Return of the Repressed: Revisiting Dissociation and the Psychoanalysis of the Traumatized Mind

Clinical Evidence, Triangulation of Perspectives and Contextualization. Part 1: The Beginning of Carla's Treatment

We propose to critically evaluate and strengthen the level of clinical evidence in psychoanalysis, using a strategy of triangulating clinical phenomena from different perspectives and increasing contextual knowledge. Insufficient discussion of alternative hypotheses and limited contextual information are two Achilles heels of psychoanalytic case presentations. We examine the concept and quality standards of clinical evidence in psychoanalysis and related disciplines, with particular attention to the contribution of the three-level model (3-LM). We analyze the case of a patient treated with transference-focused psychotherapy (TFP), making explicit the theoretical-clinical agreements and disagreements of the authors. We discuss the strengths and limitations of triangulation and contextualization, concluding that they make clinical work and psychoanalytic writing more reliable, transparent, auditable, and replicable.

The Innate Capacity for Representing Subjective Experience: The Infant's Mind is Neither Primitive nor Prerepresentational

The author cites the prominence of theories that locate serious adult psychopathology in the preverbal infant's inability to formulate or represent traumatic experience. The work of two such authors, H. Levine and D. B. Stern, is briefly considered. The frame of reference for this investigation is that clinical and academic research findings are highly relevant to psychoanalytic theorizing. It is argued that when such findings are considered, a view of the infant with "primordial and unrepresented" states of mind has little evidence to support it. In fact, research findings summarized herein point to an opposite view: that of the "competent infant," one with highly accurate perceptual discrimination capacities and an innate ability to register and represent subjective experience in both procedural and declarative memory, even prenatally. Given the infant's competencies, it seems implausible to hold that representational deficits are at the heart of serious adult psychopathology, which is instead seen to be the result of defensive maneuvers against unknowable and unspeakable truth rather than the absence of a preverbal representational capacity. Current research findings seem to pose a significant challenge for psychoanalytic theories that espouse "primitive mental states"; "unrepresented," "unformulated," or "unsymbolized" experience; or "nonconscious" states.

The Architecture of the mind: A Psychodynamic Case Study of Dissociated Selves

The author seeks to explore the development and treatment of dissociative symptoms emerging in a 17-year-old nonbinary individual throughout two inpatient psychiatric hospitalizations. The patient endorsed the presence of multiple selves that remained connected with reality and internally with each other, emphasizing their existence in spatial allocations within the patient's mind both while dreaming and in waking life. The author highlights the therapeutic space as an opportunity to allow the interaction between dissociated selves surging from violent childhood experiences in hopes of allowing the integration of the fragmented parts of the main self. The roles of dreamwork, creative expressions, and language will be highlighted as essential components that allowed symbolization for a bicultural, bilingual individual who recently immigrated to the United States. Treatment was conducted within the limitations and particularities of inpatient psychiatric treatment, restricting treatment to a preliminary phase of exploration and containment.

Silence, Second Skin, and the Unrepresented

Using the concepts of microdialect and second skin, this paper explores the idea that a patient's silence in the session may function at multiple levels of psychic and relational organization, and-by virtue of its somatically experienced qualities and the special countertransference states these may elicit-might serve as a vehicle for movement between levels. It can thus be fruitfully approached as a potential portal for access to, and creative transformation of, unrepresented experience.

Verbal Communication with the Patient Is Not Enough: The Six Languages of the Sick

Evidence shows that verbal communication is just one of the ways patients indicate their wishes. For a sufficiently careful communication, we should also grasp other five unusual though evident languages: (a) body language, (b) the way patients manage their environment, (c) unconscious language, (d) lab-evidenced language, and (e) the way they master technology. So, we have six languages that should be intertwined to understand the real language of the sick. Grasping these languages helps health professionals frame the patient’s mood, their level of suffering or mental growth, and understand what words alone cannot express. Words cannot express completely what a patient senses: for subjection, shyness, because some patients are still non-verbal or because verbal communication is just a useful way of freezing concept but has not the same fluidity and liberty of the other above-described languages. It is mandatory for caregivers to wonder how many of these languages they are actually decrypting during an interview with the patient. On the other hand, caregivers unconsciously communicate much through two unexpected languages: the architectural language and the language of medical procedures. The way they welcome or obstruct the patient, their hesitations across a treatment, or in showing a serene collegiality are forms of subtle communication. A paradigmatic scenario where all these languages should be implemented is the “informed consent” process, which should be turned into a “shared therapeutic pathway”, summing up all the communicative modes illustrated in the text.