 2014), analytic work still tends to privilege talking about the body rather than addressing and working with the body sensations themselves. The current essay advocates the inclusion in psychoanalyticallyoriented psychotherapy of knowledge and tools derived from the treatment of P.T.S.D. that focus on bodily experience. In particular, we describe the trauma technique developed by Peter Levine (1942- ) referred to as Somatic Experiencing (Levine 1997) that focuses on how trauma is registered in the body and throughout the nervous system. We are aware that we seeking to connect and integrate two very different theoretical models, yet we believe that these models have always had inherent theoretical points of contact, and that their integrated implementation is clinically efficacious. Specifically, we try to create a bridge between somatic experiencing (henceforth: S.E.) and the conceptual world of Bion and his student Antonio Ferrari (1924-2006). In our mind, S.E. can be effective in deepening analytical work with patients who suffer from early pathologies and traumas by aiding in accessing and processing memories that predate conscious thought as well as later traumatic experiences that were defended against via dissociation. The essay offers a brief description of S.E. and reviews its basic methods. Levine asserts that traumatic symptoms result from a disrupted, unbalanced autonomic nervous system. In situations of extreme stress, the human body employs defensive responses of “flight, fight… or freeze.” Massive physical energy must be enlisted by the nervous system to carry out the chosen response. Mammals are equipped with the ability to regulate and discharge this energy, returning to equilibrium once the threat ceases. Yet in many instances-that we refer to as traumatic in retrospect-the intensity of the situation, qualitatively, quantitatively and dimensionally, is too powerful or ongoing and the enlisted energy cannot be discharged (or is perceived as ongoing, such as in complicated mourning and P.T.S.D., and thus as not yet allowing for discharge!). Levine claims that trauma puts the primitive brain into a state of constant activation, leaving the nervous system in a state of dysregulated arousal. S.E. aims to discharge the activation in the body and restore equilibrium as well as to integrate and process the traumatic experience mentally. For our purposes the most important ‘tool’ in S.E. is the Felt Sense. This emphasis requires the ability to focus one’s awareness inside the body and, as the analytic dialogue continues, to track what transpires within. It is similar to the attention focused inward during meditation. Levine has coined the acronym S.I.B.A.M. to describe the five channels of experience that the Felt Sense is registering: Sensation, Images (memory, dreams, pictures, metaphors, word), Behavior (posture, facial expressions, movement, gestures, voice), Affect (feelings) and Meaning (thoughts). When physical activation and constriction appears in response to information arising from channels of the S.I.B.A.M., work is done to discharge and regulate this bodily tension in order to enable a free flow and integration between the elements of the SIBAM. In the essay, we discuss some techniques designed to facilitate discharge, illustrated by short vignettes. We feel that the clinical psychoanalytic stage is ripe for the kind of integration we promote. Gathering evidence from several sources, we note the ideas of Lombardi (2009) and his notion of the infant’s body as the Concrete Original Object. This is an ‘object’ that predates internalized objects, composed of the infant’s concrete body, the sensations that emanate from the body and a primitive mind entity that emerges from it, in order to perceive, register and organize early chaotic bodily experience. Lombardi claims there are two types of primary relationships: the first is from the body to the mind, transpiring on what he calls the vertical axis; the second, between the infant and the external object, transpires on the horizontal axis. These relationships exist simultaneously and are impacted upon by each other. Psychoanalytic therapy tends to place emphasis on the horizontal relationship between the therapist and patient. The S.E. perspective helps to focus work on the vertical axis by initiating a dialogue between the body and mind. Grotstein (1925-2015) as well wrote (2009), with a similar distinction and proposed integration in mind, in his work on the theory and function of dreams. In order to enable criticism and evaluation of our approach, we try to create a bridge between S.E. and Bion’s theory of psychic functions and the psychic container. Bion wrote about containment as the process where raw sense data (beta elements) are transformed into alpha elements. Alpha elements are storable and available for thinking and the creative expression of unconscious waking dream thoughts which further process emotional experience (Bion 1962, p. 8). Bion claimed that the infant’s immature psyche is incapable of this processin independently of the mother, and needs her mind to enable, through her reverie, the internalization of a receptive organ for the projection of the beta elements. The other uses her own alpha function to process and contain the raw beta elements and return them to the infant. With optimal frustration the infant slowly develops thoughts in response to absence. But in cases where intolerable frustration and overwhelming death anxiety is aroused, thoughts cannot develop and obviously containment does not occur. Infant anxiety and distress are experienced somatically. We argue that in order for the beta elements to be contained by the mother in Bion’s model, she herself must be capable of physical and psychical self-regulation. In order to `dream the infant’ the mother has be able to bear pain and process her own somatic state as well as the infant’s without being overwhelmed and disconnected. Bion claims that a similar process occurs in analytic therapy, wherein the analyst adopts the role of the mother. We argue that this process is augmented when the psychotherapist uses S. E. techniques on him- or herself. The S.E. concept of Resonance offers an important example- the ability to listen to one’s own bodily experience in response to the communications of the patient. This dimension allows for a deep empathic stance. The idea that the analyst’s bodily responses signal that important processes are taking place is not new (see Ogden1994; Rik 2014), yet containing the sometimes violent and bizarre projections of the client can be difficult. Enhanced facility with Felt Sense offers better capacity to sense and contain the resonances that are aroused in the analyst’s body by the communications of the patient, as a sort of body-countertransference), and improves the chances of detoxifying projected unmentalized material by ‘dreaming’ the patient. We outline as specifically as possible the phases by which this kind of sensitivity is experienced and turned gradually into workable mental experience, by the analyst, which can then be shared with the patient. [ABSTRACT FROM AUTHOR]

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