Presentation Summary by Annette Richard, M.Ps for IAPSP.com
Case Presenter: Amanda Kottler, M.A.
Presenters: James L. Fosshage, PhD; Frank Lachmann, PhD; and Joseph Lichtenberg MD
Discussant: Jeffrey Stern PhD
Jim Fosshage and Joe Lichtenberg opened this panel by presenting their newest theoretical and clinical proposals on their motivational systems theory, spelled out in their latest book (Psychoanalysis and Motivational Systems : A New Look, 2011). Amanda Kottler then offered us a case presentation which Frank Lachmann explored from the standpoint of motivational systems. Properly entitled ” Sir : A Story of Trauma “, we were first given a vivid view of the multiple traumatic events in this woman’s life history. She chose to be called ” Sir “, as Frank Lachmann proposed, in a ” self-mocking attempt to ascribe to herself the respect that she deserved… ” and felt so deprived of, including as a woman. In her forties, Sir complained of being ” unfulfilled “, although she seemed to have many social, professional and intellectual assets. She had been hospitalized after a suicide attempt at 27, and diagnosed as borderline. She was overweight and had evidence of cutting on her arms.
Amanda reconstructed Sir’s traumatic childhood history as the youngest of 6. From the start, she seemed to have been abandonned to her own means by a withdrawn, physically and emotionally unavailable and, at times, deeply invalidating mother, who had herself grown up in an orphanage. Referring to Karlen Lyons-Ruth research, Lachmann identified the situation in which Sir grew up as the context for the formation of a disorganized attachment pattern, conducive later to ” many disturbances across a spectrum of motivations “. Yet as a baby, Sir seemed to adapt by drawing on her own resources and was reported being able to entertain herself for hours. As Frank remarked, she seemed to develop enough self-regulatory capacities to compensate for the poor interactive regulation available, but with the downside consequence that she had no limits to her endurance in difficult and depriving situations.
Not surprisingly in this absence of a caretaking environment, even feeding herself was difficult. Very early on Sir had to make her own breakfast and lunch, and when unable to, starved all day. At night, she was the last to help herself and was often left hungry again, so that she would take too much when there was enough food available for her. Frank Lachmann observed that ” coping with disregulation of bodily needs became another solitary burden for Sir “.
When Sir was 5, the family took on a lodger, Kurt, to supplement their income. His drunken abusive behavior was tolerated by her mother particularly, and soon he began to seek sexual favours from the little girl who felt wanted for the first time. She heeded to his plea to keep this secret because ” no one would understand ” and she held on to his promise that they would get married when she grew up. As time went by, Kurt became increasingly violent and abusive physically and verbally. Lachmann concluded that this relationship ” cemented attachment with sexual submission… Thus, by sacrificing self-respect Sir found some self-affirmation “.
As an adolescent, Sir remained very confused between friendship, love and sex. She started feeling ” clean ” when she discovered she was good at tennis and joined a tennis club. Falling in love with an older teammate, she was later on devastated when this woman moved out of the club and did not seek her out. Feeling abandonned, she gave up that ” clean ” part of her life, trapped again in the violent relationship with Kurt. She started to get drunk and pick up guys for random sex in bars. It was a very destructive period of her life filled with shame. Frank proposed that sexuality, because of its early massive activation, had become ” a major source of compensation for Sir’s disorganized attachment to her mother “. He further hypothesized that physiological regulation of bodily needs also ” became a powerful organizer of experience for the opposite reason, its underactivation “. He explained her overeating, drinking and impulsive sexual seeking as an effort to compensate for the void left by her deprivation and neglect [which] activated [her] aversiveness “. This led, after another experience of abandonment, to the suicide attempt at 27 by driving into a wall at high speed. After what seemed to be a positive experience in the psychiatric hospital where she found some ” like-minded others “, she was supported by her therapist to enter university.
Even if this was A Story of Trauma, Frank suggested that it was also a story of ” enormous persistence “. Of her own avow, and in spite of all the negative experiences, Sir had never lost her curiosity. This had activated her motivation to explore her environment on her own even as a baby. She had been successful in school, in sports, and in University, she thrived reaching ” the top of her profession, …recognized internationally as an expert in her field ” according to Amanda’s report. Although becoming assertive in her professional world, Sir remained extremely submissive in her intimate relationship. When she started her treatment with Amanda, she was with Cal, the last of many others with whom she had filled the role of caretaker. For Sir, as Amanda noted, ” relationships were about giving “, either sexually or financially, and as Frank noted, feeling ” intrinsically worthless, she feared she would be abandoned as soon as she stopped being their submissive, selfless caretaker”. Cal’s younger alcoholic brother, John, who periodically had psychotic episodes, had moved in with them, and Cal, who adored her brother, stopped working to care for her brother, leaving Sir trapped in the provider’s role. But worse, John painfully echoed Kurt’s verbally abusive treatment towards Sir and was also treated with care so as not to upset him.
Amanda described the very sensitive therapeutic work she did with Sir, focusing at first on her cutting which was prevalent at the time, on her weight and constant social humiliation around it, and on her feeling more and more trapped in her relationship with Cal and John. Frank noted two of Amanda’s inspired ideas. First, she provided Sir with worry beads when she stopped smoking, a ritual that allowed her to feel some sense of control but also serving as a symbol of her attachment to Amanda, a transitional object. Secondly, addressing what Frank called Sir’s concrete cognitive functioning, Amanda linked her patient’s self-cutting to the cuts she had endured on her arms when, in her childhood, she used to crawl out of her bedroom window through an extremely thorny rose bush in order to escape the many household chores she was expected to do. The more she felt trapped by the demands of others, the more she repeated the self-cutting thereby meaning she was freeing herself.
Amanda described her ” intense mixture of feelings “, positive and negative, which was present all through her work with Sir, along with a familiar presence of nausea. This occured for instance when Sir handed her the brown bag containing her blades so as to not cut herself during a therapy break. One of the painful issues in this dyad is centered on Sir’s desire for a physical and sexual relationship with her therapist. Amanda remarks that ” she has no other way of ‘knowing’ that she means anything to anyone “, and Frank noted that this is again the manifestation of the concrete cognitive functionning : others and relationships are to be physically present to be real. Finally, the main issue which stands out from Amanda’s verbatim report of a therapy session, is what Amanda termed ” Withdrawal vs. Reclaiming her life “. Through her interaction with Amanda, Sir had ” begun to experience the validity of her feelings and needs ” which were previously seen as ” selfish “. The various forms of withdrawal developped in order to escape the pain or the conflicts in her relational situation were starting to be insufficient to cope with the increasing frustration and sense of trappedness in her life. The session’s verbatim offers a poignant view into this very complex and painful conflict in Sir’s life between self-assertiveness, self protective needs and the needs to maintain attachment in order to survive her great aloneness through caretaking and submissiveness. As Frank noted, we can feel how Sir’s and Amanda’s values or motivational systems collide here. He inferred that ” Sir’s life-goal, to secure attachment at any price, conflicted with Amanda’s central value, self-respect “. He also predicted that for the future of their work together, it will be a ” therapeutic challenge ” for this dyad to negotiate this transference-countertransference clash, that is to ” balance needs for assertion and exploration, needs for intimacy through attachment, and requirements for physiological regulations with Sir’s longstanding, powerful organizing patterns of survival : caretaking through self-sacrifice and to smother her self-respect “.
Finally, I end this report with what Frank called an ” extraordinary association ” on the part of Sir, at the end of the session’s verbatim, a marked shift from the concrete cognitive functioning to a more metaphoric and symbolic one. After having been supported by Amanda in her growing refusal to put up with the abusive situation at home and thereby gain some self respect, Sir, endorsing Frank’s observation that this would risk her relationship with Cal, said : ” I feel like the chickens have not come home to roost yet “. Then she said :
“I don’t know why, but in the last 2 days there has been, in my head, a totally distressing image that I saw about the Warsaw ghetto clearances of the Jews. People living in a particular area had to go to a central square where the trucks would be filled. When full, the remaining Jews could go home again. You see this woman with an infant 3 months old when the truck leaves. She is wailing unbearably. You realize her baby had begun to cry and she had covered it because she was terrified that it would draw attention to them, but she has smothered it to death….”
Frank inferred that Sir is both the baby who is starting to cry and protest but does not know of the danger and the terrified mother who has to protect them both in a world dominated by the Nazis by smothering the baby. This was the most poignant picture which closed off this moving clinical story.