The International Journal of

Int J Psychoanal (2011) 92:173–195 doi: 10.1111/j.1745-8315.2010.00388.x

Education Section
On psychosomatics: The search for meaning

Catalina Bronstein
7 Mackeson Road, London NW3 2LU, UK – c.bronstein@btinternet.com

Mind: Hullo! Where have you sprung from?

Body: What – you again? I am Body; you can call me Soma if you like. Who are
you?
Mind: Call me Psyche – Psyche–Soma.
Body: Soma–Psyche
Mind: We must be related
Body: Never – not if I can help it.
Mind: Oh, come. Not as bad as that, is it?
(Bion, 1979, p. 433)

Introduction
In 1964, an Expert Committee of the World Health Organization noted two
different meanings implied by the term psychosomatic. The first referred to
‘‘the holistic outlook in medicine, a move away from a narrow focusing on
diseased organs and systems to a study of the patient in his environment,
both social and psychological’’ (Whitlock, 1976, p. 16). This intended to
bring a more humanistic, unitary approach to diagnosis and treatment of
physical diseases. At the same time, with the enlargement of the concept
came the loss of its more specific meaning. The second and more limited
use of the term confines it to those diseases in which psychological factors
are supposed to play a special role. Whitlock noticed the paradox involved
in these two different uses, because when the term is used to describe only
certain diseases it appears to undermine the unitary approach to medicine.
This paradox, as yet, remains unsolved.
The term ‘psychosomatic’ is now in common use although its definition is
still less than clear. We can perhaps adopt Whitlock’s definition of psycho-
somatic conditions as those ‘‘in which emotional influences play a signifi-
cant part in their genesis, recurrence or potentiation’’ (Whitlock, 1976, p.
19). This certainly does not exclude the possible co-existence of many other
factors that contribute to the development of a particular illness (genetic,
physical, environmental, etc.). However, the specific domain covered by the
term ‘psychosomatic’ is open to debate. Given that this subject of study is

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174 C. Bronstein

at the confluence of different disciplines that try to address these same

issues from their own perspectives, it is very difficult to define the scope and
limits of a psychoanalytic view on this subject. There are many develop-
ments within and outside the psychoanalytic domain that bear a direct
impact on our thinking about it (Taylor, 1987).
The terminology used to describe what happens in psychosomatic phe-
nomena is highly relevant as it indicates a certain position, a vertex from
which these conditions are being thought about. Do we see a difference
between the concepts of ‘soma’ and ‘body’? When are we talking about the
psychic representation of the body and when are we addressing the actual
body? Is it valid to make this distinction? And what is the place of the
‘brain’ and of the relationship between mind ⁄ brain? Given that this field
involves thinking about the body and how it operates in conjunction with
the mind, should we include the new developments and research in neuro-
psychoanalysis as pertaining to this particular field? The whole issue of
psychosomatics can also be considered as part of a wider debate that
involves the ancient metaphysical discussions on the mind–body problem
and on monistic and dualistic ways of thinking about the individual
(Edelson, 1986).
Grotstein proposed that while the mind–body constitutes a single holistic
unity and mind and body are always inseparable they ‘‘seem to lend them-
selves to the Cartesian artifice of disconnection so that we can conceive of
one or another for the sake of discrimination’’ (Grotstein, 1997, p. 205).
Andr Green sustains that a monistic approach does not necessarily entail a
homogeneous unity and that somatic and psychic organizations differ in
their structures. While it would be useful to see the connections between
both of them, it also seems important to distinguish the notion of soma
from that of the body. Green sustains that, while the body refers to the libid-
inal body (erotic, aggressive, narcissistic), the soma refers to the biological
organization (Green, 1998a,b). The ‘somatic’ language would seem more
appropriate for writings on medicine, biology or statistics. While this point
of view is different from the one sustained by Marty, who places great
emphasis on changes in relation to the ‘soma’, other approaches give more
prominence to the role of the ‘body’ in the analytic discourse. That is, while
some psychoanalytical schools of thought describe how the patient brings
their ‘soma’ and aim at helping the patient acquire a libidinal body so that
the physical symptom can acquire meaning (Fine, 1998), others take for
granted that the illness is already inscribed in a libidinal body and that the
illness has and always had unconscious representation. I personally agree
with Green’s notion that in analysis we always deal with the patient’s ‘body’
rather than with the ‘soma’ (Green, 1998, a). I also think that there can be
some grounds for confusion as different analysts may mean different things
while using the same term ‘body’.
There are a number of additional points that contribute to the differences
amongst theories on this subject:
• Diverse theories about both infant development and what is believed to
be at the ‘origin’ of psychic life (or even ‘before’ the constitution of

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 Education Section: On psychosomatics: The search for meaning 175

psychic life) inform the different theoretical approaches to psychoso-

matics. Theories about the psyche-soma or the soma-psyche are very
much connected to theories of early development.
• Another issue of contention between different theoretical approaches is
whether the meaning attributed to a particular physical symptom or ill-
ness as it appears in an analysis is linked to its possible ‘causality’ or if
it has been constructed ‘a posteriori’. This is of importance as the Paris
School of Psychosomatics places an emphasis on the lack of psychic
meaning in psychosomatic illnesses. This is a speculative dilemma that
is still important to address as it informs the different theoretical per-
spectives that support analytical practice. This issue is also connected to
a more general idea of ‘causality’ and to whether we should think of lin-
ear processes and causal sequences, or rather assume that we are always
confronted by the ‘concurrence’ and complementarity between somatic
and psychic processes (Jackson, 1979).
• The differences in the conceptualization of the role that instincts and
drives, representations and phantasies have in connection to the body ⁄
soma and to organic illnesses are reflected in the questions that are being
formulated. The same applies to the development of the capacity for sym-
bolization in that one of the fundamental questions about psychosomatic
illnesses is whether they carry symbolic meaning (Gottlieb, 2003).
• Traditionally, within psychoanalysis, a differentiation was made
between psychosomatics, hypochondria and hysteria. This differentia-
tion was based on the idea that, while in psychosomatic phenomena
one can find actual physical damage and ⁄ or physical reactions, in
hypochondria the body is not affected although the patient believes it
is. In hysteria there can be real impairment of bodily functioning but
there is no organic damage that can explain or justify it (Freud,
1888, 1910). While conversion hysteria was seen to mainly affect
voluntary innervations involving striate muscles, symptoms arising in
vegetative organs (controlled by the autonomic nervous system) were
far more difficult to connect with ideational processes. The difference
between hysteria and hypochondria was not just based on how the
body was affected, it also encompassed psychopathological and meta-
psychological differences. While hysterical conversion was defined by
Freud and Breuer as ‘‘the transformation of psychical excitation into
chronic somatic symptoms’’ (Breuer and Freud, 1893–95, p. 86) and
was intimately connected to the mechanism of repression and to con-
densation and displacement, hypochondria was described by Freud as
the outcome of a stasis of narcissistic libido projected onto the body
(Freud, 1917).
The distinction between psychosomatic illness, hysteria and hypochondria
is one that is still generally maintained today although sometimes it is not
easy to discriminate between the three entities and there are many analysts
who question the validity of making a big difference between them. Valabre-
ga sustains that this differentiation oversimplifies a very complex subject.
He sees a continuum of a spectrum between hysteria and psychosomatic
phenomena and he proposes a theory of a more general psychosomatic

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176 C. Bronstein

conversion where every symptom has a meaning and within which hysterical
conversion has a place (Valabrega, 1954). McDougall (1980) also sees
the existence of a missing link between psychosomatic and hysterical
phenomena. Within the Kleinian tradition, Herbert Rosenfeld (1964, 2001)
described a similar mechanism underlying both hypochondriacal and psy-
chosomatic states. I think that the distinction between these three pathologi-
cal entities is not as clear as is sometimes described, with the three often
overlapping. In fact, it is not infrequent to find a combination of the three
pathologies even within the same session.
• A last but not least important consideration regarding the subject of
psychosomatics is whether we should employ a different ‘technique’ for
patients who present psychosomatic disorders.
The above points illustrate the huge divide and complexity that surrounds
this subject. In this paper I will address some of the main psychoanalytical
theories on psychosomatic illnesses, but as this is a vast field I will pay spe-
cific attention to the developments that originated in Britain and how they
compare and contrast to other theories, especially to those developed by the
Paris School of Psychosomatics.
I will start by delineating some historical developments. I will use the term
‘psychosomatics’ in a rather broad way, respecting what each author believes
to be a psychosomatic phenomena.

The development of the psychosomatic field

Freud and the ‘actual neurosis’: His legacy
The German physician Walter Georg Groddeck (1866–1934) is considered
to be the founder of psychosomatic medicine. Groddeck saw both physical
and psychic phenomena as forms of expression of the ‘It’ (a term he bor-
rowed from Nietzsche).
In a letter to Freud he wrote:
‘ I had become convinced that the distinction between body and mind is
only verbal and not essential, that body and mind are one unit, that they
contain an It, a force which lives us while we believe we are living’
(Groddeck, 1917, p. 32. Also in Shoenberg P., 2007).
Freud himself did not write about psychosomatic phenomena but his preoc-
cupation with the relationship between body and mind was always present in
his writings. It not only led him to formulate his Project for a scientific psychol-
ogy but to write that: ‘‘The ego is first and foremost a bodily ego’’ (Freud,
1923a, p. 26) and to speak of the ‘‘puzzling leap from the mental to the physi-
cal’’ (Freud, 1917, p. 258). Still, the notion of the ‘body ego’ was one that
Freud seems to have chosen not to develop in greater detail. In a letter where
he is replying to Ferenczi’s comments on The Ego and the Id, Freud states:
I would like to decline your second question as to how you should interpret the
sentence that the conscious ego is above all a body ego. The genetic meaning is
certainly clear, and I would not like to touch the indefiniteness further.

(Freud, 1923b)

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We can broadly say that the different psychoanalytical approaches to the

understanding of psychosomatic phenomena depend in great measure on
the emphasis that different theories place on specific aspects of Freudian
theory.
In his first classification of the neurosis, Freud differentiated between what
he described as ‘Psychoneurosis’ and what he called ‘Actual Neurosis’ (which
included neurasthenia and anxiety neurosis). He suggested that these two
groups called for different practical assessment and for special therapeutic
measures (Freud, 1898). Within the ‘actual neurosis’ (meaning a ‘present-day
neurosis’) Freud placed neurasthenia, anxiety neurosis and hypochondria
(which he initially saw as a form of ‘anxious expectation’) (Freud,
1895[1894], p. 93). The common feature in the ‘actual neurosis’ was that the
excitation did not reach the psychic apparatus and that it was transformed
into anxiety, therefore symptoms could not be attributed to a psychic mecha-
nism as they were devoid of either conscious or unconscious mental content.
The condition called neurasthenia was initially described by the American
neurologist, George Beard, who developed his main thesis on the subject
between 1867 and 1880 (Gay, 2002; Hartocollis, 2002; Wessely, 1990). Beard
did not doubt that neurasthenia was a physical disease. While both physical
and mental fatigue were an integral feature of it, Beard listed over 70 symp-
toms linked to this condition (Wessely, 1990). More recently, the relevance of
the syndrome of neurasthenia has been highlighted by Wesseley (1990) who
discusses it in the light of chronic fatigue (myalgic encephalomyelitis or ME).
Though Freud did some thinking in relation to the syndrome of neuras-
thenia he developed in more detail what he denominated ‘anxiety neurosis’
(Freud, 1895[1894]). These conditions were extensively discussed with Fliess
(Freud, 1985). The symptoms manifested in anxiety neurosis can be summa-
rized as general irritability, attacks of sweating, of tremor and shivering, of
ravenous hunger, vertigo, attacks of paraesthesias, and alternation between
diarrhoea and constipation. The cause of these symptoms was felt to be
accumulated sexual tension that was not discharged (a dammed-up libido)
and was often linked by Freud to the effects of masturbation.
In order to fully understand Freud’s thinking it would be relevant to men-
tion his first theory of anxiety which he developed roughly until 1926 and
that he never completely abandoned (Freud, 1926, 1938). In this first theory
of anxiety, Freud tried to understand the source of anxiety and its possible
links to sexuality. He suggests that anxiety is the result of a physical
accumulation of sexual tension and that anxiety neurosis is a ‘neurosis of
damming up’ that happens when sexual discharge is prevented (Freud,
1894). Anxiety might be employed for accumulated physical tension in
general. He follows with a further observation:
This is once again a kind of conversion in anxiety neurosis, just as occurs in hysteria
…, but in hysteria it is psychic excitation that takes a wrong path exclusively into
the somatic field, whereas here it is a physical tension, which cannot enter the
psychic field and therefore remains on the physical path. The two are very often
combined.

(Freud, 1894, p. 82, italics in the original)

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178 C. Bronstein

It is worth noticing two issues that arise from the preceding quote. One
has to do with the idea of a possibility of ‘transformation’ from psychic into
physical phenomena. Another is the emphasis placed on the amount or
quota of affect or sum of excitation which possesses the characteristics of a
quantity (capable of increase, decrease, displacement, discharge). Freud’s
economic theory and his theory of cathexis are very much linked to the
‘principle of constancy’. Another important element described by Freud is
that of ‘psychic linkage’. The ways by which representations are linked to
each other, the possibility of freedom of associations as well as the attacks
on the capacity to make links, all form part of different theoretical
approaches to psychosomatic phenomena.

Psychosomatics: Its pioneers and the notion of specificity

Even though Freud never lost touch with the relevance of the individual’s
body in connection to illnesses, it was mainly left to other analysts such as
Ferenczi, Deutsch, Alexander, Flanders Dunbar and others to develop
the field of psychosomatics. In Britain a number of authors wrote about
psychosomatics, although without creating a particular specific school of
psychosomatics as happened in Paris.
In 1926, Ferenczi wrote his paper on Organ neurosis and their treatment
(Ferenczi, 1926, p. 22). He saw ‘neurasthenia’ as the most familiar form of
organ neurosis. He thought that these were real disturbances of the normal
functioning of a physical organ and that there were objective and subjective
disturbances that would make them different from hysteria. However, he
also clarified that it was not possible to draw a sharp line between organ
neurosis and hysteria. He thought that the cause of neurasthenia was sexual
malpractice but, unlike Freud, he stressed that this was not the result of the
physical act of masturbation but the psychological result of obsession and
guilt feelings. He also associated it with depression linked to masturbation:
a psychical expression of the libido-impoverishment that has taken place and the
damage done to the beloved ego by the waste of libido, the ‘sin against oneself’.

(Ferenczi, 1921–22, p. 208)

Ferenczi’s explanation of organ neurosis involved the idea of organ eroti-
cism, meaning that our organs, apart from their role in self-preservation,
also serve the purpose of procuring pleasure, a kind of organ pleasure (this
was also stated by Freud (1914), erotogenicity being a general characteristic
of all organs). This can be evidenced in the pleasure of masticating, swal-
lowing, etc. It was thought that in organ neurosis there was a proliferation
of its erotic function.
Felix Deutsch further developed the notion of specificity in organ neuro-
ses. He thought that a particular organ might be affected at a very early
stage of development, a stage which antedated ‘‘the full evolution of instinc-
tual life’’ and that the instinctual response to the organic dysfunction
created at that time a ‘‘psychosomatic unit’’ which brought together an
interaction between psychic conflict and a specific organ (Deutsch, 1939,

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p. 252). He proposed that when the old conflict became active again the
organ which was associated to produced the same symptoms (Deutsch,
1939).
H. Flanders Dunbar noted that the question of emotional specificity will
‘‘never be solved in terms of discrete specific factors, but only in terms of a
complex combination of psychic and somatic factors playing different quan-
titative and qualitative roles …’’. Despite this, she also stated that she found
certain specific characteristics in patients with asthma and hay fever such as
‘obsessive-compulsive’ (Flanders Dunbar, 1938, p. 27).
One of the pioneers in this field, Franz Alexander, stressed that the
expression ‘psychosomatic’ was exclusively a methodological concept, a type
of approach in medicine, a simultaneous study and treatment of psychologi-
cal and somatic factors in their mutual interrelation. He proposed that every
disease was psychosomatic because both psychological and somatic factors
take part in its causes and influences its course. Alexander pointed out the
intimate connection between acute emotions and their influence on the
body:
Corresponding to every emotional situation there is a specific syndrome of physical
changes, psychosomatic responses, such as laughter, weeping, blushing, changes in
the heart rate, respiration, etc.

(Alexander, 1949, p. 39)

This very broad conceptualization led him to consider most diseases,
from ulcerative colitis to tuberculosis, as ‘psychosomatic’. However, he
described seven illnesses in particular that he classified as ‘classic’ psycho-
somatic illnesses: bronchial asthma, essential hypertension, peptic duodenal
ulcer, regional enteritis, ulcerative colitis, Graves’ disease and rheumatoid
arthritis.
Alexander supported the idea of specificity, that is, he saw an intimate
affinity between certain emotional states and certain vegetative functions,
between certain nuclear conflicts and somatic responses. He followed the
idea that certain personality types are predisposed to certain diseases. He
thought that symptoms were a symbolic expression of unconscious conflict
and looked at the ‘choice of illness’ in connection to how it corresponded to
particular types of conflict (Alexander, 1934). For example, he looked at the
specific type of emotional conflicts present in skin disorders. He thought
that the sensation of pain played a central role in the ‘psychology of the
skin’. From his studies he arrived at the idea that:
Masochistic tendencies must have a close affinity to the skin … in eczema and neu-
rodermatitis, sadomasochistic and exhibitionistic trends have a rather specific corre-
lation to the skin symptoms.

(Alexander, 1952, p. 166)

This approach led to extensive research but was met with the criticism
that one can find these difficulties in many patients who do not suffer from
the same conditions. It also proved to be very difficult to work out what

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180 C. Bronstein

were the psychological factors that contributed to trigger an illness from

those that appeared as a consequence of it. This is still an important issue
with which all theoretical approaches struggle.

Psychic mechanisms: Deficit and conflict

The search for a single explanation or a pattern specific to a particular
illness started to give way to an attempt to understand the more general
psychological mechanisms used by these patients. When I say that nowadays
there is an interest in looking more at mechanisms, I have in mind two main
approaches to the understanding of psychosomatic illnesses. We can broadly
divide these two perspectives into those that see the symptoms to be the
product of psychic conflict with its underlying unconscious phantasies and
those that place the accent on a deficiency in the patient’s psychic structure.
Are psychosomatic symptoms the result of a lack or a deficit of some nature
or the consequence of a defensive strategy? Do psychosomatic symptoms
carry specific unconscious meaning such as we find in hysteria, where there
is a richness of symbolic functioning, or are they devoid of symbolic mean-
ing, and even appear because of a lack in the patient’s capacity to function
at a symbolic level?
I will concentrate more on developments that took place in the UK whilst
just mentioning the most important aspects involved in the Paris School. I
would also like to stress that, even though this differentiation is a relevant
one, there are also some authors who think that elements described by dif-
ferent schools of thought can operate at the same time. For example,
McDougall (1986) describes the discharge operating in ‘actual’ neurosis as a
way of functioning linked to primitive phantasies and the urgent need to act
rather than to reflect.

A. Models of deficit: The economical dimension, death drive and

regression
A common characteristic that has been described in psychosomatic patients
is that they are unwilling to face their emotional problems and, as Wolff
described:
It is as if the psychosomatic patient has become so alienated from the reality of his
psychic experience and his feelings and conflicts that he wants to think only of his
body as involved in his illness, thus denying all personal responsibility for his disor-
der and presenting the diseased part of his body to his medical attendant to have it
cared for and cured by him.

(Wolff, 1962, p.346)

This alienation from their own psychic experience can be thought about
from different perspectives. Some authors explain this as a lack of a capacity
to experience and express conflict via phantasy and psychic representations
(even in a primitive way). This theory is inspired by Freud’s notion of the
‘actual neurosis’ where the libidinal energy goes back into the body instead
of acquiring psychic representation. These ideas were expanded and further

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developed by the Paris School of Psychosomatics (Pierre Marty, Michel de

M’Uzan, Michel Fain, Christian David).
A similar line of thinking was developed by Nemiah and Sifneos who
used the term alexithymia (which means literally ‘without words for feel-
ings’) (Apfel and Sifneos, 1979; Nemiah, 1978, 1982, 1987; Sifneos, 1975).
Apfel and Sifneos described alexithymic patients as those who present the
doctor with endless description of physical symptoms, show a striking
absence of fantasies and have a marked difficulty in finding appropriate
words to describe feelings (Apfel and Sifneos, 1979). The phenomenological
description of these patients is similar to that described by the Paris School
but the psychoanalytical approach is far less elaborated.
Pierre Marty’s idea is that the somatic manifestation replaces a conflic-
tive situation (Marty, 1967). Marty proposes that psychosomatic illnesses
act like points of fixation in a move towards a more general mental and
physical disorganization. He gave the name ‘progressive disorganization’ to
the process by which there is a destruction of the actual libidinal organiza-
tion in a given individual. These types of disorganization are different
from the more global disorganization that could be transitory and still rich
in libidinal potential (Marty, 1967). Progressive disorganization can
become a progressive, anarchic destruction of mental functions. It entails a
cancellation of libidinal activity that can lead to a general decathexis of all
libidinal areas producing an ‘essential depression’. Organizing mental
functions (such as identification, projection, association of ideas, symboli-
zation) disappear. This process shows how ‘‘the death instinct asserts
itself ’’ and it can end in death through serious somatic illness (Marty,
1968, p. 248). Progressive disorganization can eventually lead to death but
the process can be limited by the stimulation of some potential libidinal
cohesive capacity (David, 1967). Psychosomatic patients would have a less
‘developed’ ego than neurotic patients and they are not able to phantasize,
elaborate and integrate thoughts and feelings. These patients appear to
function in a concrete way presenting a type of thought process that he
called ‘operational or mechanical thinking’ [pense opratoire]. Marty
places importance on the limitations of the System Preconscious in these
patients.
The relationship between patient and clinician cannot be described as a
proper relationship either. It constitutes what Marty called a ‘relation
blanche’ with no real emotional involvement. All associations are linked to
material facts within a limited temporality. Even when there is high capacity
for abstraction what is always missing is the reference to a live internal
object. Operational thinking seems to be devoid of libidinal value and shows
a precarious connection to words (Marty and de M’Uzan, 1963; Marty,
1981).
In order to understand the Paris School and its difference from other
schools of thought we need to appreciate the importance it places on the
role of the economic dimension of psychic life. For Marty the instinct
becomes a drive when it becomes connected to representations. Instincts sus-
tain the psychosomatic economy. Marty’s economic viewpoint is linked to
the idea of good or poor mentalization and this in itself will influence

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182 C. Bronstein

whether or not somatizations are reversible (Stora, 2007). Marty takes into
account the existence of both life and death drives but, whilst he sees the life
drive as one that has an autonomous existence, the death drive operates
once the life drive fails (Fain, 1967). There is then a regression to disorgani-
zation and deconstruction (Smadja, 1998). In his account of Marty’s work,
Smadja proposes that, even though Marty discusses the importance of the
death drive, his position is mainly monistic rather than dualistic as he sees
the main force underlying psychosomatic construction as coming from the
life drive. He thinks this is different from Freud’s dualistic conceptualization
of the binding and unbinding of life ⁄ death drives (Smadja, 1998). This is an
important issue that, in my opinion, brings a fundamental difference with
the approaches sustained by analysts from the Kleinian School of thought
for whom the death drive is as active as the life drive and in permanent con-
flict with each other.
As a point for an argument about theoretical differences it is perhaps
worth noticing that in Marty’s conceptualization of the role of the drives
the object of the drive does not seem to play a fundamental role. The drive
seems to be a concept more linked to the biological notion of instinct rather
than part of the psychic domain. This led Andr Green to state that he
thought Marty was describing a pre-psychic phenomenon rather than a psy-
chic one (Green, 1998b, p.20, 102).
Analysts of the Paris School and the authors who write on alexithymia
are not the only ones who see the lack of the capacity to symbolize as one
based on deficit. In the UK, Rose Edgcumbe studied the acquisition of lan-
guage in children. She described the process of somatization as one based
on a lack of a capacity to symbolize, which she linked to an incapacity in
the mother to use words with her child and to her proneness to respond
mainly in physical ways. Edgcumbe (1984) described somatization in chil-
dren as the only means (in the child’s unconscious view) of communicating
with the object.
From a different perspective, the lack of a capacity for mentalization in
patients with psychosomatic conditions was also described by Fonagy
(Fonagy and Moran, 1990).

B. Models of conflict and phantasy: Life ⁄ death drives, anxiety and

symbol formation: The role of the body in unconscious phantasy
The notion of psychic conflict is basic to the understanding of both neu-
rotic and psychotic pathologies. Different theoretical schools place the
emphasis on different aspects of psychic conflict. In the UK the develop-
ment of Kleinian ideas introduced a particular way of thinking about
psychic conflict. It placed psychic conflict within the duality of life ⁄ death
drives and postulated the notion of an early ego capable of perceiving
anxiety and of relating to an object from the beginning of life. Klein
described the development of primitive defence mechanisms with splitting,
projection and introjection as being basic to the constitution of the ego
(Klein, 1930). In this theory unconscious phantasy and internal objects
can be defined as being in a dialectical reciprocal relationship as they

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come together as part of the same psychic experience (Baranger, 1980;

Bronstein, 2001).

The role of the life ⁄ death drives: The body as ‘source’ of

phantasy life
I think that one fundamental difference between the approaches of the Paris
School and the Kleinian School has to do with the different conceptualiza-
tion of the notion of drives, in particular with that of the death drive. At
the basis of Marty’s theories is an evolutionist notion that associates coun-
ter-evolutionary forces with a weakness of fixation-regression systems
(Smadja, 2005) This conceptualization is based on an idea of early primary
fixations on the instinctual development of the subject and on the regression
to these positions in the course of movements of disorganization. This is
linked to a notion of death drive which is biologically based.
The notion of ‘drive’ [Triebe] is a concept that rides between the ideas of
the somatic and the psychic. This concept can be used to describe the cor-
poreal bases of the psyche rather than present an antithesis between what is
physical and what is mental (Ahumada, 1999 ).1 In Kleinian theory, while
the death drive can, in theory, be unbound from the life drive, the conflict,
via unconscious phantasy, is one that is still anchored in the mind. The
notion of ‘drive’ is inherently attached to the notion of internal objects as
both drives and object come together from the beginning of life. It seems to
me that it is in this locus where the notion of unconscious phantasy finds its
meaning as it originates from the intimate connection between drives and
object, thus bringing together affect and representation.2
Klein’s definition of phantasy is much wider than Freud’s as for Klein
unconscious phantasy is the mainspring, the original and the essential con-
tent of the unconscious (Bott-Spillius, 2001). It includes very early, primitive
forms of infantile thought, sometimes in a very raw way, as well as later
complex and more sophisticated phantasies. Susan Isaacs described uncon-
scious phantasy as the ‘‘mental corollary, the psychic representative of
instinct‘‘ (Isaacs, 1948, p. 83). The earliest phantasies are preverbal, based
on early sensory experiences and feelings and have attributes that Freud

1
In her Introduction to the 1995 edition of Le Moi-Peau, Evelyne Schaud reminds us of Didier Anzieu’s
three planes of description of the relationship between the ego and the body (specifically the skin): (1)
a metaphorical dimension: the skin-ego (more the ego-skin) as the ego as a metaphor of the skin;
(2) a metonymic dimension: ego and skin mutually containing themselves as the whole and the part; and
(3) as an ellipsis (like a figure with a double focus: mother and child). I think this is an interesting way
of thinking about this subject. This triple-level of understanding acknowledges the relationship to the
object, includes both a metaphorical dimension and takes into account the continuity between the
physical and the mental dimension , between the ‘real’ body (which we can also refer to as the ‘soma’,
the site of ‘instincts’) and the phantasized body: the recipient of projections, the imaginary one. It brings
together the separateness of mind and body as well as its unity. It is in this latter locus where I think the
‘drive’ comes into place and, with it, the concept of phantasy, of internalized objects and of
identifications. The metonymic dimension brings in the continuity between ego and soma, mediated by
the body. The ellipsis alludes to the container, to the object relation between mother and child (Schaud,
in Anzieu, 1995; Bronstein, 2007).
2
The notion that both representation, that is ideation, and emotion always come together and that
thought takes part in the constitution of emotion has been discussed by a number of authors who hold
different theoretical perspectives (Cavell, 1993; Green, 1977, 1999).

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184 C. Bronstein

thought were characteristic of primary processes (Bott-Spillius, 2001; Isaacs,

1948 ). Kristeva describes this use of the concept of phantasy as a ‘‘meta-
phor incarnate’’ (Kristeva, 2001, p. 150). In my view, this conceptualization
would make it impossible to entertain the idea of a state of anxiety that is
not linked to some sort of mental representation, however concrete and
primitive this might be. We could then think of different forms and levels of
symbolic functioning rather than in terms of either presence ⁄ absence of a
capacity to symbolize.
Following this we could postulate that the body is intrinsic to mindedness
and that it is a source of unconscious phantasy. The body is not only a source
of unconscious phantasies but can also become an important part of the
content of unconscious phantasies. A third dimension is that the body can
function as the arena onto which unconscious phantasies can be projected and
unconsciously enacted. I think that psychosomatic phenomena are linked to
more primitive phantasies and to a more concrete form of symbolic function-
ing than the one found in hysterical symptoms but that, however rudimentary
and primitive the patient’s capacity to function symbolically might be, there is
always a possibility of establishing some meaningful contact with his internal
world.
Symbolism is central to all our mental activities and is a continuous
evolving process from the beginning of mental life (Klein, 1930; Segal, 1957,
2001). Hanna Segal described two different types of symbol formation: one
where the symbol is like a metaphor, that is proper symbolization, and one
in which, rather than a capacity to form symbols, there is a more concrete
form of psychic representation, which she called symbolic equation. An unre-
solved intense conflict with the object can then be relived in the psychoso-
matic symptom.3
As an example of symbolic equations, I can describe a research with
patients who suffered from facial neuralgias. We can distinguish typical and
atypical facial neuralgias. In the typical ones patients suffer from facial pain
in areas innervated by the trigeminal nerve. In the atypical ones the
pain does not exclusively follow the predictable innervations. Patients
presenting atypical facial neuralgias do not respond to surgery as positively
as those whose neuralgia is typical. The neurosurgeon who referred these
patients to us was worried about the high percentage of surgical failure in
trying to help patients who presented atypical facial neuralgias. We did a
short study in which we asked patients from both groups three fixed open
questions and we recorded their answers. We asked them to talk about their
pain, to tell us the history of their lives and to talk about the history of
their pain. It was interesting to see that, while the patients with typical facial
neuralgias spoke clearly and distinctively about their facial pain, describing
it from a physical perspective, when the pain had started, how long it went
on for, whether it got better or worse with cold weather, patients with atypi-
cal trigeminal pain used the word ‘pain’ to describe both emotional and
physical pain, mixing up the use of the word ‘pain’ in its emotional and

3
I believe that some physical ‘somatic’ predisposition must also play a part but once the symptom is
brought to the analytic session we can only address it from and within a psychoanalytical perspective.

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 Education Section: On psychosomatics: The search for meaning 185

physical meaning. In patients with atypical neuralgia there seemed to be a

clear relation between the onset of the pain and an important loss (i.e. the
loss of the mother). At the same time they strongly rejected the possibility
of any connection between their emotional and physical pain. We suggested
a relationship between atypical facial neuralgias and the melancholic person-
ality. One possible way of thinking about this is that the pain symbolized the
dead object, that it represented the loss and its unresolved mourning. What we
postulated though was that the pain did not represent the dead object, but that
the dead object became pain. ‘That is, from ‘having’ pain, they ‘become’ pain’
(Carpinacci, p.86, my transl) This is close to Segal’s concept of symbolic equa-
tion (‘‘The early symbols … are not felt by the ego to be symbols or substitutes
but to be the original object itself’’ (Segal, 1957, p. 53). ‘‘The symbol is treated
as though it was the object’’ (Segal, 2001, p. 150). We came to the conclusion
that the atypical neuralgias suffered by many patients encapsulated an uncon-
scious link with a loved dead object and that in the resurrection of the pain
there was an imaginary resurrection of the dead loved object that continued to
be alive in and through the pain. This could be also partly explained, following
McDougall, as a massive and archaic form of defence against mental pain in
all its forms (McDougall, 1974 ).

Psychosomatics and latent psychotic states

Another difference between the approaches of the Paris and the Kleinian
School is that, while with the first the role of fixation plays a very important
part in the understanding of the psychosomatic illness, Klein’s conceptuali-
zation of the notion of ‘positions’ provided a different perspective. She
moved away from an idea of stages or phases of development and of fixa-
tion to them, as she felt these were far more fluctuating than were originally
described and introduced the notion of ‘positions’ as a constellation of
impulses, anxieties, defences and object-relations. Position characterizes the
posture that the ego takes up in relation to its objects (Hinshelwood, 1989).
The development of Klein’s notion of the paranoid–schizoid position led a
number of authors to investigate and write about the vicissitudes of
‘psychotic anxieties’ in psychosomatic pathology. Sperling (1955), for exam-
ple, linked the paranoid phase in a patient suffering from chronic ulcerative
colitis to unconscious phantasies of a poisonous breast and penis.
Between 1978 and 1985 Herbert Rosenfeld gave a series of seminars in
Milan and Rome. One of these seminars dealt with the relationship between
psychosomatic symptoms and latent psychotic states. Rosenfeld developed
his previously explored notion of early confusion as a consequence of a defi-
cient early splitting into a more complex understanding of how the ego can
defend itself from psychotic anxieties by attempting at projecting them into
an external object. If this process fails, the projections are then withdrawn
into the self and are projected into the body or a body organ conforming to
what he called ‘psychotic islands’ which are split from the psyche and are
inaccessible to the more integrated aspects of the self (Rosenfeld, 2001).
Rosenfeld sees this process as one that operates both in hypochondria and
psychosomatic phenomena. He sees the origin of this in a failure in the

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186 C. Bronstein

early normal splitting between good ⁄ bad objects.4 In hypochondria and in

psychosomatic states anxieties are split off, projected into external objects
and quickly re-introjected into the body and body organs. He sees the differ-
ence between hypochondria and psychosomatics as one that is determined
by whether or not the split is complete. While in hypochondria, after the
projection of the delusional content into the body, the mental anxiety is
retained, in psychosomatic illnesses there is an apparent lack of anxiety as
the split between mental and psychic spheres is complete.
In a paper on ulcerative colitis, Sydney Klein described a patient
who developed an acute psychosis after a great physical improvement.
S. Klein linked this to the patient’s inability to tolerate separation and to
the destructive feelings aroused by it. He saw the emergence of a psychotic
episode during the analysis as proof that the colitis had previously served
the purpose of splitting off primitive paranoid and depressive anxieties con-
nected with sadistic attacks on the breast. He proposed the notion of an
early stage of development when the infant could not differentiate between
physical pain and its emotional counterpart. Defecation was felt by the
patient as a way to get rid of both unpleasant intestinal feelings and
emotional feelings (Klein S, 1965).

The work of Bion

The work of Bion was highly influential on both Kleinian and post-
Kleinian theoreticians as well as on many other analysts who belong to
other schools of thought. Bion’s work on the development of a capacity
to think and of learning from experience and on the interaction between
Love (L), Hate (H) and Knowledge (K) have deep implications regarding
the relationship we establish with ourselves and with the external world.
Bion explored the role of the early interaction between mother and baby
that enables the baby’s development of the capacity for ‘alpha function’
which transforms sensuous impressions into ‘dream-thoughts’. Raw sense
impressions related to emotional experience (beta elements) need to be
transformed into alpha elements in order to be able to be used to form
dream-thoughts. When the emotional experience is not processed into
symbolic representations that can lead to dream-thoughts, it will be evacu-
ated. One of the possible routes for evacuation is via psychosomatic disor-
ders (Bion, 1962; Meltzer, 1986; Ogden, 2009). The process leading to
evacuation of unprocessed beta elements is quite different from the idea
of a lack of capacity for mentalization described by Marty in that, even
though it also relates to a failure in the containing capacity of the mother,
it involves an active psychic process rather than the passive dismantling of
the mind.

4
According to Klein (1946) normal splitting is necessary in order to protect the ‘good’ aspects of both
self and object from being overwhelmed and destroyed by the ‘bad’ aspects of the self (linked to the
death drive and to anxiety of annihilation). The inability to achieve this normal splitting can cause an
early state of confusion between persecutory and depressive anxieties. Rosenfeld proposed that, as a
result of this failure in differentiation and in order to deal with the confusion, patients resort to further
splitting and projective identification.

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 Education Section: On psychosomatics: The search for meaning 187

Bion’s notion of maternal containment had both a profound theoretical

and clinical impact. The notion of raw beta elements that need to be pro-
cessed into alpha elements as a necessary step for the development of a
capacity to think, together with the changing view of projective identifica-
tion as one that included the notion of the necessity for maternal reverie in
order to process these raw aspects and anxieties influenced many analysts’
theories on the relationship between mind and body and on psychosomatic
illness (Bick, 1968; Ferrari, 2004; Ferro, 2009, Meltzer, 1975; Ogden, 2009;
Pistiner de Cortinas, 2009, amongst many others).
In his early works, Bion postulated the existence of a ‘protomental’ system
where physical and psychological or mental processes are undifferentiated
and he indicated that such primitive experiences can be still actively func-
tioning in the adult (Bion, 1959 ). In the later years of his working life, Bion
returned to his earlier interest in ‘protomental’ functioning and its relation-
ship with bodily processes. Bion placed importance on the continuity
between intrauterine life into postnatal life at both a physical and mental
level. He thought that embryonic stages have a distinct representation in the
structure of the self and that there are primitive parts of the self that do
their thinking with the body and follow laws closer to neurophysiology than
to psychology. He thought that some intense inchoate feelings might be then
experienced to be physiological (‘subthalamic’). It would be a world very
much influenced by a degree of quantities of excitation rather than by emo-
tional nuances (Meltzer, 1986). Bion stressed that some symptoms cannot be
understood without relating them to an archaic state of mind. He saw the
idea of a ‘caesura’ of birth as one that prevented us from thinking about
the continuity between the premental experience of gestation and postnatal
thought. In A Memoir of the Future (Bion, 1991) he writes of the ‘soma-
psychotic’ as that which would be the reverse side of the psycho-somatic but
as if both sides would be reluctant to see the other perspective:
Look on this side and see a delineation of a psycho-somatic disorder; look on this
side and see a soma-psychosis.

(Bion, 1979, p. 487)

It seems to me that in this later development of his theories we can find
some similarities with the explanations sustained by the Paris School of
Psychosomatics (for example, of the importance played by the economic
dimension). However, Bion emphasizes far more the role of a very early
splitting in the foetus which operates when it is confronted with intolerable
sensations ⁄ feelings (Bleandonu, 1994; Symington and Symington, 1996).

Integration ⁄ disintegration
Beside the important notion of containment introduced by Bion, Esther
Bick’s paper on the containing role of the skin in the early relationship
between mother and child also influenced a number of works in the UK
and abroad (Bick, 1968). She postulated that the baby’s skin has a pri-
mal function of binding together the parts of the personality that are not

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188 C. Bronstein

yet differentiated from parts of the body. These aspects of the personality
have no
binding force amongst themselves and must therefore be held together in a way that
is experienced by them passively, by the skin functioning as a boundary.

(Bick, 1968, p. 484)

This early unintegrated state, linked to a passive experience of total help-
lessness, is different from the states of disintegration following splitting
processes and prior to the early mechanisms of splitting and projective iden-
tification as described by Klein (1946). In this state of unintegration, the
baby’s function of containing the parts of the self is dependent on an exter-
nal object who is ‘experienced concretely as a skin’ and who can fulfil this
function that, hopefully, the baby will later introject. Faulty development
can lead to a pathological projective identification that brings a confusion
of identity, a ‘second-skin’ which manifests itself as either a muscular shell
or verbal muscularity. Bick’s contribution was discussed by Didier Anzieu
who saw the similarities between her conceptualization and his formulation
of the ‘skin-ego’ (Anzieu, 1995). Anzieu’s work on the psychic envelope and
the skin-ego was more extensive than Bick. In the UK though, Bick’s paper
became highly influential and led to a still ongoing debate between authors
who sustain the existence of an early period of helpless passive ‘unintegra-
tion’ as part of normal development and those who sustain that a phase of
passive unintegration is not a baby’s normal first phase but that it would be
a desperate defence in order to survive and not disintegrate (Alvarez, 2006;
O’Shaughnessy, 2006; Symington, 1985, 2002; Waddell, 2006). This debate
has implications for the understanding of psychosomatic phenomena as
these are seen to be based on very early psychic processes and speculation
about what are the roots and manifestations of early anxieties and how
these modify the capacity for symbolic thinking influence our perspective on
these phenomena. For example, the role of splitting and projective identifi-
cation as underlined by Rosenfeld necessitates a certain capacity for ego
functioning. This is different from a conception that sees the eruption of the
psychosomatic illness as the consequence of a state of unintegration out of
a lack of internal ⁄ external containment.
Bick’s notion of how the mother is experienced concretely as a skin was
extended by Dinora Pines who worked as a dermatologist and later as an
analyst. Her work was also influenced by Winnicott’s ideas. She described
how infants who experience extended periods of bodily soothing learn to
translate psychic pain into bodily suffering. The failure to introject a con-
taining function developed a disturbance of the self and acute sensitivity to
object relations.
I personally agree with McDougall’s notion that everybody possesses a
certain ‘psychosomatic potentiality’ that reveals itself under conditions of
psychic stress (McDougall, 1980, p. 457) and that patients who are exposed
to serious psychosomatic disorganization are dealing with psychotic anxi-
eties through the erection of primitive defences. I think that these ‘psychotic’
anxieties are linked to an experience of feeling dangerously close to the

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 Education Section: On psychosomatics: The search for meaning 189

unbinding of life ⁄ death drives towards the primary object and, hence,
towards the self. I think that the eruption of a psychosomatic illness can
often follow an experience of intense, unprocessed raw feelings towards the
primary object (or its representative in later years), often charged with a
sense of danger as the hated object is also felt to be needed for the subject’s
own physical ⁄ emotional survival. This anxiety of disintegration is experi-
enced as belonging to both the emotional and physical realms (such as an
unbearable and threatening sense of psycho-physical tension). The object
(i.e. the analyst) is then experienced not only as somebody who lacks the
capacity to contain the patient’s anxiety but as the one who is triggering it.
This threatening life ⁄ death experience also carries erotic cravings (linked to
the erotic binding of the death drive), often adding a sadomasochistic qual-
ity to the relationship to the object with an attempt to control and punish
the object via guilt and pain.
An 8 year old girl with a history of early maternal deprivation and suffer-
ing from extensive eczema and asthma since birth demanded a great amount
of physical contact from me. I was required to be extremely aware of her
great physical needs and she often felt that interpretations were the proof of
my rejection of her. When she felt I did not provide her with what she des-
perately ‘needed’ (she wanted to sit on my lap, to comb my hair, to make
me comb her hair, etc.), she would give up trying to make me touch her; she
sat down and started to cough. I knew that once she started to cough it
could easily develop into a full-blown asthma attack. By then the more
reproachful and guilt-inducing aspects of the relationship to me would take
over. I felt though that the trigger of the physical symptoms in the session
was linked to the intense experience of her desperately needing ‘something
physical’ from me that she felt I should and failed to give her. Her need to
be touched by me gave her a sense of feeling wanted, of boundaries and
containment. I also thought that it was the only way she could convince
herself that I did not hold hostile thoughts and feelings towards her – expe-
rienced as a me who was then accepting her body with all the damage and
damaging feelings she felt it contained. It therefore became a ‘desperate’
need. My refusal to caress her not only corroborated that I was hostile to
her but made her aware of her own hostility which was felt to be danger-
ously overwhelming and threatened to overpower the precarious trust on
my ⁄ her capacity to love. The threat now came both from the outside as she
felt attacked by me and also from her body as the hateful feelings were felt
to be lodged in her body. I think that the asthma attack was the embodi-
ment (at the level of symbolic equation) of this conflict (Bronstein, 2009).

The basic fault; Dissociation and splitting – Michael Balint

The question of what is the origin of a psychosomatic disposition was also
discussed by the Hungarian analyst, Michael Balint, who settled in Britain.
He described a ‘‘basic fault in the biological structure of the individual,
involving in varying degrees both his mind and his body’’ (Balint, 1957, p.
255). The origin of this ‘basic fault’ was linked by him to a state of defi-
ciency in relation to a discrepancy between the needs of the infant and the

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190 C. Bronstein

care and nursing available at relevant times. Balint placed an emphasis on

the ‘lack of fit’ between the child and the people who represent the environ-
ment (usually the mother) (Balint, 1968). In connection to physical illnesses
he felt that:
No matter whether illness is a severe shock or a welcome justification for with-
drawal, it is always a form of life. This is especially true of illnesses of some dura-
tion, allowing time for the patient to adjust himself to it.

(Balint, 1957, p. 258)

Balint stressed that no form of life can be maintained without some grati-
fication but he was also aware that in chronic illnesses gratifications were
partial, additional to, or almost completely overshadowed by suffering. In
his study of the gratifications produced by physical illnesses he described the
role of the erotogenic zones of the body (ibid., p. 259), of the withdrawal
from all sorts of unsatisfactory, or frustrating, demanding or over-exacting
relationships with people (ibid., p. 160) and of introversion and regression.
One of Balint’s important contributions was to develop what would be
called ‘Balint groups’. These are groups composed of general practitioners
working with an analyst and examining cases that are brought by a physi-
cian. The group tries to understand the complexities underlying the relation-
ship between the doctor and his patient and aim at reaching a more
comprehensive and deeper diagnosis (Balint, 1957).

The work of Winnicott

Winnicott’s notion of the importance of maternal holding and his ideas on
the psychesoma also had an important repercussion on the development of
ideas on psychosomatics. He presented an innovative way of focusing on
the body ⁄ mind problem: he thought that it was false to have a concept
of ‘mind’ as a localized phenomenon. The notion of ‘mind’ is a special
case of functioning of the psychesoma. He placed great importance on early
development and on the interrelation of the psyche with the soma being part
of the notion of the baby’s continuity of being, provided this continuity of
being is not disturbed. For this there is a need for a perfect environment that
adapts to the needs of the new baby. A bad environment becomes an
impingement ‘‘to which the psyche-soma (i.e. the infant) must react’’ (Winni-
cott, 1949, p. 245). The early need for the absolute good environment can
then change and become relative, that is, just needing an ordinary good
mother. One of the interesting ideas he presents is that the somatic distur-
bance has a ‘positive value’ as it counteracts the seduction of the psyche
into the mind and draws the psyche from the mind back to the original inti-
mate association to the soma. Winnicott’s description of how the mind ⁄ -
body dissociation is enacted and externalized places the accent on the
importance of the role of splitting. This can be extended to the splitting of
medical care. While the symptom indicates the split that has happened at
the same time, it also indicates hope that the communication will be heard
(Abram, 1996).

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 Education Section: On psychosomatics: The search for meaning 191
Psycho-somatic disease is sometimes little more than a stressing of this psycho-
somatic link in face of a danger of a breaking of the link: this breaking of the link
results in various clinical states which receive the name ‘depersonalization’.

(Winnicott, 1963, p. 224)

Winnicott’s ideas in relation to the psychesoma were further developed by
Renata Gaddini who, influenced by both Mahler and Winnicott, described
the role of ‘fantasies in the body’. Following Winnicott’s description of
the psychosomatic symptom as the negative of the positive (this being the
tendency towards integration), Gaddini suggested that the psychosomatic
symptom is the negative of the development of a transitional object. In her
description of several psychosomatic symptoms such as infantile colic and
asthmatic attacks, she stressed their role as a defence from early sudden loss
and a way of seeking a reunion with the mother (Gaddini, 1978).

Discussion: Technical issues

As we can see from the above description of the different ideas that origi-
nated in the UK, beyond the argument of whether or not psychosomatic
illnesses carry symbolic signification, the accent is placed on the role of
splitting, dissociation and projective identification. Some theoreticians see
this as part of an active process stemming from the need to defend from
potentially overwhelming internal annihilating forces while others see it
more as the passive consequence of a lack of maternal holding. These two
positions might not be necessarily absolute and exclusive but they do inform
the type of technical approach to patients’ illnesses.
It seems that in the last 20 years there has been a decrease in the number
of psychoanalytic papers on psychosomatics in the UK. There is now a
reawakening of interest in this subject. It seems to me that one possible rea-
son for the fewer number of publications on the subject was that in the last
decade psychoanalytic attention became more focused on trying to under-
stand the complexities underlying the psychoanalytic process itself rather
than looking at more general psychopathological syndromes.
From the point of the actual psychoanalytical technique, the question as
to whether patients suffering from ‘psychosomatic’ illnesses could or should
be offered analytical treatment is addressed differently by different analysts.
Analysts from the Paris School of Psychosomatics approach the work with
psychosomatic patients in a way that is consistent with their theory. They
feel that these patients lack the necessary ego integration to be able to func-
tion symbolically and to free associate. They would therefore not recom-
mend ‘traditional’ psychoanalysis. They work face to face for quite a long
time on a psychoanalytically based psychotherapy (that at times seems to
me to be closer to supportive therapy) and psychodrama. It is only later
that they would refer these patients to analysis or intensive therapy. In the
Paris School these patients would not be asked to lie down and there is a
prevalence of the basic relationship to transference interpretations –
although the transference would be taken into account it would not be
interpreted (Kamienicki, 1995).

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192 C. Bronstein

One has to take into account that unlike what happens in Paris where
many patients are referred to the clinic of the Paris School of Psychoso-
matics, in Britain these type of referrals are not very common. However,
some patients with psychosomatic complaints are seen by psychotherapists
in their Hospital settings and some do seek analysis. We also encounter
severe illnesses in many of our patients. It is quite common to have patients
in analysis who in the course of it, either communicate the existence of a
previous illness or develop one whilst in analysis. From my perspective,
when seeing patients with psychosomatic disorders it does not seem justifi-
able either on theoretical or clinical grounds, to make changes to the
analytical technique . Issues of timing and levels of interpretation should be
taken into account as with any other patients. It might be necessary to take
into account the different levels in the patient’s capacity to function symbo-
lically but this does not mean that four or five times a week analysis should
not be the treatment of choice.
The work with patients who are in a constant state of physical pain and
suffering from life-threatening illnesses places a huge strain on analyst’s
countertransference. Even though psychosomatic illnesses often improve
during the analysis, the analytic process also reactivates conflicts inherent in
the development of an illness, which can sometimes contribute to outbreaks
of illness and somatic deterioration. Sometimes patients bring their ill
bodies demanding that the analyst focus on the illness, concretely obliterat-
ing any space for thinking and for free associating. The analyst might then
lose sight of his ⁄ her role whilst ‘the illness’ saturates the analytic field and
ends up dictating what goes on in the treatment. The focus on the patient’s
psychic reality and how this is lived out in the transference relationship can
then get lost. This can easily lead to enactments in the countertransference
as the analyst might feel unconsciously responsible for the patient’s physical
deterioration. As Ferro proposes, we need to stay in touch with what might
be the analytic status that a particular communication, such as ‘‘stomach
pain’’, has in the analytic session (Ferro, 2009, p. 73).
I think that both patients and analysts have to work through the disap-
pointment that analysis does not provide a magical solution. The study and
understanding of the cause, role and meaning of somatic illnesses and the
interplay between the soma and the psyche can easily slide into an omnipo-
tent belief that if we found the right theory we might be able to ‘cure’ physi-
cal illnesses. I think that this is a slippage that could allow psychoanalysis
to lose its specificity and one in which the notion of ‘cure’ might then
become too dominant. Marie Bonaparte warned us that we should be care-
ful to not assume that psychoanalysis can cure physical illnesses as this
would be akin to a revival of the old spirit of magic:
For one of the most ineradicable of man’s desires is to believe in the supremacy of
the ‘soul’ over the body, a supremacy which would assure to them the omnipotence
of their thought over themselves, as over the universe.

(Bonaparte, 1950, p. 52)

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