The Past in the Present

Therapy Enactments and the Return of Trauma

David Mann, Valerie Cunningham, David Mann, Valerie Cunningham

• Publisher: Routledge
• Year: 2008
• ISBN:
  9781134080601
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The Past in the Present brings together, for the first time, contemporary ideas from both the psychoanalytic and humanistic therapy traditions, looking at how trauma and enactments affect therapeutic practice.

Enactments are often experienced as a crisis in therapy and are understood as symbolic interactions between the client and therapist, where personal issues of both parties become unconsciously entwined. This is arguably especially true if the client has undergone some form of trauma. This trauma becomes enacted in the therapy and becomes a turning point that significantly influences the course of therapy, sometimes with creative or even destructive effect.

Using a wealth of clinical material throughout, the contributors show how therapists from different therapeutic orientations are thinking about and working with enactments in therapy, how trauma enactment can affect the therapeutic relationship and how both therapist and client can use it to positive effect.

The Past in the Present will be invaluable to practitioners and students of analytic and humanistic psychotherapy, psychoanalysis, analytic psychology and counselling.

1 Enactments and trauma

The therapist’s vulnerability as the theatre for the patient’s trauma

David Mann

Enactments are often experienced as a crisis in the therapeutic relationship. I use the word ‘theatre’ in my subtitle to place emphasis on how both the client and the therapist may participate as characters in scenes authored by the other and themselves, in effect become characters from the split-off aspects of the self. I will describe how enactments are particularly likely if the patient presents with a history of trauma. Enactments are most appropriately viewed as aspects of the erotic transference where the passions of the therapeutic relationship are in the full throes of love and hate.

Current thinking in the Intersubjectivity and Relational Schools of thought is that there is a considerable amount of unconscious interaction that happens in therapy that the therapist is not at first aware of. This unconscious relationship operates in the transference and countertransference. Amongst the many implications of this is that the patient’s material finds a place in the therapist’s blind spots. A review of the literature will suggest that the patient’s problem comes into play with difficulties that the therapist is experiencing either temporarily or chronically in his or her own life. The result is an enactment whereby both the patient and therapist unconsciously find expression in the other for their own difficulties. Enactments are therefore joint creations of the therapist and the patient; unconsciously communicated feelings become ‘unwitting participation’ (Hirsch, 1993). Regarding trauma specifically, it will be suggested that patients often repeat their trauma in the transference. This is widely understood clinical experience. The expression of trauma in the patient’s transference might encounter therapeutic difficulties if the patient also comes to represent something significant in the therapist’s countertransference. The collision between the patient’s trauma and the therapist’s trauma can lead to a traumatic crisis in the therapy: the enactment. This might either advance treatment or prevent the therapy from developing.

Enactments and unconscious process

The term ‘enactment’ entered psychoanalytic theory with Jacobs (1986) closely followed by McLaughlin (1987) referring to non-verbal interaction between analyst and patient. The concept of enactment is especially useful in focusing on the interactional aspects of the analytic relationship.

Some authors like McLaughlin (1987) focus on the less conspicuous elements of enactment, for example, the ‘kinesic level of communication’ (p. 557) in both verbal and non-verbal data. Jacobs (2001) considers that not only do we register more information about our surroundings than we realise, we also communicate to others far more than we realise. These communications in both directions are at a nonverbal, subliminal level outside conscious awareness. He describes ‘covert enactments’, as opposed to the more overt which are easily recognised by both participants. ‘Covert enactments’ are easily overlooked or missed as they might be expressed subtly in tone or slight shifts in body posture and minor alterations of the frame, though they can influence the course and outcome of an analysis. Jacobs writes:

Operating silently outside of the awareness of the patient and analyst, not uncommonly, they contribute to the development of difficulties in treatment. And when, as often happen, these forces go unrecognized, they can neither be understood nor, like their more recognizable brethren, made part of the analytic work. In such instances, they constitute invisible, but dangerous, shoals in the waters of analysis, perilous areas that can disrupt the analytic journey and can contribute to blocks, impasses, and failures in treatment.

(p. 8)

In a similar vein, Cassorla (2001) suggests that enactments relate to either repressed early trauma or threatening unconscious fantasies that would cause too much suffering if perceived. Chused (1991) defines enactments as ‘symbolic interactions between analyst and patient which have unconscious meanings to both’ (p. 615, italics in original). That is to say, they occur during regression to experiences beyond words, either from preverbal life or from traumatic experience that cannot be symbolised and processed. When the patient has been stimulated to a significant regression, they may at that stage attempt to actualise the transference through enactment. In this way enactments bridge the past and the present, not in a like-for-like repetition, but close enough to the original experience to appear identical to the participants. Whereas the past is largely reported through the verbal content of the session, enactments change the time frame to ‘now’ in the session. In this sense, the term ‘enactment’ accurately evokes the dramatic quality of the interaction. The difference from the past is that the other participant is re-experiencing their own past and not that of the other. In other words, though both are recreating something of their past, by coming together in the chemistry of this particular relationship, it is not an exact replica for either. In that sense, the enactment is a joint creation, something new to them both, but each experiences it as familiar from their respective pasts. Conscious communication is not part of this process; both patient and therapist are caught in archaic, primitive unconscious experience dramatising real or fantasised hopes and fears. The point is that neither participant is conscious of what is really going on at the time. A common understanding concerning enactments is that they are not under the therapist’s conscious control; therefore no matter how careful the analyst might be, the unconscious processes cannot be known beforehand, only after they have occurred. They cannot be guarded against, but the analyst at least has the foreknowledge to know something unconscious is likely to be enacted. In effect: expect the unexpected!

McLaughlin (1991) proposes that both patient and therapist are:

vulnerable to falling back on behaviours that actualize their intentions …reflecting transference hopes, fears and compromises shaped in their developmental past. Specifically, enactments can then be defined as those regressive (defensive) interactions between the pair experienced by either as a consequence of the behaviour of the other.

(p. 595)

Friedman and Natterson (1999) describe something similar and see an added benefit of enactments being to provide the opportunity for the analyst to wonder, ‘What are my wishes and hopes, what values am I communicating, how am I conveying them, am I reacting only to the patient or am I presenting a separate agenda of my own?’ (p. 243). This encourages the analyst to reflect upon the continuous involvement of their subjective life in the therapy.

Analysis is a profound two-person experience and cannot always be captured by an exclusive focus on the patient’s inner world. In that sense, enactments serve as a humbling reminder that transference ghosts from the past are not resolved once and for all. New relationships may revive forgotten conflicts. Enactments facilitate the two-sidedness of the therapeutic relationship.

In the American literature there is some common ground about definitions (e.g. Chused, 1991; McLaughlin, 1991). Enactments result from the interplay of unconscious processes that involve the analyst at an affective and behavioural level resulting from the patient trying to create an interactional representation of an object relationship. Put another way: enactments have to do with the specifics of the unconscious of both the patient and the analyst. As Chused writes: ‘Enactments occur when an attempt to actualize a transference fantasy elicits a countertransference reaction’ (author’s italics, p. 629). If, once they are aware of being caught in an enactment, the therapist can subject themselves to rigorous self-analysis, they will often have new information available that was not understood or known when they were less involved or engaged.

There is another aspect to enactment that I think is worth noting. An enactment is generally thought of as an event followed by analytic working through in the aftermath. While it seems clear that enactments, or working through them (or not) are significant factors, I believe they need to be considered in the context of the therapy as a whole. A number of psychological transactions may have taken place before a significant enactment arises in the therapy. There is widespread agreement that it is not the enactment but what happens afterwards that influences the therapy. However, it could also be said that what happens before the enactment is also important: that is to say, the patient and therapist have already built some sort of relationship; some of this would be unconscious as well as what we might think of as the ordinary therapeutic alliance. It is quite possible that the patient needs to feel fairly secure and safe before a traumatic enactment can occur which might permit an unconscious trauma to repeat itself.

Definitions and distinctions

Any definition of enactment is difficult. As one panellist discussing the subject put it: ‘The definition of enactment is bound to be blurry at the edge’ (1992, p. 84). This is partly because, like all other psychoanalytic terms, it gets used in an idiosyncratic fashion by different analysts. One distinction is to be made between acting out and enactment. For example, acting out is often considered as a motor action, embedded in drive theory and one-person psychology: acting out is something the patient or the therapist might do, but either way it is derived from one participant’s issues. Enactment has developed out of two-person psychology and the inevitability of the analyst’s intersubjective participation. Clearly these concepts were not to be thought of as mutually exclusive, but they are distinctive. There is also a distinction to be made with projective identification. The Panel discussion (1992) suggests projective identification carries the idea of ‘a single theme view. The patient is “out there” instead of being viewed as an interactive pattern’ (p. 836). Crude descriptions of projective identification, e.g. Bion (1959), depict the analyst as a container of the patient’s projections. More sophisticated descriptions of projective identification, e.g. Ogden (1979) identify the inciting fantasies and behaviour of patients as eliciting a mirrored response in the analyst: these have the therapist’s own, not projected, feelings and result from the impact of a different personality system. Ogden falls short of seeing the analyst’s feelings as originating from the analyst’s own wishes, feelings and object representations. While projective identification might recognise the analyst’s responsiveness to the patient, it does not acknowledge the therapist’s contribution to the analytic experience which is a function of the therapist’s own psychology. Enactment emphasises the conjoint process of attempted mutual influence and invites exploration of both the patient and the analyst.

It is worth noting that some Kleinian writers, e.g. Weiss (2002) and Cassorla (2001, 2005) describe enactments in terms of ‘crossed projective identifications’. In so doing, they follow the object relations tradition rather than the intersubjective model: the concentration on the patient’s internal world that the therapist is caught up in. In my opinion, this does not constitute true enactments as it does not account for the contribution of the analyst’s own subjectivity. I would suggest that the confusion arises in Kleinian thinking as it fails to distinguish and indeed muddles up ‘role responsiveness’ and enactment. Sandler (1976) introduces the idea of ‘role responsiveness’ to describe how both participants seek to impose on the other an intrapsychic object relationship whereby the analyst might find themselves accepting the role imposed on them by the patient and thereby colluding with the patient’s acting out.

Enactments and trauma

I would suggest that trauma is particularly prone to expression through enactment. Freud (1916–17) had described the ‘function of a protective shield’ which might be overwhelmed when the mind experiences a stimulus too powerful to be dealt with in the normal way, thus leading to a disturbance in mental operations. Dorpat (quoted in Roughton, 1993) proposes a ‘cognitive-arrest’ theory to explain memory gaps in those who suffered childhood trauma: denial at the time of trauma prevents the formation of representation memory of the event, which is not easily recovered verbally. Roughton suggests perceptual defences and denial block the encoding of representational memory, though this may be organised in a ‘sensory motor mode’ and accessible only through ‘enactive memory’ (p. 454). Hartke (2005) proposes that in analysis a traumatic situation provokes emotions that exceed the capacity for containment in the therapy couple. This excess can originate from either participant. Hartke describes how this ‘excess’ can bring about a period of ‘dementalisation’ sufficient to disturb the analytic relationship in either a positive or negative manner. ‘Dementalisation’ refers to the failure in the mental function to transform sensory impressions and raw emotions into ‘mental experience’. He notes that greatly traumatised people not only tend to carry such experiences into the analytic encounter but are also more likely to enter a new trauma as a result of any circumstantial or specific limitations in the therapeutic capacity for containment. Hartke formulates these ideas in the concepts of Klein and Bion. In more general psychoanalytic terms, this can be transcribed to suggest that experiences that cannot be formulated symbolically into words are more likely to find expression through the unconscious. This suggests the greater the trauma the more likely the unconscious disturbance. The difficulty or incapacity to transmute trauma into symbolic thinking processes means trauma is most likely to be expressed through the only outlet available, which is through action. Trauma, I would add, is therefore likely to be a consistent feature in enactments precisely because the overwhelming unconscious experience compels action rather than words and is not easily contained by the ordinary analytic functions of the patient and the therapist.

Like everybody else, therapists might be blown about by events in their own lives whether this is in relation to current circumstances or the reactivation of old issues. The analyst is not an invulnerable participant-observer. Each therapist brings a full set of hopes, needs and fears to their work. Both the analytic training and a more or less strong ego serve the therapist well much of the time. However, this is vulnerable to disruption and regression to less evolved states both from the work itself and from the pressures of everyday. A number of writers indicate that the patient’s material at the time found a resonance in what was happening in their, the therapist’s life. For example, Jacobs (2001) recounts that his father was very ill after a stroke which left him with cognitive and expressive defects; at this time, Jacobs began to make mistakes with bills, appointments and breaks, his identifications with his father’s symptoms finding a place in his patient’s material even though he was quite unaware of his own symptomatic behaviour. Bemesderfer (2000) traces the trauma of having her son diagnosed with cancer and how such tragedies profoundly influence what we do and how we do it. Reviewing some of the literature where analysts have written about personal illness, or of deaths of family members, she refers to ‘self disclosure and countertransference enactments, both of which appear to be inevitable consequences of the analyst’s traumatic experiences’ (pp. 1522–1523). She notes that patients sense changes in us even though they do not understand the causes.

The therapist enacts their own inner conflicts but in so doing also creates a situation that involves the patient having to come face-to-face with a situation they are avoiding. The mutual resistance blocks progress in the analysis and life as well. When caught in an enactment the therapist’s observations are clouded.

Clinical vignettes

I will give three instances of enactment in therapy. I am mindful of the slant that the therapist always brings to material either in the consulting room or publication. In all three examples I wish to describe, I am making a selection of thoughts that may give a distortion to the work with these patients as a whole. For example, I could cite the same three patients to describe other aspects of the therapeutic process, such as the erotic transference and countertransference or the function of regression in therapeutic process. Since I am describing enactments what I write will not be representative of the complete therapy.

In the following examples I will describe three enactments: in one where I think it helped the therapy, the second where it wrecked the therapy altogether and a third which illustrates enactment processes that did not significantly impact on the therapy. My purpose is to indicate how powerfully unconscious processes can take a grip during an enactment, the fact that the therapist’s contribution is made through their vulnerabilities and how this can decisively influence therapeutic development for better or for worse.

Enactment 1

I have had, from quite a young age, a poor reaction to the sight of blood. When I was 12 I witnessed at close hand a stabbing incident in my school, and even as I write this I can vividly recall the sight of blood oozing from the victim’s neck. My reaction at the time was to come over all weak, I needed to sit down, felt faint, broke out into a cold sweat and got spots before my eyes. After this specific incident, this reaction became generalised, in true Pavlovian style, to the sight of blood on any occasion in any context. My professional development took me at one time to work as a residential therapist in a crisis centre. Here I had ample opportunity to compound my feeble reaction to the sight of blood: many of the patients self-harmed. Two in particular stay in my mind: the patient who slashed her arm with a razor blade in front of me, a situation from which I had to walk away because I could not deal with it; on another occasion mopping up a large pool of blood after another patient had used a meat cleaver on his wrist. Frankly, I am feeling a bit queasy just recalling this and writing it down! I still have the same physical reactions as I did as a child, which can momentarily overpower and incapacitate me. My personal analysis, so helpful and transformative in many ways, did nothing to change this reaction to the sight of blood. And sometimes it is not even the sight of blood that leads me to collapse. Possessing, as I do, a vivid imagination, at times even the thought of it can create realistic scenes in my mind. The only thing that has given me a more adaptive response is fatherhood. Only great love has enabled me to override such a neurotic reaction to the sight of blood; only with my children can I avoid collapsing because they need to be looked after and comforted. When my squeamish reaction to the sight of blood comes up in conversation, as it does from time to time, I sometimes make a joke: I can cope with most forms of madness, pathology or mental distress, so I am okay as a psychotherapist but I could never have been a doctor or nurse.

This preamble about my vulnerability to the sight of blood provides the context for the enactment I wish to describe. Mr V was in his mid-thirties and had a medical background. He had sought therapy for a variety of reasons amongst which were issues concerning his mother’s death and what he considered to be his difficulty in getting close to people and drifting through life. Early on in his therapy he wondered if he would have to regress to a ‘messy heap’ in order to allow his defences to diminish. His mother had not liked mess. As a baby he had suffered from constipation for the first year and mother had taken this as a sign he was a clean baby. He felt a deadness inside and wondered if he would ever feel fully alive. He was worried therapy would not change this and that I would not understand him or be able to connect with him.

His mother had died when he was in his ea...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• List of Contributors
• Acknowledgements
• Introduction
• 1 Enactments and trauma: the therapist’s vulnerability as the theatre for the patient’s trauma
• 2 Mutual enactments within the therapeutic relationship
• 3 The abandonment: enactments from the patient’s sadism and the therapist’s collusion
• 4 The ghost at the feast: enactments of cumulative trauma in the therapeutic relationship
• 5 Loves and losses: enactments in the disavowal of intimate desires
• 6 Action, enactment and moments of meeting in therapy with children
• 7 Bad faith in practice: enactments in existential psychotherapy
• 8 Tangled webs: enactments on an inpatient ward for eating disorders
• 9 Past present: person-centred therapy with trauma and enactment
• 10 The therapist as a ‘bad object’: the use of countertransference enactment to facilitate psychoanalytic therapy
• 11 Working with refugees: an enactment of trauma and guilt
• 12 Chronic and acute enactment: the passive therapist and the perverse transference