Integration and Self Healing

Affect, Trauma, Alexithymia

Henry Krystal

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317758327
• Edition: 1
• Topic: Psychologie
• Subtopic: Relations interpersonnelles en psychologie

First published in 1993. Aexithymia is the single most common cause of poor outcome or outright failure of psychoanalysis and psychoanalytic psychotherapy. The reason that this problem has escaped recognition for so long is part of the mystique and paradox of emotions. Affects are familiar to everyone. They are part of our experiences, so ordinary and common that they are equated with being human. The first part of this book is devoted to those mysterious and much studied experiences: emotions. The second part of the book concerns psychic trauma. Certain aspects of these two subjects have to be established in order to give us a broad enough view to approach the third subject: alexithymia.

Part One
Emotions

1
Clinical Aspects of Affect

In this chapter we consider the nature of affect development and affect regression and their implications for the theory of psychoanalytic therapy. By way of introduction, it may be valuable to explain the use of the terms for affects in this book now, although their utility and relative merit will be taken up at a later time.

I find it useful to think of emotions in terms of certain components. The cognitive element of affects is of clinical importance. It is useful for both patients and therapists to pay attention to the meaning of the affect, that is, the message contained in the affect experience itself as distinguished from the "story behind it." The meaning of an affect frequently needs identification for clinical purposes because it clarifies some aspects of the problem at hand that the patient may not have consciously registered. Thus, both anxiety and fear signal the perception of impending danger. Their meaning is, Something bad is about to happen. But the story behind them is different. Fear refers to the possibility of external, veridical danger, whereas anxiety refers to some danger deriving from within oneself. Exploring the latter gives only limited results because part of the story is not conscious, and experience shows that patients readily rationalize the fears in terms of global dangers. By way of illustration in depression, the "meaning" of the affect is that something bad has happened already and the fault or responsibility is attributed to oneself. Seligman has arrived at a similar definition of depression based on the attribution of the state of helplessness to oneself and an expectation of future helplessness as well (Miller and Seligman, 1982, p. 151).

"The story behind" the depression may contain a nucleus of a loss, but that is frequently buried by various self-blaming and complaining responses, beneath which may be the ambivalent relationship to the object. The unconscious aggression is one of the determinants of unfinished, unresolved mourning.

To illustrate again, in anger the idea of the affect is that something bad has happened, and responsibility is attributed to an external factor. This constellation accounts for the angry person's feeling justified and even righteous about the anger and therefore tending to promote it. The story behind the anger is that the perpetrator is experienced as bad, and the angry person feels entitled to hate and punish him/her.¹

In Figure 1, I distinguish current sources of an affect from memories of the past. Approaching the "syntax" of emotions analytically is a major aspect of adaptive information processing. Knowing what measure of affect is derived from the current situation is helpful in moderating one's responses and choosing, on the basis of one's best judgment, the most appropriate response. Probably the key operation in affect handling is the ability to recognize instantly the extent to which the intensity of the affect experience is appropriate to the current event and when the associative linking of this event with a similar one or one involving similar "objects" from one's past has rendered it much greater than it needs to be. The accuracy of this evaluation, however, refers to the reaction to having the emotions; in other words, affect tolerance or affect handling. Affect tolerance, in turn, will determine the selection of the appropriate responses to the situation (the left column of Figure 1).

Note item No. 2 in the right-hand column, the "expressive" element of affects. This term refers to the physiological component of the affects, for the most part, an activation of the parts of the body innervated by the autonomic nervous system. The term "expressive" is retained here in preparation for a later discussion on the psychoanalytic conceptions of the expressive function of affect.

The hedonic (3) element of affects refers to their being endowed with a quality of pleasure, or suffering, which lends them the motivating role. Along with that, the hedonic element of affects supplies an important coloring or blending of the affect experience. For instance, anxiety attended by a pleasurable, hopeful expectation of winning at the races is experienced differently from anxiety in posttraumatic states, in which the profound pessimism and expectation of the return of the trauma rules out a pleasurable or "racy" experience. Thus, the blending of affects (discussed in chapter 6) contributes to the meaning and the message of the affect, as well as to the state of psychic reality that will be established. These three components of affect—the cognitive, physiological, and hedonic—represent the totality of the informational or signal contents of an affect. But only if these three components of affect occur simultaneously, free of blocks that cause isolation or dissociation (or other "defenses" against affects)—and only if one is capable of adequate "reflective self-awareness" (Rapaport, 1951b; Schafer,

FIG. 1. Information processing view of affects

1968a) or has the capacity for sensitive self-observation—can one make the observation that one is experiencing a "feeling." In my thirty years as a teacher of physicians, I found through direct inquiry that fewer than half the ordinary run of patients in a doctor's office are able to engage in the process of self-observation. Being able to determine and consciously recognize that one is experiencing a feeling makes it more likely that one will be able to utilize the emotion as a signal. It is sometimes an early, but key, psychotherapeutic challenge for patients to discover that they are the persons who are having feelings rather than that these scary and powerful bodily reactions have taken them over.

In addition to these three components, which are purely signal and autonomic information, there is a fourth aspect to emotions that goes beyond mere signaling. This is the activating aspect of emotion. In essence, affects influence the state of arousal and most bodily functions—such familiar phenomena as "psychomotor retardation." This aspect of affect is, in fact, the heart of psychobiology. That is, when the activating aspect of affect is fully acknowledged, the essential unity of the individual becomes clear.

Figure 1 notes that the state of activation influences—"feeds back"—and modifies the cognitive style, which, in turn, influences the nature of the evaluation of the perception or impulse, which, in its turn, modifies the affective state. But the activating aspect of emotions represents the rate at which the entire organism functions. Thus, the effect of emotions goes beyond the autonomic system activation (see Figure 1, No. 3) to the whole psychobiological activity of an individual. Another feedback loop was mentioned earlier, that affect tolerance represents a store of memory and response patterns to having an emotion. This subject is so crucial to my conception of the clinical problems of dealing with affective disturbances that chapter 2 is devoted to it. At this point, the comment pertains to the diagram in that the left side—that affect tolerance, or the reaction to the affect—may influence and thus modify the right side. For instance, when people become involved in certain vicious circles of maladaptive responses to having the affect, their attention is taken up with the affect instead of with the message that the affect communicated originally. If that problem can be avoided and one has been able to get the information from the affect, then one may consider the repertoire of responses to the stimulus, situation, or whatever mental element is at hand, and select a response.

This scheme is designed to facilitate the observation of the function of affects as signals and the related factors that may interfere with that function. It represents the hypothetical state in the adult who has adult-type affects that are best suited for signal functions. Such affects are minimal in the intensity of "expressive" components and modulated according to the intensity of the experience. For the most part they are cognitive. That is, they are idealike and work well in dealing with oneself and the world.

But, beginning with my paper in 1962, I realized that this was not always the case, that there was a great deal of variation in the way people experienced their emotions. Once the genetic point of view of affects dawned on me, I became aware of a variety of clinical problems related to the variation in affect form.

In this chapter, I review the kind of clinical problems that can be understood as manifestations of a regression in the affect form. All we need to assume is that such regression is possible. In considering affects, we find that there is a special communication on a nonverbal plane, which is, of course, the primary mode of communication between mother and infant. As a result of this universal experience, we clinicians, and other people as well, tend to assume that our perception of other peoples' feelings are correct and that, given a situation we "know," we can imagine what another person's affective reactions are. Such assumptions have enough validity to make them an important part of human interactions, and they are an essential aspect of empathy.

Our ability to perceive and imagine the nature of another person's affective experience, however, is subject to significant errors and distortions. We expect the affects of another person to be like our own, and, in adults, we expect them to be mature affect reactions. To the extent, however, that affect regression is a reality, such an assumption is not warranted. As clinicians, we have learned that patients' reflective awareness of their affects is unreliable. We have become accustomed to look for the physiological aspects of affects, such as moist palms, dry mouth, rapid pulse or respiration, even in patients who profess to be "fine." But even if we do observe such physiological signs, we tend to attribute to them the mature type of affects, for example, anxiety, when they may represent one of its regressed forms. The possibility presents itself that the reason for our failure to recognize affect regression lies in our repression of the memories of our own infantile affects. This amnesia is evident in our failure to recognize pain as an affect component or its equivalent.

It is important, therefore, to study affect regression and our recognition of it. It is not unusual to find that some types of psychiatric emergencies (including those occurring in psychoanalytic practice) consist of "affect storms," affect experiences that envelop the patient in a panic with the dread that the affect is about to overwhelm and destroy him. Even in the absence of such overwhelmingly threatening situations, many patients present themselves to the physician because they "cannot stand" some feelings, such as depression or anxiety. Doctors are inclined to respond by agreeing that the patient had "too much feeling" and by trying to diminish that unbearable "excess of affects" by drugs, psychotherapy, or a variety of other techniques.

For the most part, psychoneurotic patients are able to verbalize the nature of their affects and to discover with a reasonable effort the nature of the fantasies behind them. However, as analyses have become more prolonged and the explorations have extended to preoedipal phases of development and at times even preverbal ones, we find that even in "healthy-neurotic" patients there may be (or perhaps there inevitably exists) a core of disturbing affects that cannot be verbalized. The following vignettes from two psychoanalytic patients' work illustrate this point:

Case Illustration

Mrs. A., who could be diagnosed basically as having an hysterical character problem, was especially verbal and had excellent ability for reflective self-awareness and description of her moods and feelings. During the second year of analysis, her husband went away for two weeks, leaving her and her family at home.

Though she was able to verbalize her resentment of her husband's absence, a depressive quality to her function, of which she was not even aware, became apparent. It manifested itself in her reaction to both her art work and her children, whom she started treating as worthless objects (albeit the children only to a very slight extent). When this reaction was brought to her attention, she was able to observe that she felt somewhat "bad," but she was not able to verbalize the nature of her feelings. We were able to utilize clues from her dreams, metaphors, and fantasies in such a way that the analyst had to supply the words to the patient, which she then could recognize as descriptive of a component of her feelings. These feelings represented a mixture of self-condemnation and hopelessness in which she experienced the husband's absence as a repetition of a rejection and abandonment that she had felt in her childhood. She reacted, as she had then, by assuming the blame, feeling that she must have been bad to deserve it and experiencing herself as thoroughly bad inside.

Her vagina was portrayed as a "rotten hole," her mouth was "dangerous and repulsive"; she used her smoking to illustrate cannibalistic and self-destructive impulses. Also involved in the unverbalized feeling were others that became apparent in somatic symptoms, such as tenseness, "jumpiness," lack of appetite, insomnia, and physical pain. We did in fact wonder for a while if she had the "flu." 1 concluded that the "common cold" is sometimes a period when just such primitive and preverbal affects are experienced in an especially strong way, as was the case on this day during the husband's absence.

In the presence of such a regression, when memories present themselves in a nonverbal affect-only manner, we have to do a different kind of reconstruction than we are accustomed to doing with regard to the word-traces of the memories derived from a later period. In dealing with memories derived from the period preceding the acquisition of language, we must reconstruct the nature of the affective experience and affective memory and some clues to the nature of the subjective experience. We certainly cannot reconstruct the "traumatic situation" as opposed to the psychic reality of the child. Since the acquisition of language and symbols is a gradual one, subject to lapses and distortion, many infantile memories have to be viewed as nonsymbolic, nonverbalizable affect memories.

Mr. B. had been in analysis for three and a half years, mainly for characterological problems that were, for the most part, phallic-aggressive with some narcissistic aspects and some greed involving a combination of phallic and oral problems. He had been up to then quite capable of verbalizing his affects. When he started treatment, he had asthma, though not as severely as he had had during childhood and adolescence. It disappeared completely after a fairly short time in analysis without our having discovered its affective and cognitive contents.

Occasionally, under circumstances in which one would have expected certain affects to develop, such as anxiety or sadness, he would instead develop stuffiness of the nose and "scratching" in the throat. At times he had a "sighing respiration," which he mistook for a while for asthma.

On this occasion he came to his analytic appointment sneezing, with sighing respiration, and complaining of a subjective feeling of air hunger. He had awakened in this state after the following dream: He was moving to an apartment that was like the apartment to which his parents had moved when he was about 26 months old. It was located above a store. He was furnishing the flat with cheap furniture and very cheap dishes. The patient's associations were mainly to events that had taken place about the time he was two years old, when his parents suddenly moved out of his grandparents' home and into an apartment. He pictured the apartment as empty and dark. He thought it was possible that there was hardly any furniture. He then recalled (for the first time) that soon after he had moved to this apartment, his younger sibling was born, and he elaborated how he felt "displaced." Three recollections ensued: (a) that he had cried for long hours and pleaded with his parents to let him come back to their bedroom, since he feared the "empty room"; (b) that he developed asthma at that time; (c) that he had probably had eczema previously, but at this time it "got so bad that sometimes they had to tie down [his] hands, so [he] would stop scratching."

The work with the other parts of the dream brought up associations to things he was acting out in his life, but to which no previous associations were available, relating to disappointment with his mother and shift of affection to his younger sibling, whom in fantasy he babied or wished he had been himself. Other parts of the dream shifted to references to his "discovery" of phallic competitiveness. This trend of thought also involved his "victory" over his father and aggressive strivings in respect to the analyst.

However, while his aggressive strivings had been well verbalized since his childhood, the affects related to his feeling of abandonment, worthlessness, despair, envy, and hopelessness had not been subject to verbalization, but were instead expressed in psychosomatic symptoms and "covered over" by his phallic-aggressive gratifications. Only with the help of a dream producing somatic responses were we able to verbalize these affects and to find some cognitive aspects in them.

Whereas in these two cases, affect regression as manifest by inability to verbalize the affects was limited in scope, in some patients this reaction is very widespread.

The psychosomatic diseases are definable by their being chronic overactivities of an affect-related function and by the absence of verbalization or conscious awareness of the affect. In the following case, the inability to verbalize and tolerate affects was so widespread that it involved virtually every affect:

Dr. C., an alcoholic for a number of years, was now a member of AA and had found that AA "didn't work as far as drugs were concerned." He started supportive psychotherapy, and later the frequency and intensity of the treatment could be increased. He described his many rituals, which took two hours each morning. By the time he woke up, his coffee would be ready. He would drink several cups of coffee while reading the morning paper. He realized that he felt "different" after the first cup and the first page of the paper: he was able to move and even read faster.

At first he felt "very slow" and very tired, "like [he] could not move." He was not aware of mood changes. I often asked him whether he felt depressed, but he always denied it, though he was aware (especially on his vacation) that he did not enjoy anything.

On this occasion, following our previous and preparatory phase of his treatment, he said about the way he felt in the morning, "You can almost say I feel depressed." He then talked about his brother, who was "very slow" and whom he described as an alcoholic and "hypot...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgments
• Preface
• Part One — Emotions
• Part Two — Trauma
• Part Three — Alexithymia and Posttraumatic States
• References
• Author Index
• Subject Index