The ego – development of a psychsomatically reacting patient during her inpatient psychotherapy

Andreas von Wallenberg Pachaly

The milieu therapeutic field of the dynamic-psychiatric clinic enables even patients with ego diseases of the most severe extent to catch up in ego and identity development. The focus is not on special techniques, but on the therapists’ attitude towards the patients and the provision of a life-affirming milieu-therapeutic community that enables them to find their identity. Particular importance is attached to the identity aspect in the catching-up development of deficiently pronounced ego functions. The author discusses the development of a severely psychosomatically ill patient in interaction with the milieu-therapeutic community of the dynamic psychiatric clinic using the example of the ego-function of the body-ego, as well as the body-ego identity. The psychosomatic reaction of the patient becomes understandable within the framework of the theory of the archaic ego patients (Ammon) as the result of an unconscious pathological experience in the earliest childhood and as an expression of an acquired deficit of the ego structure. On the basis of a therapy process, the author shows that a therapeutic setting must be offered for severe ego disorders on the body level, which on the one hand can counter an archaic acting in areas of somato-psychic undifferentiatedness communicatively and understandingly, and on the other hand provides an institutional and interpersonal network of relationships within which a positive experience and internal physical and psychological identity is possible catching up.

In my presentation I would like to give a detailed description of the development of ego and identity within the framework of a dynamic psychiatric clinic using the example of a psychosomatically reacting patient who suffered from severe feelings of depersonalisation. I will discuss above all the catching up development of the central ego-function of the body ego, with special consideration of the role of the body help ego and the therapeutic identity made available in the dynamic-psychiatric clinic.

Schilder (1923) has described the formation of the body schema as a historical process in which the body transcends itself as a biological being in the field of tension between two orders of forces, the biological substance and the social forces, which with yes or no meet the needs of man. He saw the development of the body in connection with the development of an ego. Schilder (1924) described depersonalization as a disturbance of the central ego, which he understood to be closely related to the body schema, which he conceived in a dynamic process. In the further development of these thoughts, Federn (1913) provided a detailed description of the body ego, the body ego feeling, and the body ego boundaries which he understood as the result of an inner-psychic process of ego occupation taking place between different instances. He held like shields, Freud.

following a “special organic disposition” as the basis of a disturbance on the body level.

Lichtenstein (1961) postulates the existence of a primal identity, an original life plan, which remains decisive for a person’s lifelong being in the world. According to Lichtenstein, primordial identity emerges as the child’s reaction to the mother’s conscious and unconscious expectation of the child. In particular , since man does not have the innate identity of the animal , the extreme expression of the symbiotic relationship of the child to the mother means the central source for the emergence of a human identity . Ammon (1974) investigated the genesis and possibilities of changing this original identity. He found that disturbances of the body identity are not hereditary, but can be understood psychodynamically as an expression of a pathogenic interpersonal event and can therefore be changed with the help of adequate psychoanalytic therapy. Ammon (1974) understands the primary identity as the matrix from which the ego-boundaries and gradually also the body-ego-boundary of the child develop. The body-ego thus also has an identity aspect. Disturbances in the field of archaic body-ego development are always also identity disturbances, which psychodynamically imply at the same time damages of the ability to experience in interpersonal relationships. For the child, the experience of his body in the interpersonal space between himself and his mother is shaped by the experience and understanding of himself by the mother as representative of the surrounding group. A severely deficient body-ego must therefore be understood as the result of the mother’s lack of perception and her refusal to perceive and promote the child’s constructively aggressive steps in her own right. The approach of a psychosomatic technique resulting from this understanding of psychosomatic diseases as an archaic identity disorder in the boundaries of the ego and the body and ego differs fundamentally from all approaches based on a psychophysiological or drive-psychological model of intraindividual conflicts between different psychological instances, in that it presupposes an internalized deficient interaction scheme. For patients who cannot make use of outpatient therapy due to the severity of their archaic identity defect, there is a need for a therapeutic setting in which archaic action in the field of somato-psychic undifferentiatedness, i.e. the inability to meet needs other than physically, is met with understanding. An interpersonal and institutional network of relationships must be available within which a positive experience of physical and psychological identity is possible.

The destructive aggression, i.e. the archaic prohibition of identity of the original, deficient identity design, must be opposed by a structured milieu that represents a therapeutic, life-affirming identity design. The therapeutic community within the framework of a dynamic psychiatric clinic, which encompasses the entire current life situation, provides such a setting. Using a differentiated therapeutic spectrum, which includes group therapy, individual therapy, milieu therapy, the situation of a group-dynamically working large group situation and a variety of informally structured contact possibilities, such as eating, on excursions, during sports, the severely body-ill patients will be able to perceive, feel and enjoy the pleasurable experience of their body and its primary ego functions such as motor skills, tactile perception, sense of balance and visceral perception. In addition, the dynamic-psychiatric clinic represents a maternal breeding ground in the sense of Spitz’s primeval cave, which assumes the entire biological functions as well as the psychological manifestations of a patient.

When we took the 30 year old, married patient into inpatient psychotherapy, she was severely depressed. She spoke monotonously, her facial expressions were sparse and her head seemed walled in between the raised shoulders. Her staking stilted gait contrasted with her slender, handsome figure and pretty clothes. In conversation, she was gruff, and in a TAT protocol recorded at the time of recording, she described herself as a dead child held by the mother in her arms.

We had had to admit the patient to our clinic because she had been unable to do her job as a secretary since the death of her mother one year ago, who had died of pancreatic cancer 16 years ago, and her father had been unable to live in her apartment completely isolated and withdrawn.

The patient was plagued daily by agonizing head and neck pain, suffered from trigeminal neuralgia, a carcinophobia that drove her from doctor to doctor and had already had several benign tumors extirpated. She suffered from vaginismus and experienced every sexual intercourse with her husband as painful. She expressed the feelings of depersonalization that seized her like a raid in her panic, fear of going mad or losing the ground under her feet. This was associated with her multiple phobic symptoms, her street anxiety, her paranoid fear of crowds, in short her fear of being in the world, which made it possible for her to leave her apartment only accompanied by her husband.

In the admission interview, the patient presented herself and the network of relationships of her family as a configuration of a deficient body-ego experience, trying to roll over the exploding doctor with her complaints about her pain and the description of her odyssey of the futile search for a doctor who could finally have diagnosed her illness. As personality traits of her parents, she centrally described their cancer diseases. She could not communicate a differentiated perception of psychological aspects. She placed her symptoms like a wall between herself and the doctor who took her in. Only after laborious asking could she, completely separated from her person, provide biographical data.

The eerily quiet, absent-minded and starved mother had always described the patient, who was the eldest of her three daughters, as a headstrong, malicious Satan and had regarded her life as a hopeless case. She had never made friendly contact with her, but she often, when she was too lively and impudent, hit her in the neck, in the same place where the patient today often felt unbearable pain or locked her away in the basement. As a result of this refusal of the mother’s friendly emotional attention to her and a family atmosphere, which was characterized as an absolute silence at the table, the patient was often lost for hours in a fantasized paradisiacal dream world, walked autistically across meadows and even had to be searched once by the police. When her father had died, she had been put into boarding school by her mother, because she was “no longer finished” with her. There also began her psychosomatic complaints, with her toothaches being the only way for her to leave the boarding school for a short time. The demarcation function of her somatic complaints against a mother holding her in her arms and forbidding her life becomes clear here.

She felt a warm relationship with her performance-oriented father, who was in the outsider position, when she sat silently next to him on his business trips, on which he sometimes took her. She could only talk to him about his work. Later, she established this relationship time and again with her office chiefs, for whom she provided extraordinary services based on her father’s expectations of secondary ego functions.

On the day of her mother’s death, which she had nursed for months, the patient had been relieved, she felt liberated from a life-prohibiting superiority. However, on the day of the funeral, given the final separation, her symptoms had entered with full force. A life in her own right was not permitted for the patient due to a lifelong experienced identity ban. She, who had previously embodied the negative self of her mother and had only felt herself accepted as unfeeling, evil, non-existent in the relationship with her mother, now only experienced herself as alive in the relationship to her tormenting symptoms.

In the pathologically symbiotic relationship with her husband, who had had a sick mother throughout her life, she now took over this position, whereby she now, as in the relationship with her mother, felt that the deficient, non-living had been accepted by him and thus, according to her mother’s valid identity design, had also rediscovered in the relationship with her husband the only possible level of interpersonal contact she could have.

At the beginning of her in-patient therapy, we allowed the patient to represent the deficit relationship pattern of her primary group in a psychodynamic way within the entire hospital group. In the morning large group she sat petrified, emotionless and spread a paralyzing mood. She gave the impression of being emotionally completely absent, only her body showed us that she was there. Any attempt to talk to her sought to destroy her by her nihilism and persistent distrust of having a brain tumor or multiple sclerosis. Eisern held her to the fact that nobody could help her and tried to escape into her original, deficient body-ego-identity by being repeatedly transferred to a neurological station. But contrary to her efforts to offer herself to us as non-existent , physically deficient , but to withdraw as a person who lives in his own right , we had already given the patient a living space before her transfer to inpatient psychotherapy . In the group of the clinic’s therapeutic team, we had taken into consideration the patient’s medical history and the reports of the preliminary talks that several colleagues had had with her, and had given her a place by deciding to take her in. The whole patient group had been introduced to her by us, and right at the first meeting when she arrived, a number of fellow patients had approached her and were interested in who she was. In the first weeks we allowed her to simply be there, accepted her complaints about her pain, repeatedly addressed her rigid posture, but in demarcation from her deficient body I, which she offered again and again, also taught her the positive aspects, such as her tasteful clothes and hairstyle and her handsome body, which we perceived in her. It was always necessary to distance ourselves from the massive feelings of anger, powerlessness, helplessness and the urge to deport them and to realize what she was trying to create because of her family history. Only by the fact that in the hospital a continuous analysis and a common carrying of these feelings took place, it was at all possible to avoid a Mitagieren with the nihilistischen and destructive portions of the patient and to separate us, in order to win again and again by a mutually supporting perception access to its constructive ego shares and to ask us the question: “What can become of this patient? At the same time, in the group of the entire clinic staff, our own feelings of powerlessness and nihilism, activated by the patient, were processed so that we could not help such a patient after all.

We dealt with the life-prohibiting aspects manifesting in the group of patients in daily large group meetings. The milieu of a therapeutically effective group dynamic, which develops against the background of this daily confrontation with and demarcation from identity-denying identifications, made it possible for us to initially accept the patient as a petrified, painful body without angrily giving her up and were able to perceive her positive physicality in demarcation from her previous experience. Behind her rejective posture we gradually sensed, and at first only in isolated places, a friendly or hidden erotic smile, a helpful gesture, a pretty dress, a beautiful hairstyle or body posture, and a facial expression that betrayed grief and tension. The more we got to know the patient, the more lovable she became for us. In the therapeutic group, in contrast to the patient’s deficient body-ego experience, I was now able to represent more and more the attractive and constructive qualities of her physicality and make the anger triggered by her understandable to the group than the aggression with which her mother had rejected any of her constructively aggressive expressions of life. By perceiving the patient as a woman and by attracting her against her originally deficient design of physical identity, also finding her erotic and liking, I made it possible for the group to internalize a relationship scheme towards her, by repeatedly tearing her out of her deficient body-ego experience and confronting her with her attractive and lovable physicality and humanity. Whenever the patient was not allowed to withdraw into her old deficient body identity of the somatically and neurologically ill and she was confronted with perceptions of her healthy body, to which she initially reacted with denial, later with anger, we offered her a piece of psychological as well as physical structure that she could gradually internalize.

In the relationship that the patient had with a seriously ill fellow patient suffering from cirrhosis of the liver after a few months, in which she re-experienced her sick mother, her gain manifested itself in interpersonal psychic structure that exceeded the physical level. While she had only been able to laugh at her mother’s grave and had expressed her grief and fear of separation in physical symptoms, she now broke out when the patient had to be transferred to a closed ward into deep sobbing and showed us her pain. For the first time in her life in the protection of the surrounding clinic group and a relationship to her therapists as well as due to the psychological structure acquired in the group, she could feel sadness and separation and experience herself as alive in demarcation to her mother. Her following symbiotic feelings for warmth and security she showed us by sitting in the morning big group always with her legs dressed in a bag filled with polystyrene and giving the impression that she is rolling herself together in the uterus, whereby I got the feeling towards her that she actually still had to be born.

In order to enable her to further differentiate herself from her deficient body identity, we now invited the patient to participate in excursions of the clinic group. At first, she still tried to hold on ironically to her original identity design. She refused to come along because she was afraid of losing the ground under her feet and not being able to walk. Much rather she wanted to go home with her husband and meet his demands for a sick woman . When I told her that she could walk very well, she insulted me desolately and confronted me with all the aggression of her nihilism and defeatism.

At first she stalked awkwardly, stepped away and lost amidst the patient group. However , unlike her early childhood , autistic walks she was not alone now , whenever she was unsure she was hooked right and left by two fellow patients and so , adopted and supported by two body-aid me , as a small child is taken by the mother by the hand and held . Later, when she had a certain feeling that we were standing reliably by her side, she no longer needed the concrete support and could walk out in big steps whenever a therapist walked beside her. We had offered her a catching up friendly symbiosis at the body-eg level, which she could gradually internalize.

On these trips, where the whole group also went swimming, we therapists had the opportunity to see her body as an example for the whole clinic group, to tell her that we found her attractive and feminine and to communicate with her about it.

By perceiving these hitherto hidden qualities of her physicality, I had supported the patient group in adopting their female identity and enabled an interpersonal relationship scheme by perceiving her more and more as a woman. She experienced that she became desirable for male fellow patients and felt that she was demanded as a woman by her therapists, like fellow patients.

In the interaction with the clinic group, she was able to internalize this perception of herself and make it a component of her ego and body ego structure. As a result of this process, and as an expression of her increasing female identity and her increasingly solid body-ego boundaries, her period, which had been absent for years, began again.

This compensation of her deficient body image under the protection of a group, whose borders gradually became their own ego and body ego borders and which held ready for her the identity design of a living, sensitive woman, made it possible for her, with our support, to distance herself from her internalized life prohibition, to exist, also against the needs of her husband, whom we had motivated to ambulatory therapy, to have a sick woman. Now, due to the internalization of the life-giving group identity that the whole group had provided to the Dynamic Psychiatric Clinic, she was able to approach a newly admitted young anorectic patient who, like her, initially denied her body and sexuality, was able to empathize with her, take her into her arms, and help her take her place in the clinic group. Through this constructive symbiosis, which she offered to this patient, she further separated herself from her own problems, whereby it was important that she had experienced her own body as lovable and desirable in the direct physical interaction with this patient and at the same time had been able to accept her own weaknesses, but also that we had perceived her emphatic behaviour and friendly approach to the patient and had also communicated this to her, which was in stark contrast to her experiences in her primary group.

After this experience, where she had experienced physical contact unlike before not as destructive and anxious, but as helpful and pleasant, she also became able for the first time to have painless pleasurable intercourse with her husband.

In the subsequent separation phase the patient experienced in me first of all once again her original life prohibition against which she could now delimit herself aggressively, screaming and scolding . I was it now that forbade her to live, to look for an apartment or to establish a relationship with her husband. While at first she had aggressively opposed her negative identity design with a positive therapeutic one and had exemplified a level of interaction of positive experience with the patient to the group as an example, I took her focus on me about a non-lived life on me. She was now able to express her anger verbally and, due to the structuring of central and primary ego functions in the interpersonal field of the clinic group, to express her feelings of grief about the separation verbally and physically, but under the control of her ego, and no longer had to express them autistically and psychosomatically.

In her group, she gave everyone a rose to say goodbye, embraced everyone and told him what he had meant for them. After her stay at the clinic, the patient decided to undergo outpatient therapy and started a qualified job. She is now a lively, friendly woman who appears to her fellow men completely changed.

Using the example of this psychosomatically reacting patient, I have shown catching up ego and identity development on the body level. It became clear that it was not a matter of working through various deficient aspects interpretatively. Rather, we had to provide a situation in which we could enable her to experience an intact, life-affirming, physical and psychological identity, which she could then gradually internalize as part of her own body-ego structure.

Ammon (1974) described the mediating function of mother-child symbiosis during and after pregnancy, “in which the mother on the one hand represents the primary group as a whole and on the other hand represents the needs of the child to the group. Only if the mother is able to understand the previously undifferentiated physical expressions of the child as organ and body language, and to adequately respond to the needs and feelings expressed in this language, can she enable the child to develop a successful body-ego-development in the sense of the formation of a body-ego-boundary and a physical feeling of existence, which the mother imparts to the child at the level of tactile and olfactory contact, but certainly also intrauterine.”.

In therapy, the dynamic-psychiatric clinic represented a comprehensive milieu of primary maternity (Winnicott), in contrast to the deficit primary group, as analogously explained for the family group Pohl in 1976, in that the specific life needs of the patient are perceived and satisfied and are validated within a protective group. Although we had initially assumed the patient’s old, deficient physical identity, we had opposed it with our therapeutic, life-affirming identity design. Again and again we remembered what the patient was trying to create based on her original experience, anger, nihilism and powerlessness and dealt with these feelings at all therapeutic levels. Our therapeutic identity design made it possible for us to perceive and accept her intact, feminine, motorically functional and also attractive physicality. The dynamic-psychiatric clinic was the protective frame, in the sense of a uterus, in which we made a constant delimitation of her deficient body identity and in the sense of a continual reparation were offered her a group perception that granted her identity and a group feeling of her living body. This perception and this feeling of her body was conveyed to her with the support of her therapist in a variety of situations, in the group, on excursions, in the relationship with her therapist as well as with fellow patients, so that she could experience it bit by bit as part of her self and as part of her body I structure. It was a therapeutically decisive task to represent the identity draft of a physically attractive healthy woman, brought to her by the dynamic-psychiatric clinic, again and again in the presence of her fellow patients in relation to her original prohibition of identity and to point out and exemplify to the group a relationship level of verbal, averbal or physical kind, on which it was possible to obtain for her a perception of her living physical identity, and thus to make it possible for her fellow patients to approach her in the same way. In identification with the therapist, her fellow patients were then able to enter into a catching up symbiosis with her on the body-eg level.

The therapist himself was supported by a protective group of therapists and collaborators to distance himself from his often massive feelings of countertransference, which would have been impossible for him alone due to the extent of the patient’s archaic prohibition of identity, and was therefore able to constantly maintain his own therapeutic identity against her and assert himself against the destructive aggression of her original archaic prohibition of identity.

In summary, it is true that for severe ego disorders at the body level a therapeutic setting must be offered which, on the one hand, can counter an archaic acting in areas of somato-psychic undifferentiatedness communicatively and comprehensively and, on the other hand, provides an institutional and interpersonal network of relationships within which a positive experience and internalization of physical and psychological identity is possible. The task of the therapist is to constantly develop a community of milieu therapists that offers the patient a life-affirming identity. The institutional level of the dynamic-psychiatric clinic provides the matrix, in the sense of a uterus, in the reparative process, in which the body ego is experienced positively on an interpersonal level and the development of physical and psychological structures becomes possible.

The Body-Ego Development of a Psychosomatically Reacting Patient as a Result of Psychotherapy in a Dynamic Psychiatric Hospital

Andreas von Wallenberg Pachaly

The author discusses the therapeitic process of psychsomatically reacting patient and the retrieval of body development with special emphasis on the therapeutic identity , made available by a dynamic psychiatric hospital .

Lichtenstein (1961) postulated the existence of a primary odentity that determines the being-in-the-world man , and defines it as the child`s reaction to the concious and unconcious expectations of his mother towards him .

Ammon (1974) understands primary identity as the matrix out of which the child`s ego- and body-ego-boundaries develop . For the child , the experience of his body is determined by being experienced and understood by the mother as the representative of the primary group . A severely deficient body-ego , therefore , has to be understood as the outcome of the mother`s deficit of percieving her child and her refusal to accept and faciliate any of his constructive aggressive moves .

The therapeutic community developed by Ammon within the framework of a dynamic psychiatric hospital , covers the patient`s entire present living situation . It makes available a therapeutic setting for severely ill psychsomatic patients which counters their original deficient life-denying scheme by a therapeutically structured life-affirming milieu .

At the time of hospitalization the 30-year-old patient had torturing head- and neckaches , she suffered from trigeminus neuralgic , from vaginism , and was tormented by fear of cancer . Ever sincs the death of her mother she had been unable to work and had isolated and withdrawn herself completely into her apartment .

Her mother had never taken up friendly body contact with her , however , when she thoeght her daughtertoo lively she had beaten her into the neck , Where until today the patient often felt unbearable pain . With her achievement-oriented father , the patient could only talk about his work .

At the beginning of her therapy the patient sought to destroy any attempt to talk to her by nihilism and her persevering suspicion that she got a tumor of brain . Rigidly she insisted that nobody would be able to help her and tried to take refuge into her deficient body-identity .

The milieu of therapeutically effective group dynamics , which had been created in the daily process of working through the identity-denying aspects in the group of the staff as well as of the patients , made it possible to accept the patient . The accepting attitude of the therapist influenced the whole group and enabled the patient to internalize the new experience . Thus the group had offered her a reparative , friendly symbiosis on the body-ego-level . In this process the dynamic psychiatric hospital represented a comprehensive milieu of primary motherhood in which , in opposition to the deficient primary group , the specific needs of the patient were percieved and satisfied . In this environment there could be attained a steady deliniation of her deficient body-identity , she was offered an identity-approving group-perception and group-feeling of her female body , which she could accept as part of her body-ego-structure .

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