Turning points in

modern psychoanalysis'

Sara Sheftel

The author discusses Rothman's work with patients on the primitive

edge in the context of the modern psychoanalytic approach to
the treatment of severe narcissistic disorders, The writer also
touches on the work of the Paris School of Psychosomatics and of
modern analysts who have treated somatic cases. Salient features
of the modern psychoanalytic philosophy and theory of treatment
for preoedipal conditions as developed by Hyman Spotnitz are
presented in some detail.

Rory Rothman's (2011) paper provides an excellent account of

a modern psychoanalytic research project. Its merit is further
enhanced in that it illustrates how a modern analyst works in
integrating research and treatment. Rothman uses compel-
ling language to describe her observations of the patients she
works with and the frame through which she observes them.
She brings to bear all parts of herself in her clinical work and
her research: her observations are informed by her theoreti-
cal knowledge, enriched by keen awareness of her emotional
and sensory responses to the patients and by her capacity to
*This paper is based on a presentation given at the Center for Mod-
ern Psychoanalytic Studies Annual Scientific Conference, New York,
November 20, 2010.
summon up visual metaphors for understanding them. This is
not accidental; she was trained as a visual artist. She writes, for
example:
I tend to understand my patients visually and viscerally; I picture
their inner life in terms of energy blocked off and try to allow
an image or association to come to mind that helps me to create
some understanding, (p. 5)
I find it notable that in many of these patients there is an absence
of prominent, observable symptoms. It reminds me of the idea of
"negative space" in visual art. (p. 6)
Rothman's work has made me think of tbe role the analyst's cre-
ativity plays when doing research and treatment. For example,
she discovered a new way of listening to this particular category
of patients, whicb she describes as "sensorial and vigilant lis-
tening," a significant departure from Freud's evenly hovering
attention. She bas brought to her research and clinical work
the drive to know and understand, plus sensitivity, imagination,
and the ability to make links. These elements inform every as-
pect of tbe process, much in tbe same way as tbey would in any
creative work, whether artistic or scientific. I find this botb in-
spiring and liberating—bearing in mind that to work with tbis
kind of freedom is only possible when we are as sure-footed as
we can be in traversing a rocky clinical terrain and when we also
possess a strong foundation in theory and technique and, of
critical importance, remain in analysis and have good supervi-
sion. Spotnitz (1963) makes tbis point when he writes:
Even experienced practitioners who have no difficulty in treating
neurotics may find it necessary to return to their training analyst
or secure other aid in resolving personal problems they become
aware of when they start to work with more intractable patients.
The therapist wbo is unable to analyze the severe neurosis or psy-
chosis they induce courts the actual development of psychotic or
psychosomatic reactions unless he secures immediate help. (p. 93)
Spotnitz's experience alerts us to the need to be in analysis and
supervision when treating cases on the primitive edge, for botb
tbe analyst's and the patient's protection.
Working with severe narcissistic disorders shaped Spotnitz's
clinical philosophy, wbich the modern school upholds to tbis
day. In the first issue of Modern Psychoanalysis, the first paper.
entitled "The Origins of Modern Psychoanalysis," written by the gj
editors (1976), explains:

There are many theories about the human personality and its |-
development—all of which may or may not be correct. What mod- i§
ern psychoanalysis tries to develop are theories that, when ap- §
plied to the patient, help to cure him. Any theory that enables the ^
analyst to understand the patient but becomes a detriment to cur- ^
ing him is discarded. In other words, modern psychoanalysis de- E.
pends on and accepts only pragmatic concepts. It does not limit 3
itself to psychodynamic treatment alone. Althotigh the modern 'S
analyst cooperates with physicians who use physical and chemical 3-
methods with patients, he relies on psychodynamic communica- §
tion to resolve transference resistances that interfere with healthy ^
functioning, (p. 13) ^
en

This statement clearly articulates and defines the modern ana- ^

lytic position. Gritics have pointed out that there is no modern S:
analytic metatheory. That is correct. Unlike most of the theore-
ticians who came in Freud's wake and significantly changed or
discarded Freud's metatheory—and who with few exceptions did
little or nothing to advance his clinical theory—Spotnitz went
in an entirely different direction (Bergmann, 1993; Richards,
1990). He embraced Freud's theoretical conceptualizations be-
cause they provided an explanation for the functioning of the
human mind that paved the way to understanding the psycho-
dynamics of severe narcissism: he used them to develop his clini-
cal philosophy, his definition of the narcissistic defense, and his
theory of technique. These were groundbreaking developments.
Spotnitz bad one major goal in mind: how to cure, how to be
tberapeutic. An opportunist in the best sense of tbe word, be
was prepared to adopt whatever theories or concepts suited this
purpose. Having been rigorously trained as a researcher in neu-
rology and psychiatry, he transferred those skills to his work in
psychoanalysis. He assiduously reviewed the psychoanalytic and
scientific literature and took from it whatever he found interest-
ing; if it proved to be clinically valid, be adopted it. Tbis lesson
was not lost on Phyllis Meadow who was in charge of guiding
the Genter's curriculum: she introduced modern analysts to the
works of Piontelli, Gaddini, Edelman and other neuroscientists,
as well as Lacan, Green, and others, and today we are able to see
her legacy reflected in Rothman's work.
Some critics have maintained that research and clinical work
are incompatible and should not be performed simultaneously.
Spotnitz (1992) takes a different position and elucidates the
problem in "A Note on Psychoanalytic Research":

There is constructive research and destructive research. In de-

structive research, the analyst loses sight of the patient. Tbe pa-
tient is forced into a state of regression because the analyst is
preoccupied with the research goals and fails to notice what is
happening to him. The constructive researcher always keeps the
therapeutic goals in mind. . . . [He] considers what will benefit
the patient while at the same time considers what will add to the
body of human knowledge, (p. 134)

What Rothman's work demonstrates is exactly what Spotnitz

had in mind. Her research, guided by Phyllis Meadow, started
out with clinical observations that aroused her intense curiosity
and sparked her need to know more. She brought all her clinical
skills and theoretical knowledge to the research process: how to
listen, how and what to observe, how to use her countertrans-
ference, how to follow a line of investigation that would create
understanding and provide meaning. Her observations became,
with the passage of time, more and more specific, more and
more clearly defined, more elaborate in their richness of detail,
until finally a clear picture emerged that took a specific shape:
the picture of patients who use their bodies to do the talking.
This, in itself, is admirable. But what is more admirable still is
to find out that each patient she has presented bas remained in
treatment for a remarkably long time: Mei for over 15 years, Jim
for more than 20, and Liz more than 18. The inevitable question
that comes up is. What kind of psychoanalytic work has Rothman
been doing with these patients on the primitive edge?

Rothman states at the beginning of her paper that using the

modern psychoanalytic treatment techniques developed by
Spotnitz as her foundation, she has, over many years, developed
as an analyst and treated a wide variety of patients. The somatic
patients included in her study present the greatest challenge be-
cause even though they are capable of functioning to a greater
or lesser degree in the outside world, their psychic lives appear
inaccessible, if not inexistent. This is not Freud's stone wall of
narcissism as in psychosis, but as in psycbosomatosis, with its
origins in earliest trauma or deficit, before the establishment 33
of object or even part-object mental representations. It is as if
the psychic development of these patients was stunted from the
first and the energies deflected to an entirely different mode
of functioning: negative tension states are expressed through
bodily symptoms, barred from discharge through adaptive
pathways. The psyche gets short-circuited at the very beginning ^
of life. °
CD
3
In Spotnitz's formulation of the narcissistic defense in schizo- "^
phrenia, the destructive instinct is turned against mental func-
o
tion, and the life instinct is put in the service of protecting the D
self-object from the vast reservoir of bottled-up rage. When the
schizophrenic defense breaks down the unbound primitive rage
erupts, and we hear in the news that an individual who was re-
leased from a mental institution as being "safe" pushed someone
off a subway platform. In the psychosomatic defense, we see the
destructive drives discharged into and against the body. As in
schizophrenia, the libidinal drive is also in the service of self-
object protection. What strikes me most powerfully about Roth-
man's patients is the enormous amount of violence, volcanic
rage, and malignant toxicity encapsulated in their bodies with
no available mechanism for discharge. I believe that when the so-
matic defense breaks down a condition similar to marasmus—or
failure to thrive—sets in, resulting ultimately in death.

Rothman has developed a clinical profile for psychosomatic

patients that resonates with the work of the researchers of the
Paris School of Psychosomatics, today's leading theoreticians in
this field. Her findings corroborate theirs although at the time
she prepared her research she was not acquainted with their
work. We are somewhat familiar with their orientation from
reading Joyce McDougall. Even though she is not a member of
that group, she shares many of their views and has both influ-
enced and been influenced by their work. The founder of the
Paris School is the physician and psychoanalyst Pierre Marty,
who started working in this area in the early 1950s in collabora-
tion with Michel Fain and Michel de M'Uzan.

It is interesting to draw a parallel between their work and the

research Spotnitz started doing with schizophrenic patients a
decade earlier, in the early 1940s. His ultimate goal was to find
a cure for schizophrenia using the psychoanalytic method. In
the same way as he developed a psychodynamic theory of the
narcissistic defense in schizophrenia, Marty and Fain worked
out a unified homogeneous psychodynamic theory for psy-
chosomatic patients. It is also interesting to note that both the
modern and the Paris schools have turned to Freud's economic
and dual drive theories to understand and conceptualize the
severe narcissistic disorders they studied. Following Marty and
Fain, many other serious and dedicated researchers affiliated
with the Paris School of Psychosomatics are making valuable
contributions. Most prominent among them are Glaude Sm-
adja (2005), Marilia Aisenstein (2010), and Elsa Rappoport
de Aisemberg. There is one more powerful link between their
group and modern psychoanalysis: André Green. Just as Roth-
man found Green's conceptualizations enormously useful in
understanding her patients and in formulating aspects of her
research methodology, so too has the Paris group turned to his
work in developing insights specific to psychosomatic patients.
There is one notable difference between the Paris School of
Psychosomatics and modern psychoanalysis: while the Paris
group has greatly advanced its theoretical concepts, its clini-
cal approach appears to rely on a modified classical method
that includes interpretation and could be described as psycho-
analytically based psychotherapy. In other words, the Paris psy-
chosomaticians do not appear to have developed techniques
specifically designed to treat psychosomatic patients.
The psychoanalytic theory of technique that Spotnitz originally
developed to treat schizophrenics was found to be applicable to
all preoedipal disorders. Many modern analysts have treated
psychosomatic patients and continue to do so to this day. Two
of those analysts stand out because they made a special point of
working with cancer patients: Selwyn Brody and Jane Goldberg.
Brody (1977, 1995), who believed discharge of rage was cura-
tive, reported mixed success. Not all cancer patients he treated
wanted to be angry, feel angry, or express anger. Some declined
treatment. Goldberg (1995) found a different way to work suc-
cessfully with cancer patients by fostering the development of
a narcissistic transference in which they could achieve an ex-
perience of oneness with her: "It should feel to the patient like
a warm bath" (p. 80). She found that helping her patients to
experience all their thovights and feelings was curative.
5
3'
This brings me back to Rothman's work and her success with
her patients. I say success advisedly because success with pa- i
tients such as these has to be measured by standards very differ- 5
ent from those used to evaluate progress with more functional ^
patients. The work is slow, difficult, and at times even danger- §"
ous for the analyst. In the case of Mei, Rothman (2011) writes: -a
<
At this point in her treatment, I notice a glimmer of feeling près- ^
ent in the room and a faint lessening in the boundaryless, toxic §
invasiveness in my presence. I assume that this is due to her ongo- •<"
ing discharge and release of tension states within the treatment "
setting, (p. 19) I"
B9
GO

In t h e case of J i m w h o n e e d s to b e in relatively close physical prox- S]

imity to his analyst, I would venture to say t h a t h e is in t h e p h a s e of —
a primitive anaclitic transference, based o n Spotnitz's (1983) idea
that t h e anaclitic transference is a new m a t u r a t i o n a l experience
created in t h e "thirdness" of t h e patient-analyst relationship. As
for Liz, so totally d o m i n a t e d by t h e destructiveness of t h e d e a t h
instinct, I would say that she is i n d e e d b e i n g h e l p e d by h e r analyst
to mitigate that destructiveness a n d thereby stay alive.
Psychosomatic disorders have b e e n a focus of interest in m o d -
e r n psychoanalysis since its i n c e p t i o n . It is i n t e r e s t i n g to n o t e
that in his preface to Psychotherapy of Preoedipal Conditions, Spot-
nitz (1976) places psychosomatic conditions at the head of a list
of "psychologically reversible problems originating in the pre-
oedipal phase of development," followed by psychotic states and
character and behavior disorders. He (1977) also alludes to the
difficulties in diagnosing psychosomatic patients:
Schizophrenic or severely depressed patients are relatively easy
to diagnose because they give the seasoned analyst strange sensa-
tions which are familiar to him, based on previous versions ex-
perienced with similar patients. Psychosomatic patients with a
narcissistic component are sometimes difficult to diagnose, usu-
ally presenting other, seemingly unrelated, symptoms which may
make the diagnosis unclear, (p. 150)

In a paper written in 1961, Spotnitz describes a maturational

problem that could lead to the development of the somatic de-
fense: "The child who tends to discharge frustration-aggression
into his body, for example, is a likely candidate for psychoso-
matic illness later in life" (p. 24). The problem of psychosoma-
tosis resulting from regression due to excessive frustration or
other motivating factors appears in many of his writings (1985,
p. 7; 1992, p. 133; 1997, pp. 35, 36 & 37).

In 1982 Spotnitz includes somatic disorders among the psycho-

logically reversible narcissistic conditions:
It is becoming clear that it may be possible to reverse many ill-
nesses: pre- and post-psychotic conditions, borderline cases,
schizophrenia, and psychosomatic illnesses. We do not yet know
the limits of psychological reversibility of illness. Those of you
who treat seriously disturbed patients willfindyourselves increas-
ingly successful in treating the disturbed individual who has psy-
chosomatic problems, (p. 186)

In an interview conducted by Phyllis Meadow in 1999, Spotnitz

talks about his approach to the treatment of somatic conditions.
He explains that the patient's experiences, contained in the
soma, are accessed by the analyst through the induced coun-
tertransference. It becomes the repository for all the analyst's
feelings, thoughts, sensations, fantasies, somatic reactions, and
other phenomena that arise from the analytic work with the
patient. The information gained through the countertransfer-
ence enables the analyst to help the patient bring those experi-
ences into language. The countertransference also holds the
key to providing the emotional "feeding" the patient may re-
quire in order to move forward: "There are psychoanalyses that
require the analyst to have feelings that the patient needed and
didn't experience from the mother and father" (p. 9). Spotnitz
describes this phenomenon as the "anaclitic" (dependent) type
of transference that grows out of certain feelings—positive,
negative, or both—that the patient needs to become a mature
adult, but did not get (1983, p. 169; Liegner, 1991, 1995).

In that same interview Spotnitz specifically refers to accessing

the somatic patient's unconscious:
When it comes to psychosomatic medicine, you have to under-
stand the unconscious all the way. . . . The patient doesn't have
to understand the unconscious. What matters is that it is put into
words. (Meadow, 1999, p. 16)
In 1997 Spotnitz further defines the problems analysts encoun-
ter in treating severely regressed patients and presents guide-
lines for future research:
If the analyst suffers from blocks in the area of early experience,
he will not be able to resolve resistances that would help the pa- 5.
tient avoid undesirable outcomes, somatization among them.
This is an area in which I would suggest research must go. How
can we resolve the resistances that help the patient to grow but
not at the cost of physical or psychosomatic illness, either for the
patient or the analyst? (pp. 36-37)
n
3"
O
To return to a question raised earlier in this paper: What kind
of work has Rothman done with her psychosomatic patients? It
can best be described by presenting Spotnitz's (1976) blueprint
for treatment, which she faithfully adhered to, originally out- 3
GO
lined in his 1957 paper "The Borderline Schizophrenic":
Therapeutic Factors

The primary emphasis is placed on meeting two basic needs: (1)

the need for adequate psychological nourishment in the form of
emotional communication or attitude [italics added]; (2) adequate
psychological release for the high accumulations of destructive or
libidinal energy in the mental apparatus of the borderline schizo-
phrenic [or accumulations in the soma of the psychosomatic pa-
tient]. Adequate nourishment and adequate release are specified
because too much or too little of either one is not therapeutic for
this type of patient [italics in original], (pp. 275-276)

Rothman brought to the treatment of her patients what Spot-

nitz is writing about; that is, she provided adequate nourish-
ment and facilitated adequate release. In terms of "attitude,"
her capacity to tolerate, sustain, and control the most difficult
induced countertransference states constituted in itself a pow-
erful emotional communication to the patient. Her attitude was
totally therapeutic. This explains the longevity of her cases.

The term "attitude" reappears in a Spotnitz writing of 1976:

[I] strive through words and attitudes to advance the science and
art of helping each person produce in his own physico-chemical
organization—the body's own laboratory—whatever rearrange-
ment of his physiological and psychological functioning would
permit him to feel, think and accomplish what he wants to in life,
(p. 16; italics added)
I am bringing the term attitude into relief—a term never explic-
itly elaborated on by Spotnitz or his followers—because I believe
it is critically important in the treatment of preoedipal cases and
therefore merits our careful attention. I also believe that atti-
tude, and I am now referring to therapeutic attitude, is implicitly
embedded in all of Spotnitz's clinical techniques that relate to
the patient's need for ego insulation and protection, such as the
contact function, joining, mirroring, emotional communication,
and creating the emotional climate that the patient needs. Spot-
nitz (1976) also drew attention to another critical factor when
working with primitive patients: "Preverbal patterns are only
responsive to symbolic, emotional, and reflective interventions.
Affective nonverbal communications, even the analyst's state of
being, give the preoedipal personality the freedom to grow"
(p. 45). This kind of communication is largely determined by the
quality of the analyst's attitude, the kind of attitude that Rothman
has brought to the treatment of her patients.
Attitude falls in tbe realm of the intangible unconscious commu-
nications that flow from patient to analyst and analyst to patient.
It may have to do with the patient's response to the analyst's tone
of voice, general demeanor, particular choice of words and how
they are uttered, or in the way analyst and patient greet each
other, as well as all aspects of the patient/analyst interaction.
Preoedipal patients are particularly sensitive to what they may
perceive visually and aurally—and also to what they may proj-
ect into the analyst since ego boundaries are indistinct. This is
understandable if we think of primitive patients as being either
fixated at or regressed to the earliest stages of life, trapped in the
primitive transferences they develop when they do not yet have
mental representations of objects or are just starting to develop
them, as in the case of Rothman's patients Mei and Jim.
A fascinating document taken from the Spotnitz Archives, dated
October 7, 1964, contains notes Spotnitz prepared for a teach-
ing lecture on the technique of psychoanalytic treatment he was
giving at the Stuyvesant Polyclinic in New York City. These notes
provide, in capsule form, the Freud-derived theoretical founda-
tions of his work and the salient features of his thinking:
Attitudes [italics added] and experience in applying the economic
and dynamic points of view in working with patients.
 Economic point of view—based on hypothesis that the organism 20
has a given quantity of energy at its disposal, and that distribution of
these energies may be decisive "as to whether or not certain psychic ^
activities gain access to mobility and consciousness" Greenson. 5.
Dynamic point of view—based on proposition that behavior can -a
be understood as the result of the interaction of instinctual im- 5
pulses and counterinstinctual forces. Greenson. ".
[These theories are at the core of modern psychoanalytic 3
thinking.] g-

Fenichel, Problems of Psychoanalytic Technique. 1941: ^

"If we consider once more how instinctual impulses that press S-
toward discharge are in conflict with defensive impulses that pre- §
vent the discharge, we see that we work always and exclusively on M:
the latter, the defensive impulses." w'
Do you recognize the relevance of these hypotheses in what you 3
observe and experience while working with a patient, and also in ^
what you yourself say and do with them? g=
[Modern analysts work not on eliciting negativity or aggression,
but on resolving the forces that prevent their expression. Rothman
used these hypotheses in studying and working with her patients.]

Do you employ the concept that treatment is a maturational expe-

rience? Or an organized series of energy interchanges, conducted
through interpersonal communication to resolve pathological
patterns of energy discharge?
[Rothman's work with her patients demonstrates this approach.]

How [do you] conceptualize the difference between tensions

which are within the normal range and tensions which are
pathological?
Would it be useful to distinguish between tensions caused by the indi-
vidual's appropriate reactions to very forceful stimuli originating in the
outside world and tensions produced by defective or inhibited processes of
energy transformations and discharge in the organism"? [italics added]
[The approach Spotnitz suggests here clearly applies to understand-
ing and formulating a theory of the psychosomatic problem.]

Do you apply yourself in treatment with the idea of improving the

functioning of the patient at the moment?
[This refers to working in the here and now to resolve resistance
and to Spotnitz's (personal communication) idea that the patient
should leave the session feeling better than when he came in.]

The area of clinical practice having to do with therapeutic at-

titude is one that Meadow and other modern analysts richly
mined. It is reflected in the clinical and theoretical writings of
all the analysts who joined with Spotnitz in developing modern
psychoanalysis and is contained in a body of literature span-
ning more than 60 years. In the resolution (rather than over-
coming) of resistance, emotional experience takes precedence
over intellectual understanding.
Modern psychoanalysis cannot be learned from books, however.
It can only be learned from the emotional and intellectual expe-
riences gained over a period of many years through one's own
analysis individually and in groups, through the interactions
that take place in modern analytic classrooms and supervisory
settings, and finally through the accumulation of clinical expe-
rience. All contribute to the development of the modern analyst
in consonance with the modern analytic concept of cure: "Mod-
ern psychoanalysts have come to think of cure quite simply as
the development of a mature personality capable of thinking
and feeling everything" (Spotnitz & Meadow, 1995, p. 1).

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