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IPA Publications Committee
Gennaro Saragnano (Rome), Chair and General Editor; Leticia Glocer
Fiorini (Buenos Aires), Consultant; Samuel Arbiser (Buenos Aires); Paulo
Cesar Sandler (São Paulo); Christian Seulin (Lyon); Mary Kay O’Neil
(Montreal); Gail S. Reed (New York); Catalina Bronstein (London); Rhoda
Bawdekar (London), Ex-officio as Publications Officer; Paul Crake
(London): IPA Executive Director (ex-officio)
Recent titles in the Series include
(for a full listing, please visit
Primitive Agony and Symbolization
René Rousillon
In the Traces of Our Name: The Influence of Given Names in Life
Juan Eduardo Tesone
Psychic Reality in Context: Perspectives on Psychoanalysis, Personal
History, and Trauma
Marion Michel Oliner
Shame and Humiliation: A Dialogue between Psychoanalytic and
Systemic Approaches
Carlos Guillermo Bigliani and Rodolfo Moguilansky
Theory of Psychoanalytical Practice: A Relational Process Approach
Juan Tubert-Oklander
Art in Psychoanalysis: A Contemporary Approach to Creativity and
Analytic Practice
edited by Gabriela Goldstein
The Female Body: Inside and Outside
edited by Ingrid Moeslein-Teising and Frances Thomson-Salo
Death and Identity: Being and the Psycho-Sexual Drama
Michel de M’Uzan
Unpresented States and the Construction of Meaning: Clinical and
Theoretical Contributions
edited by Howard B. Levine and Gail S. Reed
The Ethical Seduction of the Analytic Situation: The Feminine–Maternal
Origins of Responsibility for the Other
Viviane Chetrit-Vatine
Time for Change: Tracking Transformations in Psychoanalysis—The Three-
Level Model
Marina Altmann de Litvan
Psychopathology of Work: Clinical Observations
Christophe Dejours
Embodied Memories, Trauma,
and Depression

Marianne Leuzinger-Bohleber
First published in 2015 by
Karnac Books Ltd
118 Finchley Road, London NW3 5HT

Copyright © 2015 to Marianne Leuzinger-Bohleber.

The right of Marianne Leuzinger-Bohleber to be identified as the author of

this work has been asserted in accordance with §§ 77 and 78 of the Copyright
Design and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in

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mechanical, photocopying, recording, or otherwise, without the prior written
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ISBN 978 1 78220 209 7

Edited, designed and produced by The Studio Publishing Services Ltd

Printed in Great Britain






Psychoanalysis as a “science of the unconscious” and its
dialogue with the neurosciences and embodied cognitive
science: some historical and epistemological remarks 1

Finding the body in the mind: embodiment and approaching
the non-represented—a case study and some theory 19

The relevance of the embodiment concept for psychoanalysis 33


“I still don’t know who I really am . . .” Depression and
trauma: a transgenerational psychoanalytical perspective 49

Inspiration of the clinical psychoanalytical practice by the
dialogue with the neurosciences and embodied cognitive
science: some examples 81

How to investigate transformations in psychoanalysis?
Contrasting clinical and extra-clinical findings on changes of
dreams in psychoanalysis with a severely traumatised,
chronically depressed analysand
Tamara Fischmann, Marianne Leuzinger-Bohleber,
Margarete Schoett and Michael Russ 161

“Finding the body in the mind . . .” and some consequences
for early prevention: the concept “outreaching psychoanalysis”
and some realisations 185




I would like to extend my sincere appreciation to a number of people:

Prof. Dr ret. Ulrich Moser, my scientific mentor and friend, who had
already convinced me of the importance of the radical openness of
psychoanalysis for interdisciplinary cooperation in the 1970s; Prof. Dr
Rolf Pfeifer, who has encouraged me, over three decades of close
collaboration, to continue to build bridges between psychoanalysis
and cognitive science; and Dr med. Lotte Köhler and Prof. Dr
Wolfgang Mertens, who made it possible for Prof. Dr Martha Koukou-
Lehmann and me to organise the colloquium “Psychoanalysis and the
Neurosciences” at a time when such an enterprise ran counter to the
Zeitgeist. I extend my most cordial thanks to all the above! I am also
indebted to my co-director at the Sigmund Freud Institute, Prof. Dr Dr
Rolf Haubl, and Prof. Dr Heinz Weiss, as well as to my colleagues,
among them, first and foremost, PD Dr Tamara Fischmann and PD Dr
Ulrich Bahrke, Dipl. Psych. Lisa Kallenbach, Dipl. Psych. Margerete
Schoett, Dipl. Psych. Johannes Kaufhold, PD Dr Katrin Luise Laezer,
Dr Judith Lebiger-Vogel, Dipl. Psych. Constanze Rickmeyer, MA Soc.
Anne Busse, Dipl. Psych. Korinna Fritzemeyer, MA Verena Neubert,
Dipl. Psych. Lorena Hartmann, MA Peter Ackermann, Dipl. Ed. Maria
Schreiber, and the many young scientists impossible to name here, but


without whose collaboration all projects—as complex as transgenera-

tive commitment—would not have been possible. Special thanks go to
the statistics consultants of all of my projects, Prof. Dr ret. Bernhard
Rüger, and my friends and psychoanalytic colleagues Dipl. Ed.
Angelika Wolff and Dipl. Ed. Claudia Burkhardt-Mußmann. I am like-
wise greatly indebted to many of my international colleagues and
friends, among others, Prof. ret. Robert N. Emde and Prof. Dr Henri
Parens, who have been dedicated supporters of our early prevention
projects; Prof. Dr Peter Fonagy, with whom I organised most of the
Sandler Conferences and has generously supported the SFI over the
years; Prof. Dr Mary Target, Prof. Dr Linda Mayes, Prof. Dr Rolf
Sandell, Prof. Dr Stephan Hau, Prof. Dr Ricardo Bernardi, Prof. Dr
Jorge Canestri, Prof. Dr Sverre Varvin, Prof. Dr Siri Gullestad, Dr
Nicola Tzavaras, and Prof. Mark Solms, who included me in the
Action Group for Neuropsychoanalysis at an early stage, and who
worked as Guest Professor and friend at the SFI. I am also grateful to
Gail Reed who first proposed the idea for the present publication.
For help with the design of the manuscript, I would like to thank
MA Dipl. Soc. Anne Busse, and Justin Morris for the swift and profes-
sional translation.
Most of all, I would like to thank Dr Werner Bohleber—with whom
I share my passion for psychoanalysis—now, as ever, such a great gift.

Marianne Leuzinger-Bohleber is a training analyst in the German

Psychoanalytical Association. She had her training in the Swiss
Psychoanalytical Society, and is a former Chair of the Research
Subcommittees for Conceptual Research. She is Vice Chair of the
Research Board of the IPA; Full Professor for Psychoanalysis at the
University of Kassel; and Head Director of the Sigmund-Freud-
Institute, Frankfurt/Main. Her main research fields include epistemol-
ogy and methods of clinical and empirical research in psychoanalysis,
interdisciplinary discourses with embodied cognitive science, the
neurosciences, educational sciences, and modern German literature.


The Publications Committee of the International Psychoanalytical

Association continues, with this volume, the series “Psychoanalytic
Ideas and Applications”.
The aim of this series is to focus on the scientific production of
significant authors whose works are outstanding contributions to the
development of the psychoanalytic field and to set out relevant ideas
and themes, generated during the history of psychoanalysis, that
deserve to be known and discussed by present psychoanalysts.
The relationship between psychoanalytic ideas and their applica-
tions has to be put forward from the perspective of theory, clinical
practice, technique, and research so as to maintain their validity for
contemporary psychoanalysis.
The Publication Committee’s objective is to share these ideas with
the psychoanalytic community and with professionals in other related
disciplines, in order to expand their knowledge and generate a
productive interchange between the text and the reader.
Finding the Body in the Mind: Embodied Memories, Trauma, and
Depression is an original book authored by Marianne Leuzinger-
Bohleber, a well-known German analyst who has long been engaged
in clinical psychoanalytic research as well as in a continued dialogue


with neurosciences and embodied cognitive science, always trying

to build conceptual bridges among these different disciplines. The
volume deals essentially with the fundamental question of how
unrepresented and unconscious meanings can be discovered, remem-
bered, and worked through, a problem that is at the core of con-
temporary psychoanalytic research and practice. The concept of
embodied memories, the way the unconscious memories of trauma
can be kept in one’s body, how they can be understood in the trans-
ference, the relation between them and depressive states, are only
some of the interesting issues discussed in this valuable book that
enriches the Psychoanalytic Ideas and Application series.

Gennaro Saragnano
Series Editor
Chair, IPA Publications Committee

There is no such thing as research in psychoanalysis. Over the last

hundred years, psychoanalysis has developed a great variety of
research strategies and cultures within the International
Psychoanalytical Association (IPA). I feel honoured that the IPA
Publishing Committee has approved my application to publish this
volume and thus to communicate some of my experiences in research,
and particularly the dialogue with contemporary Neurosciences and
Embodied Cognitive Science, and the influence of these on my clini-
cal practice with colleagues from the English-speaking psychoanalytic
For many years I was given the opportunity to exchange research
results with several colleagues within the IPA, and to become
acquainted with the different cultures within this organisation.
I held the Chair of the Research Committees for Clinical,
Conceptual, Epistemological, and Historical Research (2001–2009).
The former IPA President, Daniel Widlöcher, founded the new
Research Committee in 2001 in the hope of thereby reviving the chal-
lenging and ambitious discourse on the various ideas and approaches
to psychoanalytic research among the IPA’s different traditions and
cultures. Members of the committee included: Ricardo Bernardi


(Montevideo), Rachel Blass (Jerusalem), Jorge Canesti (Rome), Anna

Ursula Dreher (Frankfurt), Ilse Grubrich-Simitis (Frankfurt), Norbert
Freedman (New York), Alain Mijola (Paris), Mark Solms (Cape Town),
Mary Target (London), and Roger Perron (Paris). We put forward our
ideas for discussion at various events and in a number of publications
(cf., among others, Leuzinger-Bohleber et al., 2002). Our ideas
contributed to the variety of present-day psychoanalytic research at an
institutional level: the subcommittees for General (Conceptual),
Clinical, and Empirical Research were appointed under the aegis of
the International Research Boards in 2011 (Mark Solms, Chair; Ricardo
Bernardi, Vice-Chair for South America; Robert Galatzer-Levy, Vice-
Chair for North America; and myself, Vice-Chair for Europe). One
further productive framework for controversial discussion on research
in psychoanalysis was the Joseph Sandler Research Conferences,
which originally took place at University College and the Anna Freud
Center in London. I have been organising this most important IPA
research conference together with Peter Fonagy (Chair of the IRB)
since 2006. The conferences were dedicated to the following subjects:

2008: Early development and its disturbances: psychoanalytic

perspectives and ADHD and other psychopathologies
2009: Religion and fanatism. recurrence of a subject
2010: Persisting shadows of early and later trauma. One hundred
years International Psychoanalytical Association, fifty years
Sigmund Freud Institute, twenty years IPA research conferences
2011: The significance of dreams. Bridging clinical and extra-clinical
research in psychoanalysis
2012: Research in early parenting and the prevention of disorder:
interdisciplinary challenges and opportunities
2013: Finding the body in the mind. Researchers and clinicians in
2014: The unconscious: a bridge between psychoanalysis and cogni-
tive science. Researchers and clinicians in dialogue.

The IPA has now decided to rotate the most successful Sandler
Conferences in its three regions and to link them to the Research
Training Program (RTP) that, initiated by Peter Fonagy, Joseph Sandler,
Robert Wallerstein, and Otto Kernberg during the 1990s, contributed
substantially to supporting young scientists in psychoanalysis. As the

present-day situation in Germany testifies, we urgently need new, tal-

ented academics, fully trained in psychoanalysis, to fill vacant univer-
sity positions. Without such a new influx, psychoanalysis will
increasingly lose access to coming generations.
I found the close collaboration with the IPA to not only be of substan-
tial personal support, but also helpful at an institutional level. With a
part-time position as Professor of Psychoanalysis at the University of
Kassel in 2001, I then became Director of the Sigmund Freud Institute
Frankfurt (SFI) (since 2002 together with Prof. Dr Dr Rolf Haubl)—an
institute with a renowned tradition in Germany. In 1960 the institute
served, above all, to firmly reinstate Freudian psychoanalysis in
Germany—previously banned under the National Socialist regime as a
“Jewish science”—and to join it to international psychoanalysis.
Furthermore, the founding of the Sigmund Freud Institute was also an
expression of political recognition for Alexander Mitscherlich who,
courageous and undaunted, researched the atrocities committed by
medical doctors during the National Socialist era, and who was also a
vehement advocate of a new, psychoanalytically grounded psychoso-
matics. Another of his key concerns was to understand the unconscious
repercussions of National Socialism in the postwar years by way of a
psychoanalytical social psychology. His works, such as “Die Unfähigkeit
zur Trauern” (The Incapability to Mourn, co-written with Frau
Margarete Mitscherlich-Nielsen) decisively influenced public enlighten-
ment discourse within Germany during the 1960s and 1970s.
Over the initial fifty years of its history the SFI evolved into an
inspiring magnet for, among others, substantial public and psychoan-
alytic discourse. We are thus indebted to Alexander Mitscherlich and
subsequent directors, Clemes de Boor, Hermann Argelander, Dieter
Ohlmeier, and Horst Eberhard Richter, as well as to the more than 300
colleagues, for firmly anchoring Freudian international psychoanaly-
sis within Germany and, consequently, the affiliation to the ongoing
development of our clinical methods of treatment and training stan-
dards, its presence among a broad, intellectual, and political public as
well as the overall versatility of psychoanalytic research.
Those of us who work at the Freud Institute today follow this
tradition and incorporate it, along with the new challenges, into a
modern psychoanalytic research institute characterised by the incisive
changes to present-day globalised, politicised, and media-driven
knowledge society which naturally, as outlined in Chapter One of this

publication, does not abruptly cease before the doors of a psychoana-

lytical research institution. Clearly, while these political developments
and their impact upon an institute such as the SFI cannot be denied,
they can be understood and productively shaped only in collaboration
with our colleagues in contemporary, intergenerational dialogue at the
SFI, as I will discuss in more detail in the present volume by way of a
selection of research projects. In all these projects, we attempt to
account for and utilise the specific competence of psychoanalysis for
researching unconscious factors in socially relevant subjects, such as
depression, trauma, violence, migration, and social disintegration,
and thereby take up the culture-critical tradition of this institution. In
so doing we also seek a connection to the new realities of a present-
day psychoanalytic research institute situated in the context of glob-
alised scientific and media competition.
The same holds for the project on the dialogue between psycho-
analysis, the neurosciences, and embodied cognitive science. Scientific
theory and questions of research methods have interested me ever
since my time as an assistant at the Institute of Clinical Psychology in
Zurich (Director: Prof. Dr U. Moser). The detailed discussion of these
questions—aside from the talks with my discussion partners in
philosophy (among others, Helmut Holzhey, Michael Hampe, Axel
Honneth, Joel Whitebook, Jorge Canestri, Jorge Ahumada, and Doria
di Medina) and literature (among others, Peter von Matt, Dagmar von
Hoff, Sigrid Weigel)—and the ongoing dialogue with Rolf Pfeifer, at
that time assistant at the same institute, and now Professor Emeritus
for Informatics and Head of the Laboratory for Artificial Intelligence
at the University of Zurich, I have found to be exceptionally challeng-
ing and fruitful. Cognitive science has always understood itself as an
interdisciplinary science that, by way of its theories on memory, affec-
tive and cognitive problem-solving etc., aims to integrate the contem-
porary status of the neurosciences, biology, genetics, psychology,
psychoanalysis, linguistics, developmental psychology, and even
engineering. The present volume includes a summary of the unique
and professional exchange with cognitive science over the last four
decades. Extensive case studies will illustrate how these interdiscipli-
nary dialogues have inspired me in my clinical understanding of my
analysands. As will be discussed in each of the chapters: the clinical
work with patients always has been at the heart of my research activ-
ities as a psychoanalyst.

In my capacity as Director of the Sigmund Freud Institute, I was

able to connect this tradition to that which Wolfgang Leuschner devel-
oped together with a number of colleagues, among others, Tamara
Fischmann and Stephan Hau, that centered on an experimental sleep
and dream laboratory. The team carried out a series of original studies,
for example, on the subliminal processing of stimuli in dreams, in
order to experimentally expose, or rather refute, the Freudian theory
of dreams. The conceptual justification of these experiments was based
on the dialogue with the neurosciences, which draw on contemporary
knowledge in experimental sleep and dream research and thus, inter
alia, on central controversies in neurophysiological connections
between sleep and dream (such as those between Solms and Hobson).
In the years between 1992 and 1996, the Köhler Stiftung GmbH
Darmstadt funded a colloquium in which twenty psychoanalysts and
neuroscientists under the direction of neuroscientist and psychiatrist
Martha Koukkou-Lehmann, and myself as psychoanalyst, attempted
to build a bridge between these two disciplines, an experiment that,
from a present-day vantage point, might be considered as a “pioneer
experiment” (cf., Koukou et al., 1998; Leuzinger-Bohleber et al., 1998).
When assuming my responsibilities as Director of the SFI in 2001, I
aimed to focus research on “neuropsychoanalysis”, the objective of
which was to integrate the above-mentioned tradition of experimen-
tal sleep and dream research at the SFI with my experience in the
colloquium to which I referred, as well as to the many years collabo-
ration on the dialogue with psychoanalysis—(embodied) cognitive
science with Rolf Pfeifer and the engagement in the newly founded
Society for Neuropsychoanalysis (founded by Mark Solms et al.). In
all large-scale research studies on psychotherapy and psychoanalysis
(among others, the LAC-Depression Study) and early prevention, our
conceptual basis is the interdisciplinary dialogue between psycho-
analysis and the neurosciences. Through the guest professorship of
Mark Solms at the SFI, and the collaboration with the Max Planck
Institute for Brain Research, Frankfurt a.M. (Wolf Singer, Aglaia Stirn,
Michael Russ, and others), the Department of Psychosomatics at the
University Clinic Frankfurt a.M. (Ralf Grabhorn, Harald Mohr, and
others), and the IDeA Zentrum (Marcus Hasselhorn, Christian
Fiebach), we were in a position to get a series of studies off the
ground, under the increasing engagement of Tamara Fischmann,
examples of which are reported in Chapter Six of the present volume.

Freud is not dead. Far from it. In the year of the 150th anniversary of
his birth we can truly say that his ideas are undergoing a renaissance.
Freud is everywhere. And especially in neuroscience, we are taking a
new look at his work and concluding that it is “still the most coherent
and intellectually satisfying view of the mind” (Kandel, 1998) that we
have. (Mark Solms, 2006, last page)

It is interesting from the perspective of the history and sociology of

science that, since the 1990s, many different scientific disciplines have
intensified their interest of the so called “mind-body-problem”:
psychoanalysis, philosophy, academic psychology, cognitive science,
and modern neurosciences. In cognitive science, for example, twenty
years ago a kind of revolution took place: from the “classical to
embodied cognitive science”.1 The conceptualisation of how the mind
works has changed completely and, as will be shown in this publica-
tion, has great implications for clinical psychoanalytical practice as
well as for theorising in contemporary psychoanalysis. The question
of how unrepresented, unconscious meanings can be discovered,
remembered, and worked through is and has been, as is well known,
*Translator: Justin Morris.


one of the central topics of psychoanalysis (see, for example, Levine

et al., 2013).
In 2006, which had been declared as “the Year of Freud”, one could
easily obtain the impression that the dialogue between psychoanaly-
sis and the neurosciences was the most important window, opening
modern day psychoanalysis to the world of contemporary scientific
discourses. Can we, as psychoanalysts, really get into a fruitful
dialogue with neuroscientists and gain additional knowledge of the
unconscious, psychoanalysis’ specific research object?
Throughout his entire life Freud had hoped that new developments
in the neurosciences would contribute to exploring psychoanalytic
processes from a natural scientific point of view. In many of his histor-
ical and theoretical papers, the South African neuropsychologist and
psychoanalyst Mark Solms substantiates that Freud—due to the stan-
dard of neuroscientific methods during his times—turned his back on
this vision and defined psychoanalysis as a solely psychological
science of the unconscious. Over the past few years recent develop-
ments in the neurosciences, for example investigating the living brain
with the help of neuroimaging techniques, as well as the neuro-
anatomic method, as described by Solms and other psychoanalytic
researchers, have stimulated and intensified the interdisciplinary
dialogue between psychoanalysis and the neurosciences. Thus it has
been a kind of a gift to the 150th birthday of Sigmund Freud in
Germany, that even the widely read journal Der Spiegel talked of a
“renaissance of psychoanalysis”. A main contributor to this new atten-
tion that was devoted to psychoanalysis was the Nobel laureate neuro-
biologist Eric Kandel. His twin papers published more than a decade
ago in the American Journal of Psychiatry, “A new intellectual framework
for psychiatry” (1998) and “Biology and the future of psychoanalysis:
a new intellectual framework for psychiatry revisited” (1999), created
a large interest in the dialogue between psychoanalysis and the neuro-
sciences, initiating an internationally challenging, broad discussion of
fascinating new interdisciplinary research perspectives.
For many authors, as for Kandel, a vision of Sigmund Freud
turned into reality in the last decades: Freud never gave up his hope
that developments in the neurosciences might someday contribute to
a “scientific foundation” of psychoanalysis. He abandoned this
attempt, his “Project for a Scientific Psychology” (1950a[1895]), due to
the obvious limitations of the neurosciences’ methodology at that time

(see Kaplan-Solms & Solms, 2000), subsequently defining psycho-

analysis as a “pure psychology of the unconscious”. As Kandel points
out in his twin papers on the developments in the neurosciences, the
neuroimaging techniques (such as MEG, EKP, PET, fMRI) open a new
window for psychoanalysis to “prove” its concepts and findings,
applying the methodologies of current “hard natural sciences”.
Kandel is passionate on this vision: his unique spirited speeches claim
that the future of psychoanalysis mainly depends on its taking up this

The necessity to investigate psychoanalytic treatments by

neuroscientific methods
To Kandel, psychoanalytic treatments must also show effectiveness in
studies applying methods of contemporary neurosciences. His vision
is connected with challenging epistemological and methodological
questions, as will shortly be discussed below (Northoff et al., 2006).
But, seen from a perspective of the sociology of science, of course,
Kandel is right: if psychoanalysis could show that psychoanalytic
treatments influence the brain’s functioning, this would tremendously
heighten its acceptance as a treatment method in medicine and the
Mental Health systems. Several groups of researchers presently
engage in such studies. To mention some in the field of depression
research: the Hanse Neuro-Psychoanalysis Study, by Buchheim and
colleagues (2008), investigates the changes of depressive patients
during psychoanalytic treatments, for example by fMRI. The research
group of Northoff and colleagues (2006) at the Psychiatric University
Clinic in Zürich compares different treatments of severely depressed
patients by neuroimaging methods. At the Sigmund Freud Institute
Tamara Fischmann, Leuzinger-Bohleber and others—in cooperation
with the Max Planck Institute for Brain Research (Wolf Singer) and the
Psychiatric University Clinic Frankfurt (Aglaja Stirn, Michael Russ
and others)—are realising a substudy of the large LAC depression
study, comparing psychoanalytic and cognitive behavioural long-term
treatment with chronically depressed patients using fMRI and EEG in
the sleep laboratory of the Freud Institute (see Chapter Six of this
volume). Other psychoanalytical research groups are also engaged in
similar studies: for example, the Mainz Psychosomatic Department

(Manfred Beutel and others), researchers at the Yale University

(e.g., Linda Mayes and others), at the Columbia University in New
York (e.g., Bradley Peterson and colleagues, Andrew Gerber and
colleagues, Steven Roose), at the University College London (Peter
Fonagy and his team) and at the University of Cape Town (Mark
Solms and others), to mention just a few. Thus many international
research groups are taking up Kandel’s demand. For an overview of
the ongoing studies, see Chapter Six of this volume.


Kaplan-Solms and Solms (2000) neuro-anatomical research method

investigated patients with brain lesions with clinical psychoanalyti-
cal research methods, initiating a boom of such studies. In different
countries, interdisciplinary research groups work systematically
with patients with precisely localised brain lesions, seeking specific
psychoanalytic treatment techniques, enabling us to help them—for
example, those suffering from a neglect syndrome after a stroke (see
Leuzinger-Bohleber et al., 2003; Röckerath et al., 2009). Their find-
ings are broadly relevant for studying the old mind-body problem
in new and fascinating ways (see e.g., Damasio, 1999 and many
The first volume of the international journal Neuropsychoanalysis was
published in 1999; where leading psychoanalysts and neuroscientists
present studies on emotion and affect, memory, sleep and dream,
conflict and trauma, conscious and unconscious problem solving, etc.
Eric Kandel, Wolf Singer, and other leading experts are on its Board.
The International Society for Neuropsychoanalysis, founded in 2000,
organises annual international conferences.

Inspiration and critical reflection on clinical practice in exchange

with modern neuroscience and embodied cognitive science
As is well-known, in their daily endeavours to decode the uncon-
scious fantasies and conflicts of their patients, psychoanalysts
frequently draw on literary portrayals, on art, myths, and fairy tales
for inspiration.

As all chapters in this volume illustrate, the findings from affili-

ated sciences can also be sources of inspiration for clinical practice.
Interdisciplinary research results, especially in subjects such as recol-
lection, memory, dream, trauma, and affective and cognitive problem-
solving have proved apposite for the psychoanalytic understanding of
unconscious mental process in our analysands; in psychoanalytic
practice, the analysts are invariably concerned with conscious and
unconscious processes of memory, dreams, and the frequently
unrecognised repercussions of early experiences on current thought,
feeling, and action. As illustrated in Chapter Two, by way of the
detailed analysis of the behaviour of a severely traumatised analysand
in a first interview, and the analyst’s subsequent countertransference
triggered by this, concepts such as “embodied memories” have
proven fruitful for ultimately decoding the unconscious enactment of
analysands in the analytic situation. Models drawn from embodied
cognitive science provide initial explanations for such detailed obser-
vations in the psychoanalytic situation.
Indeed, the intense exchange is not only enriching for psychoana-
lysts, but also for the interdisciplinary dialogue partners from the
neurosciences and embodied cognitive science. In my view, one of the
strengths of psychoanalysis is that it is capable of understanding
peoples’ apparently bizarre forms of behaviour, and of communicating
these to both psychoanalysts and non-psychoanalysts in case-studies.
Thus, the narrative tradition of psychoanalysis is also highly valued in
the interdisciplinary dialogue with the neurosciences. As narration
researchers have repeatedly emphasised, such complex meaning struc-
tures “can only be told and not measured” (cf., among others, also
Stuhr, 1997; Leuzinger-Bohleber, 2014). Unlike other disciplines, with
its professional and uniquely rigorous approach to field research with
individual human beings (or groups and institutions), only psycho-
analysis is equipped to advance the great many discoveries that have
been made in unconscious psychic processes. An increasing number of
neuro-scientific research groups have incorporated these discoveries,
and test them with the methods of modern neurosciences (e.g., works
by the research team of Bradley Peterson, now University of Southern
California, of Andrew Gerber, Columbia University, NY; of Linda
Mayes, Yale University, New Haven, of Peter Fonagy at the Unversity
College, London, and in Germany Manfred Beutel, at the University of
Mainz or the Cologne research group linked to Axmacher).

Challenging key psychoanalytical concepts by way of the

interdisciplinary dialogue with modern neurosciences and
embodied cognitive science

We have discussed in a number of papers how important it is for

psychoanalysis as a scientific discipline, to continue developing its
concepts and theories (cf., among others, also Leuzinger-Bohleber,
2010b,c; Leuzinger-Bohleber & Fischmann, 2008;). As is generally
known, in time even the most fruitful concepts begin forfeiting their
creative explanatory potential once they have lost their elasticity and
plasticity, and are no longer repeatedly applied to new phenomena in
a creative manner.
As various chapters of the present volume show, the dialogue with
the neurosciences and embodied cognitive science opens up several
opportunities for critical reflection and the further development of
central concepts, such as transference, countertransference (cf.,
Chapters Two and Three), dream (cf., Chapter Six), trauma (cf.,
Chapters Two, Three, and Four), and enactment (Chapter Three).
Various psychoanalytic research groups have meanwhile focused
on the question as to whether and in what ways psychoanalytic
concepts should be modified in view of contemporary insights
acquired in the neurosciences and cognitive science (cf., among others,
Guttman & Scholz-Strasser, 1998). Talvitie, 2009, has made several
contributions to the journal Neuropsychoanalysis. In a keynote lecture
on the occasion of the 150th anniversary of Sigmund Freud’s birth
held at the Arnold-Pfeffer-Center for Neuropsychoanalysis, New York
(May 6, 2006), Mark Solms showed impressively the way central
psychoanalytic concepts of Sigmund Freud have either been
confirmed by current research in the neurosciences, further developed
or questioned. He writes:

The most fitting way to celebrate the 150th anniversary of Freud’s

birth is to look forwards rather than backwards. I would therefore like
in this article to take stock of the current scientific standing of Freud’s
conception of the mind. My aim in doing so is neither to praise Freud
nor to bury him, but rather to assess his scientific legacy today, in
order to set an appropriate course for the future. This is, I believe, the
best tribute we can pay to a true scientist. (Opening remark, Solms,
2006, original italics)

Solms discusses twelve theses concerning the central under-

standing of psychic processes by Sigmund Freud. First, he consid-
ers Freud’s proposition to the effect that most of our mental activity
is unconscious. Second, he addresses his proposition that a portion
of this unconscious mental activity is actively withheld from
consciousness—that it is positively suppressed or repressed from
awareness. Third, he considers the proposition that this dynamically
unconscious activity exerts an indirect effect upon conscious mental
life—that unconscious mental contents are re-represented through
“substitute formations”, via mechanisms such as displacement and
symbolisation. Fourth, he discusses the proposition that uncon-
scious mental processing occurs by different functional principles
than those governing conscious and preconscious (or descriptively
unconscious) processing. These are the so-called “primary” and
“secondary processes” of the mind. Fifth, Solms considers the
proposition that the secondary process, which governs “ego” func-
tions (that is to say, executive control of the mind), is based upon
inhibition of the primary process—upon the so-called delay of
discharge. Sixth, he discusses the notion that primary processes are
dominated by emotional, as opposed to rational, considerations—
that the primary process is governed by a “pleasure principle” that
disregards reality constraints (the so-called “reality principle”).
Next, Solms addresses the idea that the pleasure principle conveys
the influence upon the mind of an extremely powerful drive,
grounded in the reproductive and survival needs of the body. This
is Freud’s “libido” concept. At this point, eighth, he tries to integrate
some of the components of the emerging picture, by saying some-
thing about the interaction between the different parts in a brief
consideration of Freud’s proposition to the effect that dreams are the
royal road to an understanding of the (normally hidden, drive-
dominated contents of the) unconscious. This was followed by a
broader consideration of Freud’s drive theory in general. Tenth,
Solms reviews the current standing of Freud’s views regarding the
aetiology of the neuroses. This provides a good foundation for
discussing, eleventh, the mode of action of psychoanalytic therapy.
Finally Solms briefly considers the concept of infantile sexuality, the
famous Oedipus complex, and Freud’s views on the differences
between the sexes, as well as gender identity and sexual orientation
(Solms, 2006, p. 2).

The constraints of the present volume preclude a more detailed

discussion of his fundamental insights. Here, I must limit myself to
refering to the lecture and the German translation (Solms, 2006), and
quote Solms’ conclusion in relative detail:

My general conclusion then, if I may quote the words that were embla-
zoned across the cover of a recent issue of Newsweek magazine, is that
“Freud is not dead”!
Ironically, his greatest errors appear to have come from his under-esti-
mation of our capacity for self-deception—that is to say, from his
apparent over-estimation of what we can learn from introspection
about the fundamental workings of an apparatus which is, by Freud’s
own admission “unconscious in itself”. In other words, the most
recent findings, emerging from affective neuroscience in particular,
suggest that representational cognition masks and obscures the real
basic forces that drive us to an even greater extent than Freud realised.
On the other hand, perhaps Freud’s greatest legacy will be to show us
that we should never forget the importance of the conscious agent of
the mind: the salient, feeling, volitional ego. This factor is all too over-
looked by cognitive scientists and neuroscientists who seem to really
believe that we can treat the human mind as an object only, ignoring
the subject as if it were a mere information-processing device, or an
organ akin to the liver.
Oliver Sacks made this point particularly well: “Neuropsychology,
like classical neurology, aims to be entirely objective, and its great
power, its advances, come from just this. But a living creature, and
especially a human being, is first and last . . . a subject, not an object.
It is precisely the subject, the living ‘I’, which is excluded [from
neuropsychology]”. (Sacks, 1985, p. 164)
What makes the brain unique is its capacity for subjectivity, feelings,
and agency. No other bodily organ or mechanical device possesses
these qualities. For this reason, unless we place these properties of the
brain at the centre of our attempts (both theoretical and methodolog-
ical) to understand the “mechanisms” that govern this most mysteri-
ous and wonderful organ, we shall never truly understand it.
This is my vision of the future of psychoanalysis. It will occupy a suit-
ably modest place in the family of sciences, as a methodological and
theoretical approach with both strengths and weaknesses, which
explores the unique perspective on the brain that can only be obtained
by talking to it—that is, a perspective on the organism that only the

human brain can provide. By dint of its capacity to reflect and report
on its personal functioning, we may obtain a better understanding of
how the brain differs from a machine, or non-salient organ—and
thereby obtain a better understanding of what subjective feelings and
“free will” are for. To imagine that we can even understand human
behaviour without understanding how these aspects of the brain work
is to truly delude ourselves.
All of this, of course, is predicated on the assumption that we will
break down the barriers which still currently isolate psychoanalysis
from the rest of science and from the brain sciences in particular. That
is what the neuro-psychoanalytic movement explicitly aims to achieve
What I am sure about, of course, is that there will always still be a need
to educate clinicians to the highest standards of excellence, as we have
always done at our best training institutes.
But now, I must bring these reflections to a close before they degener-
ate into a manifesto, I will do so by repeating my earlier conclusion:
Freud is not dead. Far from it. In the year of the 150th anniversary of
his birth we can truly say that his ideas are undergoing a renaissance.
Freud is everywhere. And especially in neuroscience, we are taking a
new look at his work and concluding that it is “still the most coherent
and intellectually satisfying view of the mind” (Kandel, 1998) that we
But in the end, we must recall that it is ultimately “not a matter of
proving Freud wrong or right but rather of finishing the job” (Guterl,
2002, p. 63). It seems that, at long last, we really are returning to the
project that Freud started, and seriously attempting once more the
(probably impossible) task of finishing the job. I am proud of the part
that I have played in this development. (Solms, 2006, last page)

The application of insights gained in interdisciplinary

collaboration in the field of medicine
For psychoanalysis, the interdisciplinary dialogue with the neuro-
sciences opened new doors to the world of medicine. In many insti-
tutes the above-mentioned collaborative studies on the results of
psychoanalytic treatment or the experimental review of Freudian
concepts established new collaborative possibilities between psychia-
trists and neurologists, for example, the psychiatric university clinics

in Zurich; at Frankfurt, Mainz, Heidelberg, and Munich here in

Germany; and at University College, London; Columbia University,
New York; and the medical faculties in Montevideo and Santiago de
Chile (to mention just a few). Many of these collaborative research
endeavours are still developing, but appear to me to offer promising
perspectives for psychoanalysis which, as is well-known, have in
recent years suffered a loss of several positions in a number of coun-
tries, such as psychosomatics in Germany.
The present volume cites several other interdisciplinary collabora-
tive endeavours in the field of medicine. I report here on a liaison
service with one of the largest gynaecological clinics in Frankfurt,
which developed in connection with the EU project “Ethical Dilemma
due to Prenatal and Genetic Diagnostics” (EDIG) (cf., Chapter Five).
Experienced psychoanalysts at the Sigmund Freud Institute offer
crisis intervention for women/couples following positive prenatal
findings, in order to make accessible the unconscious dimensions
inevitably reactivated through the decision about the life and death of
their unborn child. As has been proven empirically, the probability of
women developing severe depression following an interruption of the
pregnancy is thereby reduced (cf., Fischmann & Hildt, in press;
Leuzinger-Bohleber & Teising, 2012; Leuzinger-Bohleber et al., 2008a).
By way of these crisis interventions a new and fruitful collaboration
with gynaecologists and prenatal diagnosticians emerges. At the same
time, in addition to their well-founded neuro-scientific knowledge on
pregnancy, prenatal and genetic diagnosis is decisive for psychoana-
lysts carrying out crisis interventions.
No less decisive are the results of neuro-scientific studies for vari-
ous prevention projects, which we are presently conducting at the SFI
(cf., Chapter Seven). These constitute the basis for our concrete formu-
lation of early prevention in close collaboration with gynaecological
clinics in Berlin, Frankfurt, and Stuttgart (in planning). The conver-
gence of neuro-scientific and psychoanalytic research on the signifi-
cance of pregnancy, birth, and the first weeks of life, as well as the
sustained influence of traumatisation during this period—above all in
the case of risk groups—such as traumatised refugees and migrants,
caught the interest of our colleagues in medicine and prompted them
to collaborate with us. In short, from the outset, psychoanalysis
emphasised the significance of the first year of life for psychic devel-
opment, and in recent years its perspectives have indeed been

confirmed and advanced in fascinating ways by knowledge gained in

developmental neurobiology. Fascinating studies on the plasticity of
the infant brain corresponding to the clinical-psychoanalytic experi-
ences have proven just how fruitful clinical-psychoanalytic experience
is for severely traumatised children (see also the impressive case stud-
ies on the psychoanalytic therapy of a twenty-four-month old girl by
Agneta Sandell, 2014, or the works of Ted Gaensbauer, 2014). As
reported in Chapter Seven, these insights have inspired us to carry out
various projects in the field of early prevention.

Neuroscientific knowledge and concepts: inspiration for

psychoanalytical studies in developmental research and early
Though going beyond the limits of this volume, I would at least like
to mention that a series of other projects we are currently carrying out
at the SFI build upon the interdisciplinary dialogue with the neuro-
sciences. This connection becomes most evident in the Frankfurt study
on the effectiveness of therapy on children with so-called attention
deficit hyperactivity disorder (ADHD), which was conducted between
2002 and 2014. In the latter study we compared the results of psycho-
analytic treatment of children with so-called ADHD with behavioural/
medicinal therapy (cf., Leuzinger-Bohleber, 2010b,c; Leuzinger-
Bohleber et al., 2006). We were able to show that psychoanalytical
treatment, like behavioural therapeutic/medicinal, led to an unam-
biguous reduction of ADHD symptoms (cf., also Laezer et al., 2014). I
provided detailed substantiation of the interdisciplinary study in
earlier publications (cf., Leuzinger-Bohleber, 2010b,c; Leuzinger-
Bohleber et al., 2008c, 2011). The following is a short summary.
The core of psychoanalytic conceptualisation has always been that
a child’s symptoms are the product of complex unconscious and
conscious factors: idiographic, biographical, and societal factors, on the
one hand, and specific genetic, biological, and neurobiological deter-
minants on the other hand. Therefore, we agree with many contempo-
rary authors that psychoanalysis, both as a theory and as a treatment
method, has a lot to offer in understanding children with ADHD and
could even, once enriched by awareness of the biological determinants,
be seen as a promising, non-medical treatment possibility for these

children, offering intensive corrective emotional experiences to them

(for example, Bürgin, 2005; Carney, 2002; Gilmore, 2000; Leuzinger-
Bohleber, 2009a; Rothstein, 2002; Sugarman, 2006; Zabarenko, 2002).
The work of Jaak Panksepp (1998), a leading neurobiologist and brain
researcher into emotional development, supports our position
concerning the treatment of ADHD children. In brief, recent brain-
imaging data provided by Panksepp reveals that the major difference
in the brains of individuals with ADHD is in the frontal areas. At the
gross structural level, brains of children diagnosed with ADHD
exhibit a five per cent reduction of overall size. There are also some
neurochemical differences, but none of them are sufficiently large to
permit us to conclude that the differences constitute a medically
significant abnormality. According to this view, the fundamental prob-
lem in ADHD is not a deficit in attention, but an abnormally low level
of behavioural inhibition, a global function that allows better reflec-
tion, imagination, empathy, and creativity. These abilities promote
behavioural flexibility, better foresight, and a more mature regulation
of behaviour. If we accept the existence of a frontal lobe contribution
to ADHD, we still must consider whether there are environmental or
physical ways to improve such frontal lobe functions permanently
(Panksepp, 1998, p. 93). Medical treatment offers the “physical” possi-
bilities. Without a doubt, short-term behavioural improvements occur
with psychostimulants. The problem, as many studies show, is that
there has been little evidence of long-term improvement. When
medication is terminated, ADHD symptoms typically return, suggest-
ing that the children are not learning to manage their lives better.
Evidence for long-term improvements of cognitive functions and
other abilities remains practically non-existent (for a summary of such
work, see Barkley, 1997; Panksepp, 1998). Panksepp argues that the
short-term benefits of the treatment with psychostimulants would be
acceptable if they did not have any negative physical consequences
(which have been argued to include a small decrease in the rate of
physical growth; a relatively rare incidence of seizure, tics, mania, and
delusional tendencies; and the controversial finding of a range of
other difficulties when these children grow up, such as drug abuse).
Due to methodological problems, the long-term effects of treatment
with psychostimulants can hardly be studied in human beings.
Panksepp, therefore, relies on animal studies. There is some evidence
from these studies that psychostimulants decrease, instead of increase,

neural plasticity. “In general, dopaminergic arousal, as can be

achieved with psychostimulants, tends to reduce glutamate-mediated
neural plasticity” (Panksepp, 1998, p. 95). Panksepp thus pleads for a
different strategy in the treatment of ADHD children in our societies:
to create more possibilities for young children to develop the frontal
lobe executive functions by playing and, in particular, by playing so-
called rough-and tumble games:

The urge to indulge in rough-and-tumble play is a birthright of the

mammalian brain . . .. Social play may be an experience-expectant, or
preparatory, process that helps program higher brain areas that will
be required later in life. Indeed “youth” may have evolved to give
complex organisms time to play and thereby to exercise the natural
skills they will need as adults. We already know that as the frontal
lobes mature, frequency of play goes down . . .. Might access to rough-
and-tumble play promote frontal lobe maturation? (Panksepp, 1998,
pp. 95–96)

To sum up, like many contemporary brain researchers, Panksepp

postulates a user-dependent emergence of brain organic changes in
hyperactivity and attention deficit. Particularly for children born with
an impulsive temper and character (probably genetically determined),
the possibility of engaging in active exploration of their environment
and in rough-and-tumble play seems to be essential in order to
develop frontal lobe executive functions. If, for various reasons, chil-
dren do not have sufficient possibilities to engage in such exploration
and play (due to their early object relations, traumatic experiences, or
simply environmental factors such as the absence of a playground for
small children) they may develop ADHD. Medication probably does
not help to compensate for this deficit in the frontal lobe executive
functions. Organic brain changes (just like psychological changes) can
only take place “userdependently”, that is, in new, playful, and explo-
rative situations. They are particularly effective if combined with
intense, positive, emotional relationship experiences (see also
Damasio, 1994/1997; Dawirs et al., 1992; Doidge, 2007/2008; Fuchs
et al., 2010; Hüther, 2006; Moll et al., 2000; Leuzinger-Bohleber,
2010b,c; Leuzinger-Bohleber et al., 2008b; Passolt, 2004).
In my view, medication should only be given after a careful neuro-
logical, psychiatric, and psychological investigation. It should be
reserved for children in whom no psychotherapeutic or pedagogic

intervention seems to be available or shows signs of being successful.

This caution is consistent with many psychiatric, neurological, and
psychoanalytic authors who warn of early medical interference with
the growing brain and a risk for later drug abuse.
This example may illustrate that the dialogue between psycho-
analysis and the neurosciences may already have practical conse-
quences, for example, in the field of intervention and prevention. In
psychoanalytical therapies as well as in psychoanalytically oriented
early prevention, intensive object relationships as well as an adaptive
learning environment helped even traumatised children—due to the
enormous plasticity of the infantile brain and psyche—to develop
resilient capabilities and to overcome some of their traumatising expe-
riences on early object relations (see Chapter Seven).

Some consequences for psychoanalytical treatment techniques

Since the dialogue between psychoanalysis and neurosciences is rela-
tively new, and in view of epistemological considerations (cf. Chapter
Two), it would appear that one should be cautious of prematurely
drawing any specific conclusions for psychoanalytic treatment
One exception would be technical methods of treatment for
severely traumatised patients, since, as is shown in the various contri-
butions to the present volume, an interdisciplinary exchange had
already been carried out in the field of trauma research many years
ago. Just to mention one example: the relationship between “narra-
tive” and “historical-biographical truth” in psychoanalytic treatment
has become the subject of many controversial debates in recent years.
Findings of contemporary memory research have lead to great scepti-
cism as to whether therapists are able to objectively and reliably
reconstruct biographical events on the basis of their observations in
the therapeutic situation. Some authors even claim that psychoana-
lysts should concentrate exclusively on observing the here and now of
the patient’s behaviour within the transference relationship to the
analyst. Considering the findings of interdisciplinary trauma research
and extensive own case studies in several chapters of this volume it
will be discussed whether the baby has been thrown out with the
bathwater in this debate. Centred around the insights from a third

psychoanalysis with a patient who suffered from a severe case of

childhood polio in Chapter Four, the hypothesis will be discussed,
that working through the traumatic experience in the transference
with the analyst, as well as the reconstruction of the biographical-
historical reality of the trauma suffered, proved to be indispensable
for a lasting structural change in this patient. The concept of “embod-
ied memory” offered some helpful theoretical explanation for these
clinical observations. Thus the integration of the trauma, including the
knowledge of what really had happened to the patients (mostly
during the first years of life) into one’s own personal history and iden-
tity is and remains one of the main aims of a psychoanalytic treatment
with severely traumatised patients. The reconstruction of the original
trauma is indispensable in helping the patient to understand the
“language of the body” and to connect it with visualisations, images,
and verbalisations. The irreversable wounds and vulnerability of his
body as the “signs of his specific traumatic history” have to be recog-
nised, emotionally accepted, and understood in order to live with
them and not deny them any longer. Another important aspect in
psychoanalysis is to develop the capability to mentalize, in other
words to understand the intentions of central (primary) objects related
to the trauma (see also Leuzinger-Bohleber, in press; Fischmann et al.,
2012a, Fischmann et al., 2013; Chapters Two, Three, and Four).
In a collaborative work with Werner Bohleber, detailed considera-
tions on modified psychoanalytic treatment techniques with severely
traumatised patients were discussed (Bohleber & Leuzinger-Bohleber,
in press). Similarly, a number of initial provisional theses on this
subject are also presented for discussion in this volume (above all, in
Chapters Two and Four), though a more detailed and well-founded
discussion is included in the above-mentioned publication.

Epistemological perspectives concerning the dialogue between

psychoanalysis and the neurosciences
As will be discussed in this book, challenging epistemological topics
are connected to the dialogue between psychoanalysis and the neuro-
sciences. If we do not take into account epistemological questions
of this dialogue carefully, we once more might risk a harmful split
in the psychoanalytic community between those who are in favour

and those who are against this interdisciplinary exchange (see

Chapter One).
To mention an example: according to my personal experiences in
the above-mentioned endeavour of twenty psychoanalysts and neuro-
scientists studying memory, dreams, and cognitive and affective prob-
lem-solving in a joint research project 1992–1998 (supported by the
Köhler Foundation, Darmstadt, Germany) it seemed essential to criti-
cally reflect on its epistemological dimensions (see Leuzinger-
Bohleber et al., 1998a; Leuzinger-Bohleber et al., 2008f). Such
interdisciplinary exchange, while fascinating and innovative, is chal-
lenging and complicated for both sides. We often do not speak the
same language and apply different concepts in analogous terms, and
often identify with divergent traditions in science and in philosophy
of science. Much tolerance and stamina is needed to achieve an inten-
sive exchange of ideas enabling us to reach new intellectual frontiers;
to review former understandings and concepts, and resist idealising
tendencies to expect “solutions” for unsolved problems in our own
discipline from the other, foreign one; that—like a white screen—
attracts projections and projective identifications. To take new find-
ings of the other discipline means to undergo uncertainty and unease:
it is painful to leave aside “certainties” and false beliefs developed in
your own field. Going through a period of uncertainty and unease is
inevitable; a must for a productive and constructive dialogue reaching
beyond a rediscovery of already established disciplinary knowledge.
The comparison of models developed by both disciplines in order to
explain their specific data collected by specific (and very different)
research methods is linked to complex and sophisticated problems of
philosophy of science and epistemology. The well-known danger of
the eliminative reductionism of psychic processes onto neurobiologi-
cal processes or the consequences of a transfer of concepts without
reflecting them, methods and interpretations from one scientific disci-
pline onto another need to be prevented.2
Therefore, we can not agree completely with the passionate convic-
tion of Eric Kandel that modern neurosciences really can save the
future of psychoanalysis. On the one hand we are sharing his view
that curiosity and openness towards scientific developments, neuro-
sciences included, are a must for innovation and creativity. In order to
remain a “Wissenschaft”3 of the mind, psychoanalysis must refresh and
further develop its concepts and theories showing again and again

that psychoanalytic theories are “externally coherent” (Strenger, 1999)

with the state of art of other disciplines, for instance, the neuro-
sciences. In this sense the future of psychoanalysis as a productive
“Wissenschaft” depends on openness towards contemporary neuro-
But, on the other hand, we must carefully avoid “categorical
mistakes” (see e.g., Leuzinger-Bohleber & Pfeifer, 2002). The data of
the neurosciences are on a completely different level than those of
psychoanalysis, aiming to understand and decode meanings of
unconscious psychic functioning of human beings. Epistemologically,
psychoanalysis is a “specific science” (Wissenschaft) with a specific
methodology suited to investigate its specific research object (uncon-
scious conflicts and fantasies) and its specific scientific quality criteria.
Psychoanalytic research method has contributed a large body of
knowledge and cannot be replaced by any other one; also not
by neuroscientific ones (see e.g., Leuzinger-Bohleber et al., 2003;
Chapter One).
“External coherence” should not mean losing psychoanalysis’
autonomy as a specific “Wissenschaft”, nor to reduce it to neurobiol-
ogy. It can only mean systematically comparing the knowledge base
and the models of both disciplines, initiating critical reflection on one’s
psychoanalytical models’ explanatory power again and again, to
foster innovative theoretical developments. Neurosciences cannot
“solve the unsolved theoretical problems of psychoanalysis”.
Conceptual problems in psychoanalysis must be “solved” in psycho-
analysis’ own core field for gaining scientific insights: the genuine
psychoanalytical (research) situation (see e.g., Brothers, 2002;
Gullestad, 2013; Hagner, 2004; Hampe, 2003; Kandel, 2005; Kaplan-
Solms & Solms, 2000; Lemma, 2013; Leuzinger-Bohleber, 2005, 2006,
2010b,c, 2012; Mancia, 2006).
Again just one short example as illustration: Freud’s drive theory
recently became controversial, being inconsistent with findings in
attachment research and in animal and neurobiological research.
Yovell (2008), linking findings of current psychological research to the
neurobiology of sexuality, concludes that Freud’s view “is probably
inconsistent with what we know today about the functioning of the
seeking system (reviewed by Panksepp, 1998) and about attachment
in human and other mammalian infants (reviewed by Main, 1995)”
(p. 16). But even if neurobiological research could show the existence

of two independent motivational systems, the sexual system and the

attachment system, this would not put Freud in the wrong in positing
a single drive system (Leuzinger-Bohleber, 2008c). Freud’s drive
theory is a purely psychological theory based on observations in the
clinical psychoanalytic situation with individual patients, grasping
and interpreting the analysand’s drives and longings, particularly
those reactivated in the here and now of the transference relationship
with his analyst. Understanding the specific meanings of the uncon-
scious dimensions in the patient’s longings and drives might enable
him to modify inadaptive, pathological features of his actions, feelings
and thoughts: scientifically seen, a “proof” for the “truth” of the
psychoanalytic approach (and its underlying concepts). Clinically,
sexual wishes connect with desires for “nurturing”, for experiences of
tenderness, safety, and continuity, in “normal” and “pathological”
love relationships. The unconscious reasons for failures to link sexual
and tender wishes in a love relationship (for example, upon uncon-
scious memories of the loving and nurturing relationship with the
same primary object) are at the focus of psychoanalytic theorising
from Freud onwards (cf., Brothers, 2002; see also case material in
Chapter Two).
Neurobiological research is on a quite different observational and
explanatory level (see, e.g., Lehtonen et al., 2013; Peterson, 2013). The
way in which neurobiological models explain their data (say, gathered
in fMRI studies)—for example, why specific regions of the brain are
activated during a psychic state of sexual arousal or while seeing a
picture of a central attachment figure—says nothing about the subjec-
tive experience and its meaning. Such explanations, following
mechanical models, should not be mixed up with psychological
models encoding the personal meaning of unconscious conflicts or
fantasies concerning a subjective experience of romantic love.
Confounding the levels (the level of mechanical explanations of brain
mechanisms with the experiences of the subject building meanings on
a psychological level) would be a categorical mistake.
To summarise: neuroscientific research can neither directly replace
psychoanalytic theorising nor strongly improve the psychoanalytic
clinical work with a given patient’s unconscious conflicts in the realm
of human love and attachment. Improving psychoanalytic concepts
and treatment methods must rest upon psychoanalysts’ own clinical
research. In this sense only psychoanalysts can save the future of

psychoanalysis (see, for example, Leuzinger-Bohleber, Chapter One).

On the other hand, as will be shown in this volume, an open, careful,
and self-critical dialogue with the neurosciences and embodied cogni-
tive science might be an important source of inspiration and innovation
for clinical practice as well as for further developing psychoanalytical
concepts and research.
Thus, in engaging both clinical and extra-clinical psychoanalytic
research, we encounter a specific field of tension. On one hand we feel
that psychoanalysis has developed a very specific method to investi-
gate its very specific research subject, unconscious fantasies and
conflicts, upon specific quality criteria for the observations in the
psychoanalytical situation that can barely be grasped by non-psycho-
analytical researchers. Withdrawal into the psychoanalytical ivory
tower with an exclusive exchange among psychoanalysts ”reflecting
on clinical observations, art, literature, and philosophy” may seduce us
again and again. We can empathise with colleagues who opine that the
dialogue with contemporary neuroscientists does not have much to
offer for psychoanalysts (see Ahumada, 2001; Blass & Carmeli, 2007).
On the other hand—and here we agree with Kandel—we passionately
find that psychoanalysis as clinical practice and as “Wissenschaft”
requires an open, curious dialogue with the non-psychoanalytical
world. Interdisciplinary exchange is challenging and fruitful for our
psychoanalytic practice; however, we also feel the danger that psycho-
analysis submit too much to a mechanistic “Zeitgeist” and a research
methodology which is not its own, risking part of its identity.
We hope that reflecting on the epistemological questions of this
dialogue between all kinds of researchers and clinicans may help us
productively cope with these tensions, building better bridges for
understanding each other.
This publications aims at contributing to build such bridges.

A short overview of the aims of this publication and its chapters

All contributions in this volume further the discussion of the various
facets in the dialogue between psychoanalysis and the neuro-
sciences/embodied cognitive science. All contributions, methodical,
conceptual, epistemological, and social critical considerations are
interrelated and illustrated by clinical examples, whereby in each case
the focus is placed on various perspectives.

In Chapter One some historical, conceptual, and methodological

issues will be focused. Some of the central epistemological and histor-
ical issues of the dialogue are discussed and illustrated by examples
from clinical and extra-clinical psychoanalytical research ongoing at
the Sigmund-Freud Institute, based on the dialogues between psycho-
analysis and the neurosiences/embodied cognitive science.
In the first three clinical chapters (Chapters Two, Three, and Four)
I try to illustrate how the concept of “embodied memories” might
provide first explanations for the spontaneous, “theory-free” appear-
ance in the analysis of innovative and creative intuitions. They form
the decisive step for grasping hitherto unrepresented images and
language, and thus for reconstructing the forgotten trauma history of
a sexually abused, chronically depressed woman in the first assess-
ment interview. The traumatic experiences of being sexually abused
by her uncle during her adolescence were unconsciously linked with
earlier traumatisations, for example, in the interaction with her
severely depressed mother and early separations from her primary
object within the first year of life during the Second World War. The
bizarre bodily behaviour of the analysand during the assessment
interview already indicated the unconscious, “embodied memories”
of her traumatisations that had been kept in her body (see also Freud,
1916d). Particularly for psychoanalyses with severely traumatised
patients, understanding embodied memories in the transference may
be one via regia to the unconscious fantasies and conflicts of this group
of patients as will be discussed in Chapters Three and Four.
Memory has always been a central issue in psychoanalytic theory
and practice. As discussed in this volume, recent developments in the
cognitive and neural sciences suggest that traditional notions of
memory, based on stored structures that are also often underlying
psychoanalytic thinking, cannot account for a number of fundamental
phenomena and thus need to be revised. In the contributions of the
volume we suggest that:

a) memory be conceived as a theoretical construct explaining

current behaviour by reference to events that have happened in
the past
b) memory is not to be conceived as stored structures but as a func-
tion of the whole organism, as a complex, dynamic, recategoris-
ing, and interactive process, which is always “embodied”, and

c) memory always has a subjective and an objective side. The

subjective side is given by the individual’s history, the objective
side by the neural patterns generated by the sensory motor inter-
actions with the environment. This implies that both “narrative”
(subjective) and “historical” (objective) truth have to be taken into
account achieving stable psychic change as is illustrated by exten-
sive clinical materials (see Chapters Two, Three, and Four).

In Chapter Four, clinical examples of analysands with different

diagnoses will illustrate that the dialogue with the neurosciences, and
particularly with the embodied cognitive science, might turn out to be
inspiring and interesting for innovative conceptual discussions in
psychoanalysis as well as for understanding complex clinical material
in psychoanalyses.
Surprisingly often in the psychoanalyses of chronically depressed
patients, depression represents an unconscious attempt to psychically
cope with unbearable psychic pain following severe traumatisation:
dissociative states, a chronic psychic state of shock, a disappearance of
emotions, an emptying of the self and the object relationships, as well
as a disappearance of the psyche in the body, are among the possible
consequences. The treatment of these difficult groups of analysands
can also frequently bring analysts to the limits of their endurance.
Often related to this is the repeated danger of denying the trauma, and
a re-traumatisation of the analysand in the analytic situation.
The first section of Chapter Four discusses the fact that, in compar-
ison with other therapeutic approaches, psychoanalysis is spread over
a highly differentiated conceptualisation of the psychic determinants
and the treatment of chronic depression. However, in order to retain
its creativity and innovation as a scientific discipline and to be thus
perceived in the non-psychoanalytic world, it must constantly further
develop its conceptualisation by way of systematic and extra-clinical
research—as is seen in the insufficient conceptual account of severe
traumatisation during the genesis of chronic depression. In this
connection, several exemplary examples from extra-clinical studies in
the sphere of psychotherapeutic research, neurobiology, epigenetics,
and embodied cognitive science will be accounted for. As will be
discussed in the final part of this section, of no less importance are the
conceptualisations in clinical research on psychoanalysis, which are
based on meticulous, careful analyses of trauma reactivation in the

transference, and understanding and working through them in the

analytic relationship.
As already mentioned above, in the second section of Chapter
Four, I will discuss whether remembering the “reality of trauma”
proves to be essential in psychoanalyses. Centred around the insights
from a third psychoanalysis with a patient who suffered from a severe
case of childhood polio, the hypothesis will be discussed that working
through the traumatic experience in the transference with the analyst,
as well as the reconstruction of the biographical-historical reality of
the trauma suffered, prove to be indispensable for a lasting structural
change. The reconstruction of the original trauma is indispensable in
helping the patient to understand the “language of the body” and to
connect it with visualisations, images, and verbalisations.
Understanding the “embodied memories” often open doors for de-
coding the meanings of intolerable bodily pain as the “signs of his
specific traumatic history”. As will be discussed, the concept of
“embodied memory” might thus be helpful in understanding
precisely in what way “early trauma is remembered by the body”.
Observing in detail the sensory-motor coordinations in the analytic
relationship enables one to decode the inappropriate intensity of
affects and fantasies which match the original traumatic interaction
and are revealed as inappropriate reactions in the present, new rela-
tionship to the analyst.
Later in Chapter Four, intensive clinical experience with a group of
psychogenic sterile analysands are presented. The bodies of these
women are denied the chance to become mothers due to the uncon-
scious convictions that motherhood means an existential danger for
the lives of themselves and their partners, as well as of their children.
The “Medea-myth” helped to understand this unconscious truth,
determining the feelings, thoughts, and fantasies of all these women.
Myths have always been powerful vehicles for the projection of ubiq-
uitous unconscious fantasies. Having noted the importance of certain
male protagonists of the Greek myths in Freud’s theories, the observa-
tion is summarised that their female counterparts exert an equal fasci-
nation, and suggests that the Medea myth as recounted by Euripides
can be invoked to elucidate a central unconscious fantasy found to
underlie the psychogenic frigidity and sterility of the group of female
patients presented in this chapter. The manifestation of this “Medea
fantasy” is illustrated by a clinical account in which a dream is

analysed. The Medea story as told by Euripides is summarised, and the

attempt of a psychoanalytic interpretation of it. A case history shows
how the progressive understanding and working through of the
Medea fantasy led to a change in the analysand’s experience of femi-
ninity and enabled her to have children. It is postulated that both early
infantile sexual fantasies and repressed (embodied) memories of early
object relations traumas such as maternal depression combine with
ubiquitous bodily fantasies to produce the unconscious Medea fantasy.
The previous three chapters have focused on extra-clinical
research. They serve, in the first place, to illustrate the thesis that the
dialogue between psychoanalysis and neurosciences in the everyday
running of a psychoanalytical research institute is fruitful. As
mentioned in the forward, I hope, furthermore, to illustrate the way in
which at the SFI we take up the social critical tradition of the house,
and connect these to the requirements of a contemporary, psychoana-
lytical research institute. We have characterised this research project
as “outreaching psychoanalysis” since, in all these projects, we
attempt to take the well-founded clinical experience of psychoanalysts
and the wealth of concepts on unconscious fantasies and conflicts out
of the ivory tower, and make them fruitful for people who would
otherwise hardly find their way to psychoanalytic practice.
Chapter Five summarises the results of the above-mentioned
large-scale EU project entitled “Ethical Dilemma due to Prenatal and
Genetic Diagnostics” (EDIG), and illustrates the combination of inter-
disciplinary, empirical and clinical research. The “Medea Fantasy”,
clinically described in detail, in Chapter Four, served as a genuinely
conceptual psychoanalytic contribution to the understanding of the
unconscious world of fantasy, which is invariably activated in
women/couples during the decision for or against the life of their
unborn child. If a mutual understanding and a partial working
through of this fantasy world succeeds, then, as has been empirically
shown, a development of severe depression following abortion can be
In Chapter Six we provide further insight into how, as we had also
attempted in the LAC Study on Depression, to combine clinical and
extra-clinical research. We on the meticulous clinical-psychoanalytical
research of a group of therapeutically difficult, chronically depressive
patients. Many of them could be treated only as part of the study with
the weekly supervision group, and the possibility for psychoanalytic

expert validation (see Chapter One). The framework of the study also
proved indispensable for motivating these patients to be examined in
the sleep clinic, and to thus adopt Eric Kandel’s above-mentioned
requirements, while at the same time verifying the results of psycho-
analytic treatment by way of neuro-scientific methods. To us it would
appear that dreams, as via regia to consciousness, provide a unique,
sustained approach to clinically and neuro-scientifically verifying
unconscious transformational processes in meticulously conducted
studies of single cases.
To conclude, some considerations for prevention will also be
discussed (Chapter Seven). Taking Freud’s thesis seriously—that all
psychic and psychosocial experiences are retained in the body and
determine future problem-solving, emotions, fantasies, and object
relations—is something that might motivate many psychoanalysts to
engage in other forms of “Outreaching Psychoanalysis” in early
prevention (see, for example, Emde & Leuzinger-Bohleber, 2014). In
all these projects the enormous plasticity of the brain and the psyche
in the first months of life is seen as a great opportunity to also reach
children and their families who have suffered severe traumatisation
by way of alternative relationship experiences and, through these
means, implement alternative, progressive developmental paths. As
psychoanalytic resilience research has impressively shown, alternative
relationship experiences have proven life-saving for these children
decades later—even when, compared to primary object relationships,
it has only been possible to offer these in part (cf., also, among others,
Hauser et al., 2006). Inwardly, these children appeared to have an
affect akin to a “Principle of Hope” (Ernst Bloch) and, in the best cases,
contribute to ensuring that these children avoid regression into a state
of psychic resignation, or else attempt to overcome the traumatisation
suffered by way of violent or self-destructive means. Thus, in an
attempt to make psychoanalytical knowledge available to children
and their families on the periphery of our society living as trauma-
tised refugees, as forced migrants following war and persecution, or
as losers in the contemporary acceleration and competition-driven
society, we place ourselves in the tradition of Alexander Mitscherlich
and his vision of psychoanalytic, culture-critical research.


Psychoanalysis as a “science of
the unconscious” and its dialogue
with the neurosciences and
embodied cognitive science:
some historical and
epistemological remarks

As you know, we have never prided ourselves on the completeness

and finality of our knowledge and capacity. We are just as ready now
as we were earlier to admit the imperfections of our understanding, to
learn new things and to alter our methods in any way that can
improve them. (Freud, 1914g, p. 159)


hat kind of a science is psychoanalysis really? What did

W Freud mean when he defined psychoanalysis as a special

“science of the unconscious”? As a young man Freud was
very interested, as is known, in philosophy and in the humanities
before he turned with a remarkably strong emotional reaction to the
natural sciences. He worked at that time on research in medicine and
neurology in the laboratory of Ernst Brücke’s Institute of Physiology,
where he became acquainted with a strict positivistic understanding
of science, that attracted him throughout his whole life. As we know,
however, Freud later turned away from the neurology of his time
since he recognised the boundaries of the methodological possibilities
concerning research of the psyche in this discipline. With The


Interpretation of Dreams, the founding work of psychoanalysis, he

defined this as “pure psychology” (Grubrich-Simitis, 2009). He further
understood himself, however, to be a physician who observed very
precisely as a natural scientist. His wish of a precise, “empirical”
examination of hypotheses and theories protected Freud, as Joel
Whitebook (2010) notes, from his own predilection to wild specula-
tion. Thus, Freud as a “philosophical physician” could establish a new
“science of the unconscious”.
Concerning the history of the International Psychoanalytical
Association (IPA), this understanding of psychoanalysis has been a key
to its success. It is well known that Freud, even in 1909, considered inte-
grating psychoanalysis into the medical organisation, “medical psy-
chology and psychotherapy”, of August Forel, or even into the “Orden”
(Order, a professional organisation) for ethics and culture. Fortunately,
he decided during New Year’s Eve of 1910 to found his own, indepen-
dent organisation, the IPA (see Falzeder, 2010). As a result of this deci-
sion, the independence of psychoanalysis as a scientific discipline with
its own research methodology and institution was protected.
Afterwards, Freud always emphasised that psychoanalysis did not
deserve to be “swallowed by the medical faculty, but could instead as
‘the psychology of the unconscious’ (Tiefenpsychologie), the discipline of
the unconscious, become indispensible to all sciences that have to do
with the emergence of human culture and its great institutions as art,
religion and social systems.” (Freud, 1926e, p. 247).
In the century of its history, the specificity of psychoanalytic
science became more and more precise. Psychoanalysis developed a
differentiated, independent method of research for the examination of
its specific object of research, of unconscious conflicts and fantasies.
It has additionally, as all other current disciplines, its own criteria
of quality and truth that it has to represent with transparency and self-
confidence in scientific dialogue, in order, as with any science, to be
criticised from outside. As will be discussed in this chapter, this
conceptualisation of psychoanalysis as a scientific discipline has to be
critically reflected in a fruitful dialogue with other contemporary
scientific disciplines, particularly in the dialogue with contemporary
neurosciences and embodied cognitive science.
In this introductory chapter I would like to present my view for
discussion, that it is important for psychoanalysis in our current
media-influenced “knowledge–society” to authentically present to the

public in new forms that it has its own elaborated, empirical-clinical

research and treatment methods, that connects it in countless studies
with various forms of extra-clinical research, for example, empirical-
quantitative, experimental but also interdisciplinary, socially critical
research. I am starting with some remarks on psychoanalysis in the
contemporary “knowledge–society” compared with some episodes
during its 100 years of history, and then illustrate the specifics as well
as the richness of contemporary psychoanalytical research (focusing
on the situation in Germany, mostly referring to concrete research
examples of ongoing projects at the Sigmund-Freud-Institute in
Frankfurt and without being able to give a complete overview).

Psychoanalysis—a special scientific discipline in the politicised,

commercialised, and media-influenced world of science, part of
the “knowledge–society”
Western societies have used a large part of their resources in the last 300
years for the acquisition, expansion, and examination of their know-
ledge. The “industrial society” has changed to a “knowledge–society”
in the last century. If psychoanalysis wants to remain in this world
of science then it must realise the extreme changes in this field and to
attempt to understand its influence on the reality of psychoanalytic

a) The first component of the change in science has to do with differ-

entiation. As Hermann von Helmholtz ascertained one hundred
years ago, each single researcher is increasingly forced to dedi-
cate himself to more and more specific methods with more and
more narrow questions. For this reason the age of the universal
geniuses belongs to the past: modern scientists are, for the most
part, highly specialised experts with a limited knowledge about
adjacent disciplines (Helmholtz, 1986, quoted by Weingart, 2002,
p. 703). They are dependent upon networking on an interna-
tional, intergenerational, and interdisciplinary level. In connec-
tion with this process of differentiation, also the criteria of
“science” and “scientific truth” in the respective disciplines have
changed and this is becoming also more specific, not only in the
natural sciences but also in the humanities. The concept of a

unified science, of “science”, relying on the experimental design,

on the double-blind experiment in classical physics has proven to
be a myth: we live in the times of the “plurality of science” (see
also Hampe, 2003; Leuzinger-Bohleber & Bürgin, 2003).
b) A second characteristic of these changes has to do with the rela-
tionship of science and society: modern scientific disciplines—and
thus also psychoanalysis—are in permanent, accelerated, and
globalised competition at different levels with one another. Thus,
the practical relevance of its research results is permanently evalu-
ated by society’s foundations and political interest groups, that, for
example, increasingly gain influence over the financing of research
projects. In this sense, science loses more and more of its self-deter-
mination. Science becomes politicised—politics more scientific.
c) A third characteristic is connected with this. Because politics and
society expect quicker results from science concerning recom-
mendations for the solution of societal problems, less and less
peace and quiet is left for basic research, from which relatively
certain knowledge for practical application was derived. This
leads to a paradox situation: on the one hand ever fewer “normal
citizens” and politicians have confidence in their own judgment
on complex issues without consulting scientists, but on the other
hand it has become common knowledge that even scientific
experts do not have “objective” truths, that so-called “scientific
knowledge” is to be regarded critically. Moreover, it also carries
new risks, as the catastrophes of Chernobyl, the BSE crisis, and
now the financial crisis have suddenly shown. This leads to a new
source of insecurity and diffuse fears. Which scientific expert is
given the most confidence is dependent on his media-transmitted
credibility, which now becomes a relevant factor in society that
is competed for in politics and in public.
d) A fourth factor is the role of the media. Scientific knowledge is
usually taken note of, when it—correspondingly simple and
dramatic but credible—finds its way into the media.
“It is paradox—the more independent science and the media are, the
tighter their coupling. And as the media gain importance, science is
losing the monopoly of judging scientific knowledge. The abstract
criterion of truth is no longer sufficient in the public debate because the
media add the criterion of public acceptance. This does not mean that
scientific verification is being replaced, but it is being supplemented by

other measures . . . The loss of distance [between science and the

media] will not lead to the end of communication of truths. Trust and
confidence remain both constitutive and rare values in communica-
tion, and the more society depends on reliable knowledge, the more
these are required. The main characterization of today’s society is the compe-
tition for trust. Once achieved, this is invaluable and science should be
keen to preserve it. Therefore, it is only the efforts needed to produce
trust and confidence that have become greater. (Weingart, 2002, p. 706,
my emphasis)

Remarks to the one hundred year old history of research of

What influence did and do the above mentioned changes have on
psychoanalysis specifically? It is my opinion that psychoanalysis, as a
science that relies on the intimacy of the psychoanalytic situation, is
quite severely hit by the paradox and dilemma of these changes. As a
science of the unconscious, it seems to me to be especially dependent
upon if and how it is successful in gaining and keeping the confidence
of the world of science, of the public, of politicians and funders, but
also of potential patients, candidates in training, and the health
system. In the last century the dominating zeitgeist has changed
several times, as Bohleber (2010a) has discussed in respect to German
psychoanalysis. This has, although seldom discussed, had its effect on
the understanding of research of psychoanalysis and on its concrete
research projects, its questions, designs, and goals. In this framework
just a few remarks may be allowed.
Freud’s life-long hope that, due to the development of the modern
natural sciences, the time would come in which the insights of psycho-
analysis that have been won with pure psychological, clinical-empiri-
cal methods of observation, could be also “objectively” examined with
the “hard” methods of natural science, seems to often become reality
today through the dialogue with the modern neurosciences (see also
the introduction to this volume). Forty years ago, however, it is known
that Jürgen Habermas (1968) called this Freudian longing the “scien-
tific misunderstanding” (Szientistisches Selbstmissverständnis) of
psychoanalysis. He characterised psychoanalysis as following an
emancipatory interest in insight, in contrast to behaviour therapy, that
has a technical interest. This distinction met with a positive response

from a whole generation, and psychoanalysis, of course, due to other

factors, was at its zenith as it has never been before or since.
Psychoanalysis experienced, on the whole, as a critical hermeneutic
method of individual and social contradictions, of unconscious sources
of psychic and psychosomatic suffering, an exclusive social acceptance
in these years that at times verged on idealisation. Although there
were always attacks and controversies, psychoanalysis as a method of
treatment and as a critical theory of culture did not have to worry
about its existence during this period.
The social acceptance of that time also formed the understanding of
the science and research of psychoanalysis in those decades. Briefly
summarised, in the 1970s and 1980s, beside the genuine clinical psycho-
analytic research, this concerned above all hermeneutic–oriented and
social psychological approaches, analysis of culture, and an interdis-
ciplinary exchange with philosophy and sociology, and the sciences of
literature, humanities, and pedagogy, as well as film and art.
Empirical and especially quantitative research in psychoanalysis, and
the dialogue with the natural sciences, were considered by many to be
naïve and not fitting for psychoanalysis, even to the point of being
harmful. This problematic way of communication had long-lasting
consequences: To mention just one example, Siri Hustvedt (2010),
writes laconically in her new bestseller The Shaking Woman:

Although American psychiatry was once heavily influenced by

psychoanalysis, the two disciplines have grown further and further
apart, especially since the 1970s. Many psychiatrists have little or no
knowledge of psychoanalysis, which has become increasingly margin-
alized in the culture. Large numbers of American psychiatrists now
leave most of the talk to social workers and stick to writing prescrip-
tions. Pharmacology dominates. Nevertheless, there are still many
psychoanalysts practicing around the world, and it’s a discipline I’ve
been fascinated by since I was sixteen and first read Freud. (Hustvedt,
2010, p. 17)

As Thomas Kuhn describes in his analysis of the history of science,

different paradigms often exist side by side within a scientific disci-
pline. However, one of them usually dominates—the one that fits best
to the zeitgeist. It seems to me that the above mentioned understand-
ing of psychoanalysis as a critical hermeneutics of the 1970s and 1980s
is still currently represented in French psychoanalysis and partly in the

Latin-American IPA societies (see e.g., Ahumada & Doria-Medina,

2010; Bernardi, 2003; De Mijolla, 2003; Duarte Guimaraes Filho, 2009,
Green, 2003; Perron, 2003, 2006; Vinocur de Fischbein, 2009; Widlöcher,
2003), while in the Anglo-Saxon and German-speaking psychoanalysis,
the discussion, or perhaps even the adjustment to an empirical–quan-
titative research paradigm, has been pushed to the fore (see, among oth-
ers, Fonagy, 2009b). In these countries the zeitgeist has changed: in
times of “evidence–based medicine” and of medical guidelines the
impression can at times arise, that also for psychoanalysis there exists
only one form of research, namely empirical–quantitative psychoana-
lytic research, in the sense of the classical natural sciences, of “science”.
This is—by closer inspection—a strange reoccurrence of an out-dated
and problematical idea of a “unified science” (Einheitswissenschaft) (see
e.g., Hampe, 2003), an unconscious simplification of the complexities of
research in the above-mentioned knowledge–society, which, as is my
impression, also involves certain dangers for psychoanalysis.
I would like to briefly illustrate this point by means of a diagram
of clinical and extra-clinical research in psychoanalysis, which I have
developed in another paper. In order not to argue mainly on an
abstract level, I refer in my plea for the creative use of a broad spec-
trum of current psychoanalytic research strategies, to current research
projects of the Sigmund-Freud-Institute in which we attempt to
encounter the actual zeitgeist and without renouncing the autonomy
and specifity of psychoanalysis as a scientific discipline.

Clinical and extra-clinical research in psychoanalysis

Today, we can differentiate between two different groups of psycho-
analytic research, the clinical and extra-clinical. By clinical research we
mean the genuine research in the psychoanalytic situation itself.
Ulrich Moser describes it as on-line research, while the extra-clinical
research (the off-line research) takes place after the psychoanalytic
sessions and embraces a variety of different research strategies as will
be described below.
But first, clinical research: It takes place in the intimacy of the psy-
choanalytic situation, and can be described as a circular process of dis-
covery in which—together with the patient—idiosyncratic
observations of unconscious fantasies and conflicts are successively
visualised, symbolised, and finally put into words at different levels of

abstraction, an understanding that moulds our processes of perception

in subsequent clinical situations, even though we enter into each new
session with the basic, genuine psychoanalytic attitude, that has been
described as “not knowing”. The circular processes of discovery take
place first above all unconsciously and in the realm of implicit private
theories. Only a small part hereof is accessible to conscious reflection
by the psychoanalyst (see EPF Working Party of Bohleber, Canestri,
Denis, and Fonagy, Project Group for Clinical Observation of the IPA,
Altman de Litvan, 2014).
The insights that are won in this clinical research are presented
inside and outside the psychoanalytic community for critical discus-
sion. In agreement with many current psychoanalysts, clinical
research is for me the central core of psychoanalytic research in general. It
is connected with a characteristic psychoanalytic idea of experience
and linked to epistemic values (Erkenntniswerte) (compare Hampe
2004, 2009; Toulmin, 1977). Clinical, psychoanalytic research deals
with the understanding of the unconscious construction of meaning,
of personal and biographical uniqueness, as in the exact analysis of
the complex weavings of various determinants in the micro-world of
the patient (Moser, 2009), and for that reason can be characterised, as
mentioned, as critical hermeneutics.
The professionalism of the psychoanalyst includes the technique of
the so called “free floating attention” (gleichschwebenden Aufmer-
ksamkeit), the critical analyses of his countertransference reactions, of
the scenic observation of “embodied enactments” of the patient (see
also Argelander, 1972; Leuzinger-Bohleber & Pfeifer, 2002; Leuzinger-
Bohleber et al., 2008e), Freudian slips, dreams etc., for the successive
understanding of the actual unconscious psychodynamic of the
analysand. The typical groping, psychoanalytic process of searching
for “unconscious truths” can only be carried out with the analysand,
and is regarded as one of the marked characteristics of psychoanaly-
sis—for example in opposition to the top-down procedure of behav-
iour therapy. As Jonathan Lear (1995) so impressively described it,
psychoanalysis is distinguished as the most democratic of current
therapeutic procedures. Combined with this is the characteristic
“criterion of truth” of psychoanalytic interpretation: if a certain inter-
pretation of unconscious fantasies or conflicts is “true”, this can only
be decided together with the patient, that is by the common observa-
tion of his (unconscious and conscious) reactions to an interpretation.

As is known, we owe our specific psychoanalytic, clinical–empiri-

cal method of research, the intensive and detailed “field observations”
with single patients in the analytic situation, to the majority of all
insights that we have won in the last 100 years of our scientific history—
for example the genesis and treatment of chronically depressed
patients. Christina von Braun (2010) also sees in clinical research of psy-
choanalysis the unique chance to recognise and critically reflect the
deeper cultural changes by the ubiquitous exploitation mentality of
global and “emotional capitalism” (Illouz, 2006) on the unconscious of
modern man in the analytic relationship, that is not only highly rele-
vant for the affected individual but also for an analysis of culture.
But still, let there be no misunderstanding. Peter Fonagy is right
when he points out that not every clinician is automatically a
researcher. A methodologically systematic procedure, that—through
exact description and lucid considerations—makes clinical observa-
tions accessible to the understanding and the critique of a third party,
is a precondition, that a gain in knowledge in this form is not only a profes-
sional skill but also a clinical science. Psychoanalysis has at its disposal,
as do very few other clinical disciplines, a differentiated culture of
intervision and supervision—closely modeled on psychoanalytic prac-
tice—in which the clinical processes of research and gains in insight
can be critically discussed. However, there is much room for improve-
ment. Many problems are well known, for example the chance selec-
tion of clinical case reports that only illustrate theoretical concepts
instead of verifying them and critically developing them. Moreover,
psychoanalytic concepts are too seldom compared with the results of
extra-clinical research, something I would like to deal with later.
We urgently need good clinical research in order not only to hold
our standing in the world of psychotherapy but also to continually
develop our professional treatment skills (compare Boesky, 2002, 2005;
Chiesa, 2005; Colombo & Michels, 2007; Eagle, 1994, Haynal, 1993;
Knoblauch, 2005; Lief, 1992; Mayer, 1996). This was a goal of the
former IPA president Professor Hanly, who had not only named a
Project Committee for Clinical Observation (Chair: Marina Altmann)
but also a Clinical Research Committee (Chair: David Taylor) in order
to secure and improve the quality of clinical research in the IPA.
Thus we are developing, for example, in the LAC Depression study
(see Chapters Three and Four)—similar to the working parties of the
EPF or now also of the IPA—our own form of clinical research. In weekly

“clinical conferences” we discuss the treatment sessions that have been

partially taped and systematically document our discussion. Based on
this joint clinical research, narrative case reports that have been
“expert-validated” are developed and provide the most important
results of this study. These case studies convey psychoanalytic insights
about the specific psychodynamics of chronic depression, its complex
individual and cultural determinants, as well as the details of treat-
ment to the psychoanalytic and non-psychoanalytic community.
The method of expert-validation4 was developed in the DPV
Follow-Up Study. It is now integrated into the Three Level Model of
Clinical Observation that we developed in the Project Group for
Clinical Observation since 2009 (see contribution of Leuzinger-
Bohleber in Altman de Litvan, 2014).

Psychoanalytic Conceptual Research

The above is a sketch of new forms of clinical research that are always
part of a creative and original research on concepts, a field of research
that likewise is as old as psychoanalysis itself. The creative develop-
ment and enhancement of concepts always distinguished the innova-
tive minds of psychoanalysis and gives our discipline a great attraction
for intellectuals, writers, artists, and researchers of other disciplines.
A new characterisation of psychoanalytic conceptual research was
finally laid out by Joseph Sandler and Anna Ursula Dreher in the
1990s, setting themselves apart from other forms of psychoanalytic
research. In the Research Subcommittee for Conceptual Research that
was initiated by the then IPA President Daniel Widlöcher in 2002 with
the wish of building more bridges between the conceptual traditions
in the different IPA regions, we attempted to further delineate and
differentiate the research on concepts in the last eight years, as well as
to clarify criteria of quality for this specific psychoanalytic research
and other involved epistemological questions (compare Figure 1
below) (see also Forward to this volume; Hagner, 2008; Leuzinger-
Bohleber & Fischmann, 2006; Leuzinger-Bohleber et al., 2003a;
Weingart et al., 2007).
In the former administration of the IPA this theme has been
renewed and with great effort the existing psychoanalytic concepts
have been integrated in new ways in order to counteract the risk of

Figure 1: Different forms of research in psychoanalysis

theoretic fragmentation. The Project Committee for Conceptual

Integration (Chair: Werner Bohleber) dedicated itself to this work (see
e.g., Bohleber et al., 2013, and in press).

Extra-clinical Research
The results of not only the clinical–psychoanalytic but also of the
conceptual research can then in the next step become the subject of
other extra-clinical studies (see Illustration One). We distinguish
between empirical, experimental, and interdisciplinary studies.

Illustration One. Extra-clinical empirical studies: an example of

psychoanalytic psychotherapy research
As an example of extra-clinical empirical studies, I would like to
briefly discuss psychoanalytic psychotherapy research because it is
indispensable in the “knowledge-society” for political and public
reasons, in order to also prove the effectiveness of psychoanalytic
treatment by the criteria of evidence-based medicine.
Robert S. Wallerstein (2001) traces these attempts back to their
beginnings in 1917, and defines different generations of psychotherapy
researchers. He mentions above all a number of American studies, that

I—without making a claim to be all-exclusive—will supplement with

some European studies.
The first generation (1971–1968) consisted, for the most part, of
retrospective studies, that verified with unspecific criteria of success,
that most psychoanalytic treatment was successful (Alexander, 1937;
Coriat, 1917; Feldman, 1968; Fenichel, 1930; Hamburg et al., 1967;
Jones, 1936; Knight, 1941).
The second generation (1959–1985), in which two different groups of
studies were carried out:

a) prospective, aggregated comparisons of different, exactly defined

groups of psychoanalytic treatment. These studies relied on more
sophisticated research methods and operationalised, for example,
the criteria of success for the expected success of the therapy. Also
they could verify that approximately eighty per cent of all
psychoanalytic treatment was successful. (Bachrach et al., 1985;
Erle, 1979; Erle & Goldberg, 1984; Knapp et al., 1960; Sashin et al.,
1975; Weber et al., 1985a,b,c).
b) Individual studies resulted from a methodological uneasiness that
individual differences between the patients should not be mixed
with group examinations, but to place the main focus on the indi-
vidual consideration of the single treatment of different patients,
as is fitting in psychoanalytic procedure, in which it always has to
do with the understanding of unconscious structures of meaning.
For this reason they also used careful psychoanalytic methods in
their interviews, such as psychoanalytic follow-up interviews
(Norman et al., 1976; Oremland et al., 1975; Pfeffer, 1959, 1961,
1963; Schlessinger & Robbins, 1974, 1975; later follow-up studies
at the Anna Freud Center by Target & Fonagy, 1994; DPV Follow-
Up Study by Leuzinger-Bohleber et al., 2001, 2002b, 2003b). These
studies verified not only the effectiveness of psychoanalytic ther-
apy, but also developed a number of unexpected, clinically inter-
esting, questions, for example, that with reference to the reduction
of symptoms and to other therapy goals, some treatments proved
to be effective, but that these patients had not gone through a
psychoanalytic process in a narrower sense.

The third generation (1945–1986). In these systematic and formal

psychoanalytic studies of psychotherapy an examination of results and

of the process were combined, that is, statistical comparisons were made
between the groups but in combination with systematic single case stud-
ies, that, for example, followed the fates of single patients over a longer
period of time. (Bachrach et al., 1991; Kantrowitz, 1986; Kantrowitz et al.,
1986; 1987a,b; 1989; 1990a,b,c). An example of this third generation of
psychoanalytic psychotherapy research is exemplified by the Psycho-
therapy Research Project of the Menninger Foundation that led to a
wealth of insights on the results of psychoanalytic and supportive
psychoanalytic therapies and on details concerning treatment tech-
niques. Impressive is, for example, the careful longitudinal study of
forty-two patients over the course of several decades that Wallerstein
published with the moving title Forty-two Lives in Treatment (Wallerstein,
1986; Wallerstein et al., 1956).
The fourth generation (1970 on) combines not only research of results
and therapeutic processes but, thanks to new techniques (video/audio
recordings), links microanalysis of therapeutic processes with research
on results (beginning with early analysis of tape recordings by Earl Zinn
(Beenen, 1997; Busch et al., 2001; Busch et al., 2009; Dahl et al., 1988;
Grande et al., 1997; Huber et al., 1997, in press; Krause, 2005; Leuzinger-
Bohleber, 1987, 1989; Leuzinger-Bohleber et al., 2002a, 2003b; Sandell,
1997; Strupp et al., 1988; Wallerstein & Sampson, 1971). Compare also
Opens Door Review by Fonagy 2002 (third edition will be published in
2015), or his excellent overview, 2009a,b; as well as new studies of long-
term therapies complied by Leichsenring and Rabung, 2008.
Above all, perhaps it is too little known by clinicians of the IPA how
many psychoanalytic research groups are currently involved in extra-
clinical studies. Fonagy (2009a,b) spoke in a comprehensive survey of
the worldwide “psychotherapy bee-keepers” that have verified with
their industrious bee colonies the effectiveness of psychoanalytic short-
term therapies (compare further overviews, e.g., Emde & Fonagy 1997;
Fonagy, 2001; Galatzer-Levy, 1997; Hauser, 2002; Holt, 2003; Jones,
1993; Kächele, 2009, Kernberg, 2006; Leichsenring & Rabung, 2008;
Perron, 2006, Safran, 2001; Schachter & Luborsky, 1998; Schlessinger,
2008; Stern, 2008; Wallerstein, 2002).
Careful extra-clinical research requires enormous expenditures that
can only be carried out in a research network that is correspondingly
endowed and supported by a constant process of reflection of the
accompanying dependencies—also among the generations of involved

The LAC study may serve as an illustration (see Chapters Four and
Six). In this multi-centric study we are reacting to the threat, that in
Germany the health insurance companies may cancel their existing,
generous support of psychoanalysis and of long-term psychoanalytic
treatment if it is not possible in corresponding studies to verify its
effectiveness as measured by the criteria of the current health care
system. We have therefore developed a design that on the one hand
meets these criteria and have currently recruited 408 chronically
depressed patients, a group of patients that has societal relevance
since the large quota of recidivism resulting from all forms of short-
term therapies can only attain lasting therapeutic change in long-term
treatment (compare also Fonagy, 2009a,b, pp 4. ff; Kopta et al., 1999;
Puschner et al., 2007). On the other hand we attempt simultaneously
to further clinical and conceptual research of psychoanalysis, and thus
to represent, in a self-critical but authentic manner, psychoanalysis as
an independent, specific research method in the actual discourse
concerning the politics of health care.
Another example is the Frankfurter ADHD Study briefly
mentioned in the introduction of this volume. We compared the
outcomes of psychoanalytical compared with behavioural/medical
treatments of children suffering from so called ADHD (see Laezer et
al., 2014; Leuzinger-Bohleber, 2010a)

Illustration Two. Experimental psychoanalytic studies

It is self-evident that it is impossible to test psychoanalytic processes

directly in an experimental design. However, over the last decades
different research groups have been successfully working on an exam-
ination, also experimental, of single psychoanalytic concepts, for
example, on the preconscious and the unconscious processing of
information in memory and in dreams. These groups include: the
workgroup of Howard Shevrin and his group (see e.g., Shevrin, 2000,
2002); Steven Ellman and his group in New York (see e.g., Ellman,
2010; Ellman & Antrobus, 1991; Ellman & Weinstein, 1991), by
Wolfgang Leuschner, Stephan Hau, and Tamara Fischmann at the
SFI (Hau, 2008), to the concept of embodied memory from Pfeifer and
his research group in Zurich (Leuzinger-Bohleber & Pfeifer, 2002;
Pfeifer, 2007), as well as other studies of facial interaction with the
help of the FACs from Rainer Krause in Saarbrücken (e.g. Benecke,

2014; Krause, 2005). For early studies see Erdelyi, 1985; Kline, 1972;
Sarnoff, 1971.
As mentioned in the introduction to this volume, the dialogue with
the neuroscientists has opened new doors for psychoanalysis in the last
years, probably a reason why, for example, in the Society for Neuro-
psychoanalysis newly founded by Mark Solms, and in other institutions,
currently a wealth of experimental fMRI and EEG studies involving
psychoanalytic questions have been carried out. Some of these include:
studies at the Anna Freud Center, (Peter Fonagy), at Yale University
(Linda Mayer among others), at Columbia University (Brad Peterson,
Andrew Gerber, Steven Roose), or in Germany at the University of
Mainz (Manfred Beutel et al.), dem Wissenschafts Hanse Kollege (Horst
Kächele, Anna Buchheim, Manfred Cierpka, Gerhard Roth, Jürgen
Bruns, among others), the Psychiatric University Clinic in Zürich (Heinz
Böker and Georg Northoff), and also from us at the SFI, Lethonen in
Kuopio, and many other groups (compare publications in Neuro-
Psychoanalysis; Mancia, 2006; Pincus, 2000; Chapter Six of this volume).
In the FRED Study we are combining the extra-clinical empirical
LAC Study with an experimental investigation of some chronically
depressed patients in the sleep laboratory of the SFI, and the brain
imaging centre of the Max Planck Institute for Brain Research in
Frankfurt. In Chapter Six of this volume we summarise some of the
results of this ambitious study.

Illustration Three. Interdisciplinary research

In this volume we are focusing on the interdisciplinary dialogue with
the neurosciences and embodied cognitive science, and summarise
clinical, conceptual, and empirical studies in this field. In this overview
I would like to mention that these interdisciplinary studies are fasci-
nating, but not the exclusive research projects for the acceptance of
psychoanalysis in the modern world of science. The creative exchange,
with attachment research and empirical developmental research, for
example, are other important fields of interdisciplinary research. Just
as important is the interdisciplinary research in cooperation with liter-
ature and cultural studies, with social psychology, philosophy, the
media, and communication sciences as well as ethnic psychoanalysis.
In the last chapter of this volume I will summarise our concept of
“outreaching psychoanalysis” in different ongoing projects of early

prevention. These projects are connecting us with ongoing political

debates and multidisciplinary discourses, for example, in the IDeA
Center in which around 120 scientists are studying “children-at-risk”
in fifty different projects.
In the IDeA Center the psychoanalytic researchers of the SFI have
the unique chance to be in an interdisciplinary dialogue with
colleagues from many different disciplines, psychology, educational
sciences, mathematicians, linguists, philosophers, and neuoscientists
Another chance is the exchange with the social psychologists of the
department chaired by Rolf Haubl at the SFI. Many topics of the
mentioned projects of the Clinical Department and the Department for
Basic Research (chaired by M. Leuzinger-Bohleber) are also studies
from a social psychology perspective (e.g., depression, ADHD, or
trauma). The results of these studies are important supplements to the
clinical and empirical findings, as we have discussed in different publi-
cations and conferences (see e.g., Leuzinger-Bohleber & Haubl, 2011).
At the same time the political and public awareness of science
demands from such specialised research projects, as from the above
mentioned example of the study on the effectiveness of psychother-
apy for chronic depression, that the new found insights, for example,
of the lasting therapeutic change, be carried out in an interdisciplinary
dialogue involving culture critique of the societal roots of the illness.
According to the prognosis of the World Health Organization, depres-
sion will be the second most widespread disease worldwide in 2020.
Psychoanalysis as a specific treatment and research method could take
on other themes again and again that are of societal relevance in order
to communicate the indispensable nature of its research results to the
world of the media. For example such topics are the field of early
prevention, ADHS, of migration, youth violence, right-wing radical-
ism, nationalism, and anti-semitism, and the return of fundamental-
ism, religion, and violence, as well as the short- and long-term
influence of new media and technologies on processes of psychic
development, and of modern conflicts in the realms of sexuality and
object relations.
Finally, today the candidates in full psychoanalytic training are
won through the fascination of the Stachel Freuds (“thorn of Freud”,
Alfred Lorenzer), through authentic encounters with psychoanalysts
in the media, the universities, and in the public, through films, plays,

and novels, that often, as in the works of Siri Hustvedt, have the touch
of a declaration of love to psychoanalysis. Similar public esteem is also
experienced by psychoanalysis from leading natural scientists, to
mention a few, such as Oliver Sachs, Gerald D. Edelman, Antonio
Damasio, Stephen Suomi, or Eric Kandel.

Freud hoped that psychoanalysis, by means of “objective research
results”, could win the acceptance in the scientific community of
medicine and natural sciences. On the other hand it was only through
the insistence on its own autonomy and specifity—as a method and
institution—that psychoanalysis as a scientific discipline could secure
its survival and its productive unfolding in the last one hundred
In the first century of its history, psychoanalysis developed a
differentiated, specific method of research for the examination of its
own specific research object, of unconscious fantasies and conflicts,
that it connected in diverse studies with a variety of forms of extra-
clinical research.
Contemporary psychoanalytic research takes place in an extreme
field of tension. On the one hand exists the danger of retreating to the
psychoanalytic ivory tower and refuting the dialogue with the non-
psychoanalytic community, on the other hand the over-adaptation to
an inadequate understanding of science, and therefore a loss of iden-
tity and independence. This field of tension cannot be resolved but
can only be critically reflected upon and productively shaped again
and again in an interdisciplinary and intergenerational dialogue. This
critical reflection may also be seen as a safeguard against submission
to the dominating zeitgeist. It is well known that the gold of contem-
porary science may well be the iron of the future.
The future of psychoanalysis will be dependent upon which inno-
vative and creative insights can be found in its rich spectrum of differ-
ent fields of research in the clinical, conceptual, empirical,
experimental, and interdisciplinary research and be transferred into
the scientific and non-scientific community.
In today’s political, economical and media-influenced “knowl-
edge–society” in which scientific experts compete at all levels for

authenticity and credibility, it has in a new way become a question of

survival for psychoanalysis—if it can assert itself as a specific, irre-
placeable, effective, and productive clinical method of treatment and
as a theory of culture. If it remains publicly visible that psychoanaly-
sis is still, through its specific research method, developing unique
and effective forms of short-term and long-term treatments and has
interesting and innovative explanations to offer for the complex
phenomenon of society, then it will time and again exert its attrac-
tiveness as a “specific science of the unconscious”. In recent years, the
dialogue with contemporary neurosciences and embodied cognitive
science is one such promising door that has been opened for psycho-
analysis. This is an enormous chance that could be productively used
for an innovative future of psychoanalysis as a clinical practice and as
a wissenschaft.

Finding the body in the mind:

embodiment and approaching the
non-represented—a case study
and some theory

Embodied countertransference responses in the first

interview—the key to the un-representable?
reud wrote in 1914 in “Remembering, repeating and working

F through”:

Above all, the patient will begin his treatment with a repetition of this
kind . . . What interests us most of all is naturally the relation of this
compulsion to repeat to the transference and to resistance . . . The
greater the resistance, the more extensively will acting out (repetition)
replace remembering. (Freud, 1914g, p. 150)

Generations of psychoanalysts since Freud have concerned them-

selves with the way in which repetition in transference can provide a
healing process of remembering. This primarily involves symbolically
represented and repressed memories or relationship patterns.
However, theory and clinical psychoanalysis has focused for quite
some time on psychic material present in the analytical relationship in
other ways. Levine, Reed, and Scarfone entitled their anthology
Unrepresented States and the Construction of Meaning (2013) in honour of


André Green, and focused on the question of the search for meaning
in the unrepresented from a contemporary perspective. With his
widely accepted concept of “dead mother”, Green (2007) described
the early identification with an absent mother leading to a withdrawal
cathexis and thus to a disappearance of the inner representation that,
in the transference relationship, can be perceived by the analyst as an
empty, negative hallucination of the object, “a representation of the
absence of representation” (Green, p. 196, in Reed, 2013, p. 39). Reed
(2013, p. 29 ff.) points out that this negative hallucination of the object
leads to an emptiness rather than a representation of the lost object—
an empty mirror that, with these patients, is always there, but that is
frequently observed in the analysand’s extreme reactions to separation
from the analyst.
Green is concerned with the process of de-objectification, namely,
the obliteration of representation. Other psychoanalysts, by contrast,
focused on the psychic material of patients, which had only insuffi-
ciently, if at all, gone through the processes of symbolisation.
Dominique Scarfone (2013) presented a conceptual integration of
different forms of psychic representation and their various psycho-
analytic conceptualisations. He compared Pierce’s sign theory to
Freud’s conception of primary and secondary processes, Lacan’s
theory of the real, the imaginary, and the symbolic, Wilfred Bion’s
beta- and alpha elements, Jean Laplanche’s infantile sexual theories
and their decoding in analytic discourse, and Pierra Aulangier’s
concept of the primary, such as “primary violence”, which entered
the stage (mise-en-scène) and that could ultimately open up the
discourse on secondary processes: a brilliant example of contempo-
rary concept research.
In the next three chapters, I pursue another path by drawing on
several studies in the field of basic research, more specifically, embod-
ied cognitive science and the cognitive neurosciences, in order to
show that these disciplines offer first explanations for this clinically
important phenomenon, such as the analyst’s spontaneous inspira-
tion, which represents an initial central step to understanding hitherto
unrepresented psychic material, and that is capable of making
psychoanalytic processing accessible. Hence, this should provide new
perspectives on familiar concepts, such as “scenic understanding”
(Argelander, Lorenzer), “hearing with the third ear” (Reik), “cracking
up” (Bollas) or the “now-moments” by the Boston Change Process

Study Group. Furthermore, aspects of current discourse on intersub-

jective psychoanalysis and on enactment are touched on, as well as
further understanding of countertransference around the bodily
sensations of the analyst (cf., also Scharff, 2010). Reference to works
on musicality, dynamically emotional syntax, and performance of the
analytic relationship are plausible (cf., among others, Buchholz &
Gödde, 2013; Dantlgraber, 2008; Leikert, 2013).
In the following section, I draw on a clinical example from a first
interview as a starting point in order to show how these more recent
interdisciplinary conceptualisations of recollection and memory prove

Enactment and countertransference reactions in an assessment

interview: a clinical example
Hardly had I opened the door before Ms M stormed in across the
threshold. She clasped my hand feverishly, pressing it between hers in
a peculiar and sexually stimulating manner while stepping up very
close to me, thus encroaching on my normal sense of distance: “Well,
hi there . . . I’m so glad to have the opportunity of speaking with you
. . .” I immediately noted a forceful, negatively emotional reaction
combined with an aversive physical response: what an overwhelming
woman! I find this too much. She’s really coming too close for comfort
. . . Why did I propose an appointment? Will I ever be able to send her
away? Evidently, she is very needy . . .
After enquiring about the location of the toilet, she made her way
in leaving the door wide open, which I found thoroughly strange.
Only once having seated herself in the chair opposite me did I first
notice her pretty, girlish face as it clearly endeavoured to maintain a
permanent smile, and her beautiful female form, which she appar-
ently sought to conceal beneath loose-fitting jeans and a frayed, plain
pullover. Though in her mid-forties, her mannerisms are rather char-
acteristic of a sixty-year-old. She had previously informed me over the
telephone that her family doctor had recommended she seek out
psychotherapeutic help. She is ill and suffering from burn-out
syndrome with attendant heavy depression: “I can’t go on any
longer—I haven’t been able to sleep at night for weeks, can barely eat,
am unable to work—and I am scarcely able to tolerate the teenagers

who I supervise in my work as social worker. I repeatedly break down

in tears in front of them.”
Characteristic for her in the interview situation is that she begins by
enquiring into my frame of mind—whether it is alright for her to come
at this late hour in the evening, whether I am too tired to listen to her
after such a tiring day at work, etc. Only after having explicitly con-
firmed that I am not exhausted but would like to learn more about her
is she then able to begin her narrative. “I have no idea what happened
to me—I have always functioned very well. Nothing works now . . .”
When enquiring about the context of her “collapse” she explained that
her boyfriend, with whom she has been in a relationship over some
years, had just announced his plans to move to another city. And fur-
ther, that the daily confrontations between her fourteen year-old
daughter and her mother are increasing. “But these things are just tri-
fling matters—my boyfriend does not really mean that much to me any-
way, and quarrels with an adolescent are anyway more than normal. I
have no idea why I have no fallen into such a deep hole . . . things no
longer seem to make any sense. I’m now completely out of energy . . .”
In the next section, I would like to start out from this initial scene
before moving on to show how Ms M’s bizarre physical behaviour
contains the key to early traumatic experiences, embodied memories,
the significance of which we were only able to understand together in
transference, thanks to the very detailed observations during the third
year of psychoanalysis.
In the subsequent theoretical section of this chapter, I would like
to show that the concept of “embodiment” has proven helpful for
recognising indicators for earlier traumatisation in the transference
and, as outlined above, combine these with images, metaphors, and
language. In Chapter Three I will show that these concepts may help
to understand the clinical material in detail.

Embodiment: discovering the body in the psyche. An old

problem and a revolutionary concept
Many years had elapsed during which nothing of Combray, save what
was comprised in the theatre and the drama of my going to be there, had
any existence for me, when one day in winter, as I came home, my
mother, seeing that I was cold, offered me some tea, a thing I did not
ordinarily take. I declined at first, and then, for no particular reason,

changed my mind. She sent out for one of those short, plump little cakes
called “petites madeleines”, which look as though they had been
moulded in the fluted scallop of a pilgrim’s shell. And soon, mechani-
cally, weary after a dull day with the prospect of a depressing morrow,
I raised to my lips a spoonful of the tea in which I had soaked a morsel
of the cake. No sooner had the warm liquid, and the crumbs with it,
touched my palate than a shudder ran through my whole body, and I
stopped, intent upon the extraordinary changes that were to take place.
An exquisite pleasure had invaded my sense, but individual, detached,
with no suggestion of its origin. And at once the vicissitudes of life had
become indifferent to me, its disasters innocuous, its brevity illusory—
this new sensation having had on me the effect which love has of filling
me with a precious essence, or rather this essence was not in me, it was
myself. I had ceased nor to feel mediocre, accidental, mortal. Whence
would it have come to me, this all-powerful joy? I was conscious that it
was connected with the taste of tea and cake, but that it infinitely tran-
scended those savours, could not, indeed, be of the same nature as
theirs. Whence did it come? What did it signify? How could I seize upon
and define it? . . . I drink a second mouthful, in which I find nothing
more than in the first, a third, which gives me rather less than the
second. It is time to stop; the potion is losing is magic. It is plain that the
object of my quest, the truth, lies not in the cup but in myself. The tea
has called up in me, but does not itself understand, and can only repeat
indefinitely with a gradual loss of strength, the same testimony; which
I, too, cannot interpret, though I hope at least to be able to call upon the
tea for it again and to find it there presently, intact and at my disposal,
for my final enlightenment. I put down my cup and examine my own
mind. It is for it to discover the truth. But how? What an abyss of uncer-
tainty whenever the mind feels that some part of it has strayed beyond
its own borders; when it the seeker, is at once the dark region through
which it must go seeking, where all its equipment will avail it nothing.
Seek? More than that: create. It is the face with something which does
not so far exist, to which it alone can give reality and substance, which
it alone can bring into the light of day. . . . And suddenly the memory
returns. The taste was that of the little crumb of madeleine which on Sunday
mornings at Combray (because on those mornings I did not go out before
church-time), when I went to say good day to her in her bedroom, my aunt
Léonie used to give me, dipping it first in her own cup of real or of lime-flower
tea. (Proust, 1978, p. 61 ff., my emphasis)

With respect to the impressiveness of its force and precision, Marcel

Proust’s description of “embodied memories” remains unsurpassed:

the struggle in deciphering unexpected and, thus, initially incompre-

hensible bodily sensations in a specific, present situation of interaction:
in the body—by way of analogous sensomotoric coordination—at
lightning speed, and initially unconscious memories of an earlier situ-
ation are constructed with analogous bodily sensations: “No sooner
had the warm liquid, and the crumbs with it, touched my palate than
a shudder ran through my whole body, and I stopped, intent upon the
extraordinary changes that were to take place. An exquisite pleasure
had invaded my sense, but individual, detached, with no suggestion
of its origin . . .” The memory is there immediately but, as Proust indi-
cates, it must first be recorded in images and language “and then, at
once, the memory was there” (Proust, 1978, p. 61ff.).
In spite of Marcel Proust and other poets who described memories
with comparable degrees of lucidity, psychoanalysis would still need
until the close of the twentieth century before finally conceptualising
these relevant processes as embodied memories. In the psychoanalytic
model of representation and in the computer metaphor derived from
“classic cognitive science”, memory and recollection were for a long
time understood as processes whereby (statically) retained knowledge
was transformed from long-term memory to short-time memory, and
called up into a current problem-solving situation. We still find
comparable thinking in some textbooks in clinical psychology.
Aristotle’s famous example comparing memory to a wax tablet into
which experiences etch themselves appears to live on. This (erro-
neous) idea of memory has also entered popular language usage: “We
call up saved knowledge” or “We search for forgotten names in
memory” (much like the search for an object in a wardrobe). Roediger
(1980) established that seventy-five per cent of the thirty-two
metaphors he found in literature on the subject of memory are all vari-
ants of this “store-house metaphor”. Until today, little if anything has
changed in this respect.
According to various views in embodied cognitive science, today
memory can no longer be compared to a computer, as a storage disk
with statically stored content from which information can be
“retrieved” in a current situation. What Ms M expected was a new,
existential, and, for her, important relationship to the analyst, not an
unconscious “statically entrenched” representation of the relationship
to her uncle unconsciously reactivated, as had been understood, for
example, in reference to the model of representation in classical

psychoanalysis (cf., e.g., Menninger, 1958). Memory is a function of

the entire organism, the product of complex, dynamic, re-categorising
and interactive processes, which are invariably “embodied”.
“Embodied” not only means “non-verbal”: memory arises by way of
a “coupling” of reciprocally influential sensoric and motoric
processes. This “coupling” is biologically implemented through
neuronal maps embedded in the organism’s sensomotoric system.
Thus, Clancey (1993a) defined memory as the ability to coordinate
neurological process, and to categorise sensoric and motoric
processes, as these occurred in an analogous earlier situation. With the
following deliberations, these apparently abstract conceptions of
memory will, I hope, become more clearly evident.

Embodiment: a revolutionary concept for understanding memory,

recollection, problem-solving and learning, affect, cognition, and

Memory as a function of the whole organism

The distinction between the new, biologically inspired and “classical”
models of memory becomes very clear in a diagram published by
Gerald Edelman in 1992 (see Figure 2; cf., also Leuzinger-Bohleber &
Pfeifer, 1998, pp. 897ff.). In the case of traditional models of memory—
analogous to information processing in computers—one assumes a
precise storage of knowledge, which is static and unchanging, and
thus making transference to new problem solving possible.
By contrast, “knowledge storing” in the dynamic models of
embodied cognitive science, though less exact, precisely through this
quality enables optimum generalisation and adaption to a new situa-
tion. In the process, so-called neuronal maps are produced through
the functional circulation of the organism’s constant interaction with
its environment.

These consist of several 10,000s of neurons, which work functionally

in one direction. Thus, each system of perception has, e.g. the visual
apparatus, the sensuous surface of the skin etc, and a multiplicity of
maps which are stimulated by qualitatively different impressions:
colour, touch, direction, warmth etc. These maps are connected to one
another by parallel and reciprocal fibres, which guarantee the

Figure 2: A comparison of “classic” and “embodied” memories according to

Gerald Edelman

renewed and repeated entry, flow and exchange of signals. If one map
is selected by way of the stimulation of groups of neurons, then a stim-
ulation of the maps to which it is connected simultaneously results.
Due to the reciprocal connections (“reentry”), the nerve impulses are
returned, whereby the reinforcement or attenuation of synapsis in the
neuronal groups occurs in the synapses of each map: the connections
of the maps themselves undergo modification. Through this, new
selective qualities emerge, in other words, “automatic” re-categoriza-
tions of current stimuli from different sense channels. (Leuzinger-
Bohleber & Pfeifer 1998, pp. 898f.)

Through such “sensomotoric coordination”, which is connected

with permanent re-categorisations, the organism ensures a sustained
ability to orient itself in the environment, namely, to connect current
experience with previous experience whereby, due to the new situa-
tion, previous re-categorisations are adapted by way of the retained
Hence, due to the above-outlined radical conceptual rethinking, in
embodied cognitive science memory is understood as a function of the
total organism, the product of complex, invariably “embodied”,
dynamic re-categorising and interactive processes (cf., among others,
Leuzinger-Bohleber & Pfeifer 2013).
Gerald Edelmann’s (1987) book, Neural Darwinism; António
Damásio’s (1994/1997) Descartes’ Irrtum; Lakoff and Johnson’s (1999)
Philosophy in the Flesh. The Embodied Mind and its Challenge to Western
Thought; and Rolf Pfeifer and Josh Bongard’s (2007) How the Body
Shapes the Way We Think, are probably the most well-known examples
that show that the Cartesian dualism between mind and body must
be revised in favour of a radically new perception of an “embodi-
ment” of the psyche in the body.
There exists no Kantian radically autonomous person, with absolute
freedom and a transcendent reason that correctly dictates what is and
isn’t moral. Reason, arising from the body, doesn’t transcend the body.
What universal aspects of reason there are arise from communalities
of our bodies and brain and the environments we inhabit. The exis-
tence of these universals does not imply that reason transcends the
body. Moreover, since conceptual systems vary significantly, reason is
not entirely universal. . . . Since reason is shaped by the body, it is not
radically free, because the possible human conceptual systems and the
possible forms of reason are limited. (Lakoff & Johnson, 1999, p. 5)

Each interaction with the environment changes the organism: a new

view to the nature–nurture problem
As indicated above, from the viewpoint of embodied cognitive science,
psychic processes are constituted only through the subject’s adaptive,
re-categorising interaction with the environment, in which memory is
actively constructed. One further assumption is that the organism finds
itself in ongoing transformation. I would also like to give an example of
this from epigenetics, a highly interesting research field for psycho-
analysis—which, thanks to recent technical advances in molecular
genetics, has brought forth a wealth of interesting studies. Furthermore,
proven genetic vulnerabilities do not represent the victim’s destiny, but
first make their appearance where previous, weighty environmental or
relationship experiences play a role. Thus, those studies, among others,
by Caspi and colleagues (2003) and Hauser (2008) that were capable of
verifying genetic vulnerability by way of the so-called moderated
5–HHT allele of the serotonin transporter gene were given considerable
attention. This proved that people with this genotype only then suffer
from depression when subjected to ongoing weighty life circumstances
or earlier traumas, such as child abuse. Kaufman and colleagues (2006)
and Goldberg (2009) were also able to show that a responsive, empa-
thetic motherly behaviour in the first months of life represents a protec-
tive factor, whereby the risk of becoming ill from depression is also
reduced in cases of proven vulnerability (cf., also Hill et al., 2004; Jacobs
2009; Risch et al., 2009; Suomi, 2011).
These studies on epigenetics confirm the basic psychoanalytic
thesis of an ongoing and determining interaction between genetics
and environment, between biology and social experience, especially in
early and earliest childhood. The developmental perspectives of
embodied cognitive science differentiates these general theses, among
others, by empirically showing that the organism’s interaction with
the environment, as one has imagined for considerable time, is not
regulated exclusively by a “genetic programme”, but by an ongoing
dynamic and “embodied” interaction between subject and environ-
ment, namely, from the outset. I go on to elaborate this in greater
detail in the following section.

Embodiment, self-regulation and “learning by doing” (Dewey, 1896)

Just how radically the view of self-regulatory processes of the embodi-
ment concept has questioned our previous understanding of psychically

functioning processes, is best illustrated by Pfeifer and Bongard’s

experiment in fundamental research (2007, pp. 177–211).
For the purposes of examining the effects of sensomotoric coordi-
nations and the principle of self-regulation, researchers reconstructed
a molecular chain comprising motoric, sensoric elements (“cells”) as
well as binding elements in an experiment (see Figure 3). Through the
connection of sensoric and motoric elements, such a molecular chain
can set itself in caterpillar-like motion, without thereby following a
corresponding (genetic) control programme: the sensoric stimulation
moves the motoric element, which consequently shifts the sensoric
element, etc.

Figure 3. Schematic representation of the research experiment according to

Pfeifer and Bongard (2007) for sensomotoric coordination

After having left their experiment one evening, researchers were

surprised to discover when returning the following morning that a
fascinating, complex structure on a new cell structure had developed
(see the first image in Figure 2): this was the fundamental evidence of
embodiment, namely, of a self-organising principle that, by “learning
by doing” (Dewey, 1896)—without (central) regulation of performing
sensomotoric coordination—a cell structure forms; this cell structure
is “intelligent” to the extent that it generates self-organised intelligent
behaviour over the course of time (in the experiment: shifting an
obstacle). A short film on this experiment can be found at
What do these experiments show us?

i) Biological systems are self-organised and develop “intelligent”

bodies, namely, structures in which they interact with the envi-
ronment by way of sensomotoric coordinations without central
ii) In the case of (biological) beings, learning always simultaneously
occurs sensomotorically (in the body) and in the brain (in
neuronal networks).
iii) Learning, problem-solving and memory are thus no longer func-
tions of a “saving in the brain”, but invariably the product of
complex, self-regulated, sensomotoric coordination.
iv) Psychic processes, such as “unconscious memories” or affects
and fantasies evoked in a certain situation, are “constructed”
between subject and environment in the here and now of a
current interaction. Consequently, thinking, feeling, and action
arise only interactively: the subject cannot learn in an insular
quasi-autistic capsule and further develop itself. It requires inter-
action with the environment.
v) Similarly, such categories that constitute the basis of all learning
and understanding do not develop by retrieval or modification of
stored knowledge. They are automatically brought forth by
sensomotoric coordination (spontaneously “constructed”).
Since this is decisive for our subject of understanding that
which is non-represented, one further experiment should be cited:
if we give a one-year-old child a red rubber ball in one hand and a
brown chocolate bar in the other, he will put both in his mouth sev-
eral times, though he will prefer the chocolate bar after no more

than two or three attempts: through sensomotoric coordinations—

the learning by doing—he has formed categories without an adult
having to explain it to him, namely, without the aid of cognitive
schema: the brown, long-shaped object tastes good, one can eat
it—and although one can bite the round object, it does not taste
good, one cannot eat it! And yes, at some point the mother will
remark, “and, does the chocolate taste good?” from which point
on the child also associates the linguistic concept with his self-con-
structed categories. As this example indicates, the concept of
embodiment provides a solution for one of the central problems of
developmental psychology, namely, the early pre-linguistic acqui-
sition of categories and, finally, also symbols and language.
vi) The concept of “embodiment” is thus radically “historical”, as
psychic processes in the present always take place as the product
of sensomotoric coordinations analogous to those in the subject’s
idiosyncratic past: the past inevitably impacts the present and
future—that is, for the most part, unconsciously.
vii) In that each new experience further develops sensomotoric coor-
dinations, earlier experiences are permanently rewritten. Hence,
the “historic truth” can never be reconstructed “one to one” on
the basis of specific behaviour in the present. Put more bluntly,
this is the subjective part of all psychic experience. And yet, in the
sensomotoric coordinations, past real experiences are retained
“objectively” (“embodied”) and can be measured, in principle,
with the aid of neurobiological methods. For this reason, psychic
experiences, such as memory, always receive a “subjective” as
well as an “objective” side.

The relevance of the embodiment

concept for psychoanalysis

ut what relevance does this fundamental scientific knowledge

B have for psychoanalysis?

The embodiment concept in psychoanalytic literature

In psychoanalytic literature there are a number of papers that take up

the concept of embodiment, though frequently not in the radical sense
we postulate here (Leuzinger-Bohleber et al., 2013a; Emde &
Leuzinger-Bohleber, 2014). In his historical survey, Sletvold (2011)
employs a very broad definition of embodiment in the sense of “work
with the body in psychoanalytic therapies”, a tradition that, among
other things, goes back to Wilhelm Reich’s psychotherapy of the body.
Based on the latter therapy, he even develops practical guidelines for
the work of the analyst with “unconscious embodied expressions”
(Sletvold, 2012; cf., also Bloom, 2006). Similarly, in his work
“Fundamentally embodied: the experience of psychological agency”,
Frie (2008) points to the works of Lakoff and Johnson (1999) and
Damasio (1994/1997), though using the concept of embodiment not in


the sense of a new theoretic explanation of specific clinical phenom-

ena, but very generally, as a document of complex processes of reflec-
tion “informed by personal history and fundamentally embedded in
biological and sociocultural contexts” (p. 374; cf., Langan, 2007; Mizen,
2009). In a similarly global manner, Vivona (2009) argues for an
“embodied language” as expression of a modern integration of neuro-
sciences and psychoanalysis.
Hannabach (2007, p. 253) points to embodiment so as to point out
the relevance of the bodily dimension in the discussion on gender-
specific experiences of sexuality (cf., also Green, 2010; Marshall, 2009).
Similarly, Knoblauch (2007) postulates that the analyst can draw on
observations of “body-based counter-transference experience” for
understanding clinical phenomena, such as enactment, with a greater
degree of differentiation (cf., also Shapiro, 2009). Coming from a
Jungian tradition, Stone (2006) draws on the concept of embodiment
in a more metaphorical sense for the description of physically
perceived resonance processes between analyst and analysand (cf.,
also Corrigall et al., 2006).
Also of interest is the conceptual integration of “embodied simu-
lation” along with the studies on mirror neurons, which Gaensbauer
presented (2014) as an explanation for the re-enactment of earliest
traumatisation. With three impressive case studies he illustrates that
very young children also (the two-and-a-half year-old Kevin, the four-
month-old Jennie, and the three-and-a-half year-old Margaret)
precisely repeat suffered or observed traumatisation in their play,
such as the death of the father who was stabbed to death in a fight
(Kevin). He explains these “embodied memories” by way of the func-
tionality of the mirror neurons and “embodied simulation”. He
pointed out similar explanatory attempts, such as “deferred imita-
tion” (Gaensbauer, 2002, 2011), various forms of implicit, procedural
memory (Siegel, 1995) or “behavioural memory” (Terr, 1994).
However, Gaensbauer also draws on a specific and at the same time
broad definition of embodiment as physically anchored emotions in
human interaction:
The concept of “embodiment” referring to the bodily states that arise
during the perception of an emotional stimulus, has a long distin-
guished history in psychology having been articulated most notably by
William James (1890), among others. Over the past several decades,
emotion researchers have provided strong evidence that people

“embody” the emotional behaviour of others—that is, experience a set

of bodily sensations and emotional states that correspond to those being
expressed by a person they are observing. (Gaensbauer, 2011, p. 94)

In contrast to these authors, in our work we argue in favour of a

narrow definition of embodiment, which goes beyond a general
emphasis of the “physicality of psychic processes”.

Embodiment: a new insight into early developmental processes and

“early parenting”

The following diagram in Gerald Edelman’s book Neural Darwinism (see

Figure 4) illustrates the above-mentioned central thesis of “embodied
cognitive science”, namely, that neuronal networks are in a permanent
state of dynamic development. Environmental experiences in the uterus
lead to a developmental selection as early as the embryonic stage, and
thus to the formation of the primary repertoires. Environmental influ-
ence, namely, of social relations, is increased in the first year of life:
experience selection leads to the formation of secondary tepertoires. All
these processes correspond to the principles of a neuronal Darwinism:
successful, used connections between the nerve cells are strengthened—
those which are not used atrophy and wither away (for a more detailed
discussion, cf., Leuzinger-Bohleber & Pfeifer, 1998, p. 897 ff.).
What is important is the reciprocal coupling of maps based on
sensomotoric coordinates. Embodiment, therefore, means that social
experience finds sustained expression through sensomotoric coordi-
nates, and literally enters the hardware of body and brain. Hence,
leading neuroscientists refer to the “social brain”. However, they must
also always add that this “social brain” cannot be considered in isola-
tion but as part of a “social body”, a position which supports the
“intersubjective turn” in psychoanalysis (for further details, see also
Fuchs et al., 2010; Gallese, 2009, 2013; Knox, 2009).
Thus, “embodied” means far more than simply “non-verbal” or
based in the body. Memory arises through a coupling of sensoric and
motoric processes, which reciprocally influence one another without
central regulation. This coupling is implemented biologically by way
of neuronal maps embedded in the organisms’ sensomotoric system.
Thus, Clancey, for example, defines (1993b) memory as the possibility
of coordinating neurological processes, and to thus categorise sensoric

Figure 4: Principles of neuronal Darwinism in the development of neuronal

networks (on the definition of maps: cf. Figure 3).

and motoric processes such as these occurred in comparable earlier

This central thesis of embodied cognitive science was further
supported by Makaken through the discovery of mirror neurons by
Giacomo Rizzolatti and his colleagues (1996, 2002). Their findings
have, meanwhile, been verified for human infants by way of numer-
ous experiments. These studies increase awareness of the fact that the
infant is influenced by the earlier identification process with its first
relationship persons (with the aid of mirror neurons) long before
developing consciousness and language. These earliest identifications
are reflected in the sensomotoric coordinations (maps etc.), which
influence later interactions. Gallese (2013) also discussed the signifi-
cance of mirror neurons for early embodied interaction processes in
the intersubjective consideration of emotional, social, and therapeutic
exchange, among others, when he wrote:

The discovery of the actions responsible for the mirror neuron mech-
anism led to the hypothesis that the mirror neurons most probably
constitute the mere tip of a huge, hitherto undiscovered iceberg, which
is concealed in the sphere of emotional and physical sensibilities
(Gallese, 2003a, 2003b; Goldman & Gallese, 2000). This hypothesis is
also supported by empirical findings . . . Taken as a whole, these
results suggest that one important aspect of intersubjectivity when
observing the expression of important aspects of external emotions
and sensations may be understood as re-utilisation of the same circuit
which constitutes the foundation of our own emotional and sensory
experiences . . . One supported the thesis that a common functional
mechanism, namely, “embodied simulation” (ES), is capable of coher-
ently and neuro-biologically explaining the multiplicity of intersub-
jective phenomena. (Gallese, 2013, pp. 95 ff.)

Meanwhile, the many studies that have been carried out on the
infant’s processes of early, pre-linguistic identification with primary
attachment figures/care-givers correspond to the psychoanalytic view
that the early object relationships express themselves in the basic
melody of the psyche. Now well-known, the so-called “Still Face
experiment” (Tronick, 2003) provides impressive empirical evidence
about the degree to which the infant’s psychic sensitivities are depen-
dent on a resonant, affective, and consistent interaction with its
mother. A mother is requested following a “customary” affective reso-
nant game sequence with her one-year-old baby to show no mimic
reactions, a “still face”. The baby reacts immediately, and attempts
with all means at its disposal to regain her “normal” behavioural
interaction. When unable to achieve this, the infant reacts in a visibly
irritated manner and turns away before beginning to cry bitterly.
Hence, there emerges a close connection between embodiment and
early development. As “embodied memories” the early experiences of
interaction determine subsequent development and the spontaneous
(not cognitive) expectations and unconscious interpretations of new
interactive situations. Psychoanalytic knowledge of just how decisive
and definitive are the first relationship experiences during the initial
weeks and months over the long-term—determined as these are by
extreme vulnerability and enormous plasticity—are given fascinating
empirical support by way of interdisciplinary research on “embodi-
ment” and early parenthood. As is well-known, Freud had already
claimed that originally the ego was a bodily one.

Thus, a narrowly defined concept of embodiment casts a new light

on the development process or the determining impact of earlier and
the earliest experiences of interaction. As a consequence, they funda-
mentally determine later thought, feeling, and action. They form the
basis of further psychic and somatic development and not only, as has
frequently been understood, as “non-verbal communication behaviour”,
but as the basal constitutive elements of psychic processes in general.
Hence, embodiment is never solely “non-verbally” or “physically
expressed”, but means that, here and now, a new interaction situation is
recognised by sensomotoric coordination by way of comparable earlier
situations (not cognitive, but in the body), and that memories are newly
constituted each time, and thus determine a current problem-solving
situation. These processes are played out not only in the brain but,
above all, in the body, in sensory perceptions, which interact in
complex, unconscious ways and determine thought, action, and feel-
ings. In doing so, they follow the coordination as played out in earlier
interaction situations: embodiment is thus a perspective which invari-
ably accounts for the aspect of development. This is why embodiment
is extremely fruitful for psychoanalysis: psychoanalysis has always
postulated that psychic realities are a product of complex, bodily-
psychic, and also invariably confrontational experiences retained in
the unconscious, and unconsciously determine present thought, feel-
ing, and action in new situations of interaction. Embodiment is a
concept which can precisely explain psychoanalytic knowledge in
new innovative ways (cf., also Gullestad, 2013; Leuzinger-Bohleber, in
press; Sandel’s case presentations, 2014).
The original studies of Finnish psychoanalyst, neurologist, and
psychiatrist, Johannes Lehtonen, point to these connections in an
exemplary manner. He shows impressively how breastfeeding is influ-
enced by genetic factors, and also by the relationship experience with
the breastfeeding mother, and how it literally constitutes the body’s
fundamental pattern of satisfaction—having been invariably postu-
lated by psychoanalysis even on the basis of clinical observations—on
the archaic longing to relive the paradisiacal states of happiness in the
union with the object of love, and thereby probably to the most impor-
tant sources of motivation for us human beings. Recent experiments by
sleep-dream researcher and psychoanalyst Steven Ellman and Lissa
Weinstein (Weinstein & Ellman, 2012a,b) arrived at a similar conclu-
sion. In a series of experiments they showed that, depending on

temperament, infants are born with rhythms of sleeping and waking

(cf., also Greenberg et al., 1990). Ellman’s research group discussed the
consequences that adequate or inadequate interpretations have for the
individual infant’s sleeping and waking rhythm, as well as for its
temperament through its primary objects. A temperamental baby is in
danger of over stimulation (through to the inability to sleep), and, by
way of an over stimulated primary object, is placed in an unbearable
psychophysiological state. It needs a sensitive primary object who
understands how to avoid over stimulation. By contrast, infants of a
more “lethargic temperament” require adequate stimulation in order
to experience a pleasurable inner state, which leads to a sufficiently
good activation during the period of wakefulness, and that first facili-
tates subsequent sleep as recuperation. Ellman (2010) offers a detailed
discussion of the long-term effects of misinterpretation by the infant’s
idiosyncratic, largely genetically determined behaviour by its primary
objects. An “good enough” interpretation of the idiosyncratic neurobi-
ological (sleep-wake) cycle by a sensitive primary object enables the
infant to develop into a “Winnicott baby” (cf., also Weinstein &
Ellman, 2012). A frequent misinterpretation of the individual rhythms
and needs by the primary object leads to failure in early affect regula-
tion. The infant is subject to extreme experiences of stress and negative
affects, such as pain, anger, despair, and powerlessness. It develops
into a “Kleinian baby”, filled with archaic destructive fantasies and
impulses towards the primary object and the emerging self. Such
processes could be observed in vivo in video recordings of the interac-
tion between severely traumatised mothers and their children in a
study carried out by Schechter and Rusconi Serpa (2014). A teenage
mother left her infant alone in a room in front of a running video
camera—for some apparently inexplicable reason. The eleven- month-
old boy reacted in panic and desperation, searched for the mother, beat
heavily on the door injuring himself in the process—incapable of calm-
ing his storm of affects himself. As could be elicited from subsequent
interviews with the mother, her crying child unconsciously reminded
her of her own personal traumatic feelings of helplessness and power-
lessness, such that she was unable to calm the infant, but instead with-
drew herself from him. This example may not only count as an
example of a trans-generational transfer, but for an impenetrable affect
regulation by the primary object as well. As is well-known, the regula-
tion for so-called “peak-affect states” (Kernberg, 2012) is decisive for

early self-development (cf., also Leuzinger-Bohleber, 2010d, 2013).

Similarly, the interaction behaviour determined by the mother’s own
traumatisation leads to the infant’s subjection to traumatic experiences
in situations of separation, which remain in his body as “embodied
memories”, and that exert a decisive long-term effect, thereby uncon-
sciously influencing the expectations of new interaction experiences
with important reference persons. In their prevention programme,
Schechter and his research group attempt to soften this trans-genera-
tive transfer of traumatisation or, in the best case, to interrupt them.
Early interaction of depressive mothers with their infants has been
well researched empirically and clinically (cf., among others, Beebe &
Lachmann, 2002; Feldmann, 2012; Rutherford & Mayes, 2014; Stern,
1985/1992). Due to its depression, sensitivity and emotional resonance
for the infant’s individual needs are severely restricted or even break
down to a large extent. How infants of depressive mothers have no
choice other than to identify with the affects of their “dead mothers”
in order to establish a proximity to their primary objects is described
impressively by Daniel Stern. One of the four possible coping strate-
gies he outlines that strongly influence the emerging personality, is the
development of a “false self” (cf., also Leuzinger-Bohleber, 2012).
As Helena Rutherford and Linda Mayes (2014) point out, this
postulate can meanwhile be specified in empirical and, above all,
neurobiological studies: the early, “embodied” experiences of interac-
tion with primary objects are deposited in a formative manner. For
this reason, leading neuroscientists today refer to the “social brain”.
However, they are obliged to qualify this by adding that the “social
brain” cannot be considered in isolation, but comprises part of a
“social body”. Consequently, Vittorio Gallese (2013), one of the
discoverers of the mirror neuron, summarises several fascinating
results of recent brain research that suggest a revolutionary new
conceptualisation of psychic processes. As postulated by the concept
of “embodiment”, he likewise emphasises the ongoing construction of
psychic states in interaction situations, a position which the “inter-
subjective turn” in psychoanalysis supports by way of an interdisci-
plinary approach (cf., Fuchs et al., 2010; Gallese, 2009; Knox, 2009).
Naturally, this does not mean that only the earliest relationship
experiences express themselves as “embodied memories”, although
these, as already indicated, determine the psychic basic melody, or—
to use spatial terminology—the basic orientation of the sensomotoric

coordinations taken up by further development. Later experiences

also enter into the body in the form of a continuous development
process. Of decisive importance here are, above all, traumatic experi-
ences which, due to their extreme, psychic non-processable quality,
metaphorically speaking bring previous sensomotoric coordinations
to the point of collapse at any age, thus affecting the same for psychic
self-regulation, creativity, and integrative problem-solving. To cite one
of Edelman’s metaphors: in later analogous relationship situations,
unconscious memories of traumatic object relations trigger “storms”
in the body and the brain, which render mature psychic functioning
impossible and repeat the traumatic experience time and again (as in
the case of Ms M) (cf., also Leuzinger-Bohleber, in press).

A deeper understanding of clinical processes of transformation in

psychoanalysis: the decoding of the unrepresented by way of
embodied memories in transference, or “how do thoughts of the
unrepresented emerge?” (Case study of Ms M, Chapter Two)
As mentioned in the introduction, the question as to how it is possi-
ble to not only sense that which remains unrepresented in the analytic
situation, but to also articulate it in visualisations, images, and
language, and thereby transfer unconscious repetition in a transform-
ing therapeutic memory process, has remained largely unclear in
contemporary psychoanalytic literature. Here, as is well-known, the
analyst’s associations, and spontaneous thoughts, provide a first key
to understanding the meaning of that which, hitherto, has remained
entirely misunderstood and which is then operative in the transfer-
ence. In analytic literature, this spontaneous knowledge, these spon-
taneous insights and thoughts, are frequently rewritten
metaphorically as “turning points” in the treatment, the “meeting of
the minds”, the communication of unconscious to unconscious, the
“now moments” etc. And yet, as far as I am aware no plausible expla-
nations hase been given, to date, for the occurrence of these important
thoughts. This is precisely what that the knowledge of embodied
cognitive science as summarised in this paper offers. As outlined
above, categories form in the interaction between the subject and his
environment (in “system environment interactions”), and are always
based on sensomotoric coordination, namely, are “automatic” and are
not centrally regulated, but self-regulative. The human brain—and the

human psyche—find themselves in a perpetual process of re-cate-

gorising experience: without spontaneously self-forming (uncon-
scious) “categories of understanding” all orientation in a new
situation is missing; the organism could not survive in the present,
would not be able to orient itself in the present—there would be no
adaptive reactions, no processes of problem solving, no spontaneous
memories that play out, which could be fruitful for the current situa-
tion, and no learning (cf., the above-mentioned experiment by Pfeifer
and Bongard). The same holds for the analytic relationship.
As explained in the above, the mirror neuron system enables the
analyst to identify with the analysand’s current sensomotoric coordi-
nations (the unconcious memory processes), while at the same time
bringing this to bear in his own countertransference—namely, in his
own body. Through this, analogous sensomotoric coordinations in
current interaction are activated, as they are in the analysand. These
processes bring forth categories—automatically, spontaneously, and
unconsciously—which, thanks to the processes of identification, are
connected with the analysand’s unconsciously running memory
processes from earlier, important relationship experiences. In the case
of traumatised patients, it is above all memories of psychically unbear-
able flooding experiences, of extreme powerlessness, of doubt, pain,
panic, and the fear of death. Through the identification processes in his
spontaneously self-forming categories, the analyst re-categorises these
reactions—as conditioned by traumatic experiences, namely, uncon-
scious “understanding”. However, the extreme qualities of the trau-
matic experiences also leads to spontaneous defence and initially
hinder the process of becoming conscious. Consequently, at first
contact, namely, at the first interview, he predominantly registers a
combination of immediate sensomotorically categorised perceptions
and his own defence processes, as illustrated by the example of Ms M.
“What an overpowering woman! I find this all too much. She’s really
getting under my skin . . . Why did I offer her an appointment?” These
(conscious) thoughts clearly contained both the perception of an over-
powering quality of the patient’s psychic reality as caused by a trauma
as well as my own defence movements.
The first, unconscious perception of the specific traumatic experi-
ences of the analysand did not involve a singular occurrence, but
rather a complex process that repeats itself continually. On the
one hand, by way of the identification with the many variations of

occurring sensomotoric coordinations it requires a constantly repeat-

ing enactment in the transference so as to ultimately be able to recat-
egorise the traumatisation suffered in one’s own embodied
countertransference. On the other hand, it is inevitable that the analyst
processes his defence against a possible flooding through the patient’s
traumatic material (unconsciously), so as to become conscious of the
unconsciously formed categories about the traumatisations suffered
by the patient. As clinical-psychoanalytical experiences have shown in
various ways—especially with severely traumatised patients—a direct
revival of the traumatic experience in the transference of both parties
is only then possible if a supporting, retaining, and containing analyt-
ical relationship has developed.
In the language of cognitive science, in the therapeutic interaction
(new) sensomotoric coordinations develop, which build successively
on carrying capacity, of being understood through a new, psychoana-
lytic object. As is well-known, among the most sustained experiences
of severe traumatisations is the complete breakdown of trust in a help-
ing object. Connected to this are the unconscious convictions and
fantasies to which the person affected attributes self-guilt for the trau-
matic experience. Thus, initially unconsciously, traumatised patients
will continually repeat this “inner truth” in transference, and only due
to alternative forms of relationships begin to limit their validity. In
other words, the sensomotoric coordinations, analogous to the trau-
matic experiences of relationships, cannot be deleted; they are repeated
time and again in the analytic relationship—and yet alternative senso-
motoric coordinations (namely, metaphorically speaking, alternative
neuronal paths) connected with categories, such as “security”, “relia-
bility”, “understanding”, and “survival” can be successively built up.
The “old” re-categorisation processes based on traumatic relationship
experiences run disconnected and parallel to the new re-categorisation
processes forming in the psychoanalytic relationship. Only once the
“new” re-categorisation have finally led to the more or less stable cate-
gories, such as “trust”, “security”, etc., do the two paths of sensomo-
toric coordinations (the maps) become connected to one another. Now
the analyst is in a position to access the hitherto unconscious category
“trauma” by way of an accurate, specific idea (for example, sexual
abuse), and thereby open up a first door for a psychoanalytic
processing of the traumatisation. I will briefly illustrate these complex
processes by way of the clinical example.

Only in the third year of psychoanalysis did the meaning reveal

itself in the above scenes in the first interview. The intrusive behav-
iour outlined in the above was repeated in several variations in the
analytic treatment (for example, Ms M repeatedly used our private
toilet, opened the doors to our private rooms, got into my car to turn
off the light, etc.). One day before the analysis session to be described
below, Ms M’s intrusive behaviour once again irritated me consider-
ably. She appeared, unannounced, at my lectures in a public institu-
tion and seated herself in the first row. When listening to Ms M for ten
minutes in the subsequent session in silence while she explained to me
that her uncle had told her shortly before his death how, on each occa-
sion, she would impatiently wait for him in front of his studio, it
suddenly occurred to me that this could involve a case of sexual abuse
perpetrated by the uncle, and I was surprised by Ms M’s reply.
A: Could it be that what you remember of your impatience and the visits
to your uncle was your initiative, indeed, that you actively sought his
closeness, because it was too painful to think that your uncle had abused
the longing you felt for your father and had thus transgressed the bound-
aries of intimacy?
M: Naturally, we shared mutual affections—but I enjoyed this. When he
touched my breast, I finally felt like an attractive young woman . . ..

The subject disappeared from the sessions for a considerable time,

but then brutally sexualised scenes increasingly began to emerge in
her dreams, which I once again sought to address:

You were already adolescent when you began visiting your uncle, and
can probably remember the experience of the time. You told me some
time ago that affections had been exchanged between you and your
uncle. Could it be that you are reluctant to think about any further
details which occurred between you, because it could be too shameful
to talk about your memories?

Ms M reacted vehemently to this question. She went to the toilet

and vomited.
In subsequent sessions she was able to relate her memories of the
coitus experiences with her uncle that were marked by violence.
Nausea, disgust, and aversion appeared: the acting out of the
overwhelming, traumatic experiences gave way to successive memory
and verbalisation.

Ms M blamed herself for these events: “I was so in need of affec-

tion. No wonder that my uncle responded to this . . .”
Only gradually was she able to admit that this really was a case of
abuse that had a major impact on her adolescence and her sexuality
as a woman:

When visiting my uncle as a thirteen-year-old, I would always storm

into the studio and take the initiative in our sexual adventures: I was
the one who sought emancipation, to be unconventional, and not him.
I found this interesting . . ..

Only then did I understand that the indicated scenes in the first
interview contained unconscious “embodied memories” of her trau-
matic experiences with her uncle: I was also, quite literally, overrun,
overwhelmed by her in the first interview and she “got under my skin”.
However, at that time it was not yet possible to decode these uncon-
scious memories in the enactment of Ms M: only once I had got to know
the analysand much better and had often directly experienced the intru-
sive encroachments in the transference relationship to me while simul-
taneously building a supporting psychoanalytic relationship to
her—something which allowed for great empathy to the desperate,
traumatised child in Ms M—did a decisive thought occur to me.
Again, expressed in the language of embodied cognitive science:
only once I had—unconsciously—repeatedly experienced the charac-
teristic sensomotoric coordinations of Ms M in the psychoanalytic
sessions, and adopted them through identifications in my “embodied”
countertransference reactions, and only once new categories of a
sustainable psychoanalytic relationship had developed, did it then
become possible to connect the hitherto disconnected paths of memory
with one another. Much like in Proust’s “madeleine scene”, ultimately
this connection all of a sudden gave rise to the thought (the category)
of “sexual abuse” due to my own (unconscious) sensomotoric coordi-
nations. Naturally, unconsciously, it was linked to the “embodied
memories” mediated by the repeated sensomotoric coordinations.
With this I had evidently hit the mark. As then became evident, Ms
M had been sexually abused by her uncle from the age of thirteen to
twenty. And yet, only through the ongoing psychoanalytic relation-
ship was it possible for her to admit, by way of new memories of
brutal scenes, that this was really a matter of sexual assault and had
nothing to do with an “emancipated happy” affair that she had initi-

ated. Only through the secure psychoanalytic relationship did it

become possible to admit the painful insight as to how destructive
these experiences had been for her; that they had been a major contri-
bution to her inability to allow herself a constant, affectionate, and at
the same time passionate, love relationship, but must instead, among
others, remain content with the boyfriend mentioned above, a married
man, and to live a very limited sexual life over which she has tight
My thought made it possible for the first time to articulate in
language that which had hitherto remained unrepresented, and to
thereby initiate a process of working through in the transference rela-
tionship. The scope of the present volume limits a more detailed
discussion, though mention must be made of the fact that—as the
concept of embodied memories postulates—Ms M’s traumatic experi-
ences were repeatedly overwritten. Thus, in the fourth year of psycho-
analysis dreams led to a further unexpected discovery: along with her
adolescent experience of abuse Ms M enacted other unconscious
“embodied memories” of a brutal rape of her mother by Russian
soldiers during the Second World War, to which she bore witness as a
three-year-old; furthermore, these were traumatic memories that
unconsciously prompted her during late adolescence to engage in
dangerous sexual adventures that had led to seven abortions within
the space of ten years. The unconscious feelings of guilt that this trig-
gered determined, among others, her depressive state, as later
revealed itself in psychoanalysis.
These “embodied memories” were ultimately closely connected to
the traumatic experience of separation in her mother’s severe post-
partum depression during Ms M’s first year of life, which were, inci-
dentally, also contained in the initial scene. The way in which Ms M
pressed my hand between her own two hands, not only had a sexu-
ally stimulating character, but we also understood it as an attempt to,
quite literally, hold on to me and not let me go. “Will I ever be able to
send her away? She seems so needy . . .”, were my categories of under-
standing that spontaneously formed at the time, and which—in retro-
spect—were already perceived as early separation trauma; but
which—also due to my own above-mentioned defence reactions—
could not be decoded in detail.

Psychoanalytic literature is rich with creative metaphors of the unrep-
resented and the unconscious that open up the understanding and, as
are expressed in enactment, that transform the patient’s split off trau-
matic memory into painful, though healing, processes of remember-
ing. This chapter discusses how concepts of basic research and studies
in the field of so-called “embodied cognitive science” and cognitive
neurosciences offer first explanations for the spontaneous, “theory-
free” appearance of innovative, creative thoughts in analysts. They
constitute the first decisive step for grasping that which has hitherto
been unrepresented in images and language.
With reference to techniques of treatment, it becomes evident that
the consideration of the new memory theories based on biology influ-
ence psychoanalytic attitudes to the extent that they sensitise one to
one’s own, subtle (embodied) bodily responses (cf., also Chapters Four
and Six). In the case of fault-prone attempts to decode unconscious
elements in the enactments of the analysand, for the analyst, the couch
setting has proven a great help, since it eases the processes of identi-
fication with the sensomotoric coordinations of the analysand, as well
as the direction of one’s own antenna to the most subtle embodied
countertransference reactions. In a face-to-face setting, the subtle reso-
nance mirror processes are continually overlayered by current senso-
motoric coordinations, and thus complicate the perception of
dissociated, split psychic realities (cf., also Bender, 2014).
Finally, psychoanalytic research in recent years has also experi-
enced that both exclusive work with transference as well as an exclu-
sive (mostly intellectual) reconstruction of the analysand’s (traumatic)
life history does not lead to a sustained therapeutic change.
Above all, psychoanalyses with severe traumatic patients require
both the reflection of a horizontal as well as a vertical dimension of
psychic processes (cf., Buchholz & Gödde, 2013). On the one hand,
psychic processes invariably play out in the subject’s current interac-
tion situation with his environment (or his persons of reference), and
are thus invariably “horizontal”, “intersubjective”, and determined by
the present, which means in the transference relationship with the
analyst. On the other hand, current experiences are invariably deter-
mined by sensomotoric coordinations, which have formed in the
subject’s idiosyncratic (biographic) past. The distinctive history of the

individual is, thus, “embodied” because the sensomotoric coordina-

tions emerged in the earliest relationship experiences and, as outlined,
continually (causally) determine the later, current, psychic processes
in relationships.
This conceptualisation has far-reaching clinical consequences (cf.,
also Bohleber, 2012, Leuzinger-Bohleber, 2008a, and in press). In psy-
choanalyses with severely traumatised analysands it has proven indis-
pensable for approaching the distinctive life and trauma history, the
“historical reality of the trauma”, even when it is never possible to dis-
cover the historical truth of the trauma in a one-to-one sense. While life
historical events—in the sense of resentment—are time and again
rewritten and adapted to the current present, the “historical truth” nev-
ertheless remains in essence. Thus, the successive analytical process of
understanding in “embodied memories” and their working through in
the analytic relationship, allow especially traumatised patients to bet-
ter psychically integrate the dissociative states, the fragmentations of
the self and the inner objects. Thus, as in the case of Ms M, the analysand
gained a healing access to her own, distinctive trauma and life history.

Figure 5: Illustration of understanding the enactment of embodied memories

of the analysand (Ms M) in the initial interview and in a psychoanalytic
session in the third year of psychoanalysis

“I still don’t know who I really am . . .”

Depression and trauma:
a transgenerational psychoanalytical

Introduction: depression—the most frequent psychic disorder

with the danger of chronification
Mrs M had a depressive break down in her early fifties. She was not
able to work anymore as a social worker with delinquent adolescents.
She was highly suicidal and suffered from severe sleeping and eating
disorders. In the initial interview she told that her boy-friend, married
to another woman, had moved to another town. Another reason for
her breakdown were the daily quarrels between her adolescent
daughter and her grandmother, all living in the same house. She
always told her daughter: Be nice to the old woman and respect her
although she realised that the strange behavior of her mother was
quite pathological. (see Chapters Two and Three)

sychoanalysts all over the world currently have many patients

P like Mrs M in treatment. Severe depression, often in combina-

tion with personality disorders, is one of the most frequent
diagnoses of patients in psychoanalytic long-term-therapies and
psychoanalysis today, and often has, as in the example of Mrs M, an
obviously trans-generational dimension.
According to the WHO, depression will be the second most frequent
illness in Western countries in 2020. Depressive illness is even now the


leading cause of disability in the whole world in terms of the number of

people afflicted: around 300 million individuals are suffering from
severe depression.5 Fifty per cent of the depressed patients (with the
diagnosis of major depression) will develop a chronic state of depres-
sion. Around twenty per cent do not show positive effects from medica-
tion. Around 30% of the patients with medication suffer from a
recurrence of the depression within one year: seventy-five per cent
within five years. Similarly high is the recurrence after any form of
short-term psychotherapy, of both psychodynamic and cognitive behav-
ioural approaches (Hautzinger, 2010).6
How do we explain this increase of depression? This question is a
topic of a fascinating and interesting interdisciplinary discourse. Some
authors see in depression the shadowy backside of modernity, of the
breakdown of continuous family structures, traditional value systems,
the Entwurzelung (uprooting) of the individual as well as the extreme
Beschleunigung (acceleration) of modern times, which influences the
“flexible man” (Sennett, 1998) in a globalised, extremely competitive
world. Alain Ehrenberg (1998), a French sociologist, talks about the
“exhausted self” (Das erschöpfte Selbst). According to his analyses
modern individuals are often suffering from constant demands to
create a very special, unique identity differing from all others and
fulfilling one’s own narcissistic needs as well as those from the social
environment. In contrast to depressed patients in Freud’s times,
contemporary patients do not suffer primarily from feelings of guilt
but from shame for not being able to fulfil their ambitions to become
the unique, brilliant self they think they have to be.
These societal changes can be considered as one cluster of causes
leading into depression—while in another, we find neurobiological
and genetic factors, which have to be taken into account as well.
Contemporary psychoanalysts and psychiatrists agree that only a
multifactor model can do justice to the complex and always very indi-
vidual causes leading into a depression. “There is no unitary concept
of depression . . .” (McQueen, 2009, p. 225).

Psychoanalytic concepts for the genesis and the psychodynamics

of depression
Psychoanalysis postulates that there are many different unconscious
determinants, which finally may lead to a depressive symptomatic. All
our experiences, from the very beginning, are kept in the unconscious

and determine—as secret unknown sources of our psyche—the affects,

cognitions, and behaviour in the present. Particularly traumatic expe-
riences but also “normal” developmental conflicts and fantasies have
left their individual marks and characteristics in the dynamic uncon-
scious of each person. Therefore “normal” and “pathological” psychic
and psychosocial functioning is always the product of one’s own,
specific biography.
To make a long story short, psychoanalysts working with
depressed patients are trying to discover the very individual uncon-
scious roots of his or her depressive functioning: each patient has his
or her complex individual pathways, which are leading into his or her
specific form of depression. Each depression has its very specific
feature and face. Depression is not a closed category, but is considered
as an ongoing process.
Bleichmar (1996, 2010), one of the best known psychoanalytic
researchers on depression has developed a model which recognises
multiple paths through which a person procedes from one circuit
dominated by one factor to another in becoming depressed. Bleichmar
(1996) describes different, not exclusive pathways ending in a depres-
sion (see above). He mentions the influence of traumatic external real-
ities on depression (see also Balint, 1968; Baranger et al., 1988; Bollas,
1989; Brown & Harris, 1978; Winnicott, 1965a,b as one of several possi-
ble pathways. But as I would like to discuss in the following sections
of this chapter, clinical and extra-clinical research in the last decades
have shown that the connection between trauma and depression is
much more dramatic than the classical psychoanalytical literature had
Therefore, I think that the role of trauma causing depression is still
often underestimated in psychoanalytical literature, as some authors
also discussed in recent papers (Blum, 2007; Bohleber, 2005;
Bokanowski, 2005; Bose, 1995; Bremner, 2002; Denis, 1992; Leuzinger-
Bohleber et al., 2013a; Slalew, 2006; Bahrke et al., 2006; Taylor, 2010). I
would like to illustrate this thesis with an unexpected finding of a large
extra-clinical, psychoanalytic study, the DPV Follow-Up Study of
Psychoanalyses and Psychoanalytical Longterm Therapies (see
below). But first just a short summary of the understanding of trauma
in contemporary psychoanalysis and some other disciplines (see also
Chapter Five).

Psychoanalytical trauma research

Understanding trauma and its shorter- and long-term effects is a

central topic for clinical psychoanalysis as well as for the neuro-
sciences.7 The scientific discourses trauma can be traced back to the
mid-nineteenth century (Bohleber, 2000b, 2010a,b; Mertens &
Waldvogel, 2008; Sachsse et al., 1997) where Freud developed his first
theoretical understanding of trauma in 1895 in his “Project for a scien-
tific psychology” (1950a[1895]). In the 1920s he developed the struc-
tural model of psychoanalysis, a “solely psychological” theory.
Nevertheless, as mentioned above, Freud always kept his interest in
the neurological base of psychic functioning, particularly also
concerning the topic of trauma.
After the Second World War the consequences of “man-made-dis-
asters” refocused the professional attention to trauma. On the one
hand, the extremely traumatising experiences of the Holocaust, which
led many survivors to reach out to psychoanalysts for treatment or an
assessment due to reparation claims, compelled a reviewed analysis of
short- and long-term consequences of extreme traumatisation. On the
other, the treatment of the survivor’s children conveyed the insight that
traumatic experiences of this extent also intrude on the life of follow-
ing generations. “Man-made-disasters” have various transgenerational
effects, not only for the families directly involved, but also for society
as a whole, and for the trauma’s representation within the collective
memory and group identity (Bohleber, 2000a, p. 795, 2010a,b).8
Among others, Hans Keilson (1979) characterised Auschwitz as a
place “which our language cannot reach”, where the traumatic expe-
rience destroyed the human shield that is the structure of meaning.
The traumatic experience carves itself into the body and directly
influences the organic base of psychic functions. Psychic space and
the ability to symbolise are destroyed (Bohleber, 2000b, 2010a,b,
Bohleber & Leuzinger-Bohleber, in press; Kogan, 2002; Laub et al.,
Throughout any age traumatisation can lead to severe incursions
of a person’s psychic structures (also see Leuzinger-Bohleber et al.,
2010; Leuzinger-Bohleber, 2010a,c,d, 2013). One of the effects of an
acute severe traumatisation is that the affected person is snatched
from reality by the traumatic experience. Within a dissociated condi-
tion he now experiences the reality surrounding him in a completely

different way, unreal, fey, separated from all the other people, isolated
and lonely. Intuitively he/she realises that this experience depicts an
infraction in his life, which he/she will carry within from now on.
Nothing will be as it was before. Psychoanalysts know by treating
severely traumatised patients that they did not find their way back
into their old lives after such an experience: psychically they are
“never totally present” anymore, they have permanently lost
their foothold, feel disconnected towards others, and never retrieve
being the active centre of their own lives (see also Chapters Two
and Three).
These psychoanalytic insights on psychodynamics and the genesis
of traumatisation are generally based on psychoanalysts’ intense work
with individual patients that come to them because of their psychic or
psychosomatic problems. Most often the insights to unconscious
determinants of psychic grief not only turn out to be “healing”
pertaining to the physical symptoms, but also in a meaning giving
way, in the sense that so far unknown effects of sustained traumatisa-
tion are now recognised as memories or memorials of the personal,
distinctive life story and psychically integrated.
In contrast psychiatric and neuroscientific literature debate trauma
centred on “post traumatic stress disorder”. The DSM-IV definition of
post traumatic stress disorder (PTSD) is regarded as the international
standard, and its definition has become the basis of many interdisci-
plinary studies. One has to keep in mind, though, that this definition
is solely descriptive in nature, and does not give an account of which
psychic and/or neurobiological mechanisms lie at the root of this
psychic traumatisation. In terms of the DSM-IV, post traumatic stress
disorder is “the development of characteristic symptoms after being
exposed to a traumatic event”. This event is defined as: “The person
has experienced, witnessed, or been confronted with an event or events
that involve actual or threatened death or serious injury, or a threat to
the physical integrity of oneself or others” (APA, 1994).
Such an event impacts the subject in the form of an external,
massive stressor, and changes the structural features, which have been
formed in part by genetics, prenatal, and early childhood attachment,
and experiences in the outside reality. This impact is identified as a
threat by the brain and therefore quickly leads to a somatic stress reac-
tion accompanied by severe psychic reactions (cf., Reinhold &
Markowitsch, 2010; Sachsse & Roth, 2008).

Among others, DSM-IV lists the following symptoms for PTSD:

intense fear, helplessness or horror, recurrent and intrusive distressing

recollections of the event, persistent avoidance of stimuli associated
with the trauma, as well as persistent symptoms of increased arousal.
The causes for traumatising situations are e.g. wars, natural disasters,
severe accidents, as well as harm caused by others such as torture or
rape. (APA, 1994, p. 487)

It is important to keep in mind that not all people react to these

extreme experiences in the same way. Based on a string of trials,
Fischer and Riedesser (2006, p. 104) determined that “only” an esti-
mated quarter to one third of all people develop a PTSD after events
or life circumstances considered to be of a semi-severe to high distress
level. Hence, over the past few years, resilience research has been
focusing on the question, which factors let individuals avoid PTSD
and react “astonishingly normal”. Based on meticulous follow-up
studies with violent, severely traumatised children and adolescents
after their stay at a psychiatric ward Hauser and colleagues (2006)
postulated that an understanding of their own part in their severe
developmental crisis, as well as minimally supportive conditions (at
least one trustworthy object relation during early childhood) posi-
tively influenced the children’s resilience. Eglé and colleagues (2000)
summarised various international studies on another area of severe
traumatisation, that of sexual abuse. According to their findings
between nineteen and forty-nine per cent of sexually abused children
do not show psychopathological symptoms at first. Good object rela-
tion experiences, secure boundaries between different generations,
and age appropriate sexual education proved to be important
From a psychoanalytical point of view today in cases of traumatic
experiences, the natural stimulus barrier is interrupted by unforeseen,
extreme experiences, usually linked to a threat to life or mortal fear.
The ego is exposed to an extreme feeling of powerlessness and inabil-
ity to control or manage the situation and is therefore flooded with
panic and extreme physiological reactions. The flooding of the ego
leads to a psychic and physiological state of shock. The traumatic
experience also destroys the empathic shield of the internalised
primary object, the confidence in the constant presence of good
objects, and the expectancy of human empathy. In trauma the inner

good object, the negotiator between self and surroundings becomes

mute (Cohen, 1985; Hoppe, 1962).
In reference to the victim families of the Holocaust, Faimberg
(1987) described how the boundaries between the generations have
been blurred by the traumatisation that has proven impossible to
process. She refers to a “telescoping of the generations”. Cournut
(1988) refers to a “borrowed sense of guilt”, which often uncon-
sciously determines people’s entire sense of life following an
unmourned traumatic loss. Laub and colleagues (1995) talk of a “black
whole”: extreme traumatisation exerts an unrecognised effect in the
form of an all-engulfing energy centre, which not only determines the
psychic experience of the first, but also second and third generation
Holocaust survivors. Abraham and Torok (1978) describe similar
phenomena in connection with the concept of inclusion, or crypt. The
traumatic loss is banished to an inner tomb from which place, instead
of being mourned, it exercises a constant and unrecognised effect.
For understandable reasons it took almost sixty years before
psychoanalysts here in Germany turned their attention to the effects
of severe traumatisation in perpetrators and followers among the
German population. What remained unbroken here is the concern that
through the study of this subject, the unimaginable and historically
unprecedented event of the Shoah might be relativised. In the German
Psychoanalytical Association (DPV) it was, above all, the representa-
tive results of studies in psychoanalyses and the psychoanalytical
long-term therapies that were carried out during the 1990s that ignited
the discussion around this theme. One completely unexpected result
of the study was that sixty-two per cent of the over 400 investigated
patients treated in long-term treatments by DPV analysts during the
1980s had experienced severe traumatisation as infants, mostly in
connection with the Second World War (see Chapter Three and,
among others, Leuzinger-Bohleber, 2003a,b, 2006; Radebold, 2000;
Radebold et al., 2006). Most suffered from chronic depression. Hence,
contemporary discussion increasingly turns on whether some of the
mechanisms in the transgenerational transmission of traumatisation
discovered in victims’ families could also be found among families of
perpetrators. Consequently, through the long-term psychoanalysis of
a daughter of a high-ranking SS officer, the unconscious repetition of
pathological object relations induced by trauma experiences, uncon-
scious identifications in the (corrupted) superego and ego-ideal as

well as non-integrated, over-stimulated (sadistic) instinctual impulses

were indicated (Leuzinger-Bohleber, 1998). Furthermore, the ubiqui-
tous mechanism in the “overcoming” of traumatic experiences, the
conversion of that which has been passively suffered also played a
decisive role in the transgenerational passing on of traumatisation in
the perpetrator or follower families (cf., also Schlesinger-Kipp, 2012).
The long-term influence of traumatisation and depression is
increasingly discussed in expert psychoanalytic literature, also inde-
pendently of patients with traumatisation and in connection with man-
made disasters. For a considerable time it was barely known that
patients who had suffered from severe organic illnesses as children
(such as polio) would often, in certain situations, lapse into dissociative
states, since they would be reminded of earlier traumatisations (cf.,
also, among others, Bohleber & Drews, 2001; Bokanowski, 2005; Hartke,
2005; Leuzinger-Bohleber, 2013). To recognise such states and to allo-
cate them biographically proved indispensable for the therapeutic
process of these patients. For this reason, as argued in several papers,
the approach to such “historical-biographic truths” (that is, the recon-
struction of suffered traumatisation) is no less necessary for the psychic
recovery of these patients as the re-experiencing and working through
of traumatisation in the transference relationship to the analyst (cf., the
case example in last the section of this chapter and, among others,
Bohleber, 2010a; Bohleber & Leuzinger-Bohleber, in press; Gullestad,
2008; Leuzinger-Bohleber, 2013; Leuzinger-Bohleber & Pfeifer, 2002).

Several interdisciplinary research results on trauma and

Several other different studies from affiliated disciplines also discuss
the connection between trauma and depression, and the possibilities
of transgenerative transmission of family burdens (for an overview
see also, among others, Böker & Seifritz, 2012; Schore, 2012). Only a
few select examples are provided in this context.

Early emotional neglect, physical, and sexual abuse: the increased

risks for depression in adulthood
In his overview article, Hill (2009) stresses, for example, that numerous
studies have proved that the probability of falling ill from depression

as an adult increases from an earlier loss of parents or an experience of

earlier emotional neglect (Bifulco et al., 1987; Hill, 2009, pp. 200 ff.;
Hill et al., 2001). Fergusson and Mullen (1999) have also shown, in
their major overview of literature, that victims of sexual abuse in
childhood are far more susceptible to falling ill from depression in
their adult lives. According to Lynne Murray (2009), the most impor-
tant result of the major Cambridge Longitudinal Study is that children
of depressive mothers show a higher risk, beginning with problematic
neurobiological reaction patterns on the HPA axis, through to depres-
sively coloured cognitions about self and other, social problems, and
psychosomatic sicknesses (cf., also Ammaniti et al., 2013, 2014;
Kernberg, 2012; Rutherford & Mayes, 2014; Schechter & Rusconi
Serpa, 2014).
An entire series of clinical and empirical studies on the influence
of maternal depression in the development of babies and infants have
meanwhile been published (for an overview, cf., Ammaniti et al., 2014;
Feldmann, 2012; Rutherford & Mayes, 2014; Negele & Leuzinger-
Bohleber, in press; Schechter & Rusconi Serpa, 2014). As early as 1988,
Pound and colleagues established the frequency of maternal depres-
sion and the degree to which it has grave influence on the develop-
ment of infants. They discuss the implications for institutional and
individual preventive possibilities. The works of Daniel Stern (1995)
were also broadly widely received. By way of video recordings, Stern
showed the specific disorders, mirroring processes, the affect-attune-
ment, and affect-resonance in depressive mothers through early
mother–child interactions, as well as describing the various patterns
in the treatment with the depressive primary object in the baby. These
earliest interaction experiences, which to a large extent determine the
later development of the child’s personality (cf., also Broth et al., 2004),
Murray’s research group (2010) showed that twenty-eight per cent of
the sixty-eight mother-child pairs they examined suffered from post-
natal depression. They discussed gender-specific aspects and their
influence on the interactive style in early parenting. In a summary of
their overview study, Murray and colleagues. (2010, p. 201) state:

Postnatal depression is a common and disabling disorder associated

with a range of adverse infant and child outcomes. These occur prin-
cipally where the maternal depression is chronic or recurrent, and in
the presence of other background risks. Adverse patterns of parenting

associated with postnatal depression are likely to play a major role in

bringing about poor child outcome.

Other authors also emphasise that the decisive issue is whether the
mother’s depression (and father’s) develops into a chronic condition.
Cummings and Davies (1994, p. 73) point out that children of depres-
sive parents develop behavioural problems anywhere from twice to
five times more frequently than do children of “normal” parents. For
this reason they call for, as do many other research groups in this field,
earliest and early prevention in these families (cf., also Eisenbruch,
1989; Emde & Leuzinger-Bohleber, 2014; Foss et al., 1999; Fox &
Gelfand, 1994; Frankel, Lindahl & Harmon, 1992). One interesting
finding was presented by Meadows and colleagues (2007). By way of
a large-scale sample (n=2,120), they were able to show that the depres-
sion of the mother has a significant influence on three-year-old chil-
dren with respect to their anxiety, depression, attention, and
oppositionally-driven disorders. The father’s depression indicated no
significant effect on these developmental disorders. However, if both
parents were depressive, then the negative influence on the develop-
ment of the child would be reinforced.
Thus, today, the understanding of the etiology of severe depres-
sion is based on a multi-factorial explanatory model: genetic, early,
and late environmental factors (especially influential relationship
experiences, but also poverty, precarious family burdens, etc.) are
closely interrelated.

Selected results of epigenetic research on trauma and depression

Of particular relevance for the psychoanalyst, as the first epigenetic
studies seem to show, is that genetic vulnerability only then leads to
a depressive illness in cases in which the individual experienced an
early traumatisation. Thus, Caspi and colleagues. (2003) shows in one
of several highly respected studies that early separation traumas trig-
ger the short 5–HTTLPR, which regulates the relevant neurotransmit-
ters and thus evokes a depressive illness. In cases in which there are
no early separation traumas, individuals inconspicuously develop
with a proven genetic vulnerability, and do not become susceptible to
depressive illnesses. Thanks to new research methods, Steven Suomi
(2010), a student of Harlow, was also able to prove the influence of

early separation trauma at neuro-molecular levels in rhesus monkeys

(see also Jedema et al., 2010). An early separation from the mother
animal triggered depression, aggression, and anxieties, as well as
massively disturbed social behaviour. Without early separation, the
apes developed normally, in spite of the proven genetic vulnerability
(cf., also Medina, 2010). Of interest to psychoanalysts is evidence that
the triggering of 5–HTTLPR Allele could be halted in cases in which
the apes were returned to a caring mother ape after several days: anal-
ogous to the classic hospital studies conducted by René Spitz, the
psychotoxic effects of traumatisation could be alleviated if separation
did persist for too long, and a sensitive replacement object existed.
Robertson and Robertson replicated Spitz’s findings in their impres-
sive studies on the influence of early separation traumas on the
psychic development of small children during the 1970s.
Epigenetic models were also able to provide explanations for the
effects of familiar vulnerability for specific traumas and intergenera-
tional influences. Thus, in the example of the glucocorticoidal
genemethylation it was possible to illustrate how environmental influ-
ences alter the function of genes towards patterns (e.g., methylation,
demethylation) and specificity (e.g., methylation, acetylation), and
thus the individual reactions to the traumatic experiences which
appear later (Meaney & Szyf, 2005). In the process, epigenetic
processes appear to construct a bridge between system and world by
switching genes “on” and “off” through the influence of the promo-
tor (the placing or removing of methyl groups from the basis pairs).
In animal experimentation, diseased methylation patterns show
where the relevant gene is consequently “switched off”—a transfor-
mation that can be traced through to the fourth generation. In the case
of human beings, it could be shown in studies with homolog twins,
namely, identical twins equipped with identical gene material, that the
risk of developing a PTSD is closely connected to a fundamental
genetic vulnerability, and that over thirty per cent of the variance of
PTSD symptoms can be explained by inherited components (cf.,
Skelton et al., 2012, p. 629), which is primarily verifiable in epigenetic
markers of genetic expression patterns. As we understand it, epige-
netic transformations are an altered function induced by an ecological
disturbance, but not the structure of a gene. They are long-lasting and
stable and, in some cases, can also be transferred from one generation
to the next (Meaney & Szyf, 2005).

Considered epigenetically, a traumatic experience such as that

outlined above can effect a change in the methylation pattern where
relevant genes are “switched off” or “switched on”. These reversible
changes in the methylation pattern are transferred to the next genera-
tion. The reversibility of these changes, by contrast, depends on social
and psychological factors. Thus, it is a product of a complex interac-
tion of mind, body and environment, and is not directly “inheritable”.
Consequently, it is reversible, a decisive insight for both psychother-
apy as well as for early prevention (cf., also Emde & Leuzinger-
Bohleber, 2014).
A transgenerational passing on of trauma invariably includes
unconscious, emotional, environmentally-specific, as well as physical-
neurophysiological processes. Only their interplay determines the
extent to which and to what outcome these processes lead—they are
not independent of one another.
The result of clinical and extra-clinical studies of psychoanalysis,
thus correspond in detail to the above-outlined observations of epige-
netic research. In his overview of new studies in this field, Goldberg
(2009, pp. 245 f.) comes to the following conclusion:

These interactions between gene and environment, between behav-

iour and genotype are important in the way they provide explanations
of how the many different features that make-up the “depressive
diathesis” arise. However, they have a much wider significance. They
provide a possible pathway by which changing inter-personal and
cultural factors across the generations can be caused as well as effect
of genotype, and through which changes in human culture might
possibly be operating as an accelerator of evolutionary processes.
In summary, we see that adverse environmental conditions are espe-
cially harmful to some particular genotypes, leaving the remainder of
the population relatively resilient. Research in this area is expanding
very fast—and we may expect many more advances in the years to
come . . ..

Several neuroscientific studies on trauma and stress

Neuroscientist and psychoanalyst Bradley Peterson (2013) from
Columbia University, New York, recently made reference to studies of
three generations of patients (n=131, from the age of six to fifty-
four years) suffering from a major depression. His research group

established that these families showed a statistically significant reduc-

tion of cortical thickness in the right hemisphere. “These findings
suggest that cortical thinning in the right hemisphere produces distur-
bances in arousal, attention, and memory for social stimuli which, in
turn, may increase the risk of development depressive illness”
(Peterson, 2013, p. 1). However, his research group made no statement
with respect to increased traumatisation in these families. Meanwhile,
there are a multiplicity of studies proving the influence of stress, for
example, of post-traumatic stress syndrome on the brain, among
others on depressives (cf., among others, Böker, 2013; Reinhold &
Markowitsch, 2010, pp. 22 ff.). Several other authors drew technical
inferences from this:
OF particular interest was the result, namely, that childhood traumas
(early loss of the parents, experience of violence, sexual abuse, neglect)
clearly profit more from psychotherapy than do patients who do not
suffer from trauma. With these patients, exclusive psychotherapy was
not only more effective than medicinal monotherapy, but the combi-
nation of both methods [psychotherapy/medicinal treatment] only led
to slightly improved results . . .. The increase in knowledge over recent
decades has revealed complex connections between hormones, genes,
and environmental influences in the human psyche, while at the same
time opening the foundations for individualized, therapeutic inter-
vention. (Bosch & Wetter, 2012, p. 376; cf., also Hill, 2009, pp. 202 ff.;
Kendler et al., 2006).

Furthermore, additional neuroscientific findings illustrate the con-

nection of trauma and stress on the one hand, and emotions and mem-
ory on the other. There is interaction between the autonomous nervous
system and the cerebral and extra-cerebral regulation of inner secretion
which, in turn, exert an impact upon specific areas of the brain, such as
the limbic structures (amygdala and hippocampus), the orbito-frontal
cortex and the hypothalamus with the hypothalamic-pituitary-adrenal-
axis (HPA axis). The brain structures mentioned here alone point to a
reference of trauma to memory and emotions (cf., Tutté, 2004).
The twofold categorisation of memory that cognitive scientists
have undertaken remains controversial, and thus the related question
as to the memory of early traumatic experiences. In this connection,
see the following diagram by Milner and colleagues (1998) (Figure 6).
Following this taxonomy, the declarative, explicit memory can
only form itself consciously, but, similarly, can only be retrieved

Figure 6: Taxonomy of memory systems (drawing on Milner et al., 1998)

(Graph: Tamara Fischmann, 2013).

consciously. In contrast to the different forms of procedural, implicit

memory, though consciously formed, is unconsciously retrieved (for
example, one learns to “consciously” steer a car, though the learning
processes are soon generalised so that the processes in driving become
As Fonagy and Target (1997) emphasise, implied memory assumes
a key role in the mediation of post-traumatic symptoms. Relatively
primitive structures of the nervous system, such as the amygdala and
the hippocampus, presumably participate in the mediation of the
memory of these experiences. According to Fonagy, traumatic memo-
ries are de-contextualised via the sensory system in the form of
synaesthetic perceptions, smells, tastes, or visual images, and cannot
be conscious in cases in which they are not provided with new signif-
icance. From a psychoanalytic perspective, initially it may well be
useful that a traumatic experience is not in consciousness. However, it
continues to exert an effect unconsciously, and thus determines
current thought, feelings, and actions undetected.
A further controversy concerns memories of very early, traumatic
experiences. According to Olds and Cooper (1997), the two-year-old
human hippocampus is immature in contrast to the amygdala, which
is completely developed by this time. Hence, very early childhood
anxieties are stored in the “emotional memory” of the “immature”
amygdala-integrated circuits, and are barely accessible to (adult)
conscious verbal-narrative. These theses would appear to contradict
the findings of Rovee-Collier (1997, 1999) and Rovee-Collier and
Cuevas (2009), namely, that infants from twenty-three months on can
already form a declarative-explicit memory. Hence, there was no
developmental phase in which only procedural-implicit memory
emerged. The formation of memory is a very diverse, complex, and
variable process including feelings, motifs (one’s own and foreign),
anxieties, and conflicts, and which takes place very early on in life.
Gaensbauer (2011, 2014) holds a comparable view, showing, by way
of impressive clinical examples, that at the age of two and three years
old children already remember extremely traumatic events that took
place in their first year of life (e.g., the shooting of their father). With
the aid of the concept of “embodied memories” the Freudian thesis
can be supported that early and earliest memories deposit themselves
“in the body” (cf., also, among others, Emde & Leuzinger-Bohleber,
2014; Leuzinger-Bohleber et al., 2013b).

In keeping with our line of this argument it may appear to be

enough that relationship experiences, and especially early traumatic
experiences, remain in memory and thus, as suggested by the theses
of epigenetic research cited in the above, can “trigger” genetic vulner-
ability in depressives.
Furthermore, by way of a summary, the above-mentioned epige-
netic research findings support the psychoanalytic theses from an
interdisciplinary perspective, as early relationship experiences have
an effect on psychic and psychosocial development. It is especially the
earliest traumatic experiences that can determine later thinking, feel-
ing, and action and, ultimately, as is the case with many analysands of
the LAC Study on Depression, can flow into a chronic depression (cf.,
the introduction to this chapter). Moreover, the epigenetic findings are
encouraging in so far as they show that through suitable preventive
measures, individuals who come from genetically disadvantaged
families do not necessarily have to suffer from depression, even if they
do bring with them a genetic disposition. Only early, traumatic rela-
tionship experiences bring the depression to expression.
Moreover, there are encouraging perspectives for psychotherapeu-
tic treatment of depressives. As the final case studies suggest, through
psychoanalytic long-term treatment depression and trauma can also
be made accessible to a therapeutic processing, and can thus not only
alleviate those affected, but also, in the best cases, interrupt the other-
wise unbroken transference of traumatisation to the next generation.
Hence, genetic vulnerability does necessarily entail being fated to live
for the rest of one’s life under depression.

Trauma and depression, an unexpected finding in an extra-

clinical study (the follow-up study of psychoanalyses and
psychoanalytic longterm therapies of the German
Psychoanalytical Association, DPV)
When from 1997 until 2001 we conducted, to my knowledge, the first
representative follow-up study of patients after psychoanalyses and
psychoanalytic long-term therapies in a complete Psychoanalytical
Society, the German Psychoanalytical Association, our focus was set
on the short- and long-term effects of psychoanalytic treatment. It was
our intention to make a contribution to the empirical evaluation of

psychoanalytic long-term therapies in the context of our current

debate with the health insurance companies, which are still quite
generously supporting psychoanalysis in Germany.
It has long been an advantage of careful empirical studies that they
lead to unexpected results, which go beyond the explicit goals of the
study and raise new questions. One such unexpected observation was
the overwhelming extent to which the catastrophe of the Second
World War for the civilised world influenced many life stories of the
examined patients and their families and still, decades after the fall of
the regime of the National Socialists, had contributed to the fact that
they sought psychoanalytic therapy.
Over 200 psychoanalysts and over 400 former patients were
involved in the study (see Figure 7). In a multi-perspective approach
to the long-term effects of therapies, comparisons were made of eval-
uations and assessments of the patients by their psychoanalysts, by
the interviewer of the follow-up study, by psychoanalytic and non-
psychoanalytic experts, and, additionally, “objective data” was cited,
such as possible savings for the health system, etc. In the appraisal of
this compilation, as well as by the analysis of the data, numerous
psychoanalytic and non-psychoanalytic, qualitative and quantitative
measures were used (see Figure 8).

Figure 7: Overview of the design of the follow-up study


Figure 8: Well-being before and after therapy (N=154)

Figure 9: Changes during therapies: patient ratings


More than eighty per cent of the patients had reported that they felt
“bad” before therapy, and “good” after the long-term psychotherapy
(see Figure 8).
Eighty per cent reported positive changes with respect to their
general condition, to their inner growth, and to relationships with
others. Between seventy and eighty per cent emphasised positive
changes with respect to their mastery of life, their self-esteem, as well
as to their mood, their satisfaction with life, and their capacity for
work (see Figure 9).
With respect to the present symptomatic behavior (GSI), the
members of the follow-up sample are still slightly above the results of
the general population, but no longer of clinical relevance, and are
distinctly lower than both out-patients and in-patients. It follows then,
that seventy-six per cent of the former patients (and sixty-four per cent
of the psychoanalysts) are satisfied with the results of their treatment.
We also could show that the insurance companies save consider-
able amounts of money supporting psychoanalytic long-term thera-
pies. The days of sick leave, for example, decrease significantly during
and after therapy (see Figure 11).
As already mentioned, we determined that there was a larger
number of patients in our sample who had experienced a severe
trauma in their early childhood (that was proven in the outside real-
ity of the children). Sixty-three per cent of the interviewed patients

Figure 10: Current strain of patients compared to other samples


Figure 11: Days of sick leave (patient sample compared with general popula-

Figure 12: Traumata


mentioned these traumata spontaneously in the follow-up interviews,

that is, we should probably assume that there is a larger number of
patients with an early trauma in our sample (see Figure 12).
Two independent raters also estimated the category of “z-diagnosis”
of ICD-10 from the interview sample in order to have a general idea
about the mentioned trauma. It was amazing for us that in 10.3% of the
traumatised patients (with a z-diagnosis) evidently based on relative
clear data, sexual abuse had been determined and that 6.3% reported
severe physical abuse. However, more conspicuous for us was the fact
that every fifth person had a traumatic loss of a close member of the
family, and also every fifth person had experienced displacement from
his parental home. The exact analysis of the single cases showed that the trau-
mata of fifty-four per cent of this group of trauma patients with experiences in
connection with the Second World War had to do with flight/expulsion, bomb-
ings, hunger and sickness, missing fathers, and depressive mothers, etc. Many
of these former patients had lost at least one parent in connection with
the war. Surprisingly, many had been given as infants or small children
to relatives or to foster parents for a longer period of time. Statistically
the most common fate seemed to be that of growing up with a
depressed mother (sixty-three per cent). Ten per cent of the mothers of
the trauma patients suffered from a psychotic disorder. Other forms of
trauma were in connection with physical illness and accidents (fourteen
per cent), suicide of a parent (five per cent), as well as alcoholism of
fathers and also partially of the mothers (twelve per cent).
It has to be mentioned that these findings mostly concerned
German, non-Jewish children of war. One of the saddest observations
of the study was that we found very few Jewish–German children of
war in our representative sample. They had either been murdered in
the Shoah or had emigrated with their parents. Only a few of them
returned to the country of the Nazis and had been in treatment with
German psychoanalysts during the 1980s. The traumatisations of the
German children of war had been very different, incomparable to the
Jewish children who had survived, a topic which unfortunately can
not be discussed further here.

“Mother was buried alive . . .”

Mrs N was recommended for psychoanalytic treatment since she
suffered from extreme psychosomatic symptoms—without any

proven organic cause. “My whole body hurts”, said Mrs N in the
follow-up interview. She was also involved in a massive marriage
crisis and had many problems with her emotionally neglected
teenaged son. As with many of the patients examined, the traumatic
war experiences of Mrs N had unconsciously influenced the psycho-
somatic symptoms as well as the severe conflicts in relationships.
She fled as a three-year-old with her mother from Eastern Prussia
and lived for several years in a refugee camp. One of the most crucial
memories in her treatment was that as a five-year-old she saw how her
mother, who was suffering from typhus, was carried away on a
stretcher, probably dead. However, Mrs N assumed that her recurring
nightmares contained the oedipal fantasy, that her mother had been
living and had been buried alive because she could not save her.
Furthermore she was tormented by fantasies about the love affair of
the mother with another refugee. Since her father likewise did not
survive the war—he died in Russia—she was given as an orphan to a
foster family. She remembers the terrible loneliness and helplessness:
she was often physically abused by her foster father and used by her
foster mother as a cheap maid in the household. Thus as a fourteen-
year-old she fled from the foster family and worked in a factory until
she met and married her husband. In an impressive manner Mrs N
tells of her long struggle to be a “good mother” to both her children.
She discovered in her psychoanalysis that her serious illnesses had
also been influenced, among others, by her unconscious conviction,
that her children would “die on her”—as had her mother before.
Because of her frequent hospital stays and health treatments, her chil-
dren had to put up with many early separations, probably one of the
reasons for the emotional neglect of her son.
In our talks she said that, for her, the most important result of her
psychoanalysis was that she could alleviate the transmission of her
traumatic experiences to her children—”just in the last moment for
my son, who could make up for much in his puberty and has now
stabilised himself.”

Missing fathers and depressed mothers—a common fate of Kriegskinder

(children of war)
Almost the same words were expressed by Mrs U. She sees as the most
important result of her therapy that she could release her children

from her malign stranglehold and thus stop the transmission of her
own misery. Her father likewise had died in Russia. Her mother
reacted to the loss of her idealised young husband with severe depres-
sion and threatened throughout the childhood of her only daughter to
commit suicide. When she was thirty-years-old Mrs U suddenly devel-
oped heart- and hyperventilation attacks. After many fruitless medical
examinations, a physician finally asked her what had happened on the
day of her first heart attack. She had visited her mother, who at her
departure hatefully called to her, “If you are the way you are, you
should just die”.
The chronically traumatic relationship to the depressed mother
was re-enacted in the therapy and its effects could be understood.
Thereafter the psychosomatic symptoms disappeared. The therapy
also led to an easing of the malignly close and controlling relationship
with her own daughter.
The results of these extra-clinical, systematic-empirical studies
have made evident, how many long-term therapies were of trauma-
tised children of the Second World War. This inflamed an intensive
discussion in the DPV: why had the theme of “trauma of children-of-
the-war” not been part of the scientific debate until these findings of
the DPV study had been discussed? This is suprising because psycho-
analysts are experts who have to do with the consequences of early
traumata on lifelong psychic and psychosocial conditions all the time.
While it was imperative that the debates on Holocaust survivors and
their children within Germany occupied the focus of the debates on
psychiatry and psychoanalysis for many years, it is still nevertheless
surprising that psychoanalysts did not discuss their clinical observa-
tions on traumatised “war children” for such a long time. Perhaps
many of them were concerned that talking about the traumatisation of
perpetrators’ children could be used for harmonising, or even for a
renewed denial of the Shoah. Another reason for the silence was,
as Schlesinger-Kipp (2012) discovered in her empirical study follow-
ing the DPV Follow-Up Study, that many of the treating psycho-
analysts in the 1980s had themselves been traumatised “children-
of-the war”.
These debates are still going on. I do not have the time here to
summarise some of the arguments discussed in this context (see
Leuzinger-Bohleber, 2003a,b, 2006). Instead the following case
example of Mrs M may illustrate the topic and particularly the

clinical findings of the transgenerational transmission of trauma in

German families with “children-of-the-war” (see also Chapter 2).

Recovering one’s own life-story—a recapitulatory narrative of a

The successive understanding of my countertransference reactions, as
well as the unconscious “embodied memories” of Mrs M, as described
in Chapter Two, finally enabled her to overcome the fragmented life-
history and to re-gain her “very own, idiosyncratic trauma and life
history”. As we will discuss in the following section, re-gaining one’s
own life history has proven to be essential particularly for severely
traumatised patients such as Mrs M.
Therefore I will try to formulate a narrative summary of the
complex knowledge of the unconscious meanings of Ms M’s suffering
and its connection with her traumatisations during her childhood and
her adolescence, that, as mentioned above, had become unconscious,
but nevertheless determined the feelings and fantasies as well as the
behaviour of Mrs M in the present. As in the example of the first inter-
view, they all turn on minute observations in the transference.
It became evident during the assessment interviews that Ms M was
a single mother with two daughters, her biological child, Marion, and
a severely handicapped, adopted girl, Anna, both of whom are adoles-
cents. Furthermore, Ms M’s mother, almost eighty years old, who she
also took care of, lived in her home. One of the current points of
conflict involved the daily clashes between Marion, the fourteen-year-
old, and her grandmother, who continued to dictate the kind of
clothes she should wear, when she had to do her homework, the kinds
of friends she should spend time with, and when she should return
home on Saturday. In most cases, Ms M stood helpless between the
two—she attempted to mediate and reproached her daughter, arguing
that she should be “pleasant to the old lady”. And yet, it became clear
as early as the first interview that Ms M was also aware of the possi-
ble importance for Marion’s development (and also for her own) of her
daughter’s rebellion against the domineering, indeed even tyrannical,
and depressive grandmother.
It later became clear during psychoanalysis that the desire to
finally establish stable inner boundaries between herself and her
mother, or between herself and her daughter, was one of the most

important unconscious motives for seeking psychotherapeutic help.

But she only “allowed” herself this help once her ability to function
both at work and in her private life began to break down, and her
employer classified her as “ill”.
Until this time, Ms M had been barely concerned about herself and
her own life history: she suffered from pronounced amnesia with
respect to her first years of life. During the five-year psychoanalysis,
by way of careful work in transference, we managed to decipher the
following, hitherto unconscious structures of meaning in the trau-
matic history of Ms M.
Ms M was born in a German city, in 1942, as a second child. Shortly
after her birth, her mother received an official missing persons’ notifi-
cation stating that her husband had gone missing at the Russian front.
She responded with a psychic collapse, and was no longer able to care
for the infant. She handed over her children to her mother-in-law, a
committed National Socialist who brought up the children according
to rigorous and strict principles, as she later related to Ms M at an
advanced old age. She was still convinced that these erstwhile ideas
of education were correct as were stipulated, for example, in Johanna
Harer’s book Die deutsche Mutter und ihr erstes Kind (The German
Mother and Her First Child). Thus, she consigned her granddaughter to
two nights in the cellar, so that she could no longer hear her crying:
she was then able to enjoy proper sleep! On the whole, little Adelheid
was a conspicuously well-behaved child, who, clean and dry by the
age of two, was obedient and easy to parent, and who could be
returned to her still unstable mother by the end of 1944.
The mother struggled along with the two children while working
as a home worker. She would still talk repeatedly of the hard times
back then, and how she had suffered under her father’s National
Socialist family. However, she admired them at the same time, and
above all, the father’s uncle who was an acknowledged fine artist at
the time and—in National Socialist circles—the family had been
highly respected. She had herself been an orphan. She lost both
parents during the First World War, and in 1917, as a five year-old,
was taken in by her mother’s sister more or less against her will. At
fourteen years of age, she looked for an apprenticeship as soon as she
could, and “muddled through on her own . . .” Adelheid’s father was
her first great love, a teacher whom she had met at the local sports
club. He was conscripted at the beginning of the war. For considerable

time the family assumed that he had fallen until one day in 1953 he
unexpectedly returned as a psychic and physical wreck from Soviet
captivity. As Ms M related shortly before his death aged fifty-two,
although he had sought to re-establish contact with his wife and child,
after two years he was unable to endure living together with the hard
and embittered woman, and left the family “in spite of suffering
severe feelings of guilt”. Though Ms M would seldom see him, she
idealised him all the more. “He was warm-hearted, artistic, talented,
and understanding.” She lovingly cared for him together with his new
girlfriend until his death due to protracted complications following
the severe malnutrition and torture endured in captivity.
Her mother’s bitterness and hardness had intensely preoccupied
Ms M during psychoanalysis. She had protected her from criticism for
a long time; how much she had suffered from her coldness and
dysfunctional sensitivity, and the extent to which her life had been
influenced from the chronic psychic abuse she experienced as self-
object. Her mother’s austere and traumatic childhood during the war
years, including rape by Soviet soldiers in 1945, served her as an
explanation, and seemed to be part of the psychic umbilical cord
which unconsciously connected her to her mother’s tragic destiny. In
the third year of treatment memories began to emerge through
her—how, as a three-year-old, she was forced to watch her mother
being raped by three Soviet soldiers. Her mother confirmed her
memories when asked: “From that time on, I was no longer myself—
I despised myself and my body . . . And neither could I bear any sexu-
ality, which was perhaps one of the reasons for our failed marriage . . .”
In any case, the mother never consented to the divorce. Again, contact
with the family on the father’s side formed the sole point of contact to
the outside world.
Adelheid became the ideal daughter, whereas the older brother
seemed to fall silent; he achieved poorly at school, and emigrated to
Canada at the age of eighteen. Adelheid, by contrast, became her
mother’s “most treasured possession”, and sought to please her by
achieving good grades at school and by her artistic activities. She slept
in her mother’s bed until she was sixteen, spent holidays and her free
time almost exclusively with her, except at the weekends when—as her
mother’s delegate—she would flee to her father and his new girlfriend.
At the age of fifteen, she was raped by her uncle in the same studio in
which she had been given art lessons. She had offered no resistance. As

mentioned, it was only in psychoanalysis that she first became aware

of just how terrible this had been for her. She felt herself to have been
complicit in the act because “at that time I was so in need of love, and
was incapable of setting limits . . .” During this period she developed a
series of psychosomatic symptoms, such as migraines, sleeping disor-
ders, and bulimia but had not received any professional help.
In spite of her symptoms, she completed her pre-university exam-
inations with a good overall grade, and began her studies at a local
institution in order to live at home with her mother.
The student movement allowed for a minimum of (external) sepa-
ration from her mother: she moved into a student’s home, and had
countless affairs with men. By doing so, she frequently placed herself
in dangerous situations. Only when undergoing psychoanalysis did
she understand that in this enactment, she was repeating unconscious
fantasies about her mother’s rape and, without recognising it, “having
to prove to herself” that no better fate awaited her than that which her
mother had experienced. This consequently led to her undergoing
seven abortions within ten years. “I had no problem with this. At the
time, we all thought that our bodies belonged to us—an abortion is
less externally determined than taking the pill . . ..”
As a social worker she chose an extremely demanding profession:
supervising drug addicted youths, delinquent adolescent women,
patients with terminal cancer, and, for the last ten years, she has been
working in a socially deprived urban district.
Among other things, it became evident over the course of treat-
ment that to some degree the escape into a twelve-hour working day,
weekly shifts etc., represents an attempt to live her own life, in her
own apartment and separate from her mother. She fell in love repeat-
edly, but never permitted herself a long-term love-relationship,
however much she yearned to have her own family.
At the age of thirty-five, as a single parent, she adopted a seriously
disabled girl, Anna, who she brought up in an apartment next to her
mother’s house. While she worked, her mother assumed care for
Anna. At the age of thirty-eight, she became pregnant following a
brief affair. Almost as a matter of course she again contemplated abor-
tion. However, when Anna almost died of an asthma attack, and she
was consequently confronted with just how precarious was her
compromise solution with respect to cohabitation with her mother,
she decided to carry the baby. The healthy daughter, Marion—and the

supervision of Anna—became Ms M’s and her mother’s mutual

purpose in life. Together, they purchased a house, and spent the next
fourteen years in relatively stable balance—until Marion’s adolescence
triggered a severe crisis in Ms M.

“I still don’t know whom I really am . . .” Some developmental

psychological remarks on the blurring of generational borders in
traumatised, depressed “children-of-the war”
Based on the insights gained from demanding psychoanalysis with
Ms M, it seemed to us no mere coincidence that Marion’s adolescent
process of identification triggered Ms M’s psychic collapse. The
emerging adolescent separation of Marion put into question the previ-
ous, complex compromise solution in the cohabitation of the three
generations in Ms M’s home. Unconsciously, Ms M had left her daugh-
ter Marion to her mother as self-object, so as to, at least to some extent,
live out her own (professional) life. Through her healthy daughter, she
sought to compensate for the many traumas her mother had suffered:
she should bring “sun into her gloomy life” to once again establish
meaning for her existence—”to fill her depressive holes . . .” (all were
unconscious tasks she had sought to fulfil during her own childhood).
In view of the endless suffering, her mother’s bitterness, and the
rigidly repelled chronic depression (“hardness”, “coldness”, “egocen-
tricity”, moral rigidity, extreme social isolation etc.), it seemed to her
that any form of open self-assertion and aggressive confrontation with
the mother was impossible and forbidden. Though not permitted to
define herself as independent of her mother, she experienced herself
as an “extension” of the mother, her self-object—bound to her by an
umbilical cord in life and in death.
When Marion—the granddaughter—who had also been a model
carefree young child and primary school pupil (who had, incidentally,
never protested against the stress and the excessive demands caused
by cohabitation with her severely disabled sister) became “recalci-
trant” during her adolescent developmental phase and who, in every-
day life, withdrew from her grandmother’s self-evident control, the
arduously attained, precarious family balance finally collapsed. It
became clear that Ms M had not developed a stable core identity of
her own: “. . . in fact, I still have no idea about who I really am . . . an adult
woman, mother—or still a part of my mother . . . even today, I still

cannot bear contradicting her, disappointing or to hurting her . . .” she

said after six months of psychoanalysis. However, her dreams about
how she allowed her mother to die under horrific circumstances
revealed the degree to which she was unconsciously absorbed with
death wishes towards her mother.
Unconsciously, for Ms M, separation from her mother meant
murdering her or—conversely—as threatened by Ms M’s psychic
collapse, the resort to attempted suicide.
Thus, Ms M’s severe disorders of the self and self-identity mani-
fested themselves in the above mentioned life crisis, her severe
depression, as well as her pronounced weakness in the sphere of
narcissistic self-regulation. The psychoanalysis eventually disclosed
the early and earliest roots of this pathological merging with the trau-
matised, motherly primary object who was herself severely depressed.
Only in the transference to the analyst did Ms M attempt a
cautious approximation to the “embodied memories”, central parts of
her unconscious life history. Embodied memories often were
connected to the realm of negative emotions, discovering her own
rage, anger, and hate, and for a long time required the repeated,
concrete experience that the analyst survived her attacks and “perni-
cious thoughts”. It was impressive to observe how this process led to
a strengthening of the narcissistic self regulation—and, finally, to a
stabilisation of the inner boundaries between self and object, fantasy
and reality, psychic processes and external realities. This inner devel-
opment constituted the precondition for her to provide increasing
support to Marion while seeking her adolescent self and identity: the
umbilical cord between the generations was finally severed!
The analytic process often recalled “a painful post-development”
in a professionally understood and emotionally sensitive analytic rela-
tionship. Here, the insights proved decisive for the “historical” truths
summarised in the above, since many of the difficulties emerging in
the here and now could only be understood on the basis of recon-
structing biographic peculiarities, and worked through in the thera-
peutic relationship.
I hope that the short summary of Ms M’s life story at least gave
some insight into the successive processes of the understanding, the
meaning of the complex transgenerative connection between trauma
and depression. Among other things, conditioned by the mother’s
severe depression, neither the phase of individuation and separation

during the second year nor the oedipal phase could be more or less
adequately passed through, to say nothing of the adolescent process
of seeking self and identity. Thus, during adolescence grave psycho-
somatic symptoms began to form, an indicator, at the very least, for
the partially failed adolescent development. Having said that, what
particularly impressed the analyst in this connection was the creativ-
ity with which Ms M—in spite of all suffered and chronified trau-
mas—would repeatedly discover possibilities for compromise and, to
some extent at least, for further psychic and psychosocial develop-
ment. After all, she had, indeed, successfully completed a course of
training, had pursued her profession over decades, and gone through
pregnancy and birth without massive psychosomatic complaints, as
well as, and unlike her mother, breastfed her daughter—something
about which she was very proud! We can only surmise the psychic
sources of this vitality and creativity even in this long psychoanalysis.
We may assume that this family, which had been subject to depres-
sion over four generations, had a genetic vulnerability. However, it
was still possible, following a long and intense course of psycho-
analysis, for Ms M to be able to step out of the “shadows of Saturn”
and discover “sense and sensibility”, a new quality of life. For the first
time, she was able to experience a sexually satisfying and gentle rela-
tionship to a man with whom she allows herself “many beautiful and
exciting things” (Ms M) because she was able to differentiate her own
sexual needs and desires from embodied memories of the brutal rape
of her mother’s and her own sexual traumatisations. Like many
former patients in the DPV study, during a follow-up interview Ms M
had also expressed that, among the most important results of psycho-
analysis, she was able to sever the “depressive umbilical cord”
between herself and her severely traumatised mother but also, above
all, between herself and her daughter, and was consequently able to
allow Marion to live her own life (see Trimborn, 2001).

In this chapter I tried to illustrate my thesis that we are finding the
long shadows of trauma in most of the biographies of severely
depressed patients. Unexpectedly, we came upon this finding in the
clinical, psychoanalytic research of the DPV Follow-Up Study as well

as in the current LAC Study of Depression (see the introduction to this

chapter). Trauma and depression also have an existential transgener-
ational dimension.
Although of course more clinical and extra-clinical research is
needed, taking into account the fascinating results of epigenetics
mentioned above, some preliminary conclusions already seem plausi-
ble: we have learned from our prevention studies that we need to
focus on the transgenerational dimensions of aggressive, antisocial,
and depressive behaviour of our children at risk. Often the children
enact the trauma of their parents (see for example Mrs M). Thus, real
prevention will only be effective if we succeed in also reaching the
traumatised parents. Even if this task makes unattainable demands on
us, we are not allowed to deny it.
In our ongoing LAC depression study the practicing psychoana-
lysts became aware of the fact that growing up with a severely
depressed mother or father might be a traumatising factor for a child
as well as the relevance of embodied memories of these traumatising
interactions for their psychic functioning. As Mrs N and many former
patients of the DPV study expressed it:

For me the most important result of my treatment was that I was able
to understand and with this to finally disrupt the transmission of my
traumatic experiences to my children . . . this also allowed my son to
develop maturely during puberty and thus stabilise himself just in
time . . ..

According to the findings in epigenetics, we might postulate that

psychotherapy of traumatised parents also may influence the pheno-
type of genetic vulnerability in depressed families and thus
strengthen the resiliency of their children.
What a hopeful investment in the psychic health of the next gener-
ation! Reflecting on the “long shadows of man-made-disasters”, treat-
ing chronically depressed, traumatised patients may thus not only be
essential for these patients and their children but also have a broader
societal and political dimension.

Inspiration of the clinical

psychoanalytical practice by the
dialogue with the neurosciences
and embodied cognitive science:
some examples

Facing the pain in psychoanalyses with severely traumatised

chronically depressed analysands—new ways in
conceptualisation and treatment*
ight after night Mr P wakes up bathed in sweat and in shock

N from a nightmare following a mere few hours of sleep: for

the last twenty-five years he has been suffering from severe
depressions accompanied by extreme sleeping disorders, unbearable,
chronic widespread pain, suicidal thoughts, panic attacks, and a series
of psychosomatic symptoms, among others, acute neurodermatitis.
Mr P is one among many suffering from severe depression. As
already mentioned in Chapter Three: according to the World Health
Organization (WHO), today over 300 million people suffer from major
depression, which, according to the organisation’s prognosis, is
destined to become the second most frequent illness worldwide by
2020. This enormous increase in severely depressive sicknesses is the
object of interesting historical, sociological, and economic analyses,

*Translation: Justin Morris. This chapter is a modification of the paper published in the
International Journal of Psychoanalysis, 2015.


which I am unfortunately unable to address in present context (cf.,

Chapter Three; Bahrke, 2010; Ehrenberg, 1998; Gammelgaard, 2010;
Haubl, 2013; Illouz, 2006; Sennett, 1998). In keeping with psychoana-
lytic concept research, I will instead be focusing on clinical and extra-
clinical results relating to the intimate and frequently unrecognised
link between trauma and depression. Mr P’s nightmares also point to
this connection. Thus, for instance, following six months of psycho-
analysis, he reports the following dream:

I catch sight of a man lying at the side of the road severely wounded—
his intestines are spewing out, and everything is saturated in blood . . .
A helicopter appears. It is unclear as to whether the man is still being
shot at, or whether one should go to his aid. Someone appears claiming
that the man now has passed away. I notice that the man is still alive
and he really does open his eyes and enquires; why is nobody helping
me? The woman hands him a lid of a saucepan, which he should hold
over his open wound . . . I then wake up riveted by panic . . ..
(Leuzinger-Bohleber, 2012, pp. 66–67)

In the manifest dream,9 a traumatic situation is represented: the

dream self is in a life-threatening, absolutely helpless situation, and
overwhelmed by the fear of death and panic.10 It can do nothing
against the existential threat and danger. Neither is there any empa-
thetic, helpful object available to it: the sense of basic trust in an
autonomous self and a “good enough” object collapses.
In my view, psychoanalysis is the only contemporary method of
treatment offering patients such as Mr P the possibility to cope with
the traumatisation he suffered together with the unbearable, and thus
dissociated, psychic pain associated with this within the protected
space of the analytic relationship, and to finally find a way out from
the pathological psychic retreat. The treatment of this group of chron-
ically depressive persons, however, requires modifications to the
treatment technique, which I would like to discuss in a later part of
this chapter. In the course of this, the results, among others, of two
extensive, extra-clinical studies as well as some knowledge culled
from affiliated disciplines for the close connection of trauma and
depression are accounted for—a connection which, to this day, is often
given peripheral treatment in psychoanalytic literature on depression,
which will now be briefly discussed here (see also Chapter Three).

Psychoanalytical conceptual research on depression

Current research in depression postulates a multi-factorial model of

explanation: genetic vulnerability, experiences of early relationships,
environmental conditions, traumatisation, and acute individual, insti-
tutional, and social stress situations combine to produce severe
depressive conditions (cf., among others, Holmes, 2013; Schulte-
Körner & Allgaier, 2008). To this multifactorial explanatory attempt,
psychoanalysis contributes specific knowledge on the unconscious,
individual roots of depressive conditions. In every analysand we find
complex, idiosyncratic, unconscious determinants which, in a specific
form of depression, flow into a specific life situation: every depression
shows its, distinctive, individual face. “There is no unitary concept of
depression . . .” (McQueen, 2009, p. 225). Depression is no closed,
clearly circumscribed, and static category, but an entirely unique, indi-
vidual process. Thus, in psychoanalytical literature, we discover a
wealth of conceptual works on the emergence and treatment of
For the sake of brevity, I refer here to Hugo Bleichmar’s tables for a
short overview of contemporary psychoanalytic explanatory models of
depression in various psychoanalytic schools (2013). In these, he sum-
marises a model which sketches the multiple, though not exclusive,
paths of genesis which can lead to a chronic depression (see Figure 13).
For Bleichmar (1996, pp. 77 ff.), Freud’s work “Mourning and
melancholia” still represents one of the fundamental texts for a
psychoanalytic understanding of depression. Freud characterised
depression as a reaction to a real or imagined loss of an object. Hence, he
defined depression as a reaction which is not only connected to a
“real” loss of an object, to an idea, a self-image etc., but one which also
depends on the way in which the loss is linked to unconscious
fantasies and thoughts. In Inhibitions, Symptoms and Anxiety, Freud
(1926d) emphasises the insatiable yearning of depressive persons
following the loss of an object: the satisfaction of drives, the desire for
commitment, narcissistic needs, as well as the yearning for well-being,
can no longer be fulfilled by way of a real or fantasised object. Thus,
a central feeling of helplessness and hopelessness dominates in depression.
The self experiences itself as powerless and impotent. Those emotions
directed at the desired object are deactivated: apathy, inhibition, and
passivity belong to the results (cf., e.g., Bibring, 1953; Bohleber, 2005,

Figure 13: Overview of contemporary psychoanalytic explanatory models of

depression in various psychoanalytic schools (Bleichmar, 2013)

2010a,b; Haynal, 1977, 1993; Joffe & Sandler, 1965; Jacobson, 1971;
Klein, 1935, 1940; Kohut, 1971; Leuzinger-Bohleber et al., 2010a;
Mentzos, 1995; Steiner, 2005; Stone, 1986; Taylor, 2010). Rado (1928,
1951) noted severe rage and aggression as an attempt to retrieve the lost
object. He described, furthermore, that severe self-accusation has the
function of attenuating feelings of guilt, and of regaining the love of the
superego through self-punishment (cf., also Abraham, 1911, 1924;
Blatt, 2004; Bohleber, 2010a; Campos et al., 2011; Freud, 1917e;
Jacobson, 1971; Kernberg, 2006; Klein 1935, 1940; Kohut, 1971, 1977;
Rado, 1928, 1951; Steiner, 2005; Steiner & Schafer, 2011; Taylor, 2010).11
Similarly, Bleichmar (1996, pp. 942 ff.) emphasises the connection
between aggression, guilt feelings, and depression, and, in so doing,
distinguishes between different forms of psychodynamic processes,
which, at high intensity of pain and when enduring for extended peri-
ods of time, can lead to an extreme defence of psychic life in general,
to an inner state of “non-existence” (cf., Bowlby, 1980; Kennel, 2013;
Ogden, 1982; Spitz, 1946; Steiner & Schafer, 2011, Weiss, 2012) (cf.,
paths in Figure 13).
By contrast, Kohut (1971) and others explain that, frequently, it is
not guilt feelings that comprise the central motifs underlying a
depression, but shame and narcissistic suffering. He refers to “tragic

disturbed self-regulation as determined by an immature ego-self,

ideal-object, and superego, as the decisive components involved in the
emergence of depression. Various pathological developments lead to
different forms of depression (e.g., to mania, to anaclitic depression,
or to guilt depression) (cf., dynamic above right in Figure 13).
A further consequence of extreme feelings of helplessness and
powerlessness are phobias and anxieties: the representations of the self
as weak and impotent lead to a psychic state in which everything is
perceived as dangerous and can overcome the weak ego. In this
connection Melanie Klein (1935, 1940) underlined that the fear of perse-
cution vitiates psychic functioning, the development of the ego, the
object relations and, finally, reality-testing, which leads to depression
(dynamic above right in Figure 13). John Steiner (2005) describes the
“psychic retreat” as a chronic psychic state of the depressed with a
pathological organisation of the inner objects and the self. The projec-
tion of the needy and aggressive parts of the self lead to its impover-
ishment and to a secondary dependence on the real objects.
The identification with a depressive parent may also underlay a
depression (cf., Anna Freud, 1965; Hellman, 1978; Markson, 1993;
Morrison, 1983). In addition, all conditions that lead to deficits in the
ego (inner conflicts, traumatic realities, deficits in the parent’s egos,
deficient ability to mentalize, etc.) complicate the possibilities of enter-
ing satisfying object-relations etc., and thus increase the probability of
suffering from a depression (cf., e.g., Fonagy, 2010a; McGinley &
Varchevker, 2010) (path to the bottom right of Figure 13).
Hence, there are several ways that could lead to the central depres-
sive sense of hopelessness and powerlessness: neither of the paths has
shown itself as an obligatory condition. Each is determined by various
factors or areas of the respective pathology.
Bleichmar (1996) also mentions the influence of traumatic, external
realities in the genesis of depression (cf., also Balint, 1968; Baranger
et al., 1988; Brown & Harris, 1978; Winnicott, 1965a,b). However, as
discussed below, the link between trauma and depression appears far
more dramatic and causal than has been represented, to date, in
psychoanalytic literature on depression: although single authors have
made mention of this in recent literature, the central role which trau-
matisation plays in the genesis of severe depressions, in my view,
continues to be underestimated (Blum, 2007; Bohleber, 2005, 2012;
Bokanowski, 2005; Bose, 1995; Bremner, 2002; Denis, 1992; Hovens

et al., 2010; Leuzinger-Bohleber et al., 2013a; Lubbe, 2011; Skalew,

2006; Taylor, 2010; Varvin, 2003).

Extra-clinical research results on trauma and depression: the LAC

Depression Study
Entirely unexpectedly, we stumbled across this connection in two
extensive psychoanalytic psychotherapeutic studies, the DPV Follow-
Up Study (see Chapter Three) and the LAC Depression Study (see
Figure 14), a comparative therapy studies on the results of psychoan-
alytic, as compared to cognitive-behavioural, long-term therapies.
This is a large-scale multi-centric study12 in which we have included
over 400 chronically depressive patients. Both in extra-clinical as well
as the clinical-psychoanalytical parts of the study, we stumbled across
the unexpected result, how many of the chronic depressed patients
are severely traumatised.

Figure 14: Overview of the recruiting of chronically depressive patients in the

LAC Study of Depression

The results of this extra-clinical study of our patient group

(seventy-six per cent of severely traumatised patients in our sample in
the CTQ, see Table 1) were confirmed by the clinical psychoanalytical
research. Similarly, in a survey of analysts from over 100 on-going
psychoanalytical long-term therapies forming part of the LAC studies
in Frankfurt, we determined that eighty-four per cent of patients had
been severely traumatised in their life histories. As will be discussed
below, one’s own severe depression also always has to be understood
in a trans-generational context.14 What was impressive was the fact
that, for example, the first visible change in psychoanalysis of the
above-mentioned Mr P involved his four-and-a-half year old son, who
finally learned to do without wearing a nappy, to go to the toilet
himself, and to overcome his selective mutism in the kindergarten.

Selected findings from neuro-biological, epigenetic studies, and from basic

And yet not only psychotherapy studies, but also studies from vari-
ous neighbouring disciplines discuss the connection between trauma
and depression (overview, among others, in Böker & Seifritz, 2012;
Holmes, 2013; Schore 2012).15 In Chapter Three we have summarised
some of the most important findings.
We also have mentioned the epigenetic findings concerning the
transgenerational transmission of depression and trauma, wich are
most relevant for psychoanalysts. Holmes (2013), after discussing the
major findings of epigenetic research concerning mood disorders,
summarises: “. . . the Ed (the developmental environment), through
epigenetic mechanisms, inscribes itself in an individual’s biology,
which is then transmitted to future generations” (p. 76).

Table 1: CTQ (Trauma Questionnaire)13

Scales Clinically significant traumatisation
LAC, N=367

Emotional abuse 222 (60.5%)

Physical abuse 97 (26.4%)
Sexual abuse 91 (24.8%)
Emotional abuse 189 (51.5%)
Physical neglect 117 (31.9%)
Trauma overall 278 (75.7%)

Ultimately, interesting insights may also be gleaned from basic

research on the unconscious continued effect of traumatisation
through so-called “embodied memories” discussed in Chapter Two.
In structural analogies of current conflict situations (for example,
following the separation from an object of love), through the senso-
motoric coordination in the here and now, a current interactive situa-
tion of analogous emotional, cognitive, and psychophysiological
reactions are evoked that are akin to the original traumatic experience.
As discussed in various papers, the concept of “embodiment” proves
itself as exceptionally helpful in recognising traces of traumatisation
suffered by the patient’s body in the transference situation, and to use
it as the key for her psychoanalytical understanding (cf., Chapter Two;
Leuzinger-Bohleber & Pfeifer, 2002, 2011).16 The few examples taken
from studies of affiliated disciplines must suffice here for highlighting
the influence of earlier traumas in the genesis of severely depressive
sicknesses, and to also take account of their trans-generational trans-
mission, as well as “embodied memories” to the unprocessed extreme
experience of childhood in new conceptualisations.

Clinical research on chronic depression and the necessity of a

modified technique of treatment
This knowledge corresponds to the results of clinical-psychoanalytical
research. The final part of my paper covers several preliminary obser-
vations taken from the LAC study on depression, which offer a valu-
able possibility of combining extra-clinical with clinical research. All
treatments of chronically depressive patients are carefully docu-
mented and discussed in weekly case conferences with experienced
psychoanalytical colleagues. At the outset of the study all clinicians
were schooled by David Taylor (2010)17 himself, or else with the help
of his “manual” (a psychoanalytical textbook) for the treatment of
depressive patients. Thus, this manual forms the point of departure
for further conceptual research on chronic depression.18 We have
meanwhile published several comprehensive presentations of cases
on psychoanalyses with chronically depressive patients and the first
conceptual papers (among others in Leuzinger-Bohleber et al., 2010d;
2013a). Others are currently in preparation. These works, as well as
the clinical conferences and workshops that have been taking place
over the last five years (among others, with David Taylor and Hugo

Bleichmar) comprise the basis for the following initial hypotheses,

which we have yet to carefully examine clinically-psychoanalytically.
The confines of the present paper prohibit more detailed elaboration,
though I shall provide a very truncated example here in an attempt to
illustrate the following six theses:
i) Severe traumatisation may lead to chronic depressions if it fails
to be recognised and treated. Since the concept of the trauma is
presently being broadened, and thus loses its specific explanatory
power, in the LAC study, drawing on Cooper (1986) and Bohleber
(2012) we use the concept of trauma in the narrow sense; here, it
represents an overwhelming experience, which places the ego in
a situation of extreme helplessness and powerlessness connected
with a fear of death and panic. This leads to a breakdown of the
basic sense of trust in an active, autonomous self and a helping
“good” object connected with enduring psychic damaging. Here,
both economic aspects of a subject experience of a “too much” are
accounted for as well as object-relations perspectives in the sense
of an enduring loss of a connection of the self to a “good enough”
inner object. Bose (1995) defines trauma very similarly: “Trauma,
then, can also be defined as the frightening experience of the
destruction of all self-nurturing, functional resources supplied by
self or others and the environment” (p. 1).
ii) Various forms of traumatisation must be clearly distinguished
from one another and accounted for in diverse treatment tech-
niques. In the LAC study on depression we discovered the
following traumatisation:
n Early separation trauma
n Early loss of primary objects
n Sexual and physical experience (“attachment trauma” accord-
ing to Fonagy, 2007)
n Growing up with psychically ill parents (depression, addic-
tion, psychosis)
n Severe physical trauma (e.g., polio, sickness, severe accident)
n Experiences in connection with man-made disasters (2nd/3rd
generation of survivors of the Shoah, German war children)
iii) A careful approach to the “historical reality” of the trauma proves
itself indispensable for understanding the specifics of traumatic
experiences. The type and duration of the traumatisation (cf., ii),

the age in which they took place, the individual, familiar, and
social conditions, must be recognised in a differentiated manner
in order to decode current thinking, action, and feeling.
Naturally, the historical reality cannot be reconstructed in the
sense of an “objective”, entirely “reality true” experience. As is
known, memories are continually revised. And yet, the core of
the traumatisation remains preserved in these narrations and
must be understood in order to introduce sustainable processes
of psychic transformation.
”Embodied memories” often prove to be the key in the recon-
struction of the suffered traumatisation. Even dreams often contain
central clues to this connection, whereby, depending on the type
and point in time of these experiences, not all analysands are able
to remember their dreams and make accessible the analytic work.
iv) Analyst and analysand frequently mobilise defence strategies so
as not to have to perceive the difficult to bear traumatic experi-
ences. For an enduring, psychic transformation, the experience of
a holding, containing, emotionally resonant, understanding, and
“indestructible” analytic object (Winnicott) is indispensable,
which enables approaching carefully the terror of the traumatic
experiences on the one hand, as well as the dissociated, patho-
logical inner object world and the extremely stimulated and not
integrated archaic unconscious aggressive-destructive fantasies
and conflicts of the analysands on the other hand.
v) The trauma cannot be undone, but only successively, adequately
understood, and psychically integrated. If the trans-generational
passing on of traumata and depression in psychoanalyses is to be
processed, they can be attenuated or, in the best of cases, even
broken through.
vi) In a number of psychoanalyses, before the inner fantasies and
object world of the patient could be made accessible to the
psychoanalytic understanding, the working through of reacti-
vated traumatisation in the transference seemed indispensable.
Thus, for example, the earlier interpretations of aggressive
destructive impulses and unconscious fantasies of the analysand,
appeared in some patients as a re-traumatisation, since the inter-
preting analyst recalled, undetected, the non-empathetic, help-
less, and now foreign primary object, which proved incapable of
protecting the self against traumatisation.

Modified treatment technique in the case of severely traumatised,

chronically depressive patients: an example

During the first months of Mr P’s treatment, a serious marriage crisis

erupted: his wife fell in love with another man before leaving him and
his four-and-half-year old son. Mr P was in a desolate condition, was
hardly able to sleep, or else, as mentioned, would wake up following
terrible nightmares. In retrospect, soon after commencing the psycho-
analysis, he unconsciously enacted his serious trauma of separation:
the early adolescent detachment from his parents plunged him into a
depressive crisis at the age of fifteen. The first severe depressive
breakdown was triggered by the separation from his first girlfriend at
the age of twenty-two. Additional breakdowns were to follow, and
invariably connected with the separation from love objects. The
depressions, together with the accompanying psychosomatic
symptoms became increasingly severe, and at increasingly shorter
It became evident during treatment that these depressive break-
downs were, among others, determined by a severe separation trauma
at the age of four years that placed him in a life-threatening, trauma-
tised state of helplessness and desperation, connected with fear of
death and of absolute abandonment. At that time, his mother had to
undergo an appendectomy. The parents, both of whom were trauma-
tised children of the Second World War, and who suffered from
migraines and phobias, took the advice of their family physician, and
sent their son for recuperation to a home, which—at the end of the
1950s—was still strongly influenced by National Socialist ideologies
of education. The parents were not allowed to visit their son or to tele-
phone him, “to avoid him suffering from homesickness . . .” The trust-
ing, authority dependent parents were reassured by the information
that their son was well, that he was playing, and was happy. After a
good three weeks had passed, a courageous aunt managed to gain
access to her nephew: in spite of the official ban on visiting, she forced
her way into the home and discovered P in a life-threatening physical
and psychic state, confined with an isolation room. She alarmed P’s
father. Among P’s first memories is how his father led him out of the
home. In a second memory, possibly a screen-memory, he sees how a
girl was forced to eat her own vomit.

According to his parents, following this stay at the home, the boy
changed enormously: a quiet, shy child who was easy to care for.
Clearly, then, a depressive, resigned withdrawal, for him, proved itself
to be the most adequate way to psychically cope with traumatisation.
The disproportionate aggression and anger towards his primary
object stimulated by the trauma was dissociated and inaccessible to
psychic experience and, for a long time, to psychoanalysis as well.
Thus, in the first two years of the treatment Mr P responded to the
treatment mostly in panic or in a severely dissociative state whenever
I attempt to address his aggressive impulses, such as when I indicated
that there may be a connection between the extremely depressive lack
of self-esteem, his panic attacks, and his psychosomatic, chronic wide-
spread pain in the triangle situation with his wife, also probably with
his hard, aggressive impulses towards her and oedipal conflicts. Mr
P’s response was one of visible irritation, and for weeks it was hardly
possible for me to reach him emotionally. At one point I even fear a
discontinuation of the treatment. He finally reported the following

I hang suspended over a deep chasm—am barely able to cling to a

stone. Two women are above me. They see that I am in great distress,
but do not help. They then hit on the stupid idea of throwing a white
chord over the chasm before attempting to make their way, hand over
hand, to the other side. I know that this is not possible, and then really
witness how the two women then plummet to their death. I wake up
in a state of panic . . .

The analysand’s associations revolved around his panic and fear of

death. I myself suspected that he experienced my interpretation of his
aggressive impulses towards women as “stupid”, witless, absurd, and
helpless, or else unhelpful. Like the two women in the manifest
dream, with such interpretations the analysand probably experienced
me as analogous to the traumatising primary object, which—condi-
tioned by a massive empathy disorder for childish needs—took him
to a home and thus subjected him to a life-threatening traumatisation.
The traumatic experiences had highly stimulated his aggressive-
destructive impulses and phantasies, and finally led to a “psychic
Analogous dream motifs would emerge repeatedly (cf., also the
women in dream mentioned in the introduction to this chapter, who,

absurdly, offered the injured one a cooking lid as protection for

his wounds). Thus, in the first two years I repeatedly saw myself as
being confronted with the danger of a re-traumatisation in the analytic
No less conspicuous was the vehemence with which the analysand
resisted any approach to the trauma of separation and the conse-
quences he had suffered from. When, after five months of treatment,
I cautiously indicated a likeness between his unbearable chronic wide-
spread pain and his life-threatening illness in the home, Mr P fiercely
dismissed this with the words:

Now don’t you start with this nonsense. Even previous therapists
would repeatedly try to palm me off the idea that the depression had
something to do with the stay at the home. This is just absurd. Three
weeks stay in this home could not possibly have such severe effects.
There is something wrong with my “nervous system” . . ..

For a long time Mr P maintained that there must be a physical cause for
his symptoms, and subjected himself to several medical examinations.19
In retrospect, a productive analytical work, an understanding of
the unconscious fantasy and object world of the analysand could only
be introduced once it became possible to reactivate and process the
trauma of separation in the transference relationship. Connected with
this was the painful process of recognising the destructive long-term
effects of the trauma of separation and attachment. Only through this
did the trauma become a psychic reality for Mr P.
The following is one example of this.
In the third year of treatment, Mr P reacted intensely to the sepa-
ration from the analyst. During a holiday break, he underwent a
disputed medical operation, without discussing this with me.
Following the operation, he found himself in a terrible state, and he
was unable to work for the following two months due to massive
headaches and chronic widespread pain, threatening circulatory fail-
ure and panic. He also cancelled many psychoanalytic sessions by e-
mail without giving any detail or reason. Finally, I became concerned
due to such long interruptions. I decided to establish contact with him
and thus found out about his serious physical and psychic state.
Through several crisis intervention discussions via telephone, I was
finally able to help him to emerge from the “black hole”. Clearly Mr
P was directly acting out his early experience of separation, but now

in reference to psychoanalysis. I now became the neglecting, and

finally, “saving father” without empathy analogous to his childhood
memory whereby his father took him out of the home. Once I had
directly addressed these parallels, in a subsequent telephone discus-
sion Mr P recounted the following dream:

I am gazing at a group of people all smeared with clay and who are
working together on the outer shell of a house. A cold wind blows—
the work is torturous, arduous, and barely tolerable. And yet, in the
dream I have a certain sense that the men will succeed: at some point
the house will be built and provide them with a warm home. I then
turn to my wife and say: “You see, we can do it—one just has to stay
together . . .”. (Leuzinger-Bohleber, 2012, pp. 70–71)

In the following weeks Mr P himself drew the analogy—after three-

and-a-half years of highly frequent psychoanalysis—between his panic
attacks, the fear of death, and the unbearable “chronic widespread
pain” on the one hand, and his traumatic experiences during the stay
at the home on the other. It became increasingly evident that this really
did have to do with “embodied memories”: in the case of Mr P, situa-
tions of separation, analogous, sensomotoric coordination evoked anal-
ogous symptoms as in the original, traumatic situation in the home
when—locked up and utterly alone in an isolation room—he became
life-threateningly ill. The detailed understanding of these parallels
clearly softened his physical reactions towards separation. However,
the processing of the traumatisation, by contrast, confronted both the
analysand as well as the analyst with the limits of the bearable.
Once again, I am obliged to restrict myself to a few brief observa-
A half a year after the above-mentioned dream, Mr P was very
confident about the imminent summer recess. And yet, he seemed
absolutely desperate in the first session afterwards. “I’m completely at
my wit’s end—my physical symptoms are unbearable. I simply cannot
continue—I no longer wish to live . . .” One evening he forgot to take
his medication, and suffered a breakdown the next day. “I discovered
just how dependent I was on the medication—without it, I simply
cannot live . . .”.20 As an analyst, I likewise felt inundated by a strong
sense of powerlessness and helplessness. I was once again tortured by
extreme doubt as to whether I was able to help P at all.

A: Understandably enough, this relapse was a bitter disappointment for

you. And once again, I was not accessible to you in this terrible situation.
Did you also have torturous thoughts about psychoanalysis, and that I
cannot help you at all?

P: Yes, that’s right . . .

A: Have you lost your inner connection to me?

P: Yes, I felt terribly alone. I was no longer able to imagine you internally:
you were foreign to me and somehow entirely unreal . . .

A: Like Little John, perhaps,21 who was no longer able to remember his
parents at the home and the inner picture of them you lost . . .

Mr P broke down and wept uncontrollably, and for the duration of

the session. I also felt subject to an intense sense of hopelessness and
powerlessness.22 Mr P appeared at the next session in a somewhat
better state:
P: Somehow, it was good to weep, although I still feel desperate. In the
last few days I felt encaged and no longer felt anything—everything felt
dead within me. And at night my body began to go crazy—everything
was terribly painful, and was unable to sleep at all . . .

After a lengthy pause:

A: Perhaps it would be very important here that you could show the full
extent of your desperation and panic. Some time ago, you told me that
you notice that you carry within you a deep sense of inner truth, that
nobody, but nobody, would be in the position to understand when you
felt bad. And after the stay at the home, you clearly had nobody with
whom you were able relate your sense of misery—you simply became
silent—and your body retained the pain you suffered . . .

Mr P wept silently for a long time.

In the subsequent session Mr P continued to appear burdened and
marked by panic.
P: I simply cannot understand it. Last night I must have just briefly
dropped off to sleep. I had two dreams, which in no way corresponded to
my present condition. Initially, I dreamt that a woman fell in love with
me. I was surprised and couldn’t really say whether or not I felt attracted
to her. She then said that this was no big problem and that everything will
be alright . . . I then dropped off to sleep again, and continued to dream:

I was seated in a lecture hall. A very attractive women sat next to me and
began stroking my thigh. I experienced this as entirely pleasant. She then
said that she had fallen in love with me. That I’m so endearing and calm.
I was very attracted to the woman. And yet, in the dream I then felt
compelled to let her know that I am not calm, but depressive and that she
should know this . . .

A: Yes, you often say here that you no longer wish to put on an act . . .
neither in a love relationship nor here, in psychoanalysis . . .

P: Yes, that’s right. Do you really think that the dream could contain a
spark of truth?

Mr P now remained silent and seemed relaxed.

Over the following weeks, Mr P appeared, on occasion, to be visibly
better, though sometimes he also felt very bad. In the session, Mr P
oscillated between hope and profound desperation. And yet, in retro-
spect, this phase of processing turned out to be central for the patient’s
psychic process of psychic transformation.23 The optimistic motif in
the manifest dreams outlined above (successful building of a house,
erotic relationships to women, etc.) appeared to be indicators for the
fact that the analysand—cautious and sceptical—re-discovered once
again a minimal trust to his inner object and could regain a minimal
sense of basic trust in a helping, empathetic counterpart.24
Only after this phase of the psychoanalysis it became possible to
approach directly the pathological inner object world of Mr P, for
example, the unconscious belief due to his unconscious aggressive-
destructive impulses that no one could really understand his desper-
ation and distress or like him, since he has such destructive, vicious,
vile and peculiar fantasies and impulses.25 Again, it was dreams that
opened up access to the world of unconscious fantasies:
I was in kindergarten. There were many children there—a warm, lively
atmosphere. A boy sat on my lap—we were bantering with one another
as men tend to with one another. I gave him a hug. To my surprise, this
was not my son but another boy. My son’s teacher was also present. He
was full of admiration while watching me—I was very happy. However,
all of a sudden I studied the boy more precisely and witnessed how
beetles and a black spider were crawling out of his eyes—it was terrible,
beastly; the boy was completely transformed. He appeared pale and ill
and had deep dark rings under his eyes—I was shocked and woke up,
panic-stricken . . .

His first association was, “the eyes are the window to the soul . . .”
Then his wife’s abrupt mood-swing occurred to him. Recently, after
considerable deliberation, he went in search of a child guidance office
because his wife slept in the same bed with his ten-year old son and
refused to stop this seductive behaviour. The counsellor characterised
her as a borderline personality since, from one minute to the next, she
would be transformed from a charming, beautiful woman into a
screeching, offensive hellcat losing complete control over herself and
her affects. “And, in the dream, a relaxed, happy atmosphere was all
of a sudden transformed into a threatening, odious, and repulsive
situation—the normal, loveable boy mutated into a very ill child.
Might it not be that you are unconsciously concerned that your son
does not become as ill as your wife?” Mr P remained silent before
finally saying, “at the same time, I think that the boy in the dream
could also represent a part of myself . . . Suddenly, I am overcome by
my unbearable chronic widespread pain, and feel myself to be a
miserable, seriously ill and helpless child . . .”
In the following sessions, we cautiously approached the hitherto
terrible inner truth that not only his wife was seriously ill, and often
losing the control over herself and her affects, but that he was himself
susceptible to a threatening, uncanny and dangerous inner world—
which also contained black spiders and loathsome insects within it. It
became increasingly possible to recognise and understand the projec-
tions and projective identifications in his relationship to his wife—and
also to the analyst (see e.g., Britton et al., 1997, Rosenfeld, 1964). We
then returned to the above-mentioned dream about the chasm. Only
now was it possible for Mr P to perceive his own archaic impulses and
death wishes towards “empathy deficient”, “stupid” women (wife,
mother, analyst) and to, at least in part, psychically integrate them.


Based on several results from clinical and extra-clinical psychoanalytic

studies, as well as selected empirical findings from the neurosciences,
embodied cognitive science, and epigenetics, the close connection
between trauma and chronic depression was discussed. As the case-
study illustrates in an exemplary manner, extreme traumatisation
prompts the breakdown of the basic trust of the self in its fundamental

ability to counter threatening dangers, and shakes the basic trust in a

helping “good enough” object (object-relations theory point of view).
A basic, unconscious conviction that “nobody is in a position to under-
stand and endure the self in its distress and doubt . . .” dominates the
psychic findings. In the traumatic situation, the ego is subject to a
situation of the “too much” which it is incapable of mastering, and
becomes flooded by psychic and/or physical pain, by desperation,
powerlessness and the fear of death and placed in a state of complete
helplessness and hopelessness (economic point of view). The sense of
time freezes: present, past, and future telescope. The permanent
anxiety of a renewed, unexpected catastrophe determines the psychic
By definition, trauma cannot be overcome, and becomes psychi-
cally splintered, dissociated from other psychic experiences. However,
as with Mr P, traumatised people live in a continual unconscious state
of alarm, in anticipation of these psychic breakdowns, and that,
through a flood of “embodied memories” or a new catastrophe, they
will once again be placed in a state of total psychic helplessness and
powerlessness. This impedes the processing of the trauma in the
analytic relationship. Analysand and analyst mobilise an unconscious
defence against the reactivation of the trauma in the transference situ-
ation so as to protect themselves against the flood of unbearable feel-
ings. Frequently, it is almost impossible to recognise the defence
strategies in the countertransference without supervision or interven-
tion, and to create an inner space, which admits the perception of the
terror of the trauma into the analytical relationship. This is perhaps
the reason why the close connection of trauma and depression in
analytical literature has tended to be marginalised.
In this context, the structural similarity between the central expe-
rience of powerlessness and helplessness in chronic depression and
trauma can only be hinted at. The extreme weakening of the ego due
to a trauma increases the probability of a psychic development, which,
as is the case with Mr P leads to a chronic depression. As described in
the above, in traumas as well as chronic depressions, extreme experi-
ences of helplessness and powerlessness such as these reside at the
centre of psychic life.
Psychoanalytic work with this group of severely traumatised,
chronically depressive analysands demands a modified treatment
techniques (see also Bleichmar, 2013). Only once it has been possible,

in spite of the above-mentioned lack of a sense of basic trust in a help-

ing object, to create a basic trust to the analyst does the analysand dare
to reactivate the traumatic experience in the analytic relationship, and
to thereby open up the analytic work. Furthermore, also proving
indispensable in the case of analysands such as Mr P was the fact that
the traumatic experience was reactivated in the transference and
approximately processed prior to the unconscious fantasies and
conflicts (e.g., the role of an aggressive impulse and destructive, pre-
oedipal, and oedipal fantasies in the emergence of the depression)
being made accessible in the analytic work. Only recently has it been
shown in clinical observations that an early interpretation of the
aggressive-destructive impulses and fantasies of the analysand is
experienced by the latter as re-traumatisation through an intrusive,
traumatogenic object without empathy, and which repeatedly led to a
threatening cancellation of the treatment, severe, dissociative states
and an extreme simulation of aggressive fantasies of death wishes
towards the analyst.
As could only be outlined in the above, a precise approach to the
“historicity of the trauma” (e.g., the details of the stay at the home, the
illness at that time, the reactions to the trauma, the role of the person-
ality of the—depressive, self-traumatised—war children, parents and
pre-traumatic factors such as the mother’s severe, postpartum depres-
sion, etc.) were essential for precisely decoding the “embodied memo-
ries” of the traumatisation that took place. The process of knowledge
connected with this was the precondition for finally accepting the
trauma as part of one’s own life history, and thus to remain in psychic
dialogue with its effects which could not be eliminated. This process
allowed analysands such as Mr P to retain a sense of the meaningful-
ness of his life: one’s own trauma history became part of an idiosyn-
cratic past, and no longer determined present and future as it had
hitherto done. As for many analysands, the DPV follow-up study and
the LAC study also belong to the most important results of psycho-
analysis; they attenuated the trans-generational passing on of their
traumatisation to children, or, in the best case, could even be
cancelled. Furthermore, in this sense, for them the uttered painful
approach to the intolerability of the suffered traumatisation in the
analytic relationship was worthwhile. It constituted a counterweight
to the inevitable disappointments that the psychoanalysis and not the
fantasised “pre-traumatic paradise” could be returned.

“To myself, my husband, and my children so much pain could

have been spared, if only earlier I had had the courage to take a
close look to my traumatisations”—understanding “embodied
memories” in a third psychoanalysis with a traumatised patient
recovered from a severe poliomyelitis
The highly explosive political “false memory debate” has led to great
scepticism as to whether therapists are able to objectively and reliably
reconstruct biographical events, for instance in cases of sexual abuse
based purely on observations in the therapeutic situation. As we have
discussed in detail in other papers, we share this scepticism (Leuzinger-
Bohleber & Pfeifer, 2002, 2006). However, in this chapter I would like to
discuss whether the baby has been thrown out with the bathwater. To
mention just one example: Fonagy and Target (1997) write provoca-
tively: “. . . whether there is historical truth and historical reality is not
our business as psychoanalysts or psychotherapists” (p. 209).
Several trauma researchers have disagreed with this playing down
of the therapeutic function of the reconstruction of the reality of early
trauma (also see Bohleber, 2000a,b, 2007; 2010a,b, Bohleber &
Leuzinger-Bohleber, in press; Bokanowski, 2005; Fischer & Riedesser,
2006). I agree with their position. According to my clinical experience
and the results of the above mentioned large representative follow up
study on the long term effects of psychoanalyses and psychoanalytic
treatment by the German Psychoanalytical Association, the working
through of traumatisations in the transference as well as the approach
to traumatisations that have taken place in reality, are indispensable
for a lasting effect of the psychoanalytical process (see Chapter Three,
and e.g., Leuzinger-Bohleber et al., 2003b). Many of the interviewed
patients have expressed that the precise understanding of the connec-
tion between their psychosomatic reactions and the former trauma has
been essential for therapeutic change. A detailed biographical recon-
struction of the idiosyncratic traumata also proved indispensible for
accepting the childhood traumata and their lasting consequences as
part of one’s own life and biography. To give just one example, Mrs X
said in the interview:

It was essential for me to find out in psychoanalysis that I am not

crazy despite all my crazy symptoms. Unfortunately, I cannot change

many of them: but at least they now make sense! In my flashbacks and
daily nightmares my soul remembers being buried in our burning
house in X during the bombings of World War Two as a three year old
child, smelling the burnt human bodies and all these other terrible
things . . . These symptoms have become the voices of my very own
history. They belong to me, I have to live with them.

In this chapter I would like to consider another observation related

to this topic: it seemed to me that the thesis just outlined does not
apply only to the group of traumatised patients, whose trauma is
related to “man-made-disasters” (for instance the victims of the
Shoah, see among others Bergmann et al., 1982; Cournut, 1988;
Faimberg, 1987; Keilson, 1979; Kogan, 2007; Krystal, 1968). I will
contend that this topic is also relevant to another group of traumatised
patients, namely patients who suffered from a severe physical disease
in their early years of life, a rarely discussed problem in the more
recent psychoanalytic literature.26 In the context of the aforemen-
tioned follow-up study I interviewed four patients who as children
had suffered from severe polio infections. All four complained that
their experience of suffering from polio had not been processed
adequately during their treatment. A couple of years ago, over twenty
years after two so far successful psychoanalysis, a patient began her
third psychoanalysis with me. It turned out, that her suffering from
polio—as a traumatic experience with unconscious long-term
effects—had remained largely untreated and still continued to consti-
tute a fundamental source for the massive, frightening dissociations
that the patient experienced. This section will focus on the relatively
extensive summary of this treatment as a starting point for discussing
the thesis outlined above. In order to understand the dissociative
states of the patient it proved indispensable to decode the “language
of her body” and to connect it with visualisations, images, and verbal-
isations in the transference. But this did not seem sufficient for a struc-
tural change of her traumatised personality: additionally a precise
biographical reconstruction of the specific trauma was necessary in
order to integrate the infantile traumata into her core self and identity.
This also meant perceiving and accepting the unchangeable vulnera-
bility due to the early traumatisation in order to live with them and
not to deny them any longer, a very painful process as I will attempt
to portray.

In this respect the concept of “embodied memory” proved helpful

in my understanding of precisely how “early trauma is remembered
by the body”. Many authors engaged in the above mentioned discus-
sions claim that observing “procedural memories” in the psychoana-
lytic situation opens a window for “stored knowledge” of experiences
during the first years of life (see also Chapters Two and Three of this
volume). Procedural memories, defined on a descriptive level as a
specific form of long-term memory, cover mechanical and bodily skills
(like eating with a knife and fork). In contrast to “procedural
memory”, the concept of “embodied memories” is much more
specific, and offers a more precise understanding of the so called
sensory-motor coordination of the traumatised patient in the analytic
relationship. This unconsciously—in very specific situations—leads to
the precise reconstruction of the bodily sensations, affects, and
fantasies which match the original traumatic interaction. Their inten-
sity and quality prove to be inappropriate in the present, new rela-
tionship with the analyst. For the patient it is essential to decode in
detail the specific (sensory-motor) stimuli which, because of their
precise analogies, trigger the “embodied memories” of the traumatic
experiences (see later in this chapter). I will try to illustrate that this
means more than just “understanding procedural memories” and
refer to the concept of “embodied memories” which has been
discussed in detail in this volume (see the Introduction and Chapters
Two and Three) as well as in other papers (see e.g., Pfeifer & Scheier,
Although polio has become a very rare disease in Western coun-
tries, it is suggested that the so-called Post Polio Syndrome (PPS) is
related to Chronic Fatigue Syndrome (see e.g., Dalakas, 1995) and can
reappear decades after the acute polio infection. It is much more wide-
spread than assumed so far. Therefore it is possible that even today
analysts have patients in psychoanalytical treatment, who suffer from
Post Polio Syndrome. Furthermore I believe that although the trau-
matisations due to the polio infection are specific, as I will illustrate, we
will find, and should work on, analogous resistance and denial
processes among patients who endured other extremely painful and
life threatening diseases in the first years of their life. On the basis of
a literature survey on “Poliomyelitis” (with the help of PEP) it seeems
to me that long-term effects of somatic diseases during the first years
of life have hardly been considered in conjunction with the state of

the art of contemporary trauma research, as I will discuss in the

following section.

Polio in the psychoanalytical literature

At present, one can assume that due to widespread immunisation
during the past decades the viral disease of poliomyelitis has prati-
cally disappeared in the industrial nations of the world. The last great
epidemic in Germany took place in 1960–61. Afterwards area-wide
immunisation was established. New infections therefore rarely occur
in western countries. Conversely, it should be mentioned, that the
declared goal of the World Health Organization to have poliomyelitis
extinguished by 2002 has not yet been achieved.
Given this historical background, it is understandable that polio
often appeared as a topic especially in psychoanalytic work up until the
1960s. Yet it is surprising that the psychological consequences of this
severe childhood disease have rarely become an explicit focus of ana-
lytical papers. One of the exceptions is the detailed case report of a six-
year old boy and the aftermath of his polio infection by Bierman and
colleagues (1958), which primarily focuses on the boy’s depressive
problems. Oral incorporation fantasies, as well as fear of castration, are
mentioned as possible triggers for the depression, which the disease
additionally stimulated. Limentani (1982) reported an early termina-
tion of the therapy by a patient (Mr C), who suffered from visible con-
sequences of polio. Jealousy is seen as a possible cause of the
termination, but has not been placed in the context of the patient’s phys-
ical handicap. Eisnitz (1974) studied the phenomenon of boredom in his
discussion of Weinberger and Muller (1974). Here he is referring in
detail to a case of polio and points out the presence of a strong fear of
castration and diffuse physical fears as well as questions concerning the
stability of self-representations as a consequence of polio disease on
mental health. Hammermann (1961) analyses the masturbation fan-
tasies of a young man, one of whose legs is shortened due to having suf-
fered from polio at the age of fifteen. The female strivings of the patient
are seen as the effect of a mother fixation. The trauma of suffering from
polio remains largely unrecognised. On the other hand Jacobson (1959),
referring to Freud’s work on “Exceptions” (1916), discusses an interest-
ing, specific processing of the disease in the case of two patients with
polio. Both of Jacobson’s polio patients had developed an “exception-

self-image”, as described by Freud. This, among other things, led to the

fact that neither could accept the reality principle. However, both
patients had transcribed an unconscious “exception fantasy” into their
life arrangements in different ways, according to their most central
object relationships during their suffering.
I could not find any paper that deals with the effects of traumati-
sation on the patients’ subsequent symptom production, and that is
dedicated to the specific technical problems that arise in the interac-
tion with this group of patients. The following will focus on such a
clinical example.

Case study/example. “So much pain could have been spared to

myself, my husband, and my children, if only I had had the courage
to take a close look earlier . . .” (Mrs B)

Motivation for a third analysis

Mrs B, fifty-two years old, has decided to do another sequence of
psychoanalysis, because she still suffers from severe sleeping disor-
ders as well as from apparently psychotic “breakdowns” during
conflicts in the relationship with her husband. These unexplainable
breakdowns are a heavy burden to herself as well as to the relation-
ship. She has already completed two psychoanalyses, with which by
and large she is very content. She initiated the first analysis at the age
of twenty-three after a complete breakdown following the death of her
handicapped brother. It lasted almost three years. “As soon as I felt
better, I jumped up from the couch and tried to do everything by
myself again . . .”. She thought of the second analysis as a continua-
tion of the first, because the depression and the severe symptoms of
exhaustion kept returning and led to serious suicidal attacks. At age
twenty-nine she initiated this second psychoanalysis, which lasted
almost five years. She gives the treatment the credit for her:

having had the courage to settle in a new relationship with (another)

man and becoming pregnant. My daughter’s birth (when she was
thirty-three) was a turning point in my life—I have definitely buried
suicidal tendencies although suicidal thoughts still come to mind once
in a while. Unlike previous times, I am now absolutely sure that I am
in control of these impulses, because I am not going to do something
like this to my children. For this I am grateful to psychoanalysis.

At the age of thirty-eight she has given birth to twins and very much
enjoyed experiencing the growing up of her three children.

I was so incredibly thankful that my children were healthy, which in

contrast to my husband has never been a given for me. I always reck-
oned with catastrophe and always reacted with panic if one of the chil-
dren got sick or had a mild accident . . . Because of my psychoanalysis
I knew that these events reactivated memories of my childhood cata-
strophes—I could not do anything about that! Fortunately, my
husband was a good counterbalance to those fears, otherwise a lot
would have gone wrong . . ..

Mrs B has always been employed. She successfully directed a large

innovative institution for severely handicapped children, has written
several books about her work, and is an internationally known expert
in her field.

I know that to the outside world I represent a model career. I am much

admired, because I am able to combine motherhood, marriage, and a
professional career—but still I cannot get rid of this basic feeling, that
I live on the edge of a great abyss. A catastrophe could occur anytime
. . . often at night I am convinced, that everything is breaking down
around me. I then lie awake, get a panic attack, and hallucinate falling
into a deep, black hole. I have to get up each time, otherwise I can not
endure it . . ..

The greatest burden is the “sudden breakdowns”, which Mrs B expe-

riences in conflict situations with her husband.

They occur completely unexpectedly, mostly at times when I feel very

relaxed. Often I suddenly experience my husband as emotionally
unaccessible and withdrawn, and am then immediately convinced
that he wants to leave me. I panic, I rage, and attack him physically,
just out of control. My entire body is a single wound—everything
hurts—an unendurable state, which I only want to bring to an end.
Mostly I am acutely suicidal in this situation and would like to get the
whole thing over with. In tears and with the feeling of extreme cold-
ness I finally creep away into a dark corner, cowering like an embryo,
usually for hours. The whole thing is a nightmare. When it is over, I
am not at all able to imagine this state. Then I am terribly ashamed. I
am terrified that I can be such a different person. It is like a psychosis

and for my husband and me a horror over and over again, unbearable.
Often I am afraid that because of this the relationship will fall apart
. . . neither analysis could change anything about this.

Remembering the insights of the former two psychoanalyses: an attempt at


In the first months of treatment (four sessions a week, couch setting),

memories of the two psychoanalyses often emerged, with two differ-
ent analysts, one woman and one man, each of a different theoretical
orientation, one with a chiefly modern Anglo-American object-rela-
tional approach, the other one seeing himself mainly as a Neo-Kleinian
analyst. Telling me these memories seems to me like an attempt at inte-
gration. Unconsciously Mrs B seems to want to inform me about the
current state of her unconscious fantasies and conflicts. “It is strange
how much is coming to my mind about these former treatments. For
years I hardly ever thought of them . . .,” she once says.
To mention just one example: in the third month of treatment Mrs
B’s father dies. Mrs B reacts with terrible guilt feelings because she
was abroad when he unexpectedly passed away. In the next months
she seems to be paralysed in the analytic sessions, unable to feel
anything. “I am feeling like a robot—everything has lost its mean-
ing—it is like someone turned off the light.” After some months of not
being able to reach the mainly silent Mrs B emotionally, I am more and
more concerned about the state of her pathological mourning. I finally
dream that my patient is lying in a coffin next to a dead person. It is
not clear if she is still alive. “You seem to be paralysed here on the
couch like a severely ill or even dead person. Could it be that you are
sacrificing your own life because you feel so guilty at having given a
successful speech in Los Angeles while your father was dying?” I ask
my patient in the next session. She now remembers her dreadful feel-
ings of guilt during her first analysis after the suicide of her handi-
capped brother. “For months I was lying on the couch, silently like a
dead person . . ..” She recalls that she found out in her analysis that
the identification with the dead brother also was due to unbearable
feelings of hatred and aggression.
For years the four year older, physically visible handicapped
brother had been jealous of his younger, healthy, and talented sister,
who was also the father’s favourite child. Many memories had

appeared at that time on how her brother had secretly tortured her as
an infant, mostly unrecognised by the parents. Mrs B now recalls that
it was crucial for calming her own depression during her first analy-
sis to work through her own sadistic and aggressive fantasies, which
had been overly stimulated through her brother’s tortures, and had
been banished into the unconcious. She did not allow herself to have
such feelings towards her handicapped brother. Instead the only
option was to flee from the relationship. Mrs B recalls many scenes of
being alone in the woods as a small child, insecure and lonely, occu-
pied with intensive daydreaming.
In the following sessions we are able to understand that the death
of her father had reactivated the traumatic loss of her brother. She now
releases herself from her silence and recalls many insights of both her
former psychoanalyses. I can not report any details here, but give only
a short summary of her “life narrative” due to her psychoanalytic
Because of her high achievements and social behaviour she
excelled in school. She was considered as the “integrative element” in
her class, mediated conflicts, and cared for weak and needy children.
As became clear in her first analysis she had formed an altruistic,
beaming, warm-hearted personality, which was yet imprinted at its
core by profound loneliness, “somehow fundamentally unconnected
with the close supporting figures”. She only felt loved and respected
when she was able to be there for others. These “truths” had especially
become clear in the transference with the first analyst: often she had
the fantasy that the analyst was happy if a session could not take place
and she only received the fees.
Her first loving relationship had also followed the same pattern.
She unconsciously searched for a needy partner, whom she could care
for and nurse. Another central insight of the first analysis evolved
around her narcissistic fantasies of omnipotence, of her being able to
soothe or heal handicaps. The brother’s suicide revealed the omnipo-
tence fantasies, another trigger for the depressive breakdown. The
analytic work also dealt with oedipal fantasies and wishes, such as her
feelings of guilt, that she had preferred the lively father as opposed to
the depressed mother. Three years of analytical work led her out of
her depression: Mrs B was able to take up and successfully complete
her studies. The recurring nightmares of being pursued because of
a crime, which was unknown to her, disappeared, yet the chronic

feelings of exhaustion, as well as the basic feeling of “not really being

anchored in this world”, remained.
Because she could also profit from psychoanalysis in her profes-
sional field, which focused on disability, she decided to continue treat-
ment with another analyst in the city, in which she now lived. As she
recalls, the analyst soon realised that she was not able to lie still on the
couch, but that she constantly had to move. In this context, memories
of her polio infection, shortly after her fourth birthday, appeared for the
first time. During this illness it remained uncertain for weeks whether
she would live or die. Mrs B knew of her infection, but mostly had inte-
grated the feeling of how “lucky” she was that she survived the disease
without any visible consequences and that she, in contrast to her hand-
icapped brother, was a healthy, talented, and handsome child, “every-
body’s sunshine”, as she had often been called within her family. Her
enormous fear of passivity had been connected to the experienced fear
of death and this realisation finally led to coping better with situations
of professional overburdening. The hypothesis about the early interac-
tion with the depressive mother played a great role here. The insuffi-
cient empathy for her own body and its state was attributed to
insufficient introjection of a caring, empathetic maternal primary
object. Because, as it was assumed, the mother did not carry out her
holding and containing functions sufficiently, the archaic, and above all
aggressive impulses could not be integrated “well enough” and thus
led to a severe weakness in the area of stable representations of the self
and of others as well as to her severe suicidality. Mrs B commented:

Together we found a way out of this horrible dark world, the patho-
logical and aggressive seduction of being united with my dead
brother, the unconcious anger and revenge, which was primarily
directed towards my mother—but also towards my analyst—and
similar terrible and embarrassing fantasies. In the relationship with
the analyst I gradually thereafter rediscovered many brighter sides of
experiences in the early relationship with my father. I sensed that the
analyst liked working with me, was truly interested in me and was
able to empathise with me and my despair. Thereby I was again able
to believe that my father, and possibly my mother in her sense, loved

Such insights finally made it possible for her to free herself from a
restrictive relationship with a mathematician, in which she felt very

lonesome. Thereafter, Mrs B fell in love with a man, her future

husband, with whom for the first time she experienced a satisfying
and fulfilling sexuality.

Doubts about the “untreatable early disorder”

In the following months of psychoanalysis there appeared, among
other things, doubts about the hypothesis of an untreatable early

n Mrs B depicted her mother’s interaction with the three grand-

children in many different versions. In these situations she expe-
rienced her as jovial, humorous, and with much empathy and
fantasy for the infants. These observations raised doubts about
her mother’s diagnosis of severe personality disorder. We
discussed the question that her former perception of her mother’s
personality also could have been partially due to her infantile
(oedipal) fantasies and projections onto her primary object.
n The “psychotic states” during Mrs B’s breakdowns did not seem
to have the character of a psychosis, but rather of a dissociative
state as described by recent trauma research. At the time of Mrs
B’s first two psychoanalyses little psychoanalytic knowledge
about trauma was available. Are the “states” an unconscious
enactment of traumatic experiences?
n As an analyst, I often noticed the strange way in which Mrs B
talked about her polio infection. The narration almost had some-
thing coquettish. It appeared to be some form of a “wonderful
fairy tale of a lucky girl who (just) escaped death”, who thanks to
a “lucky star” was able to continue her way of life without restric-
tions, in contrast to many of her classmates, who bore witness to
the epidemic through visible handicaps. In her narration every
record of fright, fear of death, and physical pain was missing.
Does this express denial of the trauma suffered?
n Both psychoanalysts, as recalled by Mrs B, seemed to have shown
hardly any interest about details of her polio illness. It came to
light that even Mrs B had almost no medical knowledge about
polio, for example, she did not even know how the disease is
transmitted, what its cause is, what types of polio exist, etc.
This was extraordinary for an intellectual woman, especially

one who is employed in upper managment in a home for the

n Instead, we more and more understood that the “psychotic
breakdowns” of Mrs B were connected to “embodied memo-
ries”27 of the dramatic and traumatic beginning of her polio
disease. Which “historical-biographical truths” could be encoded
in Mrs B’s unconscious enactments in the psychoanalytic process?

Approaching the specific “embodied” trauma of the polio infection in the

transference: indispensible for structural change?
“Suddenly everything is different . . ..” Dissociation and trauma
The following sessions took place around one year after the beginning
of psychoanalysis. After a weekend Mrs B comes to the session in a
warm woollen sweater, in spite of the sunny weather. She looks pale
and tired with a frozen expression on her face. “Is she ill?”, I ask
myself. I notice that she stops several times while walking up the
stairs, breathing heavily. This is uncommon behaviour for her. I am
thinking that I myself had trouble climbing the stairs last week while
suffering from a slight infection. Lying on the couch Mrs B is silent for
a long time. She lies there in a stiff and frozen position. The longer she
is silent the more intense my depressive feelings become. Suddenly
my dream with the two people lying in a coffin comes to my mind (see
above). I panic because I suddenly fantasise that someone could close
the lid of the coffin in spite of the fact that it is not clear if the people
are really dead. Now I make the association that both of us are wear-
ing warm woollen sweaters in spite of the sunny weather outside. Are
we the dying people in the coffin? Mrs B does not know that I myself
have suffered from polio in my childhood and that I share with her
one of the generally unknown long-term symptoms, the difficulty of
regulating bodily temperature. I ask myself if my dream contains not
only the issue of the death of Mrs B’s father and brother as mentioned
above, but also our shared experience of being paralysed and threat-
ened by death during the polio infection.
Mrs B is still silent. Finally, after about half an hour, I break the
silence: “Is it difficult for you to talk today?—Where are you with your
thoughts?” “I did not want to tell you what happened during the
weekend. I do not want to burden you . . . and, well, psychoanalysis
does not change anything anyway.” “Are you afraid I would not be

able to cope with your experiences?” I comment (thinking of Mrs B’s

fantasies about her mother during her polio infection). Finally Mrs B
slowly starts to talk.
She had spent the weekend in a holiday house with her husband
and their adolescent children. She had looked forward to this event
for months because it would be the first time that the whole family
would be reunited again. The “catastrophe” happened during a walk
through the sunny meadows. She felt very relaxed and happy, made
jokes with her husband and the children. She then told her husband
about her plans to celebrate his coming birthday in an idyllic little
restaurant close to a lake, which she had already reserved. Her
husband did not react with enjoyment as she had expected but with-
drew, seemingly somehow angry (he told her many days later that he
felt overwhelmed and excluded by her plans). Immediately every-
thing changed: the positive mood collapsed, her body became stiff
and “dead”, she seemed hardly able to breath. At the same time she
had terrible headaches and a strong impulse to vomit. Her entire
body was hurting. Because she was not capable of coping with these
painful changes she started—in front of her children—to attack her
husband, verbally and even physically. Finally her husband and her
children left her extremely angry. The children went back to their
homes. She was in a desperate state. For hours she sat in a corner of
her bedroom in the dark, freezing and in a curled up position like an
embryo. “I almost could not bear it—the terrible pains in every part
of my body. I only wished that everything would come to an end.”
Her husband found her in this state when he returned in the middle
of the night. He tried to talk with her and to take her into his arms.
For hours she could not bear the bodily contact and continued to
attack him violently. Finally, after many hours cowering in the dark
corner in his presence but silent she calmed down a little and the
extreme pains diminished. In the morning she could finally allow her
husband to touch her and to bring her to bed. Exhausted she fell
Mrs B is deeply ashamed and shocked. She suffers from heavy
guilt feelings and fears having finally destroyed her relationship with
her children. “It is like an nightmare—in this state I am like a differ-
ent person. Am I crazy or psychotic?” While listening to the patient I
had realised that the topic “polio” had disappeared from our psycho-
analytic sessions for about nine months. I comment:

I can imagine how painful and degrading this is for you. You had
hoped that the breakdowns would not appear any more after all these
psychoanalytic sessions. It is understandable that you feel doubts
whether psychoanalysis will be able to change these terrible states of
mind. I was just thinking that polio as an subject of our work here has
disappeared for a long time. Could it be that your “breakdown”
unconsciously wants to remind us of this topic? Perhaps your body is
expressing some unconscious memories of unbearable physical and
emotional pain during the polio infection in this “crazy way”, memo-
ries which are normally not accessible to you as today in this session.

Mrs B seems to be touched and starts to cry. “Yes, I have forgotten

about all this for a long time again,” she says.
After this session she surfs the internet. While reading the medical
information, she recognises that she had suffered from paralytic
poliomyelitis with typical symptoms, above all symptoms of palsy. She
remembers that she was playing with her cousin in the garden feeling
relaxed and happy in the middle of her summer holiday. All of sudden
she felt very ill, and had to throw up. “From that moment on I felt
absolutely miserable—my entire body hurt, particularly my head”.
She phones her mother requesting more details. She tells her that she
had a high fever with attacks of shivering. She screamed with pain and
would not let anyone touch her, because every single touch hurt. Both
legs were paralysed. She was close to death for several weeks.
In the following sessions we discover the analogies between her
psychic and bodily sensations during her “breakdown”, and the
beginning of her polio infection. It now seems probable to us that the
extreme emotional and physical states during her “breakdown” are
specific “embodied memories”: the triggering experience of her
husband’s “sudden”, “unexpected”, and “abrupt” withdrawal in the
trustful, happy situation on the walk, the experience “that from one
moment to the next everything is different”, as well as the unbearable
pain of the entire body bear a striking analogy to her experience at the
outbreak of polio.
According to the above summarised concept of “embodied mem-
ory” we can explain the “automatically reconstructed” memory of the
traumatic experiences in the following way. The perceptions of infor-
mation in different sensory channels in the triggering situation (the
sudden, unexpected changes of the facial expressions of her husband,
his gesture and bodily position, his withdrawal, his resistance to hold

her hand anymore—while being angry he does not want to hold her
hand) lead to analogous sensory-motor coordinations as in the situa-
tion of the sudden onset of polio in the sunny garden. These sensory-
motor coordinations “construct” the “embodied memories” on the
bolidy state (head aches and pains of the entire body, throwing up,
despair, changes perception of the surrounding persons, etc.)

The catastrophe—fear of death and panic

In one of the following sessions Mrs B tells me one of the few
conscious memories of the polio infection.
Mrs B is lying in the darkened room, all by herself, peaceful and
wishing her beloved God take her with him to heaven . . .. In this
scene Mrs B does not feel any physical pain, she is lying there entirely
calmly. To us, the picture of peaceful solitude, and the childlike wish
“that the dear God may take her to him”, seem to be an expression of
massive denial of the extreme physical pain which accompanies every
bodily movement in acute polio, as well as a denial of the perception
of being paralysed and of the massive fear of death.
We finally find the analogies to the traumatic situation in infancy
triggering her “embodied memories”. In her dissociated states Mrs B
tries to get herself into a paralysed and cringing position in a corner
of the (bed)room; she tries not to move at all in order to “freeze” the
unbearable storms of affect, the panic, and the pain of the entire body.
Hours later, she successfully reaches a state of motionless calmness,
freedom from pain, and “paralysation of the feelings”, which give
enormous relief. Only when she is able to get herself into this state of
emotional peace, can she endure her husband to physically touch and
relieve her. Here she also seems to construct an “embodied memory”,
an attempt to manage the overwhelming with unbearable pain and
vehement affects by “freezing herself”.

It is most bearable, when I am by myself . . .

In her dissociative state, as just described, Mrs B attacks her husband
vigorously and sends him away, she cannot bear his physical pres-
ence, least of all “his angry-perplexed-fearful face”, although simulta-
neously she panics when he leaves her.
To us, another detail of the memory of the darkened room just
described seems to offer the key to understanding this part of the

Mrs B remembers her mother’s fearful face. To see her in this state
is far more unbearable than lying alone in the darkened room.
According to Mrs B’s (oedipal) fantasies her mother probably could
hardly contain the fear that her child might die, or survive even more
severely handicapped than the older son. “For years she told me over
and over again how many children had died in the village during the
epidemic. On Saturdays she often took me with her, and placed flow-
ers on the graves of the polio children.” Mrs B recalls how she imag-
ined lying in one of these graves herself.
In the session we assume that Mrs B identified with her mother’s
fantasised wish for death in this situation, perhaps another aspect of
her later suicidal tendencies. In any case, she developed a central
unconscious conviction that when ill and needy she would become a
heavy burden to others so that she had to hide it and “cure herself”.
I assume that a seed of Mrs B’s profound loneliness lies within this
unconscious conviction—only her husband, a very much loved child
of a physically ill mother, could again and again reach out to her
emotionally in her loneliness.
Probably the comforting bodily contact, which each time finally
gets her out of her states, is also connected to embodied memories.
She recalls that in the evenings her father used to sit down on her
bed and held her hand—for her a pleasant (maybe also psychologi-
cally life saving) experience. Apparently, it was he who was able to
control his fears for the child, and therefore also able to communicate
to his ill daughter a hopeful, positive bodily experience.

Because of these memories it is easier for Mrs B to understand why the

very empathetic analyst in the second treatment could lead her out of
the severe depressive crisis: presumably she unconsciously connected
in the transference such experiences of good object relationship with
her father.

Denial of the horror, flight into health as a “sunshine child”

In the following months Mrs B, having survived the life-threatening
disease, recovered into healthiness in an impressive way, and reinter-
preted the fear she had suffered as a remarkable “lucky stroke of fate”.
Perhaps she had received not enough support from her parents28 in
order to deal with the traumatisations. Understandably, both probably
were happy and relieved that they had their healthy, uncomplicated,

and talented child back. Unconsciously, Mrs B experienced herself as

positively selected by fate, as a chosen one, who because of her remark-
able talent or because of being especially loved by “almighty God” had
now received the existential assignment to be there for others, espe-
cially for handicapped individuals like her brother, in the form of a
“sunshine child”. She developed into an altruistic personality (see also
Anna Freud, 1936). However, the suffered trauma remained uncon-
sciously present influencing, for example, the basic feeling of being
alone and lonely, of not deserving her own existence, feeling guilty for
the tragic fates of her brother and her polio, and therefore being
allowed to exist only as the “Siamese twin of a handicapped sibling”.
The severe depressions and states of exhaustion in her late adolescence
seem to be connected to the repressed and not unassimilated fear from
the trauma.29

The struggle for memory (Bohleber). The integration of the trauma—and its
therapeutic effect
The struggle for understanding of the “embodied memories” lasted
months and was characterised by renewed denial and the wish to re-
establish the old, seemingly manic, contraphobic defence of the
suffered pain and despair. Attempts at flight set in again and again,
including thoughts about terminating the analysis before completion.
To mention just one example: after being confronted with her renewed
denial of her polio traumatisation in again not taking notice of her
exhaustion and falling into depression, she angrily jumps off the
couch and shouts at me: “You want to keep me little. You are envious
because of all my activities and successes.” In the next session she
reports a dream: “A little girl completely dressed in white, with fine
white shoes, was climbing up a large mountain of shit. As she arrived
at the top she began to sing beautifully . . .” We both have to smile.
“Yes, it really is a mountain of shit, this polio. The little girl just does
not care about it and is even capable of bringing happiness to the
whole world by singing so beautifully . . ..”
We can talk about the temptation of denying the trauma again and
again, in order to not have to confront oneself with the horror of the
trauma and one’s own vulnerabilities. Again and again Mrs B tries to
prove to herself, that “everything is fine—polio has gone away for
ever”. It is a very painful process for her, that she—physically and emo-
tionally—is still suffering from the consequences of the traumatisations

and that she will never be able to completely overcome them or to delete
all traces of the traumatic memories. She constantly experiences her
physical vulnerability as narcissistic defects. She often expresses her
sadness because, judging by her dreams, the early traumatisations
(growing up with a depressed mother and a handicapped brother, her
polio infection, etc.) have influenced her unconscious fantasies so
much, a topic which I cannot elaborate further here. 30
As far as the psychoanalytic technique is concerned it was difficult
not to be blind to Mrs B’s repeated denial of the trauma (during the
first year of psychoanalysis, see above). She often tried to seduce me
with her wish to hear that the trauma—compared, for example, with
the Shoah—had not been so severe and would not have any long-term
consequences for her. On the other hand, as we now know, I had to
cope with the risk of a re-traumatisation if the reactivation of the trau-
matic experiences in the analytical relationship became too intensive.
Many psychoanalytical authors have described that coping with the
intensity of the reactivation of trauma in the psychoanalytic process is
one of the main difficulties in the analytical work with traumatised
patients. The successful navigation of these risks must be linked to a
continual processing of the difficult feelings in the countertransfer-
ence, which is often difficult to manage without supervision.
Therefore I just want to mention how important the containing func-
tion of the psychoanalytic relationship was in the psychoanalysis with
Mrs B. I have no doubt that working through the trauma (e.g., the
state of extreme helplessness, of despair, and unbearable pain, the
panic connected with fear of death etc.) in the transference was indis-
pensable for the gradual structural change in Mrs B’s personality.
In spite of all defence manoeuvres a gradually increasing integra-
tion of the trauma takes place, which manifests itself primarily in Mrs
B’s altered basic feeling of self, for me an indicator of structural change
in her personality. In daily life she experiences herself as more fearful,
more careful, and less permanently capable of working intensively, at
first experiencing these changes as a threat and as a loss of narcissis-
tic satisfaction. She increasingly feels dependent on interactions with
others and on their support in solving problems. At the same time,
more confidence in others is gradually appearing and with it a basic
feeling of connectedness, of shared responsibility. These emotions are
completely new kinds of experience for her. She continues to work a
lot, but at the end of the second year of the treatment she notices,

“Already for quite some time now my nightmares have disappeared,

the expectation of catastrophe has decreased . . . I don’t seem to be
continuously standing on the edge anymore . . .”. It is also important
to her, that she has a better feeling for her body, especially for reac-
tions of tiredness and that she pays attention to these signals, presum-
ably a reason for her reduced feeling of chronic exhaustion. “I feel
more grounded in myself and less absent from reality than before this
analysis,” she once says. However, it is most important for her that the
breakdowns during the conflicts in her marriage rarely reoccur.

For my husband and me it is very important that we increasingly

understand what these breakdowns mean and what triggers them.
Most of the time I can detect when panic appears and then directly ask
my husband if and why he is emotionally withdrawing. I am still
incredibly frightened in such situations and I have to deal with the
expectation of catastrophes, but I don’t break down entirely anymore
. . . You probably can’t imagine how relieved I am . . ..

In many psychoanalytical sessions Mrs B occupies herself with

mourning. Reproaches towards her two former analysts appear. She
formulates these very clearly, even harshly, without however destroy-
ing the aforementioned gratitude that her two psychoanalyses,
despite their limitations, had opened many doors for transforming her

Centred around the insights from the third psychoanalysis with Mrs
B, I made attempts to verify the hypothesis that the working through
in the transference with the analyst of the traumatic experiences, and
the reconstruction of the biographical-historical reality of the trauma
suffered (emotional as well as cognitive), both proved indispensable
for lasting structural change in this severely traumatised patient. As I
have tried to illustrate with the clinical material, the traumatic experi-
ence had been integrated into Mrs B’s basic feeling of identity as an
unrecognised source which had largely determined her personality
development. Convinced of her selection by the almighty as a “chosen
one” and of her “eternal guilt as one who is preferred by fate”, she
was equally convinced of being under the obligation of sacrificing her
own life to the handicapped and to others less privileged. She thus

developed a “false self” and a life style of constant exhaustion.

Understanding the details of her biographical trauma helped her to
modify her core identity and to accept the hidden vulnerabilities of
her own body and her dependency on others, particularly her
husband. These changes are connected to the disappearance of her
nightly panic, her constant “waiting for catastrophe” and her break-
downs which is a great relief for her and her family. “So much pain
could have been spared to myself, my husband and my children if
only I had had the courage to take a close look at my trauma earlier,”,
she had once said in an analytic session.
I hope that this communication about my patient might contribute
to the discussion of some technical issues in the treatment of other
severely traumatised patients. Many questions still seem to be open
for me: do we have to modify our techniques according to the differ-
ent kinds of early trauma of our patients? Compared with victims of
man-made-disasters it seems to me that patients traumatised through
illness develop different kinds of unconscious phantasies in order to
explain their survival. As mentioned above, Mrs B was unconsciously
convinced that she was a “chosen one” who had been positively
singled out by God or fate. She also developed specific unconscious
body phantasies (being invulnerable etc). These unconscious phan-
tasies could be connected to the difficulties seen in the “the excep-
tions” (Freud, 1916d) in really accepting the reality principle
(Jacobson, 1959). Therefore, I think that former polio patients could be
considered as a specific nosological group from many points of view.
They share specific characteristics of the unconscious long-term effects
of polio infection, for instance “embodied memories” of the experi-
ence of extreme, sudden pain, of being paralysed, of approaching
death, but also of the helplessness of the primary objects and of the
doctors who did not have any possibility of treating the illness. Their
only hope was that the child’s body might be successful in its fight
against the illness. It seems most likely that a child suffering from
polio would have perceived all these factors, integrating them into the
unconscious fantasies of its own body being immortal and no longer
vulnerable. Within the framework of this paper I was not able to deal
with the question of whether patients from other nosological groups,
for example having suffered from other severe illnesses in their first
years of life, show different kinds of long-term effects (e.g., a patient
of mine from former East Germany with its rigid medical system who

suffered from severe encephalitis in her first year of life). I also think
that further clinical research on this question is necessary. However, I
assume that for these other groups of patients severely traumatised
through illness it would also prove indispensable to work on the
chronic denial of the traumatisation again and again in the psychoan-
alytic process if structural change is to be achieved.
Another topic which needs further discussion is the relationship
between “narrative” and “biographical” truth in psychoanalytic treat-
ment. As I hope I was able to illustrate, it seems clear that a largely
intellectual reconstruction of biographical facts does not lead to ther-
apeutic change. Only detailed (emotional and cognitive) understand-
ing of the enactment of traumatic events in the therapeutic
relationship and in close object relationships (Mrs B’s breakdowns)
including the scarcely bearable emotional intensity lead to structural
change. Without the holding and containing function of the analyst
and the empathetic attitude of trying to understand the not under-
standable, Mrs B would not have had the courage to look at and to
withstand the horror of the traumatic events of her life. Without this
courage in a sustaining therapeutic relationship neither understand-
ing of nor working through the trauma would have been possible.
I have tried to illustrate that the concept of “embodied memory”
might be helpful in understanding that early trauma is remembered
by the body in a more specific way than in merely understanding
procedural memories (which means mechanical or bodily skills) in the
transference, as other authors contend. Trying to understand “embod-
ied memories” means observing in detail the sensory-motor coordi-
nations in the analytic relationship. This enables one finally to decode
the inappropriate intensity of affects and fantasies which match the
original traumatic interaction, and not the present, new relationship
to the analyst. The reconstruction of the original trauma then helps to
understand the “language of the body” and to connect it with visual-
isations, images, and verbalisations.
I was able also to mention only briefly that the reconstruction of
the trauma supported the process of conceptualisation, for example,
by empathising with the intentions of the primary objects during the
polio infection. These processes improved the current relationship
with Mrs B’s parents, particularly with her mother, because for years
the relationship had been dominated by unconscious feelings of
revenge and hatred.

Therefore, the discovery of the “biographical-historical truth” of

the traumatic experiences as well as their working through in the
psychoanalytic relationship helped to integrate the trauma into the
self and the identity of the patient, which remains one of the main
aims of a psychoanalytic treatment with severely traumatised

Remembering a depressive primary object and the Medea

fantasy. Memory in dialogue between psychoanalysis and
embodied cognitive science from psychoanalyses with
psychogenic sterile women

Introduction: “Medea fantasy”—an ubiquitous unconscious fantasy

system based on early embodied memories31
Remembering is still a central issue in clinical psychoanalysis. Most
contemporary psychoanalysts probably share the common view that
patients’ inadequate, psychopathological thoughts, emotions, and
behaviour are determined by unconscious fantasies and conflicts
adopted in an unknown past situation. In other words, they think that
their patients are guided by implicit memories of former pathogenic
or traumatic object-relations and experiences unconsciously repeated
in their current feelings and symptoms (see also Chapter Four).
Sandler and Sandler (1997) speak of dynamic templates of early expe-
riences. But how do these “templates” function? How does memory
work? Can patients remember “historical truth”, or are memories
mainly “constructed” narratives containing the truth about history
which the patient can stand emotionally at the present moment and
which, perhaps, have little to do with biographical facts (see e.g.,
Cooper, 1986; Emde & Leuzinger-Bohleber, 2014; Köhler, 1998;
Leuzinger-Bohleber & Pfeifer, 1998, 2002, 2004a,b)? All such questions
are discussed in detail by the contemporary psychoanalytic commu-
nity, such as in the relevant, but emotionally charged, debate on recov-
ered and false memory (see e.g., Chapter Four and Bohleber, 2010a,b;
Brooks-Brenneis, 1996; Emde & Leuzinger-Bohleber, 2014; Loftus,
1993, Sandler & Fonagy, 1997). I have mentioned this debate in several
chapters of the present volume (see Chapters Two, Three, and Four).
In several papers, Rolf Pfeifer and I have also discussed our shared

thesis that interdisciplinary considerations on memory may well be of

interest for the critical discussion on “false” or “true” childhood
memories (see e.g., Leuzinger-Bohleber & Pfeifer, 2002, 2004a,b). We
discussed whether and how interdisciplinary memory research can
add to our understanding of how remembering occurs and functions
within the psychoanalytic situation (see also Chapters Two and Four).
This chapter focuses on the clinical relevance of the question as to
how patients remember early traumatic object relations even going
back to their first months of their lives. As I have discussed in another
paper (2001), one of the most surprising findings in nine psycho-
analyses with psychogenic sterile female analysands and in four
psychoanalytical long-term psychotherapies with this group of
patients was the discovery that all these women shared one common
biographical feature which, as we discussed, might have stimulated a
central unconscious fantasy: the Medea fantasy. Their mothers had
suffered from severe postpartum depressions and had been treated
with antidepressants for several months during these women’s first
years of life. How did my analysands recall these traumatic early
object relations? As empirical research has indicated, a mother’s
severe depression exerts considerable influence on their infant’s early
development (see Chapters Two, Three, and Four). In these chapters
we show that a model of memory—conceived as a functional
metaphor of the whole organism, as a complex, dynamic, re-cate-
gorising and invariably “embodied”, interactive process namely, as
based on actual sensory-motoric experiences that manifests itself in
the organism’s behaviour—may be helpful for explaining the influ-
ence of such early memories. I have sought to show that these
concepts of memory offer a deeper understanding of the functioning
of memory especially of the way early experiences, for example with
a depressive primary object, are contained in the memory of a certain
individual patient. These conceptualisations seem to support the clin-
ical findings that each patient has his very characteristic, “subjective”
way of reacting to “real traumatisation”, for example, of construing
his specific images of the traumatising object in the unconscious. The
original experience of trauma is rewritten again and again according
to the concept of “Nachträglichkeit” or, to use the terminology of
Edelman (1992), is constantly re-categorised in new interactions. The
historical event, for example, the specific trauma dealing with a
depressive mother in a certain period of life, cannot be evaded but

must be considered in any attempt to understand the “historical

traces” concealed in our patient’s current interactional behaviour (see
role of the “objective” information of the postpartum depression of
the mother of Mrs E below, and see the last section of the introduction
to this volume). Attempting to understand our analysands’ biograph-
ical idiosyncrasies adds certain dimensions to our clinical under-
standing of our patient’s specific psychodynamics. The original
trauma, specific reactions, and inner psychic “constructions” built into
unconscious fantasies constitute the constraints of specific re-categori-
sations in new interactional situations.
As indicated, new discoveries in memory research seem to corrob-
orate the clinical psychoanalytic evidence of the last decades, namely,
that therapeutic transformations do not come about merely by means
of uncovering the traumatisations of early infancy (“archaeological
metaphor”), by “pure insight in the mind of the patient”, but that the
process of working through in the transference relationship with the
analyst (including the sensory-motoric and affective experiences in
the therapeutic interaction in the sense of “embodiment”) is the deci-
sive factor. Thus, radicalisation in the relevance of transference for
therapeutic change finds interdisciplinary support (see Chapter Four).
It also seems important to us that according to this current memory
research, psychic processes are invariably anchored biologically and
neuro-anatomically, and thus have an “objective” dimension. Real
experiences in very early childhood (including the intrauterine stage)
seem, as Pfeifer and Bongard (2007), and others, have postulated, even
influence the construction and later modification of our neuronal
structures. Thus, such conceptualisation suggesting that the needs
and conflicts arising in early socialisation should be so persistent and
determining are plausible and, moreover,why structurally transform-
ing psychoanalyses require time. After all, transformations of biolog-
ical processes require their own time!
As I attempt to clarify in the following sections of this chapter, it is
interesting to note that some of the human being’s biologically deter-
mined experiences seem ubiquitous (e.g., the experience of pregnancy,
birth, early dependence on a primary object), and are perhaps one
reason for the fact that most human beings (at least in the Western
world) seem to share some unconscious fantasies that are also
captured in myths and fairy tales.

How is the “Medea Fantasy” best characterised?

The Medeas myth (Euripides)
Oedipus and Narcissus are two male protagonists of Greek tragedies
who, as we know, stood sponsor to Freud when he wished to draw
attention to ubiquitous conflicts of human mental life. Freud postu-
lated that myths, as narrated to us by creative writers in every age,
continue to fascinate us today because they portray central uncon-
scious human fantasies and conflicts, as a rule connected with our
repressed, early infantile sexual fantasies. These fantasies are
preserved in our own unconscious minds and, in projecting them on
to the main figures in these tales, we unconsciously recognise our own
destiny in them. “It may even be that not a little of this effect [of an
imaginative work] is due to the writer’s enabling us thenceforward to
enjoy our own day-dreams without self-reproach or shame” (Freud,
1908, p. 153).
There are of course also female Greek mythological figures who
still fascinate us today and have inspired creative writers down the
ages to depict and recreate their fate in ever new forms. One such
figure is Medea, who, it seems to me, has become particularly relevant
to our time, characterised as it is by migrations of ethnic groups, high
divorce rates, new forms of neglect, and the recurring murders of chil-
dren reported voyeuristically in the media (see, for example,
Kämmerer et al., 1998; Chapter Seven of this volume). Medea’s fate
surely confronts us unconsciously with one of the most profound
taboos of our Western civilisation, a form of female destructiveness in
which intense wounds and humiliations culminate in boundless
despair, rage, hate, and revenge—extending even to the killing of
one’s own children. Unconscious projections of such split-off, taboo
impulses of female destructiveness in psychoanalyses can give rise to
difficult and often almost unbearable countertransference reactions in
us psychoanalysts, making it hard for us accurately to perceive and
recognise this dimension of the “dark continent” of femininity in our
female analysands. We are often at a loss for images and words to help
us even begin to grasp our horror of such situations, which at first
floods and confuses us. In our struggle for visualisation and verbali-
sation, myths present themselves as a helpful, neutral “third party”,
on to which we first direct our own projections of what we can neither
grasp nor bear, thus enabling us subsequently to recover our bearings

in the images, utterances, and narrations of the protagonists. We are

then in a position to reflect critically on analogies and differences
between the clinical observations and the mythical figure, with a view
to gaining a better understanding of the unconscious dynamic oper-
ating in the analytic situation.
This chapter gives an account of such a progressive process of
discovery for which I found the “Medea” concept proved particularly
Thus first a short summary of the myth.
The enchantress and priestess Medea lives in Colchis on the Black Sea,
she is the daughter of King Aetes and the demi-goddess Hecate. When
she first catches sight of the stranger in her father’s palace, Eros is,
according to the legend, standing behind the hero and shoots his
arrow right into the heart of the king’s daughter. Medea falls victim to
her own passion. She struggles with all her might against her sexual
and erotic feelings, cursing the stranger and his appearance, but in
vain: her love for Jason finally wins the day. She is therefore unable to
turn down Jason’s request to ally herself with him against her father,
and gives him a lotion that endows him with superhuman strength
and makes him invulnerable. She sings the dragon to sleep, so that
Jason can kill it and snatch the Golden Fleece away from it. She tells
him what he must do to tame two wild bulls and yoke them to the
plough, and how to subdue the armed men who sprout from the
furrows, by casting a stone quoit among them to sow dissension in
their ranks and make them kill each other. Medea then flees with
Jason. When the Argonauts are surrounded by their pursuers, led by
Medea’s brother, she lures him into a trap and delivers him up to
Jason’s sword. Hearing of the successful escape and of his son’s death,
her father tears himself to pieces in his rage. In the legend, the tragic
fate of Medea that now ensues is the revenge for this double murder.
Back in Greece Medea first rejuvenates Jason’s old father, by cutting
him up and boiling him with magic spells in a cauldron, and entices
the daughters of Pelias to do the same with their father. However, to
avenge herself she gives them the wrong herbs, so that Pelias never
returns to life. Jason and Medea must then flee to Corinth. Jason aban-
dons Medea and falls in love with Creusa, King Creon’s daughter.
When he finally leaves Medea, apparently to secure for his two sons a
future in Corinth, Medea becomes suicidal at first. But then, after an
impressive scene in which she conjurs up the pride of a betrayed
princess, she pretends to accept Jason’s decision. She sends Jason’s
new wife an enchanted robe and diadem. When Creusa dons them,

both she and her father, who rushes to her aid, are consumed by fire.
But this is not enough to quench Medea’s thirst for revenge: to hurt
Jason to the quick, she finally kills both her sons and, at the end of the
tragedy, flies away with their bodies in a chariot drawn by winged

Clinical features of the “Medea fantasy”

In the psychoanalyses with nine psychogenic sterile female
analysands and in four psychoanalytical long-term psychotherapies
with female patients we first discovered this fantasy which uncon-
sciously seemed to determine their experience of their female body,
their femininity and potential motherhood.

In the centre of the “Medea fantasy” was the conviction that female
sexuality is connected with the experience of existential dependency
on the love partner and the danger of being left and narcisstically hurt
by him (as Medea, a princess from the Black Sea, by Jason, a Greek
hero, whom she had helped to bring the Golden Fleece back to Greece,
but was deceived by him afterwards. In order to hurt him existen-
tially, she killed her two sons). These women unconsciously feared
their own sexual passion might revive uncontrollable destructive
impulses in a close, intimate relationship, which could be directed
against the autonomous self, the love partner and above all against the
offspring of the relationship with him, against their own children.

Thus, their psychogenic frigidity and sterility unconsciously

protected these women against these fantasised dangers.
Unfortunately I cannot summarise the interesting psychoanalytical
literature concerning the concept of the “unconscious fantasy”. The
Project Group of Theoretical Integration of the IPA (Chair: Werner
Bohleber) just has published an attempt to integrate the different
conceptualizations of unconscious fantasies in different psychoanalyt-
ical traditions (see Arlow, 1969a,b; Arlow & Brenner, 1965; Beland,
1989; Bohleber & Leuzinger-Bohleber, in press; Bohleber et al., in
press; Britton, 2009; Inderbitzin & Levy, 1990; Perron, 2006; Roth, 2001;
Sandler & Sandler, 1997; Shane & Shane, 1990). To summarise: these
unconscious fantasies may, as Freud (1908e) presumed, have been
early-infantile daydream fantasies of the women, in which earliest
bodily and object relational experiences and primal fantasies (as for
example on the primal scene, birth, and death, etc.) had been

included. As Sandler and Sandler (1997) postulated, these fantasies

probably have been moved into the unconscious during the oedipal
phase in the fourth or fifth year of life, becoming part of the dynamic
unconscious. They may have been rewritten “nachträglich” again and
again, for example, by masturbation fantasies in adolescence as well
as fantasies on motherhood and feminity in late adolescence. Seen
from a perspective of the structural model in psychoanalysis the
Medea fantasy can be considered as a psychic compromise allowing a
certain unconscious drive satisfaction as well as a satisfaction of
archaic shame and guilt feelings. Besides, as terrible as the uncon-
scious self-image of a witch and a child murderer may be, these
severely traumatised women preferred to be the actress of their fate (a
“Medea” or a psychogenic sterile woman) instead of the passive victim
of their love object (see Leuzinger-Bohleber, 1998, 2001; McDougall,
1974; Pines, 1994; Rhode-Dachser, 2010).
I gave a detailed account of some analytic sessions in a paper writ-
ten in 2001. Here, I sought to illustrate the painful process of discov-
ery of this tabooed unconscious fantasy experienced with my
analysand. I must restrict my discussion in this chapter to a relatively
extensive case report in the hope of conveying a first impression of the
psychoanalyses with this group of women (see Leuzinger-Bohleber,
2001, pp. 333–338)

The unfolding of the “Medea fantasy” in the analytic process: fragments of

When Mrs E, a strikingly beautiful, fashionably dressed, thirty-year-
old student, arrived for her first interview, her thick, black hair and
good-looking, pale, somewhat rigid face reminded me of “Snow
White”—an association repeated at the end of our talk after she had
told me of her father’s death, which had driven her, as a six-year-old
princess, out of her still pristine early infantile realm.
Mrs E needed psychotherapeutic help because she was suffering
from a severe phobia: she was almost unable to leave the house and
attend her lectures and courses, and had cut herself off totally from all
social contact. At night she was overcome by fits of panic anxiety, which
left her unable to sleep and “wandering about her apartment like a
caged animal”. Her husband, who was twenty years her senior, was
unable to calm her down, although he was a professor of neurology. She

also suffered from a range of psychosomatic symptoms, such as

migraine, stomach pains, sleep disturbances, and eating problems. It
was only in the fourth year of her analysis, however, that it emerged
that her main analytic motivation was her psychogenic frigidity and
In the first interview, I learned practically nothing of her life story,
except, as already stated, that her father had died suddenly of heart
failure when she was six years old, and that she had subsequently
been plagued by the obsessive idea that she too might succumb to
sudden heart failure. I was impressed by the fact that, almost through-
out the interview, tears streamed down Mrs E’s totally expressionless,
mask-like face—without any visible connection with what she was
describing. It seemed to me that she was quite remote from her own
emotions and bodily sensations; not even her language seemed to be
her own, for she resorted substantially to her husband’s highly
abstract jargon.
Here are some of the most important biographical facts (most of
which emerged only after the third year of her analysis). The patient’s
mother had lost her first husband in an air raid in 1945. She herself
had been able to escape by running into the house, but he had been
killed outside the door. After this she had developed a severe phobia
that had left her unable to work and caused her to lead a restricted life
close to her parents. She had met Mrs E’s father at the beginning of the
1950s; according to the family romance, she had become pregnant the
first time she had slept with him and given birth to an illegitimate,
Down’s syndrome daughter. Mrs E told me that, because of this
daughter’s feeding problems, her mother had left her at the clinic,
where she had died a few weeks later. According to the mother’s
account, a heavy burden had weighed on her pregnancy with the
patient, as she had been very afraid of having another disabled child.
The birth had been dramatic—a matter of life and death. It had, again
according to the mother, been followed by a depression, for which she
had been treated with drugs for eight weeks. The patient had had
virtually no breastfeeding, but had been fed in a rigid four-hour cycle.
When the patient was five years old, her mother had undergone a
radical hysterectomy for a carcinoma. A year later, the patient’s father
had died. After his death, the mother had led a withdrawn life at
home, without ”work in the outside world” and without a fresh rela-
tionship with a man. The patient had shared her mother’s isolated life;

having virtually no childhood friends, she had developed an infantile

neurosis, which had been neither diagnosed nor treated. At puberty,
she had still slept in the same room as her mother; and her mother
would read her diaries. A frightened Mrs E told me of an impulse she
had had one morning to strangle her mother in the bed next to hers.
At fourteen, the patient’s phobia had become so intense that she could
no longer attend school, and she had gone into psychiatric treatment.
A therapy group had provided Mrs E with limited contact with other
young people. She had begun an apprenticeship, but could sit exami-
nations only in her mother’s presence. At the age of nineteen, her
phobia had made it impossible for her to leave the house, and she was
admitted to a clinic in Zurich as an in-patient. There she had met her
husband-to-be, who, finding this young woman attractive, had fallen
in love with her. The in-patient psychotherapy and the relationship
with the husband enabled her to leave her mother and move to
another town, where she had belatedly taken her school-leaving
examination and gone to university. After the marriage, however, her
symptoms had caught up with her one after another; this had badly
wounded her and ultimately motivated her to embark on a psycho-
In the present context I can give only an outline of this six-year,
four-hour-a-week psychoanalysis, concentrating on the points most
relevant to our subject. Although long stretches of this analysis were
very difficult for me, I found it at the same time interesting and impres-
sive. Owing to the intensity of the analysand’s defences against archaic
fantasies about femininity and her inability to become pregnant, it
seems to me by no means coincidental that these did not become the
focus of our attention until the fourth year of the analysis. Before that,
she appeared to be absorbed predominantly in her infantile conflicts,
doing her best to get herself cared for, comforted, and loved.
Her marital situation was also very difficult, characterised as it was
by, for example, her narcissistic functionalisation of her husband.
Without manifest guilt feelings, Mrs E could spend huge sums of his
money and take possession of his car, time, and feelings. She often
treated me in the same way in the analytic sessions, taking it for
granted that she could dispose of me as she wished. For instance, on
one occasion, without prior notice—and without a trace of perceptible
guilt feelings—she returned from holiday four weeks later than the
agreed date.

In the first two years of treatment, she would often bring dreams
of an almost psychotic quality. Once she dreamt that she was looking
out of the windows of an ice palace, watching emotionlessly as some
dwarfs outside fried parts of her husband’s body on a giant grill (cf.,
Langer, 1988). On seeing my little daughter bathing in the garden, she
had a detailed fantasy in which, beside myself with rage after a quar-
rel with my husband, I struck out at my daughter and killed her. She
would recount these fantasies in an oddly cold way, as if petrified and
emotionally frozen. This manifestly enabled her to project her own
frightening unconscious Medea fantasy on to me, so that she could
deny that she might have anything to do with such a fantasy. Again,
when she developed powerful phobic symptoms after this session, she
could not see any connection whatsoever between them and the mate-
rial of the session. In retrospect, one of the functions of these defen-
sive strategies was to help her disavow her feelings of archaic
dependence on others, which were an unconscious determinant of her
phobic symptoms: in her phobic “attacks”, she felt—consciously—
totally dependent on her environment, husband, mother, analyst.
Finally, however, her fantasy that no one could help her in her symp-
toms led us to the opposite unconscious wish, namely, to be depen-
dent on no one, not to need anyone, to cold-shoulder everyone—an
unconscious compromise formation that had arisen during her
adolescence. The analytic work on this complex exposed her archaic
anxieties about dependence, which were due to the deficiencies in the
formation of her self and object boundaries. This work led not only to
an imperceptible loosening of the narcissistic defence and its associ-
ated substitutive satisfactions but also to a diminution of her need to
flee into a “unique” phobic world.
This was followed, in the treatment, by the appearance of the
theme of sexuality. In the fourth year of her treatment, she reported
the following dream:

I am in our bathroom checking whether Mrs U [her cleaning lady] has

cleaned everything properly. I lift up the lino and see some verminous
bugs crawling out; I feel nauseated, squash these horrible creatures,
and am incredibly peeved that Mrs U did not make a better job of the

Since the second year of the analysis, Mrs E had repeatedly made
the same conspicuous slip, calling me by the name of her cleaning

lady, which had a variety of meanings. As a rule, these associations led

to feelings of triumph over, and devaluation of, myself—especially, as
it happens, if she had perceived me as an empathic, maternal woman,
emotionally involved in the sessions. Further associations led to
expressions of Mrs E’s identification with her mother’s rigid defence
against sexuality: sexual fantasies were “dirty” and had to be “got rid
of”. Like Mrs E, I, as her analyst, was “accused” of not making such
“unclean thoughts” disappear, but of taking an interest in them
instead. In the ensuing sessions, furthermore, it became clear how
much Mrs E had also unconsciously identified with her oedipal
mother’s “defective surgically mutilated belly”. In a subsequent
session she remarked that she had no feelings of any kind in this
region of the body: “It might as well be dead in there . . .!”
After this session, Mrs E was admitted to hospital as an emergency
with a suspected Fallopian pregnancy. She reacted with panic anxiety
to the prospect of having a general anaesthetic, and telephoned me in
utter desperation from the hospital, filled, as she said, with the fear of
death! She manifestly associated the loss of control under the anaes-
thetic with the conviction that she would thereby also lose control of
her body and her life. She discharged herself early from the clinic,
against medical advice. In the next session, she resentfully reproached
me: “Look what happens when we focus on this part of the body. I
would rather go on anaesthetising my belly and ‘keeping it dead’ ”. It
became clear that she was unconsciously experiencing my analytic
contact with her body as intrusive—and indeed, as though I had
“taken possession” of it, effacing the boundaries between our bodies.
Many new memories emerged in Mrs E in the ensuing weeks—
how her mother had told her, as a pre-school child, all the details of her
illness, her operation, and her bodily feelings during radiotherapy—
memories that now became mixed, often in odd ways, with her own
surgical experiences. This ultimately led us to presume that the “dead-
ening” of the belly was not only, as stated, an expression of her identi-
fication with the “defective” female body of the mother, connected
with the “dead” introject of the depressive mother, but that the with-
drawal of cathexis from these parts of the body also implied a “turning
away from the female body”, which was in addition a (neurotic)
attempt to separate the mother’s body from her own (see, for example,
Pines, 1994). A further theme later emerged in the wake of the dream
mentioned above: Mrs E associated the verminous creatures crawling

out from under the lino not only with “dirty, male semen” but also
with her half-sister’s two children, who had seemed to her, on a recent
visit, to be untamable, “crawling vermin”. In the manifest dream, she
killed off this “vermin” in a state of utter nausea—something we could
now see as part of the unconscious “Medea fantasy”, traces of which
we were to encounter again and again in the ensuing months. A vital
element in the formation of this fantasy in Mrs E was the part of the
family romance connected with the death of the Down’s syndrome
sister. Evidently the analysand had later fantasised that the mother
had “left the sister to die” in the clinic because she did not want her,
because her disablement was a nuisance to her and wounded her
narcissistically. In these fantasies, Mrs E experienced her mother as
endowed with the power of decision over life and death! However, the
dramatic tales about her own birth also stimulated the Medea fantasy.
Her mother had told her that she had almost bled to death during her
birth. She had survived only because her husband, who fortunately
had the same blood group as hers, had been able to donate blood for
her. The treatment revealed how far such tales had aroused the
patient’s magic fantasies and contributed to the unconscious “truth”
that birth was an event in which either the mother or the baby (she
herself had been almost asphyxiated by a twisted cord)—or indeed
both—might die: birth and death were intimately connected.
We now understood that Mrs E was again and again staging this
central fantasy and her associated unconscious convictions in the
transference; the transference phenomena of the first two years of
treatment were also connected with this, as well as with other factors.
Until the third year of treatment, Mrs E seemed to forget everything
we had discussed in the sessions, as if she were obliterating me and
our analytic work. During this period, I often doubted the point of the
treatment and the appropriateness of analysis, and contemplated
breaking off—”aborting”—the treatment, partly in order to protect
myself from her “destructive abuse”. In retrospect, these fantasies also
reminded me of the following theme: who is to survive; who is to kill
whom; who is to decide whether a life (or an analysis) can come into
being and grow? Furthermore—again as revealed by hindsight—the
analysand was seeking to project her still unbearable feelings of
dependence and impotence, as well as a profound depression, on to
me, and to perceive helplessness, failure, and dysphoric affects in her
analyst—in order to control them in me (projective identification). In

the transference, I became the “dead object”, the expression of an early

mother transference, in which Mrs E felt me, in this phase of the analy-
sis, to be her depressive (“dead”), “cold” and unresponsive early
mother (see concept of “embodied memories” discussed in this
volume). However, as Bollas (1995) stresses, this projective identifica-
tion ultimately proved extremely helpful to the analytic process, since
we were (progressively) able to discern, in these transference phenom-
ena and the analysand’s projections on to me, her split-off identifica-
tions with the “dead mother”—a trace that led back to her
traumatising early object relationship. In addition, in this early phase
of the analysis, the mechanism of projective identification constituted
an attempt to establish a hard and fast boundary between Mrs E and
myself—which she did by making me the stranger who ipso facto expe-
rienced completely different emotions from herself! The intensity of
her anxieties about fusing with me, putting herself at my mercy—
”turning into your product”, as she once put it—became clear to us in
the later stages of the analysis. This was another reason why intimate
themes such as sexuality and femininity were not broached directly in
the treatment for so long. She was afraid that I might thereby get too
close to her—something her dreams portrayed repeatedly in various
In the manifest dream content, I would often transgress bound-
aries, be unempathic and intrusive, accompany her to the toilet, wipe
her bottom, or persecute her in her flat. As in these dreams, I seemed
(in the mother transference) to be able to dispose of her body as I
wished. I was impressed to find that the analytic work on these
components of the “Medea fantasy” manifestly led to a deepening of
the analytic relationship and a parallel relieving of the burden on her
relationship with her husband. Looking back in the fifth year of her
analysis, Mrs E once mused:

“It is funny—I can now let my husband get closer to me without

immediately being afraid that he might slip inside me or that I might
have to push him out again. It is as if I felt a secure skin between him
and myself, so that I don’t need to erect a protective wall between us
any more.”

This sense of having secure boundaries between herself and the object
resulted in a moderation of her intense envy of men, which, although
it had often put me in mind of Freud’s concept of penis envy, was no

doubt also connected, in Mrs E’s case, with the feeling that, because of
their anatomical difference, boys could separate more easily and more
completely from their mothers (see, for example, Chasseguet- Smirgel,
1988; Grossman & Stewart, 1976). With these gradual changes, a new
closeness arose between the couple, especially in the sexual field. For
the first time in her life, Mrs E discovered pleasurable and passionate
sensations in and with her female sexual body. The intensity of her
fear of these passionate feelings hitherto now became clear in the
treatment. These new sexual experiences now led also to an intense
wish for a child, which brought out many new anxieties and conflicts
in the analysand in the ensuing months. While a detailed account is
beyond the scope of this paper, I should like to conclude with two
important dreams that illustrate the extent to which she was here
concerned, among other things, to establish an inner boundary
between her own female body and her mother’s. The first dream was
triggered by an overt conflict with her mother, who abruptly termi-
nated a visit to her daughter because—as Mrs E saw it—she could not
bear it when her daughter preferred to sleep with her husband rather
than have breakfast with her.

I was pregnant and very happy; I already had a big belly. My husband
and I wanted to go into town to buy something pretty for the baby.
We went into a baby shop. We were served by an old woman, but she
brought me nothing but rubbish, and never what I wanted. I became
quite desperate. She kept disappearing into the back of the shop.
Finally she brought me a frying pan, which she wanted to force on me.
I got terribly angry and yelled at her. My husband had already left the
shop. I slammed the door shut and ran after him, but I couldn’t find
him and had a fit of panic. And I think I didn’t have a big belly any
more . . .

She associated to her inner struggle over the ownership of her

body (“her round belly”): was it hers, her husband’s or the old
woman’s (the mother’s—and mine in the transference)? She herself
made a connection with the scene mentioned above: “I imagine I now
have to pay for the fact that I sided with my husband and threw my
mother out of my bed—for that I now have to give up my unborn
baby to her!” Another element to emerge was that she experienced the
loss of the baby as revenge for the oedipal triumph over her maternal
rival in the above scene. In the ensuing months the analytic work

again came to focus on the intense conflict of separation and loyalty

with the mother and on oedipal (and pre-oedipal) envy and rivalry, in
the form of transference fantasies connected with the forthcoming
termination. In her fantasy, I would be left behind, like her mother,
emptied out, depressive and “with my insides drained of blood” if she
terminated her analysis, felt healthy, and became a mother herself.
Through a psychic umbilical cord, goaded on by her destructive envy,
she would deprive the maternal body of nourishment, fertility, and
life, leaving it destroyed. “Your mother almost bled to death when you
were born, and now you are afraid that you might have damaged me
too, leaving me behind drained of blood, destroyed and plotting
revenge, if you are reborn psychically and separate from me.” After
this interpretation had been tossed back and forth between us over a
number of sessions, Mrs E brought the following dream:

It was a dream full of anxiety. I had a child, but it was absolutely tiny,
and I looked after it tenderly and with every care. That was very
necessary because it was so small. But [laughing] it had a tooth and
could bite me.

Her associations led first to a dream that a woman friend of hers

had had: this friend had told her she had dreamt that the two of them
had given birth to one child together, which aroused very ambivalent
feelings in her. “On the one hand it was very disconcerting to me,
because it was not clear which hole the child had come out of and who
it belonged to, but, on the other, I was also very touched by my
friend’s desire to stand by me like a midwife [holding her in her
arms].” She then recalled that the child had a tooth:
P: It is tender and cuddly, yes, but at the same time already capable of
defending itself and not completely at my mercy . . .
A: That sets your mind at rest—it is also not completely at the mercy of
your destructive side, although it very much needs your loving, caring
P: Yes, and it is also something special, like Princess Sissi, who, if I remem-
ber rightly, also came into the world with conspicuous teeth . . .

The fact that she was capable of having this dream towards the end
of the analysis, even if the child featuring in it was still very small and
in need of abundant care and attention—although at the same time

naturally endowed with means of defending itself—was seen by Mrs

E as a sign that she could now dare to terminate the analysis and
proceed along her feminine path by herself. The shared “analytic
baby”, while itself still rather small, was capable of developing, and
she would take good care of it in the future too.
We ended the treatment after just over six years. Three years after
the termination, Mrs E telephoned me. She was four months pregnant
and proud of “having been able to be fertile”; most of the time she
enjoyed her state. Thinking back to the treatment, she felt very grate-
ful. “When I sometimes have anxieties and physical troubles, I try to
remember my dreams—and then I can be my own psychoanalyst,”
she said self-confidently, although one could, at the same time, feel a
bond with me. Shortly before the birth, she telephoned me in some
anxiety to say that, partly because of her high blood pressure, the
doctor was afraid that she might develop toxaemia of pregnancy. She
herself could not decide whether this was a psychosomatic symptom
(her mother suffered from hypertension) or something organic. A
Caesarean section proved necessary; although she experienced this as
a narcissistic wound, she soon got over it without the need for profes-
sional assistance on seeing her healthy son. She reported all this to me
in a further telephone call when her son was about six months old. She
was able to experience to the full the ups and downs of early mother-
hood without being drawn into the archaic abyssal maelstrom, and to
discover herself, her son, and her husband as a “unique trio”.

It gradually became clear in the initial phase of Mrs E’s psychoanalysis
that her apparently narcissistic defence had the function of holding
back massive anxiety about dependence on the object. At the same
time we were ultimately able to discern in it manifestations of the
analysand’s unconscious identifications with her “dead mother”
(Green, 1986). Her extreme dependence anxieties were partly deter-
mined by her insecure self and object boundaries, resulting from her
traumatising early object-relations experiences. Succumbing to her
depression, the patient’s mother had probably functionalised her
daughter for the purpose of narcissistic regulation of her self-esteem;
she had probably done this already in the first year of Mrs E’s life, as
well as later, after the death of her second husband. In her depression,

the mother had probably not been able adequately to reflect back her
baby’s childish needs and to achieve an understanding of her little
daughter’s mental processes “good enough” (in Winnicott’s sense) to
allow her to develop the capacity to understand mental states in
herself and others, accompanied by a stable core sense of self, and
psychically to integrate and cultivate archaic aggressive and destruc-
tive impulses. At the same time, the father had been insufficiently
available to Mrs E during the early phase of triangulation. Released
from captivity as a prisoner of war, he had returned with a severe
heart condition and although, according to the family romance, he
constantly reforged a tender relationship with his little daughter, he
would withdraw abruptly if conflicts arose between her and her
mother. For this reason, he was virtually unavailable to the patient as
a “third party” in the process of detachment from the primary object
during the first phase of individuation. The internal and external
experiences associated with his death, as well as the mother’s radical
hysterectomy during the oedipal phase, were further severe traumas
for Mrs E. She had thereafter contracted an infantile neurosis, which,
following more traumas in adolescence, led to a psychic breakdown
when she was a young woman and consequent admission to a psychi-
atric hospital.
When the analytic work had provided Mrs E with a “psychic skin”
between herself and her love objects (and/or the analyst), when her
pre-oedipal and oedipal envy problems had become accessible in the
transference, and when the archaic aggressive impulses associated
with her basic pathology seemed to have become more psychically
integrated, it was possible for the analysis to concentrate more on her
problems of female identity (including her frigidity and psychogenic
sterility). The “Medea fantasy” now unfolded clearly in the transfer-
ence, and it became progressively possible to identify and work
through its individual components. As a result, Mrs E ceased to be
afraid of sexual passion and became capable for the first time of
having satisfying and blissful sexual experiences. She was increas-
ingly able to integrate “good” and “bad” elements of her sexual
impulses and experiences into her female core self and to feel them to
be aspects of her own feminine identity. She then became more and
more able to tolerate ambivalences in the current object relationship
with her love partner. As these inner experiences progressively
stabilised, Mrs E conceived an intense wish for children, which she

was ultimately able to fulfill with her husband after the termination of
the treatment.

Discussion and summary

On the basis of clinical observations from nine psychoanalyses and four
long-term psychoanalytic psychotherapies with female patients who
had unconsciously sought psychoanalytic help mainly on account of
their childlessness, some characteristics of a central unconscious fantasy—
the “Medea fantasy”—are outlined with reference to Euripides’s
version of the Medea myth. An extensive case history (Mrs E) exem-
plified the extent to which this unconscious fantasy determined these
women’s subjective experience of femininity. Forming an unrecog-
nised part of their own female self-representation, it was responsible
both for the profound splits in their perception and experience of their
own identity as women, and for their anxiety at their own hardly inte-
grated destructive impulses. All thirteen patients had previously been
incapable of sexual passion, which, to them, was associated with the
danger of fusing with the love object and, should they be deceived
and abandoned by that object, left at the mercy of uncontrollable,
archaic drive impulses, which were experienced as a threat both to the
autonomous self and to the object. The fantasy of endangering the
love object through “female destructive rage” was also connected with
the issue of having children—for example, with the unconscious
conviction that they would impulsively kill any child of their own.
The psychogenic sterility thus partly constituted an unconscious
protection from this risk. As outlined in the case history of Mrs E, the
“Medea fantasy” unfolded progressively in the transference, and it
ultimately proved possible, through the projections on to the analyst,
to discern and work through its individual components; Mrs E could
not otherwise have regained her capacity for sexual experience,
engaged in professional activity, and ultimately satisfied her wish for
a child.
Attention was drawn to the surprising fact, revealed by the
psychoanalytic treatments of these thirteen women, that they shared a
number of conspicuous biographical features—traumatic experiences that
had over-stimulated their unconscious, early infantile fantasies and
associated libidinal and aggressive impulses. These experiences
included severe traumas during the oedipal phase (loss of the father,

abrupt banishment from the oedipal paradise, “damage” to oedipal

rivals due to illness, destructive divorces, and the like, narcissistic
abuse by the mother during adolescence and so on). Another surpris-
ing common thread that emerged during the course of these long
treatments was that the mothers of all these women had suffered from
severe depressions during the first year of the patient’s lives and had
undergone long-term treatment with antidepressants. These serious
depressive illnesses had impressed a powerful stamp on the patients’
early self-development and the integration of archaic libidinal and
aggressive drive impulses. Fonagy and colleagues describe in detail
the pathologies of the self that babies born to depressive mothers must
develop as sheer survival strategies:

Pathology of the self arises out of an intensification of defensive

aggression, and the incapacity to tolerate one’s own destructiveness
because of the perceived fragility of the object . . . It is the combination
of the object as both fragile and dangerous which limits the child’s
opportunity to internalize a reflective or intentional stance. The
absence of such a stance further reduces the child’s capacity to contain
his own aggression. (1993, p. 480)

As the clinical material shows, my analysands had unconsciously

identified with the “dead, female bodies” of their depressive mothers,
and this had been a determinant of their psychogenic sterility. In addi-
tion, they had split off their archaic libidinal and aggressive impulses,
thereby excluding them from the process of further, differentiating
psychic development. These impulses combined—in the unconscious
Medea fantasy—with early ubiquitous bodily fantasies of a primitive,
devouring, envy-driven, destructive self. The patients subsequently
(in fantasy) ascribed their mothers’ depression to these destructive
impulses of theirs: they imagined that they had destroyed the feeding
maternal object by their envy, rage, and despair. The split-off, psychi-
cally hardly integrated impulses and fantasies determined their
subsequent psychic development. For example, against this initial
background, the early process of individuation and separation
became a life-and-death struggle: on the one hand, in the case of birth
(and pregnancy), either the self or the object but not both could
survive; and, on the other, separation from the primary object signi-
fied destruction either of the individuating self or of the (depressive)
primary object. For this reason, at an unconscious level the patients’

own bodies still belonged to their mothers, self and object boundaries
having remained relatively undeveloped. D. Stern (1995) also
describes early identificatory processes of this kind on the basis of
direct observation of interactions between depressive mothers and
their babies.
Because the children of depressive mothers cannot totally do with-
out close contact with their primary object, the only course that
remains open to them is identification, so that they ultimately align
themselves with the mother’s depression in terms of facial expression,
gesture, and affective behaviour (an example is Mrs E’s “petrified”
expression in her initial interview). Stern here also mentions the “dead
mother complex”, the reference being to André Green’s “dead
mother” concept (1983, 1999; see also Levine et al., 2013). However,
the group of patients described by Green (1999) differ from those
discussed in this paper. The mothers of Green’s patients had suddenly
become depressive after the loss of an important person in their lives
while the child was under two years old. Having abruptly lost the
capacity to engage in a responsible, satisfying, emotional dialogue
with their infants, they were subsequently experienced by their chil-
dren as “emotionally dead”. As a result, these children formed an
internal representation of a dead mother who could, without warning
and unpredictably, cut off their children’s sunshine and make their
lives meaningless. These children therefore unconsciously yearn for
the “lost early paradise” with their mothers, but are at the same time
compelled by panic anxiety to shun close relationships, which are
unconsciously associated with an early “total” object loss. Unlike this
group of patients, the analysands described here seem to use their
bodies as a protection from further trauma: their psychogenic frigid-
ity and sterility prevent “fusional” physical proximity to a love object,
which is associated with traumatic experiences in the early object rela-
tionship in the fields of sexuality, femininity, and motherhood (see
also Emde & Leuzinger-Bohleber, 2014).
Another point worth mentioning is that it was virtually impossible
for these patients to compensate for the early traumas sustained with
the unempathic, “dead” primary object because the fathers were
insufficiently available to them during the early triangulation phase.
This further impeded the process of separation from the primary
object (see, for example, Herzog, 2001; Rotmann, 1978). Many
biographical details suggest that these analysands’ mothers had begun

to overcome their depressions during their daughters’ second year of

life, and were then able to facilitate a premature, compensatory devel-
opment of autonomy in their daughters, so that the archaic destruc-
tive conflicts in these women seemed to be confined predominantly to
their fantasies of femininity.
The traumas thus sustained during the oedipal phase once again
upset these girls’ fragile psychic equilibrium: the split-off, archaic
impulses were reactivated, endowing the oedipal conflict with a simi-
lar quality to that portrayed in the Medea myth. Its focal points again
became murder and suicide—due to revenge, jealousy, and narcissis-
tic rage. The only way out appeared to be flight from the “oedipal
triangle”: like Mrs E, all my analysands had already developed a
pronounced infantile neurosis during latency. However, it was only in
adolescence, owing to the intensified pressure of the drives, and to the
process of detachment and individuation during this phase, that
psychic breakdown occurred, as in Mrs E. She developed a manifest
phobia during adolescence. As illustrated by fragments of the case
history of Mrs E, the analysand was finally able to effect a change in
the experience of female sexuality and potential and actual mother-
hood. It therefore proved essential to recognise the unconscious
fantasies if a permanent change in the female sense of self and iden-
tity was to be achieved. This chapter is therefore also intended as a
contribution to the debate aimed at securing a deeper understanding of
the “dark continent” of female sexuality (Freud, 1926e, p. 212), which,
widely documented (Blum, 1977; Escoll, 1991; Giovacchini, 1979;
Quinodoz, 1986; Shengold, 1963; Stoller, 1976; Sugar, 1979; Tyson,
1991; Young-Bruehl, 1991; see also different chapters in Emde &
Leuzinger-Bohleber, 2014 and Möslein-Teising & Thompson Salo, 2013),
is currently being conducted on an interdisciplinary basis, a discussion
which could not be summarised in the frame of this chapter.
Similarly, I have been able only to touch upon the controversies
surrounding the theoretical understanding of unconscious fantasy in
the psychoanalytic literature (on this point, see Bohleber & Leuzinger-
Bohleber, in press). The “Medea fantasy” is considered in this paper
from the standpoint of object-relations theory because, as the clinical
observations show, it incorporates both early ubiquitous bodily
fantasies and traumatic object-relations experiences. It proved just as
important to establish a patient’s individual, split-off object-relations
history as to bring out “ubiquitous biological” bodily fantasies.

Progressive insight into their biological and biographical roots thus

enabled the ten patients ultimately to discover and hence to moderate
their unconscious feminine self-image, the “Medea fantasy”—a self-
image that is reflected in Jason’s characterisation of Medea:
Tigress, not woman, beast of wilder breath
Than Skylla shrieking o’er the Tuscan sea . . .
(Euripides, 1910, pp. 74 f.).

I opted to refer to the clinical understanding of the psychodynam-

ics of psychogenic sterility in the context of this volume because, as a
clinician, I found the dialogue with the neurosciences and particularly
with embodied cognitive science as indispensable for discovering the
specific details of my analysands’ traumas, which are retained in their
bodies as unconscious “embodied memories”. The thesis, the various
versions of which are discussed in this volume (see e.g., Chapters
Two, Four, and Five), is that the body forgets nothing. Particularly
early and earliest traumatic experiences with the primary object (as
was the case in all the thirteen women described here) are retained in
the unconscious and determine—unconsciously—present experience.
As discussed in theory and illustrated by the case material, uncon-
sciously, these women protected themselves from the risk of catastro-
phes in the context of sexual passion and motherhood by their
psychogenic sterility and frigidity. After they dared to approach the
unconscious “Medea fantasy” and to understand the connected trau-
matic early experiences with their primary objects—which had prob-
ably overstimulated these unconscious bodily fantasies—they were
able to modify their concept of female self, and gradually grasp the
sense of being sexually attractive and fertile women.
Of course, the “original historical truth” of the concrete experi-
ences as (existentially dependent) babies of depressed mothers, could
not be reconstructed in a one-to-one sense—as in the analogy of
retrieving a specific piece of computer-stored information. The “truth”
has been rewritten and reformed (“re-constructed”) by new experi-
ences time and again. By contrast, I also sought to illustrate that the
historical event, namely, the particular trauma of having to deal with
a depressive mother during a certain period of life, cannot be evaded
but must be considered in any attempt to understand the “historical
traces” hidden in the current interactional behaviour of our patients
(the role of “objective” information in the postpartum depression of

Ms E’s mother etc., proved essential). The endeavour to understand

the biographical idiosyncrasies of our analysands adds important
dimensions to our clinical understanding of the specific psychody-
namics of our patients. The original trauma, the specific reactions and
inner psychic “constructs” built into unconscious fantasies, constitutes
the limits of specific re-categorisation in new interactional situations.

Reactivation of the “Medea fantasy” and its psychoanalytic

treatment with women/couples undergoing prenatal diagnostics
Introduction: “Medea fantasy”—an ubiquitous unconscious fantasy
system inevitably reactivated during prenatal diagnostic
The central unconscious Medea fantasy, described in the last chapter
in detail, is inevitably reactivated when a woman/couple has to decide
on life or death of their unborn child after a positive finding in PND.
We had the chance to investigate nearly 2,000 women/couples in an
interdisciplinary, European-wide study: “Ethical Dilemma due to
prenatal and genetic diagnostics, EDIG”. I would like to illustrate that
psychoanalysts have a specific professional knowledge and specific
professional skills to cope with this reactivation of archaic uncon-
scious fantasies. As I would like to show, psychoanalysts could thus
help women/couples in crises interventions to recognise the archaic
state of the mind in such a situation of decision-making and to return
to a more mature way of psychic functioning which is, as our study
showed, very important for the short- and long-term consequences of
such traumatic experiences.

Short summary of EDIG

These things that, by his science and technology, man has brought
about on this earth, on which he first appeared as a feeble animal
organism . . . do not only sound like a fairy tale, they are an actual
fulfilment of every—or of almost every—fairy-tale wish. . . . Future
ages will bring with them new and probably unimaginably great
advances in this field of civilisation and will increase man’s likeness
to God still more. But in the interests of our investigations, we will
not forget that present-day man does not feel happy in his Godlike
character. (Freud, 1930a, pp. 91 f.)

When Sigmund Freud published his reflections on modern civilisation

he could not yet anticipate the enormous developments in modern tech-
nology in the life sciences in the twentieth and twenty-first centuries.
Do these developments confront us more and more with new facets of
a Faustian seduction? Are we more and more “playing God” as many
contemporary critical authors of modernity are claiming?
Technology has always been, and still is, part of culture and thus
of human nature. Without it we would not be able to live and to
master our lives. However, techniques, once developed, force us to
make responsible decisions about whether and how we want to use
them. We also have to find forms of coping with the ambivalences and
dilemmas which are connected to most of modern technologies.
In EDIG we have thoroughly studied this topic in a field which is
particularly sensitive: prenatal and genetic diagnostics.
Just a short summary. Achievements in genetic research produce
ethical and moral dilemmas which need to be the subject of reflection
and debate in modern societies. Moral dilemmas are seen as situations
in which a person has a strong moral obligation to choose each of two
alternatives for action, but cannot fulfill both. Denial of ambivalences
that moral dilemmas arouse constitutes a threat to societies as well as
to individual persons. The EU wide study “Ethical Dilemmas Due to
Prenatal and Genetic Diagnostics” (016716-EDIG), which was
performed from 2005–2008, tried to investigate these dilemmas in
detail in a field which seems particularly challenging: prenatal diag-
nostics (PND). The existence of PND confronts women and their part-
ners with a variety of moral dilemmas: should they make use of this
technique at the risk of hurting the foetus by the technique itself or by
being possibly confronted with the decision for or against the termi-
nation of pregnancy? Once they have undergone PND, data regarding
abnormalities confront women and their partners with moral dilem-
mas regarding the decision on the life or death of the unborn child,
the responsibility for the unborn child, for its well-being even with
abnormalities and its possible suffering, and so on. An important
aspect is the conflict of individual beliefs and obligations and those of
society’s specific cultures. These dilemmas have not received full
attention in our societies and often remain latent, creating a source of
distress for women (and their partners) and may be a burden on the
relationships. Some couples show better coping capabilities, particu-
larly if support by competent professionals is available. However,

more research is needed to identify those with vulnerability to

psychopathology as a consequence to abortion after PND results or to
giving birth to severely handicapped children. Pathology sometimes
does not appear until years after the decision. Our study was a step in
this direction.
The study described existing care systems across participating
centres in Germany, Greece, Israel, Italy, Sweden, and the UK. Data
was collected in two sub-studies. All results were integrated into a
discourse on ethical dilemmas. Study (A) recruited two groups of
couples (positive or negative PND, total n=1,687). Experiences with
PND and connected dilemmas have been explored (questionnaires,
interviews). Results have been discussed in interdisciplinary research
groups. Study (B) interviewed psychoanalysts and their long-term
patients who showed severe psychopathologies as reactions to the
dilemmas mentioned. Results of the study help to discuss possible
protective and risk factors for women/couples undergoing PND. The
results and perspectives for training have been discussed with partic-
ipating couples, experts, the general public, and politicians in order to
develop culturally fair connected clinical practice in this field within
the EU, taking into account cultural and religious differences.
The EDIG study offered a unique chance for a multidisciplinary
dialogue between ethicists, psychoanalysts, medical doctors, philoso-
phers, and cultural anthropologists. Another innovative aspect was
the possibility that relatively detailed interviews with women/couples
after PND as well as the empirical findings based on large scale ques-
tionnaire data could be used by different authors looking at them
from different disciplinary and cultural perspectives.

Clinical examples
In our book (Leuzinger-Bohleber et al., 2008b) we have summarised
seven out of forty-five interviews with women/couples after PND in
detail. The second source have been interviews with sixteen psycho-
analytical colleagues on their psychoanalytical insights gained in
long-term psychoanalyses with women after interruptions of preg-
nancy.We tried to illustrate the broad spectrum of possible reactions
to PND in our book: for one of the women coming from a genetically
severely burdened family PND meant the chance to dare to become
pregnant at all (see Leuzinger-Bohleber & Teising, 2012). For others,

as, for example, for Mrs D, whose interviews will be summarised

below, the late interruption of pregnancy was a traumatic experience.

Example One. A severe crisis in the love relationship after pregnancy

The following interview may illustrate the reactivation of the “Medea
fantasy” and archaic kinds of guilt feelings after pregnancy interrup-
tion (trisomy 21—by the way, the most frequent reason for terminat-
ing pregnancy in our sample).

Interview with Mrs D.

I was asked to interview this woman by her partner who told me on

the phone of his girlfriend’s bad state, and her urgent need to talk to
someone. I offer her an appointment. To me, Mrs D gives the impres-
sion of a person with a capacity of bravely confronting and dealing
with even the most terrible strokes of fate. Her figure is rather
sturdy—and she proves a very sportive person. She is only twenty-
eight years old. I am impressed by her deep blue eyes and remarkably
long eye lashes, which—apparently to her own surprise—often fill
with tears during the interview (she apologises and wipes the tears
away like a courageous little girl . . .).

Five weeks previously Mrs D’s pregnancy was interrupted. She is

already back at work and “thinks that she is getting over the situation
quite well . . .” But she is now suffering acutely from hardly being able
to endure proximity or even standing close to her partner. If he had
not moved into her house, then she would have broken up their rela-
tionship and wished for “a break in their relationship for a while . . .”.
Additionally she currently cannot bear bodily contact. “This is awful,
especially for him”, she states. They find it difficult to express the situ-
ation in words. It was an unplanned pregnancy. They had known each
other for only a short time. But everything was going smoothly. She
had been very happy with him—in contrast to the relationships she
had before. Job-related as well as from their age, everything had
seemed right. And then there came unexpected information. During a
routine examination an abnormality was detected. An amniocentesis
was indicated, and the diagnosis was trisomy 21. This was a shock for
both. Neither had expected complications. Their family histories are
genetically inconspicuous and both are not yet old. They immediately

decided on pregnancy termination—which was advised by both

doctors and their families. “The childbirth was indeed painful, but I
am tough, and childbirth itself is not the problem, but the effect the
situation is having on my relationship . . .”, she explains with evident

I explain that many people within traumatic experiences regress to a

less mature way of psychic functioning, which corresponds to a rela-
tively easy shift of blame. It could very well be the case that she uncon-
sciously shifts the blame for the suffered traumatic experience to her
partner: after all he is the father of the child whose pregnancy was
terminated on purpose. She listens attentively and obviously seems to
feel relief; she asks how long such a state could last. I tell her that the
acute process of mourning can often last about one year—which is
why I can well understand her uneasiness about not wanting to make
any decisions in her present state. She is reassured to hear that this is
a well-known reaction after traumatic loss, and that it is not her
demise into a “crazy mental state”.

Within her family every upset in life has to be gallantly taken in

one’s stride. Her father, for example, diagnosed with cancer, still
appears at his shop every day in spite of undergoing chemotherapy.
At times he permits her to go home if not feeling well—but she is
aware of his disapproving glance. “Isn’t it time you pulled yourself
together now, it happened weeks ago . . .”. She assists in the family
shop. Her family has little empathy for how awful the aftermath is for
her. She herself carries a voice inside herself, telling her not to feel
so much self-pity. Then she tries to act as if nothing had happened,
tries to take her mind off things, go to parties . . . and participate in
Only when I explicitly explain that a late miscarriage is a huge
burden for most women, is she able to tentatively report her experi-
ence in more detail. She did not feel well informed about the effects of
the tablets from which she suffered vomiting and diarrhoea. Further
she did not know that pains could trigger childbirth contractions and
generally did not know what labour pains feel like. She had been to
the toilet alone and suddenly held the child in her hand, covered with
blood. She put it into the sink. Then the expulsion of the afterbirth
started (she is crying now). “Everything was covered with blood. I
cleaned everything and left the dead child there . . . It was terrible—I

felt like a child murderer” (initially she had not wanted to look at it—
and then she was confronted with it alone and totally unexpectedly).
Only when I point out how horrifying this experience must have been
for her, does she feel free enough to release her tears unashamedly.
She agrees with my impression that she unconsciously felt let down
by her partner. In any case, she cannot imagine voluntarily going
through such an ordeal once more. The thought of a further childbirth
is a nightmare to her. “What I think is that your body now might be
trying to defend itself: it is taking a rest in order to give time to your
mind to come to terms with this experience . . .” I encourage her to
take her time for the process of mourning and offer to arrange more
appointments with either myself or one of my colleagues, in case she
so wishes. She thanks me for the interview. It was of great help to her,
she says, for a better understanding of her reactions and for consider-
ing them as part of a “normal process of mourning”.

Some psychoanalytical considerations

As for Mrs D, for most of the women/couples the unexpected
confrontation with a positive finding of PND, the need to have to
decide between the life or death of one’s unborn child, and particu-
larly the experiences of a late interruption of pregnancy, have a trau-
matic quality. According to Bohleber (2000b, p. 798) experiencing a
trauma can be characterised as having to cope with a situation which
has the quality of a “too much” (in respect of the so called economi-
cal as well as the object relational model of contemporary psycho-
analysis) (for trauma definitions see Chapter One and Four).
In all the interviews the overwhelming, traumatic quality of PND
was obvious. But why do our empirical findings, which have been
summarised by Tamara Fischmann and colleagues, (2008), replicate
the findings of other studies that for around eighty per cent of the
women/couples the trauma seems to have the quality of an extreme
short crisis which can be overcome within a relatively short period of
time? And what about the other twenty per cent?
Most of the psychoanalysts that have been interviewed agree on
the following psychoanalytic considerations.
A woman (or couple) going through a traumatic situation (such as
being confronted with an unexpected, shocking diagnosis, e.g., “the
child has no face . . .”, or having to give birth to a dead child), has to
mobilise extreme forms of coping—and defence strategies in order to

“survive” the acute traumatic situation. The complexity of the situa-

tion has (for psychic reasons) to be reduced radically in order to be
able to decide and to act in the presence. One of the best known mech-
anisms for coping with trauma is “dissociation”: the self dissociates
from its emotions, fantasies, thoughts in an extreme way. It “flees”
into a different state of mind which (on the surface) has nothing to do
with the overwhelming emotions and fantasies evoked in the trau-
matic situation. The individual—at the first sight—can function
surprisingly well, is for example able to work and to cope with every-
day situations shortly after the traumatic event. But at the same time
it has lost the inner connection to one’s self, its own emotions and
thoughts, to the object (e.g., the partner) and to the “real quality of
life”. This state of dissociation is often not recognised by the individ-
ual (as for example by Mrs D) and not connected to the traumatic situ-
ation, the loss of the baby, etc. As we know from long-term
psychoanalysis such dissociative states may sometimes endure for
years and—unconsciously—determine the psychic reality of the indi-
viduals. The severely traumatised persons have never found their way
back to “normal life” again, are never ever really fully living in the
present again. They have lost the ground under their feet completely.
They do not feel connected to other persons anymore and have lost
the basic feeling of being the active centre, the drive of their own lives
(see also Leuzinger-Bohleber et al., 2008a,b). As we know from the
empirical parts of our study, around eighty per cent of persons going
through PND seem to overcome the psychic states of dissociation and
to integrate the trauma into their selves and identities often by the
help of “empathetic others” in her private lives or in therapies. But
again, what about the others?
Just some further considerations based on the classical structural
model of psychoanalysis and some newer theoretical approaches in
psychoanalysis (see Leuzinger-Bohleber, 2008a). According to clinical
observations the trauma of suddenly being confronted with life and
death of one’s own child often leads to an extreme regression into an
archaic state of psychic functioning. As Freud (1926d) has already
described, the confrontation with one’s own death or the death of a
close and beloved person (particularly one’s own child) absorbs all the
psychic energy at once. The death anxiety is the most extreme form of
anxiety that mobilises primitive coping and defence strategies. We
think of “primitive” mechanisms like denial splitting, projections and

projective identifications etc (see Moser et al., 1991). This archaic state
of psychic functioning is dominated by the so called paranoid–
schizoid position, the extreme psychic split between “bad” and
“good”; “black” and “white”, victims and persecutors, a preambiva-
lent state of the mind. Connected with this state of mind is the reacti-
vation of an archaic world of unconscious fantasies on murderers and
innocent victims, witches and saints, devils and angels, etc. The
“Medea fantasy”, mentioned above, seems to be just one example of
such an ubiquitous female (body) fantasy. The women are uncon-
sciously convinced to be the murderer of their own children, fearing
revenge and thus suffering from unbearable guilt feelings. Often also
(archaic) oral fantasies are evoked, for example, the fantasy of an oral
conception of the baby, of having poisoned the foetus perhaps by
smoking, drinking alcohol, or having taken dangerous medicaments.
We have also mentioned that the “fact” that the foetus had to be “elim-
inated” in order not to threaten the life of the mother, may evoke anal
fantasies. In other interviews and therapies we could observe that
oedipal fantasies had been reactivated by PND. Several psychoana-
lysts reported that the disability of the foetus—unconsciously—as
experienced as a punishment for ubiqitous infantile wishes (secretly
kept in the unconscious of each adult woman) to get a child from one’s
oedipal father. Thus the foetus—unconsiously—was experienced as
the product of an incestuous love relationship. The deformation of the
foetus and the interruption of pregnancy were—unconsciously—seen
as revenge or punishment for such forbidden wishes.
The regression onto this archaic level of psychic functioning with
a primitive, preambivalent logic of good and bad, right and wrong, as
well as the reactivation of the above-mentioned archaic unconscious
fantasies, may be some of the psychic sources for the unbearable qual-
ity of the guilt feelings. Unconsciously many of the patients, who had
terminated their pregnancy, were convinced to be a murderer always
expecting revenge and punishment.
From a psychoanalytical point of view, a confrontation with such
an archaic world of a murderous self and other (often the partner or
the medical doctor on which their own murderous impulses are
projected) can hardly be prevented by going through a late termina-
tion of pregnancy in which a “murdered child” is indeed part of “real-
ity”. This outside reality is then confounded with the “archaic inner
reality”. To get in touch with this state of mind and the archaic (of

course unrealistic!) quality of the fantasies and the specific psychic

functioning is a presupposition for “rediscovering” and experiencing
the complexity and the ambivalences which are always connected to
PND. Clinically this proves to be a presupposition to overcome the
trauma and the crisis and to regain psychic health.
Psychoanalysts know that in extreme (traumatic) situations, where
an individual is confronted with life and death, the inner resources of
an individual mostly prove to be insufficient. Therefore all the
women/couples undergoing late interruptions of pregnancy due to
PND absolutely need a counterpart to the archaic inner world in the
outside reality, in a loving partnership, the family, friends, but also in
the professional medical or psychotherapeutic care during PND in
order to finally overcome the regression and to regain a more mature
level of psychic functioning after a relatively short crisis. If such a
support is not given the crisis might end in a dramatic process in
which the individual needs professional help in order to overcome it.

Example Two. Crisis intervention: liaison service with a department for

PND in Frankfurt

I would like to illustrate this thesis by the second short case example.
It is taken from our experiences in a liaison service in connection with
one of the largest departments for PND in Frankfurt which was built
up after a congress 2008 in which we introduced the findings of EDIG
to our medical colleagues. We are offering crisis interventions to
women/couples during or after PND.
Mrs P was sent to me because, after a successful insemination, to
his surprise she did not show any happiness, pride, or joy but panic,
severe eating and sleeping disturbances, and other psychosomatic
symptoms. She asked for a crisis intervention (five sessions). Because
she had to stay in bed, I had to visit her at home.
Mrs P is in a miserable state when I first see her. A beautiful
woman living in a huge villa, very thin—I immediately make the asso-
ciation to anorexia nervosa—Mrs P tells me that she is not able to eat
anything and vomits all the time: she has to take infusions and to stay
in bed. She complains that ever since she has got the information that
she is pregnant she can hardly sleep and has terrible nightmares about
caring for a “monster inside of me . . . This monster is destroying

everything—my body, my job (she is a very successful business

woman), my marriage, my love for my dogs . . .”.
Her gynaecologist had told her that she, a thirty-nine-year-old
woman, already shows signs of the menopause. Suddenly she
absolutely wanted to have a baby and decided to undergo artificial
insemination. But as soon as the pregnancy was diagnosed, she was
full of panic.
Spontaneously, she tells me that she is an only child and has a very
bad relationship with her mother who seemed to misuse her as a self-
object from early childhood on. She absolutely wants to have a grand-
child. Mrs P remembers many scenes of being a very lonely child
under high pressure to be an excellent, outstanding student, violin
player, etc. Her mother seemed not to have been capable to empathise
in a “good enough way” with her needs and longings as a child. To
give just one example: each year she forced her little daughter during
her preschool years to bring her most beloved toy (a doll, a little dog,
etc.) to an orphanage before Christmas. She should learn to share her
wealth and priviledges with poor children! Mrs P reports in an
impressive way how difficult it had been to separate from this mother
and to build up her own sense of identity and autonomy. She lives far
away from her parents but has to talk on the telephone with her
mother every day. “My mother is so happy about my pregnancy . . .
she is not interested how I feel at all—my womb does seem to belong
to her again: it is her pregnancy not mine.” We can talk about her fears
of losing her autonomy and identity as well as her severe ambivalent
feelings towards her mother but also towards her own state of
“becoming a mother”. “The growing baby seems to threaten your
autonomy, your basic feeling of being a separate human being: a preg-
nancy is, of course, indeed a process of no return.” “I only feel the
impulse to get rid of all this and find back to my former equilibrium
. . . But during the nights I panic because I feel like a murderer of my
own child . . . there is no solution. Sometimes I even think of suicide
. . . In any case, I would like to terminate the pregnancy as soon as
possible—to finish this terrible physical state.” I offer crisis interven-
tions every day to Mrs P. “We know from our study that it is helpful
to have the courage to look at all the ambivalent feelings before defin-
itively deciding for or against the interruption of pregancy”, I tell her.
She agrees to wait for some more days.
In the second session Mrs P reports the following dream:

I am at Heathrow airport—pregnant, feeling horrible—and all alone

. . .. All planes have gone—I have no place to be—feel panic and want
to throw myself out of the window.

“Suicide would be a possibility to kill the monster and myself at the

same time”, she associates. I ask her to further associate: she reports
her feelings of being left alone by her husband. He has two children
from a former marriage, is much older than she is, and did not want
to have any more children. But because she absolutely wanted to
become pregnant, he finally agreed. “I felt so terribly dependent on
him—you can not become pregnant alone.” At the moment he seems
to be very tolerant—he leaves the decision up to Mrs P whether to
terminate the pregnancy or not. We can talk about the reverse of this
tolerant attitude: Mrs P feels left alone by him which strengthens her
aggressive feelings towards him—and the “monster” being the prod-
uct of sexuality with him.
Mrs P cancels the next session because she had to be hospitalised:
she was bleeding.
In the third session Mrs P reports that she felt intensive ambivalent
feelings in the clinic. On the one hand she hoped to have a sponta-
neous abortion. On the other hand she felt something like sadness. “I
am starting to have something like admiration for the strong little
monster within me—he seems to fight for his own life.” She reports
another dream:

I was in the hospital, pregnant and miserable, lying in a bed. I was

paralysed. A black nurse came: she was only dressed with a napkin
around her hip. She had huge, huge breasts. She bowed over me—I
hardly could breath because of her huge breasts . . . She had a long
injection and wanted to kill me—I woke up in panic.

Her associations lead her first to the African look of her own hair.
She was often told that her hair made her a beauty. Then she associ-
ates her mother who had become “quite fat after the pregnancy with
me. She has a huge breast—I hate this and never would like to look
similar to her.” “Pregnancy seems to mean that you are losing your
beauty and become an ugly woman like your mother.” “I am
convinced that my husband then will leave me: he hates fat women. I
am so angry that he made me pregnant—and will leave me afterwards
alone in this vulnerable state, ugly, and with a baby whom I can not

love.” “Is it possible that you are struggling with all these intensive
negative feelings towards the ‘monster’ as a product of your sexuality
with your husband, yourself, and your growing body—and perhaps
also towards your mother who did not transmit a more beautiful
picture of motherhood and femininity to you? Could these aggressive
fantasies be one reason why you (the ‘African-look woman’) kill your-
self and your little monster??” I comment.
This session seems to have an influence on Mrs P. She feels better
physically, can eat again, and starts to be up some hours of the day. In
the next two sessions it is possible to talk about all the details of the
“Medea fantasy”—her unbearable feelings of dependency and loss of
autonomy, her conviction that her husband will deceive her with
another, more beautiful, young woman, her murderous fantasies
towards herself, her partner, and the “little monster”—also in the sense
of taking revenge towards her deceiving husband and her own mother.
It is impressive that recognising and partially working through the
“Medea fantasy” has an effect on the psychosomatic and psychic state
of Mrs P: she starts to eat again, sleeps better, and even develops her
first positive fantasies of the “vital monster” and her becoming a
mother. She then decides to continue her pregancy.
After four weeks Mrs P calls me: she had a sponateous abortion.
She feels sad but also relieved that “I did not actively kill my baby son
. . . he obviously had some genetic deformation and was not able to
live. The doctor told me that I could try again to become pregnant
after six months—I will have to think about it seriously after all what
we have seen in our sessions,” she tells me.

Crises interventions: a professional offer by psychoanalysts to

women/couples after PND? Discussion and summary
As I tried to illustrated by the two short case examples, the psycho-
analyst—in a crisis intervention—proves to be a “good real object”
which helps, by his professional understanding of the world of uncon-
scious fantasies, the patient to find her way back to reality, out of the
nightmare of inner persecutions, archaic guilt feelings, shame, and
despair. Only after such a therapeutic working through is a process of
mourning—and psychic healing—possible.
For overcoming the acute crisis not only the support in the outside
reality but also a stable inner object world of the individual itself might

be a protective factor which enables eighty per cent of the women/cou-

ples to regain their psychic equilibrium, or what Kleinian analysts call
the “depressive position”, a capability to cope with mature ambiva-
lences and complexities again. If “good inner objects” can be mobilised
in the acute crisis and can be supported by the experience with “good
objects” in the outside reality, feelings of loss, guilt, and shame can be
experienced in a more mature way and lose their persecutory quality.
The other twenty per cent of women that, after PND, became
severely depressed years after the interruption of pregnancy often do
not have such protective factors (good inner objects, good ego
resources, good stable relationships in the outside reality, supporting
medical, professional, and cultural environment etc.). They had often
not gone through stable, “good enough”, early relationships and thus
were not able to develop a secure attachment pattern, the capability to
symbolise and mentalize. They have also often gone through severe
traumatisations in early childhood and/or adolescence, and suffer
from the above mentioned “embodied memories”. Particularly trau-
matic experiences with former losses (of a child or a close relative)
often prove to be risk factors. Therefore we tried to offer some diag-
nostical considerations in order to discriminate between risk- and
protective factors during and after PND.
These factors, seen from a psychoanalytic standpoint, are thus due
to idiosyncratic, biographical characteristics of one’s own inner
psychic world, which are not easy to be diagnosed because they are
not directely observable. Nevertheless, experienced clinicans learn
how to perceive (and afterwards to test) some indicators for important
features in the psychic reality. These indicators for protective and risk
factors for women/couples undergoing PND can be transmitted to
non-psychoanalytic persons, for example, medical doctors and their
staff. In the following table (see Table 2) we try to summarise some of
these indicators.

Suggestions for training of medical staff

Perceiving and reflecting on indicators for protective and risk factors
of women/couples undergoing PND could be the aims of future train-
ing of professionals involved in PND. Of course, all the above
mentioned indicators are only indicators, not “objective findings” and
therefore would have to be carefully reflected in the exchange with a
specific women/couple. Nevertheless, in the best case the knowledge

might help professionals to be “good real objects” to women/couples

in the traumatic situation after positive findings in PND, helping them
to deal with the above mentioned regressive processes into their own
inner archaic psychic world, going through the inevitable crisis in a
more or less productive way, asking for support from family, friends,
and professionals and thus increasing the probability to regain a
mature psychic level of functioning soon.
More research is needed to further test these indicators for protec-
tive and risk factors for informing couples in more detail about the
possible risks of PND, and even offering them some help in order
to prevent the longlasting consequences of (unexpected) traumatic

Containing function of culture and society for women/couples undertaking

As briefly mentioned in the introduction to this chapter, the traumatic
quality of the decision on the life and death of one’s own child often
overtaxes women and couples after PND. Helpful “good objects” in
the professional world surrounding them in this situation seem to be
very important. But many of the interviewed women/couples also
mentioned how important the public discourses on PND, handi-
capped children and, more generally, the reponsibility for the next
generation, has been for them. As is discussed in other chapters of this
volume society and culture seem to have a “containing function”
(Bion) for couples in the described traumatic situation which should
express empathy and understanding for the extremely difficult situa-
tion modern prenatal and into which genetic diagnostics may lead
individuals, individuals who are members of our society and culture,
who have to be supported and not devaluated or even condemmed for
their decisions (see also Chapter Seven). We also should not forget
that economical interests might play an increasing role in creating a
direct or indirect pressure on a couple that decides to give birth to a
handicapped child. As we have discussed in our book (Leuzinger-
Bohleber et al., 2008b) the decisions evoked by PND for or against
giving birth to a severely handicapped child touches dimensions
which go beyond the responsibility of the individual couples and have
also to be covered by society.
Table 2: Indicators

Protective Factors

Inner World Indicators Indicators during PND

Good inner objects Stable relationships with partner, Trustful, open contact with medical doctors, staff, etc.
friends, family
No severe traumatic Integrated personality (good Can communicate with medical doctors and staff in
experiences in childhood and integration of emotions, fantasies, an uncomplicated way, talks about feelings, anxieties
adolescence (“embodied thoughts, no dissociative state, etc., shows curiosity, openness for information, etc.
memories) can communicate one�s anxieties,
concerns, meets people trustfully
No former loss of child or Loss is not spontaneous topic in contact to medical doctor
close person or staff

Secure attachment Individual has access to broad Individual can show broad range of feelings (e.g., anxieties,
range of feelings, ambivalences, etc. despair, etc) when the doctor confronts it with the
problematic findings.
Depressive position Individual can perceive and express Individual can perceive and express ambivalent feelings
ambivalent feelings and thoughts and thoughts in talking to medical doctors or staff
Mature coping with guilt The self is able to withstand a Individual can talk about guilt, shame, etc. in a “mature”,
feelings sense of guilt without a basic sense adequate way
of his concept of self and self-esteem
being destroyed
Inner World Indicators Indicators during PND
Mature quality of aggression Individual can perceive and accept Individual can show or talk about aggressive, non-
his own aggressive impulses destructive impulses
because they are not associated
predominantly with destruction
Table 2: continued
Protective Factors

Stable narcissistic self-regulation Individual has stable narcissistic Individual shows a socially adequate behaviour
self-regulations in private relation- towards doctors/medical staff (can accept medical
ships, job, etc.; well-developed authority without too much submission), seems to be
autonomy, stable narcissistic self-reg: able to use information in an autonomous way.
is used with label and explanation—
thus, unclear to non-analysts
Dominance of mature defence Individual can use sublimation, In contact with medical staff person is able to show
mechanisms rationalisation, intellectualisation intellectual interest without losing emotional contact
Mature coping strategies Individual has a range of mature Individual can take up advice, suggestions by the
coping strategies for dealing with medical staff and completes them with own
difficult situations (in professional suggestions, ideas, etc.
and private situations
Sensitive to cultural and ethical Individual is capable of reflecting on Individual take up cultural and ethical questions in the
cultural and ethical issues of PND consultation with medical doctor and staff
Risk factors

Inner world Indicators Indicators during PND

Fragile, unstable inner objects Rarely good relationships to partner, Strange relationship with doctors and medical staff
friends, family, socially isolated (no basic trust, difficult communication)
Traumatic experiences in Traumatic experiences influence Not integrated emotions, signs of dissociations,
childhood and adolescence communicative style, no basic mistrustful attitude towards staff and medical doctors
trust towards partner, friends,
professionals, etc.

Former loss of child or close Person may seem depressive, anxious, talks about
person former losses
Table 2: continued

Risk factors

Insecure attachment Individual has either to deny Individual either does not show any emotions while
negative emotions (dismissed confronted with the problematic findings or is
attachment pattern) or is overfloated by panic and despair in an extreme way
overfloated by them (preoccupied
attachment pattern)
Paranoid schizoid position Individual splits in extreme ways Individual splits in extreme ways between “good”
between “good” and “bad”, and “bad”, “right” and “wrong” aspects of PND,
“right” and “wrong” aspects of decisions etc. while talking to doctors or medical staff
PND, decisions etc.
Inner world Indicators Indicators during PND

Archaic guilt feelings The guilt feelings have an archaic, individual does not seem to have guilt feelings, others
unbearable quality and therefore are blamed for the situation, one’s decision etc. indi-
have to be split off, projected, viduals often show strange psychosomatic reactions
denied, etc. instead of direct emotions
Archaic quality of aggression Individual denies, splits off, Individual can not show directly aggressive impulses
projects own aggressive impulses, or is overfloated in an uncontrolled way by them,
fears revenge, destructiveness of often individual feels to be the passive victim—
others, etc others are the persecutors
Fragile narcissistic self regulation Individual needs strong narciss- Individual seems to be in a constant vulnerable stage,
istic support by other persons, is often feels insulted (also by medical doctors, staff),
narcissistically vulnerable does not show much autonomous thinking, actions, etc.
Dominance of primitive (archaic) Psychic life seems to be dominated In contact with medical doctors the individual seems
defence mechanisms by denial, splitting, projections, to deny important information, splits between “good” and
reversal in the opposite mode, etc. “bad”, tries to project negative feelings on to others
Table 2: continued
Risk factors
Lack of, or primitive coping Individual can hardly solve Individual shows extreme helplessnes and “infan-
strategies difficult situations alone, is tile” ideas on how to cope with the difficult situa-
extremely dependent of the advice tion of PND, can hardly ask relevant questions etc.
of others
Inner world Indicators Indicators during PND
Not sensitive to cultural and
ethical factors of PND Individual seems to live in its Individual mentions strange connections between
own personal world in an extreme PND and own situation, is not capable of reflecting on
way cultural and ethical issues

How to investigate transformations in

psychoanalysis? Contrasting clinical
and extra-clinical findings on changes
of dreams in psychoanalysis with a
severely traumatised, chronically
depressed analysand

Tamara Fischmann, Marianne Leuzinger-Bohleber,

Margerete Schoett, and Michael Russ

s mentioned in the introduction of the present volume, a

A growing number of research groups throughout the world

have apparently begun to realise that the neurosciences and
psychoanalysis could benefit from each other in interesting ways. The
neurosciences are now equipped with objective, precise methods for
verifying hypotheses on human behaviour, while psychoanalysis,
based on its rich experience with patients and its unique method of
field research, has developed a variety of different models in order to
*This chapter is a modified version of a former paper by Fischmann and colleagues


conceptualise the multi-layered and complex observations that derive

from the psychoanalytic situation and to test them by means of its
specific form of empirical research, namely, clinical psychoanalytical
research. The explanatory models and insights developed by psycho-
analysis can also be of interest to neuroscientists and raise specific
research questions.
At the Sigmund Freud Institute we consider the results of the dia-
logue between psychoanalysis and the neurosciences in various ways:

a) As an interdisciplinary framework for reflecting on changes in

psychoanalyses and psychoanalytic treatments in clinical papers
(see Chapters Four and Five)
b) In theoretical papers discussing different topics of contemporary
psychoanalysis (e.g., unconscious fantasies, see Chapter Four;
memory, see Chapter Four; trauma, see Chapters Two and Three;
symbolisation and mentalization, see Chapters Four and Five)
c) As a theoretical background in the conceptualisation of our large
empirical studies in the field of psychotherapy research (e.g., the
LAC Depression Study, see Chapters Three, Four, and Five) and
the projects on early prevention (the EVA Study, the FIRST STEP
project etc., see Chapter Seven)
d) In clinical and empirical studies on the outcome of psychoanaly-
ses and psychoanalytic long-term treatments (see this chapter).

In this chapter we give a summary of an innovative attempt to

combine clinical psychoanalytical studies on changes in the manifest
dreams of an analysand treated as part of the LAC study, and the
extra-clinical investigation of the changes of dreams in the sleep labo-
ratory. As discussed in the chapter on epistemological and method-
ological problems of research in contemporary psychoanalysis
(Chapter One), contrasting findings in the genuine psychoanalytical
context (“Junktim research” according to Freud) with results obtained
by way of more “objective” instruments (investigations in the sleep
laboratory) seem both interesting and challenging.
In the introduction, Eric Kandel’s position was mentioned, namely,
that in the future it will be possible to “prove” the effectiveness of psy-
choanalyses and psychoanalytic treatments, as well as to apply meth-
ods of contemporary neurosciences. As will be shown in the following
section, many research groups have sought to realise this vision.

Neuroscientific studies on the outcome of psychoanalyses and

psychoanalytic treatment: a short overview
Margarete Schoett, a scientist at the Sigmund Freud Institute, has
collected the most important studies in this field in an overview
published in German (Leuzinger-Bohleber et al., 2015).
Further studies serve to test specific psychoanalytical concepts,
such as the studies by Gerber, (2006) and Kehyayan and colleagues
Böker and Seifritz (2012) give the following summary:

Ultimately, we still do not know how substantial the outcome variance

for the effect of psychotherapy by way of a neurobiological perspec-
tive will be. Whereas the answer to immediate leading research has, to
date, only been approximate in its initial approach, through inspired
perspectives and heuristics, the findings in neuroscientific research
have made major contributions to the understanding of mechanisms
of action and, no less, to the success of a therapy . . .
In sum, neurobiological research will make essential contribution in
the future to the discovery of mechanisms of action in specific
psychotherapeutic interventions for the identification of predicators of
responsiveness in psychotherapy (above all, also in comparison to
psychopharmacotherapy) and to obtaining risk indicators for relapse
probability. (p. 632)

To illustrate these authors’ estimations, we present one of our own

studies—the so called FRED Study.

Changes of dreams: a genuine psychoanalytical indicator for

transformations in psychoanalysis with traumatised, chronically
depressed patients
As we have discussed in previous papers, within the transference rela-
tionship with the analyst it is inevitable to revive the traumatic expe-
rience and understand its biographical (“historical”) dimension in
detail when dealing with severely traumatised, depressive patients
(see chapters Two and Four; Fischmann et al., 2012; Leuzinger-
Bohleber, in press. Only then does trauma in its enclosed, psychic exis-
tence become accessible to therapeutic work: the unutterable horror is
linked to visualisations, metaphors, and eventually to verbalisations.

Dreams are often helpful in this context: with many analysands they
convey indicators for an incipient symbolisation process and conclu-
sively the onset of “meaning giving” therapeutic coping with the trau-
In dream research, dreaming is described as a thought-process
where our inner system is engaged to process information (Dewan,
1970). Inner (cognitive) models are constantly being modified in coor-
dination with that which is perceived. In contrast to dreaming, reac-
tions to our environment are immediate during the waking state, thus
enabling information consolidation into memory only limited by
capacity restrictions of the system itself. Nevertheless, consolidation
processes do continue during sleep in an “off-line” modus, thus
enabling integration into long-term memory here as well (Fosshage
2007; Stickgold et al., 2001).
According to Moser & von Zeppelin32 (1996)—psychoanalysts and
dream researchers at the same time—so-called “dream complexes”—
activated by current events—process the entirety of information deriv-
ing from unsolved conflicts and traumatic situations while dreaming.
The dream searches for solutions, or rather for best possible adapta-
tions for these dream complexes. A dream, which is usually pictorial,
consists of at least one situation produced by a “dream-organiser”.
Dream-organisation may be considered—according to Moser—as a
bundle of affective-cognitive procedures, generating a micro-world—
the dream—and controlling its course of action. Within this system the
“dream-complex” is a template facilitating dream organisation.
Thus it may be assumed that a “dream-complex” originates from
one or more complexes stored in long-term-memory, rooted in conflict-
ing and/or traumatising experiences, which are associated with the
introjects of the individual. These introjects are closely related to trig-
gering stimuli from the outside world and structurally similar to
stored situations of the complex. The searched-for solution of the
complex is governed by the need for security and the wish for involve-
ment, that is, the security-principle and the involvement-principle,
managing the dream-organisation. Wishes within these complexes are
links between self- and object-models and RIGs (Representation
Interaction Generalised), which are accompanied by convictions and a
hope for wish-fulfilment. Conflicting complexes are areas of bundled
wishes, RIGs, and self- and object-models with a repetitive character,
thus creating areas of unbound affective information. Affects within

such an area are inter-connected by k-lines, which are blocked and

therefore not locatable. In order to solve these conflictuous complexes
it is necessary to retrieve this affective information into a relational
reality in order to make them come alive and locatable. This is
attempted in dreams, their function being the search for a solution of
the complex. This search for a solution within a dream again is
governed by the above-mentioned security-principle and involve-
ment-principle. The following illustration may serve as an elucidation
of this model. (See Figure 15)

The Frankfurt fMRI/EEG Depression Study (FRED Study)*

Could the above-mentioned “meaning giving” psychoanalytic

processes also become a part of studies based on the new possibilities
of neuroimaging studies? As already mentioned, Eric Kandel is
convinced that psychoanalysis must apply these new methods in
order to prove neurobiologically the sustainability of its results
(Kandel, 2009; and verbal accounts). Otherwise it will vanish from the

Figure 15: Memory model of conflicting complexes according to Moser and

von Zeppelin (1996)

world of science and only be remembered as a historical relic, a

memory attesting to Sigmund Freud’s enlightening spirit in the twen-
tieth century. In society it will be marginalised even though to this day
it is the most exciting and complex theory of the human spirit.
Although many scientific theoretical and philosophical arguments
could be imposed against this point of view, Kandel’s assessment is
surely correct in the sense that proving the sustainability of psycho-
analysis and psychoanalytic therapies with neurobiological tests such
as fMRI or EEGs would immediately enhance the acceptance of
psychoanalytical procedures within the world of medicine.
Keeping this in mind, we saw the opportunity of an institutional
cooperation with the Max Planck Institute for Brain Research in
Frankfurt am Main in order to additionally examine a number of the
chronically depressed patients in our LAC study33 (see Chapters Two,
Four, and Five) with fMRI and EEGs—FRED34 (at the sleep laboratory
of the SFI), which is designed as a replication of the Hanse-
Neuropsychoanalysis Study (see Buchheim et al., 2012) as an enor-
mous chance. The previously tested methods of the
Hanse-Neuropsychoanalysis Study are implemented here in combi-
nation with our sleep-dream-research. This is an on-going study,
therefore we can only give an account of our attempts to correlate
psychoanalytic and neuroscientific methods within this study by
presenting a single case study.
FRED35 (Frankfurt fMRI/EEG Depression Study) is an example of
a fruitful combination of the two domains—psychoanalysis and
neurosciences. This very ambitious project currently conducted at the
Sigmund Freud Institute (SFI) and BIC (Brain Imaging Center) in
cooperation with the MPIH Frankfurt (Max Planck Institute for Brain
Research)36 seeks to examine changes of brain functions in chronic
depressed patients after long-term-therapies, aiming to find multi-
modal-neurobiological changes in the course of psychotherapies.
When looking at depression from a brain-physiological angle,
some interesting findings have been put forth: for instance that
depression is related to a neurotransmitter disorder, or a frontal lobe
dysfunction (cf., Belmaker & Agam, 2008; Caspi et al., 2003; Risch et
al., 2009). Northoff and Hayes (2011) have convincingly put forth that
the so-called “reward system” is disturbed in depression and that
there is evidence that deep brain-stimulation can improve severe
depression (see also Solms & Panksepp, 2012).

But despite all these findings, no distinct brain-physiological

marker for depression has been found so far. It therefore deemed
plausible to pose the research question of whether changes in the
course of therapy have brain-physiological correlates, which we are
currently investigating in FRED.
Generally speaking, psychotherapists—especially psychoana-
lysts—work with what can be remembered and with recurring—
usually dysfunctional—behaviours and experiences. The assumption
is that this has precipitations within the brain, like synapse configu-
ration, priming, axonal budding, and more, giving ground to the
hypotheses of FRED that first, psychotherapy is a process of change in
encoding conditions of memory, and second, elements of memories
can be depicted in fMRI by a recognition experiment of memories
related to an underlying conflict. This constitutes the neuro-psycho-
analytic aspect of the FRED-study, of which some preliminary result
will be given in the following paragraphs. Another aspect of change
relevant for the study is that of clinical change found in dreams in the
course of psychotherapy. The analysis of dreams with the specific
method of Moser and von Zeppelin (1996)—as will be outlined—
enables the comparison of empirically elicited findings with clinically
reported ones from the therapist.
We will illustrate in the following—in an attempt to combine clin-
ical and extra-clinical (experimental) research—a single case taken
from the LAC depression study.37 I have reported the changes of
dreams of a severely traumatised, chronic depressed patient as one
indicator for therapeutic changes from a clinical perspective in
another paper (Leuzinger-Bohleber, 2013, Chapter 5). The same
patient, part of a subsample of more than 400 chronically depressed
patients recruited in the LAC depression study, was willing to spend
the necessary two nights in the sleep laboratory of the Sigmund Freud
Institute, since investigating his severe sleeping disturbances was of
clinical importance. The patient’s EEG data elicited indeed showed
pathological sleep patterns so that he had to be referred to a medical
expert for sleeping disturbances. As a result of this “therapeutic inter-
vention” in the sleep laboratory we were able to compare his dreams
obtained in the laboratory with those reported in psychoanalysis,
giving us the unique opportunity to compare changes in dreams
obtained “naturalistically” in psychoanalytic treatment with those
dreams collected in the frame of an experimental sleep laboratory.

In this paper we can only give a short overview of a model of the

generation of dreams developed by Moser and von Zeppelin (1996)
which is the theoretical background for our hypotheses, looking at
changes of dreams in depressed patients and applying a coding system
for investigating the manifest dream content based on this model. In
the following part of this chapter we relate these data to neurophysio-
logical measures associated to his dreams elicited from this patient
within the FRED study. We then focus on contrasting the experimental
findings of the changes in dreams from the sleep laboratory with those
reported in psychoanalysis regarding this single case.

The FRED-Study investigates the hypotheses that first psychotherapy
is a process of change in encoding conditions of memory, and second
that change in memory encoding will precipitate change in brain acti-
vation patterns detectable in fMRI scanning.We hypothesised that
changes in memory processing during the psychotherapy will impact
the processing of trauma related memories. In the FRED study we
aimed at highlighting changes in memory processing during the
psychotherapy, scanning depressed patients during a recognition task
involving stimuli related to an underlying conflict, at the beginning of
the psychotherapy and seven and fifteen months later. With such a
paradigm, we predicted that the contrast—recognition of trauma-
related words/sentences vs. control conditions—will highlight brain
regions known to be involved in processing self-relatedness and the
retrieval of autobiographical memory and/or emotional memory
(emotional memory; amygdala, hippocampus, prefrontal cortex,
episodic memory and processing self-relatedness; medial prefrontal
cortex, parietal cortex, temporal poles, see Legrand & Ruby, 2009;
autobiographical memory: medial frontal cortex and hippocampus)
and that such a pattern of activation will change across time and in the
course of psychotherapy. Our predictions for the session effects are as
follows: healthy control subjects without any treatment show no
significant session effects. Unfortunately, this expected change may
also be caused by simple forgetting and “blurring”, not solely due to
an effect of psychotherapeutic interventions. This is especially true for
the dream-word experiment. Therefore, a control group is needed to
observe the “normal” time course in non-treated subjects. Above that,

the experimental procedure should take into account forgetting and

blurring in the follow-up sessions by appropriate subject instructions
(see below), and the activation patterns remain constant over time. In
successfully treated psychotherapy subjects, the patterns of activation
are changing from Time One to Time Three, therefore producing
significant session effects in statistical terms. For this investigation,
chronically depressed patients were recruited with whom an
Operationalized Psychodynamic Diagnostics Interview (OPD
Interview) concentrating on axis II (relational) and a dream-interview
were conducted in a first diagnostic phase. From these two interviews,
the stimuli for the fMRI-scanning are created individually for each
patient because they are considered to be good triggers to elicit
memory of an underlying conflict. Dream-Words are taken from a
significant dream elicited in the dream interview, and dysfunctional
sentences taken from the OPD-Interview are formulated.
Measurements are taken at three different time points revealing
changes in activation-patterns occurring during the course of therapy.
At T1 OPD-Sentences and Dream-Words were elicited and patients
spent two nights in the sleep laboratory where verbal Dream-Reports
were collected in the second night after awakenings from two differ-
ent sleep phases (REM211 to REM312) and in the morning. Finally the
fMRI-Experiment was conducted using the OPD-Sentences and
Dream-Words collected previously. At T2 and T3 EEG–Sleep Lab data
and fMRI data were collected in the same manner using OPD-
Sentences and Dream-Words from T1.

At present sixteen patients with recurrent major depressive disorders
(major depression, dysthymia, double depression for more than
twenty-four months; Quick Inventory of Depressive Symptoms (QIDS)
>9 [scale range 0–27, clinical cut-off ! 6]; Beck Depression Inventory
(BDI) >17 [scale range 0–63, clinical cut-off: ! 9]; age: M=43, range 23–58
years, SD=11.57) take part in the FRED study. Patients of the FRED
study were recruited at the Sigmund Freud Institute’s outpatients
department from the LAC Depression Study (Leuzinger-Bohleber,
2013, Chapters Three, Five) conducted there, diagnosed by trained
clinicians using the Structured Clinical Interviews I and II for DMS-IV
Diagnosis (German version, 1998). Exclusion criteria were other

psychiatric conditions as main diagnosis, substance abuse, significant

medical or neurological conditions (including medical causes of
depression), psychotropic medication, and eye problems. All partici-
pants were right-handed. In both groups, depression severity and
general symptoms of psychopathology were assessed using the Beck
Depression Inventory (BDI) and the revised Symptom Check List
(SCL–90–R, Franke and Derogatis, 2002), respectively. The control-
group consists of eighteen healthy volunteers (thirteen females)
matched in age (M=34, range 22–65 years, SD=14.59). All participants
gave written informed consent.

To gather individualised and personally relevant stimuli relating to
dreams, dream interviews were performed with each subject. After ten
minutes of REM sleep, the dreamer was awakened and asked: “Can you
report a dream?” Thirty Dream-Words were extracted together with the
subject, ensuring that they reflect the narrated dreams as concisely as
possible and as close to the dream experience as possible. The dream
interviews were conducted by a trained clinician (TF) and audiotaped.
The participants were asked to memorise these words one day prior to
the fMRI-investigation. These thirty Dream-Words served as stimuli
during the fMRI-session (dream experiment). The control condition
comprised thirty accordant words taken out of a subjectively neutral
“everyday life-story”, which had no specific meaning for the individ-
ual patient, and was taken from a travel report in a newspaper article
describing a camping vacation. They were matched in length and fre-
quency of the words in the native language of the patient (Neutral-
Words). The participant was instructed to memorise these words as
well one day prior to fMRI-scanning. These thirty Neutral-Words
served as stimuli during the fMRI-session (neutral condition). All
words were presented in German.

fMRI Stimuli
Four to six weeks prior to fMRI assessment, the participant was inter-
viewed (SCID I+II, OPD), completed questionnaires (BDI, SCL-90-R),
and gave written consent to participation. At the beginning of the

fMRI session, and prior to scanning, the subject was presented with
his individual dream-words and asked whether these words
adequately represented his significant dream. To control for state
affectivity, the participant filled out the German version of the Positive
and Negative Affect Schedule (PANAS) before entering the scanner.
After scanning, a second PANAS was completed together with a ques-
tionnaire assessing on a seven-point Likert scale the extent to which
the dream-words caused emotional arousal.

fMRI experiment
The fMRI was performed using a 1.5-Tesla whole-body scanner
(Magnetom Vision) with a standard head coil and gradient booster
(Siemens, Erlangen, Germany). Applying an EPI mosaic sequence
(Tr/TE=80.7/40 ms, matrix 64x64, voxel size 3.44x3.44x5 mm, 26 trans-
verse slices, AC-PC orientation), obtaining a series (390 measurements)
of blood-oxygenation-sensitive echoplanar image volumes every 3.08 s.

Psychoanalytic dream material

Clinical case: dream series from psychoanalytic sessions and from dream
Biography and trauma history38
The patient explained in the assessment interviews that he had been
suffering from severe depression for the last twenty-five years, and
that he came to our Institute because after the last depressive break-
down he had submitted an application for retirement pension. The
doctor who assessed his application concluded that he did not require
a pension, but an “intelligent psychoanalysis”—initially a response
Mr P found highly insulting. He felt that he had not been taken seri-
ously, especially his substantial physical symptoms; the unbearable
pains covering his entire body, his acute eating disorders as well as his
suicidal tendencies. Furthermore, the patient suffered severe sleeping
disorders. Often he is unable to sleep at all. As a rule, he wakes up
after one and a half hours, or after three hours at the most. He feels
physically exhausted and is barely able to concentrate his mind on
anything (see also Chapter Five).

Mr P had already undergone several unsuccessful attempts at ther-

apy, including behavioural therapy, Gestalt therapy, “body therapy”,
as well as several inpatient treatments in psychiatric and psychoso-
matic clinics. He is among the group of patients that for the most part
seem unable to respond to psychotropic drugs, and whose relapses
occur at ever-shorter intervals and with increasing intensity. After
many consultations with various psychiatrists and neurologists, he
then discovered that only Lyrica39 enabled him more or less to deal
with his states of physical stress and his anxiety attacks.
The patient is an only child. One of the known details about his
early history is that he was a “cry-baby”. When he was four years old
Mr P’s mother fell seriously ill. He was admitted to a convalescent
home for children, evidently founded on authoritarian, inhumane
educational principles reminiscent of National Socialist ethos. Just
how traumatic an experience this stay in a home was is something that
became transparent during psychoanalysis. Mr P’s first childhood
memories revolve around the following event: he recalls how his
father took him by the hand and led him out of the home. He also
recalls how a girl had been forced to eat her own vomit.
Mr P experienced two further separations from his ill mother, but
these incidents had proven less traumatic since he had been taken in
by relatives.
In spite of the dissociative states following the traumatic separa-
tions and his social isolation, Mr P was a good pupil, who went on to
complete first his apprenticeship training and later his university
studies. During adolescence, he had a psychosomatic breakdown,
which the parents diagnosed as a “crisis in growing up”. At the age
of fifteen years, he met his first girlfriend. His condition improved. At
the age of twenty-two he ended the relationship with his first girl-
friend because he fell in love with another woman. Although the sepa-
ration ran in his favour, he reacted very severely to it. Although he
had also initiated the separation from his second girlfriend, he
suffered for weeks due to the separation. After entering another rela-
tionship he was dramatically overcome by a nervous breakdown
during a party held by his new girlfriend: he had to be taken to hospi-
tal due to hyperventilation during panic attacks.
As already mentioned: Mr P had undergone several psychotherapies.
Although all his therapies alleviated him, “neither of them cured him”.
His depression became worse and worse until it became chronic.

Clinical material: dream series elicited in psychoanalytic treatment40

Clinical dream one: first year of treatment

I catch sight of a man lying at the side of the road severely wounded—his
intestines are spewing out, and everything is saturated in blood . . . A heli-
copter appears. It is unclear as to whether the man is still being shot at, or
whether one should go to his aid. Someone appears claiming that the man
now has passed away. I notice that the man is still alive and he really does
open his eyes and enquires; why is nobody helping me? The woman
hands him a lid of a saucepan, which he should hold over his open wound
. . . I then wake up riveted by panic . . .. (Leuzinger-Bohleber, 2012,
pp. 66–67)

Clinical dream two: third year of treatment

I am gazing at a group of people all smeared with clay and who are work-
ing together on the outer shell of a house. A cold wind blows—the work
is torturous, arduous, and barely tolerable. And yet, in the dream I have
a certain sense that the men will succeed: at some point the house will be
built and provide them with a warm home. I then turn to my wife and
say: “You see, we can do it—one just has to stay together . . .”. (Leuzinger-
Bohleber, 2012, pp. 70–71)

Laboratory material: dream series elicited in the dream laboratory41

Laboratory dream one—T1 (end of first year of treatment)

I am standing on a bridge over a dam. To my right and left are steep

slopes—mountains (S1). There is a landslide. I see the slope and an entire
house approaching me very fast, rapidly sliding rushing towards me (S2).
I think to myself, that I will not be able to escape it. I am running (S3) and
am amazed at how fast I can run. I succeed to save myself from the rapidly
descending house (S3). I am in safety at the edge of this bridge (S4).

Laboratory dream two—T1 (end of first year of treatment)

There are more people in the room. I wear this cap. You three are here and
somebody else, who will come up right after me. He has a lot of preten-
sions. It is morning and I wake up. I wear this cap and am hooked up to
all those cables (S1). It is lively around me and you and the others are
walking around and talk to each other. I pick up on you whispering and

being annoyed at someone or making fun of him. The one that you are
annoyed with is in the room as well, and he is supposed to put the cap on
after me (S2). I remember that I have seen him once before in front of the
door of my analyst (S3). He is here in the room and constantly poses
pretensions. Everything should be the way he wants it. You are annoyed
that you have to fulfil these wishes (S4). I think to myself: “Just take it

Laboratory dream three—T2 (second year of treatment)

A Formula 1 race with Michael Schumacher (S1). Directly after the race he
flies to Germany, in order to inaugurate a bridge (S2). Totally bonkers. He
is in Germany and inaugurates the bridge (S3). He speaks with a few
people sitting at a table. I am sitting at the table next to it and observe him
and the others in debate (S4). How do I come up with something like this?

Laboratory dream four—T2 (second year of treatment)

I am on my way with my little son. Other children and adults are with us.
A boy is there too, who has something against my son. It is summer. It is
warm. We are walking along the banks of a river (S1). We want to buy a
wagon or trailer (S2). The children are of different ages. One boy is already
eleven or twelve years old. This boy is on edge, because the other children
and also my son are so young and they cannot do what he wants them to
do, because they are too small for this (S3). Then my mother appears. She
sews a button back onto my shirt (S4). I don’t know how this fits in. I say:
“Just leave this stupid button alone”. This unnerves me (S5). I am there to
oversee everything. A woman is there too. She is the mother of that boy (S1).

Data analysis
fMRI data analysis
The functional data was be analysed as “event related” using the
SPM99 software from the Wellcome Department of Cognitive
Neurology, London, UK, running under Unix and Matlab 5.3
(Mathworks Inc., Sherborn, MA). An event was defined by the begin-
ning of the visual presentation of an action description. All images
were realigned (for motion correction), normalised into a standard
space (MNI template, Montreal Neurological Institute), and smoothed
with a 6-mm full-width-at-half-maximum Gaussian kernel. Low-
frequency fluctuations were removed by setting a high-pass filter with

170 s cut-off, and a low-pass filter was set to hemodynamic response

function. Post hoc, the events were assigned to their corresponding
image acquisition, and these images were then grouped under the
appropriate experimental condition. For each subject, a fixed-effect
model (within the General Linear Model approach of SPM99) was esti-
mated, and the main condition effects of dreamwords>neutral words
and neutral words>dreamwords were calculated based only on events
for which the following response was correct. Intersubject variability
was taken into account by a subsequent random effects analysis of the
resulting four t-contrast images using a multisubject t-test model.
Only activations significant at p<0.001 (corrected for multi compar-
isons within a volume of 10 mm radius around the centre of each clus-
ter) are reported.

Psychoanalytical-clinical dream analysis

Dreams were analysed working with the dream associations in the
psychoanalytical sessions (see e.g., Leuzinger-Bohleber, 2012 and in
press, see also Chapter Five).

Dream-coding-analysis (Moser & von Zeppelin)

The dream-coding-method of Moser and von Zeppelin (1996) is an
evaluating system used to analyse the dream material based on their
model of cognitive-affect regulation using formal criteria to investi-
gate manifest dream-content and its changing structures (for a more
detailed description cf., Fischmann et al. 2012).
For our purpose here it suffices to know that according to Moser
and von Zeppelin the regulating processes of dream-organisation are
based on:

1. Positioning elements into the dream-world.

2. Monitoring the dream activity.
3. A working-memory containing (affective feedback-) information
of each dream-situation and its consequences.
4. Regulating procedures responsible for changes.

The coding system defines formal criteria and structures of a

dream discernable within the manifest dream narrative elucidating

affect-regulation processes of the dream: number of situations, type of

places, and social settings named in a dream (descriptions, attributes),
objects occurring (descriptions, attributes), placement, movement,
interactions of objects as well as the question of whether the dreamer
himself was involved in interactions, or if he remains spectator.
As mentioned above, two principles of affect-regulation are
assumed: first the security-principle and second the involvement-
principle, which can be discriminated by the “positioning” of
elements within the dream and through “interactions” taking place.
Common to both principles is their ruling by negative and positive
affects, that is, anxiety is the motor for an enlargement of security also
regulating involvement by, for instance, breaking off interactions and
generating a new situation. It is assumed that problem-solving can
only take place and be tested in interaction; therefore the dream tends
towards interaction.
It is assumed that the more elements used in a dream scene, the
more possibilities are available for the dreamer to regulate his affects
and contents processed in the dream. If the dream omits “interac-
tions” security aspects are dominant.

The patient Mr P confronted with dream-words in contrast to neutral
words (dream-words>neutral words) taken from the first year of treat-
ment (T1) in comparison to those of year two (T2) showed differential
activation of the precuneus, the prefrontal cortex, and the parietal lobe
(see Figure 16). Activations in these brain areas that are known to be
significant to emotional processing of the self (experience of self-
agency) largely disappeared in T2 as well as MFC activation—an area
postulated to serve as an online detector of information processing con-
flict (Botvinick et al., 2004)—but also has a regulative control function
for affective signals (Critchley, 2003; Matsumoto et al., 2003; Posner &
DiGirolamo, 1998; Roelofs et al., 2006; Stuphorn & Schall, 2006).

Psychoanalytic dream evaluation

Clinical dream one reported above is a typical dream of a severely
traumatised person where the patient himself is in a position of an

Figure 16: T1 and T2 comparison of Dream-Word-recognition in a single case


observer: the dream subject is in an extreme life threatening situation,

completely helpless, in unbearable pain—and not being helped by
anyone. In clinical dream two (two years later) the patient is the active
dreamer, observing a situation which still is painful but with hope that
“something can be done” in order to overcome a hopeless situation.

Dream-coding-analysis (Moser & von Zeppelin)

Laboratory dream one (T1) after being subdivided in its elements and
given a coding in the respective column of either the positioning field
(PF), the field of trajectories (LTM), or the interaction field (IAF)
reveals the following (see Table 3):
The first situation of this dream (S1) is coined by the security
principle—many cognitive elements are simply being placed. But it
also hosts a multitude of involvement potential as many attributes are
being named for the elements placed. In the second situation (S2) a
first attempt is made to deal with this potential—albeit rather limited
(LTM)—but again increasing potentiality by adding another attribute
(ATTR). As a result the affectivity seems to increase to such an extent
that the dream-scene has to be interrupted by a comment. In S3 the
Table 3: Moser coding sheet of laboratory dream 1 (T1)

PLACE (dam)
CEU1 (bridge)
CEU2 (mountains)
ATTR (steep)
PLACE (slope) 1 ATTR
CEU3 (house)
ATTR (rapidly sliding)

dreamer finally succeeds to invoke a “successful” interaction between

the threatening cognitive element (CEU3 (house)) and himself (SP).
Initially this leads to another interruption. The dreamer is surprised
by his capabilities and finally in S4 a cathartic self-changing interac-
tion is conjured up—he is in safety.
In summary the patient describes a threatening situation, which is
initially determined by the security-principle. The relatively sophisti-
cated description of the first scene bears potential, which the dreamer
makes full use of in order to regulate the threatening affects. The wish
to “bring himself to safety” is fulfilled in this dream.
Laboratory dream two (T1) shows characteristics of a typical
“laboratory dream”. The patient uses the research situation as an
opportunity to regulate his anxieties to be “too pretentious”. He
projects this onto an object processor (OP) turning into an observer.
Thus he successfully distances himself, which gives him the possibil-
ity to comprehend the events in more detail.
In the first situation (S1) there is a lot of potential to regulate
affects—albeit still governed by the security principle. It includes a
social setting (SOC SET), variable attributes (ATTR) and a lot of
processors inviting action. By placing another patient (OP2) into the
dream scene the dreamer (subject processor SP) gets the opportunity
to take an observational stance, which leads to a movement (trajectory
LTM) of the OP1 group of researchers in S2. S3 is regulated by the
security principle and the potential existent in S2 (LTM) cannot be
exploited in S3. In S4 finally this is achieved by an interaction just to
disembogue in another interruption. The affectivity of the situation
increases to such an extent that it has to be interrupted: the dreamer
cautions the object processor (OP2) or rather himself “to take it easy”.
In laboratory dream three (T2) the dreamer again takes an obser-
vational stance. In contrast to the previous dream he succeeds in creat-
ing a connecting interaction between two CEs, which is not
interrupted but seamlessly leads into a displacement relation.
Although this may still be considered to be a distancing manoeuvre
from an affective event, it is not as marked as in the previous dream.
The involvement principle is more distinct here than it had been
previously. The interrupt at the end of the dream is not a rebuke as
before, but rather expresses astonishment at what occupies his mind
and a (conscious) approximation to the underlying complex may be

Laboratory dream four (T2) is regulated from the beginning by the

involvement principle, which alludes to an advanced therapeutic effect.
In all successive situations more interactions appear: also connecting
self-changing relations of subjects and objects. The self-processor (SP)
himself is involved and does not have to retreat into an observing posi-
tion anymore (no IR.D)—he faces his affects increasingly. After S4 trig-
gers an interruption, the dreamer (SP) interactively “fends this off” via
verbal relation (VR). Thus we might assume that the dreamer progres-
sively deals with the affects underlying the dream-complex in an inter-
active manner and is able to depict them in dream scenes. The affects
are no longer isolated—which implies that previously isolated affects
of the dream-complex can be integrated now.
In summary, the analysis shows that the patient’s laboratory dreams
from the end of his first year in therapy were still abundant with anxi-
eties, and yearning for security making him hesitant to get involved
with others. Nevertheless in these dreams he already showed potentials
of what we might consider to be the result of the on-going therapy, that
is signs of involvement abilities, enabling him to make use of others by
projecting his fears into them and testing if he could bear the rising anx-
ieties involved in the actions he projected onto them while he still
remained in a distant observer position. In the end his fears of getting
involved dominated, for he could not yet exploit these potentials. In the
second year of analysis his dreams revealed his enhanced abilities to
get involved (laboratory dream four is largely dominated by the
involvement principle from the beginning) and were abundant with
interactions with others portraying his increased ability to face his
affects. Rising affectivity is now met, albeit still with an interruption but
followed by a dream scene of a different quality, he fends off his rising
anxiety via a more aggressive response (VR S5 in laboratory dream
four) alluding to a progressive approach to the underlying (uncon-
scious) conflict-laden dream-complex. Affects are no longer isolated
but increasingly integrated into existing memory networks.
To illustrate theses changes occurring from a more experimental
perspective the following graph might deem to be helpful (Figure 17):

Via analysis of the manifest content of Mr P’s laboratory dream series,
by applying a specific empirically validated method (Doell-

Figure 17: Relative frequency of single codes relativised by the average number of
words There is a clearly recognisable increase in potentials (PF) from T1 to T2,
which can be exploited for interaction (IAF). The finding of an enhanced ability to
get involved can be seen here by simply having a look at the manifest dreams.

Hentschker, 2008), we gained insights to his clinical improvement

corresponding to the clinical analysis of changes in his manifest
dreams as discussed by Leuzinger-Bohleber (2012), where she applied
a specific technique (cf., Leuzinger-Bohleber 1987, 1989, p. 324), which
is largely based on Moser’s memory- and affect-regulation-models.
Comparing the clinical dreams from the beginning of psycho-
analysis with those of the second year of analysis she observed
changes in the patterns of the relationships, where the dream-subject
shows better relationships with others (e.g., people helping each other in
the second reported dream). In the first dreams the dream subject had
mostly been alone: no one helped him and smoothed out his anxieties,
panics, and despair. The range of actions of the dream-subject is increased
and the emotional spectrum is enlarged (in the dreams at the beginning
of psychoanalysis we find only panic—in the third year of analysis we
also observe surprise, joy, satisfaction, humour, and yet continuous
anxieties and pain).
There is also a noted change in the dream atmosphere, with the
variety of affects as well as its increased intensities and manifest anxiety
being less frequent. The dreamer’s increased capability to perceive different

and even contradictory emotions become more and more visible. New
feelings of anger, rage, but also positive affections, tenderness, and
sexual attractions appear towards the second year of treatment. The
dream subject is no longer a (distant) observer but plays an active part
and is involved in intensive emotional interaction with others.
Furthermore, Leuzinger-Bohleber distinguished clearer problem-
solving strategies (more successful than non-successful problem-solv-
ing) and a broader range of different problem-solving strategies from the
manifest dreams. The dream-subject is no longer as flooded as in a
traumatic situation in which he experiences extreme helplessness and
lack of power. In his dreams he encounters objects willing to help and
support him. This seems to be a very important indicator that the
inner object world of the severely traumatised patient has changed
(see Leuzinger-Bohleber, 2012, in press).
The consistencies of the clinical and extra-clinical analyses are
remarkable, which from a scientific perspective is of utmost relevance.
But to be sure the clinical case study still provides greater psychody-
namic relevant clinical and structural information, as the extra-clinical
analysis suffices with the content of the manifest dreams and it has no
further biographical data at hand with which results could be
enhanced. The consistency in the finding on the other hand consoli-
dated the reliability of the clinical case analysis, which substantiates
the method of clinical case studies.
The fMRI results regarding changes in brain activation patterns
when confronted with conflict-laden dream material (dream-words)
elucidate the brain areas involved. These preliminary results point to
the precuneus and left parietal lobe when conflict is still acute. The
changes found clinically have thus found their neurobiological reso-
nance and validate them furthermore. This is further supported by the
finding that the MFC—usually involved when conflict-laden informa-
tion and control of affective signals is being processed—is no longer
contrastingly active after one year of treatment.

Concluding Remarks
By illustrating the differences between the clinical use of dreams as
an indicator for changes in the inner (traumatic) object world in psy-
choanalyses and the systematic, “scientific” investigation of laboratory
dreams by the so-called Zürich Dream Process Coding System
(ZDPCS) and by showing that these changes are also evident on a

neurobiological level these results give impressive evidence of how

psychoanalytical treatment can be evaluated enriching on an empiri-
cal, clinical and neurobiological base. The case report focused on the
importance of the psychoanalytic context of dreams, the observation of
transference and countertransference reactions, the associations of the
patient and the analysand and so on necessary to unravel the uncon-
scious meaning of the dream (Leuzinger-Bohleber, 2012). One great
advantage of the psychoanalytical clinical “research” on dreams
continues to be the understanding of the meaning of a dream in coop-
eration with the dreamer—the patient. His association, and conscious
and unconscious reactions to a dream interpretation still are the crite-
ria in order to evaluate the “truth” of the interpretation (see, e.g.,
Leuzinger-Bohleber, 1987, 1989, 2008b). To make a long story short: the
transformation of the unconscious world (like dreams)—and as prod-
ucts of it the maladaptive emotions, cognitions, and behaviours
(“symptoms”) of the patient—still remain the final psychoanalytical
criteria for a therapeutic “success” based on “true insights” of the
patient in his unconscious functioning.
On the other hand this kind of “truth” often remains fuzzy and
subjective at least in the eyes of the non-psychoanalytical, scientific
community. Therefore we have seized the unique possibility to
analyse changes in the manifest dreams—gathered in a controlled,
laboratory situation—by a theory driven, precise systematic coding
system as the Zürich Dream Process Coding System (ZDPCS) is
further supported by its simultaneous neurobiological evidence.
These analyses have a high reliability—and inter-subjectivity—and
thus may convince independent observers or even critics.

This work was supported by the DGPT, the Heidehof Foundation,
Dr von der Tann and other private donors, the Sigmund Freud
Institute and the IPA (LAC-Depression study), and the HOPE-foun-
dation as well as the RAB of the IPA. The authors would also like to
thank the two independent reviewers for thorough, thoughtful, and
constructive critiques of the original manuscript.

“Finding the body in the mind . . .”

and some consequences for early
prevention: the concept “outreaching
psychoanalysis” and some realisations

s mentioned in the introduction, the last chapter of this

A volume is given over to some of the consequences of the

contemporary dialogue between psychoanalysis and the
Neurosciences in the field of early prevention. If one takes Freud’s
thesis seriously, namely, that all psychic and psychosocial experiences
are retained by the body and determine future problem-solving, then
emotions, fantasies, and object relations could prompt many psycho-
analysts to engage in another form of “outreaching psychoanalysis” in
early prevention (see, e.g., Emde & Leuzinger-Bohleber, 2014). In all
these projects we see the enormous plasticity of the brain and the
psyche in the first months of life as a great opportunity to reach out
to children suffering from severe traumas and their families and,
through this, to implement alternative, progressive developmental
paths by way of alternative relationship experiences. As has been
impressively documented by psychoanalytic research on resiliency,
when compared to the primary object relationships, for these children
alternative relationship experiences have often proven life-saving
decades later—even though it may have been possible to only
partially offer such alternative experiences (cf., also, among others,
Hauser et al., 2006). For some of these children, inwardly, they seemed


to be like a “principle of hope” (Ernst Bloch) and, in the best of cases,

to contribute to the avoidance of psychic resignation among children,
or their attempt to overcome their suffered traumatisation by violent
and self-destructive means. In this sense, in the attempt to make
psychoanalytic knowledge available to children and their families
living on the periphery of our society as traumatised refugees, as
migrants forced into exile by war and persecution, or as losers in a
modern society chiefly determined by speed and competition, we see
ourselves in the tradition of Alexander Mitscherlich and his vision of
a psychoanalytic, cultural-critical research (Mitscherlich &
Mitscherlich, 1967).

Introduction: early prevention as a societal responsibility

In its report the OECD deplores “that migrants in almost no other

country have such a bad level of education as in Germany”
(Klingholz, 2010, p. 129). Every fourth child with a background of
migration leaves school without a certificate. Many of them become
unemployed, as are their parents, and lead a life on the fringe of soci-
ety. The societal disparity between them and other children in
Germany, who have never had it better, becomes greater and greater.
Early deprivation, violence, and the increase of psychosomatic and
mental illness such as depression and addiction are among the conse-
quences. Seventy per cent of violent criminals have themselves been
abused as children. Twenty to thirty per cent of their children, in turn,
become violent criminals (e.g., Eglé et al., 2000).
As a consequence, early and earliest prevention of so-called children
at risk has become a paramount responsibility of society. The results of
psychoanalytic, developmental psychology and neuroscientific stud-
ies, as discussed in many chapters of this volume, all concur that such
early support and intervention programs are promising and sustain-
able. Since René Spitz’s pioneering studies in the 1940s on hospitalism,
many psychoanalytic research groups have, in ever increasing detail,
studied clinically, empirically, and in interdisciplinary groups the
results of early deprivation and trauma on psychic development (see
also Emde & Leuzinger-Bohleber, 2014 ). Thus, for example, De Bellis
and Thomas (2003) have summarised many studies that verify that
the early experience of violence and emotional neglect leads to the

development of post-traumatic stress syndromes (PTSD) in children

and adolescents. They point to the fact that in the US approximately
three million children are affected by such early trauma.
Above all, the results of research on the attachment behaviour of
disorganised attached children are cause for concern (type D, see
Neubert et al., 2014). On the basis of many longitudinal studies, it has
been shown that these children will, with great probability, develop
hostile-aggressive behaviour, massive psychological problems, and
poor school achievement (Green et al., 2000; Lyons-Ruth et al., 1993).
These are the children, primarily, that have experienced extreme
trauma and violence from their primary care-givers (Fonagy, 2010a,b;
Lyons-Ruth et al., 1999).
Although further research is necessary in this area, most experts
share the opinion that it is this group of children that are most desper-
ately in need of offers of early prevention. Psychoanalysts possess
immense knowledge about the effects of early traumatising object rela-
tions and their consequences (see Chapters Two, Three, and Five). How
can this knowledge be made fruitful for such endangered children?
The Sigmund Freud Institute (SFI), in cooperation with the Anna
Freud Institute (AFI), has been involved with this question since 2003.
Jointly, we have initiated diverse early prevention projects. In all of
these psychoanalytic projects, the Frankfurt Prevention Study, the
projects Starthilfe, EVA, and currently First Steps, we link the specific
psychoanalytic, interdisciplinary, and intergenerational competency
of the research institute (SFI) with the specific competency of the train-
ing Institute for Psychoanalytical Child and Adolescent
Psychotherapy (AFI), and the knowledge and year long clinical expe-
rience with preschool children and infants. This association has made
it possible in the last years to realise these studies concerning
sustained effects in the field of early prevention (cf., Wolff, 2014). All
these projects are combining the following modules:

a) Regular supervision of the teachers in the Kindergartens

(preschool) by experienced psychoanalysts.
b) Weekly consultation of the Kindergarten (preschool) teams and
parents in the institutions themselves by experienced child
c) Child therapies offered to “children-at-risk” in the institutions
themselves (paid by the insurance companies).

d) Violence prevention programme Faustlos (second step) offered to

the five-year-olds by trained teachers.
e) Education of parents.
f) Individual support of the transmission of children from
Kindergarten (preschool) to grade school.

In this chapter I will report on our experiences in applying psycho-

analytic knowledge to early prevention in these projects (for more
details concerning the different projects, see e.g., Emde & Leuzinger-
Bohleber, 2014; Wolff, 2014; First, I
will briefly locate our own studies in the landscape of national and
international research. Considerations about the specific contribution
of psychoanalysis on the founding of extra-clinical projects on early
prevention will follow. Finally, some conceptual considerations on the
“outreaching psychoanalysis” in the field of prevention will be given.

Psychoanalysis and early prevention: some national and

international examples
As a recently published report of the German Federal Agency for
Migration and Refugees shows, most programmes of integration
support in Germany are concerned with the furtherance of language
competency of the parents and children (cf., Friedrich & Siegert, 2009).
Furthermore, some projects include the early social integration of
“children at risk” and focus partially on the migration background of
these children (Friedrich & Siegert, 2009). Only few psychoanalysts
are engaged in this field (exceptions are e.g., Karl Heinz Brisch, Emil
Branik, Manfred Cierpka, Michael Günther). Furthermore, hardly one
of these projects has been intensively scientifically evaluated from
independent scientists, a fact that endangers, among others, the long-
term financing of these projects.
The most controlled studies (the so-called RCT studies,
randomised controlled trials) were conducted in the United States.
Some psychoanalysts and developmental researchers were committed
for years in this area, the likes of Robert Emde, David Olds, and Henri
Parens (cf., Raikes & Emde, 2006; see Emde, 2014). Olds and
colleagues (2008) establish in their general review of these studies that
in the meantime a great number of international RCT studies on the

efficacy of early prevention exist, that, though many still leave various
questions open, they do, however, allow some final conclusions:

In spite of these constraints, a number of trials has been reported in

the last ten years that give us reason to believe that carefully crafted
programs aimed at improving parents’ early care of the young child
can have significant and enduring effects on children’s health and
behavioural adaptation. A number of such efforts has failed to
produce the desired effect, however, and it appears that the failure can
be traced to insufficient development of the intervention models with
clear attention to engaging parents in the program and specification of
methods for reliability bringing about changes in targeted aspects of
parenting or family context. (Olds et al., 2008, p. 356)

RTC studies have, as is well known, the advantage that, in the spirit
of the age of evidence-based-medicine, they minimise bias due to
selection factors, and may lead to worthwhile prevention projects for
society (see Chapter One). Yet, the results of individual trials convey
little about the complex interplay of different factors in early preven-
tion (see Emde, 2014). I believe we can provide important insights into
this complex and intricate interplay of factors through clinical-psycho-
analytic studies and through studies that include quantitative as well
as qualitative approaches. For this reason, in our Frankfurt prevention
studies we combine both approaches in addition to clinical and extra-
clinical (psychoanalytic) research methods (see Leuzinger-Bohleber,
2007, Chapter Two). In this way, we attempt to transport clinical
knowledge and psychoanalytic concepts based on it into non-psycho-
analytic settings, for example, in prevention projects in day-care
centres and to utilise it for the deepened understanding of children.

Psychoanalytic early prevention

Factors in the early object relations and their long-term effects
Psychoanalysis with patients with psychosocial disintegrations are a
unique clinical–empirical possibility for research in order to study the
complex interplay of the genesis of different trauma factors in early
development and their long-term effects. The insights that were won
in the long psychoanalysis with Mr A that will be briefly summarised
here, may illustrate this point.

A short clinical example42 illustrating the importance of early prevention

Mr A is a twenty-eight-year-old athletically built young man, who
comes from the Arabian world, was unemployed and socially fully
isolated when he sought therapeutic help. He said that closeness to
other people was problematic for him. “Always when someone gets
close to me, someone, for example, at an odd job or a woman, it
produces panic in me—I develop an inner compulsion to go to the
next airport in order to book any last-minute-flight to fly to any other
continent . . .”. We refer these fears also to a possible therapeutic rela-
tionship: “—I can naturally try many things to assuage these fears”, I
mentioned, following a spontaneous notion, “but I can’t take my
couch and follow you into the next airplane with it”. We could both
smile about this fantasy without it appearing to offend or to create
distance between us, which for me was an indicator that a productive
form of unconscious communication could develop between us.
During the first two assessment interviews, I could learn little
about his life history other than that Mr A is a child of a bicultural
marriage of an Iranian refugee, an engineer, and a German secretary,
a relationship that he describes as chronically unhappy. Both have had
a problem with alcohol. The father was now severely physically ill and
worked once in a while in a snack bar. The mother owned a store for
cleaning carpets that, however, was near bankruptcy. He had three
other siblings—two older brothers and a younger sister. Both brothers
have had a problem with drugs, were recurrently involved in acts of
violence, and unemployed for years. The sister still went to school and
was obese. He too suffered from “episodes of binge eating”, followed
by severe stomach colic and insomnia.
After his training as an auto mechanic, Mr A finished his high
school degree in evening school—despite attention and concentration
problems—and after two years obtained—despite extreme difficul-
ties—a Bachelor’s degree in America. He returned to Germany in
order to save his mother’s shop, without success. “Now, I myself have
been unemployed for the last year and earn some money once in a
while as a travel guide.”
I must limit myself to mentioning one of the central crises in the sec-
ond year of treatment that opened the door for us to a deeper under-
standing of the long-term effects of the multiple early trauma of the
patient. Mr A was silent for weeks on the couch. He was emotionally

less and less accessible—in the hours, dull despair and severe depres-
sion diffused their atmosphere. As I finally—after several weeks,
inwardly resigned—confronted Mr A with it, he finally broke his
silence. “Just now I saw my mother lying in a dark room, rigid and
silent—I must have been about seven-years-old. She was unable for
years to cook us a warm meal. . .” “Could it be that you put me in the
role of a depressive, helpless mother or rather, are convinced that I will
not take care of you and that it does not matter to me if you come for
your appointment or not, since you will not get anything nourishing or
vitally necessary anyway?”
It became apparent in the next sessions that the silence in the last
hours was the staging of an unconscious truth that the primary object
is unable to empathise with his despair and existentially threatening
condition and to bring him out of his psychic horror. The closeness to
the loved object reactivated apparently such an archaic longing for
being loved and understood that he felt completely flooded by it and
developed a massive fear of losing his autonomy and his self.
Connected with this was also the conviction that, in his nearness to the
loved object, he would lose control over his own aggressive, destruc-
tive impulses and either psychically or in reality destroy the object.
These unconscious fantasies and convictions stood, as we finally
found the shared understanding, in correspondence to the early
emotional neglect by his depressed primary objects and the later
cumulative trauma, among others, through the early separations, the
suicide attempt of his father, and so on.
His mother suffered after his birth from severe postpartum depres-
sion and was treated for months with antidepressants. When he was
two years old, Mr A experienced a six weeks separation because of her
hospitalisation. In the day-care centre his hyperactive and unfocused
behaviour was conspicuous and he was often caught up in aggressive
conflicts with other children. At the age of four, he was in a children’s
home for almost half a year since his mother was again depressed and
felt unable to cope. Also, during the entire time in grade school his
mother often lay in bed, as just mentioned. He had to take care of his
little sister himself. During the psychoanalysis it became apparent that
the intimate contact to the young child touched him in his great loneli-
ness and meant, therefore, very much to him. When he was in pre-
puberty, about ten years old, he had an erection when she sat on his lap,
he became frightened and was afraid apparently to lose control over his

sexual impulses: he refused from that time on to babysit his sister and
turned his attention to a group of boys that played football together.
When he was eleven years old he discovered his father after a
suicide attempt with pills and, by calling an ambulance, saved his life.
After this profound experience, he gave up all his activities in the foot-
ball club and attempted to concentrate his efforts on school. When an
idolised German teacher embarrassed him in front of the class by
reading his paper with humiliating remarks to the class, it was
another catastrophe for him: he lost the last spark of hope for a “good,
empathetic object” in his external reality that he could identify with
and thereby could have again found traces of a “good inner object”.
Thus, he also lost his interest for school, skipped classes, and became
more and more influenced by a right-wing, violent gang.
In his psychoanalysis the memory of a physical quarrel with his
father became a key scene: his father beat him up in a bar in front of
his friends. He remembered his fear of hitting back and, like one of his
friends, killing his father. This teenager had protected his mother
while the drunken father beat her. He had thrown him against a radi-
ator in such an unfortunate way that he died from severe head
injuries. After the scene in the bar, the parents refused to let Mr A live
with them any longer: he lived almost half a year on the streets, petty
crime helped him to get through, he took part in violent, right-wing
operations, took drugs, and was severely suicidal. In what seemed to
us almost a wonder, he met one of his few friends from grade school
by coincidence and he took him home. He was fondly taken in there
and he fell in love with the sister of his friend. With the help of this
guest family, he was able to extricate himself from the violent gang
and, as mentioned, began his training as an auto mechanic.
The psychoanalytic process gradually led Mr A out of his total
social isolation and unemployment and made it possible for him to
take up an intensive, stable loving relationship. Also his psychoso-
matic symptoms were fully alleviated (Leuzinger-Bohleber, 2009a).
However, a long, intensive psychoanalysis was necessary. “With how
much less effort and pain could I have been helped in kindergarten,”
Mr A said at the end of his treatment.

Early object relation experiences, trauma and resiliency

The early object relations experienced by Mr A were affected by the
multiple trauma of his parents (the fate of migration of the father, the

tragically unhappy, bi-cultural marriage, poverty, psychic vulnerabil-

ity, etc.), of the chronic depression of the mother and in connection
with it, the early emotional neglect as well as the cumulative experi-
ences of separation et cetera. They made, among others, the psychic
integration of archaic–hostile impulses within a stable feeling of self
more difficult, as well as the development of adequate affective regu-
lation processes.
Clinical-psychoanalytic research has developed, emanating from
psychoanalyses involving problems similar to Mr A, differentiated
concepts on the meaning of early object relations, on the short- and
long-term results of trauma, the impact of depressive mothers on the
early self development of the child, of the inadequate formation of
early affect regulation (Stern, 1990), as well as the risk factors involv-
ing migrant families. It goes beyond the scope of this chapter to
adequately summarise and differentiate these concepts (cf., Chapter
One; Laezer et al., 2010, 2013; Leuzinger-Bohleber, 2009a; Leuzinger-
Bohleber et al., 2008c, 2010b). Since we have a surprisingly high
number of children with a disorganised attachment type (D) in the
EVA study and this attachment type, as mentioned above, is more
often found in children with cumulative, severe early trauma, in the
following only some brief results of psychoanalytic research on the
result of early trauma will be mentioned, as well as the question how
the resilience of early traumatised children can be strengthened in the
framework of prevention programs (see last sections of this chapter).

Early trauma and its influence43

As Bohleber (2000b, pp. 803ff.) shows, the discussion about the trau-
matic effect of emotional neglect and other deficits in the early mother-
child interaction goes back to the 1950s, or rather the 1940s. The
hospitalism studies of René Spitz were mentioned above. Also, the
studies of Anna Freud and Dorothee Burlingham (1951) on the impact
of the separation of infants and small children from their mothers
because of the German bombing raids on London had a great influ-
ence, as well as the report of John Bowlby (1951) on the WHO (World
Health Organization). Bowlby had already, as a young man, observed
the influence of early attachment in his work in a home for adolescents
with behavioural problems. In his retrospective study of forty-four
thieves, he postulated that disturbances of early mother–child rela-
tionships were a determining factor in the dissocial development of

adolescents, adolescents that he characterised as “cold-hearted”. All

had experienced long separations as babies or small children. After
years of further observation of children who grew up in children’s
homes, he described, in a now famous report to the WHO, the influ-
ence of early separation and deprivation on psychic development.
Greenacre showed (1950) that happenings that have a traumatic effect
in the early, pre-oedipal phases of development can lead to severe
neuroses, that are accompanied by disturbance of the development of
the self, character disturbances, and perversions. Ernst Kris (1956)
described the subliminal continual stress that such children experience
as stress trauma. In the theoretical language of the time, the insufficient
stimulus protection was described, which the mothers gave their child,
exposing it thereby to a constant and overwhelming fear of separation
and abandonment. Hoffer (1952) described the constant conditions of
early inner stress as “silent trauma”. Winnicott (1965a,b) focused on
the traumatic consequences of maternal malfunctioning in the phase of
the self-development of the child. If the child cannot integrate the trau-
matic effects (mostly set off by a disturbance of the empathy of the
primary object), it splits off the true self and develops a “false self”,
which is then used to protect against further traumatic over-flooding
of the true self. Keilson (1979) developed the terminus of “sequential
traumatization”, since in his study the quality of object relations before
and after the traumatic loss of the primary objects by Holocaust
orphans played a decisive role. Khan (1963) spoke of cumulative
trauma, Sandler (1967) of retrospective trauma.

Early development of self and attachment

During the past decades empirical infant-, attachment-, and
mentalization-research has verified psychoanalysis’ clinical–empirical
findings through extra-clinical and experimental methods and also
stimulated new conceptualisations pertaining to socio-emotional
development processes (see Leuzinger-Bohleber, 2009a; Rutter, 2009;
Stern, 1985). Many studies have explored the affective, reflecting, and
resonating communication with the primary care-giver showing the
interplay of genetically determined, neurobiological, and socially
interactive processes (see Rutherford & Mayes, 2014). Gergely and
Unoka (2011) define early affect regulation as a social biofeedback
process. These highly fragile processes are indispensable for the
early development of socio-emotional competences. The “still-face-

experiment” impressively shows the high level of irritation in infants

when the mother’s facial expression freezes for the duration of three
minutes (see Beebe & Lachmann, 2002). The negative impact of post-
partum depression on the early mother–child interaction has been
thoroughly researched (see also Chapter Three).
The findings of empirical attachment research complement those
of infant research in many ways. For instance, the antagonism within
attachment- and exploration-behaviour as depicted by Bowlby (1969)
also reveals a high potential explaining social-emotional learning
processes. The motivation-systems cannot be activated simultan-
eously. When a child feels secure it is able to activate its exploration
system and, in order to learn, explore the surroundings. When a child
perceives danger fear is activated, hence the attachment behaviour is
also activated. The child will then interrupt its exploration behaviour
and seek out the care-giver for safety.
Many studies concentrated on the long-term effects of negative
early experiences on neglected and abused adolescents (see e.g.,
Cicchetti & Toth, 1997; Teicher et al., 2002), as well as adolescents, who
had experienced separations from their primary objects in their early
childhood and who, for example, had been placed in foster families or
orphanages (e.g., Rutter & O’Connor, 2004). Furthermore, other stud-
ies have proved the correlation between early deprivation and
emotional problems in adolescence (see Dozier et al., 2002; Gunnar et
al., 2000). As Bowlby had already emphasised, such findings are not
further surprising because of the evolutionary perspective: for
primates there is hardly any greater danger than the loss of early care-
givers, who secure their survival44. Moreover, early experiences of
deprivation are often connected with poor conditions of care in
general, as with abuse or severe neglect, either by the early care-givers
themselves or other corresponding institutions (as orphanages) (see
Dozier et al., 2002; Gunnar et al., 2000). Early emotional, physic, or
sexual neglect or abuse correlates with later affective difficulties and
problems of adaptation (De Bellis & Thomas, 2003; Teicher et al., 2002).
In all groups of adolescents after early deprivation, there was found to
be a high level of fear and an increase in the numbers of depressive
illnesses in comparison to “normal” adolescents (Cassidy & Shaver,
2008; De Bellis & Thomas, 2003; Maheu et al., 2010; Wolraich et al.,
1996). Such abnormality in adolescence denotes higher suicide rates,
anxiety disorders, and depression in later years (Pine, 2003, 2007).

Bowlby’s model has been enhanced in the last few decades by

Bretherton, 1985; Cassidy, 1985; Cassidy and Shaver, 2008; Crittenden,
1990; Main et al., 2011; Scroufe, 1996; and others. It became essential to
develop various tests examining the attachment behaviour according
to Bowlby, this was initially done by his colleague Mary Ainsworth.
This allowed the evaluation of the attachment quality of a one-year-old
child, going on two, towards its mother (or father) by means of the
“strange situation test”, a standardised observation situation
(Leuzinger-Bohleber, 2009a, p. 110). To this day a large number of stud-
ies have been conducted pertaining to the assessment of attachment
behaviour. Ainsworth’s Baltimore study showed sixty-eight per cent of
securely attached children, twenty per cent avoidant, and twelve per
cent ambivalent (type D did not yet exist). There are highly interesting
cultural variations: Type A is more common in the USA and Western
Europe than for example, Israel and Japan, where a higher ratio of type
C can be found than in other western countries. In his meta-analysis
Van IJzendoorn (see Cyr et al., 2010) compared many studies from dif-
ferent countries. Within a non-clinical population he detected the fol-
lowing ratio: fifty-five per cent securely attached, twenty-two per cent
avoidant, eight per cent ambivalent and fifteen per cent disorganised
attached children.
These attachment types are regarded as the effect of early attach-
ment experiences within the first year. The child has developed an
“inner working-model” that has proven to be successful in regard to
the primary care-giver. Due to the mother’s sensitivity the securely
attached child (B) has experienced the chance to establish a secure
relationship with her, in which the entire spectrum of human feelings
regarding the communication with another human being can be
perceived, experienced and expressed. The avoidantly attached child
(A) on the other hand experienced the mother being most comfortable
if he does not show intense affects, and behaves in a controlled,
distanced, and less affective way towards her. Throughout the first
year of his life the ambivalently attached child has experienced his
mother as partially appropriate, partially rejecting, or overbearing; in
short: inconsistent. Hence the mother’s behaviour cannot be antici-
pated by the child. Since the mothers of disorganised attached chil-
dren (D) were suffering from the effects of an acute trauma according
to the hypothesis the children were not able to acquire a stable inner
working model (see Meurs, 2014). The mothers were so psychically

absorbed by their trauma that they were hardly able to establish a

coherent attachment to their infant.
Many studies have shown that the attachment type is a central
precursor of the social–emotional behaviour. Hence a secure attach-
ment type is a protective factor for a child’s development (also see
Fonagy, 2008). This assessment bears great significance for all forms of
early and earliest prevention. As is generally known, a mother’s sensi-
tivity—the most valuable instrument in developing a child’s secure
attachment behaviour—is most fragile. As soon as a mother is affected
by stress and tension her empathic ability to relate to the inner condi-
tion of the infant, is compromised and in extreme cases even ceases to
exist. This is one explanation for the many studies finding negative
consequences for the social–emotional development within a strained
family atmosphere (see meta-analysis by MacLeod & Nelson, 2000;
the summary in Reichle & Gloger-Tippelt, 2007, p. 204). Tension
between parents affects the way they handle the children, especially
infants, in the sense of a “spillover” effect, “sometimes leading to
emotional inaccessibility, rejection, aggression, and hostility . . .”
(Reichle & Gloger-Tippelt, 2007, p. 204). Thus early prevention tries to
decrease stress factors in parents and families by different approaches.

The capability to mentalize

Fonagy and his colleagues define mentalization according to the
philosophical tradition of Brentano (1874), Dennett (1978), and others,
as a form of pre-conscious imaginative mental activity, since human
actions are interpreted by terms of “intentional” mental states.
Imaginative in the sense that we have to envision what other people
could be thinking or feeling. Admitting that we do not know what is
really on somebody else’s mind proves a high mentalization level. In
children and adolescents empathy for mental conditions of others is
important regarding social–emotional competence and a prerequisite
to not seriously injuring someone during a dispute. In order to under-
stand that the self and the other have a “mind” the child requires a
symbolic representation system of mental conditions. Even though
mentalization may be associated with a larger number of brain activ-
ities it is usually connected to the activation of the medial prefrontal
cortex—and possibly the paracingulate area.
Through various studies Peter Fonagy, Mary Target, George
Moran, Miriam and Howard Steel, Anna Higgitt, György Gergely,

Efrain Bleiberg, and Elliot Jurist found that the development of a

healthy mentalization ability is strongly connected to the attachment
system, yet they are not identical. The reliability of the early childhood
attachment to the mother is not set during the pregnancy but deter-
mined by the mother’s ability to understand her own child–parent
relationship with her parents regarding psychic conditions, in other
words her ability to mentalise (Fonagy & Target, 2003, p. 270). This
ability is not biologically provided for it is gradually obtained through
interactions with important attachment figures. Yet the authors do not
consider this ability to be solely cognitive: “Its origin lies in the
‘discovery’ of affects through the medium of primary objects relation-
ships. Therefore we have focused on the concept of ‘affect-regulation’,
which is very important in many areas of developmental theories and
psychopathology” (Fonagy & Target, 2003, p. 276).
Fonagy and Target (2003) developed several ideas regarding the
development processes concerning mentalizing (pp. 274–276):

1. During early childhood the main characteristic of the reflection

function is that inner experiences are related to outer situations
in two ways: (a) when in a serious inner condition the child
expects their own inner world and the inner world of others to
correspond with reality; subjective experiences are often
distorted in order to adapt to information coming from outside
(psychic equivalence mode); (b) a child engaged in play knows
that its inner experience does not necessarily reflect the outer
reality, yet it assumes that the inner condition is in no way related
to the outer world and bears no implications for it (pretend-
2. Around the age of four a child will usually begin to integrate
both modes and subsequently obtain the ability to mentalize—
meaning it will obtain the reflection mode—up to a point where
mental conditions can be perceived as representations. It is able
to see a connection between inner and outer reality, and simulta-
neously notices that inner and outer can be very different—they
no longer need to be equated nor dissociated from each other.
3. Usually mentalization becomes apparent when a child detects
that its experiences are reflected (mirrored by the parents or a
sibling in the form of a refinement of early mirroring processes
during the mother–child interaction).

4. This integration can fail in traumatised children due to the

intense feelings and the connected conflicts. Aspects of function-
ality are marked by the pretend-mode of the psychic equivalence.
(Fonagy & Target, 2003, p. 274.)

This last aspect is of major importance for our topic. Since

maltreatment causes the child to retreat from the abusive care-giver
and leaves it no longer willing to empathically understand the other
person’s feelings, abuse, and other traumatisations affect the develop-
ment of mentalization and reflection abilities. Also the abuse of a child
ensues the loss of resilient abilities which are connected to the ability
to understand interpersonal situations.
According to Fonagy and Target (2003), mentalization and secure
attachment result from successful containment during early socialisa-
tion, even though they are not one and the same. The ability to mental-
ize is commonly found in empathic, securely attached mothers, but
can also be found in traumatised mothers after successful psychother-
apy. The ability to critically reflect their own disorganised attachment
pattern enables these mothers to develop an “earned secure attach-
ment” and break the transgenerative cycle of relaying their attachment
type onto their children. They often have children with a secure attach-
ment pattern. Insecure-avoidant attachment on the other hand can be
seen as identification with the mothers’ defensiveness for example,
these mothers often feel incapable of mirroring the child’s experiences
of negative affects or stress, since they feel threatened and cannot
mentalize these processes. Most likely memories of personal unbear-
able experiences are triggered by the perception of these negative
effects, which cannot be monitored or coped with. Therefore the child
is solely capable of staying close to the mother by sacrificing reflection
abilities. In contrast insecure–ambivalent mothers mirror the child’s
negative affects in an exaggerated way or confuse them with their own
experiences, which seems alienating or alarming to the child. In both
cases the children will internalise the attachment figure’s conduct. The
lack of synchronisation of their own affect–condition and that of their
mother will then become the sole content of self experience.
The effects of early traumatisation on development and particularly
non-development of mentalization abilities is even more dramatic.
Fonagy (2007), for instance, gives an account of such gravely trauma-
tised children and adolescents interviewed and treated in prisons. Their

acts of violence were also conditioned by the fact that they had hardly
obtained any mentalization abilities and were therefore incapable of
empathising with their victim’s physical and psychological condition.
He refers to this as “violent attachment” or “attachment-trauma”.
He references studies indicating that the ability for mentalization
is inhibited in most people who have suffered any form of trauma.
Traumatised children do not acquire a vocabulary in order to express
feelings (Beeghly & Cicchetti, 1994), and traumatised adults have diffi-
culties understanding intentions deriving from facial expressions. The
equation of the inner and the outer is a second major aspect. In the
face of trauma dilapidated mentalization is followed by the loss of
awareness regarding the relationship of inner and outer reality. In
most cases traumatised survivors refuse to recollect the past experi-
ences because remembering means reliving.
Dissociation is the third aspect of attachment-trauma’s phenome-
nology. As mentioned before, the pretend-mode is a developmental
complement to the psychic equivalence. Not yet capable of mentally
envisioning inner happenings, child fantasies are extremely far away
from the outer world. Younger children are incapable of engaging in
make-believe (even when they are aware that it is make-believe) and
dealing with reality at the same time. When questioned whether their
imaginary rifle is a rifle or a branch it ruins their game. Especially in
dissociative experiences, Fonagy views a collapsing of an adequate con-
nection between equivalence and pretend-mode as a result of trauma
and the limited mentalization ability. Dissociative thinking inhibits any
connections—the principles of the pretend-mode in which the imagi-
nation is cut off from reality expands to the extent of nothing having
any relation (Bohleber, 2010a). Interaction with others on a mental level
is substituted by the attempt to substitute thoughts and feeling with
action (often a main reason for aggressive-destructive behaviour).

Stuart describes his feelings upon being sent to a foster home at the
age of eleven as follows: “I tried to make them understand that I was
upset, so I started throwing things around, I threw my bed out of the
window, I broke every window in the room. It was the only way of
showing them that I didn’t want to go.” Not only especially trauma-
tised children such as Stewart find a physical way of expression to be
more convincing than words—words which were also experienced as
meaningless in the pretend-mode. Following a trauma we are all in
need of a physical reassurance of safety. (Fonagy, 2007, p. 6)

With reference to early prevention, we can cull from these studies

the importance of enabling professional care-givers of children to
become more sensitive to the manifestation of trauma in children’s
behaviour and to more adequately understand these children.
A short example may illustrate this idea.
In a supervision of the EVA project (see www.sigmund-freud-insti-, the team reports with distress about a five-year-old Chinese
boy, whom they described as autistic. He plays mostly by himself,
repetitively places, hour after hour, the same animals in the same row
behind each other, hardly talks with another child or the day-care
personnel, or completely flips out if he is disturbed in his repetitive
activities or is merely interrupted. For this reason, the teachers do not
take their eyes off of him. The provocation of his bizarre, strange
behaviour is too great for other children to enter into his world or to
intentionally disrupt him, which regularly ends in extremely aggres-
sive conflicts, often with injuries.
The day-care personnel found out that the little boy is not physi-
cally touched either by his mother or his father, for example, he is not
embraced by them. They did not want to give him any time to adjust
to the situation in the day-care centre, but deposited him one day with
the expectation, that he should stay six hours in the facility right from
the start. As it turned out, Li had been brought shortly after his birth
to his grandparents in China and lived there in the country for three
years in poverty. Presumably, he experienced little emotional warmth
since his grandparents worked more or less the entire day in the
fields. When he was three years old, his parents brought him to
Germany so that he could go to kindergarten (preschool). Tragically,
his father became severely ill shortly after the boy’s arrival. The
parents, who were self-employed, had to give up their jobs and now
live off welfare. Li has been in several other facilities, but the parents
took him out again as soon as the day-care personnel mentioned his
Li has apparently experienced diverse, severe trauma. His seem-
ingly autistic defence could be an attempt to cope with the trauma.
Due to their joint understanding of the inner and outer situation of Li,
it was possible for the day-care centre team to motivate the parents to
allow Li to be given a psychological and paediatric check up and
subsequently an analytic child therapy. For the facility, an application
for integration measures was made as otherwise Li was not tolerable

in the facility. After two years of psychotherapy, Li had notably

changed: he had become less isolated, had made two friends, and
made “exceptional growth in his development” (teacher A). The
parents have joint weekly sessions with the child therapist, which, as
they express it, is a big help for them to cope with the illness of the
father but also with their fate as migrants.

Early object relations and resilience

In the example described above, it was possible to work together with
the parents and to treat Li’s trauma in an analytic child therapy. As
already mentioned we found a very high number of “children-at-risk”
in the sample of the EVA Study (for more details see www.sigmund- we had only thirty-three per cent securely attached
children in our sample (compared with around 55–60% in normal
populations) and thirty-eight per cent children with the attachment
pattern C and D, which means, “children-at-risk”, which are in danger
concerning their future development if they do not get any
psychotherapeutic or psychosocial support.
As expected, only about the half of the parents of those children,
who urgently need a psychoanalytic therapy (D Type and C Type) in
the framework of the EVA project agreed to the treatment. Can we
even reach the other fifty per cent of children at risk (most with a
disorganised attachment type) through other modules of our preven-
tion offers? And if yes, then how?
Some results of psychoanalytic and non-psychoanalytic resilience
research give us cause for some hopeful considerations in this context
that will be briefly outlined here. Since we have dealt with research on
resilience and the role of early prevention more thoroughly in another
paper (Leuzinger-Bohleber et al., 2008c), we will restrict ourselves
here to two of the most relevant psychoanalytic long-term studies: the
study of Hauser and colleagues (2006) and the catamnestic investiga-
tion of the study of Brody and Axelrod by Henry Massie and Nathan
Szajnberg (2006).
The research group of Stuart Hauser conducted a comprehensive
follow-up study of 150 adolescents, who had been hospitalised in a psy-
chiatric clinic because of drugs, violence, and suicidal tendencies.
Within the scheme of the so-called “High Valley Resilience Study”, the
researchers conducted yearly interviews over a longer period of time
(since 1978) with the 150 teenagers. Half of these teenagers were treated

in the psychiatric institution, the Children’s Center of High Valley

Hospital. Approximately twenty-four children between five and sev-
enteen years from widely different milieus, from different parts of the
US were placed here. Some of the children suffered from psychosis or
autistic disturbances, many from depression. Some presented neuro-
logical problems (Tourette Syndrome). All of them had one thing in
common: they had uncontrollable anger and were violent.
For the authors, it was the most amazing result of the follow-up
study, that some of these children, despite their poor prognosis, had
developed into “normal adults”. In order to understand the reasons
for these unexpected developments, sixteen adolescents were more
carefully examined again. Nine of them had, for the most part, recov-
ered from their severe adolescent crisis. In extensive case studies, the
authors reported on four of the former patients. In former times
researchers explained such amazing positive development with the
idea that with these children had especially strong personalities,
who—presumably because of their genetic predispositions—despite
adverse conditions, found the strength to adjust to the demands of
later realities. Hauser and colleagues (2006) call this conception an
idealisation. It was in lieu of a more adequate definition of resilience.

For children of adversity are wounded, often severely. To imply other-

wise is to deny the acuteness of suffering in children, who don’t
“come” resilient but become resilient—after they have been hurt.
There is no shield that keeps them safe from all harms, no intrinsic
toughness such as the older terms implies. It is not the illusionary
toughness such as the older terms imply. It is not the illusionary
vulnerability of resilient children that should command attention and
respect, but their powers of self-healing. And these are powers that
vary with circumstances, people’s styles of adaptation change and
evolve over their lifetimes. (Hauser et al., 2006, p. 4)

In order to speak of resilience, therefore, two conditions must be

fulfilled: first that such a person develops normally, and second that
this person was faced with the great risk of not being able to overcome
this grave misfortune and adversity by his own strength. In the study,
thirteen per cent were diagnosed as “resilient”, using objective test
criteria. The authors see—with reference to studies on the Adult
Attachment Interview (AAI)—cues, most of all in the narrative
specifics of the stories of the teenagers, that resilient children, despite

their experienced trauma, possess to some extent an inner relatedness

to other people. They infer, among other things, that resilience cannot
solely develop from an inner strength of these children, but that at
least some “good enough” object relations are necessary.
These hypotheses were tested by the authors through detailed
analyses of the teenagers’ lives. They discovered that resilient chil-
dren—in contrast to those whose careers ended in criminality, drug
addiction, or mental illness—had at least one reliant, good experience
of a relationship (to a grandmother, a neighbour, a befriended family).
These positive relationships were experienced by the children as a
source of hope, that protected them inwardly from psychic resigna-
tion and capitulation. They built up a counter-balance to the experi-
ences of violence and to the severe trauma that they were at the mercy
of for years.
In most of the cases described by Hauser and colleagues the non-
familial, to some extent also professional attachment persons,
contributed to the psychic survival of these children. These results
seem to underscore the already briefly mentioned clinical-psychoana-
lytic experiences that, especially for children from problem families,
non-familial positive experiences of relationships, also when they may
seem to be very rudimentary, are not to be underestimated. In the best
case, they can, though unnoticed, ensure the psychic survival of these
children. Therefore with our prevention studies we connected the hope that
it might be possible also in the restricted framework of a study—because of
the experience with an empathetic, reliable adult—to open a window of hope
in their dark, childish world. However, this attempt, as we have seen
again and again in all prevention studies, often involves enormous
feelings of insufficiency for the day-care personnel, since the offers of
help seldom seem to reach the children. Often, only years later are the
positive long-term effects observable.
Thus, it was at the same time always clear, that, at best, we could
help children not to lose their courage to turn to the world of the
adults and to hope for a future worth living for themselves. The
suffering under the partly unbearable reality of their childish every-
day life should not, though, be denied or trivialised (see e.g., von
Freyberg & Wolff, 2005, 2006). There is indeed a certain danger in the
use of the term “resilience”. Thus, Henry Massie and Nathan
Szajnberg (2006), for example, showed in their impressive study, that
traces of psychic and physical abuse, and experiences of violence can

still be found in those adults, who—according to the criteria of

resilience research—had developed surprisingly well. The authors
conducted a follow-up study thirty years later of those infants, whom
Sylvia Brody and Sidney Axelrad had studied. They write in
summary: “Resilience, however, may be a superficial concept, for, in
this series of cases, seemingly adequate coping in formerly mistreated
children always came at the price of emotional vulnerability and
compromised potential” (Brody & Axelrad, 1978, p. 471).

The concept of an “out-reaching psychoanalysis” in the

prevention studies at the Sigmund Freud Institute: some historical
and conceptual remarks
Can the immense knowledge of psychoanalysis about early develop-
ment be made useful for early prevention dealing with children at risk
that live on the fringe of our society? And how? These questions are
in the centre of all our preventions programmes (see Lebiger-Vogel
et al., 2014; Neubert et al., 2014; Wolff, 2014).
We know that, with this concern, we are again taking up an old
tradition in psychoanalysis if we think of some of the famous person-
alities of “applied psychoanalysis” or “ psychoanalytic pedagogy”,
such as August Aichhorn, Bruno Bettelheim, Anna Freud, Fritz
Redlich, Chezzi Cohen or, in Frankfurt am Main, Aloys Leber. Yet, we
will not place the main emphasis here on historical reflection, but on a
description of a new attempt to connect clinical and extra-clinical
research in this area. Being identified with a “research-oriented atti-
tude” (Leuzinger-Bohleber, 2007), we attempt to offer psychoanalytic
experiences and concepts to traumatised children, their parents, and to
the day-care personnel in day-care facilities in areas with greater social
problems. In contrast to earlier approaches, above all of the psychoan-
alytic pedagogy, we are pursuing, for example, in the EVA Project, a
kind of “out-reaching psychoanalysis”, a psychoanalysis that goes into
the field in order to understand in a more differentiated manner the
unconscious processes in certain children, in the group, and in the
team—jointly with the day-care personnel. A differentiated under-
standing of complex, mostly unconscious processes seems to us to be a
prerequisite for an adequate, professional “containment” in this diffi-
cult field. These processes manifest themselves in the individual child

in its idiosyncratic behaviour towards the teacher and other children—

alone or in the group—and mobilise in the teachers many different
affects, countertransference reactions, projections, and projective iden-
tifications as well as fragmentations and wishes for expulsion (see
examples above). As we have briefly mentioned with reference to the
psychoanalytic resilience research, we hope through such a “out-
reaching psychoanalysis” to enable the day-care personnel, despite the
daily overload and often frustrating, institutional structures, to offer to
the many traumatised children in their facilities (above all for many
disorganised attached children) an alternative, supportive object rela-
tion, that could be decisive, in the best case, for the future development
of these children. Thus, the deeper understanding of certain children
builds the centre of the supervision every two weeks and inculcates, as
we hope, a psychoanalytic view of certain children and their specific
(traumatic) stories.
A second dimension of “out-reaching psychoanalysis” is created
by the presence of an experienced child therapist in the facility one
day a week. She offers the team and the parents in single consultations
her professional understanding and the possibility for reflection, as
well as her broad psychoanalytic knowledge about early development
and its disturbances, trauma, migration, etc. In single cases, child ther-
apies are conducted in the facilities (with the concomitant counselling
with the parents) since these families generally do not find their way
to private psychoanalytic practices. As far as we know, this is a new
possibility to provide children and their families with psychoanalytic
experience and competency in therapies directly in the facilities. In
contrast to the approaches of psychoanalytic pedagogy, a psychoana-
lytically based concept of education is not introduced, but rather a
professional dialogue is induced: the day-care personnel fulfil their
educational obligations (including aspects of social work, the contact
with the youth welfare office etc.)—and the analytic supervisors and
child therapists carry out the psychoanalytic supervision and/or ther-
apies. The competencies are not mixed together, but are used in a
mutual exchange to understand the psychic and psychosocial situa-
tion of certain children and finally in a joint consultation to advise
how the child and its family can best be supported. The day-care
personnel are still day-care personnel; the supervisors still supervi-
sors, and the therapists still therapists. The professional identities are
respected: the professional exchange is on equal terms.Therefore we

speak of the “research-oriented attitude” of the analytic child thera-

pists and supervisors who work in the prevention projects with chil-
dren and families. These families are often strange and new to them
in comparison with clientele in their “normal psychoanalytic prac-
tices”. For this reason, the specific unconscious fantasies and conflicts
of these children, who come from other cultures and classes of the
population, must first be jointly psychoanalytically studied and
understood. In regular meetings of the supervisors and therapists, it
becomes very clear: all professional colleagues experience the study as
truly a new chance that rouses curiosity and interest, but often also
insecurity and self-doubt. Thus, as a rule, it is especially difficult, to
motivate the parents of these children at risk to work together with us
and to adjust the treatment technique to the unusual setting and the
often unusual children.
In the EVA project we have the unique chance, in the scheme of a
model project, to connect this clinical-psychoanalytic research with
extra-clinical research, the evaluation of “Early Steps”. In this context
we could not deal with methodological questions (see Wolff, 2014), but
can only mention that we use, among others, a new instrument to diag-
nosis the attachment type, the MCAST (Manchester Child Attachment
Story Task). As is well known, it is the merit of attachment research,
that it attempts to describe the central psychoanalytic concepts, such as
the inner object world of children and central unconscious fantasies, in
one terminology (inner working models, attachments types, etc.), that
is understandable and empirically verifiable for the non-psychoana-
lytic world. We consider it to be new that, on the one hand, we bring
together psychoanalytic concepts and clinical, psychoanalytic knowl-
edge in the supervision and therapies as professionally and with as
much differentiation as possible. On the other hand, we employ such
attachment classification instruments, as the MCAST, for extra-clinical
research without melting together the two research fields and episte-
mological key beliefs. In contrast to other early prevention projects as,
for example, Circle of Security (Ramsauer, 2010) we do not attempt to
adapt theoretical attachment theories into practical (“manualised”)
instruction for day-care personnel and parents, but see ourselves in an
open and critical dialogue with these theories and the corresponding
empirical results. To choose just one example again: we have
mentioned the many disorganised-attached children of our sample.
Clinical-psychoanalytic knowledge about these traumatised children

would assume analogous conclusions like those from attachment

research on the disorganised attached children: These children exhibit
a high risk for their development and need intensive educational
and/or psychotherapeutic support. For this reason, among others, we
use the results of the MCAST to systematically identify these children
in our sample. In a second step we attempt, however, to regard these
children, their unconscious object world, their fantasies and deficits in
their development from a psychoanalytic perspective (e.g., in the case
supervisions), that allows us to see a much more differentiated picture
of the psychodynamics of the single child than that of the attachment
theory, which only diagnoses four different basic types of attachment
patterns. We attempt to motivate all disorganised children and their
families for an analytic child therapy. If they are not ready to accept
this support (or as an addition to therapy), we search for alternative
possibilities such as individual pedagogical care, using the existing
social resources to accompany these children in the transition between
Kindergartens and grade school (see above and more detailed descrip-
tion of the prevention projects, see Wolff, 2014).
The conceptualisation of “out-reaching psychoanalysis” can also
be transferred to other fields. Later results of our model projects could
offer a scientific legitimation for this. The model project, with its
connection between clinical and extra-clinical research, is, however,
only possible, as we see it, through the unique institutional coopera-
tion between a psychoanalytic research institute, the Sigmund Freud
Institute and the Anna Freud Institute (former Institute for
Psychoanalytic Child and Adolescent Psychotherapy) with its rich
clinical experience and professional knowledge. We regard this
“psychoanalytic sibling relation” as a special chance that, however, as
it is among siblings, needs constant reflection and libidinous caring.
This reflection is assuaged through our joint political engagement for
children with endangered childhoods.

1. A change of paradigms is always connected with a change of research

methodology. One fundamental criticism of the storehouse metaphor
characterising the so called “classical cognitive science” came from
biologically oriented memory researchers. From a perspective of adaptive
behaviour, they argued that living systems could not survive in a
constantly changing environment if memory would function like a
computer. Living organisms are forced to adapt constantly to new situa-
tions transferring knowledge gained in past situations to new ones which
are never identical. Therefore constructive, adaptive processes are indis-
pensable. The organisms can be characterised as self-learning and self-
regulating systems in constant interaction with environment (see Chapter
Two of this volume).
2. A fascinating book by Michael Hagner (2004) discusses the enormous
influence of the neuroimaging techniques onto current science and soci-
ety. The fantasised possibility “to have a direct look into the living and
working brain” involves a huge seduction and fascination. It may, for
example, mobilise the fantasy to gain new and direct diagnostical possi-
The alteration [from psychoanalysis to the application of neuroimaging
techniques] could lead to the danger that the variety and relevance
of mental life will be evaluated according to their possibilities to be


visualized . . . The prize for such a development is that the investigation

of the deeper connections, correlations, explanations, calculations and
narratives, in other words the historical, scientific, textual linear think-
ing, will be displaced by a new, visualizing, “superficial” kind of
thought. In respect to the sciences of human beings this means that the
“deep digging”, for which pychoanalysis stands, could be replaced by
superficial insights into neuroimaging pictures. Whereby the under-
standing of human beings would turn into an “externalization of mate-
rialized forms of representation”. I don’t mean that the subject will be
eliminated, but another anthropology could turn into reality which—in
a double sense of the word—would produce structures of the surface.
(pp. 278–279, translation: M. Leuzinger-Bohleber. (See also Hanly, 2008;
Leuzinger-Bohleber & Fischmann, 2006.))
3. The German expression “Wissenschaft” means “creating knowledge”, a
formuation which indicates that “Wissenschaft” should not be equated
with (natural) science as some US authors postulate.
4. The method of psychoanalytic expert “validation” is very close to clinical
practice. Supervision and intervision groups, as well as courses with
candidates or IPA members, could be systematically used to expertly
validate ongoing psychoanalyses and document the knowledge gained in
extended case reports with different theoretical foci. In my view, this
would be a contribution to improving clinical psychoanalytic research in
contemporary psychoanalysis.
The method has been developed in the frame of a large retrospective
study on the long-term outcomes of psychoanalyses and longterm
psychoanalytic psychotherapies, the so-called “DPV Katamnesestudie”
[Follow-up study of the German Psychoanalytic Association]. In this
study, we investigated a representative sample of all the patients who
had terminated their psychoanalyses and psychoanalytic long-term
psychotherapies with members of the DPV between 1990 and 1993
(n=402 patients). We applied a large variety of different instruments,
questionnaires, psychological tests, analyses of “objective data” from the
health insurance companies, and intensive psychoanalytic follow-up
interviews. The study led to important results: for example, around
eighty per cent of all the treatments showed—on average six years after
termination—a good outcome according to the evaluations of the former
patients, their analysts, independent analysts, and nonanalysts, as well as
“objective information” concerning mental health data (significant reduc-
tion of costs by a significant reduction of days off work, days spent in
hospitals, etc.; see Leuzinger-Bohleber et al., 2002a, 2003b). But the
most important, often unexpected insights were gained through the 200
intensive, psychoanalytic follow-up interviews with the former patients

and with their former psychoanalysts by independent psychoanalytic

interviewers. The interviews were mostly tape-recorded or, if patient or
analyst did not consent, carefully documented directly after the inter-
view. This documentation proved to be a unique and rich source for
psychoanalytic and non-psychoanalytic insights (particularly concerning
the tragic findings of the four per cent of the psychoanalyses with nega-
tive outcomes). The richness of the interview material confronted us with
the methodological challenge of how to summarise and communicate the
complexity of the conscious and unconscious discoveries of these inter-
views in a critical way that would be transparent, reliable, and acceptable
by members of the psychoanalytic, as well as the non-psychoanalytic,
community. In this context, we developed the so-called psychoanalytic
expert validation, which proved to be a very helpful and convincing
method to summarise the psychoanalytic findings of the follow-up inter-
views. I shall briefly describe the method.

i) An expert group of psychoanalysts (6–8 members) was constituted

and met regularly for two hours a week. It was important that we had
a good mixture of very experienced and relatively young psychoana-
lysts who also had different theoretical preferences (Kleinian, British, or
American object relational theories, modern ego psychology, self
psychology, etc.)
ii) One psychoanalyst (A) of the group met a former analysand for two
psychoanalytic interviews (following an open psychoanalytic tech-
nique, with certain questions to be asked at the end of the second inter-
view). Between the two interviews, he had a supervision with another
member of the group (C) in order to understand his transference–coun-
tertransference reactions, associations, psychodynamic hypotheses, etc.,
and “test” them by means of a psychoanalytic interpretation, if possi-
ble, in the second interview. Because of confidentiality reasons, it was
important that the former patient lived in another city and that his
analyst was not known to the interviewer and the supervisor.
iii) Independent of these interviews with the former patients, another
member of the group (B) interviewed the former psychoanalysts
(mostly by telephone in order to guarantee the confidentiality and the
anonymity of the analyst).
iv) The group met for a two-hour session (close to the dates of the inter-
views), adhering to a clear procedure: (a) interviewer A summarised the
two follow-up interviews with the former patient (approximately
twenty minutes); (b) the group listened to five minutes of the tape-
recorded interview (if possible); (c) free association in the group about

the unconscious and conscious communication of the former patient to

the interviewer, and of the interviewer to the group (by carefully observ-
ing one’s own transference–countertransference reactions, association,
etc.). Analysts A, B, and C did not participate in this round of “free asso-
ciations” (about ten to fifteen minutes); (d) analyst B summarised his
telephone interview with the former analyst of the patient (about ten
minutes); (e) each member of the group filled out questionnaires focus-
ing on the outcome of the treatment (Scales of Psychological Capacities,
by Wallerstein et al., and some other short questionnaires) (about five
minutes); (f) the group associated further about the clinical material,
focusing on questions concerning the outcome of the psychoanalysis or
the psychoanalytic long-term treatment (thirty minutes). Possible
controversial clinical aspects were registered, discussed, and not
harmonised; (g) one member of the group summarised the group
discussions and the different positions after the session and sent it to the
members of the group; (h) at the beginning of the next group meeting,
this summary was briefly discussed. Statements of agreement and
disagreement were documented; (i) the summary of the “case history”
based on the follow-up interviews with the former patient and his
analyst, as well as the group discussion and the questionnaires, were
written up by one of the group members and given to the other members
of the group for correction, modification, etc. Still open controversial
perspectives were discussed and again documented instead of being
The psychoanalytical expert validation proved to be very helpful for
the publication of the many follow-up interviews (see, e.g., Leuzinger-
Bohleber et al., 2002a). Compared with other methods (e.g., content
analyses of the interviews, linguistic analyses, method of “Typenbildung”,
by Stuhr et al., 2001), the method was relatively time saving and econom-
ical. It helped to condense the complexity of the clinical material in a
functional way, taking into account possible “blind spots” of the inter-
Because the method takes up the genuine psychoanalytic tradition of
supervision and intervision, it was well accepted by the psychoanalytic
colleagues. Many of them told us how fruitful and interesting the group
sessions and the joint endeavour had been for them, being able to under-
stand the retrospective view of former patients and their analysts of their
psychoanalyses as well as their outcomes (and limitations), and how
much they had learnt by carefully listening to former patients and

5. Depressions in adults have similar features. The prevalence depends on

the definition used and on the population samples. Using ICD-10 criteria
for depression (excluding adjustment disorders and dysthymia) the
Office of National Statistics (Singleton et al., 2001) survey of psychiatric
morbidity for the UK gives the number affected at any one time as
26/1000 (23/1000 male and 28/1000 female), the peak being between the
ages of thirty-five and fifty-four years. Adults with depression are more
likely to be divorced or separated, living alone or as a lone parent, have
no educational qualifications, have a predicted IQ below ninety, be in
social classes IV and V, be unemployed, and to have moved three or more
times in the last two years. When the less severe concept of mixed depres-
sion and anxiety is used, the prevalence approaches ten per cent of
the population (88/1000, 68/1000 males, 108/1000 females) (McQueen,
2009, p. 230).
6. Depression is increasingly a problem also in children and adolescents.
The prevalence of depression in pre-school children is not known,
although we have found quite a large number of depressed children in
all our ongoing early prevention studies with families at risk in Frankfurt.
The prevalence rate of pre-pubertal children is 1–2% (Costello et al.,
2003); in adolescence between 3–8% (see Bhardwaj & Goodyer, 2009,
p. 179). There is a forty per cent probability of recurrence of depression
in adolescents within two years after treatment, which increases to 75%
in five years. The likelihood of further episodes in adulthood is 60–70%
(Birmaher et al., 1996; see also Bhardwaj & Goodyer, 2009, p. 180). Pre-
pubertal depressed children with a family history of depression have a
similar risk of recurrence (Birmaher & Brent, 2007). “Both depressed chil-
dren and adolescents are at increased risk of developing other psychiatric
or psychological problems such as substance misuse, conduct disorder,
personality disorder und suicidal behaviour. They are also at increased
risk for obesity, risky sexual behaviour, problematic social and interper-
sonal relationships and educational and occupational underachievement
(Fergusson & Woodward, 2002)” (Bhardwaj & Goodyer, 2009, p. 180).
7. One interesting and unexpected finding for psychoanalysis as well as for
neurosciences stemming from the on-going LAC-Depression study (see
Chapter Four) is that a large majority of chronically depressed in long-
term psychoanalytic therapy suffered from severe traumatisation during
8. To this day psychoanalytic literature is struggling to achieve an adequate
understanding of trauma. Bohleber (2010a, p. xxi) summarised the
current state of knowledge as follows:

Psychoanalytic trauma theory has evolved on the basis of two

models, one psycho-economic, the other hermeneutic based on object
relations theory. To grasp the phenomenology and long-term conse-
quences of trauma, we need both models. The psycho-economic model
focuses on excessive arousal and on anxiety that cannot be contained by
the psyche and that breaks through the shield against stimuli. The model
based on object relations theory concentrates on the collapse of internal
object relations and the breakdown of internal communication, which
produces an experience of total abandonment, precluding the integration
of trauma by narrative means.
9. For changes to the manifest dream contents, as well as the treatment with
the latent dream content in psychoanalyses of sufferers of chronic depres-
sion, see Fischmann and colleagues, 2012.
10. Today, the term trauma is often used in an inflationary manner, and thus
loses its specific explanatory content. For this reason, following Cooper
(1986), I used the definition of trauma in the narrower sense: “A psychic
trauma is an event which abruptly overwhelms the abilities of the ego
to ensure a minimal sense of security and integrative completeness,
and which leads to an unbearable anxiety or sense of helplessness, or
else leads to the threat of this; it leads, furthermore, to an enduring change
of the psychic organisation” (Cooper, 1986, p. 44). This definition
includes both psycho-economic as well as object-relations theoretical
perspectives, as Bohleber (2012, p. xxi) also points out: “Psychoanalytic
trauma theories have evolved on the basis of two models, one psycho-
economic, the other hermeneutic and based on object relations theory. To
grasp the phenomenology and long-term consequences of trauma, we
need both models. The psycho-economical model focuses on excessive
arousal and on anxiety that cannot be contained by the psyche and that
breaks through the shield against stimuli. The model based on object rela-
tions and the breakdown of internal communication which produces an
experience of total abandonment, precluding the integration of trauma by
narrative means.”
11. Bleichmar (1996, pp. 940 ff.) differentiates between different forms of
aggression in depression:
a) Aggression and deterioration of the internal object: the subject feels
as though he destroyed the object. The most speculative theory in this
context is the concept of the death drive which is seen to be responsible
for the fact that the patient does not return to life after the loss of an
object, but remains attracted by death (see also Steiner, 2005, p. 83). Mr
W’s self-observation of having been depressed ever since he can remem-
ber would descriptively match the phenomena Freud has in mind: the

analysand has been absorbed by suicidal tendencies, the “longing for

death” for years.
b) Aggression directed at the external object: the subject not only
displays aggression against the representation of the object, but also acts
it out in the external world (destroying friendships, family relations, etc.).
c) Aggression directed against the self: due to a rigid superego, aggres-
sion is turned toward the self (see e.g., the role of masochism in depres-
sion or in introjective depression one of the two basic types of depression
described by Sidney Blatt, 2004).
d) Guilt through introjection of aggression against the object: the self is
reproached in the conscious, the object in the unconscious.
e) Guilt due to the quality of the unconscious wish: guilt may be the
product of the existence of certain sexual and hostile desires.
f) Guilt caused by the codification of wishes: the (sadistic) superego
codifies the wishes as aggressive and destructive for the object.
g) Guilt through identification: there is an unconscious belief of a global
identity of being bad, of being aggressive, of a self of being harmful.
h) Guilt through introjection of aggression against the object: the self is
reproached in the conscious, the object in the unconscious.
12 The study is realised in Frankfurt am Main, Berlin, Hamburg, and Mainz
by a large group of researchers (Chairs: M. Leuzinger-Bohleber,
M. Hautzinger, M. Beutel, W. Keller, G. Fiedler, B. Rüger, see
13. In the LAC study, the patients had the choice to opt either for a psycho-
analytical or a behavioural therapeutic long-term psychotherapy
(“preferred treatments”), or to be randomly selected. Considered statisti-
cally, in the CTQ patients suffering from severe traumatisation signifi-
cantly opted for a psychoanalytic rather than a behavioural-therapeutic
14. We have made observations in many psychoanalyses. We have related
these to the most important psychoanalytic works on the trans-genera-
tional passing on of traumas (cf., among others. Bohleber, 2012; Faimberg,
1987; Keilson, 1979; Kogan, 1995a,b).
15. This was the recent report, for example, of neuroscientist and psychoan-
alyst Bradley Peterson (2013) from Columbia University in NY of the
fMRI studies on three generations of patients (n= 131, from the ages of six
to fifty-four years old) who suffered from a major depression. His
research group determined a statically significant reduction of cortical
thickness of the right hemisphere in this family. “These findings suggest
that cortical thinning in the right hemisphere produces disturbances in
arousal, attention, and memory for social stimuli, which in turn may

increase the risk of development depressive illness.” (Petersen, 2013,

p. 1). His research group, however, made no statement on increased trau-
mas in these families. And yet, there is a multitude of studies available
proving the influence of stress for example in post-traumatic stress
syndrome on the brain, among others, in the case of those suffering from
depression (cf., among others Böker, 2013; Reinhold & Markowitsch,
2010, pp. 22 ff.). Technical treatment inferences from this by many
What was especially interesting was the result that patients with child-
hood traumas (early loss of parents, experiences of violence, sexual
abuse, neglect) clearly profit from psychotherapy considerably more
than patients who have not suffered from trauma. With these patients,
only psychotherapy was not only more effect than medicinal mono-
therapy, but also the combination of both processes
[psychotherapy/medicinal treatment] only led to minimally improved
results . . .. The increase in knowledge over the last two decades has
revealed complex connections between hormones, genes and environ-
mental influences on the human psyche, while at the same time opens
the foundation for individualized, therapeutic interventions. (Bosch &
Wetter, 2012, p. 376)
16: A most impressive example of “embodied memory” is the famous child-
hood memory of Marcel Proust evoked by the “madleine in the tea” in
Search of Lost Times:
An exquisite pleasure had invaded my senses . . . with no suggestion of
its origin. Whence could it have come to me, this mighty joy? What did
it signify? How could I seize upon and define it? I can measure the
resistance, I can hear the confused echo of great spaces traversed . . . the
object of my quest, the truth, lies not in the cup but in myself . . . I put
down my cup and examine my own mind . . . but How? (pp. 48–51)
(English translation quoted by Blum, 2012, pp. 684–686, see also
Leuzinger-Bohleber & Pfeifer, 2011)
17. Unfortunately, presenting the manual would exceed the limits of the
present paper. It contains an excellent description of both psychodynam-
ics as well as knowledge of the technical treatment chronic depression
(cf., among others, Taylor, 2010).
18. For a year, the Frankfurt Group have also been using the model for the
clinical observation, as developed by the Project Group for Clinical
Observation (Chair: Marina Altmann), and which was presented at this
congress. Siri Gullestad and I discussed this model by way of a case
presentation from the LAC study by Erwin Sturm. The method of
psychoanalytical expert validation serves to improve the quality of clini-
cal research (cf., among others, Leuzinger-Bohleber, 2014).

19. Hence, he had the fillings in his teeth renewed, since he was convinced
that his depression was related to quicksilver poisoning; he underwent
the most diverse vitamin cures, naturopathic treatments as well as
repeated new neurological and psychiatric examinations. He tried out a
broad palette of antidepressants. With Lyrica he experienced a certain
relief from his unbearable inner disorder.
20. For him, the medicine was confirmation of the unconscious truth, that
“he was not master in his own house”, an interesting theme in psycho-
analysis; the constraints of the present paper, do not permit of a more
detailed discussion of this (cf., among others, Küchenhoff, 2010)
21. Already during my first countertransference fantasy, in the first inter-
view, Mr P reminded me of Little John from the 1970s Robertsons films.
In a later phase of the psychoanalysis Mr P came across these films
himself. The extreme reactions of Little John to the ten-day separation
from his parents helped him to approach the hitherto unbearable insight
into what, for the adults, was the unimaginable consequences of the early
trauma of separation, and to recognise his own destiny therein.
22. The reactivation of the trauma led to extreme countertransference feel-
ings of powerlessness, helplessness, and analytical impotence, indeed,
even to returning impulses on my behalf to break with the treatment. In
this connection, the intervision in the context of the LAC study proved an
indispensable aid to understanding the reactions, the impulses to break
the treatment and, among others, to recognise my impulse to escape the
confrontation with the intolerableness of the trauma.
23. As I have shown in greater detail in other works, I altered both the mani-
fest trauma content and the handling of dreams in the treatment, as well
as the “embodied metaphors” contained therein (Leuzinger-Bohleber &
Pfeifer, 2013).
24. I think it is important that the reactivation of the trauma in the analytic
relationship with the characteristic experience of extreme powerlessness
and helplessness appears to be an essential precondition with which the
analysand successively grasps the broken trust in a helping object, as well
as the flooding with extreme anxiety, panic and distress, and to thereby
counter these experiences, to some extent. Again and again, he provoked
the danger in the analytic relationship; I also thus began to seriously
doubt to the point of being convinced that I was unable to help the
analysand, and must end the treatment. As analyst—probably analogous
to the primary objects in the traumatic separation situation—I felt help-
less and powerless, disturbed in terms of empathy, impotent and despair-
ing. In phases such as these, the regular intervisions as part of the LAC
studies proved decisive for conveying to the analysand’s experience in

the sense of Winnicott, such that I survived both as analytic object, the
reactivation of the trauma in the relationship and was also able to endure
contain his pain—a precondition for the approach to the horror of the
trauma and its consequences.
25. Oedipal fantasies were, among others, introduced into these unconscious
convictions; due to his oedipal love desires and aggressive impulses
towards his father he was taken to a home. Furthermore, the traumatic
experience disproportionately stimulated the aggressive-destructive
26. At the Congress of the IPA in Copenhagen (1967) a Panel dealt with the
effects of physical diseases for mental development (see e.g., Rodrigue,
27. The explanation of the concept of “embodied memories” will not be
repeated here (see Chapter Two, Three, and Four)
28. Trying to understand her parents’ behaviour during her polio was essen-
tial for her increasing capacity for understanding more profoundly the
intentions and motives of her primary objects. This had an observable
effect on her social relationships.
29. After having studied the medical literature Mrs B also asked herself
whether the unusual symptoms of exhaustion, which had been the main
reason for her earnest suicidal intentions during the second analysis,
were related to a post polio syndrome (twenty-six years after the polio
infection). The main hypothesis was hardly to be tested a posteriori,
mainly because medical information, which assumes episodic but also
progressive development of PPS, bore contradictions. Yet it seemed
important to her that the analytical treatment, without knowledge of PPS,
had made possible better coping with her body: avoidance of extreme
muscle exertion, as in the movement and dance groups during the previ-
ous years, good phases of relaxation with the infants, less stress etc. These
are all recommendations which are given to patients of PPS today.
30. To mention just one example: apparently during the polio infection age-
related oedipal, sexual fantasies had been mixed with a magical processing
of the respiratory complaints. She had repeated infantile dreams of anacon-
das suffocating her (see danger of suffocation during polio) or about poiso-
nous snakes: the venom destroying the body from the inside—this also
possibly being a processing of oral fantasies in connection with polio (see
also case descriptions of Bierman et al., 1958). Mrs B narrates that uncon-
scious body fantasies played a great role in her second psychoanalysis,
triggered by the pregnancy. “That I had such an easy birth and that I could
experience my body in a new way as healthy and functioning had also to
do with the important processing of my fears that something destructive

could be hiding in my body.” But apparently the connection to polio was

not explicitly recognised back then. In our psychoanalytical work we still
came across more body fantasies: Mrs B attributed surviving polio to her
“very special body”, a body that could defeat a deadly disease and there-
fore was immortal, invincible. and without boundaries. These body
fantasies were probably in part the basis for the aforementioned extraordi-
nary dissimulation of physical states (such as pneumonia) or her
pronounced contraphobic behaviour (see also Jacobson, 1959)
31. In this chapter I seek to conceptualise “unconscious fantasy systems” in
close connection to the concept of the “unconscious fantasy”, which I
attempt to develop further (see Bohleber & Leuzinger-Bohleber, in press).
With this concept I describe infantile daydreams in which already early
memories of body experiences as well as primal fantasies were included.
These fantasies have probably been banished to the unconscious during
the oedipal phase (becoming part of the dynamic unconscious). They
have been “rewritten” in the sense of “Nachträglichkeit [resentfulness]”
again and again according to later experiences and fantasies (e.g., during
adolescence and late adolescence). The chapter takes up some of the core
ideas of the paper published in the International Journal of Psychoanalysis
(Leuzinger-Bohleber, 2001).
32. Ulrich Moser and Ilka von Zeppelin are fully trained psychoanalysts who
have been engaged in interdisciplinary research for decades. Ulrich
Moser was professor for Clinical Psychology at the University of Zurich.
Since the in the 1960s and 1970s he has been involved in modelling parts
of psychoanalytic theories. By the means of computer simulation he
tested the logical and terminological consistency of psychoanalytic theo-
ries of defence and the generation of dreams. Based on this basic research
on dreams he developed his own model of the generation of dreaming as
well as a coding system for investigating the manifest dreams. In this
chapter as well as in the chapter by Varvin, Fischmann, Jovic, Rosenbaum
and Hau the dream model and the coding system by Moser and von
Zeppelin are applied.
33. The LAC Study is an ongoing, large multicentric study comparing the
outcomes of psychoanalytical and cognitive-behavioral longterm treat-
ments of chronic depressed patients. Since 2007 over 400 of such patients
have been recruited (see Chapters Two and Four; Leuzinger-Bohleber et
al., 2013a,
34. In September of 2007 we were very pleased to announce that the American
foundation Hope for Depression had granted us financial support
35. Funded by the Neuro-Psychoanalysis Society—HOPE (M. Solms,
J. Panksepp et al.) and the Research Advisory Board of the IPA.

36. We are grateful to the BIC and MPIH (W. Singer, A. Stirn, M. Russ) and
the Hanse-Neuropsychoanalysis-Study (A. Buchheim, H. Kächele,
G. Roth, M. Cierpka, et al.) and LAC-Depression Study for supporting us
in an outstanding way.
37. In the on-going large LAC depression-study we are comparing the short-
term and long-term effects of long-term psychoanalytic and cognitive-
behavioural psychotherapies. Up to this point we have recruited more
than 400 chronic depressed patients in different research centres:
Frankfurt am Main, Mainz, Berlin, and Hamburg (participating research
team and methods: see
38. I have described the clinical and biographical background of this severely
traumatised, chronic depressed patient extensively in other papers
(Leuzinger-Bohleber, 2012, in press, see also Chapter Four). From my
clinical perspective I illustrate how the manifest dreams as well as the
dream work changed during psychoanalysis and also reports of the
transformation of the inner (traumatic) object world. In this paper we
would like to contrast my clinical views with a more systematic investi-
gation of the changes in the manifest dreams.
39 Lyrica (generic name Pregabalin) is an anticonvulsant drug used for
neurotic pain, also effective for generalised anxiety disorder (since 2007
approved for this use in the European Union).
40. Within the frame of this paper we cannot elaborate the psychoanalytical
understanding of the transformations of the manifest dreams as well as
the working with the dream associations in the psychoanalytical sessions
(see e.g., Leuzinger-Bohleber, 2012, and in press). We can only commu-
nicate a first impression to these changes of the dreams to the reader by
two dreams, one from the first and one from the third year of treatment
here. The first dream reported here is a typical dream of a severely trau-
matised person where the patient himself is in a position of an observer:
the dream subject is in an extreme life threatening situation, completely
helpless, in unbearable pain—and not being helped by anyone. In the
second dream the patient is the active dreamer, observing a situation
which still is painful but with hope that “something can be done” in
order to overcome a hopeless situation
41. A total of four dreams—two from the end of the first year of therapy and
two elicited one year later—serve as material to be analysed for changes
within the course of therapy using the Moser method. Elements of the
coding system are included in parentheses.
42. The summary is based on two extensive depictions of psychoanalysis in
Leuzinger-Bohleber (2009a,b).

43. Although we have met many early traumatised children in all early
prevention projects, it would exceed the scope of this chapter to dwell on
the psychoanalytic trauma theories again (cf., Chapters Two, Three, and
Five; Leuzinger-Bohleber, 2009a,b).
44. Crying is also a biologically embedded behaviour that should activate the
succour of the care-giver. If these attachment needs are not satisfied, the
child will develop, with great probability, symptoms of a partial depri-
vation, an exaggerated need to be loved, severe feelings of guilt and
depression, among others. Also other characteristics such as superficial-
ity, listlessness, lack of concentration, tendencies toward fraud, and
compulsive stealing are next to developmental delay or retardation—all
possible consequences of early experiences of deprivation.

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Abraham, N., 55 Aichhorn, A., 205
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69, 87, 100, 216 156, 196, 199
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37, 39–41, 51, 57, 97, 102, 113, 119, Anderson, C. M., 195
122, 131, 164–165, 171, 176, anger, 39, 77, 92, 108, 111, 113, 133, 152,
178–182, 194–196, 198–199, 206 see 182, 203
also: Positive and Negative Affect Angold, A., 213
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behaviour, 139 Anna Freud Institute (AFI), 187,
negative, 199 208
problem-solving, xvi, xxiii, xxxiv Antrobus, J., 14
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193–194, 198 132–135, 137, 139, 148, 156–157,
Agam, G., 166 172, 176, 179–181, 195, 213–214,
aggression/aggressive, 59, 76, 84–85, 92, 217, 220
99, 106, 108, 138, 152, 156, 158, 180, Argelander, H., xv, 8, 20
191, 197, 201, 214–215 Aristotle, 24
behaviour, 79, 187, 200 Arlow, J. A., 125
–destructive, 90, 92, 96, 99, 200, 218 Arnold-Pfeffer-Center for
fantasies, 90, 99, 107, 153 Neuropsychoanalysis, xxiv
impulses, 92, 96, 99, 108, 136–138, 156, Aronson, A., 13
158, 218 arousal, xxxi, xxxvi, 54, 61, 131, 134, 143,
phantasies, 92 171, 214–215


attachment, xxxv–xxxvi, 15, 93, 193–200, cognitive, xxi, 50, 86, 219–220
204, 207–208, 221 depressive, 79
avoidant, 196, 199 emotional, 35, 197
behaviour, 187, 195–197 human, xxvii, 161
childhood, 53 inhibition, xxx
disorganised, 187, 193, 196, 199, 202, intrusive, 44
206–208 memory, 34
figure(s), xxxvi, 37, 198–199 normal, 37
insecure, 158 physical, 22
pattern(s), 154, 158, 199, 202, 208 seductive, 97
secure, 154, 156, 196–197, 199, 202 social, 59, 107
system, xxxvi, 198 sexual, 213
trauma, 89, 200 therapy, xxix, 5, 8, 172, 215
attention deficit hyperactivity treatment(s), 14, 215, 219
disorder (ADHD), xiv, xxix–xxxi, Beland, H., 125
14, 16 Belmaker, R. H., 166
Atwood, G., 187 Belz, A., xxviii, 148
Auerhahn, N. C., 52, 55 Bender, T., 47
Aulangier, P., 20 Benecke, C., 14–15
Auschwitz, 52 Bergmann, M. S., 101
autonomy, xxxv, 7, 17, 27, 61, 82, 89, 125, Bermpohl, F., xxi
137, 140, 151, 153, 157–158, 191 Bernardi, R., xiii–xiv, 7
Axelrad, S., 202, 205 Besser, A., 84
Axmacher, N., 163 Best, K., 163
Bettelheim, B., 205
Bachrach, H. M., 12–13 Beutel, M. E., xiv, xxii–xxiii, 12–13, 15,
Baehr, T., 163, 175, 214 84, 100, 210, 212, 215
Bahrke, U., 33, 51, 82, 84, 86, 88, 219 Bhardwaj, A., 213
Bakermans-Kranenburg, M. J., 196 Bianchi, I., 147
Balint, M., 51, 85 Bibring, E., 83
Baranger, M., 51, 85 Bibring, G. L., 12
Baranger, W., 51, 85 Bierman, J. S., 103, 218
Barkley, R., xxx Bifulco, A. T., 57
Barnard, K. E., 58 Bion, W. R., 20, 155
Barrett, W. G., 12 Birmaher, B., 213
Beck, J., xxi Blacher, R., 39
Beck Depression Inventory (BDI), Blacker, K. H., 12
169–170 Blass, R. B., xiv, xxxvii
Beebe, B., 40, 195 Blatt, S. J., 84, 215
Beeghly, M., 200 Bleiberg, E., 198
Beenen, F., 13 Bleichmar, H., 51, 83–85, 88–89, 98, 214
behaviour(al), xxiii, xxx, xxxii, xxxviii, Bloch, E., xlii, 186
28, 30–31, 38–40, 49, 51, 58, 60, 67, Bloom, K., 33
72–73, 110, 120–122, 141, 157, 167, Blum, H. P., 51, 85, 140, 216
183, 189, 191, 193, 195–196, 201, 206, Bock, N., xxxi
209, 213, 218–219, 221 see also: Boeker, H., xxi, 163
affect/affective, aggressive, Boesiger, P., xxi
attachment Boesky, D., 9

Bogerts, B., xxi Burnside, E., 57

Bohleber, W., xxxiii, 5, 8, 11, 48, 51–52, Busch, F. N., 13
56, 83–85, 89, 100, 115, 120, 125, Busse, A., 205
140, 147, 193, 200, 213–215, 219 Byatt, M., 28, 57
Bokanowski, T., 51, 56, 85, 100
Böker, H., 15, 56, 61, 87, 163, 216 Cambridge Longitudinal Study, 57
Bollas, C., 20, 51, 132 Campos, R. C., 84
Bongard, J., 27, 29, 42, 122 Canestri, J., xvi, xxxv, 8, 10, 193
Bosch, O. G., 61, 216 care-giver(s), 195, 199, 201, 221
Bose, J., 51, 85, 89 primary, 37, 187, 194, 196
Boston Change Process Study Group, Carmeli, Z., xxxvii
20–21 Carney, J. K., xxx
Botvinick, M. M., 176 Carrier, M., 10
Bowlby, J., 84, 193, 195–196 Carter, C. S., 176
Bradberry, W., 59 Caspi, A., 23, 58, 166
Bradley-Davino, B., 59 Cassidy, J., 195–196
Brain Imaging Center (BIC), 15, 166, 220 Caverzasi, E., xxviii, 148
Braithwaite, A., 23, 58, 166 Chiesa, M., 9
Brandl, Y., xxix children of war, 69–70
breakdown(s), 49, 104–105, 109, 112, Chronic Fatigue Syndrome, 102
117–119, 172 Cicchetti, D., 195, 200
depressive, 91, 94, 107, 171 Cierpka, M., 15, 166, 188, 220
nervous, 172 Clancey, W. J., 25, 35
of internal communication, 214 clinical examples
psychic/psychotic, 98, 104, 110, 136, Li, 201–202
140 Mr A, 189–193
Bremner, J. D., 51, 85 Mr P, 81–82, 87, 91–99, 171–172, 176,
Brenner, C., 125 180, 217
Brent, D. A., 213 Mrs B, 104–119, 218–219
Brentano, F., 197 Mrs D, 145, 147–148
Bretherton, I., 196 Mrs E, 122, 126–137, 139–140
Britton, R., 97, 125 Mrs M, 49, 71–72, 79
Brody, S., 202, 205 Mrs N, 69–70, 79
Bronfman, E., 187 Mrs P, 150–153
Brooks-Brenneis, C., 120 Mrs U, 70–71, 129
Brooks-Gunn, J., 58 Mrs X, 100–101
Broth, M. R., 57 Ms M, 21–22, 24, 41–42, 44–46, 48,
Brothers, L., xxxv–xxxvi 72–74, 76–78
Brown, G. W., 51, 57, 85 clinical observation(s), xxxiii, xxxvii, 9,
Bruce, J., 195 38, 71, 99, 124, 137, 140, 148, 216
Bruns, G., 166 clinical research, xiv, xxxvi, xxxix, xli, 3,
Bruns, J., 15 7–10, 51, 79, 82, 88, 119, 205, 208,
Buchheim, A., xxi, xxxiv, 15, 166, 220 216
Buchholz, M. B., 21, 47 extra, xiv, xxxix, xli, 3, 7, 9, 11, 13, 17,
Bumstead, R., 213 51, 79, 82, 86, 88, 205, 207–208
Burckhardtmussmann, C., 205 Cohen, C., 205
Bürgin, D., xxx, 4 Cohen, J. D., 55, 176
Burlingham, D., 193 Coles, M. G. H., 176

Colombo, D., 9 postnatal, 57–58

containment, 43, 90, 108, 116, 119, 138, state, xii, 46
155, 199, 205, 214, 218 Deserno, H., 84
Cooper, A. M., 63, 89, 120, 214 despair, 39, 108, 113, 115–116, 123, 138,
Cooper, P., 57 153, 156, 158, 181, 191, 217
Coriat, I., 12 Dewan, E. M., 164
Corrigall, J., 34 Dewey, J., 28, 30
Costello, E. J., 213 di Medina, D., xvi
countertransference, xxiii, xxiv, 8, 19, 21, Dietrichs, S., 15
34, 42–43, 45, 47, 72, 98, 116, 123, DiGirolamo, G. J., 176
183, 206, 211–212, 217 Dimavicius, J., 147
see also: transference Doell-Hentschker, S., 180–181
Cournut, J., 55, 101 Doidge, N., xxxi
Cox, T., 57 Doria-Medina, R., 7
Craig, I. W., 23, 58, 166 Douglas-Palumberi, H., 28
Critchley, H., 176 Dozier, M., 195
Crittenden, P. M., 196 DPV Follow-Up Study, 10, 12, 51, 71, 78,
Cuevas, K., 63 86, 99, 210
Cummings, E. M., 58 dream(s) (passim) see also: nightmare(s)
Cyr, C., 196 clinical, 175, 181
one, 173, 176
Dahl, H., 13 two, 173, 178
Dalakas, M. C., 102 coding, 175, 178
Damasio, A. R., xxi, xxxi, 17, 27, 33 complex, 164, 180
Dantlgraber, J., 21 content, 132, 168, 175, 214
Darwinism, 35–36 day, 107, 123, 125, 219
Davies, P. T., 58 experience, 170
Davis, R., 28, 57 experiment, 170
Dawirs, R. R., xxxi interview, 169–170
De Bellis, M., 186, 195 laboratory, xvii, 171, 173, 179–180,
de Boor, C., xv 182
De Mijolla, A., 7 one, 173, 178
death wishes, 77, 97, 99 two, 173, 179
Denis, P., 8, 51, 85 three, 174, 179
Dennett, D. C., 197 four, 174, 180
Denscherz, C., 13 material, 171, 175, 182
depression/depressive (passim), organisation, 164, 175
see also: behaviour(al), report(s), 169, 181, 220
breakdown(s) research, xvii, 38, 164, 166
chronic, xxi, xxxviii–xxxix, xli, 9–10, stimulus, 170
14–16, 55, 64, 76, 79, 81–83, 86, subject, 178, 181–182, 220
88–89, 91, 97–98, 163, 166–167, word, 168–171, 176–177, 182
169, 193, 213–214, 216, world, 175
219–220 Dreher, A. U., xiv, xxxv, 10
maternal, xli, 57 Drews, S., 56
mother(s), xxxviii, 58, 69–71, 79, 107, Drotar, D., 195
116, 139, 141 Duarte Guimaraes Filho, P., 7
position, 154, 156 Dulz, B., 52

Eagle, M., 9 family

eating burdens, 56, 58, 144
binge, 190 foster, 70
disorders, 49, 171 history, 145, 213
disturbances, 127, 150 romance, 127, 131, 136
Eaves, L., 28, 166 structures, 50
Edelman, G. D., 17, 25–27, 35, 41, 121 fantasies, xl–xlii, 30, 51, 70, 72, 77, 83, 99,
Edinger, J., 84 102–103, 107–111, 114, 125–126,
EEG (electroencephalogram), xxi, 15, 128–129, 131, 134, 137–138, 140,
165–167, 169 148–150, 153, 156, 185, 190, 200,
Eglé, U. T., 54, 186 208–209, 217–219 see also:
ego, xxv–xxvi, 37, 54–55, 85, 89, 98, 154, aggression/aggressive, Medea,
211, 214 oedipal
Ehrenberg, A., 50, 82 destructive, 39, 96
Eisenbruch, M., 58 inner, 90
Eisnitz, A. J., 103 masturbation, 103, 126
Eldred, S. H., 12 narcissism/narcissistic, 107
Ellman, S. J., 14, 38–39 sexual, xli, 123, 130, 218
Emde, R. N., xlii, 13, 33, 58, 60, 63, 120, unconscious, xxii, xxxv–xxxviii, xl–xli,
139–140, 185–186, 188–189 2, 7–8, 17, 43, 75, 83, 90, 93, 96, 99,
Engels, E. M., xxxi, 144, 148, 155 104, 106, 116, 118–123, 125–126,
environment(al), xxx–xxxi, xxxix, 25, 137, 140–142, 149, 153, 162, 191,
27–28, 30, 41, 47, 60, 83, 87, 89, 129, 207, 218–219
154, 164, 209 Feldman, F., 12
experience(s), 28, 35 Feldman, M., 97
factors, xxxi, 58 Feldmann, R., 40, 57
influence(s), 35, 59, 61, 216 Felice, M. E., 195
learning, xxxii Fenichel, O., 12
social, 50 Fergusson, D. M., 57, 213
envy, 115, 132, 134, 136, 138 Fiandaca, D., 147
Erdelyi, M., 15 Fiebach, C., xvii
Erk, S., xxi Fiedler, G., 84, 215
Erkanli, A., 213 Finesinger, J. E., 103, 218
Erle, J. B., 12 FIRST STEP project, 162, 187
Ernst, M., 195 Fischer, G., 54, 100
Ernst Brücke’s Institute of Physiology, 1 Fischmann, T., xvii, xxi, xxiv,
Escoll, P. J., 140 xxviii–xxix, xxxiii, 10, 14, 62,
Ethical Dilemma due to Prenatal and 147–148, 161, 163, 175, 187, 193,
Genetic Diagnostics (EDIG), xxviii, 202, 205, 210, 214, 219
xli, 142–144, 150 Fisher, C., 12
Euripides, xl–xli, 123, 137, 141 Fisher, P. A., 195
Euser, E. M., 196 fMRI (functional magnetic resonance
EVA Study, 162, 193, 202 imaging), xxi, xxxvi, 15, 166–171,
174, 176, 182, 215
Fadiga, L., 36 Fogassi, L., 36
Faimberg, H., 55, 101, 215 Fonagy, P., xiv, xxii–xxiii, 7–9, 11–15, 63,
fairy tales, xxii, 109, 122, 142 85, 89, 100, 120, 138, 187, 197–200
Falzeder, E., 2 Fooken, I., 55

Forel, A., 2 Goldwyn, R., 187

Foss, L., 58 Goodman, S. H., 57
Fosse, M., 164 Goodyer, I. M., 213
Fosse, R., 164 Gottlieb, P., 39
Fosshage, J., 172 Grabhorn, R., xvii
Fox, C. R., 58 Grande, T., 13
Frankel, K. A., 58 Grasso, D., 28
Frankfurt fMRI/EEG Depression Study Green, A., 7, 20, 135, 139
(FRED Study), 15, 163, 165–169 Green, J., xxix, 187
Freedman, N., xiv Green, S., 34
Freud, A., 85, 115, 193, 205 Greenacre, P., 194
Freud, S., xix–xx, xxiv–xxvii, Greenberg, R., 39
xxxv–xxxvi, xxxviii, xl, xlii, 1–2, Greenman, D. A., 13
5–6, 16–17, 19–20, 37, 50, 52, 83–84, Greer, P. J., 59
103–104, 118, 123, 125, 132, 140, Griem, A., 28, 166
142–143, 148, 162, 166, 185, 214 Grimm, S., xxi
Frie, R., 33 Grotevant, H. D., 195
Friedrich, L., 188 Grubrich-Simitis, I., xiv, 2
Fritzemeyer, K., 205 guilt, 43, 46, 50, 55, 74, 84–85, 106–107,
Fuchs, T., xxxi, 35, 40 111, 115, 117, 126, 128, 145, 149,
153–154, 156, 158, 215, 221
Gaensbauer, T. J., xxix, 34–35, 63 Gullestad, S. E., xxxv, 38, 56, 216
Gaertner, B., xxix, 14 Gunnar, M. R., 195
Galatzer-Levy, R., xiv, 13 Guterl, F., xxvii
Gallese, V., 35–37, 40 Guttmann, G., xxiv
Gammelgaard, J., 82 Guyer, A., 195
Gardner, C. O., 61
Gastner, J., 13 Habermas, J., 5
Gatz, M., 61 Haggard, E., 12
Gelernter, J., 28 Hagner, M., xxxv, 10, 209
Gelfand, D. M., 58 Hall, Ch., 57
George, C., xxi Halligan, S., 57
Georgiadis, S., xxxvi hallucination(s), 20, 105
Gerber, A. J., xxii–xxiii, 15, 164 Hamburg, D. A., 12
Gergely, G., 194, 197 Hammermann, S., 103
German Psychoanalytical Association Hampe, M., xvi, xxxv, 4, 7–8
(DPV), 55, 64, 71, 100, 210 see also: Hanly, C., 9, 210
DPV Follow-Up Study Hannabach, C., 34
Gianaros, P. J., 59 Hanse-Neuro-Psychoanalysis-Study,
Gilmore, K., xxx 166, 220
Giltay, E. J., 85–86 Hariri, A. R., 59
Giovacchini, P., 140 Harmon, R. J., 58
Gloger-Tippelt, G., 197 Harrington, H., 23, 58, 166
Gödde, G., 21, 47 Harris, T. O., 51, 57, 85
Goerge, C., 166 Hartke, R., 56
Goldberg, D. A., 12, 28, 60 Hartmann, L., 187, 205
Golden, E., xlii, 54, 185, 202–204 Harvey, K., 57
Goldman, A., 37 Haselbacher, A., 84

Hasselhorn, M., xvii intervention, xxxii, 98, 186, 189

Hau, S., xvii, xxviii, 14, 148, 219 crisis, xxviii, 93, 142, 150–151, 153
Haubl, R., xv, 16, 82 therapeutic, 61, 167, 216
Hauser, S. T., xlii, 13, 28, 54, 202–204 psycho-, xxxi–xxxii, 163, 168
Hautzinger, M., 50, 84, 215
Hayes, D. J., 166 Jacobs, K. S., 28
Haynal, A., 9, 84 Jacobson, E., 84, 103, 118, 219
Hellman, I., 85 jealousy, 103, 106, 140
Henningsen, P., xxxi, 8, 35, 40 Jedema, H. P., 59
Henrich, G., 13 Jennes, J., 195
Henry, W. P., 13 Jiménez, J. P., 11, 125
Herrell, R., 28, 166 Joffe, W. G., 84
Herzog, J. M., 139 Johnson, M., 27, 33
Heuft, G., 55 Jones, Enrico E., 13
Higgitt, A., 197 Jones, Ernest, 12
Higley, J. D., 59 Joraschky, P., 54, 186
Hildt, E., xxviii Joseph Sandler Research Conferences,
Hill, J., 28, 56–57, 61 xiv
Hirose, T., 58 Jovanovic, T., 59
Hobson, J., 164 Jucovy, M. E., 101
Hoffer, W., 194 Jurist, E., 198
Hoffmann, S. O., 54, 186
Hoh, J., 28, 166 Kächele, H., xxi, 13–15, 166, 220
Holmes, J., 83, 87 Kacza, J., xxxi
Holocaust, 52, 55, 71, 194 Kaechele, H., xxxiii
Holt, R. R., 13 Kallenbach, L., 84
Holzhey, H., xvi Kämmerer, A., 123
Honneth, A., xvi Kandel, E. R., xix–xxii, xxvii,
Hoppe, K. D., 55 xxxiv–xxxv, xxxvii, xlii, 17, 61–62,
Houshyar, S., 28 162, 165–166
Hovens, J., 85–86 Kantrowitz, J. L., 13
Howard, K. L., 14 Kaplan, N., 196
Huber, D., 13 Kaplan-Solms, K., xxi–xxii, xxxv
Hustvedt, S., 6, 17 Karjalainen, P., xxxvi
Hüther, G., xxix, xxxi Katz, A. L., 13
Katz, H., 39
IDeA Zentrum (IDeA Center), xvii, 16 Kaufman, J., 28, 213
Illouz, E., 9, 82 Keeler, G., 213
Inderbitzin, L., 125 Kehyayan, A., 163
Institute for Psychoanalytical Child and Keilson, H., 52, 101, 194, 215
Adolescent Psychotherapy see: Keller, W., 84, 215
Anna Freud Institute Kendler, K. S., 61
Institute of Clinical Psychology, xvi Kennel, R., 84
International Psychoanalytical Kernberg, O. F., xiv, 13, 39, 57, 84, 166
Association (IPA), xi, xiii–xv, 2, Kerr, D. D., 59
7–8, 10, 13, 125, 183, 210, 218–219 Kessler, H., 163, 166
International Society for Kestenberg, J. S., 101
Neuropsychoanalysis, xxii Khan, M. M. R., 194

kindergarten(s), 87, 96, 187–188, 192, Lear, J., 8

201, 208 Leber, A., 205
Kircher, T., xxi Lebiger-Vogel, J., 205
Kitzman, H., 188–189 Lee, A., 213
Klein, M., 84–85 Legrand, D., 168
Kleinian Lehner, T., 28, 166
analyst(s), 106, 154 Lehtonen, J., xxxvi, 38
baby, 39 Leichsenring, F., 13
object relations, 211 Leikert, S., 21
Kline, P., 15 Lemma, A., xxxv
Klingholz, R., 186 Leuschner, W., xvii, 14
Klug, G., 13 Leuzinger-Bohleber, M., xi, xiv, xvii,
Knapp, P. H., 12 xxi–xxiv, xxviii–xxxi, xxxiii,
Knight, R. P., 12 xxxiv–xxxvii, xlii, 4, 8, 10, 12–14, 16,
Knoblauch, S. H., 9, 34 25, 27, 33, 35, 38, 40–41, 48, 51–52,
knowledge-society, 2–3, 7, 11, 17 55–58, 60, 63, 71, 82, 84, 86, 88, 94,
Knox, J., 35, 40 100, 120–121, 125–126, 139–140,
Kogan, I., 52, 101, 215 144, 148, 155, 161, 163, 167, 169,
Köhler, L., 120 173, 175, 181–183, 185–189,
Köhler Foundation, xvii, xxxiv 192–194, 196, 202, 205, 210, 212,
Köhler Stiftung GmbH Darmstadt, xvii 214–217, 219–221
Kohut, H., 84 Levin, S., 12
Kopta, S. M., 14 Levine, H. B., xx, 19, 139
Kordy, H., 14 Levy, S. T., 125
Koukkou, M., xvii, xxxiv Liang, K., 28, 166
Koukkou-Leh, M., xvii Lief, E. R., 9
Kovacs, M., 28, 166 life
Kraft, S., 14 history, 47–48, 72–73, 77, 99, 190
Krause, R., 13–15 sexual, 46
Kris, E., 194 story, 53, 73, 77, 127, 170
Krohn, W., 10 -threatening, 82, 91–94, 102, 114, 178,
Krystal, H., 101 220
Krystal, J. H., 28 Limentani, A., 103
Küchenhoff, J., 217 Lindahl, K., 58
Lipschitz, D., 28
Laboratory for Artificial Intelligence, xvi Liu, S., 59
LAC Study on Depression, xli, 64, 88–89 Loftus, E. F., 120
Lacan, J., 20 Lopresti, B. J., 59
Lachman, F. M., 40, 195 Lorenzer, A., 16, 20
Ladopoulou, K., 147 Lubbe, T., 86
Laezer, K. L., xxix, 14, 187, 205 Luborsky, L., 13, 212
Lakoff, G., 27, 33 Lueger, R. J., 14
Langan, R., 34 Lyons-Ruth, K., 187
Laplanche, J., 20 Lyrica, 172, 217, 220
Lappi, H., xxxvi
Lau, J. Y., 195 MacLeod, J., 197
Laub, D., 52, 55 Maheu, F. S., 195
Läzer, K. L., xxix, 147 Main, M., xxxv, 196

Manchester Child Attachment Story research, xxxii, 121–122, 209

Task (MCAST), 207–208 short-time, 24
Mancia, M., xxxv, 15 trauma(tic), 46–47, 63, 116
Mandell, D., 195 unconscious, xii, xxxvi, 24, 30, 41–42,
Markowitsch, H. J., 53, 61, 216 45, 112
Markson, E., 85 working, 175
Marshall, K., 34 Menninger, K., 25
Martin, J., 23, 58, 166 Menninger Foundation, 13
Martius, P., xxi Menozzi, F., 57
Massie, H., 202, 204 Mentzos, S., 84
Matsumoto, K., 176 Merikangas, K. R., 28, 166
Max Planck Institute for Brain Research Mertens, W., xvii, xxxiv, 52
(MPIH), xvii, xxi, 15, 166, 220 Meurs, P., 196
Mayer, E. L., 9 Michels, R., 9
Mayer, L., 15 migration, xvi, xxviii, xlii, 16, 69, 74, 123,
Mayes, L., xxii–xxiii, 40, 57, 194 186, 188, 192–192, 202
McCarter, R. H., 12 Mijola, A., xiv
McClay, J., 23, 58, 166 Mill, J., 23, 58, 166
McDougall, J., 126 Mills, M., 57
McGinley, E., 85 Milner, B., 61–62
McLanahan, S., 58 Milrod, B. L., 13
McQueen, D., 50, 83, 213 Mitscherlich, A., xv, xlii, 186
Meadows, S. O., 58 Mitscherlich-Nielsen, M., xv, 186
Meaney, M. J., 59–60 Mizen, R., 34
Medea, 123–126, 141 Moffitt, T. E., 23, 58, 166
fantasy, xl–xli, 120–121, 123, 125–126, Mohr, H., xvii
129, 131–132, 136–138, 140–142, Moll, G. H., xxxi
145, 149, 153 Mom, J. M., 51, 85
myth, xl–xli, 123, 137, 140 Moran, G., 197
Medina, J. J., 59 Morris, H., 13
MEG (magnetoencephalography), xxi Morrison, H. L., 85
Mehnert, C. Ä., xxxi Moser, U., xvi, 7–8, 149, 164–165,
Meltzer, H., 213 167–168, 175, 178, 181, 219–220
memories (passim) see also: behaviour(al) Möslein-Teising, I., 140
autobiographical, 168 mother (passim) see also:
childhood, 94, 121, 172, 216 depression/depressive, oedipal
embodied, xii, xxiii, xxxiii, xxxviii, –child, 57, 193, 195, 198
xl–xli, 14, 22–24, 26–27, 34, 37–38, good, 70
40–41, 45–46, 48, 63, 72, 77–79, mourning, 55, 106, 117, 146–147, 153
88, 90, 94, 98–100, 102, 110, Mullen, P. E., 57
112–115, 118–120, 132, 141, 154, Muller, J. J., 103
156, 216, 218 Murray, L., 57
emotional, 168 Mustillo, S., 213
explicit, 61, 63 myth/mythology, xxii, xl, 122–124
implicit, 63, 120 see also: Medea
long-term, 24, 102, 164
procedural, 102, 119 narcissism/narcissistic, 50, 83–84, 116,
regulation, 181 125, 128–129, 131, 135, 138, 158
repressed, xli, 19 see also: fantasies

rage, 140 theory, 98, 140, 211, 214

self-regulation, 77, 135, 157–158 research, xx, xxxv, 2, 17
Narcissus, 123 self-, 74, 76, 151
National Socialist (Nazi), xv, 65, 69, 73, world, 90, 93, 96, 153, 182, 207–208,
91, 172 220
Navalta, C. P., 195 objective, xxvi, xxxii, 5, 17, 31, 90, 100,
Negele, A., 33, 51, 57, 84, 86, 88, 219 122, 154, 161–162, 203
neglect, xxii, 61, 87, 94, 123, 195, 216 data, 65, 210
emotional, 56–57, 70, 186, 191, 193, 195 information, 122, 141, 210
Nelson, G., 197 side, xxxix, 31
Neubert, V., 14, 187, 205 truth, xxxix, 4
neuroscience(s), xii–xiii, xvi–xvii, O’Brien, M., 213
xix–xxiv, xxvi–xxvii, xxix, O’Connor, T. G., 195
xxxii–xxxvii, xxxix, xli, 5, 15, 34–35, oedipal
40, 52–53, 60–61, 97, 141, 161–163, conflict(s), 92, 140
166, 185–186, 213, 215 envy, 134, 136
cognitive, 20, 47 fantasies, 70, 99, 107, 109, 114, 149,
contemporary, xxi, xxxv, xxxvii, 2, 18 218
nightmare(s), 70, 81–82, 91, 101, 107, father, 149
111, 117, 150 see also: dream(s) mother, 130
Niskanen, J.-P., xxxvi paradise, 138
Norman, H. F., 12 phase, 78, 126, 136–137, 140, 194, 219
Norrholm, S. D., 59 pre-, 99, 134, 136, 194
Northoff, G., xxi, 163, 166 rivalry, 138
triangle, 140
Oberbracht, C., 13 triumph, 133
object, 20, 43, 59, 77, 82–83, 90, 99, 121, Oedipus, 123
129, 132, 135, 137–139, 164, 176, complex, xxv
179–180, 182, 191–192, 214–218 Ogden, T. H., 84
dead, 132, 139 Ohlmeier, D., xv
external, 215 Olds, D. L., 63, 188–189
good, 54–55, 89, 98, 153–156, 192, 204 Olsen, A. S., 59
ideal, 85, 220 Operationalized Psychodynamic
loss/lost, 20, 83, 89, 139, 214 Diagnostics Interview (OPD
love, 38, 88, 91, 126, 136–137, 139, 191 Interview), 169–170
primary, xxxiii, xxxvi, xxxviii, xlii, Oremland, J. D., 12
39–40, 54, 57, 77, 89–90, 92, Ott, J., 28, 166
108–109, 118–122, 136, 138–139,
141, 185, 187, 191, 194–195, 198, Pääkkönen, A., xxxvi
217–218 Pan, H., 15
real, 85, 153, 155 Panksepp, J., xxx–xxxi, xxxv, 166, 219
relations, xxxii, xxxix, xlii, 16, 41, Paolitto, F., 13
54–55, 85, 89, 104, 106, 114, paranoid–schizoid position, 149, 158
119–121, 125, 136, 140, 147–148, Passolt, M., xxxi
185, 194, 198 see also: Kleinian Paul, L. S., 205
early, xxxi–xxxii, xli, 37, 132, 135, Payne, H., 34
139, 189, 192–193, 202, 204, Pearlman, C., 39
206, 214 Pederson, N. L., 61

Peloso, E., 195 Project Group for Clinical Observation,

Pennix, B., 85–86 8–10, 216
Perron, R., xiv, 7, 13, 125 projection, xxxiv, xl, 85, 97, 109, 123,
Peskin, H., 52, 55 132, 137, 148, 158, 180, 206
PET (positron emission tomography), projective identification, xxxiv, 97,
xxi 131–132, 149, 206
Peterson, B., xxii–xxiii, xxxvi, 15, 60–61, Proust, M., 23–24, 45, 216
215 Puckering, C., 57
Pfeffer, A. Z., 12 see also: Puschner, B., 14
Arnold-Pfeffer-Center for
Neuropsychoanalysis Quinodoz, J. M., 140
Pfeifer, R., xvi–xvii, xxxv, 8, 14, 25, 27,
29, 35, 42, 56, 63, 88, 100, 102, Rabung, S., 13
120–122, 216–217 Radebold, H., 55
Pfenning, N., 147 Rado, S., 84
Pfenning-Meerkötter, N., xxix, 84 rage, 77, 84, 105, 123–124, 129, 137–138,
Pickles, A., 28, 57 182 see also: narcissism/narcissistic
Pincus, D., 15 Raikes, H. H., 188
Pine, D. S., 195 Ramsauer, B., 207
Pines, D., 126 randomised controlled trial (RCT), 188
Poeth, K., 195 rape, 46, 54, 74–75, 78
Pokomy, D., xxi Raynor, L. C., 57
Polcari, A., 195 Redlich, F., 205
polio, xxxiii, xl, 56, 89, 101–103, 108–116, Reed, G. S., xx, 19–20, 139
118–119, 218–219 Reichle, B., 197
-myelitis, 100, 102–103, 112 Reinhold, N., 53, 61, 216
Porter, J. N., 59 Repacholi, B., 187
Positive and Negative Affect Schedule Representation Interaction Generalised
(PANAS), 171 (RIGs), 164
Posner, M. I., 176 Research Training Program (RTP), xiv
Post Polio Syndrome (PPS), 102, 218 Ressler, K. J., 59
post traumatic stress disorder (PTSD), revenge, 108, 119, 123–125, 133–134, 140,
53–54, 59, 61, 187, 216 149, 153, 158
Poulton, R., 23, 58, 166 Rhode-Dachser, Ch., 126
Pound, A., 57 Richter, H. E., xv
pregnancy, xxviii, 75, 78, 104, 122, Riedesser, P., 54, 100
127–128, 133, 135, 138, 144–145, Risch, N., 28, 166
150–153, 198, 218 Rizzolatti, G., 36
Fallopian, 130 Robbins, F. P., 12
interruption, 144–145, 147, 149–150, Robbins, L., 13, 212
154 Röckerath, K., xxii
termination, 143, 146, 149, 151–152 Rodrigue, E., 218
prenatal diagnostics (PND), xxviii, Roediger, H. L., 24
142–144, 147–150, 153–159 Roelofs, A., 176
Prestele, H., 84 Roiphe, J., 13
problem-solving, xvi, xxii, xxxiv, xlii, Rollinson, L., 28, 57
24–25, 30, 38, 41–42, 176, 182, 185 Roose, S., xxii, 15
see also affect/affective Rosenfeld, H., 97

Roth, G., xxxiv, 15, 53, 125, 166, 220 Schmeing, J.-B., 163
Rothenberger, A., xxxi Schneider, W., 149
Rothstein, A., xxx Scholz-Strasser, I., xxiv
Rotmann, M., 139 Schore, A. N., 56, 87
Rovee-Collier, C. C., 63 Schuchard, M., 123
Ruby, P., 168 Schulte-Körner, G., 83
Ruchsow, M., xxi Scroufe, L. A., 196
Rudden, M., 13 Seifritz, E., 56, 87, 163
Rudolf, G., 13 self, xxxix, 77–78, 82–83, 85, 89–90,
Rüger, B., xiv, 12–13, 100, 147, 210, 212, 97–98, 108, 116, 120, 125, 129, 135,
215 137–141, 148–149, 156, 164, 176,
Rusconi Serpa, S., 39–40, 57 179–180, 191, 193–194, 197, 211, 215
Russ, M., xvii, xxi, xxxiii, 161, 163, 175, see also: object
214, 220 -accusation, 84
Rüther, E., xxxi -assertion, 76
Rutherford, H. J. L., 40, 57, 194 -confidence, 2, 135
Rutter, M., 194–195 core, 101, 136
Ryan, N. D., 213 -critical, xxxvii, 14
-deception, xxvi
Sachs, O., 17 destructive, xlii, 138, 186
Sachsse, U., 52–53 -determination, 4
Sacks, O., xxvi -development, 40, 138, 193–194
Sadler, L., 188–189 -doubt, 207
Safran, J. D., 13 -esteem, 67, 92, 135, 156
Sampson, H., 13 experience, 199
Sandberg, L. S., 13 false, 40, 194
Sandell, A., xxix, 38 -healing, 203
Sandell, R., 13 -identity, 77
Sandler, A., 120, 125–126 -image, 83, 104, 126, 141
Sandler, J., xiv, 10, 84, 120, 125–126, 194 -organising, 30
see also: Joseph Sandler Research -processor, 180
Conferences -punishment, 84
Sarchi, F., 147 -regulation, 28–30, 41, 85, 209
Sargent, H., 13, 212 see also: narcissism/narcissistic
Sarnoff, I., 15 -relatedness, 168
Sashin, J. I., 12–13, 39 -representation, 103, 137
Sattel, H., xxxi, 35, 40 Sennett, R., 50, 82
Saunders, S. M., 14 Sepulveda, S., 195
Scarfone, D., xx, 11, 19–20, 125, 139 sexual see also: abuse, behaviour(al),
Schacht, T. E., 13 fantasies, life
Schachter, J., 13 adventures, 45–46
Schafer, R., 84 arousal, xxxvi
Schall, J. D., 176 attraction, 182
Scharff, J. M., 21 desires/needs, 78, 215
Schechter, D. S., 39–40, 57 education, 54
Scheier, Ch., 102 experience, 89, 133, 136–137
Schlesinger-Kipp, G., 56, 71 impulses, 136, 192
Schlessinger, N., 12–13 orientation, xxv

passion, 125, 136–137, 141 Squire, L. R., 61–62

system, xxxvi Stanley, C., 187
traumatisation, 78 Stanton, A. H., 12
wishes, xxxvi Stark, R., 15
sexuality, xxxv, 16, 34, 45, 74, 109, 125, Statham, H., 147
129–130, 132, 139–140, 152–153 Steel, H., 197
infantile, xxv, 20 Steel, M., 197
Shane, F., 125 Steiner, J., 84–85, 97, 214
Shane, M., 125 Stern, D. B., 13
Shapiro, S. A., 34 Stern, D. N., 40, 57, 139, 193–194
Shapiro, T., 13 Stickgold, R., 164
Shaver, P. R., 195–196 still face, 37, 194
Shengold, L., 140 Stirn, A., xvii, xxi, 163, 175, 214, 220
Shevrin, H., 14 Stoller, R. J., 140
Shoah, 55, 69, 71, 89, 101, 116 Stone, L., 84
Siegel, D., 34 Stone, M., 34
Siegert, M., 188 Strauss, L. V., xxii
Sigmund Freud Institute (SFI), xiv–xvii, Strecker-von Kannen, T., 84
xxi, xxviii–xxix, xxxviii, xli, 3, 7, Strupp, H. H., 13
14–16, 162–163, 166–167, 169, 183, Stuhr, U., xiv, xxxiii, 12–13, 84, 100, 210,
187–188, 201–202, 205, 208, 215, 219 212
Silbersweig, D., 15 Stuphorn, V., 176
Silverstein, A. B., 103, 218 Sturm, E., 216
Singer, M., 13 subjectivity, xxvi–xxvii, xxxvi, xxxix, 31,
Singer, W., xvii, xxi–xxii, 220 121, 137, 170, 183, 198
Singleton, S., 213 inter-, 21, 35–37, 40, 47, 183
Skalew, B., 86 Sugar, M., 140
Skelton, K., 59 Sugarman, A., xxx
Skolnikoff, A., 13 Sugden, K., 23, 58, 166
sleep(ing) suicide, 69, 71, 77, 106–107, 140, 151–152,
disorders, 49, 75, 81, 104, 171 191–192, 195
disturbances, 150, 167 Suomi, S. J., 17, 28, 58–59
laboratory, xvii, xxi, 15, 162, 166–169 Suzuki, W., 176
research, xvii, 38, 166 symbolism, xxv, 7, 19–20, 31, 52, 154,
Sletvold, J., 33 162, 164, 197
Smith, V., 187 Symptom Check List (SCL), 170
Society for Neuropsychoanalysis, xvii, Szajnberg, N., 202, 204
15 Szyf, M., 59–60
Solms, M., xiv, xvii, xix–xxii, xxiv–xxvii,
xxxi–xxxii, xxxv, 15, 166, 219 Talvitie, V., xxiv
Solomon, L., 13 Tambelli, R., 57
Solomon, M., 12 Tanaka, K., 176
Speck, A., 123 Target, M., xiv, 12, 63, 100, 193, 197–199
Spinhoven, P., 85–86 Tarvainen, M., xxxvi
Spitz, R., 59, 84, 186, 193 Taubner, S., 166
Spitzer, M., xxi Taylor, A., 23, 58, 166
splitting, 47, 123, 132, 137–138, 140, Taylor, D., 9, 51, 84, 86, 88, 216
148–149, 158, 194 Teicher, M. H., 195

Teising, M., xxviii, 144 von Freyberg, T., 204

Terr, L. C., 34 von Hoff, D., xvi
Teuchert-Noodr, G., xxxi von Matt, P., xvi
Thomä, H., 13 von Rad, M., 13
Thomas, L. A., 186, 195 von Zeppelin, I., 149, 164–165, 167–168,
Thomson Salo, F., 140 175, 178, 219
Three Level Model of Clinical
Observation, 10 Waldvogel, B., 52
Tischer, I., xxix, 14 Wallerstein, R. S., xiv, 11–13
Torok, M., 55 Walter, H., xxi
torture, 54, 74, 107 Weber, J. J., 12
Toth, S., 195 Weigel, S., xvi
Toulmin, S., 8 Weinberger, J. L., 103
transference, xii, xxiv, xxxii–xxxiv, Weingart, P., 3, 5, 10
xxxvi, xxxviii, xl, 17, 19–20, 22, 25, Weinstein, L., 14, 38–39
41, 43, 45–47, 56, 64, 72–73, 77, 88, Weinstock, H. I., 12
90, 93, 98–101, 107, 110, 114, Weiss, H., 84
116–117, 119, 122, 131–134, Wermer, H., 12
136–137, 163, 183, 211–212 Wetter, T. C., 61, 216
see also: countertransference Whitebook, J., xvi, 2
Trentini, Ch., 57 Widlöcher, D., xiii, 7, 10
Trimborn, W., 78 Wiersma, J. E., 85–86
Tronick, E. Z., 37 Wilkinson, H., 34
Tsiantis, J., xxxi, xxviii, 144, 148, 155 Will, A., 84
Tutté, J. C., 61 Williamson, D., 213
Tyson, P., 140 Winnicott, D. W., 39, 51, 85, 90, 136, 194,
Tzavaras, N., xxviii, 148 218
Tzivoni, Y., 147 Wissenschaft, xxxiv–xxxv, xxxvii, 18, 210
Wolff, A., xxix, 187–188, 204–205,
Unoka, Z., 194 207–208
Wolraich, M. L., 195
Valkonen-Korhonen, M., xxxvi Woodward, L. J., 213
Van Amerongen, S. T., 12 world see also: dream, object
Van IJzendoorn, M. H., 196 external/outer, 198, 200, 215
van Oppen, P., 85–86 inner, 97, 150, 156–159, 198
van Turennout, M., 176 World Health Organization (WHO), 16,
Varchevker, A., 85 49, 81, 103, 193–194
Varvin, S., 11, 86, 125, 219
Vassilopoulou, V., 147 Yang, B. Z., 28
Venzlaff, U., 52 Young-Bruehl, E., 140
Vicker, M., xxxi Yovell, Y., xxxv
Vinocur de Fischbein, S., 7
violence, xvi, xlii, 16, 20, 44, 54, 61, 111, Zabarenko, L. M., xxx
186–188, 190, 192, 200, 202–204, 216 Zetzel, E., 12
Viviani, R., 166 Zitman, F. G., 85–86
Vivona, J. M., 34 Zürich Dream Process Coding System
Vogel, J., xxix, 193, 202 (ZDPCS), 182–183
von Braun, C., 9 Zysman, S., 11, 125