Psychoanalytic Inquiry

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The Minefield of Emotions

Marion M. Oliner Ph.D. and FIPA

To cite this article: Marion M. Oliner Ph.D. and FIPA (2010) The Minefield of Emotions,
Psychoanalytic Inquiry, 30:5, 405-415, DOI: 10.1080/07351690.2010.482390

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Psychoanalytic Inquiry, 30:405–415, 2010
Copyright © Melvin Bornstein, Joseph Lichtenberg, Donald Silver
ISSN: 0735-1690 print/1940-9133 online
DOI: 10.1080/07351690.2010.482390

The Minefield of Emotions

Marion M. Oliner, Ph.D., FIPA

This article applies the approach of the French psychosomaticiens, based on the strict adherence to no-
tions of psychic energy, to the understanding of the death of one woman. Her ultimate fate appeared to
be determined by the libidinal exhaustion as a reaction to multiple traumatic experiences throughout
her life. This understanding of psychosomatic illness based on quantitative factors—the presence of
libido preventing the aims of the death instinct—was first elaborated by Pierre Marty (1968) and sub-
sequently inspired a number of his colleagues, who considered psychosomatic illness to be the result
of insufficient libido needed for the fantasies that act as a psychic cushion that can absorb life’s
vicissitudes.

The understanding of the illness and the eventual death of the patient presented in this work is
based on a unique approach used by the French psychosomaticiens. This group of French analysts
explored Freud’s first ideas about the functioning of the mind, using economic principles of en-
ergy, to explain psychosomatic illness. For Freud, an increase in energy within the mind–body unit
led to tension that needed to be discharged in a nonconflictual way in order to restore quiescence,
and this discharge of libido was considered a source of pleasure. Nowhere, in this early thinking,
did Freud raise the possibility that preoccupied the psychosomaticiens: that of depletion. For
Freud, discharge led to quiescence, epitomized by the sated baby at the breast sleeping peacefully,
and the issue of discharge exhausting the availablity of libido did not arise. The psychosomaticiens
thought differently. As a matter of fact, they thought that the inability to contain the outflow of li-
bido risked subjecting the individual to the effects of the death instinct.
Most analysts gave up the economic approach in favor of a diversity of theories, but this group
of French psychoanalysts, the psychosomaticiens, members of the Paris Psychoanalytic Society,
found the economic model useful for the understanding of psychogenic illness. They returned to
Freud’s earliest approach to mental functioning, adding to the economic model the issue of an or-
ganization, preceding the structures described by Freud, which led to the retention of libido for
self preservation. Although Freud took the availability of libido for self-preservation for granted,
Pierre Marty, the leader of this loosely constituted group and his coworkers, did not. They sug-
gested that the retention of libido, rather than being innate, presupposed that the individual had at-
tained a level of organization leading to desomatization. In the absence of such organization, pro-
moted by the libidinal energy stemming from the interaction with the caretaking environment,
distress takes the form of action leading to exhaustion and apathy and/or somatization resulting in

Marion Michel Oliner, Ph.D., is in private practice in New York City. She is a member and training analyst at the New
York Freudian Society, the International Psychoanalytic Association, a member of the faculty at the National Psychologi-
cal Association for Psychoanalysis and the Metropolitan Institute for Mental Health.
406 MARION M. OLINER

illness. According to the psychosomaticiens, the evolution of the basic organization creates the
foundation for the retention of libido and the possibility for emotional responses in the face of
distress.
Analysts in private practice, who do not have a hospital affiliation, rarely encounter cases in
which this theory appears to be applicable, but I participated in a number of case conferences at
Marty’s clinic, and eventually I had the opportunity to work for seven years with one patient to
whom this theoretical framework was applicable and follow her evolution from a distance for an-
other few years until her death. Using the model evolved by Marty and his colleagues,1 I intend to
show how the fatal outcome of her illness appeared to be caused by the libidinal depletion de-
scribed by the psychosomaticiens, and I shall contrast this threat to her survival with a famous case
in the literature (Kramer, 1955), in which the libidinal depletion threatened the patient’s narcissis-
tic integrity, but not his survival. I am approaching the comparison between the two cases with the
hypothesis that it is this difference between them that can explain the somatic involvement in my
patient and the favorable outcome of psychoanalytic treatment in Kramer’s case. I believe that the
economic theory of the psychosomaticiens explains the process of resomatization in her case
better than other approaches.
For reasons of confidentiality, I shall limit her history to the analysis of the intense transference
she developed during the years we worked together, but the restriction imposed on this presenta-
tion is not as limiting as it might seem. The transference illuminates the patient’s core, the part of
her personality that had not overcome the damage caused by her devastating childhood. In com-
paring the intense anxiety generated by her attachment to me to Kramer’s patient, who also experi-
enced his attachment to the analyst as dangerous, but who did not become physically ill, it is evi-
dent that both patients had difficulties with dependency, which threatened their fragile personality
organization. The important difference between them was that Kramer’s patient was able to work
through analytically the structure in his personality that fought to defeat the work of the analysis,
whereas my patient could only “save” herself through leaving.

THE PATIENT

The patient, whom I shall call Mary Beth,2 consulted me at the suggestion of one of my patients
with whom she previously worked, about an issue she could not resolve by herself. She could not
decide whether to stay with her husband and family or to move to Florida where her sister had
lived and died of cancer, and where her sister had a close friend whom Mary Beth met during the
sister’s last illness. After her sister’s death and before her first consultation, Mary Beth herself de-
veloped breast cancer, but she treated the illness as a narcissistic injury and otherwise with re-
markable lack of concern. With regard to her dilemma for which she needed my help, it quickly
became evident to me that her reason for leaving a good marriage was a manifestation of uncon-
scious guilt about her sister’s death and her own survival, and that this guilt seemed to compel her
to make restitution for the death of her sister by giving up what she had and to present herself to

1Ultimately, the application of their thinking is my own.

2Although fictitious, this name corresponds to the fact that the patient had a compound name. She insisted that both
names be used to set her apart from her mother, whose name was only the first of the two. We are left to guess the reasons
why the eldest girl, her sister, was not given that name.
 MINEFIELD OF EMOTIONS 407

her sister’s friend as a substitute.3 She accepted this interpretation, and the issue around her move
to Florida appeared to be resolved within the first few meetings. The problem of giving up her job,
her home, and her children did not resurface until five years after her husband’s death, in conjunc-
tion with her retirement from work. She continued coming to regularly scheduled sessions except
for vacations for seven years.
Countertransferentially and unconsciously, I enacted with her the lack of formal commitment
to a treatment process. I had been taken in by her assertion that she was just there for a consultation
and only realized when I opened her record, that I had no notes for the first 58 sessions with her.4
My casual approach apparently reinforced my own innocence in the situation that ensued: If it was
only a consultation, I was not responsible for the pain and the anxiety the process caused her from
the beginning. Furthermore, I had every right to accept to see her after ascertaining that the two
women were not close friends, and I could not be faulted for the fact that my patient immediately
became competitive with her friend, who had assured me that they hardly saw one another. Mary
Beth was convinced that I preferred the other patient and was very upset by the signs of rejection
like my looking at the clock. In the beginning, she tended to suggest that we end the session before
her time was up so as not to be sent away.
She considered her very painful attachment to me to be her main symptom, and she regretted
having entered into our relationship. It was not possible to examine the issues underlying her anxi-
ety closely. She was most ashamed of her reaction, which, according to her, simply should not be
and therefore could not be talked about. According to her, the distress meant that our contact had
to be severed for her to overcome it and be restored to her former level of functioning. But the
competition with the other patient and her own attachment to me prevented her from resorting to
this “solution” for many years.
Mary Beth claimed to have almost total amnesia for the early years of her life. She had a dim
memory of being six years old, answering a phone, yelling to her mother that Daddy was on the
line, and her mother replying angrily that Daddy was dead. Because of the way she learned about
his death, she decided to keep him for herself. Afterward, they moved from their prestigious apart-
ment, which was close to her grandfather’s residence, to many other residences. She was the mid-
dle of three children. Her older sister was sent to live with relatives; a younger brother, her
mother’s favorite, was sent away to boarding school later; and Mary Beth continued to live with
her alcoholic mother to take care of her. Their life was chaotic. As an adolescent, she “got on her
bicycle” to stay with a family whom she had befriended and who sheltered her when she could not
tolerate her mother’s abuse. Relatives made it possible for her to go to college, but she did not fare
well and became seriously disturbed. She returned home after one year, but her mother did not al-
low her into the house. Although she hated her mother, the transference reaction in which she con-
fessed her recurrent fear of my rejection suggests that, despite her constant preoccupation with
leaving, she was deeply traumatized by her mother’s not allowing her to return home after her
troubled year in college.
She never obtained a college degree, although she worked and functioned in a highly literate
environment. The man she married appealed to her because he was already a father. They had a
number of children together, and the family appeared to condone her periodic need to travel and,

3At the time of the consultation, I was not fully aware that she had undergone a lumpectomy around the time of her sis-

ter’s death.
4I no longer make this distinction and keep records on all patient contacts.
408 MARION M. OLINER

thus, to create distance between them and herself. It was an unusual arrangement that seemed to
suit both partners and even his extended family. The difficulty that brought her into treatment was
the compelling need to be closer to her sister’s friend, which would force her to leave her rich and
rewarding life in New York.
Mary Beth was a most unusual and fascinating woman, who had overcome many aspects of her
severe childhood trauma. She had the capacity to be engaged and to have others care for her.5 She
was convinced that her difficulties were caused by the psychotherapy and that she should leave to
solve that problem, which manifested itself by intense anxiety around her sessions. Approaching
my office, especially after one of her absences, was excruciating. Her sister’s friend “helped” her
by fiercely opposing the treatment and her dependency on me. It was very painful to witness her
distress, but I never considered her leaving a solution that should be seriously entertained because
of her intense attachment to me. Once she actually admitted, reluctantly, that she was plagued by
the thought: “Don’t send me away.” I also never lost interest in her, despite the constant threat of
her leaving me. She needed to “get on her bicycle” to flee from me as she had fled from her abusive
mother as a teenager and to be allowed to come back.
Mary Beth came regularly for seven years, interrupted only by some lengthy vacations. The
two-session-a-week schedule started when it became evident that the time between once-a-week
sessions was too long for her to tolerate without massive anxiety. Two years after we began treat-
ment, her husband died, and she suffered from a recurrence of the breast cancer that was treated.
One of her first reactions to his death was to move his dresser out of their bedroom. Afterward, she
tried to avoid social situations and ceremonies in which his death would be confirmed. As with
many painfully charged events, this could not be discussed, because it should not be.
After the seven-year period of regular appointments, she retired from her work and my contacts
with her tapered off as her absences from New York increased. She visited me periodically, and af-
ter four years of these meetings (approximately ten per year), she stopped coming, and I learned
that she became severely ill, resulting in kidney failure that was not properly treated. Her sister’s
friend did not let her stay with her, but she refused to return to her former home, or see the doctor
who had treated her previously. Her children stood by her and visited her during her last illness,
but she died like a waif.
Her somatic reaction suggested that her superficial independence masked a deep dependency
on not being rejected. She reacted to this dependency with shame and anxiety, and maintained the
relationship to her sister’s friend as a counterweight: an external watchdog, who cautioned her
against the dependence on therapy. The neurotic part of her personality profited from the relief she
obtained from therapy. It freed her temporarily from the guilt of having survived her sister and the
compelling need to make restitution for that victory, and allowed her to continue living her own
life. But the narcissistic solution during her adolescence of being the chosen one to replace the
man of the house was not strong enough to withstand more losses. Upon the loss of her husband,
she suffered a recurrence of the cancer, and when she left New York, her health deteriorated rap-
idly. At each important loss, she became seriously ill.
The analysis of the transference presumes that the repetitions, the dreams, and the fantasies are
structured: They have meaning that can be interpreted, but above all, structure presupposes mental

5She was very much in demand socially and walked a fine line between being wanted, as she was, and keeping in the

background. She generally kept people, including her children, wanting more of her, and her trying to get away from them,
without this ever leading them to reproach her. It was rather that she was always welcome because she was hard to get.
 MINEFIELD OF EMOTIONS 409

life. The psychosomaticiens think that structure, which is familiar to all schools of psychoanalytic
thinking in one form or another, is based on the retention of libido, enabling the individual to re-
spond to trauma and loss emotionally in all the ways described in the psychoanalytic literature.
The response is psychic because the underlying organization is capable of containing the outflow
of libidinal energy. In the absence of the capacity to contain sufficient libido for self-preservation,
the patient falls ill. Mary Beth’s case appeared to me to illustrate the kind of personality organiza-
tion described by the psychosomaticiens. In the face of the losses she sustained, she fell ill and
died. She apparently knew her vulnerability and exercised tight control over her sessions. The fail-
ure in the mental organization appears evident in the patient’s reaction when she left therapy per-
manently in order to test her ability to “get on her bicycle.” She was not able to remain with a psy-
chic, that is, mental reaction. Apparently, she exceeded the limits of her capacity to contain her
emotions. Judging from the rapidity of her decline, her personality organization did not hold up
under the severe losses she imposed on herself and disorganization set in. Her need to prove her
autonomy in fantasy and action did not meet her actual needs, in contrast to her experience of the
four years during which she retained the contact with me and remained physically healthy. Her in-
tense attachment, as ambivalent as it was, appeared to have shored up the organization that re-
tained her vitality.

SELF-PRESERVATION AND SURVIVAL

Mary Beth navigated carefully in order to safeguard against an attachment that she considered
dangerous. With me, as well as with her family, she created distance periodically in order to shore
herself up against this threat. The anxieties that her attachments generated could not be success-
fully analyzed. Instead her friend functioned as an external support for her independence. Ulti-
mately I, who encouraged her to hold on to the life she had, became the antagonist. Not that her at-
tachment appeared to diminish but, rather, that it was not permitted to be effective in containing
her self-destructive actions, and she felt compelled to leave. According to the psychosomaticiens,
this need to resort to action is the sign of a poorly organized personality, that is unable to retain the
libido necessary for an emotional response to the need for distance: One that would allow a psy-
chic experience instead of action or, in the face of trauma, resomatization. Seen from this angle,
the patient lacked a reliable psychic organization that might have stemmed her reaction to attach-
ments whose potential loss through rejection or death she experienced as devastating, like a hem-
orrhage (see Pasche, 1964). The danger she experienced consciously was beyond thinking, and
would be interpreted by the French psychosomaticiens as the threat of libidinal exhaustion, result-
ing in psychosomatic illness.
The disorganization described earlier is different from the problems in forming attachments de-
scribed by Kramer in his 1955 article, “On Discovering One’s Identity.” Kramer’s patient was able to
remain in analysis using an unusual defense: a part of the ego experienced as the “little man” func-
tioned to prevent threatening attachments. Thus, with the help of this internalized separate part of his
personality structure, an internal watchdog, Kramer’s patient expressed verbally, but with great anx-
iety, the danger he experienced in cooperating with the analyst and the treatment, but he was able en-
gage the analyst’s help in his struggle against the “little man who won’t let me live.” The threat con-
cerned the patient’s ability to form close and loving relationships without losing his separate
identity, but despite the patient’s sense that the “little man won’t let him live,” somatic illness was not
410 MARION M. OLINER

an issue mentioned by Kramer. The organization that permits problems to be worked out psychically
was in place even though the structure of the personality was threatened at a very primitive level.
Mary Beth could only defend herself by fantasizing about leaving or actually doing so.
The conscious dangers threatening both patients centered on self-preservation. Kramer’s pa-
tient fought against the loss of self and identity. Mary Beth, as it turned out, fought against the loss
of her life. She imagined that attachments would deplete her, when in reality losing those whom
she loved and giving up her dependency needs weakened her body’s ability to fend off disease.
Her somatic reaction to loss presupposes, according to the theoretical framework developed by the
psychosomaticiens, that her immune system was weakened and could not defend against disease.
The analysis of the transference yielded valuable insights into Mary Beth’s personality. The in-
tensity of the transference suggested that being the only one left at home to take care of her mother
was a lifesaving achievement, despite the mother’s abuse. The other children of the family lived
with relatives and seemingly had better opportunities, but she appeared to have benefited from the
fantasy of replacing the man in the house. Through her fear of my rejection, especially after one of
her lengthy vacations, it became apparent that being kept at home or its equivalent in later life was
crucial, and that her mother’s rejection upon her return from college was a determining experi-
ence. The transference revealed the importance of her narcissistic solution, that of being chosen as
the one, the substitute for her father, who had to take care of her mother and who was able to get on
her bicycle to find shelter elsewhere when the mother became too abusive. The narcissism resided
in the illusion of control it gave her. This invalidated the superficial impression of her as the least
fortunate of her siblings, considering that the others were sent away to a better environment.
These ideas are new even though some of the vocabulary is familiar. When Freud worked on his
first instinct theory, he postulated the existence of an instinct of self preservation, also called ego
instinct, but it was not linked to the complexities of development. Freud treated self-preservation
as innate, and his interest in survival waned soon after he turned his attention to the conflicts
around libidinal energy as an expression of sexuality and its objects.
However, depletion was not totally absent from Freud’s thinking: He presumed the existence of
narcissistic depletion because of excessive investment in objects. In his study of narcissism, he
postulated there to be “an antithesis between ego-libido and object-libido. The more of one is em-
ployed, the more the other becomes depleted” (Freud, 1914, p. 76). This was the struggle for
Kramer’s patient and applied to narcissistic investment of the self. It did not encompass self-pres-
ervation in the sense of the struggle for survival, the focus being on the subject and its objects—
not on psychosomatic illness.
In keeping with the emphasis on the relationship between subject and object, another French
analyst, Francis Pasche, studied the phenomenon of narcissistic depletion, which describes the
neurotic struggle of Kramer’s patient and mine. Pasche (1964) used the term “hemorrhage” to de-
scribe the outflow of libido to objects in extreme pathology, and he thought that psychoanalytic
theory ought to have a concept for antinarcissism describing an innate force performing a centrifu-
gal function in the opposite direction of narcissism. He suggested that

In modern psychoanalytic writings, there is no question of the tendency to take the object within one-
self, but never any mention of a tendency that would make it possible first to reach the object and then
to stop there. The theoretical consequences of this omission—and perhaps clinical and technical as
well—are not negligible, in my opinion, and that is why I thought it necessary to introduce the concept
of antinarcissism. [Pasche, 1964, p. 166]
 MINEFIELD OF EMOTIONS 411

Both patients struggled against this antinarcissism, the centrifugal force, the attachment that
depletes because it threatens to absorb all the available libido. Although it is best understood as
only the opposite of self love, it could be extended to describe the issue of the survival of the self as
a separate psychic structure, and ultimately, in those cases lacking the fundamental organization,
the survival of the body.
As a defense against this centrifugal force, Kramer’s patient had internalized a segment in the
ego he labeled the little man one of whose function was to protect him from attachments deemed
to be dangerous. According to Kramer, the patient was convinced
that a “complete” object relationship was identical with the re-establishment of the ego state that ex-
isted before the separation from the mother, i.e., before the birth of the “little man.” Consequently, it
was the narcissism of this ego segment, intent on self-preservation,6 that rebelled against the develop-
ment of object relationships. In the last sense, the formation of such a relationship meant fusion with
the object, and the forsaking of personal existence as an identity of his own. This was clearly an unac-
ceptable fate, both for the narcissism of the ego, most richly centered in the “little man,” and for the lat-
ter’s illusion of omnipotence. [Kramer, 1955, p. 68]

Kramer (1955) applies the term self-preservation to his patient’s struggle to retain his separate
identity. He calls it the narcissism of the ego, making the little man’s activity a fight for an invest-
ment in the self. Attachments to objects, including the analyst, became dangerous because of the
threat to the boundaries of the self, and it fell to the little man to protect him from this calamity.
This defense held up to the point at which the patient could analyze the function served by this seg-
ment of the ego with the help of the analyst. The little man, the antagonist, was eventually brought
under control and the patient did not have to act out his anxieties.
In his book, L’Ordre Psychosomatique (Marty, 1980),7 the French analyst Pierre Marty ques-
tioned why certain patients fall ill as a reaction to stress and why certain patients suffering from
physical illness die whereas others recover from the same disease. He and his colleagues postu-
lated that libidinal exhaustion prevents those who fall ill and remain so from fighting for their life.
He attributed the difference to the libidinal energy available to fight illness, and thereby widened
the concept of defense to include the function of the immune system. According to the psycho-
somaticiens, libidinal exhaustion can occur due to disorganization of the psyche, that otherwise
acts as a container (Marty, 1968). Marty and his coworkers suggested that individuals suffering
from psychosomatic illness lack the capacity to contain vital energy and, therefore, deplete the
libidinal resources to maintain a healthy body, one that can defend itself against illness. It is, ac-
cording to Marty (1968), progressive disorganization that is “the destruction of the actual libidinal
organization in a given individual.” He calls it progressive because “the retrograde movement is
never blocked by any available regressive system. In most cases, disorganization ends in a process
of somatization" because it occurs in patients whose “defense mechanism belong more to behav-
iour per se than to any mental elaboration (Marty, 1968, p. 246). As Marty describes the reaction to
trauma for these vulnerable patients:
the trauma is experienced as a narcissistic wound, which incites the subject to give up one of his emo-
tional interests, to abandon a whole area of his psychic or behavioral life. … The original feature of
progressive disorganization is this: following the break of a first emotional tie, a chain reaction gradu-

6Italics mine.
7All translations from the French were done by the author.
412 MARION M. OLINER

ally leads to the rupture of every emotional tie. … We are not dealing here with a masochistic with-
drawal or with a massive depression, but with a generalized disorganization. [Marty, 1968, p. 247]

It is evident that the psychosomaticiens distinguished between mental structure and mental or-
ganization. The importance of the difference between the two concepts, structure and organiza-
tion, as used by the psychosomaticiens cannot be overstated. It is the difference between
mentalization and somatization: Psychic structures are said to be the result of a personality organi-
zation that is capable of retaining the energy needed for self-care and survival. The organization of
the psyche prevents, more fundamentally, the outflow of libido that endangers survival. In this the-
oretical system, organization by establishing containing walls provides the basis on which psychic
structure rests.8 However, as Fain (1971) wrote, “There exists for everyone a threshold beyond
which, despite all our efforts of representation and verbalization, our flesh is endangered”
(p. 333).
The trajectory from the mental disturbance to the physical, from meaningful conflict to disor-
ganization, epitomizes the work of the psychosomaticiens. When, elsewhere, medication is pre-
scribed for illnesses, be they physical or mental, the French psychosomaticiens, who are not op-
posed to medication, still allude to self-preservation as a system of the psychic economy that
keeps the body alive and healthy. Marty and his coworkers applied the dual instinct theory to a way
of viewing illness according to which self-preservation derives the energy necessary for its func-
tioning from libido, and libidinal exhaustion allows the death instinct, the instinct that decom-
poses,9 free rein, leading to psychogenic illness. As Marty and de M’Uzan (1963) claim,
“Fundamentally, and for the first time, psychosomatic medicine, by rejecting the most important
aspects of the responsibility of external factors, postulates that the individual himself is capable of
destroying his body” (p. 355).

DISCUSSION

I became acquainted with the thinking of the psychosomaticiens while studying the theories of
French psychoanalysts (Oliner, 1988). In this context, I described the work of this group.10 When
these analysts function in the hospital, they are far removed from the traditional consulting room,
which most of them maintain alongside their hospital activities. They are convinced that their psy-
choanalytic training is essential for the work they do, although it is not psychoanalysis in the
strictest sense.11

Not only have they applied what they have learned during their training as analysts, but they have
found it necessary to reformulate some basic tenets and to enlarge psychoanalytic theory itself in order
to account for their findings. [Oliner, 1988, pp. 215–216]

8In the early writings, these problems were thought to apply to the whole personality. As their thinking evolved, they

were more inclined to think of these issues of organization as applying only to crucial segments of the personality.
9As I mentioned earlier, the function of disobjectalizing attributed to the death instinct and introduced by André Green

(Green, 1993, p. 25) could be applied here, but does not appear in the writings of the psychosomaticiens.
10But also by those such as Laplanche (1976) in his book Life and Death in Psychoanalysis who have never been part of

the psychosomaticiens.
11They include psychotherapy in the treatment of cancer patients. Its effectiveness in prolonging life has also been dis-

cussed by Spiegel et al. (1989).

 MINEFIELD OF EMOTIONS 413

I was struck by their ideas concerning the relationship between mind and body, which eventu-
ally contributed to the thinking of their French contemporaries not immediately involved with
psychosomatic medicine.12 The divergence between the psychosomaticiens and others studying
psychosomatic illness centered on whether or not the symptoms have meaning. The psycho-
somaticiens were convinced that the symptoms had no meaning while most of the psychoanalytic
world thought that they did and busied themselves studying how best to interpret the various psy-
chogenic illnesses.
I suspended my own judgment, suspecting that these two antithetical views must describe
somewhat different phenomena since both claimed success with the application of their own the-
ory. Judging from their writings, the French approached patients suffering from psychosomatic
illnesses by trying to arouse the patient’s interest in their survival,13 whereas other analysts dis-
cussed the unconscious meaning of the symptoms. Upon closer scrutiny, however, those who are
convinced that the symptom has symbolic meaning also introduce a preliminary phase in the treat-
ment, during which they are most concerned in establishing a transference and not giving interpre-
tations (Wilson and Mintz, 1989), while the French leave open the possibility of an analytic ap-
proach to these patients once a collaborative working relationship has been established and the
patient’s survival is assured. The antithesis between the theories is, therefore, not as radical as it
seems at first, and it appears appropriate to choose between them according to that theory that best
fits the clinical picture. I believe that the case of my patient, Mary Beth, illustrates the theory de-
veloped by the French, who attributed psychosomatic illness to the depletion of libidinal energy.
At the beginning of this presentation, I suggested that the difference between Kramer’s patient
and Mary Beth could shed some light on the somatic involvement in Mary Beth’s case, using as
the model for understanding her evolution into physical illness the thinking of the psycho-
somaticiens who maintained that libidinal exhaustion challenges survival. During her treatment, I
had feared that Mary Beth’s health depended on our contact. Although such an intuition should
not be confused with factual information, her fate following her departure lends some substance to
it.14 Her case appears to illustrate the interaction between psychic structure, the mental neuroses,
and the disorganization caused by the failure in the structure. It is the distinction established by Pi-
erre Marty, between regression in mental neuroses such as both patients suffered and the disorga-
nization or failure of the “narcissistic psychosomatic investment” (Fain and Marty, 1965) as a re-
action to trauma, leading to physical illness, in the case of Mary Beth (Marty, 1980).
Mary Beth did not lack a psychic structure, but the neurotic part of her personality that was ca-
pable of elaborate dreams and analyzable motives was not based on an adequate organization to
prevent the somatic involvement that the psychosomaticiens attribute to disorganization. She was
unable to sustain a nourishing relationship when faced with the trauma of loss. Instead, she ac-
tively imposed another series of losses on herself. When her sister died, she felt compelled to leave
her husband, but she did not have to carry out this penance because of the interpretation I had
given her. Once she knew that she was motivated by guilt for her survival, as if she were responsi-

12A detailed discussion of the theories and the work of the psychosomaticiens can be found in Chapters 11, The

Psychosomaticiens, and Chapter 12, Life and Death in Psychoanalysis, of my book Cultivating Freud’s Garden in France,
also in McDougall (1974).
13The lack of interest is reminiscent of la belle indifférence attributed to hysterics.
14There is also scientific corroboration such as studies that have shown that “psychosocial treatment” has an effect on

illness. According to one study, the treatment even prolonged the life of women with metastatic breast cancer (Oliner,
1991).
414 MARION M. OLINER

ble for her sister’s death, her need to act was expressed verbally. The interpretation coupled with
her positive transference gave her permission to hold on to her own life for a while, even after her
husband’s death. Eventually, she used her sister’s friend’s harsh judgment of her dependency to re-
inforce her own anxieties and to relinquish the support treatment provided for her, along with
many aspects of her life as a valued member of a large family and property owner.
The loss of the structuring narcissistic investment described by the psychosomaticiens can be
loosely compared to Bion’s (1962) notion of a psychic container for emotions that promotes reten-
tion of energy. The nature of the energy and its purpose vary in each of these theories, but the simi-
larity resides in the quality of containment. The opposite of containment in each case is insuffi-
ciently structured discharge, addictive behavior, or psychosomatic illness. Freud’s thinking
centered on psychic energy, Bion focused on emotions, and the psychosomaticiens concentrated
on the borderline between psychic and somatic investments. They considered organized invest-
ments to be a guarantee of the retention of vital energy in the psyche. Organization prevents the
outflow of libido, viewed as not only self love and preservation of a separate identity, but as a cru-
cial factor health maintenance.
Mary Beth’s rapid decline after leaving treatment can be understood as her inability to hold on
to the libidinal supplies necessary for her survival. After her first experience with breast cancer,
the same tendency prompted by survivor guilt manifested itself as a conflict from which she was
sufficiently relieved to contain it and experience it as an emotional issue. In as much as an interpre-
tation of her motives helped her, my intervention follows the classical model in which understand-
ing the meaning of an action frequently is sufficient to inhibit it. The impulse was contained, could
be expressed through derivatives, including words addressed to me, but did not have to be enacted
except in her periodic need to leave town. Her capacity to contain conflict diminished as a result of
her husband’s death and with it her capacity to contain the outflow of her vital supplies. According
to this view, the psychic structure was depleted to the point where the exhaustion of energy af-
fected the capacity of the immune system to fight disease.
The psychosomaticiens extended the notion of defense from the psychic to the physical realm.
They conceived of a continuum starting with the ability to invest ego boundaries libidinally so that
the relationship to the object world can be one of exchanges that resulted in the resistance to illness
because of this flexible interchange with the environment at one end (McDougall, 1974;
Braunschweig and Fain, 1975; Oliner, 1988) to the exhaustion of the containing function due to
emotional factors at the other extreme. This theory, which extends from the complex interplay of
all factors of interest to psychoanalysts to the basic issue of survival, is generally taken for granted,
as is well illustrated by my work with Mary Beth. In the process of elucidating this continuum, the
focus shifted from meaningful motivation that can be interpreted to a way of thinking that involves
energy. Using the term libido, as the psychosomaticiens did, suggests a closer relationship to the
drives with their objects and aims than they intended. The energy appears to have more in common
with the survival instinct or Eros, if taken as the opposite of Thanatos. This energy is at the source
of emotions and becomes a drive in the sense that we know it with proper containment. As the case
material shows, the capacity for containment is object-dependent.
The mother’s role in establishing the organization that is at the origin of mental life was de-
scribed by Fain (1971), with or without collaborators (Braunschweig and Fain, 1971), in many im-
portant studies. Essentially, the mother’s role is that of providing the kind of care in which the in-
fant experiences an optimum degree of quiet, without sensorimotor stimulation such as rocking, to
turn from the sense organs, including the skin, toward the inner world. The good-enough mother
 MINEFIELD OF EMOTIONS 415

gratifies the infant without the need for constant calming or soothing; consequently, the optimum
environment permits the child to acquire those faculties when left alone to do so.

CONCLUSION

In this study, I presented a case that illustrates a way of viewing psychosomatic illness that is
largely unknown but deserves its place in clinical thinking. It leads to a technique in which main-
taining emotional contact with the patient is at the forefront of the therapist’s task. Failure, with its
ultimate fatal outcome, is always a possibility, but if it is to be avoided, the transference, rather
than the meaning of the symptom, must be the focus. This approach does not invalidate other theo-
ries, but as usual, the choice of treatment depends on the nature of the illness. In these difficult
cases, mistakes can be costly or irreparable, and the psychosomaticiens trust their approach based
on the theory I have attempted to convey.

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