Two Clinical Vignettes

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In this first vignette, I will describe aspects of three sessions which illustrate the emergence of feeling memories following a head injury.

Peter is a talented middle-aged married man in one of the caring professions. His father was a gentle, scholarly man and his mother a kind, self-effacing woman who suffered from bouts of severe depression which required admission to mental hospital at irregular intervals during Peter's childhood; this meant that he was required to stay with relatives for some weeks at a time.

The week before the three sessions I shall briefly describe, Peter had a sudden, violent, but not life-threatening accident in which he struck his head and body on a concrete post and suffered transient unconsciousness. After a week's convalescence, he returned to therapy in a sorry state, with stitches in his head and a cut and bruised face. He lay down very slowly and with great difficulty. He recounted details of the accident and clearly was still quite shocked. He told me he wanted me to know what it was like to feel he was dying. Near the end of the session he attempted to sit up but said it was impossible. He tried several more times but each time he sank back in a very distressed state saying he could not get up. I fetched him a glass of water and he made it clear that he did not want me to help him up. I moved the armchair closer to the couch, reassured him that there was no hurry, and told him I was leaving the room for a few minutes. Three or four minutes later he had managed to sit up with the use of the chair. When I returned, he asked me to leave again because he said my absence made it easier for him to get up. Five minutes later he called a farewell and left. My medical knowledge reassured me that he had not had a cardio vascular episode; however, I felt quite painfully while I was outside the room that I had been neglectful of him, but I also sensed that at that moment my presence was symbolically too close to a desperately needed object.

In our next session he again slowly and painfully lay down. He told me that he had felt very reassured that I had left the room last session because it meant that I had not regarded him as a medical emergency. He spoke further about his accident and how he had thought he was dying. Then he said to me with great feeling: "There is one area where you have not understood me, you haven't realized that I want to look for what is actually true. Bottle feeding isn't real milk. My mother seems to be saying: 'Drink it up: it doesn't matter that there isn't a real breast2.' She would say, 'No such thing as can't, worse things at sea and such like.' I was longing for you to hold my hand last session. I don't want to be told my thoughts are at fault."

I told him that he was telling me what if it felt like to be "fobbed off," not to be allowed to have feelings of self pity or helplessness or need, and what it felt like to be told that "others had it worse" and that "you aren't really feeling what you're feeling." I also told him that the terrifying fear he had had after his accident that he was dying was probably an echo of a terror from childhood.

However, what I did not tell him at the time, and which I now believe in restudying the material, was that he was also struggling to disentangle the difference between his experience of me now, as a representative of his autobiographical "internal mother," and the reemergence of actual "bits" of feeling memory from the past, possibly from amygdala circuits, as a result of his head injury [67].

As the end of the session approached, once more he struggled to sit up and sank back again onto the pillow. He tried several more times and with the help of the chair eventually sat upright. He then said hesitantly: "I think you ought to leave me." I replied that I would if that was what he really wanted. Slowly and painfully he inched his legs onto the floor, smiled, and said: "You're a cunning b ... aren't you? You were absolutely right not to leave. I don't feel embarrassed any more by this incident."

In the following session he spoke more about his accident and his various medical advisors, but near the end of the session he struggled to the

2He is here illustrating his need for authenticity. He was in fact only breast fed, but on a rigid 4-hourly regime.

sitting position and said a little desperately: "I'm so sorry I'm putting on this show." I said straightaway: "This is not a performance, it is a "show"; you are showing me in the only way you can what it is like to have powerful feelings that never have had and never will have words."

Space does not allow for a full discussion of all the important material in the sessions following Peter's accident, so I will confine it to a few comments on aspects that are directly relevant to this essay. When Peter found that he was unable to move from the couch, it came as no surprise to me because I realized we had been there before and that I had been "primed" in the sense that there had been clues in his material from past sessions which indicated his need for close attachment to me; for example, he would often make jokes as he was getting off the couch; he would write out his cheque at the end of a session always borrowing my pen; if he had been angry in a session, he would always "make up" before leaving. His overinclusive accounts of happenings in his life as a defense against feelings came to be known to us both as "my seminars." Though I tried to understand his feelings using transference interpretations, it always seemed that he wanted and needed "something more" [26]. Two sessions before his accident he realized halfway through a session that he had been using his "seminar" technique to talk his way away from his feelings. He directed his frustration and amused vexation at himself and struck his forehead with the palm of his hand: "Ahrr, there I go again, I feel so frustrated, I feel I want to be hysterical ..." I particularly noticed his unusual phrase.

I suspected that most of the transference references were for the years from 5 onwards when his autobiographical memory was firmly established and deference for others and concealing painful feelings had become ego-syntonic. Intrapsychically he had to find a way of getting at these earlier feelings which had no autobiographical content . . . As with repressed contents so with implicit memory, it cannot directly be brought into consciousness.

In the sessions that followed he did much useful self-interpretation. He identified the tears in his eyes following the rendition of some French religious music with words that spoke of the relief of suffering, through the supporting hands of God. One morning he asked if he could bring his bicycle into my hall and he almost preempted my interpretation in the session with a clarity of understanding to which I had nothing to add.

There were many more sensations and phantasies in the sessions after his accident and they revealed a complex bridging system between implicit and explicit memory, the concrete experiences of Klein's internal objects, and the representations of others.

Two sessions after his head injury he wondered aloud whether this had entirely been an accident; many sessions later, he said that in retrospect, the experience had had its useful side.

The last point I wish to examine from Peter's first session after his accident is my feeling when I was out of the consulting room for a few minutes. I felt that I was abandoning him; I felt neglectful, guilty, and coerced. I worked out that I was processing a powerful projective identification, and that as a concrete version of his mother I was being punished for not being more attentive. However, a few days after the incident, I read Cimino and Correale's paper "Projective identification and consciousness alteration" [68], in which they suggest that projective identification, as well as being a defense mechanism, also has a powerful communication role. They propose that aspects of the patient's early unconscious experience can be transmitted to the analyst where it exerts strong emotional pressure, provoking emotional upheaval, a sense of coercion, and even altered consciousness. They suggest that in these situations nondeclara-tive memory is here exercising its influence, and that where the infant has not had the experience of having its projections "metabolized" and "returned" by the primary object, the patient may sometimes show this type of projective identification.

I believe that in Peter's case his autobiographical memory was nonexistent at the level we are discussing, but his unconscious emotional memory with later priming ("worse things at sea," etc.) found discharge by pro-jective identification in the way suggested by the authors and in the way experienced by me.

The second vignette is a brief description of those "devices" that a middle-aged male patient used to combat what he called "a shy penis," by which he meant an inability to urinate in public.

His first device was to remember himself aged about 11, a fine athlete, captain of football and cricket and much admired by his peers. Contemplating these times enabled him to micturate in public.

His second device was to say out loud his father's Christian name. His father had been a powerful and at times harsh figure in my patient's life, but was now very old and frail. Naming his father allowed him to urinate.

The third device puzzled him more. Since his brother, who was two-and-a-half years younger than he, had died about 10 years before, he found that saying his name out loud enabled him to urinate. He was devoted to his brother and was aware of no negative feelings towards him. He was heartbroken when he died. His younger brother had been chroni cally ill as a baby which had necessitated his mother's constant attention. My patient had "heard" that at about the age of two-and-a-half, as a consequence of his brother's illness, he had been sent away for a while, and the extent of his distress at this separation was legendary in the family. My patient had no conscious memory of this.

Of the first device, conscious and unconscious anxiety from the past and present inhibits the conscious relaxation of the urethral sphincter; bringing attention to bear on a conscious memory of feeling "cock of the walk" overrides the anxiety and allows the conscious relaxation of the sphincter.

Of the second device, the process is the same in that he brings his father's Christian name to consciousness but there are no conscious feelings of triumph or revenge, though my patient believes that these are active unconsciously.

Of the third device, his brother's name is uttered, and from then on until the point where the sphincter is consciously relaxed, the whole process involves implicit memory with no conscious recall. What I sur-mise-and my patient felt that this was correct-was that despite his sincere and profound grief, the fact of his brother's death released some implicitly stored feelings from childhood rivalry and anger with his brother which are unconsciously expressed as triumph after his death and which facilitate his ability to urinate in public.

The "conjuring" up of sexual phantasies in order to achieve orgasm no doubt uses similar neural pathways.

These vignettes illustrate the complexity of the interactions between implicit and explicit memory and the rest of the nervous system and point to the need for further research, by neuroscience and psychoanalysis, to discover more about how the past is represented in the present. Until then a theoretical model involving dynamic internal objects, animated by all types of memory, often perceived as being concrete and happening "now," is essential to avoid the reductionist view that implicit memory amounts to an assortment of physiological procedures.

We now know unequivocally that there is more than one source of unconscious psychic material. Freud spent a lifetime describing the first, the repressed dynamic unconscious, and had inspirational glimpses at others. Psychoanalysis must not be seduced away from its work with Freud's unconscious, but at the same time must not ignore the necessary refinements and adjustments to technique which will become necessary as we learn more about implicit memory and direct emotional experiences that are not transferred.

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