This study group began in an effort to provide greater awareness of the body in psychoanalytic work and to provide biological understanding of bodily changes and phenomena which are a prominent part of psychoanalytic thinking, for example, affective expression, such as blushing or changes in heart rate. Despite its immense importance, the reciprocal interaction of experience, biological processes, and then further experience has not been part of psychoanalytic training. Similarly, somatization—the expression of feelings, thoughts, and fantasies in physical ways, including the hysterical symptoms of Freud's early patients—is not part of most analytic training.
We have been interested in the interactions between a woman's state of mind and her state of body and the biological substrates and variables that influence self representation, fantasies, and feelings. Our focus on women's bodies reflects our interest in developing an understanding of women's bodies in their complexity, an understanding that goes beyond the common focus on the genitals or on reproduction, important as that is, and one that includes the effects of self concepts on bodily functioning.
The group has met since 2006, primarily at the National Meetings of APsaA. It is an interesting and complex project, since there are different levels of experience in the group and biology covers such a wide range of concepts. We have considered ways to find common ground to explore these issues.
One important area to learn about is hormonal variations and their effects. We have a gynecologist as a consultant member of our group. She has presented recent research on the effects of hormones on affective states. It is not as clear, as the popular literature suggests, that there is a simple relationship between hormonal levels and mood changes related to the menstrual cycle. The relationships are much more complex. Brain activity is influenced by hormonal levels and by changes in hormonal levels. However, research is ongoing and the changing nature of the data has made generalizations difficult. Our discussion raised some concrete questions about sexual and reproductive issues, such as approaches to contraception, infertility, and medications.
Our focus on the effects of self concepts on bodily functioning has led us to consider different representations of the body and the reciprocal importance of the body in the construction of the self. We have considered the role of pregnancy and the potential for pregnancy to play a role in body image and self concept. Some established concepts, such as the importance of “inner space” as a psychological reflection of female anatomy and Erikson's and Kestenberg's ideas of “inner genital space” as a “somatic core of the wish to have and nurture a baby” have been discussed and reexamined. These represent translations of anatomy to psychology, and particularly genital anatomy, that is, the “space” of the uterus as forming a central psychological characteristic. We have considered whether these ideas are supported clinically or represent concepts that reflect earlier ideas about women. The confusion of female psychology and female sexuality has been a problem in the past psychoanalytic literature.
To ground our theoretical discussions in clinical data we have had several presentations of psychoanalytic work with women patients in whom somatic issues were prominent. One interesting case involved a woman who had a persistent absence of sexual sensations after some period of an analysis that had been considered productive and successful in other ways. Another patient had feelings about her analyst's body that represented graphically her wishes for closeness by fantasies about being inside her analyst's body, but also a sense that they could be close because as women they shared the same sensations and their bodies were the same. These issues of identification and the relationship to one's mother are other topics considered for exploration.
Another patient who was presented represents a person whose body feelings of “dirty” sexuality had to be hidden in layers of fat as a defense against sexual feelings, reviving a long history of unacknowledged sexual abuse. This has raised the issue of the effects of trauma, acute or chronic, and its biological influences on defenses. We have not yet explicitly considered the neurobiological mechanisms by which these experiences are translated into physical expressions.
The goal of the study group has been to develop a curriculum for use in psychoanalytic training. Recognizing the role and importance of the body is important. Knowing something about the process and the physiology is valuable. Some integration of current biological knowledge and how it influences our understanding of psychoanalytic concepts is what we are aiming for.
Malkah Tolpin Notman, M.D., is a graduate of the Boston Psychoanalytic Institute. She is a training and supervising analyst at BPSI, a clinical professor of psychiatry at Harvard Medical School and senior faculty at Cambridge Hospital/Cambridge Health Alliance.