When the COPE study group, The Female Body: Integrating Psychoanalytic and Biological Concepts, started in 2006, the goal was to provide greater awareness of the female body and biological processes in psychoanalytic work, to better understand the interface of psyche and soma. Psychoanalysis had, it seemed, moved away from the body, drives, and sexuality. Although the expression of feelings and thoughts in somatic ways was an important aspect of Freud's descriptions of hysterical patients, and somatization is an important concept in medicine, it has not been prominent in psychoanalytic teaching. We have been developing some ideas as to what issues are important to know and teach.
The integration of bodily changes and psychological phenomena has proven to be a complex task. There are complex meanings to “biological” and clinicians have different levels of knowledge about physiological processes. In our discussions biological has come to mean more specifically “bodily.”
Over the last two years, we have heard scientific presentations that include current data about hormonal changes and their relationship to affective states and presentations about biological and psychoanalytic aspects of female body experiences, such as menstruation, pregnancy, menopause, and surgical modifications, such as breast augmentation. We have also considered somatic experiences, including sleep, sexuality, appetites, and substance abuse. Depression and its relationship to female body functions have also been discussed. Medical illness, past or present, and pain affect the sense of comfort with one's body.
These presentations, with both current scientific data and clinical examples, have focused on how particular body functions and conditions influence a woman's self concept and how her self concept, which can include feeling beautiful or not, feeling old, or feeling athletic, influences body functioning. Although the presentation of research and theoretical ideas has been useful, clinical case discussions have proven to be the most productive format for this group.
We discussed one clinical example of a woman who, after her breast augmentation, felt that her breasts belonged to her mother. Another patient expressed her experience and response to a long period of sexual abuse, which started in early childhood, through various bodily sensations, such as feeling she was choking and feeling that she needed to be heavy so her legs always touched. Another example was a woman who was preoccupied with her body: “All she talks about is her body.”
A broad concept that has evolved from our discussions is the “somatic self.” This concept captures a woman's sense of self and her body. It has emerged from our discussion of clinical vignettes in which everything that is known biologically about a patient is presented and then everything that is known psychoanalytically about the same patient is described. We then link the various elements of the somatic self to the psychodynamic understanding we have of the patient.
Except in the case of “psychosomatic” disorders, the somatic side of a woman's experience often seems absent from the clinician's thinking and case formulation. Often an approach is taken in which the biological and psychological understandings are seen as parallel tracks that run adjacent to one another but represent understandings from different paradigms and cannot intersect in a clinically useful or meaningful manner. Clinical data indicate that these lines do relate closely with one another. Sometimes developmental experiences are critical. For example, masochistic traits are often associated with having experienced painful medical procedures in childhood.
These moments of virtual intersection of the biological paradigm and the psychoanalytic paradigm are important and potentially valuable in understanding psychosomatic manifestations. These moments of virtual interaction may not be easily identifiable. Careful attention to bodily data, including medical illness, juxtaposed with the patient's subjective experience leads to the patient's somatic self.
We hope to refine our approach to case material in such a way as to bring to analytic training and to the continuing education of analysts a conceptual framework that includes the integration of biological and psychological data.
Malkah Tolpin Notman, M.D., is a graduate of the Boston Psychoanalytic Institute (BPSI). 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.