2006).

Journal of Child Psychotherapy, 32:153-157

A conversation about early unintegration, disintegration and integration

Edna O'Shaughnessy

Abstract
This paper discusses the beginnings of post-natal psychic life, what constitutes the ordinary state of unintegration in the neonate, the nature of the baby's ego, and the clinical relevance of these questions. It is argued that an infant's state of passive unintegration in which the object functions as a skin to bind together the parts of the personality is not a normal first stage of development, as Esther Bick suggested, but rather a sign of an aberrant and already disturbed development resulting from trauma; in such a situation, overwhelming primitive anxiety threatens annihilation, or gives rise to terror of catastrophic dispersal of the self, leading to a desperate defence involving a survival fantasy of lying passive in a containing skin. This is contrasted with normal development in which the baby in a state of ordinary unintegration actively searches for an object. This aberrant state ofunintegration, and its clinical relevance, is illustrated with reference to a case involving a 12-year-old boy who was mentally broken down at the start of treatment. I am glad of the chance to have this conversation. The area we are talking about early unintegration, integration, disintegration is large, with big questions and many perplexities. Margot Waddell has already mentioned the particular question I shall talk about: How shall we conceive of the beginnings of post-natal life? In Esther Bick's view, and Joan Symington's further development of it, the neonate is born unintegrated, in a state of passive total helplessness that requires acontaining object, concretely experienced as a skin. Furthermore, in their view, this is a usual first phase prior to the normal paranoid schizoid position. In my view, such aphase of passive unintegration, unless it is transient, is not a normal first phase, but indicates an infant who is already, in some way, traumatised, and who uses the skin as a container as a desperate means to survive and not disintegrate. Though I have this disagreement, I want to emphasise that Esther Bick's 1968 paper, The experience of the skin in early object relations, is a fine and important paper. With wonderful insight she described a syndrome, the condition of passive unintegration, in which some of our more ill patients, children and adults, are confined. Clinical experience has shown how important the recognition of this condition is, as is the
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understanding of its nature in any given case and the finding of a technique to work with it. Just to remind us, I quote from Bick's paper: The thesis is that in its most primitive form the parts of the personality are felt to have no binding force among themselves and must therefore be held together in a way that is experienced passively, by the skin functioning as a boundary (Bick, 1968: 484). Bick calls this the primal skin function. A little later she continues: The stage of primal splitting and idealisation of self and object can now be seen to rest on this earlier process of containment of self and object by their respective skins (ibid.). We might remember that the hypothesis of Bick and Symington is one among the many that have posited that the newborn is normally psychically passive rather than active; the question of passivity or activity is one of the longstanding, unresolved controversies about the nature of the baby's ego as it arrives in the outside world. Birth events make huge changes for a baby; after floating bathed and enclosed in uterine waters, the baby is pushed to make a journey out of the mother and into the air, where, as Bick puts it there is a frantic search for an object The optimal object is the nipple in the mouth, toge ther with the holding and talking and familiar smellingmother (Bick, 1968: 484). Yes. This is how it is at the start when things go well. There is indeed a baby in a state of unintegration, but one who is not passive but actively searching (the stirrings of his innate life instinct) for an object. The finding of an object that satisfies both its emotional needs as well as its need for nourishment will transform the baby's state from one of unintegration into some sort of connectedness or integration (fragile at first) oriented towards that object. A metaphor sometimes offered for the amazing change brought about in the infant by the object that gives psychological containment and feeding is the (in its way, also amazing) physical ordering of a scattering of iron filings by a magnet that aligns them in one direction.

With apologies for a schematic description of what is familiar to us all, I shall remind us how, given a mother's loving awareness of her baby's anxiety and urgency, together with the physical holding that continues the lost modes of the womb, a baby can suck actively at the nipple of the breast which closes the hole of his mouth and satisfies his hunger while her psychological attentions modify his anxieties and fulfil his desires. And of course, we know too that the nature of the baby's give and take, its reciprocity, interacts with all that comes from the mother. If the experience is good enough the baby will feel psychologically contained and internalise the experience. The pieces of his personality will then be held together internally with an orientation to the satisfying object. As we also know, the infant oscillates between such replete, connected states and states of persecution from hunger, discomfort, delays in attention and the like. All are bad objects that threaten him with disintegration, even annihilation, which he fights by getting his good object to come to his aid. An infant who is not active in this way in both gratification and distress, an infant who is persistently passive has, I believe, suffered, and continues to suffer, some huge adversity. Maybe the mother cannot love him and even hates him, or perhaps she is psychically withdrawn and does not receive and modify his emotional projections and communications. Perhaps he is nearly starving and she does not know it, or it might be that she cannot do other than project her disturbance into him. All these events, as we
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know, affect the infant grievously, in both specific and different ways. Or it is possible that the infant suffered some intra-uterine trauma, or had a difficult birth. Or perhaps he suffers from a constitutionally adverse or overly fragile temperament, and instead of a strong, active push towards life the instinct to preserve living substance and join it into ever larger units, that is, the life instinct (Freud, 1929: 118) the infant has a strong instinct to dissolve these units, to attack links (Bion's terminology) within himself and without the death instinct which in Klein's view is the original inner source of anxiety. Such a temperament has small capacity to want or sustain contact with new experience, and even a normal birth, its journey and the change of life circumstances from being in the womb to being in the world where there is a gap to a newexternal object, will be intolerable and terrifying. Any of these, singly or interacting exponentially, may prevent the occurrence of that amazing transformation described above, when a psychologically and physicallyactive infant reaches and is reached by a psychologically and physically active mother, and unintegration of the neonate changes into its first forms of mental connectedness. Instead of this normal transformation an infant may continue in its unintegrated state, and depending on the circumstances, feel attacked, intruded into, abandoned, in despair with an object that is not psychically alive and attuned and not inhabiting a body with active psychological life; instead the baby meets just thebody as an inert material substance a skin that does not help him psychologically. With any of these he is truly helpless, without help, and resorts to a survival fantasyof lying passive in a containing skin a sort of return to being in what is a ghost of a womb a skin often felt to be an unwilling, hostile and leaking object that he must tenaciously control so that the unintegrated pieces of his personality do not disperse. In my view, this is an aberrant beginning, and if the adverse conditions continue unmodified, it will not lead on to the normal, active, changing introjective and projective relations to an object of the paranoidschizoid position. Such an aberrant start will have its own aberrant evolution. I would like to illustrate what I am saying with some clinical material from the treatment of a boy whose analysis I described in a paper called A projectiveidentification with Frankenstein: some questions about psychic limits (O'Shaughnessy, 2004). When he started at the age of 12, Hugh was mentally broken down. After three years, at his urgent insistence, he left able to resume his life and education. Some of the details of the aberrant nature of his progress will, I hope, be evident in the episodes I shall report. (A full account of the strange trajectory of the analysis can be found in the paper itself.) After a year's work, Hugh told me one day that
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he could now see two-way traffic. I think he meant that, unlike before, when he was alone in various types of spaces, almost always threatening, very occasionally safely enclosing, he now saw a link between himself and others: he was now aware that things went from him to me and from me to him. It was at this juncture that his anxietylessened, as did his tenacious control of his parents, who felt for the first time in years able to leave him and take a holiday for two weeks. Hugh showed me his terrified anticipation of this event: he sat in the playroom, hugely anxious, his two hands on the table, writhing ceaselessly in over-big, ugly brown leather gloves that looked menacing and horrible. Choked with anxiety to the point that he could hardly speak, Hugh showed me how the

thumb of one of the gloves had got torn off and left a hole. In this way he was expressing his experience of his parents pulling away from him and so spoiling what is for him their primal function: to be a glove, a protective skin, and instead becoming ugly, writhing to get away from him, making a terrifying hole through which he could fall to pieces (Tustin, 1972). During the two weeks of his parents' absence Hugh made the long journey bus and train to London, then underground and a walk to my address, and afterwards a return home alone. He felt his parents going away had left him with a torn skin, a hole from which more and more of him was lost each day. He spent his sessions standing at the window, watching leaves being blown by the winter wind. He told me in a voice choked with fear that he could see a tree without any leaves on it. This was his ultimate dread: that his self would be dispersed like leaves in the wind, annihilated and cease to exist. By the end of the fortnight, he had dwindled to a standstill. I think this material shows how Hugh, even as he has been able to make some progress and see that there is two-way traffic between him and others, still needs it to be recognised that the pieces of his psychotic personality, rather than being mentally connected in the normal way, are what Bion has called agglomerated and that without a container all around him a psychotic panic ensues in which his self feels helplessly, passively widely dispersed so unintegrated as to be annihilated. Such a helpless, passive disintegration through a hole is a different experience from a normal ego's active splitting of self and object as a desperate defence to ward off overwhelming anxiety which might also end in a temporary state of disintegration. We may note also that for two weeks during his parents' absence Hugh made the long alarming journeys to get to his sessions on his own. Hugh stuck to his analysis. Was this an instance of adhesive identification? I am not sure. I tend to see his coming to his sessions (without which I think he might have broken down and been again in the paranoid state in which he first came) more in terms of the notion of orientation. I think orientation is an element in psychic life much more important than we have yet realised. Hugh managed to keep his orientation to his analysis where he knows two-way traffic happens a desperately needed orientation to an object done in his own style. We are here in a whole perplexing area: about the nature of the early ego, how active or passive it is, what capacities it has, the nature of its states of unintegration,integration, and disintegration. About all of these there is much more to be understood. And, as so often, where the nature of the phenomena is still problematic, there are related problems of unsettled terminology (see, for instance, a discussion by Meira Likierman, 2001). I would like to end with a return to my contentions that a phase of passive unintegration is not a baby's normal first phase, and that the skin as a container is not a normal primal function of the object. In my view, they are the situation of an already disturbed infant using desperate means to survive and not disintegrate. Does it matter beyond theory what our hypotheses are about the course of early development? Does it matter in practice in a family, in a hospital, or in therapy? Yes. I think it does. Theory changes practice and practical findings influence theory. My views derive from clinical practice with Hugh and others a large group of patients with many individual differences. I think the passivity and inanition inside an object as a skin, the huge
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anxiety about the hostility of the world outside this skin and even of the skin itself so that there is tenacious control of it, and the consequent terror of a catastrophic dispersal of the self if there is movement or change in the skin, plus the painfully felt difference and alienation from others, are all indicators that such persistent passive states of unintegration are not a normal first phase but one of the aberrant positions secondary to trauma, failure by the object or innate handicap of the subject's temperament. While I do not think we shall settle anything today, our conversation informs us about different conceptions and the clinical and observational evidence on which our agreements and disagreements are based and this is surely quite something.

References
Bick, E. (1968) The experience of the skin in early object relations International Journal of PsychoAnalysis 49: 484-486 Also in Collected Papers of Martha Harris and Esther Bick. Strathtay: Clunie Press, 1987 [] Freud, S. (1929) Civilisation and its Discontents SE 21 Likierman, M. (2001) Melanie Klein: Her Work in Context London and New York: Continuum

O'Shaughnessy, A. (2004) A projective identification with Frankenstein: some questions about psychic limits In Pursuit of Psychic Change ed. Hargreaves, A. Varchevker, A. Hove and New York: Brunner-Routledge Tustin, F. (1972) Autism and Childhood Psychosis London: Hogarth

Mots-clefs
Non-intgration passive dsintgration anantissement dispersion intgration orientation

Rsum
Dans cet article, aprs avoir dcrit les dbuts de la vie psychique post-natale, les lments qui constituent l'tat ordinaire de non-intgration chez le nouveau-n et la nature du Moi chez le nourrisson, l'auteur examine la pertinence de ces questions pour le travail clinique. Selon l'auteur, l'tat de nonintgration passive chez le jeune enfant, dans lequel l'objet fonctionne comme une peau qui rassemble les diffrentes parties du bb, n'est pas une tape normale du dveloppement prcoce, comme le suggrait Esther Bick, mais plutt le signe d'un dveloppement aberrant et dj perturb, la consquence d'un traumatisme ; dans une telle situation, l'angoisse archaque dbordante menace l'enfant d'anantissement ou provoque chez lui la crainte effrayante d'une dispersion catastrophique de son tre. Il en rsulte une tentative dsespre de se dfendre au moyen d'un fantasme de survie dans lequel le bb reste passif l'intrieur d'une peau qui le contient. L'auteur contraste cette situation avec celle du dveloppement normal au cours duquel le nourrisson, dans un tat de non-intgration ordinaire, recherche activement un objet. Cet tat aberrant de non-intgration et sa pertinence clinique sont illustrs en rfrence au cas d'un garon de 12 ans qui, au dbut de son traitement, se trouvait dans un tat de dcompensation psychique.

Keywords
Passive Unintegrierung Disintegrierung Annihilierung Auflsung Integrierung Orientierung Dieser Artikel diskutiert die Anfnge des postnatalen psychischen Lebens, was den blichen Zustand von Unintegrierung in Neugeborenen darstellt, die Art des Ichs des Babies, und die klinische Relevanz dieser Fragestellungen. Es wird argumentiert, dass der Zustand der passiven Unintegrierung, in dem das Objekt als eine Haut funktioniert, um die Teile der Persnlichkeit zusammenzubinden, nicht ein normales erstes Stadium der Entwicklung ist, wie das Esther Bick vorschlug, sondern eher ein Anzeichen fr eine abweichende und bereits gestrte Entwicklung als Folge von Trauma.; in solch einer Situation ruft primitive Angst Annihilierung hervor oder lsst den Terror von katastrophaler Vernichtung des Selbsts entstehen, was zu einer verzweifelten Abwehr fhrt, die eine berlebensphantasie, passiv in einer haltenenden Haut zu liegen, beinhaltet. Dies wird der normalen Entwicklung gegenbergestellt, in der ein Baby im Zustand von blicher Unitegrierung aktiv nach einem Objekt sucht. Dieser abweichende Zustand der Unintegrierung und seine klinische Relevanz, wird mit Bezug auf einen Fall eines 12-jhrigen Jungens illustriert, der am Anfang seiner Behandlung psychisch zusammengebrochen war.

Parole chiave
non-integrazione passiva, disintegrazione annientamento dispersione integrazione orientamento

Riassunto
In questo articolo si parla degli inizi della vita psichica post-natale, ci che costituisce lo stato ordinario di non-integrazione del neonato, la natura dell'ego del neonato, e la rilevanza clinica di queste questioni. Si argomenta che lo stato di non-integrazione passiva del neonato nel quale l'oggetto funziona come pelle per tenere unite le parti della personalit non un primo stadio normale dello sviluppo, come suggerito da Ester Bick, ma piuttosto il segno di uno sviluppo atipico e gi disturbato derivante da un trauma; in tale situazione, ansie primitive schiaccianti minacciano l'annientamento, o danno luogo al terrore di una dispersione catastrofica del s, che portano ad una difesa disperata che comprende una fantasia inconscia di sopravvivenza di giacere passivamente in una pelle che contiene. Tutto questo in contrasto con lo sviluppo normale nel quale il neonato in uno stato di non-integrazione ordinario attivamente cerca l'oggetto. Questo stato atipico di non-integrazione, e la sua rilevanza clinica, viene illustrato con la presentazione di un caso riguardante un ragazzo di 12 anni che all'inizio del trattamento aveva avuto un esaurimento nervoso.
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Article Citation [Who Cited This?]

O'Shaughnessy, E. (2006). A conversation about early unintegration, disintegration and integration. J. Child Psychother., 32:153-157