Chris L. Minnick, M.D.

Concreteness in Infancy, Clinical Practice, and Everyday Life

Basic Assumptions:
1 – To be an infant is to be concrete and psychosomatic!

2 – The geography of phantasy for the infant is the mother’s body, inside and outside [Donald Meltzer].

3 – At its origin, the capacity to symbolize has its root in the relationship to a mother. Whenever an infant has an experience that is powerful enough that the infant feels a need to communicate that it is being impacted by something, the mother’s response that gives meaning to that experience adds to the capacity to symbolize.

4 – The unconscious internal world and the world of external reality are gradually differentiated by the processes of symbol creation and reality testing (esp. in the depressive position).

5 – The child’s interest in the world is determined by a series of displacements of affect and interest from the earliest figures to ever new objects.

6 – As an extension of #5, the psychoanalyst is often faced with the task of understanding and recognizing the meaning not only of a particular symbol but also of the whole process of symbol formation.

7 – To study concreteness is to study the most fundamental underpinnings of the entire evolution of mental life in an individual, both healthy and disordered.

The Relationship Between the Basic Assumptions and Emotional Distress:
1 – Emotional distress in infancy promotes the maintenance of concreteness at the level of the baby core.

– The greater the emotional disturbance, the greater the interference with symbol development.

– At any age of development, when emotional distress becomes too great to bear, there will be a retreat back to psychological maneuvers (especially projective processes) that will erode the quality of symbolic activity, at least temporarily, back to concrete “symbolic equations”.

2 – The defensive maneuvers of the baby core of the personality are by nature very concrete.
– e.g. splitting-and-idealization
– e.g. splitting-and-projective (processes) identification
– e.g. denial and the use / misuse of the organ of attention
– e.g. the equation of physical states with emotional states of mind (i.e. somatization)

3 – In infancy, the absence of a good object is experienced as the presence of a bad object.

4 – Of the three primary emotional issues that an infant has with its mother, (i.e.envy, jealousy, and separation) separation is the one that is most inherently concrete in nature to the infant. It will remain so throughout the lifespan even though unconscious envy is also very concrete in its fundamental nature.

5 – Dreaming, in which symbols are used to represent split off (i.e. from consciousness) unconscious phantasies, requires some degree of separateness from objects so that these objects are symbolized. The degree to which separateness is obliterated by massive mental maneuvers, as in psychotics – borderlines – and psychopaths, parallels the degree to which normal use of symbols in dreaming will not occur. In other words, daytime phantasies and nighttime dreams all have the same emotional value and significance.

6 – Concreteness is the starting point for symbol formation and what is left when it fails.

Examples of Baby Concreteness:
1 – Early concreteness can be seen in an infant that is breast feeding vigorously, pushes too hard with its face, has a breast occlusion episode, and then refuses to feed from that breast for the rest of the feeding.

2 – Vestiges of baby concreteness can be seen in later childhood behaviors as:

– kids covering their ears when they are saying degrading things to another kid in a ‘put down’ contest

– hand gesticulations that accompany speech

– small children being unwilling to eat a broken cookie, as if once inside them, they too would be broken

– needing to keep food rigidly apart on the plate or alternately always mixing it together

– being unwilling at any age to eat something because of its color, texture, smell, flavor, etc.

– compulsive purchasing or hoarding things and unconsciously equating them with bodily products as a substitute for food from mom and a relationship with her

3 – Curiously, somewhere in early childhood, a deep gulf develops. On one hand there is a conscious awareness that it is not possible to move mental states outside the body by physical maneuvers. Simultaneously, the phantasies of doing just that continue with the same frequency throughout the lifespan, especially via unconscious projective processes. It is analyst Jim Grotstein’s “in the meantime, on another plane…”

– It may turn out in the future that this gulf is in some way a function of the separation of cerebral cortex pathways of thinking versus limbic system pathways of “proto-mental” thinking.

1 – Concrete [Webster’s]: Characterized by or belonging to immediate experience of actual things or events; real, tangible, or literal.

2 – Concreteness: Its origin is found in the state of mind that infants have at the beginning of life. They seem to treat the mental experience of physical states and emotional states of mind as indistinguishable from each other. Both are experienced as happening in the body. Physical states are dealt with by physical maneuvers such as pooping, peeing, spitting up, sneezing, crying, and going to sleep. The crucial point is that the equation of mental states with physical experiences results in states of mind being experienced as if they were the equivalent of concrete physical states and can therefore be dealt with via physical maneuvers in space.

– “Me” and “not me” becomes a physical differentiation equivalent to inside me or outside me. [Quote from a six year old: “Mom, am I yours or am I mine”?]

3 – Symbol [Webster’s]: Something that stands for or suggests something else by reason of relationship, association, convention, or accidental resemblance.

4 – Symbolism: a mental activity in which one thing is used to represent another but they are unconsciously and consciously recognized to be different.

5 – Symbol formation starts in earliest infancy, as soon as object relations commence, but ordinarily changes its character and functions with the changes in character of the self and object relations. Thus the quality of the symbols and their usage will parallel the object relations taking place in early development.

– Three parts in symbol formation = Self (ego) – Object being symbolized – Symbol representing the object

– This process of symbolization is a crucial aspect of emotional development and its disruption is evident in all severe mental illnesses.

6 – The geography of phantasy for the infant starts with mother’s body, both inside and out. By rapid extension, based in part by genetic “pre-conceptions” [see Wilfred Bion], the infant’s own body and that of significant individuals in the surround are also added, but in particular dad’s.

– These early, primitive symbols representing parts of mom and dad’s bodies, at a “part” and later “whole” object level, become the core of symbolic activity, as seen in dreams. More symbols can be added in the course of development and used in self-expression, communication, discovery, creation, etc.

– The child’s interest in the outside world is a result of a series of “displacements” of these affects and interests from the earliest to ever new objects. These displacements are achieved through symbolization.

7 – [Summary by Hanna Segal]: Symbol formation is an activity of the ego attempting to deal with the anxieties stirred up by its relation to the object and is generated primarily by the fear of bad objects and the fear of the loss or inaccessibility of good objects. Disturbances in the ego’s relation to objects are reflected in disturbances of symbol formation. In particular, disturbances in differentiation between ego and object lead to disturbances in differentiation between the symbol and the object symbolized and therefore to the concrete thinking characteristic of psychosis.]

– Therefore, problems of symbol formation must always be examined in the context of the ego’s relationship with its objects. Such explorations begin in the here and now but extrapolate to their underpinnings in infancy.

8 – Symbolic equation: When one thing is not just felt to represent another, unconsciously and possibly consciously, but is felt to actually be the same as the first thing.

– Symbolic equations are the earliest symbols, “proto-symbols”, if you will. In healthy development, as the relationship between self and object gradually evolves, there is a parallel evolutionary change in symbol formation to fully formed symbols.

– Think of a continuum. At one end a symbol is felt to be the thing and at the other end it is felt to represent the thing. In turn there would be a continuum of abstraction in the symbolic representations from portraiture to modern art.

9 – Summary: The movement toward symbol development is a necessary and normal aspect of learning to cope with ordinary mental pains such as those that ensue from separations. This is all taking place in an environment of adequate availability of good objects. Where the developmental environment is more disturbed the infant will resort to more extreme maneuvers involving greater levels of omnipotence (i.e. magic) and psychotic (i.e. massive) levels of projective processes. The consequence of resorting to more extreme maneuvers is the continuation of concrete thinking and the undermining of the development of symbol formation.
[See Case Example of a 7 year old boy at end of outline]

A Working Model of the Composition of the UCS Inner World:
1 – Humans seem to experience their emotions in early life as embedded in relationships, i.e. all emotions seem to be experienced unconsciously as occurring within an object relationship in which one is doing or feeling something to or about the other (i.e. an unconscious phantasy). This becomes a really useful paradigm for understanding any emotional state of mind. Underlying the emotion is an unconscious phantasy of an object relationship in which one can ask – who is doing what, to whom, and why?

2 – For reasons that I can only make conjectures about (most likely a combination of (1) how the brain stores early experience combined with (2) genetically based pre-conceptions (3) combined with 9 months inside one unique person) it is useful to presume that every person, after infancy, has a handful (maybe 3 to 6) of these core relationships.

The “unconscious phantasies”, that dominate these core relationships, in turn form the foundation for that individual’s outlook on life, relationships, and what we expect to happen. Each of these relationships usually involves a different ‘part of self’ locked into a rather permanently fixed relationship with a “good” or “bad” version of mom or dad. They are used as templates to think about the meaning on any life experience.

– Their recreation in the outside world, because they are the ‘only game in town’, determines how we conduct ourselves in any emotionally intimate relationship (the “repetition compulsion”), especially with family and romantic partners, and with our therapist (transference). Because these relationships can always be found to have the qualities of infantile thinking and seem to resemble and fit the early history of object relations with caregivers for that individual, I think of them as comprising the “baby core of the personality”.

3 – It is useful for us to create a working model of how this baby core is created, even if it is also mostly conjecture based on clinically observable data and recent developmental neuro-biological research. It now appears that the earliest memories of life in utero and immediately after birth are stored at a midbrain level in what is referred to as the limbic system comprised of the amygdala, hippocampus, and other nearby areas. These earliest experiences seem to be stored as “memories in feeling” without any thoughts, in the form of phantasies, attached to them.

– Since these stored emotional experiences occur first inside mother’s body, and then with key caregivers after birth, they seem to always accrue to the relationship with mother first and foremost. These experiences are then worked on at a “thinking” level in the cerebral cortex, and ultimately the frontal lobes of the cortex. While this process of the cortex coming on board is starting in utero, it accelerates its development very rapidly in the first days, weeks and months after birth. Since the infant is relating with its own body to mother’s body, most of the developing phantasies are very concretely about one’s own body and mother’s body, at what Klein calls a “part object level”.

“Limbic Leakage”, Cortical Development, and Unconscious Phantasy:
1 – If we assume that memory can be stored in the brain before it can be thought about, and that experiences get recorded mostly because they are particularly emotionally evocative or are less evocative but repeated regularly, then these stored experiences as ‘memories in feeling’ will have an impact on the developing psyche of the infant.

Because the human brain seems to work by pattern recognition and association, rather than storing a digitized snapshot of a whole experience, it is clear that current experience can evoke the recall of emotions linked to similar experiences from archaic midbrain levels of memory. Furthermore, if those earliest experiences were unusually powerful, then associations to them are evoked by a wide range of things in current life.

Premature birth, adoption, severe colic, and very short spacing between siblings (e.g. less than 18 months apart) are examples of some very powerfully evocative early experiences.

2 – So if we have these early events stored as “memories in feeling”, and we are having new ongoing experiences, both of these sets of emotional experiences are becoming part of what the cerebral cortex is trying to organize and give them a sensible meaning. As the ultimate significance of the emotion is organized, it becomes the center of the meaning ascribed to an object relationship – the aforementioned “who is doing what to whom and why”.

The object relationship could then be described as being between a part of self and a version of mom or dad, with the “unconscious phantasy” representing what they are imagined to be doing to each other for some reason.

3 – Limbic leakage is a concept representing the consequence of anything evoking the “release” of archaic memories in feeling because something in the current environment is stimulating an association to those earliest experiences. Since these memories are so deeply unconscious and literally “unthinkable”, they can powerfully evoke a mood or emotional reaction that one cannot consciously fathom. If such emotional states are being chronically evoked and were originally very disturbing, as in someone who is chronically seriously depressed or anxious, then they have no hope of getting past it without professional help.

– Since so many of these earliest experiences have phantasies formed about their meaning during infancy, and reworked as to their significance for years, then the likelihood of the phantasy being distorted is very high if not guaranteed. Again, the more powerful the emotional issue around which the phantasy is being formed, the more likely that it will be a problem in life that cannot be dealt with constructively without outside help.

4 – Summary: What will become the earliest phantasies, at a cortical level, are probably felt to be the same as the initial raw experiences of early infancy. Because these earliest experiences are so central to the infant, they become the basis for most if not all of the earliest explorations of life in the world outside the womb. As development proceeds via these explorations, new objects will be added to the earliest objects. In turn this will lead to self-expression, communication, discovery and creativity.

Much of these latter activities represent a displacement into the outside world of feelings and phantasies, as well as sublimations of those, via a process of “symbolic representation”. This means that interests in the earliest objects, will move to new objects that come to represent the early ones. Much if not all of this activity is manifested by a child’s play. If the earliest relationships have too much mental distress linked to them, then that pain will put a strain on the smooth transition of expansion of these processes of displacement and sublimation and expansion of the use of symbols. What is likely to remain is a tendency to concreteness and diminished imagination.

Concreteness, Children’s Play, and Dreaming:
1 – It is useful to conceptualize the play of children as their physically concrete way of thinking including testing hypotheses about life and the difference between the inside and outside worlds in which they live.

2 – Similarly, it is useful to conceptualize “dreaming as thinking” done by the baby core of the personality while asleep. Dreams think about whatever emotional issue is dominating the baby core of the personality at that moment and depict how the baby core is choosing to deal with that issue.

– Dreams require the depiction of parts of self, good and bad versions of mom and dad at part and whole object levels, and various states of mind and concomitant activities in those states of mind that make up the baby core of the personality. As a result, one can see the evolution of symbolic representation and one’s relationship to those symbols in a stark fashion in dreams.

– The bad part of self may evolve in the course of a successful analysis from a monster from outer space, to a prehistoric tyrannosaurus, to a vicious wolf, to foreign assassin, to a bad figure in the news, to the equivalent of one’s sibling in a perturbed state of mind. A similar evolution might occur for a parental figure.

3 – The greater the emotional disturbance in thinking, the less dreams will employ symbolism and the more they will represent “symbolic equations”. It leads to the interesting question as to whether or not psychotic individuals dream in any proper sense of the word, or whether they are just moving dream furniture around in mental space.

Klein’s Models for Early Development, Creation of Symbols, and the Experience of Separateness:
1 – Klein’s Paranoid-Schizoid Position: The infant needs to bring order to its world and does so by dividing and separating good (i.e. pleasurable) experiences and the objects linked to them, from bad (i.e. unpleasant) experiences and the objects linked to them. This process of splitting-and-idealization leads to a natural desire to have a union with the now ideal object and get rid of and totally annihilate the bad object as well as bad parts of self (linked to the experience of the bad object). Along the model of alimentary tract’s function, the bad tends to be evacuated into some container in the outside world. At this time omnipotent thinking is paramount and reality sense intermittent and precarious. The concept of absence hardly exists so that when the union with the ideal object is not fulfilled, what is experienced is a feeling of being assailed by the presence of the bad object or objects.

– This period of development corresponds to Freud’s period of hallucinatory wish-fulfillment. Projective processes are the major defensive maneuvers, i.e. splitting-and-projective identification, whereby large parts of self are projected into the object and the object then becomes equated, i.e. identified, with the projected parts that it is felt to contain. Similarly, internal (figures) objects are projected outside and identified with parts of the external world felt to contain them. These first projections and identifications are the beginning of the process of symbol formation.

– However, these early symbols are not felt to be symbols or substitutes but the original object itself thus forming a symbolic equation between the original object and the symbol in the internal world and the outside world. (This equals the basis of the schizophrenic’s concrete thinking.)
[Note: – The fact that most of the first alimentary evacuations occur in relation to mother and her body, where the infant had been living for many months, may contribute to the fact that most “projections” throughout the life span are imagined to be “into the body of someone” even though mental health professionals persist in saying “onto”. Since projections always entail a “content” that is to be moved in physical space for some “motive” in the projector’s unconscious inner world, the “consequence” that is expected in unconscious phantasy to result from the projection will follow logically. All projective processes can be made into an algebraic equation where: content + motive = consequence. Knowing any two of the components will usually allow one to deduce the likely composition of the third element.]

2 – Klein’s Depressive Position: As development takes the infant into the middle of its first year of life, the quality of its object relationships change. Instead of imagining two mom’s, i.e. an all good one and an all bad one, its brain development leads it to recognize that the mom that it at times loves is the same mom that it hates at other times. This unites the two part objects, i.e. a good version of mom and a bad version of mom, into one whole object. This means that it can have both loving and hating feelings for the same person, i.e. ambivalence. In turn, it can now feel guilt for harming, during hateful periods, the person that it also loves. This loving, guilty concern (what Klein calls depressive anxiety and depressive guilt) is a healthy, necessary step in the development of caring object relations and the whole package is referred to as the depressive position.

[Note: Despite the confusion in nomenclature, all of the above is part of normal development and not to be confused with clinical depression.]

– We now have an object relationship that has evolved to one in which guilt, fear of loss, or actual experience of loss and mourning, lead to a striving to repair, restore and re-create the object. Successful repeated experiences of this sequence lead to a good object being securely established in the inner world of the infant.

– With a gradual lessening of projective processes and a relative strengthening of introjective processes, a change in the reality sense occurs and a gradual differentiation of internal and external reality develops. The infant increases its desire to spare and save the object from its possessiveness and aggression.

– This situation is a powerful stimulus for the creation of symbols, which in turn acquire new functions, which in turn change their character. The symbol is, for example, a means for displacing aggressive impulses from the original object, lessening both guilt and fear of loss. Those symbols residing in the inner world also operate as a means of restoring, re-creating, recapturing, and owning again the original object. But they are no longer fully equated with the object.

3 – A symbol is created by the self to represent an object (i.e. person) that is felt at some level to be separate from the self, literally physically and probably emotionally. As development proceeds through infancy, the symbol can be used to remember the object during its absence. All of this is a precondition for a successful uniting of good and bad versions of mom in the “depressive position”.

4 – What happens to symbol creation and its consequences when there is an excessive reliance on projective processes to get back inside mom and rid oneself of the experience of separateness? The result is an erosion of separateness and an increase in confusion as to whether or not the symbol is the same as the object. In other words, the symbol and the object symbolized become “fused and confused”.

– Becoming an “unborn inside baby” once again is a common temporary state of mind for many people as they go about their daily life. For some, it is a way of life, and thus becomes significantly problematic.

– As Segal puts it “only when separation and separateness are accepted and worked through does the symbol become a representation of the object, rather than being equated with the object”. Where there is a disturbance in the relationship between the self and the object, it will be reflected in a disturbance in the relationship between the self, the object symbolized, and the symbol.

5 – Full symbolization can be thought of as an achievement that requires full tolerance of separateness and therefore adequate tolerance of mourning of the lost object that is represented by the symbol.

Bion’s Model for the “Mother – Infant Relationship” and a “Theory of Thinking”:
1 – The Mother – Infant Relationship: Taking off from the models of Melanie Klein, Wilfred Bion elaborated a model of the infant’s relationship with the mother in earliest infancy that gives the mother a crucial and indispensable role in the infant’s development of a capacity to think. His idea was that infants have raw, unthinkable, unusable states of mind and body that can only be emptied out of the infant’s mind (i.e. evacuated), as if they we chunks of mental concrete. He arbitrarily called these raw mental experiences “beta elements”. These evacuations are imagined to go into the mother where she performs several functions (Bion’s reverie). It is necessary for the mother to (1) take in these raw states of mind/body, (2) tolerate contact with them, (3) organize them into a meaningful idea regarding what they are and why they are being experienced, and then (4) behave back toward the infant in a fashion that is appropriate to dealing with that specific raw, unusable and unthinkable state of mind.

2 – The Theory of Thinking: The above process gives “meaning” to an otherwise meaningless and unusable piece of concrete mental furniture. Bion gave a name to the state of mind that the infant re-introjected in a more usable, thinkable form from the mother’s emotional and behavioral response. He called it an “alpha element”. This new processed version of the original raw experience was now something that could potentially be thought or dreamed about. The gradual development of a capacity to perform this “alpha function” on one’s own is a prerequisite for moving from psychotic modes of functioning to healthier modes of actual thinking and symbolizing.

– Beta elements are concrete, suitable only for evacuation, while alpha elements are moving in the direction of symbolization and potentially suitable for thinking and use in dreaming. Practically speaking, alpha elements could be seen on a continuum from the very earliest movement toward primitive symbolization (e.g. labeling an emotion) to very sophisticated and highly elaborated symbolization (e.g. poetry, contemporary art, etc.).

3 – In normal circumstances, according to Bion, an infant will develop a capacity to cope with separation and its attendant anxieties. If these anxieties are not excessive, the infant gradually learns that the parent will return and it begins to develop a capacity to create and hold on to the memory of the temporarily lost good object. Thus it learns to remember the absent object by creating an image representation of that object in its mind. This internal mental representation (called a “thought” by Bion) is used to bridge the painful gap of loneliness until the object returns and is thus the prototype of a developing capacity for symbolization.

– The success of the above process is linked to a combination of the infant’s capacity to bear frustration and the environment’s capacity to keep this frustration within bearable limits.

4 – As disturbance increases (linked to environmental failures and the infant’s predispositions), a greater degree of omnipotent maneuvers are resorted to in order to cope with such mental pains. These maneuvers invariably aim to evade the experience of separation (both psychic and external reality). In that process they undermine the maintenance of a healthy relationship to good objects by creating a relationship to omnipotent maneuvers as a substitute for object relations. These omnipotent maneuvers include:

– turning to one’s own body and bodily products (to deny that the object’s absence matters)

– resorting to a phantasy of getting back inside the object (i.e. to become an “unborn inside baby”)

– going to the extreme of / explosively evacuating/annihilating hallucinating the object out of existence.
[See Case Example at end of outline: An infant whose mother got German measles at 3 months of pregnancy.]

Concreteness in Severe Emotional Disturbance:
1 – To be psychotic is to sink into a global state of baby concreteness and resultant massive confusion between the mind, body, and outside world.

2 – The hallmark of psychosis, according to Donald Meltzer, is to resort to “massive states of projective identification” with a complete blurring of boundaries between self and object (internal or external). This is at the root of the confusional states seen in acute psychotic illness.3 –Consider some of the hallmarks of schizophrenia:
– Hallucinations including auditory, visual, olfactory, tactile, etc.
– Delusions of grandiosity, persecution, and reference
– Disordered associations including loose, clang, tangential, and circumstantiality
– Disordered affect including manic, depressed and flattened
– Disordered physical movement including psychomotor retardation and catatonia

Concreteness, the Learning Process in Childhood, and its Disruption: [See Ravel’s libretto from Klein at end of outline]
1 – Example of inhibited symbol formation summarized by Segal of Klein’s Case in 1930:
“She described an autistic little boy of four, Dick, who could not talk or play; he showed no affection or anxiety and took no interest in his surroundings apart from doorknobs, stations, and trains, which seemed to fascinate him. Analysis revealed that the child was terrified of his aggression toward his mother’s body and of her body itself, because he felt it had turned bad through his attacks on it. Because of the strength of his anxieties, he had erected powerful defenses against his phantasies about her. There resulted a paralysis of his phantasy life and symbol formation. He had not endowed the world around him with any symbolic meaning and therefore took no interest in it. Melanie Klein came to the conclusion that if symbolization does not occur the whole development of the ego is arrested.”

2 – Consider these ‘What ifs?”:

– What if the first grade child who was best at coloring between the lines was so concrete as to imagine that to draw on the line would break the drawing, and she would have her first schizophrenic break at 17.

– What if 6 year old boy’s mother was always threatening to go live away from the family and he was terrified of learning subtraction (‘takeaways’).

– What if a third grade girl felt she was keeping her mother and dad split apart out of jealous possessiveness of mom and had an unusually strong preference for printing when doing writing exercises in school and seemed to struggle to learn to do cursive, i.e. “joined up” writing.

– What if a four year old projects his violent biting phantasies, linked to his experience of colic in infancy, into a neighbor’s boisterous red haired golden retriever that snapped at him for trying to take a bone away, and then as a 8 year old seems unusually negative and uncooperative with a rather stern older teacher, Miss Order, who happens to have bushy red hair.

3 – Where infancy is disturbed there is the potential for numerous symbolic equations in the outside world which then carry the full anxiety experienced in relation to the original persecutory or guilt-producing object. This will inevitable disturb if not derail the child’s relationship to the object that has become persecutory.

4 – Infancy has many tasks that simultaneously involve the modulation of emotional distress while learning about life and how to realistically think about and manage it. Feeding is an example, par excellence, where one sees reasonable behaviors and irrational phantasies all mixed together, at times reinforcing something constructive, at others completely interfering with development. One need only consider the following to picture the positive and negative fedback loops:

– a breast feeding “occlusion” episode

– the sequelae of severe colic in infancy

5 – In ordinary development, all children have pockets of concrete thinking that interfere with normal life and development but are accepted by the parents as the price of admission to learning about life:

– Try convincing a child of four that the “monster in the closet” is just in their imagination.

6 –As an example, early separation from the biological mother as seen in normal adoption seems to universally leave issues unresolved that regularly concretely interfere with development.

Attention Deficit and Hyperactivity Disorders:
1 – To keep one’s attention focused on a task at hand for a sustained period, it is necessary to keep internal distractions at bay. But if almost anything leads by association to an emotionally charged early experience, then it is really difficult to not be constantly distracted.

– By extension, if one has very emotionally charged early experiences that one wishes to annihilate from existence, then one cannot allow any thought in any area that might undo the obliteration lest the unwanted experience return. This makes it difficult to think something through at any depth, risk learning new ideas, etc.

– e.g. If having a bad thought is indistinguishable from an act, then you don’t dare think any bad thoughts (see the movie “Jesus Camp”).

– e.g. If in phantasy you murdered mother’s unborn inside babies, then thinking about the inside of anything is dangerous.

– e.g. If in unconscious phantasy you have stopped your mom and dad from getting together, then you may have difficulty putting anything together, as it would tend to undo your control over your parents [Ron Britton’s patient shouted “stop that fucking thinking”.]

Concreteness and Sexuality in Adolescence:
1 – Whose body and sexuality is it?
– If sexuality is stolen, then sex is a crime

2 –One cannot have a boyfriend or girlfriend if it is confused with possessing mom or dad
– This is so concretely frightening that boys will fight when told “go f… your mother”.

3 – Pregnancy and abortion require an investigation of: (1) Whether in psychic reality a pregnancy has occurred yet?; (2) In psychic reality, whose baby is it, mother’s or the adolescent’s?

The Baby Core of the Personality, Concreteness and Psychosomatic Illness:
1 – Definition: Psycho-somatic refers to the interaction of the mind (psyche) and the body (soma). Therefore, psychosomatic illness would imply that this interaction is leading to a symptomatic difficulty. This is not to be confused with hypochondriasis wherein the psyche is imagining an illness.

2 – As stated at the beginning of this talk, to be an infant is to be psychosomatic. If the caregivers have a preference for conceptualizing bodily states as a source of all distress, as opposed to seeing emotions as the source of distress, then the infant will not develop “psychological mindedness”.

– In the beginning of life, infants respond to both physical and emotional experiences with a response that has a physical component. If only the physical aspect is recognized by the caregiver on a continuous basis, then the emotional component will not be given recognition and meaning. If the infant’s target zone for physical expression of emotional states is one that the caregiver’s attitudes reinforce, then somatization may take preference over mentalization. The groundwork is laid for a concrete displacement via unconscious projection of emotional states, and phantasies about, them into the body.

3 – A strong preference for making mental states a bodily issue is almost always completely intractable to mental therapy. Even if convinced that one bodily zone of difficulty is “mental/emotional” in origin, the patient is at high risk to unconsciously just find a new zone that couldn’t possibly be “all in their head”.

4 – Definition: A “folie a deux” is the presence of the same or similar delusional ideas in two persons closely associated with one another. It represents one of the most difficult if not impossible situations to treat in mental illness.

– One finds some degree of this intractability almost universally in psychosomatic illness. This is in great part a result of a desire to not see the issue at hand as mental or emotional, which in turn is commonly a result of a parental preference for the same attitude. Where one or both remained bound together by this attitude about the illness, creating a secondary gain, that area of life will likely remain immune to outside influence that might alter how the illness is perceived and used.

Concreteness in the Therapist:
1 – Patients are usually consciously aware of wanting to talk about something although they may not know why that particular something has come into their consciousness. The patient’s communication usually has a subject and an object who exist in the patient’s actual current life and are outside the relationship to the therapist. It takes significant training to see:

– In that outside situation, the patient is likely recreating something that exists as a relationship in their UCS inner world, very likely with origins in preverbal experiences of infancy.

– The patient may be talking about something in their life outside therapy that has a parallel with their feelings about the relationship to the therapist (i.e. transference).

– At times the content of the communication is less important than the process taking place at that moment. In turn, the process may represent some very early emotional issue.

2 – In all of the situations just described above, concreteness in the therapist will naturally predispose him or her toward behavioral approaches and away from thinking about the unconscious inner world. If the patient is also very concrete, then both will tend to feel driven to action in response to a problem instead of thought about issue at hand. A fix or cure becomes the goal rather than understanding the phantasies and emotions at hand.

– Never assume that because a therapist says they “believe in the unconscious” that they actually do. There is a lot of “unconscious lite” in the ranks of the mental health profession, including psychoanalysis.

3 – A strong need, at a baby level in the therapist, to be seen as good, smart, clever, funny, likable, etc. will interfere with staying separate from the material to think about it and will predispose the therapist to concretely act in response to countertransference feelings. Insight into this can allow a repair by going back to the missed interpretation.

4 – The level of “imagination” that a therapist brings to the work of analysis is highly variable and to some degree contributes to the “talent” that some have for the work. This is perhaps analogous to competitive figure skating where one has to learn the compulsory maneuvers (at which the Eastern Block always excelled) and then do free style skating (at which the freer thinking West excelled).

– Dream interpretation is typically the arena in which the freedom to imagine is most necessary.

5 – When patients are unconsciously putting pressure on the therapist to “act rather than think”, all therapists must remind themselves of the need to represent with symbols (alpha function) for the patient rather than take action in the form of giving advice, etc. This is more common when one cannot “think” of an understanding of the situation at hand, or when the patient is feeling especially helpless and needy, or at the end of sessions when “ideas” don’t seem to “fix” the situation so that patient/baby can be sent away guilt and anxiety free.

Two Reference Texts You Must Own:
Donald Meltzer. “Sexual States of Mind”, Clunie Press, 1973

Hanna Segal. “The Work of Hanna Segal: A Kleinian Approach to Clinical Practice”, Jason Aronson, 1981

Two Classic Papers:
Wilfred Bion. “A Theory of Thinking”, Int. Jour. Psychoanal., 1962, Vol 43, Parts 4-5.

Donald Meltzer. “The Klein – Bion Expansion of Freud’s Metapsychology”, Int. Jour. Psychoanal.,


Case Example of 7 Year Old Boy:
1 – A patient is brought by his mother at seven years of age. Her first pained but earnest comment was that she had been completely uncertain about how to deal with a baby or understand the needs and feeling states of her first born child. As she summarized it “no one taught me how to be a mother”. He is very odd, uncoordinated, teased at school, and has clearly inherited both his scientist parent’s intelligence and their lack of understanding of ordinary social cues.

2 – The boy, who seems chronically frustrated, ineffectually angry, confused about how life is supposed to work, seems to have summarized all of those emotional states with a decision that he is not going to engage in any more life at a given moment than he feels like doing. This quasi ‘sit down strike’ about life seems to benefit him by evading that which he doesn’t understand or at which is incompetent (i.e. sports and assorted school subjects). It has a secondary benefit of exporting his frustration and feeling of inadequacy into his mother. Beneath this level of acting out, I suspected he was dominated by a deeper despair about whether or not life is worth living at all.

3 – Now thirty two years of age, this man has been my patient off and on through every epoch of his life. I have watched him try to become a competent student who could tolerate doing what was demanded of him, learn about dating, struggle to find an identity, and ultimately a career as an accountant. I have seen his struggles to “think about” his feeling reactions to life rather than simply literally turn away from anything he didn’t immediately understand or feel good about. He has developed a gradual capacity to tolerate frustration, delay gratification, have a longer time line for plans in life, and recognize the primacy of his and other’s emotions when attempting to navigate life on a daily, monthly, or yearly time frame.

4 – He and I have come to have an appreciation of his limitations and his strengths, the greatest of which seems to be, his considerable intelligence notwithstanding, that he is a genuinely kind, sweet person (much like his “lost” but kindly mother).

5 – Along the way we uncovered that he had difficulty learning Spanish, which had lots of competition in classes, but had a talent for Japanese and Konji, where he was the only non-Asian student in most of the classes. After gaining a Master’s degree in Asian studies, but realizing his thinking was ill suited to being a teacher at the level of a college professor, he discovered by happenstance that he had a gift for accounting.

Case Example of Mom with German Measles:
1 – A woman contracted German Measles at the beginning of her second trimester of pregnancy and lived in terror for the rest of the pregnancy that the child would be born with birth defects. The baby came out of the womb screaming and almost literally did not stop for his first year of life. The woman did not attempt a second pregnancy.

2 – The boy was brought to me for therapy at eleven as he was becoming disruptive at school and difficult at home. After an extended evaluation of family therapy lasting several months, the parents felt it was best that the child have a five day a week analysis with me and they would check in occasionally with me as issues arose. The analysis lasted at a 5 day a week frequency until it ended when he was 18 and no longer wished to continue. During the seven year treatment he complained about attending but never missed a session with the exception of a week when he was about fourteen and had a brief psychotic episode.

3 – In the first few weeks of individual play therapy he would not allow me to speak, covering his ears, drowning out my words with la-la-la…, and finally threatening me with physical violence. He brought his lunch sack to his 7 AM sessions and on about the third week pulled out a book of matches proclaiming “Look what my mom put in today!” He then proceeded to light a match and throw it at me whenever I attempted to make an utterance. My supervisor, Susanna Isaacs Elmhirst remarked matter of factly: “He needs to play with fire”. For the next year or so he would set paper on fire in the sink of my child playroom and I would limit it to the number of sheets that produced the maximum amount of smoke I could tolerate in the room.

4 – At age 13 he tried to organize a chapter of the Ku Klux Klan in his elementary school. By fourteen it was clear that he had inherited the capacity to be an alcoholic like his grandfather.

5 – At sixteen he was in a single vehicle auto accident in which he and his drunk friend who was driving a jeep at a high speed were both ejected from the vehicle since neither were wearing seat belts. The crash was so violent that both of his tennis shoes were thrown off his feet yet miraculously he was uninjured save for assorted scrapes and bruises.

6 – During his entire childhood his father remained patient and close to his son, ever hopeful, and his mother struggled with feeling guilty and despairing that he would ever be “normal”. We all agreed from the beginning of treatment that our primary goal was to get him through the maelstrom of adolescence, alive at the other end of the storm.

7 – When encouraged by the family to consider enrolling in the military, he refused saying accurately that it was the “largest baby sitter” on the planet. At age 24, coming in for an incidental follow-up he remarked spontaneously that “I am the most envious person I know”.

8 – He became a construction worker and later a handyman, never able to set his sights on goals that were not grandiose, and forever struggling to take orders from people who were less intelligent than he but more reasonable and predictable.

Klein’s Example:
From Klein’s “Infantile Anxiety-Situations Reflected in a Work of Art and in the Creative Impulse, 1929:

“A child of six years old is sitting with his homework before him, but he is not doing any work. He bites his pen-holder and displays that final stage of laziness, in which ennui has passed into cafard. ‘Don’t want to do the stupid lessons,’ her cries in sweet soprano. ‘Want to go for a walk in the park! I’d like best of all to eat up all the cake in the world, or pull the cat’s tail or pull out all the parrot’s feathers! I’d like to scold every one! Most of all I’d like to put mama in the corner!’

The door now opens. Everything on the stage is shown very large – in order to emphasize the smallness of the child – so all that we see of his mother is a skirt, an apron and a hand. A finger points and a voice asks affectionately whether the child has done his work. He shuffles rebelliously on his chair and puts out his tongue at his mother. She goes away. All that we hear is the rustle of her skirts and the words: ‘You shall have dry bread and no sugar in your tea!’

The child flies into a rage. He jumps up, drums on the door, sweeps the tea-pot and cup from the table, so that they are broken into a thousand pieces. He climbs on to the window-seat, opens the cage and tries to stab the squirrel with his pen. The squirrel escapes through the open window. The child jumps down from the window and seizes the cat. He yells and swings the tongs, pokes the fire furiously in the open grate, and with his hands and feet hurls the kettle into the room. A cloud of ashes and steam escapes. He swings the tongs like a sword and begins to tear the wallpaper. Then he opens the case of the grandfather-clock and snatches out the copper pendulum. He pours the ink over the table. Exercise-books and other books fly through the air. Hurrah!…

The things he has maltreated come to life. An armchair refuses to let him sit in it or have the cushions to sleep on. Table, chair, bench and sofa suddenly lift up their arms and cry: ‘Away with the dirty little creature!” The clock has a dreadful stomach-ache and begins to strike the hours like mad. The tea-pot leans over the cup, and they begin to talk Chinese. Everything undergoes a terrifying change. The child falls back against the wall and shudders with fear and desolation. The stove spits out a shower of sparks at him. He hides behind the furniture. The shreds of the torn wallpaper begin to sway and stand up, showing shepherdesses and sheep. The shepherd’s pipe sounds a heartbreaking lament; the rent in the paper, which separates Corydon from his Amaryllis, has become a rent in the fabric of the world! But the doleful tale dies away.

From under the cover of a book, as though out of a dog’s kennel, there emerges a little old man. His clothes are made of numbers, and his hat is like a pi. He holds a ruler and clatters about with little dancing steps. He is the spirit of mathematics, and begins to put the child through an examination: millimeter, centimeter, barometer, trillion –eight and eight are forty. Three times nine is twice six. The child falls down in a faint!

Half suffocated he takes refuge in the park round the house. But there again the air is full of terror, insects, frogs (lamenting in muted thirds), a wounded tree trunk, which oozes resin in the long-drawn-out bass notes, dragon-flies and oleander flies all attack the newcomer. Owls, cats and squirrels come along in hosts. The dispute as to who is to bite the child becomes a hand-to-hand fight.

A squirrel which has been bitten falls to the ground, screaming beside him. He instinctively takes off his scarf and binds the little creature’s paw. There is great amazement amongst the animals, who gather together hesitatingly in the background. The child has whispered: ‘Mama!’ He is restored to the human world of helping, ‘being good’. ‘That’s a good child, a very well behaved child’, sing the animals very seriously in a soft march – the finale of the piece – as they leave the stage. Some of them cannot refrain from themselves calling out ‘Mama’.”

Case Example of Woman Getting a Ticket:
1 – A middle aged woman drives past a parked police car in a small business district and parks. As she unhooks her seat belt and starts to roll up the window the officer walks up and states declaratively “you were not wearing your seatbelt”. She says yes I was and he says no you weren’t and a brief back and forth argument ensues during which she lamely states “I know I was wearing it because it would have gone ding-ding-ding if I wasn’t wearing it”. He ends the 30 second argument by going back to his patrol car to write her a ticket.

2 – She gets out of her car in a quiet fury and mindlessly continues the argument that she was wearing it. He tells her to get back into her car and when she refuses he grabs her and puts her in an “arm bar” with her left arm behind her back. She manages to get out of the arm bar and demands that he call his supervisor. At that point a second patrol car drives up, a male officer gets out and walks up, and a small crowd has begun to gather watching the spectacle.

3 – “I don’t know how, but I could see in the second officer’s eyes that he was a man who was going to listen to me and I calmed down and started to be able to think.” The supervising officer also arrived within a few minutes and the woman was convinced to get back in her car with all now talking calmly and rationally.

4 – Once back in her car the woman remembered that she always tucks the shoulder harness under her left armpit so that it does not hurt her breasts thus explaining why the officer was so certain that he did not see her wearing a seat belt/shoulder harness. That fact, which might have diffused the entire situation right from the beginning, was unavailable to her consciously until the entire altercation had transpired.

5 – Consciously, the emotionally crucial feeling had been that the officer did not believe her and would not listen, mirroring much of her childhood feelings about her anxious mother and absentee father. The event, which occurred on a Friday morning left her in a deep depression all weekend, even after hunting down the same officer on Saturday and apologizing to him, apparently making him further perturbed.

6 – At her Monday session with me, having refused her husband’s urging to call me on Saturday, she said that what was so surprising to her was that she was so vehement in pursuing the officer and that she was utterly incapable of coherently explaining the situation except to keep reiterating that it would have gone ding-ding-ding if she had not been wearing it. She could not remember the word “alarm” or that she had tucked the harness under her armpit.

7 – Historically, this woman had spent her entire childhood trying to be her anxious, narcissistic mother’s perfect daughter, always with the goal to never be a problem or burden. She completely denied feeling any resentment that her mother favored her emotionally handicapped younger brother or that her mostly absent, traveling salesman father never came to her rescue.

8 – This patient complained of a lifelong feeling that she did not have a good memory and was intellectually inferior to the rest of her family. This idea has held in spite of the fact that she was a competent, self-taught auto mechanic. My experience was that she was in fact quite intelligent and quick to catch on to things that were of interest to her and did not evoke an excess of anxiety.

Assorted Clinical Examples:
1 – A woman who comes to analysis five times per week. She had an inadequate, infantile mother who left her feeling chronically deprived. The patient is forever asking for make-up sessions, double sessions, etc. to make up for perceived losses of contact with the analyst.